Online
Clinical Case Study (June 2003)
Clinical
Cardiology Series
臨床心臟科個案研究
Obstructive Sleep Apnea (OSA) and
Cardiovascular Disease
The content
of the Office Cardiology Series is provided by:
Dr. Wong Shou Pang, Alexander
F.R.C.P.,
F.H.K.A.M.(Med.), F.H.K.C.P., Specialist in Cardiology
Dr. Li Siu Lung, Steven
M.B.,B.S.(H.K.),
M.R.C.P.(U.K.), F.H.K.A.M., F.H.K.C.P., F.R.C.P.(Glasg.), Specialist in Cardiology
臨床心臟科個案研究之內容誠蒙王壽鵬醫生及李少隆醫生提供。
Answers
| 1. |
OSA
is a risk factor for hypertension.
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True. OSA
is an independent risk factor for daytime hypertension. The apnea-hypopnea
index (AHI), the number of obstructive events per hour, is an independent
risk factor for hypertension. Treatment with continuous positive airway
pressure (CPAP) reduces blood pressure. In seeing patients with hypertension,
one should now look for, in addition to conventional secondary causes,
symptoms of OSA such as snoring, daytime tiredness despite an adequate
duration of sleep.
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| 2. |
OSA
is uncommon in female.
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False. Women
account for up to one-third of OSA patients.
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| 3. |
OSA
is rare in subjects with normal body weight.
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False. A normal
body mass index is common in elderly subjects and in subjects from Southeast
Asia, so keep your index of suspicion even in local patients with normal
body weights.
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| 4. |
OSA
is associated with acute cardiovascular events.
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True. Early
epidemiological studies suggested an association between snoring and myocardial
infarction in men. One case control study of acute coronary care patients
had demonstrated OSA as an independent predictor of coronary artery disease.
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| 5. |
OSA
is associated with stroke.
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True. There
is a strong evidence of a link between snoring and stroke. The mechanisms
include hypertension, mechanical stress on carotid atheroma during the
snoring phase, altered cerebral perfusion, increased coagulability, and/or
induction of atrial arrhythmia with thrombus formation leading to embolism.
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References:
-
Lattimore JL, et al.
Obstructive sleep apnea and cardiovascular disease. J Am Coll Cardiol 2003;41:1429-37.
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Peppard PE, et al.
Prospective study of the association between sleep-disordered breathing
and hypertension. N Engl J Med 2000;342:1378-84.
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Peker Y, et al. An
independent association between obstructive sleep apnea and coronary artery
disease. Eur Respir J 1999;13:179-84.
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Waller PC, et al.
Is snoring a cause of vascular disease? An epidemiological review. Lancet
1989;1:143-6.
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Smirne S et al. Habitual
snoring as risk factor for acute vascular disease. Eur Respir J 1993;6:1357-61.
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Hu FB, et al. Snoring
and risk of cardiovascular disease in women. J Am Coll Cardiol 2000;35:308-13.
Dermatology Series
皮膚科病例研究
A 45 year old man
presented with disfigured left big toenail for more than one year. He reported
mild toenail improvement after a course of systemic antifungal treatment but
not complete resolution. The patient enjoyed good past health and there was
no history of hyperuricaemia or diabetes mellitus. He was not on any concurrent
drug treatment.
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The
content of the Dermatology Series is provided by:
Dr. Tang Yuk Ming, William and Dr. Chan Loi Yuen
Specialist in Dermatology & Venereology
皮膚科病例研究之內容誠蒙鄧旭明醫生及陳來源醫生提供。
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Answers
| 1. |
What
are the physical signs shown in the clinical photo? |
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The left big
toenail shows onycholysis, thickening, and pits filled with keratinous
material. There is fusiform joint swelling affecting the left big, second
and third toes. Scaly erythematous papules and small plaques are noted
on the foot.
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| 2. |
What
is the most likely clinical diagnosis?
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Psoriasis
with onychopathy and arthropathy. Joint involvement is not seen in tinea
pedis and unguium. Gouty arthritis does not give rise to scaly papules
nor nail changes.
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| 3. |
Why
did the patient report improvement of nail with previous systemic antifungal
treatment? |
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The improvement
could either be subjective, a natural fluctuation of the disease severity,
or an improvement following eradication of a superimposed fungal pathogen.
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| 4. |
What
initial investigations would you perform? |
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Skin scraping
and nail clipping for fungal culture should be performed to exclude fungal
infection. X-ray of the toes will demonstrate arthritic changes. Other
investigations such as blood biochemistry to exclude crystal arthropathy,
rheumatoid factor for rheumatoid arthritis, and biopsy of a skin lesion
for histopathology may be considered.
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| 5. |
What
are the treatments?
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Topical potent
steroid and calcipotriol are helpful for the skin lesion. Nail changes
are less responsive to topical treatment. Nonsteroidal anti-inflammatory
agents may ameliorate symptoms of arthritis but acitretin, methotrexate,
or cyclosporin is a more definitive treatment for psoriasis with concomitant
onychopathy and arthropathy.
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