AHA Releases Scientific Statement on OSA, Cardiovascular Disease Link in Children and Adolescents

According to a scientific statement released today by the American Heart Association, obstructive sleep apnea (OSA), a form of sleep-disordered breathing, may increase the risk of elevated blood pressure and heart structure changes among children and adolescents.

Published in the Journal of the American Heart Association, authors said that OSA is a known risk factor for cardiovascular disease (CVD) in adults, including associations with incident systemic hypertension, arrhythmia, and stroke. However, despite its prevalence in up to 6% of children and adolescents, there has been less focus on OSA as a primary risk factor for CVD in these populations.

In a prior JAMA Cardiology study, children who had OSA that persisted into adolescence were found to be 3 times more likely than the general pediatric population to have high blood pressure, a strong contributor to CVD, whereas children whose sleep apnea improved as they entered adolescence were not at elevated risk.

Furthermore, the authors of the statement referenced research that suggests OSA may pose a risk for pulmonary hypertension, arrhythmia, abnormal ventricular morphology, impaired ventricular contractility, and elevated right heart pressure in children and adolescents.

“Sleep disruptions due to sleep apnea have the potential to raise blood pressure and are linked with insulin resistance and abnormal lipids, all of which may adversely impact overall cardiovascular health later in life,” said statement writing group chair Carissa M. Baker-Smith, MD, MPH, MS, director of Pediatric Preventive Cardiology at the Nemours Children’s Hospital in Wilmington, Delaware, in an accompanying press release.

Pediatric populations with even mild OSA were indicated to be at risk for metabolic syndrome, particularly those who are obese, as approximately 30% to 60% of adolescents who meet the criteria for obesity also have OSA.

“Obesity is a significant risk factor for sleep disturbances and OSA, and the severity of sleep apnea may be improved by weight loss interventions, which then improves metabolic syndrome factors such as insulin sensitivity,” said Baker-Smith.

Baker-Smith addressed several other risk factors for the condition, including enlargement of the tonsils, adenoids, or a child’s facial structure. People with sickle cell disease and those born prematurely (before 37 weeks gestation) were also mentioned as at-risk populations for OSA.

In assessing potentially at-risk children and adolescents, the statement listed several symptoms that may signal OSA diagnosis:

• Habitual snoring, more than 3 nights per week
• Gasps or snorting noises while sleeping
• Labored breathing during sleep
• Sleeping in a seated position or with the neck hyperextended
• Daytime sleepiness
• Headache upon waking up
• Signs of upper airway obstruction

As aligned with American Academy of Otolaryngology-Head and Neck Surgery guidelines, polysomnography is recommended as the optimal approach in diagnosing OSA and other forms of sleep-disordered breathing.

Polysomnography was also recommended before a tonsillectomy in children with sleep-disordered breathing who have conditions that increase their risk for complications during surgery, which include obesity, Down syndrome, craniofacial abnormalities, neuromuscular disorders, or sickle cell disease.

“To better understand the long-term CVD-related risk associated with the presence of OSA in childhood, additional well-designed longitudinal studies incorporating ambulatory blood pressure monitoring data and measures of metabolic disease are needed over time,” concluded the authors. “Also important are studies evaluating the relationship between OSA and noninvasive markers of CVD, including carotid intima media thickness and pulse wave velocity.”

Reference

Baker-Smith CM, Isaiah A, Melendres MC, et al. Sleep-disordered breathing and cardiovascular disease in children and adolescents. J Am Heart Assoc. Published online August 18, 2021. doi:10.1161/JAHA.121.022427