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27 t m c » p u l s e | n o v e m b e r 2 0 1 9 nonprofit National Sleep Foundation. Even so, some could be misdiagnosed because the symptoms are mistaken for a side effect of post-traumatic stress disorder (PTSD), said Philip Gehrman, Ph.D., an assistant professor of psychology at the University of Pennsylvania's Perelman School of Medicine and a member of the Penn Sleep Center and the Philadelphia VA Medical Center. "When people wake up out of an apnea, they are oftentimes gasping for air, their heart is racing and it is a surge of the fight or flight reflex," Gehrman said. "People might interpret that as waking up from a nightmare—because waking up from a nightmare would be similar. Once people are accurately diagnosed with sleep apnea, it will not make the PTSD go away, but it will improve the overall severity of their symptoms." Gender and age are two factors that seem to support high rates of sleep apnea in veterans. "If you're looking at the veteran population, we know that being male increases your risk of sleep apnea and the veteran population is roughly 90 percent male," Gehrman said. "Increasing age is a significant risk factor and a large number of patients in the VA system are Vietnam-era veterans." Central sleep apnea often occurs among patients who are ill from chronic heart failure, stroke and other maladies. "As a cardiologist, when I look at it, we are treating people with central sleep apnea, but when we treat that, we are also treating a lot of overlap- ping congestive heart failure, overlapping atrial fibrillation, hypertension and more," Afshar said. The remedē system was approved by the U.S. Food and Drug Administration in October 2017 and was introduced to the Houston VA this spring. "It is personal to me to help veterans because they help our country stay safe," Afshar said. "I think our veterans deserve the best." Far left: Cardiologist Hamid Afshar, M.D., center, implants the remedē system in a patient at the Michael E. DeBakey VA Medical Center. This page: An X-ray shows the implant. Credit: courtesy Respicardia