Healthy Sleep Improves Outcomes in Cardiovascular Health for OSA, Narcolepsy

A key part of cardiovascular health is the need for healthy sleep, according to the Life’s Essential 8 guidelines published in 2022 by the American Heart Association.¹ The guidelines aim to improve overall cardiovascular health by focusing on 8 areas, emphasizing that cardiovascular health is not predicated on 1 component but rather a holistic approach. At the Sleep 2026 Annual Meeting, sleep experts discussed how the treatment of obstructive sleep apnea (OSA) and narcolepsy do not merely improve sleep health but factor into a patient living an overall healthier life.

OSA Treatment Goes Beyond AHI Score Reduction

The Apnea-Hypopnea Index (AHI) score is a trusted indicator for measuring OSA in patients, measuring how many times an individual slows or stops breathing while sleeping. AHI score is not the only means of assessing how effective treatment of OSA is, said Klar Yaggi, MD, MPH, a professor of medicine at the Yale University School of Medicine and director of the Yale Program in Sleep Medicine.

The sleep apnea cycle, said Yaggi, includes hypoxia of various severity and duration, arousal, sleep, and circles back to apnea or hypopnea. Given the disruption to breathing throughout the night, researchers looked into the association between AHI and coronary heart disease and found that patients with OSA had a higher prevalence of stroke and cardiovascular disease.²

Where the Life’s Essential 8 comes in is in the ways that OSA interacts with other parts of cardiovascular health. “When we think about sleep apnea separately from sleep health or sleep duration…. We also need to appreciate that sleep apnea probably also contributes to this risk through mediating pathways of these other truly important components for robust cardiovascular health,” said Yaggi.

“It was not lost [on me], as a sleep medicine specialist, that the graphical icon that was used to describe healthy sleep was clearly a patient with escalating snoring and [OSA],” Yaggi joked to laughs from the audience.

Studies in the past have linked OSA to stroke and mortality, with results showing that “increasing severity of sleep apnea, as measured by the [AHI], was associated with the highest risk of this composite cardiovascular outcome.” Yaggi noted that other studies have found an independent relationship between OSA and other cardiovascular health outcomes like incident hypertension, stroke, and sudden cardiac death. He also highlighted studies that have developed other types of scoring methods that can predict adverse cardiovascular health outcomes, including whether continuous positive airway pressure (CPAP) therapy can attenuate cardiovascular risk.

Anatomic predisposition for OSA is possible, but other factors and physiologic traits can also play into the development of OSA. For this reason, glucagon-like peptide-1 (GLP-1) inhibitors like tirzepatide could be a key in addressing other factors in developing OSA. Yaggi pointed to the SURMOUNT-OSA trial, which found that tirzepatide reduced AHI but also reduced body weight, systolic blood pressure, and hypoxic burden.³ “A sole focus on 1 metric is not adequate anymore for us to be thinking about in improving cardiovascular health,” he said.

Sodium-glucose transport 2 (SGLT2) inhibitors may also be a method of treating OSA, as studies have shown that patients using these inhibitors are less likely to experience major adverse cardiovascular events. The SGLT2 inhibitor, empagliflozin, may also reduce the risk for new-onset OSA based on previous findings.⁴

Overall, Yaggi emphasized that polysomnographic markers alone should not be the only method of assessing patients. Life’s Essential 8 outcomes should be improved to also address sleep health.

Cardiovascular Risk Profile in Narcolepsy Could Be Exacerbated by Lifestyle

Virend Somers, MD, PhD, a professor in the Department of Cardiovascular Medicine at Mayo Clinic, shifted the conversation to how the role of cardiovascular health in narcolepsy, especially as the link between sleep and narcolepsy is currently being more heavily researched. Somers specifically focused on how Life’s Essential 8 can play a role in treating narcolepsy, as addressing blood pressure, a healthy diet, and sleep in this population could improve both cardiovascular outcomes and narcolepsy in these patients.

Cardiovascular disease and narcolepsy were previously linked in a study that found that the prevalence of cardiovascular conditions like hypertension and coronary atherosclerosis was higher in those with narcolepsy.⁵ Sleep apnea was also more common in this group. Sleep duration is also a key factor in cardiovascular outcomes, as those who sleep for shorter amounts of time were found to have increased intake of calories, weight, and body fat.

“The baseline level of weight and the trajectory of weight gain are much steeper in the people who slept 5 hours, suggesting but not proving that, if you sleep less, you tend to gain weight and you have a higher weight to start off with,” explained Somers. How it pertains to narcolepsy, he said, is that it is worth considering that those living with narcolepsy could behave similarly to those who are sleep-deprived. This also includes the lack of energy needed to exercise to stave off the potential weight gain.

Somers posits that addressing sleep in this group could improve the overall cardiovascular health of patients with narcolepsy. “What happens if we actually treat narcoleptic patients with therapy, if we improve their sleeping? Can we actually reverse some of these changes and potentially…improve their overall cardiovascular [health] simply by improving their sleep quality?” he asked.

More data on these associations is key in making any more conclusions, said Somers, but the data that exists currently raises the question of whether the narcolepsy cardiovascular risk profiles are more a consequence of a deficiency in orexin, a consequence of the lifestyle of narcolepsy, or a mix of both.

References

1. Lloyd-Jones DM, Allen NB, Anderson CAM, et al. Life’s Essential 8: updating and enhancing the American Heart Association’s construct of cardiovascular health: a presidential advisory from the American Heart Association. Circulation. 2022;146(5):e18-43. doi:10.1161/CIR.0000000000001078
2. Shahar E, Whitney CW, Redline S, et al. Sleep-disordered breathing and cardiovascular disease: cross-sectional results of the Sleep Heart Health Study. Am J Respir Crit Care Med. 2001;163(1):19-25. doi:10.1164/ajrccm.163.1.2001008
3. Malhotra A, Grunstein RR, Fietze I, et al. Tirzepatide for the treatment of obstructive sleep apnea and obesity. N Engl J Med. 2024;391:1193-1205. doi:10.1056/NEJMoa2404881
4. Neeland IJ, Eliasson B, Kasai T, et al. The impact of empagliflozin on obstructive sleep apnea and cardiovascular and renal outcomes: an exploratory analysis of the EMPA-REG OUTCOME trial. Diabetes Care. 2020;43(12):3007-3015. doi:10.2337/dc20-1096
5. Black J, Reaven NL, Funk SE, et al. Medical comorbidity in narcolepsy: findings from the Burden of Narcolepsy Disease (BOND) study. Sleep Med. 2017:33:13-18. doi:10.1016/j.sleep.2016.04.004