Burden and predictors of subsequent/recurrent stroke, associated sex/racial disparities and in-hospital outcomes in elderly patients with obstructive sleep apnea and prior stroke/TIA
Authors: Singh S , Ashfaque M , Tankasala S , James A , Nunez F , Bandaru R R , Ghanathe P , Shaik S , Ghumare I , Brereton B , Jain A , Desai R 
Published: May 2023

Abstract

Funding Acknowledgements
Type of funding sources: None.

Background
Obstructive Sleep Apnea (OSA) increases the risk of cardiovascular events and stroke. However, limited data on burden and impact of OSA on recurrent/subsequent stroke and associated hospitalization outcomes in geriatric patients (G-OSA) with prior stroke/TIA prompted us to perform this analysis.

Methods
The National Inpatient Sample (2019) was used to identify patients with G-OSA and prior stroke/TIA. We compared the rate of SS by sex and racial subgroups. We subdivided the G-OSA with and without subsequent stroke (SS+ vs SS-) and compared demographics and comorbidities. Primary outcomes included prevalence of SS, subsequentin-hospital all-cause mortality and multivariate predictors of SS in G-OSA patients with prior stroke/TIA. Secondary outcomes included healthcare resource utilization between SS+ vs SS- cohorts.

Results
Of 133,545 patients admitted with G-OSA and prior history of stroke/TIA, 4.9% (6520) had subsequent strokes including 3.7% of acute ischemic stroke (AIS). SS+ cohort comprised mainly of Males, Asian-Pacific Islander cvs. SS- cohort. On subgroup analysis based on Racial and gender distribution, the rate of SS was highest in Asian/Pacific islander (6%), and Native Americans (5.6%) followed by white, blacks and Hispanics, (4.9%, 4.6% & 4.1%), and Males had higher prevalence vs females (5.2% vs 4.4%; p&lt;0.001). In addition, despite similar median age of admission, SS+ cohort had higher burden of uncomplicated hypertension (42.7% vs 29.7%), diabetes without chronic complications (17.9% vs 12.8%), hyperlipidemia (76.5% vs 71.7%) and alcohol abuse (2.8% vs 1.6%) (all p&lt;0.001). Furthermore, a higher all-cause in-hospital mortality was noticed in in SS+ cohort (5.1% vs 1.6%; p&lt;0.001), which was prominently highger in Hispanics compared to whites and blacks (10.6% vs 4.9% vs 4.4%; p&lt;0.001) respectively with no gender disparity noticed. Significant clinical predictors of SS in G-OSA patients on multivariable regression analysis were found to be complicated and uncomplicated hypertension (aOR 2.17 [95CI 1.78-2.64; 3.18 [2.58-3.92]), diabetes with chronic complications (aOR 1.28 [95CI 1.08-1.51]), hyperlipidemia (aOR 1.24 [95CI 1.08-1.43]) and thyroid disorders (aOR 1.69 [95CI 1.14-2.49]). However, we noticed lower odds of SS in patient with obesity (0.86 [0.76-0.98]), prior MI (aOR 1.27 [95CI 1.22-1.33]) and chronic pulmonary disease (aOR 0.54[95CI 0.47-0.62]) [Table 1]. The SS+ cohort had fewer routine discharges and higher healthcare cost.

Conclusion
Nearly 5% of G-OSA patients with prior stroke/TIA history were hospitalized with a subsequent stroke which showed significantly higher mortality rate compared to patients with no subsequent stroke and had considerably higher healthcare resource utilization. Comorbidities including hypertension, diabetes, dyslipidemia and admissions in rural hospitals were independent predictors of having SS and warrant preventive strides for secondary prevention of stroke.