Association Between OSA and Quantitative Atherosclerotic Plaque Burden: A Coronary CT Angiography Study

Obstructive sleep apnea hypopnea syndrome and vascular lesions: An update on what we currently know

Obstructive sleep apnea-hypopnea syndrome (OSAHS) is the most prevalent sleep and respiratory disorder. This syndrome can induce severe cardiovascular and cerebrovascular complications, and intermittent hypoxia is a pivotal contributor to this damage. Vascular pathology is closely associated with the impairment of target organs, marking a focal point in current research. Vascular lesions are the fundamental pathophysiological basis of multiorgan ailments and indicate a shared pathogenic mechanism among common cardiovascular and cerebrovascular conditions, suggesting their importance as a public health concern. Increasing evidence shows a strong correlation between OSAHS and vascular lesions. Previous studies predominantly focused on the pathophysiological alterations in OSAHS itself, such as intermittent hypoxia and fragmented sleep, leading to vascular disruptions. This review aims to delve deeper into the vascular lesions affected by OSAHS by examining the microscopic pathophysiological mechanisms involved. Emphasis has been placed on examining how OSAHS induces vascular lesions through disruptions in the endothelial barrier, metabolic dysregulation, cellular phenotype alterations, neuroendocrine irregularities, programmed cell death, vascular inflammation, oxidative stress and epigenetic modifications. This review examines the epidemiology and associated risk factors for OSAHS and vascular diseases and subsequently describes the existing evidence on vascular lesions induced by OSAHS in the cardiovascular, cerebrovascular, retinal, renal and reproductive systems. A detailed account of the current research on the pathophysiological mechanisms mediating vascular lesions caused by OSAHS is provided, culminating in a discussion of research advancements in therapeutic modalities to mitigate OSAHS-related vascular lesions and the implications of these treatment strategies.

Continuous Positive Airway Pressure but Not GLP1-mediated Weight Loss Improves Early Cardiovascular Disease in Obstructive Sleep Apnea: A Randomized Proof-of-Concept Study

Rationale: Obstructive sleep apnea (OSA) is an independent risk factor for cardiovascular (CV) morbidity and mortality, but the benefit of continuous positive airway pressure (CPAP) is uncertain. However, most randomized controlled trials have focused on the role of CPAP in secondary prevention, although there is growing evidence of a potential benefit on early CV disease. Weight loss in combination with CPAP may be superior but is difficult to achieve and maintain with conventional measures alone. Objectives: The aim of this study was to gain insights into the effect of CPAP on early atherosclerotic processes and to compare it with a glucagon-like peptide (GLP)-1-mediated weight loss regimen in patients with OSA. Methods: We performed a randomized proof-of-concept study comparing CPAP, a GLP1-mediated weight-loss regimen (liraglutide [Lir]), and both in combination for 24 weeks in 30 consecutive patients with OSA (apnea-hypopnea index >15 events/h; body mass index 30-40 kg/m2; and no history of diabetes, heart failure, or unstable CV disease). In addition to extensive evaluation for CV risk factors and endothelial function at baseline and end of study, subjects underwent 18F-fluoro-2-deoxy-D-glucose positron emission tomography-computed tomography (18F-FDG PET-CT) for the measurement of aortic wall inflammation (target-to-background ratio) and coronary computed tomography angiography for semiautomated coronary plaque analysis. Results: Baseline characteristics were similar between groups. CPAP alone and in combination resulted in greater reduction in apnea-hypopnea index than Lir alone (mean difference, -45 and -43 events/h, respectively, vs. -12 events/h; P < 0.05). Both Lir and combination treatment led to significant weight loss, but only CPAP alone resulted in significant decrease in vascular inflammation (aortic wall target-to-background ratio from 2.03 ± 0.34 to 1.84 ± 0.43; P = 0.010), associated with an improvement in endothelial function and a decrease in C-reactive protein. Low-attenuation coronary artery plaque volume as a marker of unstable plaque also decreased with CPAP (from 571 ± 490 to 334 ± 185 mm3) and with combination therapy (from 401 ± 145 to 278 ± 126 mm3) but not with Lir. Conclusions: These data suggest that CPAP therapy, but not GLP1-mediated weight loss, improves vascular inflammation and reduces unstable plaque volume in patients with OSA. Further large randomized controlled studies are warranted to assess the benefit of CPAP therapy in modifying early CV disease. Clinical trial registered with www.clinicaltrials.gov (NCT04186494).

Multimodal Prognostic Model for Predicting Chronic Coronary Artery Disease in Patients Without Obstructive Sleep Apnea Syndrome

BACKGROUND

Obstructive sleep apnea syndrome (OSAS), with metabolic disorders as a central feature, is closely correlated with coronary artery disease (CAD). Our goal was to develop a prediction nomogram that integrated multimodal data that could accurately predict the prognosis of patients with chronic coronary disease (CCD).

METHODS

We evaluated 393 patients with CCD with a low-to-intermediate pretest probability of OSAS based on polysomnography. A nomogram was constructed by means of least absolute shrinkage and selection operator (LASSO) and multiple Cox regression analyses to identify independent risk factors for major adverse cardiovascular events (MACEs).

RESULTS

Two hundred seventy-seven patients were randomly assigned to the training set, and 116 to the verification set. The constructed nomogram consisted of seven clinical variables: age, previous CAD, current alcohol consumption, neck circumference, apnea-hypopnea index (AHI), and triglyceride-glucose index (TyG). The nomogram showed good discriminatory power, as evidenced by Harrell's C-index values of 0.79 (95% confidence interval [CI] 0.731-0.849) in the training set and 0.78 (95% CI 0.678-0.882) in the verification set. Moreover, a high correlation was observed between the predicted and actual incidence of MACEs in both the training and verification sets. Decision curve analysis demonstrated excellent clinical utility of the nomogram based on net benefit and threshold probabilities.

CONCLUSIONS

We developed an integrated visualized prognostic nomogram that utilizes multi-modal data, including clinical characteristics, AHI, and TyG index, to predict MACEs in patients with CCD. This approach demonstrated excellent performance, highlighting the potential of combining different data sources to enhance prediction accuracy.

Prognostic implications of obstructive sleep apnea in patients with acute coronary syndrome stratified by homocysteine level: a prospective cohort study

BACKGROUND

Sporadic studies have examined the impact of OSA on ACS patients by homocysteine (Hcy) level. This study attempted to comprehensively evaluate the effects of the interaction between Hcy and OSA on long-term cardiovascular outcomes in ACS patients.

METHODS

In this prospective, large-scale cohort study, 2160 patients admitted for ACS were recruited to undergo overnight sleep monitoring. OSA was diagnosed when apnea-hypopnea index ≥ 15 events/h. Patients with normohomocysteinemia (NHcy) were defined as having serum Hcy ≤ 15 μmol/L, and the others had hyperhomocysteinemia (HHcy). The primary endpoint was major adverse cerebrocardiovascular event (MACCE), a composite of cardiovascular death, myocardial infarction, stroke, ischemia-driven revascularization and hospitalization for unstable angina and heart failure.

RESULTS

A total of 1553 eligible ACS patients (average age: 56.3 ± 10.5 years) were enrolled, among which 819 (52.7%) had OSA, and 988 (63.6%) were with NHcy. OSA did not significantly affect the level of Hcy. During a median follow-up of 2.9 (1.6, 3.5) years, after adjustment for clinical confounders, OSA was associated with increased risk for MACCE occurrence versus non-OSA ones in ACS patients with NHcy (adjusted hazard ratio [HR] = 1.36, 95% confidence interval [CI] 1.02-1.83, P = 0.039), but not in those with HHcy (adjusted HR = 0.92, 95%CI 0.62-1.36, P = 0.668). There was an absence of interaction between homocysteine level and OSA in relation to MACCE (interaction P = 0.106).

CONCLUSIONS

OSA was independently associated with worse prognosis in ACS patients with NHcy. Our study emphasized the necessity to identify potential presence of OSA in such a population.

TRIAL REGISTRATION

ClinicalTrials.gov; Number: NCT03362385; URL: www.

CLINICALTRIALS

gov .

Association Between Obstructive Sleep Apnea and Cardiovascular Events in Acute Coronary Syndrome Patients With or Without Revascularization - A Prospective Cohort Study

BACKGROUND

The effects of obstructive sleep apnea (OSA) on the prognosis of acute coronary syndrome (ACS) without revascularization remain unclear, so the aim of the present study was to elucidate the association of OSA with subsequent cardiovascular events in ACS patients with and without revascularization.

METHODS AND RESULTS

We prospectively recruited hospitalized ACS patients undergoing sleep monitoring between June 2015 and January 2020. OSA was defined as an apnea-hypopnea index ≥15 events/h. The primary endpoint was a major adverse cardiovascular and cerebrovascular event (MACCE), including cardiovascular death, myocardial infarction, stroke, ischemia-driven revascularization, or hospitalization for unstable angina or heart failure. Among 1,927 patients, 52.6% had OSA and 69.4% underwent revascularization. During a 2.9-year follow-up (1.5-3.6 years), the risk of MACCE was similar in patients with or without revascularization. OSA was an independent predictor of MACCE in the non-revascularization group (22.6% vs. 14.6%; hazard ratio (HR) 1.861; 95% confidence interval (CI) 1.239-2.796; P=0.003) but not in revascularization group (22.3% vs. 19.3%; HR 1.135; 95% CI 0.882-1.460; P=0.324). The incremental risk in the non-revascularization group was attributable to more hospitalizations for unstable angina (14.2% vs. 8.6%; HR 1.896; 95% CI 1.124-3.199; P=0.016).

CONCLUSIONS

For patients with ACS, OSA was independently associated with higher risk of recurrent cardiovascular events among patients without revascularization but not among patients undergoing revascularization. The benefits of suitable OSA treatment for patients without revascularization need further investigation.

Association between Obstructive Sleep Apnea and Intracranial Artery Calcification Stratified by Gender and Body Mass Index: A Hospital-Based Observational Study

BACKGROUND AND OBJECTIVES

Obstructive sleep apnea (OSA) is an independent risk factor for stroke. Furthermore, intracranial arterial calcification (IAC) has been validated as a marker for subclinical cerebrovascular disease. However, the relationship between OSA with IAC was less studied compared with its established association with coronary artery calcification. In this study, we aimed to investigate the association between the severity of OSA and the degree of IAC in hospitalized patients without preexisting cardiovascular disease.

METHODS

This hospital-based observational study was conducted from June 1, 2017, to May 1, 2019. In total, 901 consecutive patients who underwent head computed tomography scans and portable sleep monitoring were included. On the basis of the apnea-hypopnea index (AHI), patients were divided into four OSA severity groups (normal: AHI <5/h; mild: 5≤ AHI <15/h; moderate: 15≤ AHI <30/h; severe: AHI ≥30/h). Associations of OSA with IAC scores were assessed by using multivariate logistic regression analysis.

RESULTS

Of the 901 patients, 484 (53.7%) were men; the mean (SD) age was 66.1 (10.0) years. The non-OSA group included 207 (23.0%) patients; mild OSA, 209 (23.2%); moderate OSA, 235 (26.1%); and severe OSA, 169 (18.8%). Mean IAC scores were higher in the severe OSA group compared with non-, mild, and moderate OSA groups (4.79 vs. 2.58; 4.79 vs. 2.94; 4.79 vs. 3.39; p < 0.001). Multivariate analysis adjusted for confounding factors revealed that only severe OSA was associated with a higher IAC score (odds ratio [OR]: 1.65; 95% confidence interval [CI]: 1.43-1.91; p < 0.001). In stratified analyses by BMI, among participants with a BMI <25 kg/m2, the positive association between AHI values and IAC scores was found in the moderate OSA group (OR: 1.23; 95% CI: 1.05, 1.43; p = 0.01) and the severe OSA group (OR: 1.96; 95% CI: 1.55, 2.48; p < 0.001). When stratified by gender, in women, the positive association was found in the moderate OSA group (adjusted OR: 1.21; 95% CI: 1.02-1.51; p = 0.016) and the severe OSA group (adjusted OR: 1.76; 95% CI: 1.36-2.25; p < 0.001). For the men group, a positive association between IAC scores and AHI was only observed in the severe OSA group.

DISCUSSION

These findings suggest that OSA, in particular severe OSA (AHI ≥30), is independently associated with higher IAC scores. Women and no-obesity individuals appeared more susceptible to adverse OSA-related subclinical cerebrovascular disease as measured by IAC scores.

Daytime sleepiness is associated with increased coronary plaque burden among patients with obstructive sleep apnea

PURPOSE

To investigate the cross-sectional associations of daytime sleepiness with coronary plaque volume and composition in patients with obstructive sleep apnea (OSA), and whether or not these associations are modified by age, gender, and obesity.

METHODS

Patients who were confirmed with OSA through respiratory polygraphy and also underwent coronary CTA at a tertiary hospital were consecutively enrolled. The interval between the sleep monitoring and coronary CTA scan was  < 3 months. Every patient completed the Epworth sleepiness scale (ESS) to assess daytime sleepiness, and an ESS score of ≥ 11 was recognized as excessive daytime sleepiness (EDS). Coronary plaque volume and composition were measured using semi-automatic software.

RESULTS

Of the 394 patients with OSA (median [IQR] age, 56.0 [49.0-64.0] years; median [IQR] body mass index, 27.9 [25.5-30.2] kg/m2; median [IQR] apnea-hypopnea index, 21.3 [11.7, 36.3] events/h), a total of 200 patients had EDS. In the overall participants, a significant dose-response relationship between ESS scores and low-attenuation plaque volume was found in the fully adjusted model (P = 0.019). Further analysis demonstrated that there was a significant interactive effect of ESS levels and obesity on coronary plaque volume (all P values for interaction analysis < 0.05). Specifically, ESS levels were associated with total plaque volume, volumes of noncalcified, low-attenuation, and calcified plaque (P = 0.008, 0.006, 0.005, and 0.043 respectively) in obese patients with OSA.

CONCLUSION

Daytime sleepiness is significantly correlated with increased coronary plaque burden among patients with OSA. Thus, clinicians should recognize that patients with OSA reporting high ESS scores, especially those with obesity, are more prone to experience adverse coronary events.

Atherosclerotic plaque in individuals without known cardiovascular disease but with established obstructive sleep apnea and at high risk of obstructive sleep apnea

Objectives

In a large U.S. cohort free of CVD evaluated by coronary computed CT angiography, we aimed to assess the association between established / high risk of Obstructive Sleep Apnea (OSA) and coronary plaque.

Background

There are limited data available depicting the association between established / high risk of OSA and the presence of coronary plaque in a population-based sample free from CVD.

Methods

Cross-sectional data from 2359 participants enrolled in the Miami Heart Study (MiHeart) who underwent coronary CT angiography was used for this study. The Berlin questionnaire was used to stratify patients as having high or low risk of OSA. Multiple multivariable logistic regression analyses were conducted to investigate the association between the risk of developing OSA with the presence, volume, and composition of plaque.

Results

According to the Berlin questionnaire, 1559 participants were (66.1%) at low risk of OSA and 800 patients (33.9%) with established / high risk of OSA. Plaque characterization on CCTA revealed a greater incidence of any possible plaque composition in the established / high risk of OSA category (59.6% vs. 43.5%) compared to the low risk of OSA cohort. In logistic regression models, after adjusting for demographics and cardiovascular risk factors, a significant association could still be noted between established / high risk of OSA and any coronary plaque on CCTA (OR=1.31, CI 1.05, 1.63, p = 0.016). Subgroup analysis in the Hispanic population also portrayed a significant association between established / high risk of OSA and the presence of coronary plaque on CCTA (OR = 1.55 CI 1.13, 2.12, p = 0.007).

Conclusion

After accounting for CVD risk factors, individuals at established / high risk of OSA have a higher likelihood of the presence of coronary plaque. Future studies should focus on OSA presence or risk, OSA severity, and the longitudinal consequences of coronary atherosclerosis.

Retinal microvascular changes in patients with coronary artery disease and apnea

BACKGROUND

Optical coherence tomography angiography (OCT-A) allowed visualization of capillary level of retina; however, the relationship between coronary vascular status and retinal microvascular changes in patients with apnea is not known well. Our aim was to assess the retinal OCT-A parameters in patients with ischemia and angiographically proven microvascular disease and compare them with obstructive coronary disease in patients with apnea.

METHODS

Our observational study included 185 eyes of 185 patients, 123 eyes of patients with apnea (72 eyes from mild OSAS, 51 eyes from moderate to severe OSAS) and 62 eyes from healthy controls. Radial scans of the macula and OCT-A scans of the central macula (superficial (SCP) and deep (DCP) capillary plexuses) were performed on all participants. All participants had documented sleep apnea disorder within 2 years prior to coronary angiography. Patients were grouped by severity of apnea and coronary atherosclerosis (50 % stenosis cut-off value for obstructive coronary artery disease). Patients presented with myocardial ischemia and without coronary artery occlusion (<50 % diameter reduction or FFR > 0.80) constitute the microvascular coronary artery (INOCA) group.

RESULTS

Compared to healthy controls, patients with apnea showed deterioration in vascular density in all regions of the retina, regardless of obstructive or microvascular coronary artery disease on the ischemia background. This study has provided important observations of a high prevalence of INOCA in patients with OSAS and the presence of OSAS was a significant independent predictor of functional coronary artery disease. The relative decreases in vascular densities were more pronounced in the DCP layer according to SCP layer of macula. Only FAZ area values were significantly different according to the severity of OSAS (0.27 (0.11-0.62) and 0.23 (0.07-0.50) (p = 0.012)).

CONCLUSIONS

In patients with apnea, OCT-A can be used as a noninvasive tool to define coronary artery involvement, with similar retinal microvascular changes both in obstructive and microvascular coronary artery group. In patients with OSAS, we observed a high prevalence of microvascular coronary disease, supporting pathophysiological role of OSAS in ischemia of this group of patients.

Obstructive Sleep Apnea as a Predictor of a Higher Risk of Significant Coronary Artery Disease Assessed Non-Invasively Using the Calcium Score

The aim of this study was to assess the coronary artery calcium score in patients with obstructive sleep apnea (OSA). The study group (group A) consisted of 62 patients with diagnosed obstructive sleep apnea (mean age: 59.12 ± 9.09 years, mean AHI index in polysomnography: 20.44 ± 13.22/h), and 62 people without diagnosed obstructive sleep apnea (mean age 59.50 ± 10.74 years) constituted the control group (group B). The risk of significant coronary artery disease was assessed in all patients, based on the measurement of the coronary artery calcium score (CACS) using computed tomography. The following cut-off points were used to assess the risk of significant coronary artery disease: CACS = 0—no risk, CACS 1–10—minimal risk, CACS 11–100—low risk, CACS 101–400—moderate risk, and CACS > 400—high risk. Group A was characterized by statistically significantly higher CACS than group B (550.25 ± 817.76 vs. 92.59 ± 164.56, p < 0.05). No risk of significant coronary artery disease was statistically significantly less frequent in group A than in group B (0.0% vs. 51.6%, p < 0.05). A high risk of significant coronary artery disease was statistically significantly more frequent in group A than in group B (40.3% vs. 4.8%, p < 0.05). In group A, patients with severe OSA and patients with moderate OSA had statistically significantly higher CACS than patients with mild OSA (910.04 ± 746.31, 833.35 ± 1129.87, 201.66 ± 192.04, p < 0.05). A statistically significant positive correlation was found between the AHI and CACS (r = 0.34, p < 0.05). The regression analysis showed that OSA, male gender, older age, type 2 diabetes, peripheral arterial disease, and smoking were independent risk factors for higher CACS values. AHI ≥ 14.9 was shown to be a predictor of a high risk of significant coronary artery disease with a sensitivity and specificity of 62.2% and 80.0%, respectively. In summary, obstructive sleep apnea should be considered an independent predictive factor of a high risk of significant coronary artery disease (based on the coronary artery calcium score).

Clinical outcomes and plaque characteristics in patients with coronary artery disease and concomitant sleep-disordered breathing treated by continuous positive airway pressure

BACKGROUND

Sleep-disordered breathing (SDB) is a risk factor for recurrent adverse events in patients with coronary artery disease (CAD). However, the prognosis of continuous positive alveolar pressure (CPAP) treatment for SDB with CAD remains unknown.

METHODS

A total of 281 consecutive patients with stable CAD requiring percutaneous coronary intervention (PCI) were included and classified into three groups according to the concomitance of SDB and CPAP treatment (untreated SDB group, n = 61; CPAP-SDB group, n = 24; and non-SDB group, n = 138). The incidence of major adverse cardiac and cerebrovascular events (MACCEs) within a year after PCI was compared between the three groups. The characteristics of the culprit plaques, including macrophage accumulation, were further assessed using optical coherence tomography.

RESULTS

The incidence of MACCEs was significantly different among the three groups (p = 0.037), with the highest incidence in the untreated-SDB group (22.9%) and 8.3% and 10.1% in the CPAP-SDB and non-SDB groups, respectively. The incidence of MACCEs at 1 year was significantly lower in patients with appropriate CPAP use than that in inadequately treated patients with SDB (0.0 vs. 22.5%, p = 0.048). Macrophage accumulation differed significantly among the three groups, with the highest accumulation in the untreated SDB group.

CONCLUSIONS

CPAP treatment for SDB may be associated with a lower incidence of MACCEs following PCI and a lower prevalence of macrophages in the culprit plaques.

Obstructive sleep apnea, myocardial perfusion and myocardial blood flow: A study of older male twins

BACKGROUND

Obstructive sleep apnea (OSA) has been associated with incidence of cardiovascular disease and with nocturnal angina, but evidence of a link with coronary atherosclerosis and myocardial ischemia is limited and previous studies may have been affected by selection bias or unmeasured confounding factors.

METHODS

We performed overnight polysomnography in 178 older male twins. The Apnea/Hypopnea Index (AHI) was calculated to assess OSA from the overnight sleep evaluation. AHI ≥15 was used as indicator of moderate/severe OSA. The following day, twins underwent myocardial perfusion imaging with [82Rb]-chloride positron emission tomography. Quantitative and semiquantitative measures of myocardial perfusion and absolute myocardial blood flow were obtained.

RESULTS

The mean age was 68 years and 40% of the sample had an AHI≥15, which indicates moderate to severe OSA. Abnormal myocardial perfusion, both with stress and at rest, was more common in twins with elevated AHI. After adjusting for clinical, lifestyle and behavioral factors, and previous history of cardiovascular disease, twins with AHI ≥15 had 3.6 higher odds (95% CI, 1.5-8.9) of an abnormal total severity score, defined as a score ≥100, and for each 5-point increment in AHI, the odds of abnormality increased by 20% (95% CI, 7%-34%). Twin pairs where both twins had OSA exhibited the greatest risk. There were no differences in measures of ischemia and absolute myocardial blood flow and flow reserve by AHI status.

CONCLUSIONS

OSA is associated with myocardial perfusion abnormalities that suggest prior subclinical myocardial scarring or infarction. Early environmental factors that affect both twins equally may play a role and should be further explored.

Association between Arousals during Sleep and Subclinical Coronary Atherosclerosis in Patients with Obstructive Sleep Apnea

(1) Aim: We aim to evaluate the association between arousals during sleep and subclinical coronary atherosclerosis detected by coronary computed tomography angiography (CTA) in patients with obstructive sleep apnea (OSA). (2) Methods: This was a cross-sectional study. Consecutive newly diagnosed OSA patients, who underwent coronary CTA examinations within 3 months of the sleep study, were eligible. We used the arousal index (ArI) derived from polysomnography to assess arousals during sleep and a semi-automated plaque quantification software to characterize and quantify the subclinical coronary atherosclerosis. Multiple regression models were used to evaluate the associations of the ArI with the coronary atherosclerotic plaque presence, volume, and composition. (3) Results: A total of 99 patients with OSA were included in the study. In the multivariable models, patients with a high ArI (ArI > 32.2 events/h) were more likely to have coronary plaques compared to those with a low ArI (ArI ≤ 32.2 events/h) (OR: 3.29 [95% CI: 1.284 to 8.427], p = 0.013). Furthermore, the ArI exhibited significant associations with total (β = 0.015), noncalcified (β = 0.015), and low-attenuation (β = 0.012) coronary plaque volume after accounting for established risk factors (p = 0.008, 0.004, and 0.002, respectively). However, no association between the ArI and calcified plaque volume was found. (4) Conclusion: Repetitive arousals during sleep are associated with an increased coronary plaque burden in patients with OSA, which remained robust after adjusting for multiple established cardiovascular risk factors.

Novel Insights into the Predictors of Obstructive Sleep Apnea Syndrome in Patients with Chronic Coronary Syndrome: Development of a Predicting Model

Background

Obstructive sleep apnea syndrome (OSAS) is common in patients with chronic coronary syndrome (CCS); however, a predictive model of OSAS in patients with CCS remains rarely reported. The study aimed to construct a novel nomogram scoring system to predict OSAS comorbidity in patients with CCS.

Methods

Consecutive CCS patients scheduled for sleep monitoring at our hospital from January 2019 to September 2020 were enrolled in the current study. Coronary CT angiography or coronary angiography was used for the diagnosis of CCS, and clinical characteristics of the patients were collected. Significant predictors for OSAS in patients with moderate/severe CCS were estimated via logistic regression analysis, and a clinical nomogram was constructed. A calibration plot, examining discrimination (Harrell's concordance index) and decision curve analysis (DCA), was applied to validate the nomogram's predictive performance. Internal validity of the predictive model was assessed using bootstrapping (1000 replications).

Results

The nomograms were constructed based on available clinical variables from 527 patients which were significantly associated with moderate/severe OSAS in patients with CCS, including body mass index, impaired glucose tolerance, hypertension, diabetes mellitus, nonalcoholic fatty liver disease, and routine laboratory indices such as neutrophil to lymphocyte ratio, platelet-to-lymphocyte ratio, high-density lipoprotein cholesterol, and low-density lipoprotein cholesterol. The C-index (0.793) and AUC (0.771, 95% CI: 0.731–0.811) demonstrated a favorable discriminative ability of the nomogram. Moreover, calibration plots revealed consistency between moderate/severe OSAS predicted by the nomogram and validated by the results of sleep monitoring. Clinically, DCA showed that the nomogram had good discriminative ability to predict moderate/severe OSAS in patients with CCS.

Conclusions

The risk nomogram constructed via the routinely available clinical variables in patients with CCS showed satisfying discriminative ability to predict comorbid moderate/severe OSAS, which may be useful for identification of high-risk patients with OSAS in patients with CCS.