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First, we'll talk about integrating obstructive sleep apnea into your cardio metabolic risk assessments. So we'll start off with a question. In your adult patients with obesity, along with resistant hypertension, when do you usually initiate obstructive sleep apnea screening? A, routinely as part of a cardio metabolic review. B, only when sleep symptoms are reported. C, only after bed partner concerns. D, only when another clinician requests it. E, rarely or never. So we'll start here and link a patient case to this question. There's a 56-year-old woman with obesity, resistant hypertension, and type 2 diabetes, as well as dyslipidemia. So some cardiovascular risk factors along with this, you know, resistant hypertension. She's obese with a body mass index of 36 kg per meter squared. Her BP is elevated at 158/94 despite uh taking um an ARB, a calcium channel blocker, and a thiazide-like diuretic. Her hemoglobin A1C is 7.8. Her LDL is 120 mg per deciliter, and her estimated GFR is 1.7. She does report symptoms of fatigue, morning headaches, and nocturia, and her partner does report some loud snoring. Her cardio metabolic therapy is intensified, uh, but there's, uh, no sleep history, obstructive sleep apnea screening, or diagnostic referral that is documented in this case. So let's talk about obstructive sleep apnea in general. Uh, it is quite common and it is a serious medical condition. So it is, uh, potentially fatal. There is an increased mortality that is associated with untreated obstructive sleep apnea, and the global health burden of obstructive sleep apnea, and we define this, um, by an apnea hypopnea index of greater than equal to 5. Um, it is quite high, uh, with estimated prevalence rates in middle-aged adults is 30 to 69 years, as you can see in the figure, really ranging anywhere from, you know, 6 to 17% in Europe, um, in European countries to up to more than 30% in South America. Um, and obstructive sleep apnea is characterized by repetitive. Upper airway obstruction or collapse of the airway during sleep that then results in a variety of pathophysiologic consequences, and this includes chronic intermittent hypoxia, uh, sleep fragmentation, and therefore, uh, really broken up sleep and disrupted sleep. And symptoms are oftentimes characterized by excessive daytime sleepiness. So in the case we also saw fatigue. So fatigue can also be a symptom even without the overt daytime sleepiness. And sleep apnea is very common, uh, as we just mentioned, it's estimated to affect, uh, over 900 million adults, uh, middle-aged adults worldwide. It does tend to be more common in men versus women, with a ratio anywhere about 2:3:1 in the general population. However, we are increasingly recognizing the importance of obstructive sleep apnea in women, particularly in the perimenopausal and most postmenopausal phase of life. And obstructive sleep apnea prevalence is really significantly influenced by socioeconomic status as well. Uh, and this association can really vary across, uh, different populations such as the urban population, the rural population, and, um, even, uh, measures of socioeconomic status, uh, area deprivation index, for example. And the figures that we have identified um in the literature in terms of the epidemiology of obstructive sleep apnea, like they are actually an underestimate of the true prevalence of sleep apnea, uh, particularly in those areas that have limited access to sleep medicine diagnostic facilities. And obstructive sleep apnea has far-reaching consequences in terms of our overall health and well-being, yet it remains underdiagnosed. We probably are getting better on this front, however, this still remains a very large public health issue in terms of this underdiagnosis of obstructive sleep apnea. So the pathophysiologic mechanisms um involve um altered ventilatory mechanisms, arousal thresholds that are altered as well. Um, and several health consequences, including, uh, cardiovascular consequences, and metabolic disruptions, insulin resistance, alterations in lipids, um, neurocognitive and neurodegenerative disease that have been linked also with untreated obstructive sleep apnea, neurocognitive dysfunction, and also mood disorders, uh, particularly depression. Obstructive sleep apnea is also characterized by large um economic costs that are attributable to the medical expenditures and treatment, uh, related to, um, untreated, uh, undiagnosed sleep apnea. And these uh unfortunate negative health consequences, as well as impacts on productivity and higher uh predisposition to uh motor vehicle accidents and other um even occupational accidents that can occur. And so why do we have this under diagnosis of, of sleep apnea? Well, we just saw, uh, the sheer prevalence of obstructive sleep apnea, and that's actually quite likely an underestimate. So there's a, a large, uh, population. prevalence and attributable risk to sleep apnea. And it's estimated that about 80% of those with moderate to severe obstructive sleep apnea remain undiagnosed. And that's for epidemiologic studies where participants are coming in, uh, who may otherwise not necessarily be symptomatic and then undergo sleep testing. And it's identified that Um, about 80 to 85% remain underdiagnosed or undiagnosed. And, uh, the reasons for this are likely multifactorial. Uh, there's a low, uh, awareness of, uh, the, uh, likelihood of sleep apnea. The, uh, screening abilities, uh, may also be an issue, uh, in particular in those settings where obstructive sleep apnea may not be on the radar screen or, uh, low resourced settings. Um, the diagnostic criteria for obstructive sleep apnea, uh, continue to evolve. Uh, and polysomnography has long been considered the gold standard for diagnosis of sleep apnea, and this is quite resource intensive, requiring, um, technologists that are trained and, um, you know, patients coming in to the sleep laboratory for testing, and this may be unavailable in many regions. Um, and here it's The treatment, uh, with, uh, uh, continuous positive airway pressure also can pose a challenge. And there are also inequities in terms of access to health care across different systems. So again, multifactorial, uh, explanations for the underdiagnosis of obstructive sleep apnea. And the high cardio metabolic risk, if we even think about the, the patient case that we just reviewed, um, and, and the lady with, you know, diabetes and resistant hypertension should really trigger, um, the notion that obstructive sleep apnea should be considered and therefore screening for obstructive sleep apnea should be undertaken. And so who are the people that are at high risk for obstructive sleep apnea? So those who are obese, uh, defined by a body mass index of greater than or equal to 30 kg per meter squared. Those with cardiovascular risk factors, pre-diabetes, type 2 diabetes, hypertension, those with established cardiovascular disease, and in particular those who have symptoms of untreated sleep apnea, such as sleepiness symptoms that can really impair one's ability to engage in social activities as one would want and even