Prevent Stroke by Addressing Sleep Apnea Effectively


By Leonard J. Feld, DDS

According to most sources, stroke – also known as brain attack- is up to 80 percent preventable. However, the disease stubbornly remains on the Centers for Disease Control’s top 10 list of leading causes of death in the United States, and many people still don’t know enough about it, according to Dr. Ash Jain, M.D., cardiologist and medical director of Washington Hospital’s Stroke Program.

“It has always been best to learn about stroke before it happens,” according to Dr. Jain. “Most risk factors for stroke – such as high blood pressure- build up over time with no outward symptoms. Then you suffer a stroke, which leaves you at risk for permanent disability.”

Ischemic strokes, which account for the majority of stokes, are caused by blockages of the atrial pathways that deliver oxygen and nutrients to the brain, according to Dr. Jain. As a result, brain cells are literally starved of oxygen and begin to die off, making both prevention and early detection key, he says.

Atrial Fibrillation is not only the most common type of irregular heartbeat, but also one of the main risk factors for stroke, according to Dr. Jain. In fact, the American Heart Association cites data indicating that AF accounts for between 15 percent and 20 percent of strokes in the United States.

“With atrial fibrillation, it is very important to identify these patients and treat them so that they don’t go on to have strokes,” Dr, Jain says. “Irregular heartbeat causes blood clots to form in the heart chamber, and these then travel to the brain, clogging the circulation and causing stroke.

Also, heart function is decreased by as much as 30 percent and this decrease in function makes people tired, short of breath, and they experience less energy and weakness and tiredness. While AF and carotid artery disease require medical intervention, Doug Van Houten is a big proponent of tracking the many preventable risk factors for stroke, like high blood pressure, obesity, and sleep disorders.

Numerous studies in recent years reveal a strong correlation between obstructive sleep apnea (OSA), where breathing stops while you are sleeping, and atrial fibrillation or “A-Fib”, a leading cause of stroke.

Two primary conclusions of these studies are:

•    Those with obstructive sleep apnea are at risk of atrial fibrillation
•    A-Fib patients with untreated sleep apnea are more likely to revert back into A-Fib after treatment than A-Fib patients without sleep apnea

What these findings suggest is that a lack of oxygen while sleeping, commonly recognized by snoring, restless sleep, headaches, or fatigue upon waking, can seriously damage the heart, causing irregular heart beat and possibly stroke.
According to, a site from the American Foundation for Women’s Health, approximately half of A-Fib patients also have OSA. There is a stronger correlation between A-Fib and OSA than any other risk factors. However, when sleep apnea is treated, A-Fib improves.

How is sleep apnea treated?

Sleep apnea is best treated by a knowledgeable sleep specialist. The goal of treatment is to maintain an open airway during sleep. The challenge for the clinician and the patient is to select an effective therapy that is appropriate for the patient’s problem and that is acceptable for long term use.

Adjust Sleep Position
Adjusting sleep position (to stay off the back) in people who have OSA. This is difficult to maintain throughout the night and is rarely an adequate solution.

Continuous Positive Airway Pressure (CPAP)
A CPAP device uses an air-tight attachment to the nose, typically a mask, connected to a tube and a blower which generates a constant pressure of oxygen. Devices that fit into the nasal opening, rather than over the nose, are also available. CPAP should be used any time the person sleeps (day or night). While the treatment may seem uncomfortable, noisy, or bulky at first, most people accept the treatment after experiencing better sleep. However, difficulty with mask comfort and nasal congestion prevent up to 50 percent of people from using the treatment on a regular basis.

Dental Devices
Called an oral orthotic (similar to a retainer) or mandibular advancement device, can reposition the jaw (mandible), bringing the tongue and soft palate forward as well. This has been shown to relieve obstruction in some people. Many patients prefer a dental device to CPAP, and therefore compliance is significantly better. Side effects of dental devices are generally minor, but include changes to the bite with prolonged use.

Dr. Leonard Feld, a member of the American Academy of sleep medicine, states that, “The first step in treatment is to conduct a sleep study with a small, take home device which measures important factors in sleep position, oxygen intake, and heart rate to determine if the OSA is mild to moderate, moderate to severe, or severe. Next. we determine the location of the obstruction. If it has to do with the location of their tongue and the position of the jaw, then it is considered a TMJ disorder and an oral appliance is effective in moving the jaw forward and into a more receptive position to maximize oxygen intake and flow.”

Upon diagnosis, Dr. Feld confers with the patient’s physician to determine if an appliance is the preferred form of treatment. “The appliance is clinically proven to be very effective for mild to moderate and moderate to severe cases.” If tests results show severe, a complete sleep study is often recommended in the hospital.

Dr. Fed adds that studies show if the position of the tongue and jaw appear to be contributing factors, oxygen intake may be affected as well. “We call it personal adaptation – example: one shoulder is lower than the other, or the head is tilted (these people have neck and shoulder pain) – and what we find with patients who have the appliance (which is worn at all times) is that oxygen intake increases 24/7, improving many aspects of their health. This would include oxygen to the heart.

The biggest asset with the appliance is that it treats the cause and opens the airway, whereas CPAP forces oxygen through the obstructed airway. The oral appliance is also comfortable and easy to wear, so compliance is significantly greater with CPAP.”

Patients who have gained weight start losing weight.

The correlation between A-Fib and sleep apnea is at the forefront of A-Fib research. Considering findings to date, it is recommended that if you have sleep challenges, then treat it before it possibly leads to a more serious condition. And if you have A-Fib and sleep apnea, be sure to address both conditions with your health care team to maximize treatment results.

For more information on sleep apnea, contact Dr. Leonard Feld at the Indian Wells Smile Center. Dr. Feld is the co-founder of the TMJ & Sleep Medicine Network and his philosophy is always conservative, non-invasive and non-surgical treatment. See


1) Jain, Ash MD Washington Hospital Stroke Program

2) Kanagala, Ravi, MD, et al “Obstructive Sleep Apnea and the Recurrence of Atrial Fibrillation”, Circulation: 2003;107:2589

3) Gami, Apoor A, MD, et al, “Association of Atrial Fibrillation and Obstructive Sleep Apnea”, Circulation: 2004;110:364-367

4) Low efficacy of atrial fibrillation ablation in severe obstructive sleep apnea patients, Europace, May 20, 2010;

5) Peggy Noonan and Mellanie True Hills “ Severe Obstructive Sleep Apnea Predicts Atrial Fibrillation Ablation Failure” July 6, 2010 8:05 AM CT

6) Wolfgang Schmidt-Norwara, MD, Clinical Associate Professor of Medicine, University of Texas Southwestern Wolters Kluwer Health’s UpToDate;

7) Ferguson KA, Cartwright R, Rogers R, Schmidt-Norwara W. Oral appliances for snoring and obstructive sleep apnea: a review. Sleep 2006; 29:244

Mike Bundrant
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