Effect of obstructive sleep apnea on prognosis in patients with acute coronary syndromes with varying numbers of standard modifiable risk factors: insight from the OSA-ACS study

Abstract

Background Standard modifiable risk factors (SMuRFs) increase the risk of cardiovascular events in patients with acute coronary syndrome (ACS) and are also strongly associated with obstructive sleep apnea (OSA) in a bidirectional relationship. However, the association of OSA with recurrent cardiovascular events in ACS patients based on the number of SMuRFs remains unclear. Hence, we aimed to elucidate the prognostic implication of OSA in ACS patients stratified by the number of SMuRFs. Methods This was a post hoc analysis of the OSA-ACS study (NCT03362385), including 1927 patients admitted for ACS and undergoing portable sleep monitoring. OSA was defined as an apnea hypopnea index ≥ 15 events/h. The primary endpoint was major adverse cardiovascular and cerebrovascular event (MACCE) including cardiovascular death, myocardial infarction, stroke, hospitalization for unstable angina or heart failure, and ischemia-driven revascularization. Cox proportional hazards model and Kaplan-Meier analysis were used to investigated the relationship between OSA and subsequent cardiovascular events after patients were stratified by the number of SMuRFs. Results Among 1927 patients enrolled, 130 (6.7%) had no SMuRF, 1264 (65.6%) exhibited 1–2 SMuRFs and 533 (27.7%) presented 3–4 SMuRFs. With the increase of the number of SMuRFs, the proportion of OSA in ACS patients tended to increase (47.7% vs. 51.5% vs. 56.6%), but there was no significant difference between them (P = 0.08). After the stratification of ACS patients via SMuRF numbers and adjustment for confounding factors, fully adjusted Cox regression indicated that OSA increased the risk of MACCE (adjusted HR, 1.65; 95%CI, 1.06–2.57; P = 0.026) and ischemia-driven revascularization (adjusted HR, 2.18; 95%CI, 1.03–4.65; P = 0.042) in ACS patients with 3–4 SMuRFs. Conclusions In hospitalized ACS patients, OSA is associated with an increased risk of MACCE and ischemia-driven revascularization among patients with 3–4 SMuRFs. Therefore, screening for OSA should be emphasized in ACS patients with 3–4 SMuRFs, and intervention trials should be prioritized in these high-risk patients.

Sleep apnea in end-stage renal disease patients: Impact on cardiovascular and neurological outcomes

“…[ 2 ] Detrimental cardiovascular remodeling downstream of OSA and other risk factors can occur. [ 6 ] Rapid oxygenation upon restoration of respiration leads to free radical creation, oxidative stress, and inflammation that can cause downstream damage. [ 1 2 ] Transcription factor-1 and nuclear factor kappa-light-chain-enhancer of activated B cells (NF-kB) become activated, which results in an inflammatory process that leads to atherosclerosis.…”

“…[ 1 2 ] Transcription factor-1 and nuclear factor kappa-light-chain-enhancer of activated B cells (NF-kB) become activated, which results in an inflammatory process that leads to atherosclerosis. [ 6 ] This damage can be cardiovascular in nature and causes an event such as an MI, or it can impair cerebral perfusion and cause neurologic events such as cerebral hemorrhage or stroke. [ 7 ] Wang et al .…”

“…[ 7 ] Wang et al . [ 6 ] postulate that OSA is an independent risk factor contributing to cardiovascular outcomes. Other studies have found a bidirectional relationship between sleep-disordered breathing and stroke, with untreated OSA leading to a higher stroke risk in patients.…”

The South African Flag Sign: An Electrocardiographic Flag for All Coronary Territories?

“… 13 , 14 Women with STE-ACS have worse major adverse cardiovascular events, including mortality than men, attributed to older age, worse cardiovascular risk profiles, delayed GDMT, reperfusion, revascularization therapies, and different mechanisms in ACS pathophysiology. 15 As such, the term should be strongly reconsidered or even rendered obsolete in the lexicon due to its implicit bias and neglect of the current crisis of cardiovascular disease in women.…”