Obstructive Sleep Apnea as a Risk Factor for Stroke and Death
H. Klar Yaggi, M.D., M.P.H., John Concato, M.D., M.P.H., Walter N. Kernan, M.D., Judith H. Lichtman, Ph.D., M.P.H., Lawrence M. Brass, M.D., and Vahid Mohsenin, M.D.
Background Previous studies have suggested that the obstructivesleep apnea syndrome may be an important risk factor for stroke.It has not been determined, however, whether the syndrome isindependently related to the risk of stroke or death from anycause after adjustment for other risk factors, including hypertension.
Methods In this observational cohort study, consecutive patientsunderwent polysomnography, and subsequent events (strokes anddeaths) were verified. The diagnosis of the obstructive sleepapnea syndrome was based on an apnea–hypopnea index of5 or higher (five or more events per hour); patients with anapnea–hypopnea index of less than 5 served as the comparisongroup. Proportional-hazards analysis was used to determine theindependent effect of the obstructive sleep apnea syndrome onthe composite outcome of stroke or death from any cause.
Results Among 1022 enrolled patients, 697 (68 percent) had theobstructive sleep apnea syndrome. At baseline, the mean apnea–hypopneaindex in the patients with the syndrome was 35, as comparedwith a mean apnea–hypopnea index of 2 in the comparisongroup. In an unadjusted analysis, the obstructive sleep apneasyndrome was associated with stroke or death from any cause(hazard ratio, 2.24; 95 percent confidence interval, 1.30 to3.86; P=0.004). After adjustment for age, sex, race, smokingstatus, alcohol-consumption status, body-mass index, and thepresence or absence of diabetes mellitus, hyperlipidemia, atrialfibrillation, and hypertension, the obstructive sleep apneasyndrome retained a statistically significant association withstroke or death (hazard ratio, 1.97; 95 percent confidence interval,1.12 to 3.48; P=0.01). In a trend analysis, increased severityof sleep apnea at baseline was associated with an increasedrisk of the development of the composite end point (P=0.005).
Conclusions The obstructive sleep apnea syndrome significantlyincreases the risk of stroke or death from any cause, and theincrease is independent of other risk factors, including hypertension.
Source Information
From the Section of Pulmonary and Critical Care Medicine, Yale Center for Sleep Medicine (H.K.Y., V.M.), the Section of General Medicine (J.C., W.N.K.), and the Departments of Epidemiology and Public Health (J.H.L., L.M.B.) and Neurology (L.M.B.), Yale University School of Medicine, New Haven, Conn.; and the Section of Pulmonary and Critical Care Medicine (H.K.Y.), the Clinical Epidemiology Research Center (H.K.Y., J.C.), and the Section of Neurology (L.M.B.), Veterans Affairs Connecticut Healthcare System, West Haven, Conn.
Address reprint requests to Dr. Mohsenin at the Yale Center for Sleep Medicine, 300 Cedar St., TAC 441, P.O. Box 208057, New Haven, CT 06520.
Sleep Apnea and Heart Disease
Sinha A.-M., Skobel E. C., Breithardt O.-A., Zheng H., Zhan H., Wilcox I., Booth V., Lattimore J., Chhajed P. N., Tamm M., Strobel W., Neuberger H.-R., Böhm M., Mewis C., Bradley T. D., Floras J. S., Logan A. G., Yaggi H. K., Concato J., Mohsenin V.
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N Engl J Med 2006;
354:1086-1089, Mar 9, 2006.
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