Neighborhood Disadvantage Association with Sleep Apnea and Longitudinal Cardiovascular Events in a Large Clinical Cohort

Abstract

Background The association between neighborhood socioeconomic disadvantage and poor cardiovascular outcomes is well established; however, less is known about its interplay with obstructive sleep apnea. Methods Adult cardiovascular disease-naïve patients who underwent sleep testing at Cleveland Clinic in Ohio from August of 1998 to August of 2021 were included in this cohort. The primary exposure was Area Deprivation Index (ADI) calculated by national rank, i.e. 25th, 50th, and 75th percentiles; higher quartiles reflecting greater deprivation (ADI-Q1-4) with Q1 as reference. Cox proportional hazard models were used to determine the hazard of composite outcome of major adverse cardiovascular events (MACE), i.e. including heart failure, stroke, atrial fibrillation and coronary artery disease or death, adjusted for demographics, comorbidities, cardiac medications and objective OSA-related measures including of Apnea Hypopnea Index (AHI) and sleep-related hypoxia (percentage of sleep time spent<90%SaO2,T90). Linear models were used to examine the relationship between ADI and OSA-related measures. Interaction terms were tested between ADI and OSA-related measures. Results: Of 72,443 adults age was 50.4±14.2 years, 50.5% were men, and 18.4% Black individuals. The median AHI was 14.3[5.8, 33.3] with a median follow-up of 4.39 [IQR,1.76-7.92] years. The relative incidence of initial MACE in the presence of competing risk of death was 17% higher (HR,1.17[95%CI 1.09-1.27],p<.001) for those living in ADI-Q4. Greater levels of area deprivation were associated with sleep-related hypoxia measures including higher degree of T90(p<.001); lower mean SaO2(p<.001), and lower minimum SaO2(p<.001). Significant interactions between T90 and ADI were observed with the risk of MACE(p=0.002) or death(p=0.005). T90 conferred a 37% increased risk of MACE(HR, 1.37[95%CI:1.23-1.53]) for those living in ADI-Q1; and a 26% increased risk(HR, 1.26[95%CI:1.14-1.38%]) among patients living in ADI-Q4. For individuals living in ADI-Q2 and Q3, T90 conferred a respective 56% and 51% increased risk of death (HR,1.56[95%CI:1.23 - 1.96]; HR, 1.51[95%CI:1.21-1.88]), respectively. Conclusions: Neighborhood disadvantage was associated with an increased risk for MACE or death in this clinical cohort and this association was modified by sleep-related hypoxia. Further research is needed to identify neighborhood-specific social determinants contributing to sleep-cardiovascular health disparities to develop neighborhood-specific interventions.