Postgraduate Medicine ISSN: 0032-5481 (Print) 1941-9260 (Online) Journal homepage: http://www.tandfonline.com/loi/ipgm20 Hypertension and stroke in a young man with obstructive sleep apnea syndrome Satyanarayana K. Tikare MD, Bashir A. Chaudhary MD & Madhukar S. Bandisode MD To cite this article: Satyanarayana K. Tikare MD, Bashir A. Chaudhary MD & Madhukar S. Bandisode MD (1985) Hypertension and stroke in a young man with obstructive sleep apnea syndrome, Postgraduate Medicine, 78:7, 59-66, DOI: 10.1080/00325481.1985.11699205 To link to this article: http://dx.doi.org/10.1080/00325481.1985.11699205 Published online: 16 May 2016. Submit your article to this journal View related articles Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ipgm20 Download by: [La Trobe University] Date: 17 June 2016, At: 20:23 Hypertension and stroke in a young man with obstructive sleep apnea syndrome Satyanarayana K. Tfkare, MD, Bashir A. Cbaudhary, MD, Madhukar S. Bandiaode, MD Postgraduate Medicine 1985.78:59-66. POSTGRADUATE MEDICINE invites submission of brief case reports, especlally thoee related to ambulatory medical care. mustrations and references should be included only when essential. A 34-year-old man was admitted to the Veterans Administration Medical Center, Augusta, Georgia, on May 1, 1983, with weakness and numbness of the right upper and lower extremities since that morning. He had a history of hypertension and diabetes mellltus of five years' duration and admitted to noncompliance with both his blood pressure medications and diabetic diet. Physical examination revealed the following: blood pressure 150/100 mm Hg. pulse rate 74/ mln and regular. respiration rate 20/mln. temperature 37 oc (98.6 0 F). weight 117.9 kg (262 lb), height 177.5 cm (5 ft llln). The neck was broad and thick, the tonsils were markedly enlarged, and the uvula was elongated. Respiratory sounds were normal with no rales or rhonchi, and heart sounds were normal without murmur, gallop, or rub. Neurologic findings were consistent with right -sided hemiplegia. but speech was not affected. Results of laboratory studies were as follows: pH 7.41, PO:z 70 mm Hg. PC02 44 mm Hg. hemoglobln 16.5 gmjdl. hematocrit 49.1 %. fasting plasma glucose 227 mgjdl, serum cholesterol 104 rng!dl, serum trtglycerides 455 rng!dl, serum ANAs absent. serologic test for syphilis negative, CSF values within normal limits, no glucose 6-phosphate dehydrogenase deficiency or hemogloblnopathy detected. A chest roentgenogram and an CASE REPORT ECG were normal. A computed tomographic scan of the head done the day after admission revealed a paraventrtcular area of low attenuation. Holter monitorIng showed rare premature ventricular contractions; multiple gated acquisition radlonuclide angiocardiography revealed mild left ventricular hypokinesis with a global ejection fraction of 48%. Stertorous breathing began Immediately when the patient was placed In the supine position. Further history taking revealed excessive snoring and marked daytime somnolence of Indefinite duration. Several episodes of apnea were observed during "apnea checks" performed as he slept. Polysomnography was conducted at the sleep laboratory of Eugene Talmadge Memorial Hospital, Augusta, Georgia. on May 31, 1983. The study consisted of an EEG, measurement of chest and abdominal wall expansion, ear oximetry, and airflow measurement at the mouth and nostrils. These readings were recorded for four and a half hours. During this time the patient had 281 episodes of apnea, with each episode lasting 10 to 50 seconds. The apnea was generally obstructive, with a few epIsodes of mixed type. Oxygen saturation ranged from 70% to 85%. and the apnea Index (number of apnea episodes per sleep hour) was 77 .84. The patient spent 54.9% of his sleep time In an apnelc state. The diagnosis was severe sleep apnea syndrome and paradoxical breathIng pattern. On June 9, 1983, the patient underwent a tracheostomy and uvulopalatopharyngoplasty with continued VOL 78/NO 7/NOVEMBER 15, 1985/POSTGRADUATE MEDICINE • HYNRTENSION AND APIIU 59 1\Jssend® 8 Antitussive-Decongestant Liquid and Tablets CASE REPORT CONTINUED 1\Jssend® Expectorant 8 Antitussive-Decongestant Liquid See package literature for Full Prescribing Information. A brief summary follows. Postgraduate Medicine 1985.78:59-66. CONTRAINDICATIONS: Patients with severe hypertension, severe coronary artery disease and patients on MAO inhibitor therapy, nursing mothers, and patients with hypersensitivity or idiosyncrasy to sympathomimetic amines or phenanthrene derivatives. tonsillectomy. After surgery his sleep apnea syndrome improved; he had decreased stertorous breathing, improved sleep pattern, and decreased daytime somnolence. After removal of the tracheostomy tube eight days later, the tracheostomy stoma closed spontaneously. A moderately salt-restricted diet and hydrochlorothiazide, 50 mg once a day, controlled the hypertension; a 1,500-calorte diabetic diet and tolazamide (Tolinase), 250 mg once a day, controlled the hyperglycemta. After adequate physical and occupational therapy for his stroke, the patient was discharged on July 21, 1983. His weight at discharge was 113.4 kg (252 lb). Polysomnography was repeated in January 1984 and showed no evidence of sleep apnea syndrome. Oxygen saturation was 87% to 95%. When the patient was last seen in October 1984, Satyanarayana K. Tikare Bashir A. Chaudhary Madhukar S. Bandisode Or Tikare is assistant clinical professor of medicine, Medical College of Georgia, and staff physician, Veterans Administration Medical Center, Augusta, Georgia. Or Chaudhary is associate professor of medicine, and director, sleep laboratory, Medical College of Georgia. Or Bandisode is assistant professor c:A medicine, Medical College of Georgia, and chief of intermediate medicine, Veterans Administration Medical Center. his improved sleep pattern had persisted and he denied excessive daytime sleepiness. Hypertension was controlled with hydrochlorothiazide, 50 mg once a day, and methyldopa (Aldomet), 250 mg three times a day. However, he was noncompliant with the recommended diet and, consequently, had gained 7.65 kg (17 lb) since discharge (current weight 121.05 kg (269 lb]). Fasting plasma glucose was 172 rngtdl, although he was still receiving tolazamtde. Dl8cualon Sleep-related disorders have recently been recogntzed as quite prevalent and also potentially life-threatening. 1 The increasing availability of sleep laboratories has improved the understanding of these disorders considerably. Obstructive sleep apnea syndrome is one of the commonly encountered sleep-related disorders. Well-known presenting features of this syndrome include loud snoring, disturbed sleep, excessive daytime sleepiness, personality changes, and sexual problems. Su~ show nocturnal cardiac arrhythmias, stgntficant hypoxemta, and transient arterial and pulmonary hypertension during sleep. 2 A high incidence of established arterial hypertension has been reported in several studies continued on page 64 WARNINGS: If used in patients with hypertension, diabetes mellitus, ischemic heart disease, hyperthyroidism, increased intraocular pressure and prostatic hypertrophy, judicious caution should be exercised. Sympathomimetics may produce CNS stimulation. The safety of pseudoephedrine for use during pregnancy has not been established. Overdosage of sympathomimetics in the elderly (60 years and older) may cause hallucinations, convulsions, CNS depression and death. PRECAUTIONS: Concomitant use of other CNS depressants, including alcohol, may have an additive CNS depressant effect. Hydrocodone may produce drowsiness: patients should be cautioned accordingly. ADVERSE REACTIONS: Gastrointestinal upset, nausea, dizziness, drowsiness and constipation. A slight elevation in serum transaminase levels has been noted. Hyperreactive individuals may display ephedrine-like reactions such as tachycardia, palpitations, headache, dizziness or nausea. Sympathomimetic drugs have been associated with certain untoward reactions including fear, anxiety, tenseness, restlessness, tremor, weakness, pallor, respiratory difficulty, dysuria, insomnia, hallucinations, convulsions, CNS depression, arrhythmias, and cardiovascular collapse with hypotension. DRUG INTERACTIONS: Hydrocodone may potentiate the effects of other narcotics, general anesthetics, tranquilizers, sedatives and hypnotics, tricyclic antidepressants, MAO inhibitors, alcohol, and other CNS depressants. Beta adrenergic blockers and MAO inhibitors potentiate the sympathomimetic effects of pseudoephedrine. Sympathomimetics may reduce the anti-hypertensive effects of methyldopa, mecamylamine, reserpine and veratrum alkaloids. DOSAGE AND ADMINISTRATION: Tussend Liquid and Tussend Expectorant: Adults, and children over 90 lbs, 1 teaspoonful; children 50 to 90 lbs, 'h teaspoonful; children 25 to 50 lbs, v. teaspoonful. May be given four times a day, as needed. Tussend Tablets: Adults, and children over 90 lbs, 1 tablet. May be given four times a day, as needed. May be taken with meals. CAUTION: Federal law prohibits dispensing without a prescription. MERREU DOW PHARMACEUTICALS INC. Subsidiary of The Dow Chemical Company Cincinnati. Ohio 45215, U.S.A. MerreiiDow 60 HYNIIftNSION Ate APMA • IIOl ~ 7/N()VEMBER 15, liE/POSTGRADUATE MEDICINE 5-4603 IB-l089J MN0-848 Brief Summary: ANAPROX® (naproxen sodium) Indications: Relief of mild to moderate pain; treatment of primary dysmenorrhea. Contralndlcatlona: Patients who have had allergic reactions to NAPROSYN or ANAPROX or in whom aspirin or other NSAIDs induce the syndrome of asthma, rhinitis, and nasal polyps. Wllmlnp: Gl bleeding, sometimes severe, and occasionally fatal, has been reported. Do not give to patients with active peptic ulcer unless potential benefit outweighs risk. AdministertothoseandotherswithhistoryofGidiseaseonly CASE REPORT CONTINUED under close supervision. Precautions: DO NOT GIVE NAPROSYN" (NAPROXEN) CONCOMITANTLY WITH ANAPROX® (NAPROXEN SODIUM) SINCE BOTH CIRCULATE IN PLASMA AS THE NAPROXEN ANION. Because anaphylactic reactions usually occur in patients with a history of such reactions, question patients for asthma, nasal polyps, urticaria, and hypotension associated with NSAIDs before starting therapy. If such symptoms occur, discontinue the drug. Acute interstrtial nephritis wrth hematuria, proteinuria, and nephrotic syndrome has been reported. Patients with impaired renal function, heart failure, liver dysfunction, taking diuretics, and the elderly are at greater risk of overt renal decompensation. If this occurs, discontinue the drug. Use with caution and monitor serum creatinine and/or creatinine clearance in patients with significantly impaired renal function. Use caution in patients with baseline creatinine clearance less than 20mVminute. Use caution when high doses are required in the elderly or in patients wrth chronic alcoholic liver disease or cirrhosis. With NSAIDs, borderline elevations of liver tests may occur in up to 15% of patients. They may progress, Postgraduate Medicine 1985.78:59-66. ~~v~t7oun~c~,as"~~·~rs~m~i~~:r:~trnc~on~;~~f~t~~?~:'i'~ trials in less than 1% of patients. Severe hepatic reactions, including jaundice and fatal hepatitis, have been reported rarely. If liver disease develops or if systemic manifestations occur (e.g., eosinophilia or rash), discontinue therapy. If steroid dosage is reduced or eliminated during therapy, do so slowly and observe patients closely for adverse effects, including adrenal insufficiency and exacerbation of arthritis symptoms. Determine hemoglobin values frequently for patients with initial values of 10 grams or less who receive long-term therapy. Peripheral edema has been reported. For patients with restricted sodium intake, note that each tablet contains approximately 25 mg (1 mEq) sodium. Use with caution in patients with fluid retention, hypertension or heart failure. The drug's antipyretic and anti-inflammatory activities may reduce fever and inflammation, diminishing their diagnostic value. Conduct ophthalmic studies soon after starting therapy and at periodic intervals if the drug is used for an extended period. Information for Patients: Patients should use caution for activities requiring alertness if they experience drowsiness, dizziness, vertigo or depression during therapy. Drug Interactions: Use caution when giving concomitantly wrth coumarin-type anticoagulants; a hydantoin, sulfonamide or sulfonylurea; furosemide; lithium; beta-blockers; probenecid; or methotrexate. Drug/Laboratory Test Interactions: The drug may decrease platelet aggregation and prolong bleeding time or increase urinary values for 17-ketogenic steroids. Temporarily stop therapy for 72 hours before doing adrenal function tests. The drug may interfere with urinary assays of SHIM. Carcinogenesis: A 2-year rat study showed no evidence of carcinogenicity. Pregnancy: Category B. Do not use during pregnancy unless clearly needed. Avoid use during late pregnancy. Nursing Mothers: Avoid use in nursing mothers. Pedlatrlc Use: Indications and dosage have not been established. Adverse Reactions: Incidence Greater Than 1%: Gl: The most frequent complaints related to the Gltract: constipation; heartburn; abdominal pain; nausea; dyspepsia, diarrhea, stomatitis. CNS: headache; dizziness; drowsiness; lightheadedness, vertigo. Dermatologic: itching (pruritisj; skin eruptions; ecchymoses; sweating, purpura. Special Senses: tinnitus: hearing disturbances, visual disturbances. Cardiovascular: edema; dyspnea; palpitations. General: thirst. "Incidence of reported reaction 3%-9%. Where unmarked, incidence lessthan3%.1ncidence Less Than 1%: Probable Causal Relationship: Gl: abnormal liver function tests, Gl bleeding and/or perforation, hematemesis, jaundice, melena, peptic ulceration with bleeding and/or perforation, vomiting. Renal: glomerular nephritis, hematuria, interstitial nephritis, nephrotic syndrome, renal disease. Hematologic: eosmoph1ila, granulocytopenia, leukopenia, thrombocytopenia. CNS: depression, dream abnormalities, inability to concentrate, insomnia, malaise, myalgia and muscle weakness. Dermatologic: alopecia, skin rashes. Special Senses: hearing impairment. Cardiovascular: congestive heart failure. Respiratory: eosinophilic pneumonitis. General: anaphylactoid reactions, menstrual disorders, pyrexia(chills and fever). Causal Relationship Unknown: Hematologic: agranulocytosis, aplastic anemia, hemolytic anemia. CNS: cognitive dysfunction. Dermatologic: urticaria. Gl: ulcerative stomatitis. General: angioneurotic edema, hyperglycemia, hypoglycem1a. Overdosage:. May have drowsiness, heartburn, indigestion, nausea, vom111ng. Empty stomach and use usual supportive measures. Prompt administration of 5 grams activated charcoal may reduce drug absorption. Dosage and Administration for Mild to Moderate Pain, Dysmenorrhea and Acute Tendinitis and Bursitis: The recommended starting dose is two 275 mg tablets, followed by one 275 mgtablet every6to8 hours, as required. The total daily dose should not exceed Stablets (1375 mg). Cautl.on: Federal law prohibits dispensing without prescnpt1on. See package insert for full Prescribing Information. #22 Revised 7/85 ©1985 Syntex Laboratories, Inc. I SYNTEX LABORATORIES. INC. PALO ALTO. CALIFORNIA 94304 of sleep apnea syndrome. Lugaresi and associates3 found a relationship between snortng and hypertension in a survey of 5, 713 individuals. Hypertension was more common among habitual snorers than among nonsnorers. In the age-group of 41 to 60 years, hypertension was present in 15.2% of snorers and 7.5% of nonsnorers. In subjects with proven sleep apnea syndrome, the prevalence of hypertension is even higher. In a study by Onal and colleagues, 4 seven of eight sleep apnea patients had a history of hypertension. Guillemtnault and assoctates2 found blood pressure readings of 150/100 mm Hg or higher in 50% of 50 patients who had obstructive sleep apnea syndrome. An additional 10% had blood pressure readings of 140/ 90 mm Hg with occasionally higher pressures at later clinic visits. However, after tracheostomy, blood pressure returned to nonnallevels in only two young (12- and 14-year-old) patients. In these two patients, hypertension had developed during the months before surgery. The decline was from 150/100 to 125/ 75 mm Hg in one and from 160/ 105 to 115/65 mm Hg in the other. None of the adults with documented daytime hypertension had such a spectacular decline in blood pressure. However, 64 10 (40%) of the 25 patients with high blood pressure had their antihypertensive drug intake reduced and had a mean decrease of 18 mm Hg systolic and 15 mm Hg diastolic pressure compared with pretracheostomy readings. Our patient had had a history of hypertension for five years before obstructive sleep apnea syndrome was diagnosed. Although the syndrome resolved completely after uvulopalatopharyngoplasty and tonsillectomy, his high blood pressure did not return to nonnallevels. Hypertension is a well-known risk factor for stroke and may have been the sole causative factor for the development of stroke in our patient. Whether hypoxemia and cardiac arrhythmias, commonlyobserved with obstructive sleep apnea syndrome, played a contributory role is not known. Tracheostomy was first reported as an effective treatment of obstructive sleep apnea syndrome in 1969. 5 Guillemtnault and assoctates2 found that on a long-term basis, the tracheostomy completely relieved the symptoms of obstructive sleep apnea. However, temporary closure of the tracheostomy during sleep led to recurrence of obstructive sleep apnea. Further, tracheostomy is associated with certain psychosocial problems and with potential complica- HYPmi'TI!NSION AND APNb • VOL 78{NO ?/NOVEMBER 15, 1985/POSTGRAOUATE MEDICINE Postgraduate Medicine 1985.78:59-66. tions. 6 A new surgical approach, uvulopalatopharyngoplasty, described by Fujita and associates, 6 appears to be effective in correcttng obstructive sleep apnea syndrome. This procedure, combined with a temporary tracheostomy, was successful in correcting the problem in our patient. A nonsurgical approach to treating obstructive sleep apnea was developed recently by Sullivan and associates. 7 ·8 This method of treatment consists of applying continuous positive airway pressure, via a comfortable nose mask, through the nostrils during sleep. Sullivan and colleagues7 first reported reversal of obstructive sleep apnea by this treatment in 1981 in five patients. In 1983, the same group8 reported remission of severe obesity-hypoventilation syndrome (Pickwickian syndrome) in two other patients with use of this approach. There are times when the reliability of a piece of equipment must be without question. In determining blood pressure, isn't every time such a time? Summary In the case reported here, a 34- year-old man with severe obstructive sleep apnea syndrome had arterial hypertension and had had a stroke that caused right hemiplegia. A review of the literature reveals a surprisingly high occurrence of arterial hyperten- WA. Baum Go., Inc., Copiague, NY 11726 Blood Pressure Equipment Exclusively Since 1916 continued HYPERTENSION AND APNEA 65 Postgraduate Medicine 1985.78:59-66. QUFSI10NS? 1 What are the steps to follow in office examination of a patient with an eye complaint? 2 How can you distinguish a purely ophthalmic problem from one reflecting systemic disease? 3 Which common conditions of the eye may progress to threaten vision if untreated? 4 What should you tell patients with optic neuritis regarding the risk of future multiple sclerosis? CASE REPORT CONTINUED sion in subjects with obstructive sleep apnea syndrome, including children. The cause of hypertension in these patients is not clear. Surgical procedures and a new nonsurgical treatment have been successful in relieving the symptoms of obstructive sleep apnea. Our patient's symptoms resolved completely after uvulopalatopharyngoplasty and tonsillectomy. However, his arterial hypertension persisted. Rltll Address reprint requests to Satyanarayana K. Ttkare. MD. Veterans Administration Medical Center (lllJ-U). Augusta. GA 30910. COMING IN 1HE DECEMBFR ISSUE References 1. Orr WC. Sleep-related breathing disorders: an update. Chest 1983:84(4):475-80 2. Gullleminaalt C, Simmcma FB. M - J, et al. Obstructive sleep apnea syndrome and tracheostomy: long-tenn follow-up experience. Arch Intern Med 1981 ; 141(8):985-8 3. Lagaft:8l E, Clrlgn- F, Coccagna G, et al. Some epidemtologtcal data on snoring and cardioctrculatory disturbances. Sleep 1980:3(3-4):221-4 4. Ona1 E, Lopata M, O'Ccmnor T. Pathogenesis of apneas in hypersomnia-sleepapnea syndrome. Am Rev Respir Dts 1982:125(2):167-74 5. Kuhlo W, Doll E, Ftanck MC. [Successful management of Pickwickian syndrome using long-tenn tracheostomy.) Dtsch Med Wochenschr 1969:94{24):1286-90 (Ger) 6. Fu,jlta S, Conway w. Zoricl< F, et al. Surgical correction of anatomtc abnormalities In obstructive sleep apnea syndrome: uvulopalatopharyngoplasty. Ototaryngol Head Neck Strrg 1981 ;89(6):923-34 7. Salllvan CE, r- FG, Berthcm-Jonee M, et al. Reversal of obstructive sleep apnea by continuous positive airway pressure applied through the nares. Lancet 1981 ; 1(8225):862-5 8. Salllvan CE, Berthcm-Jonee M, r- FG. Remission of severe obesity-hypoventilation syndrome after shortterm treatment during sleep with nasal continuous positive airway pressure. Am Rev Respir Dts 1983; 128(1): 177-81 66 HYNn.NSION AND APNU