Sleep Apnea, Daytime Sleepiness Associated With Increased Atherosclerosis Risk and Progression

Érique José Farias Peixoto de Miranda, PhD

Obstructive sleep apnea (OSA) may serve as a viable predictor of incidence and progression of atherosclerosis—and therefore, future major adverse cardiovascular events (MACE), according to new findings from an international study.

In late-breaking data presented at the Associated Professional Sleep Societies (SLEEP) 2022 Annual Meeting this week, a team of investigators from Brazil and the US found evidence drawing a biological link between excessively sleepy patients and greater risk of cardiovascular disease and events.

Investigators, led by Érique José Farias Peixoto de Miranda, PhD, of the division of clinical trials at the Institute of Butantan in Sao Paulo, analyzed the role of OSA and associated clinical features on coronary artery calcium (CAC) prevalence, incidence and progression to disease in a cohort of participants from the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil) from 2008 – 2013.

“Recent evidence suggests that symptomatic OSA patients are susceptible to cardiovascular events,” they wrote. “The development of atherosclerosis is a plausible mechanism but the impact of OSA on atherosclerosis is unclear.”

ELSA-Brasil investigators had conducted a series of sleep analyses including patient questionnaires, actigraphy and home sleep studies during the trial. CAC scores were measured by a 64-slice multi-detector computed tomography, with prevalent subclinical atherosclerosis defined as CAC >0 at baseline.

Investigators additionally defined incident atherosclerosis as baseline CAC score of 0 followed by >0 at the patient’s 5-year follow-up visit. CAC progression was defined by baseline score of 0 followed by an increase in scores at follow-up.

OSA was defined by apnea-hypopnea index (AHI) scores of ≥15 events per hour. Del Miranda and colleagues assessed the link between patient OSA and subclinical atherosclerosis prevalence, incidence and progression via logistic regression. They adjusted each outcome by relevant cardiovascular risk factors. Analyses were additionally stratified based on observed excessive daytime sleepiness (EDS).

The final analysis included 1956 patients with available baseline CAC scores. Mean age was 49 years old; a majority of patients women (57.9%) and 28.2% were diagnosed with OSA.

The team observed a 12 percentage-point increased prevalence of subclinical atherosclerosis in patients with OSA (31.3%) versus those without (19.0%; P <.001). In a longitudinal analysis involving 1247 patients followed up with for a mean 5.1 years, the investigators observed a significant association between OSA and incident subclinical atherosclerosis among patients who reported EDS (adjusted odds ratio [OR], 1.97; 95% CI, 1.09 – 3.55; P = .024).

Additionally, the team’s analysis of CAC progression among 319 patients showed that OSA was associated with an 8% increased risk of atherosclerosis progression (1.08; 95% CI, 0.03 – 2.14; P = .043) while OSA and EDS were associated with a 66% increased risk (1.66; 95% CI, 0.23 – 3.04; P = .019).

“OSA, particularly with EDS, predicts the incidence and progression of subclinical atherosclerosis, a validated marker of future cardiovascular events,” investigators concluded. “These results provided biological plausibility for the higher cardiovascular risk observed in excessively sleepy patients.”

The study, “Incidence and Progression of Coronary Calcium Scores in Patients with Symptomatic Obstructive Sleep Apnea: the ELSA-Brasil study,” was presented at SLEEP 2022.