Development, Validation, and Assessment of an Ischemic Stroke or Transient Ischemic Attack-Specific Prediction Tool for Obstructive Sleep Apnea

doi:10.1016/j.jstrokecerebrovasdis.2017.03.042

Randomized Controlled Trial

. 2017 Aug;26(8):1745-1754.

doi: 10.1016/j.jstrokecerebrovasdis.2017.03.042. Epub 2017 Apr 14.

Development, Validation, and Assessment of an Ischemic Stroke or Transient Ischemic Attack-Specific Prediction Tool for Obstructive Sleep Apnea

Affiliations

¹ Neurology Service, VA Connecticut Healthcare System, West Haven, Connecticut; Department of Neurology and Center for Neuroepidemiology and Clinical Neurological Research, Yale University School of Medicine, New Haven, Connecticut; Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut; Clinical Epidemiology Research Center (CERC), VA Connecticut Healthcare System, West Haven, Connecticut. Electronic address: jason.sico@yale.edu.
² Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut; Clinical Epidemiology Research Center (CERC), VA Connecticut Healthcare System, West Haven, Connecticut.
³ Department of Biostatistics, IUPUI, Indiana University School of Medicine, Indianapolis, Indiana.
⁴ VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center, Indianapolis, Indiana; Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, Indiana.
⁵ Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut; VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center, Indianapolis, Indiana.
⁶ Department of Biostatistics, Yale University School of Public Health, New Haven, Connecticut.
⁷ Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut.
⁸ Clinical Epidemiology Research Center (CERC), VA Connecticut Healthcare System, West Haven, Connecticut.
⁹ VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center, Indianapolis, Indiana; Department of Neurology, Indiana University School of Medicine, Indianapolis, Indiana; Regenstrief Institute, Indianapolis, Indiana.
¹⁰ VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center, Indianapolis, Indiana; Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, Indiana; Department of Neurology, Indiana University School of Medicine, Indianapolis, Indiana; Regenstrief Institute, Indianapolis, Indiana.

PMID: 28416405
PMCID: PMC6006998
DOI: 10.1016/j.jstrokecerebrovasdis.2017.03.042

Randomized Controlled Trial

Development, Validation, and Assessment of an Ischemic Stroke or Transient Ischemic Attack-Specific Prediction Tool for Obstructive Sleep Apnea

Jason J Sico et al. J Stroke Cerebrovasc Dis. 2017 Aug.

. 2017 Aug;26(8):1745-1754.

doi: 10.1016/j.jstrokecerebrovasdis.2017.03.042. Epub 2017 Apr 14.

Authors

Affiliations

¹ Neurology Service, VA Connecticut Healthcare System, West Haven, Connecticut; Department of Neurology and Center for Neuroepidemiology and Clinical Neurological Research, Yale University School of Medicine, New Haven, Connecticut; Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut; Clinical Epidemiology Research Center (CERC), VA Connecticut Healthcare System, West Haven, Connecticut. Electronic address: jason.sico@yale.edu.
² Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut; Clinical Epidemiology Research Center (CERC), VA Connecticut Healthcare System, West Haven, Connecticut.
³ Department of Biostatistics, IUPUI, Indiana University School of Medicine, Indianapolis, Indiana.
⁴ VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center, Indianapolis, Indiana; Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, Indiana.
⁵ Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut; VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center, Indianapolis, Indiana.
⁶ Department of Biostatistics, Yale University School of Public Health, New Haven, Connecticut.
⁷ Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut.
⁸ Clinical Epidemiology Research Center (CERC), VA Connecticut Healthcare System, West Haven, Connecticut.
⁹ VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center, Indianapolis, Indiana; Department of Neurology, Indiana University School of Medicine, Indianapolis, Indiana; Regenstrief Institute, Indianapolis, Indiana.
¹⁰ VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center, Indianapolis, Indiana; Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, Indiana; Department of Neurology, Indiana University School of Medicine, Indianapolis, Indiana; Regenstrief Institute, Indianapolis, Indiana.

PMID: 28416405
PMCID: PMC6006998
DOI: 10.1016/j.jstrokecerebrovasdis.2017.03.042

Abstract

Background: Screening instruments for obstructive sleep apnea (OSA), as used routinely to guide clinicians regarding patient referral for polysomnography (PSG), rely heavily on symptomatology. We sought to develop and validate a cerebrovascular disease-specific OSA prediction model less reliant on symptomatology, and to compare its performance with commonly used screening instruments within a population with ischemic stroke or transient ischemic attack (TIA).

Methods: Using data on demographic factors, anthropometric measurements, medical history, stroke severity, sleep questionnaires, and PSG from 2 independently derived, multisite, randomized trials that enrolled patients with stroke or TIA, we developed and validated a model to predict the presence of OSA (i.e., Apnea-Hypopnea Index ≥5 events per hour). Model performance was compared with that of the Berlin Questionnaire, Epworth Sleepiness Scale (ESS), the Snoring, Tiredness, Observed apnea, high blood Pressure, Body mass index, Age, Neck circumference, and Gender instrument, and the Sleep Apnea Clinical Score.

Results: The new SLEEP Inventory (Sex, Left heart failure, ESS, Enlarged neck, weight [in Pounds], Insulin resistance/diabetes, and National Institutes of Health Stroke Scale) performed modestly better than other instruments in identifying patients with OSA, showing reasonable discrimination in the development (c-statistic .732) and validation (c-statistic .731) study populations, and having the highest negative predictive value of all in struments.

Conclusions: Clinicians should be aware of these limitations in OSA screening instruments when making decisions about referral for PSG. The high negative predictive value of the SLEEP INventory may be useful in determining and prioritizing patients with stroke or TIA least in need of overnight PSG.

Keywords: Ischemic stroke; Obstructive sleep apnea; Screening; TIA.

Published by Elsevier Inc.

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Conflict of interest statement

J.J.S. has served as a consultant to Acorda Therapeutics; all other coauthors have no conflicts of interest or disclosures to report.

Figures

**Figure 1**
Receiving operator curves for SLEEP INventory and other predictors of obstructive sleep apnea

See this image and copyright information in PMC

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References

1. Yaggi H, Concato J, Kernan W, et al. Obstructive sleep apnea as a risk factor for stroke and death. NEJM. 2005;353:2034–2041. - PubMed
1. Kernan WN, Ovbiagele B, Black HR, et al. Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/ American Stroke Association. Stroke. 2014;45:2160–2236. - PubMed
1. Marin JM, Carrizo SJ, Vicente E, et al. Long-term cardiovascular outcomes in men with obstructive sleep apnoeahypopnoea with or without treatment with continuous positive airway pressure: an observational study. Lancet. 2005;365:1046–1053. - PubMed
1. Kanagala R, Murali N, Friedman P, et al. Obstructive sleep apnea and the recurrence of atrial fibrillation. Circulation. 2003;107:2589–2594. - PubMed
1. Arzt M, Young T, Peppard PE, et al. Dissociation of obstructive sleep apnea from hypersomnolence and obesity in patients with stroke. Stroke. 2010;41:e129–e134. - PMC - PubMed

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[1] Yaggi H, Concato J, Kernan W, et al. Obstructive sleep apnea as a risk factor for stroke and death. NEJM. 2005;353:2034–2041. - PubMed

[2] Yaggi H, Concato J, Kernan W, et al. Obstructive sleep apnea as a risk factor for stroke and death. NEJM. 2005;353:2034–2041. - PubMed

[3] Kernan WN, Ovbiagele B, Black HR, et al. Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/ American Stroke Association. Stroke. 2014;45:2160–2236. - PubMed

[4] Kernan WN, Ovbiagele B, Black HR, et al. Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/ American Stroke Association. Stroke. 2014;45:2160–2236. - PubMed

[5] Marin JM, Carrizo SJ, Vicente E, et al. Long-term cardiovascular outcomes in men with obstructive sleep apnoeahypopnoea with or without treatment with continuous positive airway pressure: an observational study. Lancet. 2005;365:1046–1053. - PubMed

[6] Marin JM, Carrizo SJ, Vicente E, et al. Long-term cardiovascular outcomes in men with obstructive sleep apnoeahypopnoea with or without treatment with continuous positive airway pressure: an observational study. Lancet. 2005;365:1046–1053. - PubMed

[7] Kanagala R, Murali N, Friedman P, et al. Obstructive sleep apnea and the recurrence of atrial fibrillation. Circulation. 2003;107:2589–2594. - PubMed

[8] Kanagala R, Murali N, Friedman P, et al. Obstructive sleep apnea and the recurrence of atrial fibrillation. Circulation. 2003;107:2589–2594. - PubMed

[9] Arzt M, Young T, Peppard PE, et al. Dissociation of obstructive sleep apnea from hypersomnolence and obesity in patients with stroke. Stroke. 2010;41:e129–e134. - PMC - PubMed

[10] Arzt M, Young T, Peppard PE, et al. Dissociation of obstructive sleep apnea from hypersomnolence and obesity in patients with stroke. Stroke. 2010;41:e129–e134. - PMC - PubMed

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Development, Validation, and Assessment of an Ischemic Stroke or Transient Ischemic Attack-Specific Prediction Tool for Obstructive Sleep Apnea

Affiliations

Development, Validation, and Assessment of an Ischemic Stroke or Transient Ischemic Attack-Specific Prediction Tool for Obstructive Sleep Apnea

Authors

Affiliations

Abstract

Conflict of interest statement

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Conflict of interest statement

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