The timing of the publication of the article by Gupta et al.1 in the April 15, 2018 issue of the Journal of Clinical Sleep Medicine could not have been more appropriate. Recently, the American Heart Association (AHA) published their 2018 guidelines regarding early management of patients with acute ischemic stroke.2 In section 6.6 of the guidelines, they state that “routine screening of patient with recent stroke for OSA is not recommended.” Currently, this part along with another 20% of the guideline has been redacted. The members of the writing committee suggested lack of evidence as a reason for their recommendation. They based their recommendation on trials by McEvoy et al.3 and Parra et al.4 The trial by McEvoy et al. reported on a patient group whose mean continuous positive airway pressure (CPAP) usage was 3.3 h/night; one could argue that this is not sufficient adherence to treatment for prevention of cardiovascular (CV) events. Conversely the trial by Parra et al. suggested some benefit of nasal CPAP in delaying CV events in the short term. This seems to be beneficial as recurrent stroke occurrence is highest within 90 days of a transient ischemic attack.5 The study by Gupta et al.1 was a well designed, methodically strong randomized control clinical trial that suggested ≥ 1 point improvement in Modified Rankin scale score in the group treated with CPAP versus the non-CPAP group in patients who have had a stroke at 6-month and 12-month follow-up. The study by Gupta et al. and the study by Parra et al. suggest that eligible patients who had a stroke with predisposition to obstructive sleep apnea (OSA) should be screened and treated appropriately for OSA. I understand the outlook of the writing committee to avoid “cook book” protocolized medicine, but we all know that one size does not fit all. So, as the partially redacted AHA guidelines are being revised I will urge the writing committee to review this paper by Gupta et al. and get the recommendations right this time that screening eligible patients who have had a stroke for OSA can improve stroke outcome.
Dr. Ganguly is a neurologist in private practice and he is one of the partners of Neurology Consultants Medical Group, a group practice comprising two other neurologists. Neither the Neurology Consultants Medical Group nor its partners have any intellectual or financial proprieties in the writing or publishing of this manuscript. Dr. Ganguly is affiliated to the USC-KECK School of Medicine as Clinical Assistant Professor of Neurology. There are no contractual obligations between USC-KECK School of Medicine and Dr. Ganguly except for clinical assignments for overseeing residents in outpatient departments three to four times a year. The author reports no conflicts of interest.
Ganguly G. Let's get it right this time: controversies and now redacted 2018 AHA stroke guidelines. J Clin Sleep Med. 2018;14(10):1823.
Gupta A, Shukla G, Afsar M, et al. Role of positive airway pressure therapy for obstructive sleep apnea in patients with stroke: a randomized controlled trial. J Clin Sleep Med. 2018;14(4):511–521. [PubMed Central][PubMed]
Powers WJ, Rabinstein AA, Ackerson T, et al. 2018 guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2018;49(3):e46–e99. [PubMed]
McEvoy RD, Antic NA, Heely E, et al. CPAP for prevention of cardiovascular events in obstructive sleep apnea. N Engl J Med. 2016;375(10):919–931. [PubMed]
Parra O, Sánchez-Armengol A, Bonnin M, et al. Early treatment of obstructive apnoea and stroke outcome: a randomised controlled trial. Eur Respir J. 2011;37(5):1128–1136. [PubMed]
Johnston SC, Gress DR, Browner WS, Sidney S. Short-term prognosis after emergency department diagnosis of TIA. JAMA. 2000;284(22):2901–2906. [PubMed]