Sleep-disordered breathing and cardiovascular disease: an outcome-based definition of hypopneas

Abstract

Rationale: Epidemiologic studies on the consequences of sleep-disordered breathing invariably use the apnea-hypopnea index as the primary measure of disease severity. Although hypopneas constitute a majority of disordered breathing events, significant controversy remains about the best criteria used to define these events.

Objectives: The current investigation sought to assess the most appropriate definition for hypopneas that would be best correlated with cardiovascular disease.

Methods: A community sample of middle-aged and older adults was recruited as part of the Sleep Heart Health Study. Full-montage polysomnography was conducted and hypopneas were defined using different thresholds of oxyhemoglobin desaturation with and without arousals. Prevalent cardiovascular disease was assessed based on self-report. Logistic regression analysis was used to characterize the independent association between the hypopnea index and prevalent cardiovascular disease.

Measurements and main results: Using a sample of 6,106 adults with complete data on cardiovascular disease status and polysomnography, the current study found that hypopneas associated with an oxyhemoglobin desaturation of 4% or more were associated with prevalent cardiovascular disease independent of confounding covariates. The adjusted prevalent odds ratios for quartiles of the hypopnea index using a 4% desaturation criterion were as follows: 1.00 (<1.10 events/h), 1.10 (1.01-3.20 events/h), 1.33 (3.21-7.69 events/h), and 1.41 (>7.69 events/h). Hypopnea measures based on less than 4% oxyhemoglobin desaturation or presence of arousals showed no association with cardiovascular disease.

Conclusions: Hypopneas comprise a significant component of sleep-disordered breathing in the general community. By varying the criteria for defining hypopneas, this study demonstrates that hypopneas with a desaturation of at least 4% are independently associated with cardiovascular disease. In contrast, no association was observed between cardiovascular disease and hypopneas associated with milder desaturations or arousals.

Figure 1.

Adjusted odds ratios for prevalent cardiovascular disease derived from multivariable logistic regression models for the hypopnea index at different oxyhemoglobin desaturation thresholds (A: ⩾4%, B: ⩾3%, C: ⩾2%, D: any desaturation). Covariates include age, sex, race, body mass index, waist circumference, neck circumferences, total cholesterol, high-density lipoprotein cholesterol, smoking status, and the apnea index at the same threshold as the hypopnea index. Cut points for the first quartile were as follows: (A) <1.01 events/hour; (B) <3.15 events/hour; (C) <8.51 events/hour; and (D) <17.12 events/hour.