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LetterCorrespondence

Re: The Association Between Hay Fever and Stroke in a Cohort of Middle Aged and Elderly Adults

Daniel K. Ng, Ka-li Kwok and Chung-hong Chan
The Journal of the American Board of Family Medicine September 2008, 21 (5) 477-478; DOI: https://doi.org/10.3122/jabfm.2008.05.080111
Daniel K. Ng
MD
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Ka-li Kwok
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Chung-hong Chan
BSC
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To the Editor: We read with interest the paper by Matheson et al1 on the increased risk of stroke in those with hey fever (allergic rhinitis). The authors suggested the mechanism to be the systemic inflammation found in those with allergic rhinitis. We would suggest an additional explanation, ie, obstructive sleep apnea (OSA), for the increased risk.

Allergic rhinitis was associated with increased risk of OSA in adults2 and children.3 Nasal blockage caused by allergic rhinitis would lead to mouth breathing. Chronic mouth breathing will predispose to a steep mandibular plane that results in a narrow upper airway. A narrow upper airway would predispose to OSA. OSA with apnea-induced hypoxia and exaggerated negative intrathoracic pressure, arousals from sleep, surges in blood pressure, alteration in autonomic nervous activity, as well as production of reactive oxygen species, vascular endothelial growth factor, and inflammatory mediators are factors contributing to the vascular consequences. OSA is associated with atherosclerosis in adults.4 Adults with OSA had an increased risk of cerebrovascular disease independent of atherosclerotic risk factors.5

Recent researches of OSA found that inflammation was involved in the process.6 C-reactive protein (CRP) had been shown to increase even in children with OSA. CRP dropped after tonsillo-adenoidectomy in children.7 Other factors that might be involved in atherosclerosis, like fibrinogen level and p-selectin (marker of platelet activation), were shown to be higher in those with OSA.

Another potentially important factor is excessive daytime sleepiness. Allergic rhinitis8 was strongly associated with excessive daytime sleepiness (EDS). EDS is a well known risk factor for stroke in middle age and elderly. Previous studies showed that EDS, even after adjusted for the effect of sleep disordered breathing, is associated with stroke.9

In conclusion, allergic rhinitis is a very common condition that is associated with OSA that carries a high risk of mortality and morbidities. Appropriate treatment of childhood allergic rhinitis may prevent the development of OSA by preventing chronic oral mouth breathing. Adults with allergic rhinitis and habitual snoring should undergo a sleep polysomnography study as to allow diagnosis and treatment of OSA. Failure to do so may result in stroke as demonstrated by Matheson et al.1

Notes

  • Dr. Matheson declined to respond to this letter.

References

  1. ↵
    Matheson EM, Player MS, Mainous AG, 3rd, King DE, Everett CJ. The association between hay fever and stroke in a cohort of middle aged and elderly adults. J Am Board Fam Med 2008; 21: 179–83.
    OpenUrlAbstract/FREE Full Text
  2. ↵
    Canova CR, Downs SH, Knoblauch A, Andersson M, Tamm M, Leuppi JD. Increased prevalence of perennial allergic rhinitis in patients with obstructive sleep apnea. Respiration 2004; 71: 138–43.
    OpenUrlCrossRefPubMed
  3. ↵
    Ng DK, Chan CH, Hwang GY, Chow PY, Kwok KL. A review of the roles of allergic rhinitis in childhood obstructive sleep apnea syndrome. Allergy Asthma Proc 2006; 27: 240–2.
    OpenUrlCrossRefPubMed
  4. ↵
    Drager LF, Bortolotto LA, Lorenzi MC, Figueiredo AC, Krieger EM, Lorenzi-Filho G. Early signs of atherosclerosis in obstructive sleep apnea. Am J Respir Crit Care Med 2005; 172: 613–8.
    OpenUrlCrossRefPubMed
  5. ↵
    Saletu M, Nosiska D, Kapfhammer G, Lalouschek W, Saletu B, Benesch T, Zeitlhofer J. Structural and serum surrogate markers of cerebrovascular disease in obstructive sleep apnea (OSA): association of mild OSA with early atherosclerosis. J Neurol 2006; 253: 746–52.
    OpenUrlCrossRefPubMed
  6. ↵
    Tasali E, Ip MS. Obstructive sleep apnea and metabolic syndrome: alterations in glucose metabolism and inflammation. Proc Am Thorac Soc 2008; 5: 207–17.
    OpenUrlCrossRefPubMed
  7. ↵
    Li AM, Chan MH, Yin J, So HK, Ng SK, Chan IH, Lam CW, Wing YK, Ng PC. C-reactive protein in children with obstructive sleep apnea and the effects of treatment. Pediatr Pulmonol 2008; 43: 34–40.
    OpenUrlCrossRefPubMed
  8. ↵
    Woods L, Craig TJ. The importance of rhinitis on sleep, daytime somnolence, productivity and fatigue. Curr Opin Pulm Med 2006; 12: 390–6.
    OpenUrlPubMed
  9. ↵
    Davies DP, Rodgers H, Walshaw D, James OF, Gibson GJ. Snoring, daytime sleepiness and stroke: a case-control study of first-ever stroke. J Sleep Res 2003; 12: 313–8.
    OpenUrlPubMed
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The Journal of the American Board of Family Medicine: 21 (5)
The Journal of the American Board of Family Medicine
Vol. 21, Issue 5
September-October 2008
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Re: The Association Between Hay Fever and Stroke in a Cohort of Middle Aged and Elderly Adults
Daniel K. Ng, Ka-li Kwok, Chung-hong Chan
The Journal of the American Board of Family Medicine Sep 2008, 21 (5) 477-478; DOI: 10.3122/jabfm.2008.05.080111

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Re: The Association Between Hay Fever and Stroke in a Cohort of Middle Aged and Elderly Adults
Daniel K. Ng, Ka-li Kwok, Chung-hong Chan
The Journal of the American Board of Family Medicine Sep 2008, 21 (5) 477-478; DOI: 10.3122/jabfm.2008.05.080111
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