Please select the eligibility criteria that correspond to the clinical trial below.
Title: A Planning Study: Sleep Apnea Intervention for Cardiovascular Disease Reduction
Brief Summary: Moderate to severe sleep apnea (a high number of breathing pauses on a sleep study) is a common health problem that is often associated with loud snoring and sleepiness.The medical term for this problem is obstructive sleep apnea (OSA). People with OSA often have an increased risk for developing heart disease or may already have a diagnosis of heart disease.

A clinical research study is being conducted at Brigham and Women's Hospital (BWH) and Beth Israel Deaconess Medical Center (BIDMC) to compare the effects of continuous positive airway pressure (CPAP) to conservative medical therapy with participation in one of four groups:

1. Active-PAP Therapy Group (Active-Beh or Active+Beh): Will receive standard medical treatment for sleep apnea with active-PAP. Participants will be randomized to either:

   1. Active-Pap with respiratory therapist visits only
   2. Active-Pap with respiratory therapist visits and cognitive behavioral therapist visits.
2. Alternative PAP Group (Sham): Will receive lower air delivery level than active-PAP therapy group. Will also have meetings with respiratory therapist.
3. Conservative Medical Therapy Group (CMT)\*: Will receive a free supply of nasal strips for the duration of their treatment period (either 6 months or 12 months) and follow healthy sleep hygiene guidelines for how to change sleep habits to minimize incidences of apneas (breathing disturbances during sleep). Frequent follow-up support with research coordinator.

A sleep doctor or cardiologist will have indicated that a potential participant is an appropriate candidate to receive PAP or CMT as acceptable approaches to treat his/her sleep apnea. Participants will be recruited between the ages of 45-75 years who have diagnosed heart disease or between 55-75 years for those who have risk factors for developing heart disease.

This is a 6-12 month study\*\* to evaluate alternative ways to address the potential for OSA treatment to reduce heart disease and to identify those features that would strengthen a later, large-scale randomized controlled trial.

We will test the hypothesis that active treatment for OSA with CPAP reduces CVD morbidity and mortality.

\*All randomized participants will be given conservative medical therapy (CMT).

\*\*For those randomized after December 31, 2012, follow-up assessment will only be 6 months long


Options:
A: Inclusion Criteria:

* Obstructive apnea hypopnea index (AHI) ≥ 15
* Age 45-75 years, or 55 to 75 yrs if without established Cardiovascular Disease (CVD)
* Ability to provide informed consent, with the patient and physician acknowledging accepting uncertainty on the role of PAP in CVD prevention.
* Established CVD,or having diabetes mellitus, defined by one or more of the following:

  1. Prior myocardial infarction
  2. Coronary artery revascularization procedure (≥4 months before study entry)
  3. Angiographically documented stenosis (\>70%) of a major coronary artery
  4. Prior ischemic stroke without major functional impairment
  5. Diabetes mellitus treated with medication or ≥ 2 fasting glucose levels ≥ 126 mg/dl

OR

Three or more of the following established CVD risk factors:

1. Hypertension treated with medications or systolic BP \> 140 or diastolic BP \> 90 on ≥ 2 occasions
2. Male sex
3. BMI ≥ 30
4. Total cholesterol \> 240 mg/dl or LDL cholesterol \> 160 mg/dl or HDL \< 45 mg/dl
5. \> 10 pack years of smoking

Exclusion Criteria:

* Diagnosed heart failure with known cardiac ejection fraction of \< 35% or New York Heart Association (NYHA) class 3 or 4 status
* Less than 4 months since myocardial infarction (MI), stroke or revascularization procedure
* Poorly controlled hypertension (\>170/\>100)
* Prior stroke with functional impairment interfering with ability to complete the protocol
* Severe uncontrolled medical problems or medications that may influence measurements or impair ability to participate in the study exams (e.g. oral steroids; chronic opioid use; self- reported chronic kidney disease or, if measured, creatinine \> 2.5 mg/dl or glomerular filtration rate (GFR) \< 30; anemia with Hgb \< 10, etc.)
* Resting oxygen saturation \< 90% or nocturnal oxygen saturation \<85% for \> 10% of the sleep period;
* Use of prescribed PAP for sleep apnea within the prior 2 years
* Report of inability to spend \>6 hrs in bed
* Any use of prescribed PAP for sleep apnea
* Severe sleepiness defined by an Epworth Sleepiness Score of \>14 or report of falling asleep driving in the prior 2 years
* Working as a professional driver
* Low risk related to having sleep apnea defined by a Berlin Score \< 2
* Central sleep apnea, with \>50% of respiratory events classified as central apneas
* Refusal to consider PAP use after an initial split-night PAP study (pre-randomization)
* Concurrent involvement in another research study that will result in a conflict as determined by study doctors
B: Inclusion Criteria:

* Age \> 18 years
* African American / carribean American / African.

Exclusion Criteria:

* Pregnancy or breastfeeding
* Involvement with other study
* Unable to understand and sign the informed consent form
* Heart attack or stroke within the past 12 weeks
* Diagnosed with Obstructive Sleep Apnea and/or on treatment
C: Inclusion Criteria:

* Clinical diagnosis of obstructive sleep apnea
* No previous use of CPAP
* Must be a Veteran with residence within San Diego County

Exclusion Criteria:

* Home oxygen therapy
* Fatal comorbidities (i.e., life expectancy less than 6 mos)
* Contraindications for CPAP use
D: Inclusion Criteria:

* Consecutive patients aged 18-70 years of age
* Documented obstructive sleep apnea by polysomnography (AHI 5 or more/hr)
* Established diagnosis of PTSD related to any past lifetime traumatic event and have a diagnosis of current, chronic PTSD

Exclusion Criteria:

* Central sleep apnea defined as central apnea/hypopnea \>50% of the total respiratory events
* Prior treatment for sleep apnea
* Veterans with fewer than 4 teeth remaining in either arch
* Coexisting narcolepsy
* Tempo-mandibular joint disease
* Epilepsy
* Prominent suicidal or homicidal ideation
* Diagnosis of dementia

Answer: A