title: Diagnosing and managing sleep apnea in patients with chronic cerebrovascular disease: a randomized trial of a home-based strategy.
abstract: BACKGROUND
  Obstructive sleep apnea is common and associated with poor outcomes after stroke or transient ischemic attack (TIA). We sought to determine whether the intervention strategy improved sleep apnea detection, obstructive sleep apnea (OSA) treatment, and hypertension control among patients with chronic cerebrovascular disease and hypertension.
  
  
  METHODS
  In this randomized controlled strategy trial intervention, patients received unattended polysomnography at baseline, and patients with OSA (apnea-hypopnea index ≥5 events/h) received auto-titrating continuous positive airway pressure (CPAP) for up to 1 year. Control patients received usual care and unattended polysomnography at the end of the study, to identify undiagnosed OSA. Both groups received 24-h blood pressure assessments at baseline and end of the study. "Excellent" CPAP adherence was defined as cumulative use of ≥4 h/night for ≥70% of the nights.
  
  
  RESULTS
  Among 225 randomized patients (115 control; 110 intervention), 61.9% (120/194) had sleep apnea. The strategy successfully diagnosed sleep apnea with 97.1% (102/105) valid studies; 90.6% (48/53, 95% CI 82.7-98.4%) of sleep apnea was undiagnosed among control patients. The intervention improved long-term excellent CPAP use: 38.6% (22/57) intervention versus 0% (0/2) control (p < 0.0001). The intervention did not improve hypertension control in this population with well-controlled baseline blood pressure: intervention, 132.7 mmHg (±standard deviation, 14.1) versus control, 133.8 mmHg (±14.0) (adjusted difference, -1.1 mmHg, 95% CI (-4.2, 2.0)), p = 0.48).
  
  
  CONCLUSIONS
  Patients with cerebrovascular disease and hypertension have a high prevalence of OSA. The use of portable polysomnography, and auto-titrating CPAP in the patients' homes, improved both the diagnosis and the treatment for sleep apnea compared with usual care but did not lower blood pressure.
authors.affiliation: VA HSR&D Center of Excellence on Implementing Evidence-Based Practice (CIEBP), Richard L. Roudebush VA Medical Center, HSR&D Mail Code 11H, 1481 West 10th Street, Indianapolis, IN, 46202, USA. Dawn.Bravata2@va.gov.|VA Health Services Research and Development (HSR&D) Stroke Quality Enhancement Research Initiative (QUERI), Indianapolis, IN, USA. Dawn.Bravata2@va.gov.|Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN, USA. Dawn.Bravata2@va.gov.|Department of Neurology, Indiana University School of Medicine, Indianapolis, IN, USA. Dawn.Bravata2@va.gov.|Regenstrief Institute, Indianapolis, IN, USA. Dawn.Bravata2@va.gov.
authors.forename: Dawn M
authors.initials: DM
authors.lastname: Bravata
authors.affiliation: Regenstrief Institute, Indianapolis, IN, USA.
authors.forename: Vincent
authors.initials: V
authors.lastname: McClain
authors.affiliation: Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN, USA.
authors.forename: Charles
authors.initials: C
authors.lastname: Austin
authors.affiliation: Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN, USA.
authors.forename: Jared
authors.initials: J
authors.lastname: Ferguson
authors.affiliation: VA HSR&D Center of Excellence on Implementing Evidence-Based Practice (CIEBP), Richard L. Roudebush VA Medical Center, HSR&D Mail Code 11H, 1481 West 10th Street, Indianapolis, IN, 46202, USA.|VA Health Services Research and Development (HSR&D) Stroke Quality Enhancement Research Initiative (QUERI), Indianapolis, IN, USA.
authors.forename: Nicholas
authors.initials: N
authors.lastname: Burrus
authors.affiliation: VA HSR&D Center of Excellence on Implementing Evidence-Based Practice (CIEBP), Richard L. Roudebush VA Medical Center, HSR&D Mail Code 11H, 1481 West 10th Street, Indianapolis, IN, 46202, USA.|VA Health Services Research and Development (HSR&D) Stroke Quality Enhancement Research Initiative (QUERI), Indianapolis, IN, USA.|Regenstrief Institute, Indianapolis, IN, USA.|Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, IN, USA.
authors.forename: Edward J
authors.initials: EJ
authors.lastname: Miech
authors.affiliation: VA HSR&D Center of Excellence on Implementing Evidence-Based Practice (CIEBP), Richard L. Roudebush VA Medical Center, HSR&D Mail Code 11H, 1481 West 10th Street, Indianapolis, IN, 46202, USA.|Regenstrief Institute, Indianapolis, IN, USA.|Department of Communication Studies, Indiana University-Purdue University at Indianapolis (IUPUI), Indianapolis, IN, USA.
authors.forename: Marianne S
authors.initials: MS
authors.lastname: Matthias
authors.affiliation: Health Policy and Management, University of Georgia, Athens, GA, USA.
authors.forename: Neale
authors.initials: N
authors.lastname: Chumbler
authors.affiliation: Department of Biostatistics, Indiana University School of Medicine, IUPUI, Indianapolis, IN, USA.
authors.forename: Susan
authors.initials: S
authors.lastname: Ofner
authors.affiliation: Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN, USA.|Internal Medicine Service, Richard L. Roudebush VA Medical Center, Indianapolis, IN, USA.
authors.forename: Brian
authors.initials: B
authors.lastname: Foresman
authors.affiliation: VA Connecticut Healthcare System, West Haven, CT, USA.|Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA.|Department of Neurology, Yale University School of Medicine, New Haven, CT, USA.
authors.forename: Jason
authors.initials: J
authors.lastname: Sico
authors.affiliation: VA Connecticut Healthcare System, West Haven, CT, USA.|Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA.
authors.forename: Carlos A
authors.initials: CA
authors.lastname: Vaz Fragoso
authors.affiliation: VA HSR&D Center of Excellence on Implementing Evidence-Based Practice (CIEBP), Richard L. Roudebush VA Medical Center, HSR&D Mail Code 11H, 1481 West 10th Street, Indianapolis, IN, 46202, USA.|VA Health Services Research and Development (HSR&D) Stroke Quality Enhancement Research Initiative (QUERI), Indianapolis, IN, USA.|Department of Neurology, Indiana University School of Medicine, Indianapolis, IN, USA.|Regenstrief Institute, Indianapolis, IN, USA.
authors.forename: Linda S
authors.initials: LS
authors.lastname: Williams
authors.affiliation: Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN, USA.|Internal Medicine Service, Richard L. Roudebush VA Medical Center, Indianapolis, IN, USA.
authors.forename: Rajiv
authors.initials: R
authors.lastname: Agarwal
authors.affiliation: Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA.|Clinical Epidemiology Research Center, VA Connecticut Healthcare System, West Haven, CT, USA.
authors.forename: John
authors.initials: J
authors.lastname: Concato
authors.affiliation: VA Connecticut Healthcare System, West Haven, CT, USA.|Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA.
authors.forename: H
authors.initials: H
authors.lastname: Klar Yaggi
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001794:Blood Pressure; D002561:Cerebrovascular Disorders / Q000150:complications* / Q000503:physiopathology / Q000628:therapy; D045422:Continuous Positive Airway Pressure; D005260:Female; D006699:Home Care Services; D006801:Humans; D006973:Hypertension / Q000150:complications* / Q000503:physiopathology / Q000628:therapy; D008297:Male; D008875:Middle Aged; D017286:Polysomnography; D020181:Sleep Apnea, Obstructive / Q000150:complications / Q000175:diagnosis* / Q000503:physiopathology / Q000628:therapy*; D016896:Treatment Outcome
keywords: Ischemic stroke; Sleep apnea diagnosis; Sleep apnea treatment; Transient ischemic attack