Neighborhood Disadvantage Association with Sleep Apnea and Longitudinal Cardiovascular Events and Mortality

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RATIONALE: Neighborhood socioeconomic disadvantage is associated with adverse cardiovascular outcomes, but its relationship with obstructive sleep apnea (OSA) severity and sleep-related hypoxemia is not well defined. OBJECTIVE: To assess the association of Area Deprivation Index (ADI) with OSA and major adverse cardiovascular events (MACE). METHODS: We conducted an observational cohort study of adults in a large institutional sleep registry who underwent polysomnography (PSG) or type III sleep testing. Neighborhood disadvantage was quantified using Area Deprivation Index (ADI) quintiles (ADI-Q1 least disadvantaged; ADI-Q5 most disadvantaged). Associations between ADI, OSA severity (apnea-hypopnea index [AHI]), sleep hypoxemia (percentage of sleep time with oxygen saturation<90%, T90), and incident MACE (heart failure, stroke, atrial fibrillation, coronary artery disease, or death) were assessed using multivariable models adjusted for demographics, comorbidities, smoking, and cardiovascular medications. MEASUREMENTS AND MAIN RESULTS: Among 72,443 adults (52,874 PSG;19,569 type III testing), greater neighborhood deprivation was associated with more severe sleep-related hypoxia (higher T90 and lower oxygen saturation nadir; p < 0.0001) but not with AHI. Over median follow-up of 5.6 years (PSG) and 2.8 years (type III), residence in the most disadvantaged neighborhoods was associated with increased risk of MACE or death (PSG ADI-Q5 vs Q1:HR1.22,95%CI1.13-1.33; type III ADI-Q4 vs Q1:HR1.41,95%CI1.12-1.78). In the type III cohort, hypoxia modified the association between ADI and outcomes (interaction p = 0.025). CONCLUSIONS: Neighborhood disadvantage is associated with greater sleep-related hypoxia and worse cardiovascular outcomes among patients evaluated for OSA, independent of apnea frequency. Incorporating measures of sleep-related hypoxia and neighborhood disadvantage into cardiovascular risk stratification may play a role in the identification of high-risk populations.

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