Association of Unrecognized Obstructive Sleep Apnea With Postoperative Cardiovascular Events in Patients Undergoing Major Noncardiac Surgery

Chan, MTV; Chew, YW; Seet, E; Tam, S; Lai, HY; Chew, EFF; Wu, WKK; Cheng, BCP; Lam, CKM; Short, TG; Hui, DSC; Chung, F; Chung, F; Chan, M; Wang, CY; Seet, E; Choi, G; Hui, D; Gin, T; Tam, S; Iqbal, S; Chan, M; Choi, G; Hui, D; Gin, T; Tsang, M; Fung,

Chan, MTV (reprint author), Chinese Univ Hong Kong, Dept Anaesthesia & Intens Care, Prince Wales Hosp, Shatin, 4-F Main Clin Block & Trauma Ctr, Hong Kong, Peoples R China.

JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION, 2019; 321 (18): 1788

Abstract

IMPORTANCE Unrecognized obstructive sleep apnea increases cardiovascular risks in the general population, but whether obstructive sleep apnea poses a similar risk in the perioperative period remains uncertain. OBJECTIVES To determine the association between obstructive sleep apnea and 30-day risk of cardiovascular complications after major noncardiac surgery. DESIGN, SETTING, AND PARTICIPANTS Prospective cohort study involving adult at-risk patients without prior diagnosis of sleep apnea and undergoing major noncardiac surgery from 8 hospitals in 5 countries between January 2012 and July 2017, with follow-up until August 2017. Postoperative monitoring included nocturnal pulse oximetry and measurement of cardiac troponin concentrations. EXPOSURES Obstructive sleep apnea was classified as mild (respiratory event index [REI] 5-14.9 events/h), moderate (REI 15-30), and severe (REI >30), based on preoperative portable sleep monitoring. MAIN OUTCOMES AND MEASURES The primary outcome was a composite of myocardial injury, cardiac death, heart failure, thromboembolism, atrial fibrillation, and stroke within 30 days of surgery. Proportional-hazards analysis was used to determine the association between obstructive sleep apnea and postoperative cardiovascular complications. RESULTS Among a total of 1364 patients recruited for the study, 1218 patients (mean age, 67 [SD, 9] years; 40.2% women) were included in the analyses. At 30 days after surgery, rates of the primary outcome were 30.1% (41/136) for patients with severe OSA, 22.1% (52/235) for patients with moderate OSA, 19.0% (86/452) for patients with mild OSA, and 14.2% (56/395) for patients with no OSA. OSA was associated with higher risk for the primary outcome (adjusted hazard ratio [HR], 1.49 [95% Cl, 1.19-2.01]; P = .01); however, the association was significant only among patients with severe OSA (adjusted HR, 2.23 [95% Cl, 1.49-3.34]; P = .001) and not among those with moderate OSA (adjusted HR, 1.47 [95% Cl, 0.98-2.09]; P = .07) or mild OSA (adjusted HR, 1.36 [95% Cl, 0.97-1.91]; P = .08) (P = .01 for interaction). The mean cumulative duration of oxyhemoglobin desaturation less than 80% during the first 3 postoperative nights in patients with cardiovascular complications (23.1 [95% Cl, 15.5-27.7] minutes) was longer than in those without (10.2 [95% Cl, 7.8-10.9] minutes) (P < .001). No significant interaction effects on perioperative outcomes were observed with type of anesthesia, use of postoperative opioids, and supplemental oxygen therapy. CONCLUSIONS AND RELEVANCE Among at-risk adults undergoing major noncardiac surgery, unrecognized severe obstructive sleep apnea was significantly associated with increased risk of 30-day postoperative cardiovascular complications. Further research would be needed to assess whether interventions can modify this risk.

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