Increased Incidence of Stroke, but Not Coronary Heart Disease, in Elderly Patients With Sleep Apnea

Abstract

Background and Purpose— The influence of age on the relationship between obstructive sleep apnea (OSA) and the incidence of hard cardiovascular events remains controversial. We sought to analyze the relationship between OSA and the incidence of stroke and coronary heart disease in a large cohort of elderly patients, as well as to investigate the role of continuous positive airway pressure (CPAP) treatment in these associations. Methods— Post hoc analysis of a prospective observational study of consecutive patients ≥65 years studied for OSA suspicion at 2 Spanish University Hospitals. Patients with an apnea-hypopnea index (AHI) <15 were the reference group. OSA was defined by an AHI ≥15 and classified as untreated (CPAP not prescribed or compliance <4 hours/day), mild-moderate (AHI 15–29), untreated severe (AHI ≥30), and CPAP-treated (AHI ≥15 and CPAP compliance ≥4 hours/day). Results— 859 and 794 elderly patients were included in the stroke and coronary heart disease analyses, respectively. The median (interquartile range) follow-up was 72 (50–88.5) and 71 (51.5–89) months, respectively. Compared with the reference group, the fully adjusted hazard ratios for the incidence of stroke were 3.42 (95% CI, 1.37–8.52), 1.02 (95% CI, 0.41–2.56), and 1.76 (95% CI, 0.62–4.97) for the untreated severe OSA group, CPAP-treated group, and untreated mild-moderate OSA group, respectively. No associations were shown between any of the different OSA groups and coronary heart disease incidence. Conclusions— The incidence of stroke, but not coronary heart disease, is increased in elderly patients with untreated severe OSA. Adequate CPAP treatment may reduce this risk.

EAN/ERS/ESO/ESRS statement on the impact of sleep disorders on risk and outcome of stroke

“…Primary studies: Four studies of class 3 or 4 quality were included. Two studies assessed CPAP [73,74]. Two studies assessed the effect of uvulopalatopharyngoplasty (UPPP) [75] or tracheostomy [76].…”

“…CATALAN-SERRA et al [73] examined the incidence of stroke in OSA patients with CPAP treatment in a prospective, observational cohort from Spain. In the 6-year median follow-up, OSA with AHI ⩾30 events per h and CPAP not prescribed or compliance <4 h per day had significantly higher cumulative incidence of stroke compared with the reference group of individuals with AHI <15 events per h (log-rank test, 11.87, p=0.001; HR 3.42, 95% CI 1.37-8.52) after adjustments for age, body mass index, hypertension, sex, smoking habit, Epworth Sleepiness Scale and atrial fibrillation (table e5).…”

SAS Care 1: sleep-disordered breathing in acute stroke an transient ischaemic attack – prevalence, evolution and association with functional outcome at 3 months, a prospective observational polysomnography study

“…OSA, the most frequently reported SDB pattern in the context of stroke, and central sleep apnoea (CSA) including Cheyne-Stokes respiration (CSR) are both observed more frequently in patients with incident stroke compared to the general population [10,12,[17][18][19][20][21][22][23][24][25][26][27][28][29]. Accumulating evidence suggest the existence of a bidirectional association between SDB and cerebrovascular diseases; on the one hand, SDB is a severity-dependent risk factor for stroke and for stroke-related unfavourable short-term and long-term outcomes and on the other hand, stroke itself is a cause of new onset SDB or an aggravating factor of pre-existing SDB [6,30,34].…”

Sleep duration and risk of cardiovascular events: The SAVE study

“…Our finding of a potential harmful association of long sleep duration and stroke but not cardiac events in OSA patients contrasts with studies of the general population. 14,15 This may reflect the underlying mechanism of CV diseases and OSA, where a study has shown untreated severe OSA to be an independent risk factor for stroke but not coronary heart disease in elderly patients, 16 and two meta-analyses reporting much stronger associations of OSA and stroke rather than cardiac events. 17,18 One explanation is an apparent differential link in that acute or long-term intermittent hypoxia may impact differently on the brain compared to the heart in relation to variable collateral vasculature.…”