A 54-year-old man comes to the office due to daytime sleepiness and lack of energy. The symptoms began 6 months ago and have progressively worsened so that he feels "completely drained" by the end of the day. The patient's wife mentions that he snores loudly. His past medical history is unremarkable, although he has not seen a physician in over 10 years. The patient does not use tobacco or alcohol, and he works in the warehouse of an agricultural supply company. BMI is 34 kg/m². Physical examination shows a narrow oropharynx and a large neck circumference. The patient is at increased risk of developing which of the following?

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11ec160b_3b3f_f0de_9249_59f562f1e221_MD0001_00 This patient, an obese man with loud snoring, daytime sleepiness, and suggestive examination findings (eg, thick neck, narrow airway) most likely has obstructive sleep apnea (OSA). OSA is characterized by recurrent obstruction of the upper airway during sleep; each nocturnal episode of reduced ventilation causes transient hypercapnia and hypoxemia. These blood gas derangements result in reflexive systemic and pulmonary vasoconstriction, endothelial dysfunction, abnormal venous return and cardiac output, and sympathetic cardiac stimulation. Prolonged, untreated OSA can cause pulmonary hypertension and right heart failure. Most patients with OSA will develop systemic hypertension due to chronic sympathetic stimulation and elevated plasma norepinephrine levels. Patients also lose the normal diurnal variation in blood pressure. Other cardiovascular complications of OSA include atrial fibrillation and other arrhythmias, coronary artery disease, and increased risk of sudden cardiac death. (Choice A) Acquired bronchiectasis may be seen in patients with recurrent infection, impaired drainage (eg, cystic fibrosis), airway obstruction (eg, foreign body aspiration), or inadequate host defense (eg, hypogammaglobulinemia). (Choice B) Systemic hypertension, as seen in OSA, can lead to mild-to-moderate left ventricular hypertrophy and impaired systolic and diastolic function. In contrast, hypertrophic cardiomyopathy is an autosomal dominant disease of the cardiac sarcomere characterized by severe myocardial hypertrophy. It is not associated with hypertension or OSA. (Choice C) Laryngeal carcinoma is associated with cigarette smoking and heavy alcohol use. (Choice D) Like OSA, narcolepsy can also cause daytime drowsiness. However, narcolepsy is also associated with cataplexy (sudden loss of muscle tone), sleep attacks, sleep paralysis, and hypnagogic hallucinations. OSA is not a risk factor for narcolepsy. Educational objective: Obstructive sleep apnea presents in obese individuals with excessive daytime sleepiness and signs of nocturnal upper airway obstruction (eg, snoring, gasping). The condition is associated with systemic hypertension. Prolonged, untreated obstructive sleep apnea can also cause pulmonary hypertension and right heart failure. __________ References: Clinical perspective of obstructive sleep apnea-induced cardiovascular complications. (http://www.ncbi.nlm.nih.gov/pubmed/17511585)

A 54-Year-Old Man Comes to the Office Due to Daytime