Apnea and heart attack

[littlebaddow]

Hi all. I need some advice please.
I was diagnosed in 2004 and have been successfully using APAP ever since. My typical readings have been AHI around 1, 90% pressure around 8 and periodic breathing zero. I’ve generally been healthy, though do carry more weight than I should.
In September I had a heart attack and have had 2 stents inserted.
Since then, my results have been all over the place. AHI range 6 to 20 (and once 30), 90% pressure maxing out to whatever maximum setting I use (currently 15) and periodic breathing 20% to 30%.
There is no obvious pattern or improving trend.
I'm not getting any error messages from the machine, which is nearly 4 years old, and have recently replaced my mask.
I’m obviously discussing this with my GP (general practitioner) and have been referred to the respiratory specialist who originally diagnosed me, but current circumstances mean there may be a lengthy wait for an appointment.
My question is whether anyone else has experienced anything similar after a heart attack?
Thank you.

[rick blaine]

Hi littlebaddow,

Choosing as your moniker or forum name an actual place is clever – gives us a chance to guess which foundation trust hospital you attend. One of the several in or near Chelmsford, yes? And the fact that that I know where Little Baddow is tells you I know a bit about the UK and about treatment in the NHS.

First thing is: if your cardiac event was in September of this year, things may still be happening in terms of healing and recovery.

So even if some of the changes to your sleep apnea pattern are disturbing or puzzling, they may be transient.

Second thing is: what drugs are you on that you weren't on before. Something anti-coagulant? One of the ACE inhibitors? Something for anxiety? Something for the indirect treatment of pain?

These can all have an effect on your AHI.

Third, are you now sleeping on your back more than you were before? That's often how NHS hospital wards like it (it seems to me). Things is, sleeping on one's back can easily add 5 or more to your AHI. You were probably sleeping on your side before, what with an AHI of 1. If you're not sleeping on your side now, doing so is going to make a difference.

Fourth, do your cardiology team know you are on CPAP? And have they said anything about the limiting of your maximum CPAP pressure? If not, there's usually no good reason not to have your maximum at 20.

Fifth, are your resps up and your tidal volume down? (If you have Oscar or SleepyHead charts from before and after, that would be where you can find that information.) That opens up the area: what kind of breathing pattern are you having? And what does it mean?

The PR indication of periodic breathing is a good way off from true Cheynes-Stokes, and heart failure. There are several stages along the way to that.

Sixth, I know what waiting times for appointments in the NHS are like. But if your cardiology team have sent you home, they must be sufficiently happy with you at some level. Have they said anything about rehabilition club? Some FHT's have one based on the Dutch model. Eight weeks of planned and supervised walking exercise.

If you've been cleared to do some walking and in particular 'walking through the fear', an improvement in your overall heart-lung capacity may be what gets your sleep pattern to be more stable.

I'd start with that.

[littlebaddow]

Rick, thank you for the quick, informative and reassuring reply and yes, you know where I am
In response to your points:
1. Phew!
2. I'm currently taking an ACE inhibitor, 2 anti-platelets, a beta blocker and a statin, plus antibiotics for an infection, so I guess that cocktail could be having an impact!
3. I'm usually a side sleeper, but think I've been tending towards half and half since discharge so another probable cause.
4. Yes I've told the cardio team I have sleep apnea and use CPAP at every opportunity, but they haven't discussed anything about it in detail with me. The 15 max setting was my choice. After initial diagnosis (I went privately rather than NHS to get seen quicker) I've always purchased my own equipment and set the range 5 to 15 as normally I don't get near the top end. I'll reset to 20.
5. Wow, you've completely lost me there, but I think that means I needn't worry.
6. Yes I'm under the cardio rehab team who set me a weekly exercise plan, albeit by weekly telephone call rather than face to face.

The stents were put in the circumflex artery but the angiography also revealed 'diffuse calcified LAD disease which was pressure wire borderline positive' and I've had one episode of angina since my discharge so GP has referred me back to the cardio consultant, though currently 7 to 8 weeks to get an appointment and in meantime told to manage it with GP or go to A&E if symptoms worsen.

I have nothing but admiration for the NHS staff I've dealt with, but there does still seem to be a slight lack of awareness about sleep apnea and therefore a disconnect between the various medical disciplines. I've had lots of information about managing my recovery from the heart attack but no mention whatsoever of the implications for my sleep apnea.

[Pugsy]

Get OSCAR and post a typical detailed report
OSCAR https://www.sleepfiles.com/OSCAR/
http://www.apneaboard.com/wiki/index.ph ... stallation
http://www.apneaboard.com/wiki/index.ph ... rpretation

In the format explained here
viewtopic/t158560/How-to-post-images-for-review.html

Depending on what is seen we may asked for a zoomed in segment of the flagged PB time.

Periodic Breathing is nothing but a waxing and waning of the air flow. It gets flagged for further attention because of the possibility of Cheyne Stokes Respiration which is a form of periodic breathing but it isn't the only form. Not all PB means CSR which of course people think related to heart issues. Obviously your respiration has changed because of the procedures and that might be a simple explanation and with time and your respiration returns to more normal it may be that the PB also reduces.

Since your AHI has increased and there is an increase in PB...warrants at least keeping a close eye on it but without knowing what kind of events you have seen increase and are there any events happening during the flagged PB times...can't really say for sure that there's nothing to worry about or not.

[chunkyfrog]

After his stent insertion last year, the bullfrog was rx'd the heavily promoted (and expensive) Brilinta.
He suffered from a LOT of bad side effects, so he switched to clopidogrel, the older, more tested drug.
Look out for brand new drugs--they are too often insufficiently tested.
Considering the cost, one can only imagine why.

[littlebaddow]

Here you go Pugsy, last nights results attached. There does now appear to be an improving trend, had a couple of nights with AHI below 5 before this one.

[littlebaddow]

As a comparison, this was the night before my heart attack

[littlebaddow]

This shows the dramatic change after my heart attack on 20 Sep and another night in hospital 14 Oct with a suspected second attack, fortunately only angina.

[Pugsy]

Were you awake at around 07:00 on last night's rather ugly report?
Actually were you awake from shortly before 07:00 to 08:00 when all that ugly happened?

If you were asleep you think...can you zoom in about a 5 minute segment around that 07:00 time frame that includes some CAs/Central flagging?

Watch the videos here as it shows how to zoom in and how to look for evidence of arousal/awake breathing.

http://freecpapadvice.com/sleepyhead-free-software

Is your doctor aware of these recent changes?

[littlebaddow]

I'd describe it as disturbed sleep rather than awake during that period.

I'm still waiting for an appointment with the specialist who apparently is not doing face to face at the moment, will be speaking to the GP again tomorrow to try to progress it.

[Pugsy]

Can you try turning Flex exhale relief off and see if that makes any change or not?
It's a long shot but worth trying.

[littlebaddow]

ok I'll give it a try thanks.

I have to say that software is incredible, what a resource to have. Thanks to everyone involved in creating and maintaining it.

[littlebaddow]

Thanks for the comment so far, an update and request for further observations please.
There's certainly been an improvement, but still nights that concern me.
I widened the pressure range on my machine by setting the max to 20cm on 22 Oct as suggested, this appears to have helped.
I turned off the flex exhale relief as suggested on 26 Oct, but didn’t notice much difference. Turned it back on 10 Nov.
As you can see, the overall AHI has been on an improving trend with some bad nights, though the peaks are lower.
The daily report for last night shows a typical 'bad' night, where I appear to sleep well for a few hours, then go into meltdown!
Last night I woke up around 4:50, turned the machine off then immediately on again and went back to sleep, then had another hour or so of reasonable looking sleep. This has been a regular pattern on the 'bad' nights.
Thanks.

Screenshot daily 27nov.png (185.45 KiB) Viewed 1097 times

Screenshot summary 27nov.png (139.03 KiB) Viewed 1097 times

[rick blaine]

Hello again littlebaddow,

One possibility when apneas are clumped together like that for a spell, but otherwise the rest of the night is clear, is 'positional apnea'. Ie, you move while asleep or dreaming, and take up a position where your head and neck are at an angle to your body – ie, not 'in line'.

One response to that is the buying and wearing of a soft cervical collar.

It doesn't cost much to try it.

Other than that, the 'overview' chart from 22 September to the present – again, IMO – shows a patient gradually coming back to something like what they were before.

Looking at the 'overview' from 29 October on, much fewer centrals. Their presence on 26 November may be what's called 'sleep-wake-junk'.

But just to make there isn't anything more serious about those centrals, it might be an idea for you to wear a Holter ECG monitor for 24 hours. Your GP can request one for 24 hours without having to go through cardiology – although a polite letter to your cardiologist would be both the norm and appreciated.

Btw, this isn't that I, a civilian, think there's anything alarming in what you've shown here. More that it would give you some reassurance.

[southerndoc]

Have you had an echocardiogram to rule out congestive heart failure? If so, what was your ejection fraction (EF) percent?

If you're heart attack caused you to have mild CHF, then lying flat will cause you to accumulate fluid in your lungs which would altered your breathing ability and CPAP requirements.

Just a thought, but not saying it's necessarily what is causing your changes.