Discover Sleep’s Role In Heart Health

Audrey Wells, MD

That sounds great. Joel, I am happy to be here.

Joel Kahn, MD, FACC

Thank you. Absolutely no intubations. We are going to get you breathing fine. For the next 15 to 18 minutes, something concentrated, and why would we invite such a renowned sleep doctor to Reversing Heart Disease Naturally Summit? Just give us some nuggets. Not so much about sleep, but about this connection between sleep abnormalities. Why do I, as a cardiologist, care? Why do your practice and my practice have so much overlap? Just some of your observations and some of the connections.

Audrey Wells, MD

I think this has come up in the awareness of cardiology and other medical specialties in the past few years because the research has borne out that people who have short sleep and people who have long sleep have an increased risk for cardiovascular disease. The American Heart Association this year just added sleep to its Life’s Healthy Eight. It used to be, or is Essential Eight, I think. There used to be Seven Things. Now there are Eight Essentials. The Eighth was sleep. The fact is, that sleep is a fundamental biological need. You simply cannot escape it. I routinely get referrals from cardiologists who are clued into the idea that short sleepers, people who have insomnia, people who have shift work or other atypical sleep schedules, and those with obstructive sleep apnea all have a risk for things like high blood pressure, heart attack, stroke, atrial fibrillation, heart failure, and on and on. I think it is exciting that this new information is coming into our vocabulary so that we can help more people not only live better and feel better with healthy sleep but also look on the horizon and mitigate their long-term risk factors for cardiovascular disease.

Joel Kahn, MD, FACC

In about 2 minutes, you just hit so many pearls. The American Heart Association Licensed the Essential Eight now includes the Eight Point Sleep Quality as a focus to prevent heart disease. We are all about prevention. We would like to reverse the disease you have. We would rather prevent it in the first place. Figuring out how to sleep in a good and healthy manner is important. You mentioned some big diseases: heart failure, high blood pressure, corner disease, atrial fibrillation, and others. This is critical. I will just tell it quickly since we share a University of Michigan Medical School anecdote. The only thing I can remember, and I just passed my 40th reunion in medical school, was something called the Pickwickian syndrome. I remember sitting in a classroom and somebody mentioning that, and I went ahead and bought Charles Dickens, The Pickwick Papers because it stimulated my curiosity. I do not remember much about reading the book. But do you even recall? That was the only journal of sleep pathology I remember from medical school. That is just drowning in your hyper-obesity. Something to that degree.

Audrey Wells, MD

Yes. That describes obesity hyperventilation syndrome, which is a form of sleep-disordered breathing where a person has the complication of having obesity and carbon dioxide retention during sleep. When they wake up in the morning, they may feel sluggish, confused, and have a headache. It is separate from obstructive sleep apnea, but it is more common in those who have elevated BMIs. Usually, BMI is greater than 40 kilograms per meter squared, and people tend to carry most of their weight in their belly. That belly is going to push up on the lungs, reducing the amount of breathing that a person can do. One of the results can be carbon dioxide retention.

Joel Kahn, MD, FACC

You might be wondering why I brought up an English literary reference, it is because there was a character in the Pickwick Papers who was morbidly obese and had, as Dickens described it, sleep pathology. But let us bring it back. You just mentioned my BMI over 40, which would be morbid obesity. But we do know that according to those statistics, 75% of American adults are either overweight or obese. If we just took a sample of 100 of them and gave them a home sleep study or an office sleep study, do you have any estimate of how many would show sleep pathology? Everybody listening here needs to know this number. Is this a rare finding or a common finding?

Audrey Wells, MD

It depends on how severe you are a cutoff for obstructive sleep apnea. One estimate is that currently there are 50 million U.S. adults between the ages of 30 and 70-plus who have obstructive sleep apnea. 80% of those are undiagnosed. There is this enormous disease burden weighing on us out there. In a minute, I will tell you a little bit about how that relates to studies around total sleep time. But to bring this point home, you mentioned a BMI of 40 and above. There have been studies, prospective studies looking at groups of people with morbid obesity or Class 3 obesity (40 and above). The numbers vary a bit, but I can tell you that if your BMI is 40 or above, your chances of having moderate to severe obstructive sleep apnea are at least 50%. In some studies, as high as 98% was demonstrated.

Joel Kahn, MD, FACC

Because a lot of people are listening to this interview, which is a great interview, I am learning that I have atrial fibrillation, hypertension, cornerstone disease, congestive heart failure, and a family history. They do not want to get those. They want to do primary prevention and stay away. 50 million adult Americans may have obstructive sleep apnea, and 40 million of them have not been tested and do not have a diagnosis. Amazing. Let us go down that path for a minute. We are going to stick to short bullet points here at the beginning of this interview. Somebody listening tonight and says, Can I just buy a watch? Can I wear a ring? Can I wear an oximeter? Do I need to see a super-specialist, like Dr. Audrey Wells? How is somebody going to go? I am a bit concerned that my sleep is interrupted, and I might have a membership in one of these 50 million American Adult Clubs. How do they go about progressing to a more firm diagnosis?

Audrey Wells, MD

The first point I want to underscore is one that you made about prevention. Any time a person’s sleep is compromised, that awareness is almost not available to that individual because they are the person sleeping and in a state of unconsciousness. Things like daytime, tiredness, or maybe a little bit forgetful or moody here and there tend to get explained away. The truth is that we do not understand very well at what point sleep apnea starts and then how long it takes to progress until a person is symptomatic. What I want to see in the future is anticipatory testing. You would get a colonoscopy to see where you are with your sleep. Now, especially with this huge disease burden, if somebody is concerned that they have obstructive sleep apnea, the very best thing to do is to establish care with a sleep clinic and have a test, either a home sleep apnea test or an in-lab sleep study. If clinical suspicion for obstructive sleep apnea is high, then the home sleep apnea test is a very good place to start.

Joel Kahn, MD, FACC

Having a ring or an oximeter won’t diagnose obstructive sleep apnea, but it may give a clue.

Audrey Wells, MD

Or it might give a clue. It might give a clue if it is measuring drops in blood or oxygen levels. That is typically a more common profile for men. Women do not tend to drop their blood oxygen very much. What women do is sacrifice their sleep quality to breathe. Women oftentimes will present with insomnia symptoms. I cannot get to sleep. I cannot stay asleep. I am a light sleeper. I get agitated when I am sleeping. These wearable devices, these consumer-grade monitors are not sensitive or specific enough. But if you have some red flags, that can certainly help prompt somebody to get treated or get evaluated and then treated.

Joel Kahn, MD, FACC

I do not know how many vendors there are for home sleep apnea testing. You might have a better clue than me. As far as I know, you still have to work with a doctor to get one. I do not know of any online places. You just pay and have one shipped to you. There may be. I do not know. Do you have any sense about that? Do you have any preferences? You want to name three or four vendors that you think are somewhat useful and reliable for that initial test.

Audrey Wells, MD

Yes, and this is an insightful question because there is a little bit of controversy with the home sleep apnea test right now. A home sleep apnea test can be done by non-sleep physicians; sometimes dentists have access to them, sometimes primary care physicians have access to them, and sometimes cardiologists have access. Some common types are NOX Brands N-O-X. There is The Watch Pad. There are SleepImage. There is Vespers. All of these brands are something that you pick and choose depending on what you want and how much it costs. The reason I recommend that somebody get tested in a sleep center is because the interpretation of a home sleep apnea test comes with a little bit of nuance. The best way I can explain it is that if you have a home sleep apnea test and it comes back negative, it is not negative. It is inconclusive because the test may not be sensitive enough to pick up some milder forms of sleep apnea. Believe it or not, the home sleep apnea test does not measure sleep. It does not measure sleep. Because of that, women are especially prone to having a false negative test or an inconclusive test. The next best thing to do is either repeat the home sleep apnea test or move to an in-lab sleep study.

Joel Kahn, MD, FACC

Alright. Very good. You do bring up an excellent point that the dental world has. I do not know if they have board certification, but there certainly are in my community. I am sure nurse dentists dedicate their entire practice to sleep apnea and the testing and development of oral devices. I have had an experience that I think is high quality with some of these dentists. But most of them are smart enough. I think that when there is severe obstructive sleep apnea, they have a medical doctor like you, call the manager or just initiate the management and bounce back if for some reason, it is not going well and they need dental work. There are ear, nose, and throat doctors, of course, who specialize in obstructive sleep apnea. You went through the more common pulmonary, and you also. I left that out. You are Board-Certified in Obesity Medicine. Again, you have some amazing, unique credentials. For those that are tuned in here and saying, I have got the disease, and I do not want our disease, I will just run this through. As we shut down this initial discussion with you, what are some of the treatment options that can be considered? Let us say it is severe sleep apnea and somebody’s got a BMI of 34, a typical American, they are struggling with some hypertension and has some palpitations. Maybe it is a full-blown atrial fibrillation diagnosis. What are you going to advise that person when that report comes back and says severe obstructive sleep apnea?

Audrey Wells, MD

By far the most effective treatment for obstructive sleep apnea is continuous positive airway pressure treatment, or CPAP treatment. It is 95% effective. But there is a major caveat to CPAP, which is that it is only effective if the person can use it. Currently, the usage rates for CPAP prescribers are around 40 to 50%, meaning about half of the people who are using CPAP are using it for at least 4 hours a night and can do that for the long term. In my case, I give people choices, and some of them have to do with the severity of sleep apnea that I am reading about in the sleep study, which is something that makes it nice when you are getting care from a sleep center because the sleep doctor is going to have such in-depth knowledge of what else is available besides CPAP. In addition to CPAP, I would suggest two major treatments. There is oral appliance therapy, which you mentioned, sometimes abbreviated OAT, or another way to say it is mandibular advancement device or MAD. All this appliance does is bring the jaw forward, maybe a quarter of an inch or so, and that opens up the airway caliber. 

Over time, we have gained a lot of experience with OAT devices, and we now know that some people, even if they have moderate or severe obstructive sleep apnea, may still respond to this device. But it is always important to get retested after you have acclimated to this OAT device to confirm that your sleep apnea is treated because it does not work for everybody. Then I would say the third option is surgery for sleep apnea. Currently, the most popular technique is called the Inspire Implant, and it originated here in Minnesota. I can tell you that their marketing game is strong, but many criteria that go into selecting appropriate patients for this surgical device. What it involves is an incision in the upper right chest. They save the left chest for a pacemaker if needed. There is a device that is inserted just under the skin and two electrodes. One of which goes in between the ribs to measure breathing. The other one is snaked up into the neck and attached to the nerve that innovates the tongue. The way that it works is that it synchronizes with your breathing and makes your tongue scrunch forward. The hope is that it moves out of the airway when you are sleeping. These devices are not good for people who have insomnia. They tend to aggravate that. There are also caps on how big your BMI number is. There are caps on what type of sleep apnea you have and how severe it is. Insurance payments are restricted to those who meet the criteria for Inspire. But I would say CPAP oral appliance therapy and Inspire are the three treatments that I spend most of my time talking about.

Joel Kahn, MD, FACC

Okay, old-fashioned ear, nose, and throat surgery on the tonsils, the uvula, and the palate has faded and been selected.

Audrey Wells, MD

The ear, nose, and throat doctor, ENT will make the Inspired device. Sometimes, to your point, there needs to be a layered approach to surgery. Sometimes opening up the nose can help, and sometimes trimming the soft palate or changing the orientation of the muscles that elevate the soft palate can be useful. In the past, there was a procedure that was commonly done called the Uvulopalatopharyngoplasty, or UPPP. Nowadays, there is one that has fallen out of favor because it is an extreme, ordinarily painful procedure. They would cut out the uvula and trim the back of the soft palate. I have seen so many people, unfortunately, whose scar tissue has caused a contraction of the soft palate. They are left with an airway that is not only smaller than what they started with, but it is also less pliable. They need bigger CPAP pressures to hold it open. Now there are more developed techniques to do a modified UPPP.

Joel Kahn, MD, FACC

Alright. Everybody listening again, the reason this topic is on a Reversing Heart Disease Naturally Summit is that there are so many patients struggling with high blood pressure, intermittent fibrillation, and congestive heart failure, and a root cause of these very serious conditions is undiagnosed obstructive sleep apnea. That is the message because we are all looking for those root causes that we can work on to modify or prevent the progression of advanced heart disease that is going to happen. Ask your doctor if you qualify to get a home or an office for a lab sleep study. As Dr. Wells has been telling us. Just in the last two questions on this general session. I have had a few patients, have seen various doctors and busy dentists, and have had some laser therapy on their palates. One or two of them had pretty bad sleep apnea and testing, and once was for repeat testing is improved in non-surgically. Do you have any experience with that? It sounds too good to be true to me.

Audrey Wells, MD

I do. I would say that is more of an uncommon report of success. I think what you are talking about is the Laser-assisted uvulopalatoplasty. It is a customization or a sclerosing procedure. That one typically does not work. But hopefully for the patient that you are describing, their case was very specific in their anatomy or the way the palate was moving. As you were talking, I was just thinking, going back to the fundamental issues behind obstructive sleep apnea, I want to connect this to heart disease in a real way. When a person has obstructive sleep apnea, two main things happen. One is that they stop breathing. Their oxygen levels go down. That drop in oxygen level and reoxygenation is happening many times an hour. Up hundreds of times at night. If you have moderate or severe sleep apnea. You can imagine what that does to your heart and your vasculature. It increases inflammation and stress in your body. We can demonstrate increases in inflammatory cytokines of all types. The other thing that happens is drops in blood, and oxygen levels, and sleep disruption. Your brain has to record scratch and get out of sleep to engage the muscles and open up the airway. Not only are you having these drops in blood oxygen level, but you are also disrupting your sleep. All of that leads to a sympathetic nervous system response, the fight or flight response. That is how it is connected to heart and blood vessel disease.

Joel Kahn, MD, FACC

Thank you so much. That is great. Final question here. Mouth taping. So many people come to me. Would you recommend mouth taping for moderate or severe sleep apnea, or would you advise strongly against it in any, just one-minute comments?

Audrey Wells, MD

Yes, there are situations where mouth-tapping makes sense. It is not going to do any good as a monotherapy treatment for moderate or severe sleep apnea. If someone is interested in mouth-tapping, I say, Okay, fine, try it during the day. Make sure you can tolerate it because your nose is nice and open. Use medical tape meant for human skin, not electrical tape or duct tape. The last tip I have is to fold down a corner of the tape. When you put it over your lips, if you have to remove it urgently, whether you are asleep or awake, you have that corner to grab onto and peel it off.

Joel Kahn, MD, FACC

Alright. I probably learned that from some movie or TV show. A good way to deal with a hostage crisis.

Audrey Wells, MD

Well, I am a DIY person. I have tried mouth taping.

Joel Kahn, MD, FACC

So have I. I used a very gentle little wax. I do not have obstructive sleep apnea. As you said, I was preventive and did a study myself just to be certain. But I had no reports. The last comment I will make is that for so many of my patients, there is a common theme in the media: sleep divorce. They are married or partners of whatever kind and are in different bedrooms because of noise illness at night. If that is not a clue that you need to go see a board-certified sleep specialist, that you have moved out of the bedroom, and that you are down the hall, by all means, please look up somebody talented like, Dr. Audrey Wells. We are going to shut down this general conversation for those of you who are in the general audience. Thank you for tuning in. Dr. Wells, correct me if I am wrong, Audrey Wells, Med. com?

Audrey Wells, MD

AWellsMD.com is my one-on-one coach. But for problems with obstructive sleep apnea, SuperSleepMD.com is the best place to go.

Joel Kahn, MD, FACC

I have been on these fantastic websites. All is great. We are going to keep on talking for a couple of minutes. I want to say goodbye to the general audience. Thank you very much for tuning in to Reversing Heart Disease. Naturally Summit 2.0. Welcome back. We are going to just spend a few more minutes talking to our superstar tonight, Dr. Wells and everybody is learning so much from her. Maybe share a little bit about this gets a little more technical, central sleep apnea and obstructive sleep apnea, and just go a little bit into some of the actual root reasons people develop sleep pathology.

Audrey Wells, MD

Yes. With obstructive sleep apnea, three things increase your risk right out of the gate. Weight is the number one risk factor, but not everybody who is overweight or has obesity has obstructive sleep apnea. Normal-weight people get obstructive sleep apnea. too. Second, is age. Once you are past the age of mid-40s, or 50s, your risk goes up, especially for postmenopausal women. The third is sex. Not the bedroom kind, but the male-female kind. If you are male or postmenopausal female, your risk for obstructive sleep apnea goes up. Now, central sleep apnea is a little bit of a different beast. Compared to obstructive sleep apnea, it is uncommon. About 1% of sleep apnea is central. The rest is obstructive sleep apnea. Central sleep apnea represents an interruption in the brain’s signal to breathe. The brain tells your nerves, your breathing muscles, and your diaphragm to go up and down and keep pace with breathing. With central sleep apnea that is interrupted. It could be due to different things: brain injury, including forms of dementia; opiate medications; kidney failure; or heart failure. All of these put a person at risk of having central sleep apnea.

Joel Kahn, MD, FACC

An in-lab sleep study will distinguish the two, or it may take more than that.

Audrey Wells, MD

Definitely. An in-lab sleep study is a great tool for determining whether somebody has central sleep apnea or is obstructive. Sometimes there is a combination of both.

Joel Kahn, MD, FACC

Okay. It is exciting to have an expert who has advanced training, education, and experience in both sleep apnea and obesity management. How successful and what paths you go down. Someone is doing okay but says, Doc Wells, I want to get off CPAP. I had to; I did not have obstructive sleep apnea in the last five or 10 years I have symptoms. How do I get back to the old days? They are carrying a lot of weight. What are you going to advise them in terms of trying to? Is it successful that they may no longer need treatment?

Audrey Wells, MD

This is a common question, so I am glad to be able to speak to it. When a person is carrying extra weight, especially if they are carrying more weight in their belly, in their neck, or under their chin, weight loss has a greater chance of reducing and, in some cases, resolving obstructive sleep apnea. It is a little bit like the flip of a coin. In other words, if your sleep apnea is significant, if it is moderate or severe, and you reduce your weight significantly, meaning down into the overweight or even the normal BMI range, then your sleep apnea has a 50% chance of going away. What I want to tell people is that if you are undertaking the endeavor of losing weight, that all by itself is going to improve your health. Do not put all your eggs in the sleep apnea basket. But in addition to that, even if you pull your sleep apnea down to a lighter severity range, you have more treatment options opening up to you. I think that is a great piece of news for anybody tired of their CPAP machine.

Joel Kahn, MD, FACC

Yes. What is your experience with or opinion on using the new GLP-1 Agonist? The hot Ozempic, Wegovy, and Mounjaro, though Wegovy is FDA-approved solely for weight loss, but your opinion on them is that if that patient struggling, they are just not tolerating CPAP. Their BMI is 38. They have hypertension and maybe some other cardiovascular manifestations. Do you think it is reasonable to go down that path to help them?

Audrey Wells, MD

I do. In a few weeks, I am giving a webinar to health insurance payers to make a coverage case. Now, there is a shortage of this medication. Unfortunately, that means that some people’s treatment plans have been interrupted. This is worth knowing, because when you look at obesity as a disease, which it is, what I can tell you is that it will require long-term management of that disease. Just like obstructive sleep apnea, obesity is a chronic disease. When you start taking these medications, they cause significant weight loss. It should always be supported by lifestyle changes. You cannot keep eating licorice all the time and expect to be healthy. You need to support that with good nutrition and physical exercise, and exercise is especially important in the weight maintenance phase. These medications are very expensive. There is a new one that is going to come out. We do not know the name of it yet, just the generic form. But they are effective, and when handled appropriately, they can be a great new way for somebody to finally lose the weight that they have been struggling to lose all these years. For anybody who is listening, obesity is not a disease of laziness or lack of willpower. It is a brain disease, and it needs real treatment to get real results. I am excited about these medications coming out because they are opening up a new door to effective treatment.

Joel Kahn, MD, FACC

Well, that is extremely optimistic and wonderfully upbeat, and of course, it would be nice if we had some way to do it without prescription drugs. With expensive prescription drugs, a few risks and side effects need to be discussed with patients. But as you say, if we can get somebody feeling better and healthier and avoiding heart failure, hypertension, atrial fibrillation, and coronary heart disease, as we already have evidence with these drugs, then I am all for it too. I am glad we are on the same path. I am going to let you get back to your busy day, your busy life, and ministering to your health and that of your family. Thank you so much. Just as the crowd is going to leave us at this wonderful summit, tell us one more time, AWellsMD.com.

Audrey Wells, MD

That is for my one-on-one coaching opportunity.

Joel Kahn, MD, FACC

Great coaches and then SuperSleepMD.com.

Audrey Wells, MD

Exactly.

Joel Kahn, MD, FACC

Yes. Okay. You are willing to accept some new people listening tonight if they are searching for somebody good to work with?

Audrey Wells, MD

Definitely on SuperSleepMD.com. I have several courses for people who have trouble sleeping and for people who have sleep apnea, looking at treatments with CPAP and alternatives. I think that in the future we are opening up lots of group coaching opportunities where I can connect with the people who are consuming my courses, and I am certainly happy to do that now.

Joel Kahn, MD, FACC

That is fantastic. What a great resource, and one that I will start referring to. Promise. 

Audrey Wells, MD

Great. 

Joel Kahn, MD, FACC

Thank you.