Neighborhood Disadvantage Association with Sleep Apnea and Longitudinal Cardiovascular Events in a Large Clinical Cohort
Authors: Pena-Orbea Cinthya , Bruckman David , Dalton Jarrod E. , Thornton J. Daryl , Alberts Jay L. , Heinzinger Catherine M. , Foldvary-Schaefer Nancy , Mehra Reena 
Published: February 2024

Background

The association between neighborhood socioeconomic disadvantage and poor cardiovascular outcomes is well established; however, less is known about its interplay with obstructive sleep apnea.

Methods

Adult cardiovascular disease-naïve patients who underwent sleep testing at Cleveland Clinic in Ohio from August of 1998 to August of 2021 were included in this cohort. The primary exposure was Area Deprivation Index (ADI) calculated by national rank, i.e. 25th, 50th,and 75thpercentiles; higher quartiles reflecting greater deprivation (ADI-Q1-4) with Q1 as reference. Cox proportional hazard models were used to determine the hazard of composite outcome of major adverse cardiovascular events (MACE), i.e. including heart failure, stroke, atrial fibrillation and coronary artery disease or death, adjusted for demographics, comorbidities, cardiac medications and objective OSA-related measures including of Apnea Hypopnea Index (AHI) and sleep-related hypoxia (percentage of sleep time spent<90%SaO2,T90). Linear models were used to examine the relationship between ADI and OSA-related measures. Interaction terms were tested between ADI and OSA-related measures.

Results

Of 72,443 adults age was 50.4±14.2 years, 50.5% were men, and 18.4% Black individuals. The median AHI was 14.3[5.8, 33.3] with a median follow-up of 4.39 [IQR,1.76-7.92] years. The relative incidence of initial MACE in the presence of competing risk of death was 17% higher (HR,1.17[95%CI 1.09-1.27],p<.001) for those living in ADI-Q4. Greater levels of area deprivation were associated with sleep-related hypoxia measures including higher degree of T90(p<.001); lower mean SaO2(p<.001), and lower minimum SaO2(p<.001). Significant interactions between T90 and ADI were observed with the risk of MACE(p=0.002) or death(p=0.005). T90 conferred a 37% increased risk of MACE(HR, 1.37[95%CI:1.23-1.53]) for those living in ADI-Q1; and a 26% increased risk(HR, 1.26[95%CI:1.14-1.38%]) among patients living in ADI-Q4. For individuals living in ADI-Q2 and Q3, T90 conferred a respective 56% and 51% increased risk of death (HR,1.56[95%CI:1.23 - 1.96]; HR, 1.51[95%CI:1.21-1.88]), respectively.

Conclusions

Neighborhood disadvantage was associated with an increased risk for MACE or death in this clinical cohort and this association was modified by sleep-related hypoxia. Further research is needed to identify neighborhood-specific social determinants contributing to sleep-cardiovascular health disparities to develop neighborhood-specific interventions.

Clinical Perspective

What is new?

This is the largest-to-date longitudinal study using a large clinically phenotyped sample that uncovers the association of neighborhood socioeconomic position and sleep apnea with major cardiovascular events and mortality.

In this cohort, patients with increased sleep-related hypoxia living in both extremes of area deprivation had an increased risk for major adverse cardiovascular events, whereas individuals with increased sleep-related hypoxia living in moderate areas of deprivation had an increased risk for death.

What Are the Clinical Implications?

Addressing disparities in sleep-related hypoxia may be a modifiable and targetable intervention to decreased overall health disparities cardiovascular health.

There is a call to action to develop future studies examining neighborhood-level social determinants of health that influence increased sleep-related hypoxia in patients with sleep apnea to improve cardiovascular outcomes across all populations at risk for health inequities.