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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.


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.

Subramani  Y, Singh  M, Wong  J, Kushida  CA, Malhotra  A, Chung  F.  Understanding phenotypes of obstructive sleep apnea: applications in anesthesia, surgery, and perioperative medicine.  Anesth Analg. 2017;124(1):179-191. doi:10.1213/ANE.0000000000001546PubMedGoogle ScholarCrossref
Abboud  F, Kumar  R.  Obstructive sleep apnea and insight into mechanisms of sympathetic overactivity.  J Clin Invest. 2014;124(4):1454-1457. doi:10.1172/JCI70420PubMedGoogle ScholarCrossref
Heinzer  R, Vat  S, Marques-Vidal  P,  et al.  Prevalence of sleep-disordered breathing in the general population: the HypnoLaus study.  Lancet Respir Med. 2015;3(4):310-318. doi:10.1016/S2213-2600(15)00043-0PubMedGoogle ScholarCrossref
Marin  JM, Agusti  A, Villar  I,  et al.  Association between treated and untreated obstructive sleep apnea and risk of hypertension.  JAMA. 2012;307(20):2169-2176. doi:10.1001/jama.2012.3418PubMedGoogle ScholarCrossref
Gottlieb  DJ, Yenokyan  G, Newman  AB,  et al.  Prospective study of obstructive sleep apnea and incident coronary heart disease and heart failure: the Sleep Heart Health Study.  Circulation. 2010;122(4):352-360. doi:10.1161/CIRCULATIONAHA.109.901801PubMedGoogle ScholarCrossref
Arzt  M, Young  T, Finn  L, Skatrud  JB, Bradley  TD.  Association of sleep-disordered breathing and the occurrence of stroke.  Am J Respir Crit Care Med. 2005;172(11):1447-1451. doi:10.1164/rccm.200505-702OCPubMedGoogle ScholarCrossref
Gami  AS, Howard  DE, Olson  EJ, Somers  VK.  Day-night pattern of sudden death in obstructive sleep apnea.  N Engl J Med. 2005;352(12):1206-1214. doi:10.1056/NEJMoa041832PubMedGoogle ScholarCrossref
Fouladpour  N, Jesudoss  R, Bolden  N, Shaman  Z, Auckley  D.  Perioperative complications in obstructive sleep apnea patients undergoing surgery: a review of the legal literature.  Anesth Analg. 2016;122(1):145-151. doi:10.1213/ANE.0000000000000841PubMedGoogle ScholarCrossref
D’Apuzzo  MR, Browne  JA.  Obstructive sleep apnea as a risk factor for postoperative complications after revision joint arthroplasty.  J Arthroplasty. 2012;27(8)(suppl):95-98. doi:10.1016/j.arth.2012.03.025PubMedGoogle ScholarCrossref
Mokhlesi  B, Hovda  MD, Vekhter  B, Arora  VM, Chung  F, Meltzer  DO.  Sleep-disordered breathing and postoperative outcomes after bariatric surgery: analysis of the nationwide inpatient sample.  Obes Surg. 2013;23(11):1842-1851. doi:10.1007/s11695-013-0991-2PubMedGoogle ScholarCrossref
Mokhlesi  B, Hovda  MD, Vekhter  B, Arora  VM, Chung  F, Meltzer  DO.  Sleep-disordered breathing and postoperative outcomes after elective surgery: analysis of the nationwide inpatient sample.  Chest. 2013;144(3):903-914. doi:10.1378/chest.12-2905PubMedGoogle ScholarCrossref
Memtsoudis  SG, Stundner  O, Rasul  R,  et al.  The impact of sleep apnea on postoperative utilization of resources and adverse outcomes.  Anesth Analg. 2014;118(2):407-418. doi:10.1213/ANE.0000000000000051PubMedGoogle ScholarCrossref
Stundner  O, Chiu  YL, Sun  X,  et al.  Sleep apnoea adversely affects the outcome in patients who undergo posterior lumbar fusion: a population-based study.  Bone Joint J. 2014;96-B(2):242-248. doi:10.1302/0301-620X.96B2.31842PubMedGoogle ScholarCrossref
Mutter  TC, Chateau  D, Moffatt  M, Ramsey  C, Roos  LL, Kryger  M.  A matched cohort study of postoperative outcomes in obstructive sleep apnea: could preoperative diagnosis and treatment prevent complications?  Anesthesiology. 2014;121(4):707-718. doi:10.1097/ALN.0000000000000407PubMedGoogle ScholarCrossref
Griffin  JW, Novicoff  WM, Browne  JA, Brockmeier  SF.  Obstructive sleep apnea as a risk factor after shoulder arthroplasty.  J Shoulder Elbow Surg. 2013;22(12):e6-e9. doi:10.1016/j.jse.2013.06.003PubMedGoogle ScholarCrossref
Chan  MTV, Wang  CY, Seet  E,  et al; POSA Investigators.  Postoperative vascular complications in unrecognised Obstructive Sleep Apnoea (POSA) study protocol: an observational cohort study in moderate-to-high risk patients undergoing non-cardiac surgery.  BMJ Open. 2014;4(1):e004097. doi:10.1136/bmjopen-2013-004097PubMedGoogle ScholarCrossref
Ng  SSS, Chan  TO, To  KW,  et al.  Validation of a portable recording device (ApneaLink) for identifying patients with suspected obstructive sleep apnoea syndrome.  Intern Med J. 2009;39(11):757-762. doi:10.1111/j.1445-5994.2008.01827.xPubMedGoogle ScholarCrossref
Collop  NA, Tracy  SL, Kapur  V,  et al.  Obstructive sleep apnea devices for out-of-center (OOC) testing: technology evaluation.  J Clin Sleep Med. 2011;7(5):531-548.PubMedGoogle Scholar
Berry  RB, Budhiraja  R, Gottlieb  DJ,  et al; American Academy of Sleep Medicine.  Rules for scoring respiratory events in sleep: update of the 2007 AASM Manual for the Scoring of Sleep and Associated Events: deliberations of the Sleep Apnea Definitions Task Force of the American Academy of Sleep Medicine.  J Clin Sleep Med. 2012;8(5):597-619.PubMedGoogle Scholar
Chung  F, Liao  P, Elsaid  H, Islam  S, Shapiro  CM, Sun  Y.  Oxygen desaturation index from nocturnal oximetry: a sensitive and specific tool to detect sleep-disordered breathing in surgical patients.  Anesth Analg. 2012;114(5):993-1000. doi:10.1213/ANE.0b013e318248f4f5PubMedGoogle ScholarCrossref
Chung  F, Subramanyam  R, Liao  P, Sasaki  E, Shapiro  C, Sun  Y.  High STOP-Bang score indicates a high probability of obstructive sleep apnoea.  Br J Anaesth. 2012;108(5):768-775. doi:10.1093/bja/aes022PubMedGoogle ScholarCrossref
Devereaux  PJ, Chan  MTV, Alonso-Coello  P,  et al; Vascular Events In Noncardiac Surgery Patients Cohort Evaluation (VISION) Study Investigators.  Association between postoperative troponin levels and 30-day mortality among patients undergoing noncardiac surgery.  JAMA. 2012;307(21):2295-2304. doi:10.1001/jama.2012.5502PubMedGoogle ScholarCrossref
Lee  TH, Marcantonio  ER, Mangione  CM,  et al.  Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery.  Circulation. 1999;100(10):1043-1049. doi:10.1161/01.CIR.100.10.1043PubMedGoogle ScholarCrossref
O’Brien  RM.  A caution regarding rules of thumb for variance inflation factors.  Qual Quant. 2007;41(5):673-690. doi:10.1007/s11135-006-9018-6Google ScholarCrossref
Ha  ID, Vaida  F, Lee  Y.  Interval estimation of random effects in proportional hazards models with frailties.  Stat Methods Med Res. 2016;25(2):936-953. doi:10.1177/0962280212474059PubMedGoogle ScholarCrossref
Thygesen  K, Alpert  JS, Jaffe  AS,  et al; ESC Scientific Document Group.  Fourth universal definition of myocardial infarction (2018).  Eur Heart J. 2019;40(3):237-269. doi:10.1093/eurheartj/ehy462PubMedGoogle ScholarCrossref
Kaw  R, Chung  F, Pasupuleti  V, Mehta  J, Gay  PC, Hernandez  AV.  Meta-analysis of the association between obstructive sleep apnoea and postoperative outcome.  Br J Anaesth. 2012;109(6):897-906. doi:10.1093/bja/aes308PubMedGoogle ScholarCrossref
Opperer  M, Cozowicz  C, Bugada  D,  et al.  Does obstructive sleep apnea influence perioperative outcome? a qualitative systematic review for the Society of Anesthesia and Sleep Medicine Task Force on preoperative preparation of patients with sleep-disordered breathing.  Anesth Analg. 2016;122(5):1321-1334. doi:10.1213/ANE.0000000000001178PubMedGoogle ScholarCrossref
Jonas  DE, Amick  HR, Feltner  C,  et al.  Screening for obstructive sleep apnea in adults: evidence report and systematic review for the US Preventive Services Task Force.  JAMA. 2017;317(4):415-433. doi:10.1001/jama.2016.19635PubMedGoogle ScholarCrossref
Randerath  WJ, Verbraecken  J, Andreas  S,  et al; European Respiratory Society Task Force on Non-CPAP Therapies in Sleep Apnoea.  Non-CPAP therapies in obstructive sleep apnoea.  Eur Respir J. 2011;37(5):1000-1028. doi:10.1183/09031936.00099710PubMedGoogle ScholarCrossref
Chung  F, Nagappa  M, Singh  M, Mokhlesi  B.  CPAP in the perioperative setting: evidence of support.  Chest. 2016;149(2):586-597. doi:10.1378/chest.15-1777PubMedGoogle ScholarCrossref
Chung  F, Memtsoudis  SG, Ramachandran  SK,  et al.  Society of Anesthesia and Sleep Medicine guidelines on preoperative screening and assessment of adult patients with obstructive sleep apnea.  Anesth Analg. 2016;123(2):452-473. doi:10.1213/ANE.0000000000001416PubMedGoogle ScholarCrossref
Memtsoudis  SG, Cozowicz  C, Nagappa  M,  et al.  Society of Anesthesia and Sleep Medicine guideline on intraoperative management of adult patients with obstructive sleep apnea.  Anesth Analg. 2018;127(4):967-987. doi:10.1213/ANE.0000000000003434PubMedGoogle ScholarCrossref
Memtsoudis  SG, Stundner  O, Rasul  R,  et al.  Sleep apnea and total joint arthroplasty under various types of anesthesia: a population-based study of perioperative outcomes.  Reg Anesth Pain Med. 2013;38(4):274-281. doi:10.1097/AAP.0b013e31828d0173PubMedGoogle ScholarCrossref
Lee  RW, Vasudavan  S, Hui  DS,  et al.  Differences in craniofacial structures and obesity in Caucasian and Chinese patients with obstructive sleep apnea.  Sleep. 2010;33(8):1075-1080. PubMedGoogle ScholarCrossref
Li  KK, Kushida  C, Powell  NB, Riley  RW, Guilleminault  C.  Obstructive sleep apnea syndrome: a comparison between Far-East Asian and white men.  Laryngoscope. 2000;110(10, pt 1):1689-1693. doi:10.1097/00005537-200010000-00022PubMedGoogle ScholarCrossref
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