Incident coronary calcium score in patients with obstructive sleep apnea with and without excessive sleepiness: the ELSA-Brasil study

ABSTRACT

Background There is uncertainty about the impact of obstructive sleep apnea (OSA) and its phenotypes on cardiovascular disease. Research Question Are OSA and clinical features such as daytime sleepiness associated with incident subclinical coronary atherosclerosis? Study Design and Methods In this prospective community-based cohort study, we performed a sleepiness questionnaire, actigraphy, and home sleep studies at baseline. Coronary artery calcium, CAC (64-slice multi-detector computed tomography) was measured at two different time points throughout the study (baseline, between 2010-2014, and follow-up, between 2016-2018). Incidence of subclinical atherosclerosis was defined as baseline CAC=0 followed by CAC>0 at a 5-year follow-up visit. The association of incident CAC outcome was assessed using logistic regression. Stratified analyses based on excessive daytime sleepiness (EDS) were performed. Results We analyzed 1,956 participants with available CAC scores at baseline (age 49±8 years; 57.9% women; 32.4% with OSA). In covariate-adjusted analyses (n=1,247, mean follow-up=5.1±0.9 years), we found a significant association between OSA and incidence of subclinical atherosclerosis (OR=1.26; 95% CI 1.06–1.48), with stronger effects among those reporting EDS (OR=1.66; 95% CI 1.30–2.12; p for interaction=0.028). Interestingly, EDS per se was not associated with any CAC outcome. An exploratory analysis of CAC progression (baseline CAC>0 followed by a numerical increase in scores at follow-up) (n=319) showed a positive association for both OSA (β=1.084; 95% CI 0.032 to 2.136; p=0.043) and OSA with EDS (β=1.651; 95% CI 0.208 to 3.094; p=0.025). Interpretation OSA, particularly with EDS, predicts the incidence and progression of CAC. These results support biological plausibility for the increased cardiovascular risk observed among patients with OSA with excessive sleepiness.