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

Educational Objective
To understand the association of unrecognized severe obstructive sleep apnea and postoperative cardiovascular complications.
1 Credit CME
Key Points

Question  What is the relationship between unrecognized obstructive sleep apnea (OSA) and 30-day cardiovascular complications after major noncardiac surgery?

Findings  In this prospective cohort study that included 1218 at-risk patients undergoing major noncardiac surgery, the rate of a composite outcome of postoperative cardiovascular events (myocardial injury, cardiac death, congestive heart failure, thromboembolism, atrial fibrillation, and stroke) among those with OSA vs no OSA was 21.7% vs 14.2%, a difference that was statistically significant. However, the difference was significant only for the subgroup with severe OSA.

Meaning  Among patients undergoing major noncardiac surgery, severe OSA was significantly associated with 30-day cardiovascular complications.

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% CI, 1.19-2.01]; P = .01); however, the association was significant only among patients with severe OSA (adjusted HR, 2.23 [95% CI, 1.49-3.34]; P = .001) and not among those with moderate OSA (adjusted HR, 1.47 [95% CI, 0.98-2.09]; P = .07) or mild OSA (adjusted HR, 1.36 [95% CI, 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% CI, 15.5-27.7] minutes) was longer than in those without (10.2 [95% CI, 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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Article Information

Corresponding Author: Matthew T. V. Chan, MBBS, PhD, 4/F Main Clinical Block and Trauma Centre, Department of Anaesthesia and Intensive Care, Chinese University of Hong Kong, Prince of Wales Hospital, 30-32 Ngan Shing St, Shatin, Hong Kong Special Administrative Region, China (mtvchan@cuhk.edu.hk).

Accepted for Publication: April 4, 2019.

Author Contributions: Drs Chan and Chung had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Drs Chan, Wang, Seet, and Chung contributed equally to this article.

Concept and design: Chan, Wang, Seet, Hui, Chung.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Chan.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Chan, Wu.

Obtained funding: Chan, Wang, Seet, Short, Chung.

Administrative, technical, or material support: Chan, Wang, Seet, Tam, Lai, Chew, Cheng, Lam, Short, Hui, Chung.

Supervision: Chan, Wang, Seet, Tam, Lai, Chew, Cheng, Lam, Short, Chung.

Conflict of Interest Disclosures: Dr Chung reported receiving grants from the Ontario Ministry of Health and Long-term Care, Acacia Pharma, and Medtronics and holding a patent pending for the STOP-Bang questionnaire. No other authors reported disclosures.

Funding/Support: The study was funded through grants from the Health and Medical Research Fund (09100351), Hong Kong, National Healthcare Group-Khoo Teck Puat Hospital, Small Innovative Grants (12019, 15201), University Health Network Foundation (Ontario, Canada), University of Malaya, High Impact Research Grant (UM.C/625/1/HIR/067), Malaysian Society of Anaesthesiologists K Inbasegaran Research Grant and Auckland Medical Research Foundation, New Zealand. ResMed has supplied the ApneaLink devices and PULSOX-300i oximeter wristwatch in all sites as an unrestricted loan. These were returned at the end of the study.

Role of the Funder/Sponsor: The study funders/sponsors had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Group Information: The Postoperative Vascular Complications in Unrecognized Obstructive Sleep Apnea (POSA) Study Investigators: Steering Committee: Frances Chung (chair); Matthew Chan, Chew-Yin Wang, Edwin Seet. Event Adjudication Committee: Gordon Choi (chair), David Hui, Tony Gin. Investigators: Canada:Scarborough Health Network—Central Campus: Frances Chung, MBBS, Stanley Tam, MD, Sohail Iqbal, BSc; Hong Kong:Prince of Wales Hospital: Matthew Chan, MBBS, PhD, Gordon Choi, MBBS, David Hui, MD, Tony Gin, MD, Matthew Tsang, BSc, Beaker Fung, BSc, Angela Miu, BSc, Alex Lee, MSc; Tuen Mun Hospital: Benny Cheng, MBBS, Carmen Lam, MBBS, Sharon Tsang, MBChB, PhD, Chuen Ho Cheung, MBChB, Hoi Lam Pang, MBBS; Malaysia:University of Malaya Medical Centre: Chew Yin Wang, MBChB, Hou Yee Lai, MBBS, Carolyn C.W. Yim, MBBS, Alvin S.B. Tan, MBBS, Ching Yen Chong, BA, Jason H. Kueh, BSc, Xue Lin Chan, MBBS; Hospital Kuala Lumpur: Eleanor F.F. Chew, MBBS, Su Yin Loo, MBBS, Simon M.T. Hui, MBBS; New Zealand:Middlemore Hospital: Joyce Tai, MBChB, Stuart Walker, MBBS, Sue Olliff, BSc; Auckland City Hospital: Ivan Bergman, MBBS, Nicola Broadbent, MBBS, Maartje Tulp, MBBS, Timothy Short, MD, Davina McAllister, BSc; Singapore:Khoo Teck Puat Hospital: Edwin Seet, MBBS, Pei Fen Teoh, MBBS, Audris Chia, BSc.

Additional Contributions: We thank Andrew Forbes, PhD (Monash University, Australia), for his statistical advice and Ying Liu, MPH, Thomas Lo, MSc, and Beaker Fung, MSocSc (Chinese University of Hong Kong), who helped with figures preparation. None of these individuals received compensation for their contributions.

Study Coordination: This study was coordinated by the Chinese University of Hong Kong, Hong Kong Special Administrative region, China.

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