Is acute pulmonary embolism more severe in the presence of obstructive sleep apnea? Results from an observational cohort study

Changes in sleep-disordered breathing from the acute to the stable phase of pulmonary embolism: The ESAET study

BACKGROUND

/Objective: Sleep-disordered breathing (SDB) may change from the acute to stable phase of some cardiovascular disorders, but little is known whether these dynamic changes also exist in pulmonary embolism (PE). This study aimed to analyze the changes in the apnea-hypopnea index (AHI) from the acute to stable phase of PE as well as the factors associated.

PATIENTS/METHODS

We conducted a prospective, longitudinal and multicenter study of consecutive adults requiring hospitalization for non-hypotensive acute PE, with a protocol including clinical, imaging (transthoracic echocardiography [TTE] and computed tomography), blood tests and a sleep study within 48 h of diagnosis of PE. After 3 months of follow-up, the sleep study was repeated. Right ventricular (RV) dysfunction was defined according to TTE criteria.

RESULTS

One hundred and eleven patients (mean age [SD]: 63 [15] years; body mass index: 28.4 [4.7] kg/m2) were included. The initial AHI was 24.4 (21.8) events/h (AHI≥5: 82.8 %; AHI≥30: 33.3 %). Seventy-seven patients (69.4 %) had RV dysfunction. In the overall cohort, the AHI decreased by 8.7 events/h from the acute to stable phase (24.4/h vs. 15.7/h; p=0.013). Patients with RV dysfunction showed a greater decrease in AHI (mean decrease 12.3/h vs. 0.43/h). In the multivariable analysis a drop of an AHI≥5 events/hour was independently associated with the presence of initial RV dysfunction (hazard ratio 3.9; 95%CI 1.3 to 12.1).

CONCLUSIONS

In hemodynamically stable patients with acute PE, there is a transient but clinically significant decrease in the AHI from the acute to stable phase, particularly when initially presenting with RV dysfunction.

Right Ventricular Recovery: Early and Late Changes after Acute PE Diagnosis

Right ventricular (RV) failure is a critical cause of morbidity and mortality in patients presenting with pulmonary embolism (PE). The presentation of RV failure is based on the combination of clinical findings, laboratory abnormalities, and imaging evidence. An improved understanding of the pathophysiology of RV dysfunction following PE has given rise to more accurate risk stratification and broader therapeutic approaches. A subset of patients with PE develop chronic RV dysfunction with or without pulmonary hypertension. In this review, we focus on the impact of PE on the RV and its implications for risk stratification, prognosis, acute management, and long-term therapy.

Impact of Obstructive Sleep Apnea on Disease Severity and Adverse Outcomes in Patients with Acute Pulmonary Embolism

Purpose

Acute pulmonary embolism (PE) poses a life-threatening risk with high mortality rates. While the coexistence of PE and obstructive sleep apnea (OSA) is gaining recognition, its influence on PE severity and prognosis remains uncertain. This study aims to investigate the associations between OSA and disease severity, as well as outcomes, in patients with acute PE.

Patients and Methods

We conducted a retrospective cohort study on patients diagnosed with acute PE who had undergone previous cardiorespiratory polygraphy. OSA severity was assessed using the apnea-hypopnea index (AHI) derived from cardiorespiratory polygraphy. The severity of acute PE was evaluated using the simplified Pulmonary Embolism Severity Index (sPESI) score. Logistic regression analysis was performed to investigate the associations between AHI and the risk of belonging to the sPESI≥1 group. Cox regression analysis was used to examine the relationship between AHI and long-term adverse events, defined as a composite of all-cause mortality and non-fatal cardiovascular events.

Results

Among 145 acute PE patients (mean age 62.2 years, 49.7% male), 94 (64.8%) had OSA. Patients with OSA had a significantly higher proportion of sPESI≥1 (89.4% vs 68.6%, p=0.002) than non-OSA patients. Each unit increase in AHI was associated with a 15% increased risk of severe PE (sPESI≥1) (odds ratio: 1.15, 95% CI 1.05-1.26, p=0.002) after adjusting for confounders. During a median follow-up of 15.2 months, 27 (18.6%) patients experienced adverse events. Increased AHI independently predicted a higher risk of adverse events (hazard ratio: 1.03, 95% CI: 1.00-1.05, p=0.026), even after adjusting for potential confounders. AHI ≥8 events/h was associated with a significantly higher adjusted hazard ratio of 2.56 (95% CI: 1.15-5.72, p=0.022) for adverse events compared to AHI <8 events.

Conclusion

OSA is common in acute PE patients and is linked to increased disease severity and adverse outcomes. Implementing routine OSA screening and management may aid risk stratification and improve outcomes in acute PE patients.

Impact of obstructive sleep apnea on outcomes of pulmonary embolism: A systematic review and meta‑analysis

The current review aimed to assess the effect of obstructive sleep apnea (OSA) on the severity and outcomes of pulmonary embolism (PE). PubMed, Embase, ScienceDirect, CENTRAL and Google Scholar were searched for studies assessing the impact of OSA on severity and outcomes of PE. A total of 12 studies were included. Meta-analysis revealed that simplified PE severity index of >1 and pulmonary artery obstruction index score was significantly higher in patients with OSA as compared with controls, but there was no difference in right ventricle to left ventricle short-axis diameter. The need for non-invasive ventilation was significantly higher in patients with OSA but there was no difference in the need for mechanical ventilation. Patients with OSA had a significantly higher incidence of recurrence of PE. Meta-analysis also showed a statistically significantly lower risk of in-hospital mortality in patients with OSA as compared with controls, but without any difference in the risk of late mortality. Adjusted data on mortality indicated a significantly lower risk of mortality in PE patients with comorbid OSA. Limited data shows that comorbid OSA increases the severity of PE but has no effect on right ventricular function. OSA may increase the risk of recurrent PE. Paradoxically, the presence of OSA may also reduce the risk of in-hospital mortality. Results must be interpreted with caution owing to high inter-study heterogeneity and lack of matching of baseline characteristics. Current evidence needs to be confirmed by high-quality prospective studies.

Association Between the Severity of Obstructive Sleep Apnea and the Risk Stratification of Acute Pulmonary Embolism

Obstructive sleep apnea (OSA) has been associated with the initiation and progression of cardiovascular disease. This study aimed to explore the relationship between the severity of OSA and the risk stratification of acute pulmonary embolism (PE). In this single-center cohort study, patients diagnosed with PE were evaluated for OSA via polygraphy monitoring. The simplified PE severity index (sPESI) and the number of patients requiring systemic thrombolysis were used to determine the severity of the disease. Echocardiography was performed on all participants. All patients were divided into 2 groups (OSA group and non-OSA group), and the patients in OSA group were then divided into 3 groups based on the severity of OSA. Patients with severe OSA had a significantly higher number of patients with sPESI ≥ 1 (P = .005). A higher proportion of patients with severe OSA require systemic thrombolysis (P = .010). Patients with apnea-hypopnea index (AHI) > 30/h had a much higher fibrinogen (P = .004) and D-dimer (P = .040) level than those in the non-OSA group. The levels of creatinine were significantly higher in patients with OSA (P = .040). Echocardiography showed a significant difference in left ventricular ejection fraction (LVEF) between patients in non-OSA and severe OSA groups (P = .035). And brain natriuretic peptide (BNP) also exhibited a progressive worsening related to the deepest desaturation and oxygen desaturation index. OSA, especially with AHI > 30/h, is correlated with the severity and prognosis of acute PE. This might be attributed to the prothrombotic effect, renal impairment, and cardiac dysfunction in patients with severe OSA.

Obstructive Sleep Apnea as a Risk Factor for Venous Thromboembolism: A Systematic Review

Obstructive sleep apnea (OSA), is a prevalent condition characterized by repeated episodes of pharyngeal airway obstruction resulting in hypopnea and apnea episodes during sleep leading to nightly awakenings. OSA is a major contributor to the healthcare burden worldwide due to its high cardiovascular morbidity and mortality. There is growing evidence to support a pathophysiological link between OSA and venous thromboembolism (VTE). The pro-inflammatory state along with intermittent hypoxia that is invoked in OSA is associated with blood hypercoagulability, venous stasis, and endothelial dysfunction leading to deep vein thrombosis (DVT) and pulmonary embolism (PE). In this systematic review, we aim to analyze and assess the available literature on OSA and VTE (or DVT/PE) to determine whether OSA is an independent risk factor for VTE.

Association between obstructive sleep apnea and venous thromboembolism recurrence: results from a French cohort

Background

Growing evidence suggests the relationship between obstructive sleep apnea (OSA) and venous thromboembolism (VTE). Few studies focused on VTE recurrence risk associated with OSA after anticoagulation cessation.

Methods

In a prospective cohort study, patients with documented VTE, were followed for an indefinite length of time and VTE recurrence were documented and adjudicated. The primary outcome was recurrent VTE after anticoagulation discontinuation. Secondary outcomes included all-cause mortality and the clinical presentation of VTE. Univariable and multivariable analyses were performed to identify risk factors for recurrence and mortality.

Results

Among the 2109 patients with documented VTE included, 74 patients had moderate to severe OSA diagnosis confirmed by home sleep test or polysomnography. During a median follow-up of 4.8 (interquartile range 2.5–8.0) years recurrent VTE occurred in 252 patients (9 with OSA and 243 without OSA). The recurrence risk in the univariable and multivariable analysis was not increased in patients with OSA, regardless of the time of diagnosis (before or after index VTE or pooled). VTE phenotype was significantly more often PE with or without associated deep vein thrombosis in the first event and recurrence for OSA patients compared to non-OSA patients. The risk of death was not increased in the OSA population compared to non-OSA patients in multivariable analysis.

Conclusions

In patients with OSA and VTE, the risk of all-cause mortality and VTE recurrence after anticoagulation discontinuation was not increased compared to non-OSA patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12959-021-00358-8.

Sex-differences in the effect of obstructive sleep apnea on patients hospitalized with pulmonary embolism and on in-hospital mortality

We determined sex differences in the prevalence of obstructive sleep apnea (OSA) among patients hospitalized with pulmonary embolism (PE) in Spain (2016–2018). We also compared outcomes according to the presence of OSA, and identified variables associated with in-hospital-mortality (IHM) after PE using the Spanish National Hospital Discharge Database. We identified 46,794 hospital admissions for PE; of these, 5.47% had OSA. OSA was more prevalent among men than women (7.57% vs. 3.65%, p < 0.001), as in the general population. Propensity score matching did not reveal differences in concomitant conditions or procedures between patients with and without OSA, except for the use of non-invasive ventilation, which was more frequent in patients with OSA. IHM was similar in patients with and without OSA (3.58% vs. 4.31% for men and 4.39% vs. 4.93% for women; p > 0.05). Older age, cancer, atrial fibrillation, non-septic shock, and need for mechanical ventilation increased IHM in men and women with OSA hospitalized with PE. The logistic regression model showed no sex differences in IHM among patients with OSA.

Obstructive sleep apnea, intermittent hypoxemia and prothrombotic biomarkers

Objective

To study the serum levels of fibrinogen and d-dimer in patients with obstructive sleep apnea (OSA) and its correlation with apnea hypopnea index (AHI), oxygen desaturation index (ODI), minimal oxygen saturation and arousal index.

Methods

It was a case control study in which 23 cases of OSA and 23 controls were enrolled. Morning fasting serum fibrinogen and d-dimer were measured in cases of OSA and controls.

Results

Serum fibrinogen levels among OSA patients (268.47±53.11mg/dl) were elevated as compared to the levels in controls (221.52±65.84mg/dl) (p<0.05). Serum fibrinogen co-related positively with AHI (r=0.6381, p=0.0011) and ODI (r=0.7434, p=0.0000), negatively with minimal oxygen saturation (r=-0.4461, p=0.0329). There was no statistically significant correlation of fibrinogen with arousal index (r=0.2697, p=0.2133). There was no statistically significant difference between mean fasting d-dimer level in cases (0.12mg/L, 0.06±0.18mg/L) and controls (0.12mg/L, 0.02±0.22mg/L) (p=0.8926).

Conclusions

The observation of elevated fibrinogen levels with the increasing severity of OSA and hypoxemic events makes OSA one of the important risk factor for cardiovascular disorders.

The role of obstructive sleep apnea on the prognosis of pulmonary embolism: a systemic review and meta-analysis

PURPOSE

The relationship between obstructive sleep apnea (OSA) and pulmonary embolism (PE) has been reported by some studies but the underlying mechanism remains unclear. We aimed to systematically assess the role of OSA on the disease prognosis of PE.

METHODS

We searched for studies on the relationship of OSA and the prognosis of PE published up to February 2020 among PubMed, Web of Science, EMBASE, and Cochrane Library databases. Two independent reviewers conducted the process of study search and screening, quality assessment, and data extraction. Meta-analysis was carried out using RevMan 5.3.

RESULTS

A total of 9 articles were included, and the funnel plots suggested no evidence of publication bias among studies. The results showed that compared to PE patients without OSA, the PE patients with moderate-severe OSA were more likely to be high-risk type (OR = 1.96, 95% CI [1.14, 3.34]) and with higher index of disease severity (sPESI: OR = 2.29, 95% CI [1.50, 3.47]; PAOI%: MD = 13.52, 95% CI [7.2, 19.83]). The prevalence of recurrent PE was higher in PE patients with OSA than those without OSA (RR = 3.87, 95% CI [1.65, 9.07]). However, there was no significant difference in right ventricle to left ventricle short-axis diameter (MD = 0.08, 95% CI [- 0.06, 0.21]), length of hospital stay (MD = 1.03, 95% CI [- 1.11, 3.17]), or prevalence of deep vein thrombosis (OR = 0.87, 95% CI [0.48, 1.57]). Sensitivity and subgroup analysis showed that the pooled outcomes were stable.

CONCLUSION

OSA, especially moderate-severe OSA, was a risk factor for high-risk PE and recurrent PE. However, the current evidence showed that the length of hospital stay is not influenced by OSA.

Acute pulmonary embolism in patients with obstructive sleep apnea: frequency, hospital outcomes, and recurrence

STUDY OBJECTIVES

The objectives of this study were to assess the effect of obstructive sleep apnea (OSA) on the risk of acute pulmonary embolism (PE), hospital outcomes including mortality, and PE recurrence.

METHODS

We retrospectively enrolled adult patients, admitted to Mayo Clinic Hospital in Rochester, Minnesota, within a 5-year period (2009-2013). We compared frequency of PE, hospital mortality, and secondary outcomes in patients with OSA versus patients without OSA. We assessed risk of PE recurrence in relation to compliance with OSA therapy.

RESULTS

Of 25,038 patients, 3,184 (13%) had OSA and 283 (1.1%) experienced PE. Frequency of PE in patients with and without OSA was 2.4% versus 0.9% (odds ratio [OR], 2.51; 95% confidence interval [CI], 1.9-3.3; P < .001). OSA was independently associated with increased risk of PE after adjusting for demographics and comorbidities (OR, 1.44; 95% CI, 1.07-1.9; P = .017). Adjusted hospital mortality was increased in patients with PE (OR, 2.88; 95% CI, 1.7-4.9; P < .001) but not in patients with OSA (OR, 0.98; 95% CI, 0.7-1.4, P = .92). OSA was not a significant determining factor for mortality in patients who experienced a PE (OR, 0.56; 95% CI, 0.1.1-2.78; P = .47), adjusting for demographics, PE severity, and Charlson comorbidity index. Adjusted risk of PE recurrence was greater in patients with OSA compared with patients without OSA (OR, 2.21; 95% CI, 1.05-4.68; P < .04). The patients compliant with OSA therapy had a lower rate of PE recurrence (16% vs 32%; P = not significant).

CONCLUSIONS

Although OSA significantly increases risk of acute PE occurrence and recurrences, related hospital mortality was not greater in patients with OSA compared with those without OSA. OSA therapy might have a modifying effect on PE recurrence.

D-Dimer Predicts Disease Severity but Not Long-Term Prognosis in Acute Pulmonary Embolism

D-dimer might be correlated with prognosis in pulmonary embolism (PE). The predictive value of plasma D-dimer for disease severity and survival was investigated in the lowest and highest D-dimer quartile among 200 patients with PE. Patients with high D-dimers were significantly more often hypotensive (P = .001), tachycardic (P = .016), or hypoxemic (P = .001). Pulmonary arterial obstruction index (PAOI) values were significantly higher in the high D-dimer quartile (P < .001). Elevated troponin I (TNI) levels (P < .001), simplified PE severity indices ≥1 (P < .001), right-to-left ventricular (RV/LV) diameter ratios ≥1 (P < .001), and thrombolysis (P = .001) were more frequent in the high D-dimer quartile. D-dimer was associated with RV/LV ratios ≥1 (P = .021), elevated PAOI (P < .001) or TNI levels (P < .001), hypotension (P < .001), tachycardia (P = .003), and hypoxemia (P < .001), but not with long-term all-cause mortality. D-dimer predicts disease severity but not long-term prognosis in acute PE, possibly due to a more aggressive treatment strategy in severely affected patients.

Obstructive sleep apnea and venous thromboembolism: Overview of an emerging relationship

Obstructive sleep apnea (OSA) is a risk factor for cardiovascular syndromes. Venous thromboembolism (VTE) is a chronic disease, and pulmonary embolism (PE) is the major expression of VTE and the third most frequent cardiovascular disease. An increasing and emerging number of cross-sectional and longitudinal studies have linked OSA to VTE, and have postulated different putative pathways to explain how OSA might increase the risk of PE. We aim to provide a critical overview of the existing evidence about the complex relationship between these two conditions, with some factors and confounding variables still to be clarified. A global interpretation of the studies shows OSA is highly prevalent in VTE patients. This association represents a major public health burden, given the high prevalence and the mortality rates of both disorders. Although still not proven, OSA may induce a persistent hypercoagulable state that may contribute to increase VTE rate and its recurrence. Coagulant activity, platelet function and fibrinolytic system may improve after continuous positive airway pressure (CPAP) in OSA. However, there is a still a lack of randomized controlled trials to evaluate the potential of CPAP and/or extend oral anticoagulation to reduce PE incidence, recurrence and mortality by PE in patients with OSA.

Obstructive sleep apnea is associated with pulmonary artery thrombus load, disease severity, and survival in acute pulmonary embolism

INTRODUCTION

Obstructive sleep apnea (OSA) may have prothrombotic effects.

OBJECTIVE

To investigate the effect of OSA on disease severity, pulmonary artery thrombus load, and prognosis in patients with acute pulmonary embolism (PE).

METHODS

In 101 PE patients, disease severity was determined by the simplified PE severity index (sPESI) score, pulmonary artery thrombus load was quantified by the pulmonary artery obstruction index (PAOI), and sleep-disordered breathing was evaluated by nocturnal polygraphy.

RESULTS

Obstructive sleep apnea patients with an apnea-hypopnea index (AHI) ≥ 15/h cohort were significantly older (p < 0.001) and had significantly lower oxygen saturations (p = 0.008) when acute PE was diagnosed. The sPESI scores (p < 0.001), the PAOI (p = 0.005) and the N-terminal pro-brain-type natriuretic peptide (NT-proBNP) values (p = 0.009), were significantly higher in the AHI ≥ 15/h subgroup. In a multivariate regression analysis, the AHI remains a significant predictor for sPESI scores ≥ 1 (p = 0.003), increased NT-proBNP levels (p = 0.047), and elevated PAOI (p = 0.032). During the median follow-up time of 53 (interquartile range 38-70) months, all-cause and cardiovascular-related mortality was significantly higher in the AHI ≥ 15/h cohort (p = 0.004 and p = 0.015, respectively).

CONCLUSIONS

Obstructive sleep apnea is associated with pulmonary artery thrombus load, disease severity, and survival in acute PE possibly due to its prothrombotic effects.

Obstructive sleep apnoea and venous thromboembolism: pathophysiological links and clinical implications

Obstructive sleep apnoea (OSA) and pulmonary embolism (PE) remain major health issues worldwide. Data from pathophysiological studies suggest that both intermittent hypoxia and sleep fragmentation are associated with increased blood coagulability, endothelial dysfunction and venous stasis. There is growing evidence that OSA is potentially prevalent in and a risk factor for PE. Conversely, patients with acute PE have two to four times greater risk of moderate-to-severe OSA. The role of continuous positive airway pressure (CPAP) treatment in improving clinically meaningful outcomes in PE patients remains unclear, although some authors have suggested that CPAP could improve the hypercoagulability state and normalise circadian alterations in some of the coagulation molecules, as observed in patients with OSA. Emerging research highlights the complex interdependent relationships between OSA and PE, emphasising the need for rigorous, well-powered trials that address the impact of OSA and its treatment on the prevention and management of PE. Undoubtedly, these will require closer collaboration between the sleep medicine and clinical/venous thromboembolism communities.