What Tim Russert's Doctors May Have Missed
What Tim Russert's Doctors May Have Missed
He died despite being on medications for high blood pressure and elevated cholesterol, and had no symptoms of heart disease. He even exercised every day, as part of a regimen to lose some weight. His autopsy report ultimately revealed that he had advanced blocked arteries in his heart. There's been much speculation in the media about the circumstances surrounding his untimely death, but in retrospect, all the data and his medical history strongly suggests that he may have had untreated OSA. One of the great myths perpetuated in the medical community (and the media) is that only men who are older, heavy-set, loud snorers, and have big necks can have obstructive sleep apnea (OSA). OSA is a common condition where one stops breathing repeatedly at night during sleep, with poor sleep quality and lowered oxygen levels, which stresses the heart. This perception started decades ago as sleep apnea was first described only in these type of men. Recent studies have shown, however, that even young, thin women who don't snore can have significant OSA.
There are dozens, if not hundreds of studies that show that having OSA can lead to high blood pressure, elevated cholesterol, increased CRP, weight gain, as well as heart disease. In fact, having OSA increases one's chances of having a heart attack is about 40%. Snoring alone significantly increased ones chances of having a stroke. Despite all the tomes of evidence, it's estimated that 80-90% of people with OSA in this country are not diagnosed.
We in the medical community will always tend to focus on the latest trendy test result or measurement. Years ago, cholesterol level was the hot topic, a few years ago it was CRP, and now it's waist measurement. Next year, it will be something else. But what every one of these past, current and future measurements reveal is the end result of OSA. Sleep apnea not only can cause weight gain, but causes generalized systemic inflammation, thus leading to elevated markers of inflammation, such as CRP. Every day in my practice, I see patients with medical histories very similar to Mr. Russert's. They are usually on high blood pressure and cholesterol medications, mildly to moderately overweight, and have very intense and stressful occupations. Nine out of ten times, a sleep study will reveal significant OSA. In fact, almost everyone with a history of heart disease or high blood pressure, if investigated carefully, will have some degree of a sleep-breathing disorder.
Another problem with our health care system is that a condition like OSA (and high blood pressure or diabetes) is something that you either have or don't have, based on a numerical test value. These threshold-based diagnostic tests tend to pick up only the severe or extreme cases of a medical condition. OSA, as we know it, is the extreme end of a sleep-breathing continuum. Even normal people can have mild levels of breathing stoppages, to various degrees: a completely normal person can have temporary OSA if he or she has a stuffy nose. This is why you don't sleep well when you have a cold.
One major reason that all of us are susceptible to sleep-breathing disorders is that our oral cavity anatomy is uniquely predisposed to breathing problems at night. The position of our voice boxes lower down in the neck, underneath our tongue, predisposes our tongues to fall back easily, especially when we are in deep sleep due to muscle relaxation. Interestingly, this lower position of the voice box is thought to allow complex speech and articulation. If you already have a potentially narrowed airway and you add any degree of narrowing due to either inflammation or throat fat enlargement, then slight degrees of obstruction and breathing pauses can set in. The good news is that OSA is a treatable condition. Treating OSA can also prevent onset or progression of high blood pressure, diabetes, weight gain, heart disease, heart attack or stroke. My greatest frustration is that even in men who fit the typical profile for someone with OSA, many doctors are too focused on lowering blood pressure or cholesterol levels. Perhaps if Mr. Russert's doctors had only considered the possibility of sleep apnea, he may still be with us today.
Steven Y. Park, M.D.
Author of forthcoming book, Sleep, Interrupted: A physician reveals the #1 reason why so many of us are sick and tired.
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