Obstructive Sleep Apnea in Patients Admitted for Acute Myocardial Infarction: Prevalence, Predictors, and Effect on Microvascular Perfusion

doi:10.1378/chest.08-2336

Chest

Volume 135, Issue 6, June 2009, Pages 1488-1495

https://doi.org/10.1378/chest.08-2336 Get rights and content

Background

We investigated the prevalence and predictors of obstructive sleep apnea in patients admitted to the hospital for acute myocardial infarction and whether OSA has any association with microvascular perfusion after primary percutaneous coronary intervention.

Methods

Recruited patients were scheduled to undergo an overnight sleep study between 2 and 5 days after primary PCI. An apnea-hypopnea index of ≥ 15 was considered diagnostic of OSA. Impaired microvascular perfusion after primary PCI was defined as an ST-segment resolution of ≤ 70%, myocardial blush grade 0 or 1, or a corrected Thrombolysis in Myocardial Infarction [antegrade flow scale] frame count > 28.

Results

Sleep study was performed in 120 patients and completed in 105 patients (study cohort, mean age 53 ± 10 years, male 98%) with uncomplicated myocardial infarction. An AHI was ≥ 15 in 69 patients (OSA-positive), giving a prevalence of 65.7%. Diabetes mellitus was found to be a significant risk factor for OSA (odds ratio, 2.86; 95% confidence interval, 1.06 to 8.24; p = 0.033). There were no differences between OSA-positive and OSA-negative groups with regard to the percentage of patients with ≤ 70% ST-segment resolution (73% vs 64%, respectively; p = 0.411), myocardial blush grade 0 or 1 (39.1% vs 38.9%, respectively; p = 1.000), or corrected TIMI frame count > 28 (21.7% vs 25.0%, respectively; p = 0.807).

Conclusions

We found a high prevalence of previously undiagnosed OSA in patients admitted with acute myocardial infarction. Diabetes mellitus was independently associated with OSA. No evidence indicated that OSA is associated with impaired microvascular perfusion after primary PCI.

Section snippets

Study Design and Patient Population

This was a prospective observational study in a tertiary institution in which primary PCI is the recommended revascularization strategy for acute myocardial infarction presenting within 12 h of symptom onset. Patients 21 to 80 years of age who were admitted to the National University Hospital in Singapore with a first acute myocardial infarction and who underwent a primary PCI were eligible. Exclusion criteria were patients with known OSA, those who were intubated and receiving mechanical

Results

Between January 2007 and April 2008, a total of 290 patients who had undergone primary PCI for a first acute myocardial infarction were screened. An overnight sleep study was done in 120 patients and completed in 105 patients (Fig 1). The sleep study was not tolerated, and therefore discontinued prematurely, in the remaining 15 patients. Among the 105 patients who formed the study cohort, the mean (± SD) age was 53 ± 10 years, and the majority (n = 103, 98%) were men. Table 1 shows the baseline

Discussion

The intimate relation between OSA and cardiovascular diseases has been gradually uncovered over the last decade. In patients with stable coronary artery disease, depending on sex and AHI cutoff, prevalence of OSA ranges from 30 to 54%.31, 32 Treatment of OSA with CPAP is associated with a decrease in the occurrence of new cardiovascular events.³³ However, the prevalence and predictors of OSA in patients with acute myocardial infarction, as well as whether OSA has any association on

Conclusion

In conclusion, we found a high prevalence of previously undiagnosed OSA in patients admitted to the hospital with acute myocardial infarction. Diabetes mellitus is a significant predictor for OSA. Although we did not find an association between OSA and impaired microvascular perfusion after primary PCI, in view of the high prevalence and negative impact on long-term clinical outcomes, screening for OSA is warranted. We suggest that overnight sleep studies be performed on patients with diabetes

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Cited by (133)

Proteomic profiling for prediction of recurrent cardiovascular event in patients with acute coronary syndrome and obstructive sleep apnea: A post-hoc analysis from the ISAACC study
2023, Biomedicine and Pharmacotherapy
Obstructive sleep apnea (OSA) is associated with a recurrent cardiovascular event (CVE) risk in patients with a first acute coronary syndrome (ACS). However, the pathological pathways by which OSA promotes this deleterious role are unknown. We aim to explore the proteomic profile associated with OSA that promote the recurrent CVE risk in severe OSA patients with ACS without previous cardiovascular diseases.
This post-hoc analysis from the ISAACC study (NCT01335087) included 86 patients admitted for ACS. Patients underwent respiratory polygraphy for the first 24–72 h to OSA diagnosis. We analyzed of 276 cardiovascular and inflammatory related proteins in baseline fasting plasma samples using proximity expression assay technology (Olink®, Sweden). Protein levels were compared between severe OSA patients with/without recurrent CVEs during follow-up. Random forest was conducted to select relevant proteins and generate a predictive model of recurrent CVE.
We included 86 patients (median age: 61 years, median BMI: 29.4 kg/m² and 86 % males) admitted for ACS with severe OSA (56 without recurrent CVE/30 with recurrent CVE). The plasma levels of 38 proteins were differentially expressed between groups. Additionally, 12 proteins had a significant association with respiratory polygraphy parameters. Three proteins discriminate with an AUC of 0.81 (95 % CI of 0.71–0.9) between severe OSA patients with and without recurrent CVE. These proteins were implicated in cell proliferation, communication and apoptosis, and regulation/response to the inflammatory and immune systems.
In ACS patients with severe OSA, a proteomic profile was associated with recurrent CVEs. This proteomic profile was correlated with specific OSA parameters from respiratory polygraphy. Proteomic profiling may provide an new direction for patient risk stratification and clinical management.
Obstructive sleep apnea during acute coronary syndrome is related to myocardial necrosis and wall stress
2021, Sleep Medicine
The relative contribution of pathophysiological mechanisms in acute coronary syndrome (ACS) towards obstructive sleep apnea (OSA) is not well-studied. We examined the correlation between severity of OSA and inflammation, myocardial necrosis, wall stress, and fibrosis.
A total of 89 patients admitted with ACS underwent a sleep study during index admission. Plasma levels of high-sensitivity C-reactive protein (hs-CRP), troponin I, N-terminal pro-brain natriuretic peptide (NT-proBNP), and suppression of tumorigenicity 2 (ST2) were prospectively analyzed. Two patients diagnosed with central sleep apnea were excluded.
The recruited patients were divided into no (AHI <5 events/hour, 9.2%), mild (5-<15, 27.6%), moderate (15-<30, 21.8%), and severe (≥30, 41.4%) OSA. Compared to the no, mild and moderate OSA groups, the severe OSA group had a higher body mass index (p = 0.005). They were also more likely to present with ST-segment elevation ACS (versus non-ST-segment elevation ACS) (p = 0.041), have undergone previous coronary artery bypass grafting (p = 0.013), demonstrate complete coronary occlusion during baseline coronary angiography (p = 0.049), and have a larger left atrial diameter measured on echocardiography (p = 0.029). Likewise, the severe OSA group had higher plasma levels of hs-CRP (p = 0.004), troponin I (p = 0.017), and NT-proBNP (p = 0.004), but not ST2 (p = 0.10). After adjustment for the effects of confounding variables, OSA was independently associated with troponin I (ie, myocardial necrosis; p = 0.001) and NT-proBNP (ie, myocardial wall stress; p = 0.008).
Severe OSA during the acute phase of ACS was associated with extensive myocardial necrosis and high myocardial wall stress, but not with inflammation and myocardial fibrosis.
Integrating the STOP-BANG Score and Clinical Data to Predict Cardiovascular Events After Infarction: A Machine Learning Study
2020, Chest
OSA conveys worse clinical outcomes in patients with coronary artery disease. The STOP-BANG score is a simple tool that evaluates the risk of OSA and can be added to the large number of clinical variables and scores that are obtained during the management of patients with myocardial infarction (MI). Currently, machine learning (ML) is able to select and integrate numerous variables to optimize prediction tasks.
Can the integration of STOP-BANG score with clinical data and scores through ML better identify patients who experienced an in-hospital cardiovascular event after acute MI?
This is a prospective observational cohort study of 124 patients with acute MI of whom the STOP-BANG score classified 34 as low (27.4%), 30 as intermediate (24.2%), and 60 as high (48.4%) OSA-risk patients who were followed during hospitalization. ML implemented feature selection and integration across 47 variables (including STOP-BANG score, Killip class, GRACE score, and left ventricular ejection fraction) to identify those patients who experienced an in-hospital cardiovascular event (ie, death, ventricular arrhythmias, atrial fibrillation, recurrent angina, reinfarction, stroke, worsening heart failure, or cardiogenic shock) after definitive MI treatment. Receiver operating characteristic curves were used to compare ML performance against STOP-BANG score, Killip class, GRACE score, and left ventricular ejection fraction, independently.
There were an increasing proportion of cardiovascular events across the low, intermediate, and high OSA risk groups (P = .005). ML selected 7 accessible variables (ie, Killip class, leukocytes, GRACE score, c reactive protein, oxygen saturation, STOP-BANG score, and N-terminal prohormone of B-type natriuretic peptide); their integration outperformed all comparators (area under the curve, 0.83 [95% CI, 0.74-0.90]; P < .01).
The integration of the STOP-BANG score into clinical evaluation (considering Killip class, GRACE score, and simple laboratory values) of subjects who were admitted for an acute MI because of ML can significantly optimize the identification of patients who will experience an in-hospital cardiovascular event.
Non-traditional risk factors and the risk of myocardial infarction in the young in the US population-based cohort
2020, IJC Heart and Vasculature
Although most prevalent in elderly, myocardial infarction (MI) also affects younger adults. We sought to investigate baseline characteristics in young patients (<55 years) with MI using the National Inpatient Sample (NIS) database between 2004 and 2015. Multivariable logistic regression models were used to assess factors associated with acute myocardial infarction (AMI) in young patients. After multivariable analyses adjusted for age, sex, race, family history of atherosclerosis, body mass index (BMI), diabetes, hypertension, hyperlipidemia, chronic kidney disease, and current cigarette smoking; novel risk factors such as human immunodeficiency virus (HIV), systemic lupus erythematosus (SLE), and obstructive sleep apnea (OSA) were associated with a higher risk of developing an AMI in the young (adjusted OR for HIV 4.06; 95 CI 3.48–4.71, p < 0.001), (adjusted OR for SLE 2.12; 95 CI 1.89–2.39, p 0.04), and (adjusted OR for OSA 1.16; 95 CI 1.12–1.20, p < 0.001), respectively. Rheumatoid arthritis was associated with a lower risk of AMI (adjusted OR 0.83; 95 CI 0.76–0.89, p < 0.001). After multivariable analyses, cigarette smoking (adjusted OR 1.98; 95 CI 1.95–2.02, p < 0.001), obesity (adjusted OR 1.37; 95 CI 1.33–1.41, p = 0.003), hyperlipidemia (adjusted OR 1.07; 95 CI 1.04–1.08, p < 0.001) and a family history of CAD (adjusted OR 1.35; 95 CI 1.3–1.4, p < 0.001) were also associated with a higher risk of developing an AMI in the young. In conclusion, young patients with AMI have both traditional risk factors and non-traditional risk factors. In addition to traditional risk factors, close attention should be paid to emerging risk factors such as SLE, HIV and OSA.
Screening and treatment of obstructive sleep apnea in acute coronary syndrome. A randomized clinical trial
2020, International Journal of Cardiology
We evaluated the effects of sleep-study guided multidisciplinary therapy (SGMT) of obstructive sleep apnoea (OSA) in patients presenting with acute coronary syndrome.
Eligible patients were randomized into (1) SGMT, comprised a sleep study during the index admission and continuous positive airway pressure and behavioral therapy for those with at least mild OSA or (2) standard therapy. The primary end point was the change in the plasma N-terminal pro-brain natriuretic peptide (NT-proBNP) level from baseline to the 7-month follow-up.
A total of 159 patients completed the trial. Of the 70 patients randomized to SGMT, 21 (30%), 15 (22%) and 27 (39%) were diagnosed with mild, moderate and severe OSA, respectively. Continuous positive airway pressure and a positional pillow were prescribed to 57 (91%) and 6 (9%) patients with OSA. Although plasma NT-proBNP levels were lower after 7 months compared to the baseline, the levels did not differ significantly between the SGMT and standard therapy groups at baseline (579 ± 1117 vs. 611 ± 899 pg/dL, p = .851) or at 7 months (90 ± 167 vs. 93 ± 174 pg/dL, p = .996). The changes in NT-proBNP levels from baseline to 7 months were similar with SGMT and standard therapy (−489 vs. –518 pg/dL, p = .726). Similar findings were observed for the plasma ST2 and hs-CRP levels.
OSA screening and multifaceted treatment during the sub-acute phase of acute coronary syndrome did not further reduce the levels of cardiovascular biomarkers when compared with standard therapy.
Clinical Trial Registration: clinicaltrial.gov NCT02599298
Syndrome ‘Z’: A Predictor of Angiographic Severity of Coronary Artery Disease in Patients of Acute Coronary Syndrome
2019, Heart Lung and Circulation
Owing to the growing evidence that the pathophysiology of obstructive sleep apnoea (OSA) and metabolic syndrome (MS) overlap considerably and both adversely impact cardiovascular health, we hypothesised that the presence of OSA with MS additively and adversely affect the severity of coronary artery disease (CAD). Exploration and understanding of this may have direct implications for the development of targeted, preventive strategies for CAD. Thus, this prospective study was aimed to determine the prevalence of ‘Syndrome Z’ in patients of MS who present with an acute coronary event and to correlate it with the angiographic severity of CAD in these patients.
The present study was a single centre, cross sectional study conducted in a university teaching hospital. In a span of 6 months, 922 patients with acute coronary syndromes (ACS) were screened for the study. Among these, 861 patients had no evidence of MS. The remaining 61 patients who were diagnosed to have MS were then subjected to an overnight sleep study. Only 58 had good sleep data so were included for further analysis. Angiographic parameters in terms of number of vessels involved and culprit lesions were noted and correlated with presence and absence of OSA and also with its severity based on the Apnoea/Hypopnoea Index (AHI).
The prevalence of OSA positivity in patients with MS who presented with ACS was 34.5% (n = 20). Most of the patients in the OSA negative group (78.9%, n = 30) had disease limited to only one vessel while in the OSA positive group only a minority (15%, n = 3) of patients had their disease limited to a single vessel (p = 0.001). The number of lesions in the culprit vessel was also significantly less in the OSA negative group compared to the OSA positive group. While in the OSA negative group 68.4% (n = 26) patients had a solitary lesion, followed by two and three lesions in 15.8% (n = 6) of the patients each, multiple lesions were more common in OSA positive patients, involving 80% of cases (45.0%, n = 9 with two lesions; 35.0%, n = 7 with three lesions; only 20%, n = 4 had a solitary lesion).
Prevalence of ‘Syndrome Z’ is high in patients having MS presenting with ACS and it correlates with the angiographic severity of CAD.

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The authors have no conflicts of interest to disclose.

Source of funding: Cardiac Department Fund, National University Hospital, Singapore.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/site/misc/reprints.xhtml).

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Chest

Original ResearchSleep MedicineObstructive Sleep Apnea in Patients Admitted for Acute Myocardial Infarction: Prevalence, Predictors, and Effect on Microvascular Perfusion

Background

Methods

Results

Conclusions

Section snippets

Study Design and Patient Population

Results

Discussion

Conclusion

Lancet

Lancet

Lancet

J Am Coll Cardiol

Lancet

J Am Coll Cardiol

Chest

Thromb Res

J Am Coll Cardiol

Lancet

Am Heart J

Chest

Am J Med

Chest

Sleep Med

Am J Cardiol

Chest

Chest

J Am Coll Cardiol

Am Heart J

Prospective study of the association between sleep-disordered breathing and hypertension

N Engl J Med

Obstructive sleep apnea as a risk factor for stroke and death

N Engl J Med

Original Research
Sleep Medicine
Obstructive Sleep Apnea in Patients Admitted for Acute Myocardial Infarction: Prevalence, Predictors, and Effect on Microvascular Perfusion