Cardiovascular mortality in obstructive sleep apnea in the elderly: role of long-term continuous positive airway pressure treatment: a prospective observational study.

RATIONALE: Obstructive sleep apnea (OSA) is a risk factor for cardiovascular death in middle-aged subjects, but it is not known whether it is also a risk factor in the elderly. OBJECTIVES: To investigate whether OSA is a risk factor for cardiovascular death and to assess whether continuous positive airway pressure (CPAP) treatment is associated with a change in risk in the elderly. METHODS: Prospective, observational study of a consecutive cohort of elderly patients (≥65 yr) studied for suspicion of OSA between 1998 and 2007. Patients with an apnea-hypopnea index (AHI) less than 15 were the control group. OSA was defined as mild to moderate (AHI, 15-29) or severe (AHI, ≥30). Patients with OSA were classified as CPAP-treated (adherence ≥ 4 h/d) or untreated (adherence < 4 h/d or not prescribed). Participants were monitored until December 2009. The end point was cardiovascular death. A multivariate Cox survival analysis was used to determine the independent impact of OSA and CPAP treatment on cardiovascular mortality. MEASUREMENTS AND MAIN RESULTS: A total of 939 elderly were studied (median follow-up, 69 mo). Compared with the control group, the fully adjusted hazard ratios for cardiovascular mortality were 2.25 (confidence interval [CI], 1.41 to 3.61) for the untreated severe OSA group, 0.93 (CI, 0.46 to 1.89) for the CPAP-treated group, and 1.38 (CI, 0.73 to 2.64) for the untreated mild to moderate OSA group. CONCLUSIONS: Severe OSA not treated with CPAP is associated with cardiovascular death in the elderly, and adequate CPAP treatment may reduce this risk.

Cardiovascular mortality in women with obstructive sleep apnea with or without continuous positive airway pressure treatment: a cohort study.

BACKGROUND: Obstructive sleep apnea (OSA) is a risk factor for cardiovascular death in men, but whether it is also a risk factor in women is unknown. OBJECTIVE: To investigate whether OSA is a risk factor for cardiovascular death in women and assess whether continuous positive airway pressure (CPAP) treatment is associated with a change in risk. DESIGN: Prospective, observational cohort study. SETTING: 2 sleep clinics in Spain. PATIENTS: All women consecutively referred for suspected OSA between 1998 and 2007. INTERVENTION: Every woman had a diagnostic sleep study. Women with an apnea-hypopnea index (AHI) less than 10 were the control group. Obstructive sleep apnea was diagnosed when the AHI was 10 or higher (classified as mild to moderate [AHI of 10 to 29] or severe [AHI ≥30]). Patients with OSA were classified as CPAP-treated (adherence ≥4 hours per day) or untreated (adherence <4 hours per day or not prescribed). Participants were followed until December 2009. MEASUREMENTS: The end point was cardiovascular death. RESULTS: 1116 women were studied (median follow-up, 72 months [interquartile range, 52 to 88 months]). The control group had a lower cardiovascular mortality rate (0.28 per 100 person-years [95% CI, 0.10 to 0.91]) than the untreated groups with mild to moderate OSA (0.94 per 100 person-years [CI, 0.10 to 2.40]; P = 0.034) or severe OSA (3.71 per 100 person-years [CI, 0.09 to 7.50]; P < 0.001). Compared with the control group, the fully adjusted hazard ratios for cardiovascular mortality were 3.50 (CI, 1.23 to 9.98) for the untreated, severe OSA group; 0.55 (CI, 0.17 to 1.74) for the CPAP-treated, severe OSA group; 1.60 (CI, 0.52 to 4.90) for the untreated, mild to moderate OSA group; and 0.19 (CI, 0.02 to 1.67) for the CPAP-treated, mild to moderate OSA group. LIMITATION: The study was observational and not randomized, and OSA was diagnosed by 2 different methods. CONCLUSION: Severe OSA is associated with cardiovascular death in women, and adequate CPAP treatment may reduce this risk. PRIMARY FUNDING SOURCE: None.

[Appropriateness of hospital admissions to a pulmonology department]. / Adecuación de los ingresos hospitalarios en un servicio de neumología.

OBJECTIVES: To analyze the rate of inappropriate admissions to a pulmonology department over the period of a year and to establish the reasons for such admission and predictors. PATIENTS AND METHODS: All 2004 admissions to the pulmonology department of the Hospital de Valme were analyzed using a version of the Appropriateness Evaluation Protocol (AEP) developed for concurrent review. Two physicians who were not directly involved in admitting the patients performed the review. A logistic regression analysis was performed in order to identify the independent predictors of inappropriate hospital admission. RESULTS: Of the 633 admissions analyzed, 92.1% (n = 583) were appropriate and 7.9% (n = 50) were inappropriate. The main reason for considering an admission to be inappropriate was that the patients in question could have been managed as outpatients (70%), whereas appropriate admissions were most frequently justified by the need for parenteral treatment (76.3%) or respiratory therapy (62%). In the logistic regression analysis, the variables that were independently associated with inappropriate admission were nonurgent admission (odds ratio, 2.82; 95% confidence interval, 1.28-6.21; P = .01), and a neoplasia diagnosis as the reason for admission (odds ratio, 8.57; 95% confidence interval, 2.69-27.24; P < .0005). CONCLUSIONS: The rate of inappropriate hospital admissions was lower than that reported in other studies. Most inappropriate admissions were of patients who could have been managed as outpatients. An admission diagnosis of neoplasm and nonurgent admission were independent predictors of inappropriateness.

Mortality in obstructive sleep apnea-hypopnea patients treated with positive airway pressure.

STUDY OBJECTIVES: The aims of this study were to analyze mortality in patients with obstructive sleep apnea-hypopnea syndrome (OSAHS) treated with positive airway pressure (PAP) and to know whether PAP compliance affects survival, as well as to investigate the prognostic value of several pretreatment variables. DESIGN AND PATIENTS: A study was made of an historical cohort of 871 patients in whom OSAHS had been diagnosed by sleep study between January 1994 and December 2000 and who had been treated with PAP. Patients were followed up until December 2001. The mean (+/- SD) age of the group was 55.4 +/- 10.6 years, the mean apnea-hypopnea index (AHI) 55.1 +/- 28.7, and 80.9% were men. To assess whether mortality was influenced by PAP therapy compliance, patients were assigned to one of the following compliance categories: < 1 h/d; 1 to 6 h/d; or > 6 h/d. Survival rates were calculated according to the Kaplan-Meier method. Survival curves were compared with the log-rank test and the trend test, when necessary. Univariate and multivariate analyses using a time-dependent Cox model were performed to elicit which variables correlated with mortality. SETTING: Outpatient sleep disorders unit. RESULTS: By the end of the follow-up period (mean duration, 48.5 +/- 22.7 months), 46 patients had died. The 5-year cumulative survival rates were significantly lower in patients who did not use PAP (compliance < 1 h) than in those who used the device for > 6 h/d (85.5% [95% confidence interval (CI), 0.78 to 0.92] vs 96.4% [95% CI, 0.94 to 0.98; p < 0.00005]) and 1 to 6 h/d (85.5% [95% CI, 0.78 to 0.92] vs 91.3% [ 95% CI, 0.88 to 0.94; p = 0.01]), respectively. A trend in survival rates across the groups was identified (p = 0.0004). The main cause of death in 19 cases was cardiovascular disease (CVD). Variables that independently correlated with mortality in the multivariate analysis were the following PAP use categories: compliance for > 6 h/d (odds ratio [OR], 0.10; 95% CI, 0.04 to 0.29); compliance for 1 to 6 h/d (OR, 0.28; 95% CI, 0.11 to 0.69); arterial hypertension (AHT) [OR, 3.25; 95% CI, 1.24 to 8.54]; age (OR, 1.06; 95% CI, 1.01 to 1.10); and FEV1 percent predicted (OR, 0.96; 95% CI, 0.94 to 0.98). CONCLUSION: Mortality rates in OSAHS patients who did not receive PAP therapy were higher compared with those treated with PAP and were moderately or highly compliant with therapy. A trend in survival across compliance categories was found. Patients died mainly from CVD. Categories of PAP compliance, AHT, age, and FEV1 percent predicted were the variables that independently predicted mortality.