Obstructive sleep apnea and risk of stroke: A meta-analysis of prospective studies

Positive Airway Pressure, Mortality, and Cardiovascular Risk in Older Adults With Sleep Apnea

Importance

Positive airway pressure (PAP) is the first-line treatment for obstructive sleep apnea (OSA), but evidence on its beneficial effect on major adverse cardiovascular events (MACE) and mortality prevention is limited.

Objective

To determine whether PAP initiation and utilization are associated with lower mortality and incidence of MACE among older adults with OSA living in the central US.

Design, Setting, and Participants

This retrospective clinical cohort study included Medicare beneficiaries with 2 or more distinct OSA claims identified from multistate, statewide, multiyear (2011-2020) Medicare fee-for-service claims data. Individuals were followed up until death or censoring on December 31, 2020. Analyses were performed between December 2021 and December 2023.

Exposures

Evidence of PAP initiation and utilization based on PAP claims after OSA diagnosis.

Main Outcomes and Measures

All-cause mortality and MACE, defined as a composite of myocardial infarction, heart failure, stroke, or coronary revascularization. Doubly robust Cox proportional hazards models with inverse probability of treatment weights were used to estimate treatment effect sizes controlling for sociodemographic and clinical factors.

Results

Among 888 835 beneficiaries with OSA included in the analyses (median [IQR] age, 73 [69-78] years; 390 598 women [43.9%]; 8115 Asian [0.9%], 47 122 Black [5.3%], and 760 324 White [85.5%] participants; median [IQR] follow-up, 3.1 [1.5-5.1] years), those with evidence of PAP initiation (290 015 [32.6%]) had significantly lower all-cause mortality (hazard ratio [HR], 0.53; 95% CI, 0.52-0.54) and MACE incidence risk (HR, 0.90; 95% CI, 0.89-0.91). Higher quartiles (Q) of annual PAP claims were progressively associated with lower mortality (Q2 HR, 0.84; 95% CI, 0.81-0.87; Q3 HR, 0.76; 95% CI, 0.74-0.79; Q4 HR, 0.74; 95% CI, 0.72-0.77) and MACE incidence risk (Q2 HR, 0.92; 95% CI, 0.89-0.95; Q3 HR, 0.89; 95% CI, 0.86-0.91; Q4 HR, 0.87; 95% CI, 0.85-0.90).

Conclusions and Relevance

In this cohort study of Medicare beneficiaries with OSA, PAP utilization was associated with lower all-cause mortality and MACE incidence. Results might inform trials assessing the importance of OSA therapy toward minimizing cardiovascular risk and mortality in older adults.

Obstructive sleep apnea and cardiovascular risk

Patients with obstructive sleep apnea (OSA) experience repetitive episodes of upper airway obstruction due to recurrent collapse during sleep. This leads to intermittent hypoxia episodes, which, through complex pathophysiological mechanisms, trigger sympathetic overactivation, endothelial dysfunction, hypercoagulation, and metabolic dysregulation. Consequently, other cardiovascular risk factors such as hypertension, metabolic syndrome, and diabetes are induced. Furthermore, this enhances target organ damage, affecting the heart, arteries, and kidneys, leading to an increased risk of cardiovascular morbidity and mortality. Among the various treatments for OSA, Continuous Positive Airway Pressure (CPAP) has been extensively studied. To date, this treatment has shown mild benefits in reducing blood pressure, particularly noticeable in patients with resistant hypertension. Furthermore, CPAP treatment appears to reduce cardiovascular events, both in primary and secondary prevention, though this benefit is limited to individuals with good compliance (CPAP use ≥4h/night). Future research perspectives in OSA seem to focus on identifying patients in whom the condition significantly influences cardiovascular risk, thus determining those who would benefit the most from treatment in the reduction of cardiovascular risk.

Nocturnal hypoxemic burden and micro- and macrovascular disease in patients with type 2 diabetes

BACKGROUND

Micro- and macrovascular diseases are common in patients with type 2 diabetes mellitus (T2D) and may be partly caused by nocturnal hypoxemia. The study aimed to characterize the composition of nocturnal hypoxemic burden and to assess its association with micro- and macrovascular disease in patients with T2D.

METHODS

This cross-sectional analysis includes overnight oximetry from 1247 patients with T2D enrolled in the DIACORE (DIAbetes COhoRtE) study. Night-time spent below a peripheral oxygen saturation of 90% (T90) as well as T90 associated with non-specific drifts in oxygen saturation (T90non - specific), T90 associated with acute oxygen desaturation (T90desaturation) and desaturation depths were assessed. Binary logistic regression analyses adjusted for known risk factors (age, sex, smoking status, waist-hip ratio, duration of T2D, HbA1c, pulse pressure, low-density lipoprotein, use of statins, and use of renin-angiotensin-aldosterone system inhibitors) were used to assess the associations of such parameters of hypoxemic burden with chronic kidney disease (CKD) as a manifestation of microvascular disease and a composite of cardiovascular diseases (CVD) reflecting macrovascular disease.

RESULTS

Patients with long T90 were significantly more often affected by CKD and CVD than patients with a lower hypoxemic burden (CKD 38% vs. 28%, p < 0.001; CVD 30% vs. 21%, p < 0.001). Continuous T90desaturation and desaturation depth were associated with CKD (adjusted OR 1.01 per unit, 95% CI [1.00; 1.01], p = 0.008 and OR 1.30, 95% CI [1.06; 1.61], p = 0.013, respectively) independently of other known risk factors for CKD. For CVD there was a thresholdeffect, and only severly and very severly increased T90non-specific was associated with CVD ([Q3;Q4] versus [Q1;Q2], adjusted OR 1.51, 95% CI [1.12; 2.05], p = 0.008) independently of other known risk factors for CVD.

CONCLUSION

While hypoxemic burden due to oxygen desaturations and the magnitude of desaturation depth were significantly associated with CKD, only severe hypoxemic burden due to non-specific drifts was associated with CVD. Specific types of hypoxemic burden may be related to micro- and macrovascular disease.

Identifying clusters of patient comorbidities associated with obstructive sleep apnea using electronic health records

STUDY OBJECTIVES

The objectives of this study were to understand the relative comorbidity burden of obstructive sleep apnea (OSA), determine whether these relationships were modified by sex or age, and identify patient subtypes defined by common comorbidities.

METHODS

Cases with OSA and noncases (controls) were defined using a validated electronic health record (EHR)-based phenotype and matched for age, sex, and time period of follow-up in the EHR. We compared prevalence of the 20 most common comorbidities between matched cases and controls using conditional logistic regression with and without controlling for body mass index. Latent class analysis was used to identify subtypes of OSA cases defined by combinations of these comorbidities.

RESULTS

In total, 60,586 OSA cases were matched to 60,586 controls (from 1,226,755 total controls). Patients with OSA were more likely to have each of the 20 most common comorbidities compared with controls, with odds ratios ranging from 3.1 to 30.8 in the full matched set and 1.3 to 10.2 after body mass index adjustment. Associations between OSA and these comorbidities were generally stronger in females and patients with younger age at diagnosis. We identified 5 distinct subgroups based on EHR-defined comorbidities: High Comorbidity Burden, Low Comorbidity Burden, Cardiovascular Comorbidities, Inflammatory Conditions and Less Obesity, and Inflammatory Conditions and Obesity.

CONCLUSIONS

Our study demonstrates the power of leveraging the EHR to understand the relative health burden of OSA, as well as heterogeneity in these relationships based on age and sex. In addition to enrichment for comorbidities, we identified 5 novel OSA subtypes defined by combinations of comorbidities in the EHR, which may be informative for understanding disease outcomes and improving prevention and clinical care. Overall, this study adds more evidence that OSA is heterogeneous and requires personalized management.

CITATION

Te TT, Keenan BT, Veatch OJ, Boland MR, Hubbard RA, Pack AI. Identifying clusters of patient comorbidities associated with obstructive sleep apnea using electronic health records. J Clin Sleep Med. 2024;20(4):521-533.

Sleep Apnea and Incident Stroke in a National Cohort of Black and White Adults

BACKGROUND AND OBJECTIVES

Racial/ethnic differences have been documented in the relationship between obstructive sleep apnea (OSA) and stroke incidence, yet racial differences in OSA symptoms or treatment and their relationship with stroke incidence are underexplored and may contribute to stroke disparities. We comprehensively examined OSA symptoms and their relationships to stroke incidence by race/ethnicity.

METHODS

Data were collected from the REasons for Geographic and Racial Differences in Stroke (REGARDS) study, a population-based cohort of Black and White individuals in the United States. Participants free from a stroke diagnosis at baseline were included. Participants self-reported the following: (1) snoring; (2) daytime sleepiness; (3) provider-diagnosed sleep apnea (PDSA); and (4) treatment for PDSA using positive airway pressure (PAP). OSA risk was categorized as high or low based on the Berlin Sleep Questionnaire. Incident stroke was defined as first occurrence of stroke over an average of 12 (SD 3.9) years of follow-up. We report the relationships between snoring, OSA risk, PDSA, PAP therapy use, and incident stroke by race/ethnicity using Cox proportional hazards models after adjusting for demographic and socioeconomic factors and stroke risk factors.

RESULTS

Among the 22,192 participants (mean age [SD] 64.2[9.1] years), 38.1% identified as Black. Overall, snoring was not associated with incident stroke (hazard ratio [HR] 0.98, 95% CI 0.85-1.13). However, among White individuals but not Black individuals, high OSA risk and PDSA were associated with incident stroke (HR 1.22, 95% CI 1.01-1.47; HR 1.33, 95% CI 1.04-1.70, respectively). PAP therapy use among those with PDSA (compared with non-PDSA) was associated with incident stroke in White individuals (HR 1.38, 95% CI 1.05-1.80). PAP therapy use among those with PDSA (compared with those with PDSA without PAP therapy use) was associated with reduced risk of incident stroke in Black (HR 0.39, 95% CI 0.17-0.91) but not White (HR 0.63, 95% CI 0.37-1.10) individuals.

DISCUSSION

White individuals with high OSA risk and those with PDSA with or without PAP therapy use were at increased incident stroke risk, whereas Black individuals reporting PDSA and PAP had reduced incident stroke risk relative to those not using PAP. Future research is needed to understand the mechanisms underlying racial differences in OSA and stroke such as differences in assessment modes and treatment.

A multi-branch convolutional neural network for snoring detection based on audio

Obstructive sleep apnea (OSA) is associated with various health complications, and snoring is a prominent characteristic of this disorder. Therefore, the exploration of a concise and effective method for detecting snoring has consistently been a crucial aspect of sleep medicine. As the easily accessible data, the identification of snoring through sound analysis offers a more convenient and straightforward method. The objective of this study was to develop a convolutional neural network (CNN) for classifying snoring and non-snoring events based on audio. This study utilized Mel-frequency cepstral coefficients (MFCCs) as a method for extracting features during the preprocessing of raw data. In order to extract multi-scale features from the frequency domain of sound sources, this study proposes the utilization of a multi-branch convolutional neural network (MBCNN) for the purpose of classification. The network utilized asymmetric convolutional kernels to acquire additional information, while the adoption of one-hot encoding labels aimed to mitigate the impact of labels. The experiment tested the network's performance by utilizing a publicly available dataset consisting of 1,000 sound samples. The test results indicate that the MBCNN achieved a snoring detection accuracy of 99.5%. The integration of multi-scale features and the implementation of MBCNN, based on audio data, have demonstrated a substantial improvement in the performance of snoring classification.

Positive Airway Pressure Therapy Predicts Lower Mortality and Major Adverse Cardiovascular Events Incidence in Medicare Beneficiaries with Obstructive Sleep Apnea

Background

Obesity is associated with obstructive sleep apnea (OSA) and cardiovascular risk. Positive airway pressure (PAP) is the first line treatment for OSA, but evidence on its beneficial effect on major adverse cardiovascular events (MACE) prevention is limited. Using claims data, the effects of PAP on mortality and incidence of MACE among Medicare beneficiaries with OSA were examined.

Methods

A cohort of Medicare beneficiaries with ≥2 distinct OSA claims was defined from multi-state, state-wide, multi-year (2011-2020) Medicare fee-for-service claims data. Evidence of PAP initiation and utilization was based on PAP claims after OSA diagnosis. MACE was defined as a composite of myocardial infarction, heart failure, stroke, or coronary revascularization. Doubly robust Cox proportional hazards models with inverse probability of treatment weights estimated treatment effects controlling for sociodemographic and clinical factors.

Results

Among 888,835 beneficiaries with OSA (median age 73 years; 43.9% women; median follow-up 1,141 days), those with evidence of PAP initiation (32.6%) had significantly lower all-cause mortality (HR [95%CI]: 0.53 [0.52-0.54]) and MACE incidence risk (0.90 [0.89-0.91]). Higher quartiles of annual PAP claims were progressively associated with lower mortality (Q2: 0.84 [0.81-0.87], Q3: 0.76 [0.74-0.79], Q4: 0.74 [0.72-0.77]) and MACE incidence risk (Q2: 0.92 [0.89-0.95], Q3: 0.89 [0.86-0.91], Q4: 0.87 [0.85-0.90]).

Conclusion

PAP utilization was associated with lower all-cause mortality and MACE incidence among Medicare beneficiaries with OSA. Results might inform trials assessing the importance of OSA therapy towards minimizing cardiovascular risk and mortality in older adults.

Sleep Disorders in Patients with Neurologic Disease

OBJECTIVE

This article provides an overview of the growing body of evidence showing bidirectional relationships between sleep and various neurologic disorders.

LATEST DEVELOPMENTS

Mounting evidence demonstrates that disrupted sleep can negatively impact various neurologic disease processes, including stroke, multiple sclerosis, epilepsy, neuromuscular disorders including amyotrophic lateral sclerosis, and headache syndromes. Abnormal sleep can also be a precursor to Alzheimer disease and neurodegenerative disease states such as Parkinson disease and dementia with Lewy bodies. Interventions to improve sleep and treat obstructive sleep apnea may play a vital role in preventing neurologic disease development and progression.

ESSENTIAL POINTS

Sleep disorders are common among patients with neurologic disorders. To provide comprehensive care to patients with neurologic conditions, neurologists must ask patients about sleep issues that may warrant further diagnostic testing, treatment, and sleep medicine referral when indicated.

Association Between Insomnia Symptoms and Trajectory With the Risk of Stroke in the Health and Retirement Study

BACKGROUND AND OBJECTIVES

Insomnia is a common condition affecting more than a third of the US population. However, the link between insomnia symptoms and stroke is understudied and the underlying mechanism remains unclear. This study aimed to investigate the relationship between insomnia symptoms and the incidence of stroke.

METHODS

The Health and Retirement Study, a survey of Americans older than 50 years and their spouses, from 2002 to 2020 was used as the data source. Only those who were stroke-free at baseline were included in this study. The exposure variable was insomnia symptoms and was derived from self-reported sleep-related factors including difficulty initiating sleep, difficulty maintaining sleep, waking up too early, and nonrestorative sleep. Repeated-measures latent class analysis was used to identify insomnia trajectories over time. To investigate the relationship between insomnia symptoms and stroke events reported during the follow-up period, Cox proportional hazards regression models were used. Mediation analyses of comorbidities were performed using causal mediation within a counterfactual framework.

RESULTS

A total of 31,126 participants were included with a mean follow-up of 9 years. The mean age was 61 years (SD = 11.1) and 57% were females. Insomnia symptom trajectories remained constant over time. Compared with those with no insomnia symptoms, an increased risk of stroke was observed for those with insomnia symptom scores ranging from 1 to 4 and 5 to 8 (hazard ratio (HR) = 1.16, 95% confidence interval (CI) 1.02-1.33) and (HR = 1.51, 95% CI 1.29-1.77), respectively, indicating a dose-response relationship. The association was stronger in participants younger than 50 years (HR = 3.84, 95% CI 1.50-9.85) than in those aged 50 years and older (HR = 1.38, 95% CI 1.18-1.62), comparing those with insomnia symptoms ranging from 5 to 8 with those with no insomnia symptoms. This association was mediated by diabetes, hypertension, heart disease, and depression.

DISCUSSION

Insomnia symptoms were associated with an increased risk of stroke, especially in adults younger than 50 years, and the risk was mediated by certain comorbidities. Increased awareness and management of insomnia symptoms may contribute to the prevention of stroke occurrence.

Pathophysiology and probable etiology of cerebral small vessel disease in vascular dementia and Alzheimer's disease

Vascular cognitive impairment and dementia (VCID) is commonly caused by vascular injuries in cerebral large and small vessels and is a key driver of age-related cognitive decline. Severe VCID includes post-stroke dementia, subcortical ischemic vascular dementia, multi-infarct dementia, and mixed dementia. While VCID is acknowledged as the second most common form of dementia after Alzheimer's disease (AD) accounting for 20% of dementia cases, VCID and AD frequently coexist. In VCID, cerebral small vessel disease (cSVD) often affects arterioles, capillaries, and venules, where arteriolosclerosis and cerebral amyloid angiopathy (CAA) are major pathologies. White matter hyperintensities, recent small subcortical infarcts, lacunes of presumed vascular origin, enlarged perivascular space, microbleeds, and brain atrophy are neuroimaging hallmarks of cSVD. The current primary approach to cSVD treatment is to control vascular risk factors such as hypertension, dyslipidemia, diabetes, and smoking. However, causal therapeutic strategies have not been established partly due to the heterogeneous pathogenesis of cSVD. In this review, we summarize the pathophysiology of cSVD and discuss the probable etiological pathways by focusing on hypoperfusion/hypoxia, blood-brain barriers (BBB) dysregulation, brain fluid drainage disturbances, and vascular inflammation to define potential diagnostic and therapeutic targets for cSVD.

International Consensus Statement on Obstructive Sleep Apnea

BACKGROUND

Evaluation and interpretation of the literature on obstructive sleep apnea (OSA) allows for consolidation and determination of the key factors important for clinical management of the adult OSA patient. Toward this goal, an international collaborative of multidisciplinary experts in sleep apnea evaluation and treatment have produced the International Consensus statement on Obstructive Sleep Apnea (ICS:OSA).

METHODS

Using previously defined methodology, focal topics in OSA were assigned as literature review (LR), evidence-based review (EBR), or evidence-based review with recommendations (EBR-R) formats. Each topic incorporated the available and relevant evidence which was summarized and graded on study quality. Each topic and section underwent iterative review and the ICS:OSA was created and reviewed by all authors for consensus.

RESULTS

The ICS:OSA addresses OSA syndrome definitions, pathophysiology, epidemiology, risk factors for disease, screening methods, diagnostic testing types, multiple treatment modalities, and effects of OSA treatment on multiple OSA-associated comorbidities. Specific focus on outcomes with positive airway pressure (PAP) and surgical treatments were evaluated.

CONCLUSION

This review of the literature consolidates the available knowledge and identifies the limitations of the current evidence on OSA. This effort aims to create a resource for OSA evidence-based practice and identify future research needs. Knowledge gaps and research opportunities include improving the metrics of OSA disease, determining the optimal OSA screening paradigms, developing strategies for PAP adherence and longitudinal care, enhancing selection of PAP alternatives and surgery, understanding health risk outcomes, and translating evidence into individualized approaches to therapy.

Obstructive Sleep Apnea - Influence on the Cardiovascular System and Cognition

Kardiovaskuläre und kognitive Erkrankungen sind ebenso wie die obstruktive Schlafapnoe sehr häufige Krankheiten mit einer erheblichen Beeinträchtigung der Lebensqualität und einer deutlichen sozioökonomischen Bedeutung. Die Auswirkungen einer unbehandelten obstruktiven Schlafapnoe (OSA) auf das kardiovaskuläre und kognitive Erkrankungsrisiko und die Therapieeffekte einer OSA sind für die meisten kardiovaskulären und kognitiven Folgeerkrankungen wissenschaftlich nachgewiesen. Für die klinische Praxis besteht ein deutlicher Bedarf nach mehr Interdisziplinarität. Aus schlafmedizinischer Sicht müssen bei der Therapieindikation das individuelle kardiovaskuläre und kognitive Risiko berücksichtigt und kognitive Erkrankungen bei der Beurteilung der Therapieintoleranz und residuellen Symptomatik beachtet werden. Aus internistischer Sicht sollte bei Patienten mit schlecht einstellbarem Hypertonus, Vorhofflimmern, koronarer Herzkrankheit und Schlaganfall die Abklärung einer OSA in die Diagnostik integriert werden. Bei Patienten mit milder kognitiver Beeinträchtigung, Alzheimer-Krankheit und Depression können sich die typischen Symptome wie Fatigue, Tagesmüdigkeit und Reduktion der kognitiven Leistungen mit OSA-Symptomen überschneiden. Die Diagnostik einer OSA sollte in die Abklärung dieser Krankheitsbilder integriert werden, da eine Therapie der OSA die kognitiven Beeinträchtigungen reduzieren und die Lebensqualität verbessern kann.

Association of Heart Rate Variability with Obstructive Sleep Apnea in Adults

Background and Objectives: Heart rate variability (HRV) analysis is a noninvasive method used to examine autonomic system function, and the clinical applications of HRV analysis have been well documented. The aim of this study is to investigate the association between HRV and the apnea–hypopnea index (AHI) in patients referred for polysomnography (PSG) for obstructive sleep apnea (OSA) diagnosis. Materials and Methods: Patients underwent whole-night PSG. Data on nocturnal HRV and AHI were analyzed. We determined the correlation of time- and frequency-domain parameters of HRV with the AHI. Results: A total of 62 participants (50 men and 12 women) were enrolled. The mean age, body mass index (BMI), neck circumference, and AHI score of the patients were 44.4 ± 11.5 years, 28.7 ± 5.2, 40.2 ± 4.8 cm, and 32.1 ± 27.0, respectively. The log root mean square of successive differences between normal heartbeats (RMSSD) were negatively correlated with BMI (p = 0.034) and neck circumference (p = 0.003). The log absolute power of the low-frequency band over high-frequency band (LF/HF) ratio was positively correlated with the AHI (p = 0.006). A higher log LF/HF power ratio (β = 5.01, p = 0.029) and BMI (β = 2.20, p < 0.001) were associated with a higher AHI value in multiple linear regression analysis. Conclusions: A higher log LF/HF power ratio and BMI were positively and significantly associated with the AHI during whole-night PSG in adult patients.

Prevalence of sleep apnoea in patients with type 1 diabetes and its association with comorbidities and diabetic complications: A French nationwide prospective study

AIM

To investigate sleep apnoea prevalence, factors influencing severity, and associations between sleep apnoea severity and micro-/macrovascular complications in a large population of patients with type 1 diabetes.

MATERIALS AND METHODS

This French multicentre prospective cohort study was conducted between July 2016 and June 2020. Adults with type 1 diabetes using an insulin pump were eligible. Home care provider nurses collected demographic and clinical data and set up oximetry to determine the oxygen desaturation index (ODI). No, mild-moderate and severe sleep apnoea were defined as ODI <15 events/h, 15 to <30 events/h and ≥30 events/h, respectively. Univariate and multivariate analyses were performed to identify factors associated with sleep apnoea, and associations between sleep apnoea severity and micro-/macrovascular complications were determined using logistic regression.

RESULTS

Of 769 participants, 12.4% and 3.4% had mild-to-moderate or severe sleep apnoea, respectively. Factors significantly associated with sleep apnoea on multivariate analysis were age, sex, body mass index (BMI) and hypertension. After adjustment for age, sex and BMI, presence of severe sleep apnoea was significantly associated with macrovascular complications (odds ratio vs. no sleep apnoea: 3.96 [95% confidence interval 1.43-11.11]; P < 0.01), while mild-to-moderate sleep apnoea was significantly associated with presence of diabetic retinopathy (odds ratio 2.09 [95% confidence interval 1.10-3.74]; P < 0.01).

CONCLUSION

Sleep apnoea is a significant comorbidity in patients with type 1 diabetes, especially with respect to diabetic complications. This highlights the need for sleep apnoea screening and management in these individuals.

Causal Relations Between Obstructive Sleep Apnea and Stroke: A Mendelian Randomization Study

Background

Previous studies of obstructive sleep apnea (OSA) in relation to stroke have been noted. However, the exact causality remains to be clearly defined. We aimed to adopt a two-sample Mendelian randomization study to investigate the causal effects of OSA on stroke and its subtypes.

Methods

A two-sample Mendelian randomization (MR) analysis was conducted to evaluate the causal effect of OSA on stroke and its subtypes, including, based on publicly genome-wide association studies (GWAS) databases. The inverse variance weighted (IVW) method was used as the main analysis. MR-Egger regression, weighted mode, weighted median, and MR pleiotropy residual sum and outlier (MR-PRESSO) were performed methods and were adopted as supplementary analysis to ensure the robustness of the results.

Results

Genetically predicted OSA was not related to the risk of stroke (odds ratio (OR), 0.99, 95% CI, 0.81-1.21, p = 0.909), and its subtypes, ischemic stroke (IS) (OR, 1.01, 95% CI, 0.82-1.23, p = 0.927), large vessel stroke (LVS) (OR, 1.05, 95% CI, 0.73-1.51, p = 0.795), cardioembolic stroke (CES) (OR, 1.03, 95% CI, 0.74-1.43, p = 0.855), small vessel stroke (SVS) (OR, 1.13, 95% CI, 0.88-1.46, p = 0.329), lacunar stroke (LS) (OR, 1.07, 95% CI, 0.74-1.56, p = 0.721) as well as intracerebral hemorrhage (ICH) (OR, 0.37, 95% CI = 0.09, 1.48, p = 0.160) (Wald ratio method). Other supplementary MR methods also confirmed similar results.

Conclusion

There may be no direct causal relationship between OSA and stroke or its subtypes.

Development of a new non invasive prognostic stroke scale (NIPSS) including triage elements for sleep apnea and peripheral artery disease

BACKGROUND

Although sleep apnea and peripheral artery disease are prognostic factors for stroke, their added benefit in the acute stage to further prognosticate strokes has not been evaluated.

OBJECTIVES

We tested the accuracy in the acute stroke stage of a novel score called the Non-Invasive Prognostic Stroke Scale (NIPSS).

PATIENTS AND METHODS

Prospective cohort with imaging-confirmed ischemic stroke. Clinical data, sleep apnea risk score (STOPBANG) and blood pressure measures were collected at baseline. Primary outcome was the 90-day modified Rankin Scale (mRS), with poor outcome defined as mRS 3-6. Area under the ROC curve (AUC) was calculated for NIPSS and compared to six other stroke prognostic scores in our cohort: SPAN-100 index, S-SMART, SOAR, ASTRAL, THRIVE, and Dutch Stroke scores.

RESULTS

We enrolled 386 participants. After 90 days, there were 56% with poor outcome, more frequently older, female predominant and with higher admission National Institute of Health Stroke Scale (NIHSS). Four variables remained significantly associated with primary endpoint in the multivariable model: age (OR 1.87), NIHSS (OR 7.08), STOPBANG category (OR 1.61), and ankle-braquial index (OR 2.11). NIPSS AUC was 0.86 (0.82-0.89); 0.83 (0.79-0.87) with bootstrapping. When compared to the other scores, NIPSS, ASTRAL, S-SMART and DUTCH scores had good abilities in predicting poor outcome, with AUC of 0.86, 0.86, 0.83 and 0.82, respectively. THRIVE, SOAR and SPAN-100 scores were fairly predictive.

DISCUSSION AND CONCLUSIONS

Non-invasive and easily acquired emergency room data can predict clinical outcome after stroke. NIPSS performed equal to or better than other prognostic stroke scales.

Study on Relationship Between Carotid Intima-Media Thickness and Inflammatory Factors in Obstructive Sleep Apnea

Purpose

The purpose of this study was to explore the change of carotid intima-media thickness (IMT) and its correlation with inflammatory markers in patients with different degrees of obstructive sleep apnea (OSA).

Methods

One hundred hospitalized patients were selected and were divided into the normal control group (21 cases), the mild-moderate group (39 cases) and the severe group (40 cases) according to their apnea hypopnea index (AHI). Carotid IMT of all registered patients was studied with ultrasound, and serum levels of high-sensitivity C-reactive protein (hs-CRP), Lipoprotein-associated phospholipaseA2 (Lp-PLA2) and tumor necrosis factor-α (TNF-α) were measured. Pearson correlation analysis and multiple stepwise regression analysis were used to analyze the correlation between carotid IMT and inflammatory factors.

Results

Patients with mild, moderate and severe OSA Carotid IMT had significantly higher levels of serum hs-CRP, Lp-PLA2 and TNF-α compared with the normal control group (P < 0.001). The levels of carotid IMT, serum protein hs-CRP, Lp-PLA2 and TNF-α in the severe OSA group were significantly higher than those of the mild-moderate OSA group, with P values being less than 0.001. Carotid artery IMT was positively correlated with serum hs-CRP (r = 0.83, P < 0.001), Lp-PLA2 (r =0.58, P < 0.001), and TNF-α (r =0.69, P < 0.001). hs-CRP, TNF-α and AHI were independent factors affecting carotid artery IMT. In addition, AHI was an independent indicator of carotid atherosclerosis (P = 0.0012).

Conclusion

Increased inflammatory factors in OSA patients might cause the progression of atherosclerosis, which might increase the risk of cardiovascular and cerebrovascular diseases in OSA patients.

Impact of obstructive sleep apnea on platelet activation and development of silent brain infarctions

Background

Obstructive sleep apnea (OSA) is a unique potent predictor for stroke compared to other predictors. By aiding in the adherence of leukocytes and platelets, soluble P-selectin (sP-selectin) contributes to the development of ischemic stroke. The objective of this study was to investigate the independent impact of OSA on platelet activation and development of silent brain infarction. Twenty-four OSA patients and 24 controls were studied in a case–control study, who underwent one-night polysomnography, magnetic resonance imaging for evaluation of silent brain infarctions (SBI), measurement of serum (sP-selectin) levels for assessment of increased platelet activation and C-reactive protein (CRP) serum levels.

Results

Out of 24 patients, 5 (20.8%) had mild OSA and 8 (33.3%) had moderate and 11 (45.8%) had severe OSA. Serum levels of sP-selectin were statistically significantly higher in moderate and severe groups (p < 0.001). Eleven (57.9%) patients in moderate and severe OSA had SBI. Fifty percent of patients with moderate OSA had elevated serum sP-selectin and 25.0% of them had SBI and 81.8% of severe OSA patients had elevated serum sP-selectin and 81.8% of them had SBI. Patients with mild OSA and controls had no SBI and normal serum sP-selectin level. CRP was statistically significantly higher in moderate and severe OSA groups (16.6% and 45.8%) than the mild and control groups (4.1% and 0%) (p < 0.001).

Conclusion

Moderate and severe obstructive sleep apnea were associated independently with elevated serum sP-selectin reflecting increased platelet function, elevated inflammatory marker CRP and an increased risk of silent brain infarctions.

CPAP Therapy on Depressive and Anxiety Symptoms in Patients with Moderate to Severe Obstructive Sleep Apnea Syndrome

Backgrounds and Objectives: There is a link between sleep apnea syndrome (OSA) and depressive and anxiety symptoms, but the underlying mechanisms are not fully understood. The study aimed to determine the prevalence of these symptoms in patients with OSA and to evaluate the impact of continuous positive airway pressure (CPAP) on depression and anxiety scores. Materials and Methods: Ninety-nine consecutive new patients diagnosed with moderate or severe (apnea-hypopnea index AHI ≥ 15 events/h) OSA were accepted for the CPAP therapy. Patients completed a patient health questionnaire (PHQ-9) for depressive symptoms and a generalized anxiety questionnaire (GAD-7) for anxiety symptoms before the CPAP treatment, after 6 months, and after 1 year of CPAP therapy with compliance. For both scores (PHQ-9 and GAD-7), a cut point ≥10 was used to indicate the presence of clinically depressive and anxiety symptoms. Results: Forty-eight individuals (48.48%) had PHQ-9 scores above the cut-off point ≥ 10, and twenty-seven participants (27.27%) had GAD-7 scores above the cut-off point ≥10. A significant correlation has been shown between PHQ-9 score and BMI (p < 0.0001), AHI (p < 0.0001), ODI (p < 0.001), ESS (p < 0.001), GAD-7 score (p < 0.0001), and [t90] (p < 0.0001), while GAD-7 was correlated with AHI (p < 0.030), ODI (p < 0.006), and [t90] (p < 0.001). The PHQ-9 and GAD-7 scores decreased significantly after 6 months of CPAP therapy in all groups and after 1 year of CPAP use. Conclusions: OSA patients should be screened for depression and anxiety. Furthermore, CPAP should be the first choice of treatment before starting other treatments for depression and anxiety symptoms.

Brazilian Thoracic Association Consensus on Sleep-disordered Breathing

Sleep is essential for the proper functioning of all individuals. Sleep-disordered breathing can occur at any age and is a common reason for medical visits. The objective of this consensus is to update knowledge about the main causes of sleep-disordered breathing in adult and pediatric populations, with an emphasis on obstructive sleep apnea. Obstructive sleep apnea is an extremely prevalent but often underdiagnosed disease. It is often accompanied by comorbidities, notably cardiovascular, metabolic, and neurocognitive disorders, which have a significant impact on quality of life and mortality rates. Therefore, to create this consensus, the Sleep-Disordered Breathing Department of the Brazilian Thoracic Association brought together 14 experts with recognized, proven experience in sleep-disordered breathing.

Bidirectional relationships of comorbidity with obstructive sleep apnoea

Obstructive sleep apnoea (OSA) is frequently associated with comorbidities that include metabolic, cardiovascular, renal, pulmonary and neuropsychiatric. There is considerable evidence that OSA is an independent risk factor for many of these comorbidities but, more recently, there is evidence that some of these comorbidities may predispose to the development of OSA. Thus, there is growing evidence of a bidirectional relationship between OSA and comorbidity, especially for heart failure, metabolic syndrome and stroke. Potential mechanisms of bidirectional relationships differ in individual comorbidities with fluid retention and redistribution being especially important in heart failure and end-stage renal disease, whereas neural mechanisms may be more important in diabetes mellitus and stroke. The evidence for other comorbidities, such as hypertension and atrial fibrillation, support these being more a consequence of OSA with limited evidence to support a bidirectional relationship. The present review explores the evidence for such bidirectional relationships with a particular perspective on comorbidities that may predispose to OSA. The impact of therapy in bidirectional relationships is also reviewed, which highlights the clinical importance of accurate diagnosis. This aspect is especially true of COPD, where the identification of co-existing OSA has important implications for optimum therapy.

Obstructive sleep apnoea (OSA) is an independent risk factor for comorbidity, especially cardiometabolic. However, some comorbidities may be risk factors for OSA, supporting a bidirectional relationship that may have important implications for treatment.https://bit.ly/3BbJy6V

Breathing Exercises for Improving Cognitive Function in Patients with Stroke

Patients with stroke may experience a certain degree of cognitive decline during the period of recovery, and a considerable number of such patients have been reported to show permanent cognitive damage. Therefore, the period of recovery and rehabilitation following stroke is critical for rapid cognitive functional improvements. As dysfunctional breathing has been reported as one of the factors affecting the quality of life post stroke, a number of studies have focused on the need for improving the breathing function in these patients. Numerous breathing exercises have been reported to enhance the respiratory, pulmonary, cognitive, and psychological functions. However, scientific evidence on the underlying mechanisms by which these exercises improve cognitive function is scattered at best. Therefore, it has been difficult to establish a protocol of breathing exercises for patients with stroke. In this review, we summarize the psychological, vascular, sleep-related, and biochemical factors influencing cognition in patients and highlight the need for breathing exercises based on existing studies. Breathing exercises are expected to contribute to improvements in cognitive function in stroke based on a diverse array of supporting evidence. With relevant follow-up studies, a protocol of breathing exercises can be developed for improving the cognitive function in patients with stroke.

Multimorbidity and overall comorbidity of sleep apnoea: a Finnish nationwide study

The prevalence of sleep apnoea is increasing globally; however, population-based studies have reported a wide variation of prevalence estimates, and data on incidence of clinically diagnosed sleep apnoea are scant. Data on the overall burden of comorbidities or multimorbidity in individuals with incident sleep apnoea are scarce, and the pathways to multimorbidity have only marginally been studied. To study the current epidemiology of sleep apnoea in Finland, overall burden of comorbidities, and multimorbidity profiles in individuals with incident sleep apnoea, we conducted a register-based, nationwide, retrospective study of data from January 2016 to December 2019. The prevalence of clinically diagnosed sleep apnoea was 3.7% in the Finnish adult population; 1-year incidence was 0.6%. Multimorbidity was present in 63% of individuals at the time of sleep apnoea diagnosis. Of those with incident sleep apnoea, 34% were heavily multimorbid (presenting with four or more comorbidities). The three most common chronic morbidities before sleep apnoea diagnosis were musculoskeletal disease, hypertension and cardiovascular disease. In multimorbid sleep apnoea patients, hypertension and metabolic diseases including obesity and diabetes, cardiovascular diseases, musculoskeletal diseases and dorsopathies, in different combinations, encompassed the most frequent disease pairs preceding a sleep apnoea diagnosis. Our study adds to the few population-based studies by introducing overall and detailed figures on the burden of comorbidities in sleep apnoea in a nationwide sample and provides up-to-date information on the occurrence of sleep apnoea as well as novel insights into multimorbidity in individuals with incident sleep apnoea.

Two-thirds of individuals with sleep apnoea are multimorbid at diagnosis and one-third are heavily multimorbid. Dorsopathies, musculoskeletal diseases, hypertension and metabolic diseases are the most common comorbidities preceding sleep apnoea diagnosis.https://bit.ly/36WMlX1

EVALUATİON OF THE EFFECT OF OBSTRUCTİVE SLEEP APNEA SYNDROME ON RETİNAL MİCROVASCULARİTY BY OPTİCAL COHERENCE TOMOGRAPHY ANGİOGRAPHY

PURPOSE

Using optical coherence tomography angiography (OCTA), we sought to determine whether there are retinal microvascular changes in patients with obstructive sleep apnea syndrome (OSAS).

METHOD

The study included 56 patients diagnosed with OSAS by polysomnography [21 patients with mild OSAS (group 1), 14 with moderate OSAS (group 2) and 21 with severe OSAS (group 3)], and 26 healthy individuals as a control group (group 4). The vascular densities of the superficial capillary plexus and deep capillary plexus of the retinal segmentations, together with the foveal avascular zone (FAZ) width, were measured for all participants, using OCTA.

RESULT

Compared with the control group, vascular densitiy in whole image of superficial capillary plexus were found to be significantly lower in group 2. In addition, vascular densitiy in fovea region of superficial capillary plexus was significantly lower in group 1 than the control group. In deep capillary plexus, vascular densitiy of whole image, superior hemi and nasal regions were found to be significantly lower in group 2 and group 3 compared with the control group. Parafoveal region in group 3 had significantly lower vascular densities than the controls. A significantly larger FAZ was also found in group 1 and group 3 in the deep capillary plexus, compared with the controls.

CONCLUSION

We detected smaller vascular densities in both the superficial capillary plexus and deep capillary plexus and a larger deep capillary plexus FAZ in OSAS patients. Therefore, OCTA may be useful as a non-invasive method to understand the systemic effects of OSAS.

Effect of Obstructive Sleep Apnea on the Risk of Injuries-A Nationwide Population-Based Cohort Study

Obstructive sleep apnea (OSA) has been reported to increase the risk of motor vehicle accidents. However, only few studies have investigated the effects of OSA on overall risk injury. The aim of study is to investigate whether OSA increases the risk of overall injury. The data were collected during 2000–2015 from Taiwan’s National Health Insurance Research Database. A total of 8901 individuals diagnosed with OSA were inpatients, or outpatients at least three times were enrolled. Finally, 6915 participants with OSA were included as the study cohort. We matched the study cohort with a comparison cohort, at a ratio of 1:4. Cox proportional hazards regression was used to analyse the association between OSA and overall injury. Patients with OSA had 83.1% increased risk of overall injury, compared to non-OSA individuals [adjusted hazards ratio (HR) = 1.831, confidence interval (CI) = 1.674–2.020, p < 0.001]. In the stratified age group, patients aged ≧65 years had the highest risk of injury (adjusted HR= 2.014; CI = 1.842–2.222, p < 0.001). Patients with OSA were at a higher risk of falls, traffic injury, poisoning, suffocation, suicide, and abuse or homicide than non-OSA individuals, with falls and traffic injury as the leading causes of injuries. The data demonstrated that patients with OSA have a higher risk of overall injury. The study results can be a reference for developing injury prevention strategies in the future. The general population and clinicians should have more awareness regarding OSA and its negative effects on injury development.

Obstructive sleep apnea confers lower mortality risk in acute ischemic stroke patients treated with endovascular thrombectomy: National Inpatient Sample analysis 2010-2018

BackgroundObstructive sleep apnea (OSA) portends increased morbidity and mortality following acute ischemic stroke (AIS). Evaluation of OSA in the setting of AIS treated with endovascular mechanical thrombectomy (MT) has not yet been evaluated in the literature.

METHODS

The National Inpatient Sample from 2010 to 2018 was utilized to identify adult AIS patients treated with MT. Those with and without OSA were compared for clinical characteristics, complications, and discharge disposition. Multivariable logistic regression analysis and propensity score adjustment (PA) were employed to evaluate independent associations between OSA and clinical outcome.

RESULTS

Among 101 093 AIS patients treated with MT, 6412 (6%) had OSA. Those without OSA were older (68.5 vs 65.6 years old, p<0.001), female (50.5% vs 33.5%, p<0.001), and non-caucasian (29.7% vs 23.7%, p<0.001). The OSA group had significantly higher rates of obesity (41.4% vs 10.5%, p<0.001), atrial fibrillation (47.1% vs 42.2%, p=0.001), hypertension (87.4% vs 78.5%, p<0.001), and diabetes mellitus (41.2% vs 26.9%, p<0.001). OSA patients treated with MT demonstrated lower rates of intracranial hemorrhage (19.1% vs 21.8%, p=0.017), treatment of hydrocephalus (0.3% vs 1.1%, p=0.009), and in-hospital mortality (9.7% vs 13.5%, p<0.001). OSA was independently associated with lower rate of in-hospital mortality (aOR 0.76, 95% CI 0.69 to 0.83; p<0.001), intracranial hemorrhage (aOR 0.88, 95% CI 0.83 to 0.95; p<0.001), and hydrocephalus (aOR 0.51, 95% CI 0.37 to 0.71; p<0.001). Results were confirmed by PA.

CONCLUSIONS

Our findings suggest that MT is a viable and safe treatment option for AIS patients with OSA.

Associations of Obstructive Sleep Apnea, Obestatin, Leptin, and Ghrelin with Gastroesophageal Reflux

Gastroesophageal reflux disease (GERD) is commonly observed in patients with obstructive sleep apnea (OSA). Hormonal disorders observed in OSA may be relevant in the development of GERD. The aim of the study was to assess the correlations between ghrelin, obestatin, leptin, and the intensity of GERD in patients with OSA. The study included 58 patients hospitalized due to clinical suspicion of sleep disorders during sleep. All patients underwent a sleep study, and blood samples were collected overnight for hormonal tests. Survey data concerning symptoms of GERD, gastroscopy, and esophageal pH monitoring results were included in the study. In patients with OSA, GERD was twice as common when compared to the group without OSA. Among subjects with severe sleep apnea (AHI > 30; n = 31; 53%), we observed lower ghrelin levels, especially in the second half of the night and in the morning (p_5.00 = 0.0207; p_7.00 = 0.0344); the presence of OSA had no effect on obestatin and leptin levels. No significant differences in hormonal levels were observed between the groups depending on the diagnosis of GERD. However, correlations of ghrelin levels with the severity of esophagitis, leptin and ghrelin levels with the severity of GERD symptoms, and leptin levels with lower esophageal pH were found. GERD is more frequent among patients with OSA. In both GERD and OSA, deviations were observed in the levels of ghrelin and leptin. However, our analysis demonstrates that the relationship between OSA and GERD does not result from these disorders.

Obstructive Sleep Apnea in Patients with Head and Neck Cancer—More than Just a Comorbidity?

Obstructive sleep apnea is the most common type of sleep-disordered breathing with growing prevalence. Its presence has been associated with poor quality of life and serious comorbidities. There is increasing evidence for coexisting obstructive sleep apnea in patients suffering from head and neck cancer, a condition that ranks among the top ten most common types of cancer worldwide. Routinely, patients with head and neck cancer are treated with surgery, radiation therapy, chemotherapy, immunotherapy or a combination of these, all possibly interfering with the anatomy of the oral cavity, pharynx or larynx. Thus, cancer treatment might worsen already existing obstructive sleep apnea or trigger its occurrence. Hypoxia, the hallmark feature of obstructive sleep apnea, has an impact on cancer biology and its cure. Early diagnosis and sufficient treatment of coexisting obstructive sleep apnea in patients with head and neck cancer may improve quality of life and could also potentially improve oncological outcomes.

Ethnic and Racial Variation in Intracerebral Hemorrhage Risk Factors and Risk Factor Burden

Importance

Black and Hispanic individuals have an increased risk of intracerebral hemorrhage (ICH) compared with their White counterparts, but no large studies of ICH have been conducted in these disproportionately affected populations.

Objective

To examine the prevalence, odds, and population attributable risk (PAR) percentage for established and novel risk factors for ICH, stratified by ICH location and racial/ethnic group.

Design, Setting, and Participants

The Ethnic/Racial Variations of Intracerebral Hemorrhage Study was a case-control study of ICH among 3000 Black, Hispanic, and White individuals who experienced spontaneous ICH (1000 cases in each group). Recruitment was conducted between September 2009 and July 2016 at 19 US sites comprising 42 hospitals. Control participants were identified through random digit dialing and were matched to case participants by age (±5 years), sex, race/ethnicity, and geographic area. Data analyses were conducted from January 2019 to May 2020.

Main Outcomes and Measures

Case and control participants underwent a standardized interview, physical measurement for body mass index, and genotyping for the ɛ2 and ɛ4 alleles of APOE, the gene encoding apolipoprotein E. Prevalence, multivariable adjusted odds ratio (OR), and PAR percentage were calculated for each risk factor in the entire ICH population and stratified by racial/ethnic group and by lobar or nonlobar location.

Results

There were 1000 Black patients (median [interquartile range (IQR)] age, 57 [50-65] years, 425 [42.5%] women), 1000 Hispanic patients (median [IQR] age, 58 [49-69] years; 373 [37.3%] women), and 1000 White patients (median [IQR] age, 71 [59-80] years; 437 [43.7%] women). The mean (SD) age of patients with ICH was significantly lower among Black and Hispanic patients compared with White patients (eg, lobar ICH: Black, 62.2 [15.2] years; Hispanic, 62.5 [15.7] years; White, 71.0 [13.3] years). More than half of all ICH in Black and Hispanic patients was associated with treated or untreated hypertension (PAR for treated hypertension, Black patients: 53.6%; 95% CI, 46.4%-59.8%; Hispanic patients: 46.5%; 95% CI, 40.6%-51.8%; untreated hypertension, Black patients: 45.5%; 95% CI, 39.%-51.1%; Hispanic patients: 42.7%; 95% CI, 37.6%-47.3%). Lack of health insurance also had a disproportionate association with the PAR percentage for ICH in Black and Hispanic patients (Black patients: 21.7%; 95% CI, 17.5%-25.7%; Hispanic patients: 30.2%; 95% CI, 26.1%-34.1%; White patients: 5.8%; 95% CI, 3.3%-8.2%). A high sleep apnea risk score was associated with both lobar (OR, 1.68; 95% CI, 1.36-2.06) and nonlobar (OR, 1.62; 95% CI, 1.37-1.91) ICH, and high cholesterol was inversely associated only with nonlobar ICH (OR, 0.60; 95% CI, 0.52-0.70); both had no interactions with race and ethnicity. In contrast to the association between the ɛ2 and ɛ4 alleles of APOE and ICH in White individuals (eg, presence of APOE ɛ2 allele: OR, 1.84; 95% CI, 1.34-2.52), APOE alleles were not associated with lobar ICH among Black or Hispanic individuals.

Conclusions and Relevance

This study found sleep apnea as a novel risk factor for ICH. The results suggest a strong contribution from inadequately treated hypertension and lack of health insurance to the disproportionate burden and earlier onset of ICH in Black and Hispanic populations. These findings emphasize the importance of addressing modifiable risk factors and the social determinants of health to reduce health disparities.

The Social And Economic Cost Of Sleep Disorders

STUDY OBJECTIVES

To estimate economic cost of common sleep disorders in Australia for 2019-2020.

METHODS

Costs were estimated for obstructive sleep apnea (OSA), insomnia, and restless legs syndrome (RLS) using prevalence, financial, and nonfinancial data from national databases. These included: (1) financial costs associated with health care, informal care, productivity losses, non-medical accident costs, deadweight loss from taxation/welfare inefficiencies; and (2) nonfinancial costs associated with loss of well-being. They were expressed in US dollars ($).

RESULTS

Estimated overall cost of sleep disorders in Australia in 2019-2020 (population: 25.5 million) was $35.4 billion (OSA $13.1 billion; insomnia $13.3 billion, RLS $9.0 billion). Of this, the financial cost component was $10.0 billion, comprised of: health system costs $0.7 billion; productivity losses $7.7 billion; informal care $0.2 billion; other, mainly non-medical accident costs, $0.4 billion; and deadweight losses $1.0 billion. For moderate to severe OSA syndrome, insomnia unrelated to other conditions and RLS, financial costs represented $16,717, $21,982, and $16,624 per adult with the condition for the year, respectively. The nonfinancial cost was $25.4 billion.

CONCLUSIONS

The economic costs associated with sleep disorders are substantial. The financial component of $10.0 billion is equivalent to 0.73% of Australian gross domestic product. The nonfinancial cost of $25.4 billion represents 3.2% of total Australian burden of disease for the year. Health system costs of these disorders are low relative to those associated with their consequences, suggesting greater expenditure on detection, treatment and prevention is warranted.

Sleep disordered breathing as a cause and consequence of stroke: A review of pathophysiological and clinical relationships

Stroke is the leading cause of death and disability globally. Sleep disordered breathing (SDB), a potentially modifiable risk factor of stroke, is highly prevalent in stroke survivors. Evidence supports a causal, bidirectional relationship between SDB and stroke. SDB may increase the risk of stroke occurrence and recurrence, and worsen stroke outcome. While SDB is associated with an increased incidence of hypertension and cardiac arrhythmias, both of which are traditional stroke risk factors, SDB is also an independent risk factor for stroke. A number of characteristics of SDB may increase stroke risk, including intermittent hypoxemia, sympathetic activation, changes in cerebral autoregulation, oxidative stress, systemic inflammation, hypercoagulability, and endothelial dysfunction. On the other hand, stroke may also cause new SDB or aggravate preexisting SDB. Continuous positive airway pressure treatment of SDB may have a beneficial role in reducing stroke risk and improving neurological outcome after stroke. The treatment should be considered as early as possible, particularly when SDB is present post-stroke. The goal of this review is to highlight the strong link between SDB and stroke and to raise awareness for practitioners to consider the possibility of SDB being present in all stroke survivors.

Barriers and facilitators to the implementation of a novel web-based sleep apnea management platform

STUDY OBJECTIVE

Obstructive sleep apnea (OSA) is a highly prevalent yet underdiagnosed disorder affecting US military Veterans. The Remote Veterans Apnea Management Platform (REVAMP) is a web-based OSA management program created to improve access to care. REVAMP was launched within the Veterans Health Administration (VHA) in July 2017, with variable patient recruitment rates (from 0 to 573 patients per site) at the first 10 Veterans Affairs (VA) medical centers (Wave-1 sites). This study aimed to examine the contextual circumstances surrounding the implementation of REVAMP from the provider perspective to inform strategies to increase its uptake at future rollout sites.

METHODS

A purposive sample of REVAMP site leaders from the Wave-1 sites was recruited with additional staff members being solicited as well. Semi-structured interviews were conducted. Two independent coders reviewed individual transcripts using content analysis to identify emerging themes.

RESULTS

Fifteen individuals from Wave-1 sites were interviewed. Implementation of REVAMP was facilitated by the presence of leadership support, staff, and time dedicated to REVAMP, and perceived usefulness of REVAMP by staff as well as positive feedback from the Veterans using REVAMP. The difficulty of supporting Veteran creation of login credentials to the program and integrating REVAMP into the existing workflow were major barriers to its implementation.

CONCLUSION

Improving leadership engagement, simplifying the enrollment process, and enhancing the medical staff experience through shared best practice alerts were identified as actions needed to improve the penetration of REVAMP at future rollout sites.

An umbrella review of systematic reviews and meta-analyses of observational investigations of obstructive sleep apnea and health outcomes

Purpose

The previous analysis of systematic reviews and meta-analyses have illustrated that obstructive sleep apnea (OSA) is correlated with multiple health outcomes. In the present research, our main aim was to execute an umbrella review to assess the available evidence for the associations between OSA and health outcomes.

Methods

Herein, a meta-analysis of previous observational investigations that have reported associations between OSA and health outcomes in all human populations and settings was performed. We used these studies to execute an umbrella review of available meta-analyses and systematic reviews.

Results

Sixty-six articles comprising 136 unique outcomes were enrolled in this analysis. Of the 136 unique outcomes, 111 unique outcomes had significant associations (p < 0.05). Only 7 outcomes (coronary revascularization after PCI, postoperative respiratory failure, steatosis, alaninetrans aminase (ALT) elevation, metabolic syndrome (MS), psoriasis, and Parkinson’s disease) had a high quality of evidence. Twenty-four outcomes had a moderate quality of evidence, and the remaining 80 outcomes had a weak quality of evidence. Sixty-nine outcomes exhibited significant heterogeneity. Twenty-five outcomes exhibited publication bias. Sixty-three (95%) studies showed critically low methodological quality.

Conclusion

Among the 66 meta-analyses exploring 136 unique outcomes, only 7 statistically significant outcomes were rated as high quality of evidence. OSA may correlate with an increased risk of coronary revascularization after PCI, postoperative respiratory failure, steatosis, ALT elevation, MS, psoriasis, and Parkinson’s disease.

Sleep apnea and stroke

PURPOSE OF REVIEW

Stroke and sleep apnea are highly prevalent conditions with a physiologically plausible bidirectional relationship. This review addresses prestroke sleep apnea, wake-up stroke and sleep apnea, and poststroke sleep apnea, with an attempt to highlight research published in the last 18 months.

RECENT FINDINGS

Sleep apnea is highly prevalent poststroke. Poststroke sleep apnea is associated with worse poststroke functional and cognitive outcomes and a higher risk of recurrent stroke. Physiologic tests are needed to diagnose sleep apnea in poststroke patients as sleep apnea questionnaires do not perform well in this population. The role of CPAP in poststroke management is not yet well established.

SUMMARY

Sleep apnea is a well established independent risk factor for stroke that confers an approximately two-fold increased risk of incident stroke. Sleep apnea is highly prevalent poststroke and is associated with worse outcomes after stroke. Sleep apnea is an attractive target for research addressing secondary stroke prevention and recovery.

The Impact of Sleep Disorders on Functional Recovery and Participation Following Stroke: A Systematic Review and Meta-Analysis

Background

Adequate sleep is vital for health and quality of life. People with stroke and a concomitant sleep disorder may have poorer outcomes than those without a sleep disorder.

Objective

To systematically evaluate the published literature to determine the impact of sleep disorders on physical, functional recovery at the activity and participation level after stroke.

Methods

A systematic review was conducted using PubMed, CINAHL, Scopus, and PsycINFO. Studies were selected that reported outcomes on physical, functional recovery at the activity and participation levels in participants with stroke and a diagnosed sleep disorder. A meta-analysis was performed on included studies that reported Barthel Index (BI) and modified Rankin Scale (mRS) scores. Results: A total of 33 studies were included in the systematic review with 9 of them in the meta-analysis. The mean mRS score was 0.51 points higher in participants with stroke and sleep disorders versus participants with stroke without sleep disorder [95% CI: 0.23-0.78]. The mean BI score was 10.2 points lower in participants with stroke and sleep disorders versus participants with stroke without sleep disorder [95% CI: −17.9 to −2.6].

Conclusions

People with stroke and a sleep disorder have greater functional limitations and disability than those without a sleep disorder. Rehabilitation professionals should screen their patients with stroke for potential sleep disorders and further research is needed to develop sleep and rehabilitation interventions that can be delivered in combination. PROSPERO registration number: CRD42019125562.

Sleep problems worsen health-related quality of life and participation during the first 12 months of stroke rehabilitation

OBJECTIVE

Evaluate the impact of self-reported sleep problems on post-stroke recovery.

DESIGN

Cross-sectional secondary analysis of longitudinal data from the Locomotor Experience Applied Post-Stroke (LEAPS) rehabilitation and recovery study (phase-III single-blind randomized controlled clinical trial). Group medians were compared for three sleep problem groups across three time points.

SETTING

Outpatient and in-home physical therapy.

SUBJECTS

Adults during the first year following stroke (n = 408, 380, 360 at 2, 6, 12 months, respectively).

INTERVENTIONS

The original study compared effects of locomotor training with body weight support in the year post-stroke. This analysis evaluated function in three sleep/functional-impact groups: no sleep problems, sleep problems with no-to-minimal-impact and sleep problems with moderate-to-quite-a-bit of impact.

MAIN MEASURES

Participants' responses regarding if they had "a sleep problem, such as insomnia" and, if so, what the impact was on their function. Stroke Impact Scale subscales for strength, hand function, mobility, ADLs, memory, communication, emotion, participation, and percent recovery.

RESULTS

About 25% of people with stroke reported sleep difficulty, 10% perceived sleep problems negatively impact function. Groups self-reporting worse sleep performed worse in all functional subscales (except self-perceived percent recovery) during the first year post-stroke.

CONCLUSION

Self-reported poor sleep adversely effects post-stroke functional recovery.

Diagnosed Sleep Apnea and Cardiovascular Disease in Atrial Fibrillation Patients: The Role of Measurement Error from Administrative Data

BACKGROUND

Atrial fibrillation and obstructive sleep apnea are common conditions, but little is known about obstructive sleep apnea and cardiovascular risk among atrial fibrillation patients.

METHODS

Using the Truven Health MarketScan databases, we constructed a prospective cohort of atrial fibrillation patients from 2007 to 2014. Atrial fibrillation, obstructive sleep apnea, stroke, myocardial infarction, and confounders were defined using the International Classification of Disease-9-CM codes. We matched individuals with an obstructive sleep apnea diagnosis with up to five individuals without a diagnosis by age, sex, and enrollment date. Cox proportional hazards models adjusted for confounders and high-dimensional propensity scores. We included migraines as a control outcome. Bias analysis used published sensitivities and specificities to generate rate ratios adjusted for obstructive sleep apnea misclassification.

RESULTS

We matched 56,969 individuals with an obstructive sleep apnea diagnosis to 323,246 without. During a mean follow-up of 16 months, 3234 incident strokes and 4639 incident myocardial infarctions occurred. After adjustment, obstructive sleep apnea diagnosis was strongly associated with reduced risk of incident stroke (hazard ratio = 0.48, 95% confidence interval = 0.43, 0.53) and myocardial infarction (0.40, [0.37, 0.44]) and a smaller reduced risk of migraines (0.82, [0.68, 0.99]). Bias analysis produced wide-ranging or inestimable rate ratios adjusted for misclassification of obstructive sleep apnea.

CONCLUSIONS

Obstructive sleep apnea diagnosis in atrial fibrillation patients was strongly associated with reduced risk of incident cardiovascular disease. We discuss misclassification, selection bias, and residual confounding as potential explanations.

Links between obstructive sleep apnea and glaucoma neurodegeneration

In the last few years, the possible link between obstructive sleep apnea (OSAS) and glaucoma, has attracted the interest of many scientists, especially in those forms of primary open angle glaucoma (POAG) and normal tension glaucoma (NTG), in which a progression of the disease occurs, even though intraocular pressure (IOP) is in the range of normality. The increased prevalence of POAG or NTG in patients affected by OSAS, and vice versa, has stimulated interest in the pathogenetic mechanisms that could trigger these two diseases. Hypoxia generated by apnea/hypopnea cycles has been identified as the main cause of many changes in the vascular and neurological systems, which alter the functioning not only of the optic nerve, but also of the whole organism. However, many other factors could be involved, like mechanical factors, obesity, hormonal imbalance and other sleep disorders. Furthermore, the demonstration of typical glaucomatous or glaucoma-like changes in the anatomy or function of the optic nerve and retinal nerve fiber layer by sensitive specific and diagnostic methods, such as perimetry, optical coherence tomography (OCT), optical coherence tomography angiography (OCTA) and electrophysiological exams keeps interest high for this field of study. For this reason, further investigations, hopefully a source of stronger scientific evidences, are needed.

Association between adherence to continuous positive airway pressure treatment and cost among medicare enrollees

OBJECTIVE

To analyze the cost associated with sleep apnea and effects of continuous positive airway pressure (CPAP) treatment on costs among fee-for-service Medicare beneficiaries.

METHODS

Retrospective cohort design using 5% Medicare claims between 2006 and 2010. Medicare beneficiaries with and without sleep apnea diagnosis between 2007 and 2008 were identified and followed retrospectively for 2 years pre-index-date and 2 years post-index-date. We defined CPAP fill as at least one durable medical equipment claim for CPAP in 6-month period. At least three CPAP fills was defined as "full adherence," and one or two CPAP fills was "partial adherence." We used interrupted time series and generalized linear log-link models to study the association between sleep apnea, CPAP treatment, and costs. To minimize bias, we used propensity score and instrumental variables approach.

RESULTS

Sleep apnea was associated with higher costs (odds ratio [OR] = 1.60; 95% confidence interval [CI] = 1.58, 1.63) compared to those without sleep apnea. Almost half of those with sleep apnea received CPAP treatment. Interrupted time series analysis indicated post level increase in mean monthly cost for full CPAP adherence group, partial CPAP adherence group and no-CPAP group. However, the increase was smallest for the full CPAP adherence group. Full CPAP adherence was associated with lower change in cost (OR = 0.92; 95% CI = 0.88, 0.97) compared to the no-CPAP group.

CONCLUSIONS

Medicare beneficiaries with sleep apnea experience increased cost. Full adherence to CPAP treatment for sleep apnea was associated with lower increase in cost. These findings emphasize the need to effectively identify and treat sleep apnea in Medicare patients.

Is there an association among sleep duration, nap, and stroke? Findings from the China Health and Retirement Longitudinal Study

PURPOSE

The objective of this study was to assess the association among nighttime sleep, daytime napping, total sleep duration (nighttime sleep plus daytime napping), and stroke in an elderly Chinese population.

METHODS

Data were derived from the 2011 China Health and Retirement Longitudinal Study (CHARLS) with 4785 Chinese respondents over 65 years old. Four binary logistic regression models were used to estimate odds ratios and 95% confidence intervals of the association among total sleep duration, nighttime sleep, daytime napping, and stroke, adjusting for confounders.

RESULTS

After controlling for sociodemographic characteristics, lifestyle, health status, and comorbidity, there was no association between abnormal nighttime sleep and stroke (P values > 0.05). Compared to individuals with normal total sleep duration (7-8 h per day), short sleep duration (< 7 h per day) was approximately two times more likely to increase the risk of stroke (AOR = 1.81, 95%CI 1.10-2.97). Individuals who reported vision impairment, disability, hypertension, dyslipidemia, and mental health issues were at higher risk of stroke. In addition, physical activities with different levels were associated with a lower risk of stroke. Taking naps was not associated with stroke incidence (AOR = 1.12, 95%CI 0.77-1.64).

CONCLUSION

In this elderly Chinese population, short total sleep duration per 24 h, not merely daytime napping or nighttime sleep, was significantly associated with an increased risk of stroke. Preventive measures for stroke may require a focus on elderly, sedentary individuals who report other health problems.

EAN/ERS/ESO/ESRS statement on the impact of sleep disorders on risk and outcome of stroke

Sleep disorders are highly prevalent in the general population and may be linked in a bidirectional fashion to stroke, which is one of the leading causes of morbidity and mortality.Four major scientific societies established a task force of experts in neurology, stroke, respiratory medicine, sleep medicine and methodology, to critically evaluate the evidence regarding potential links and the impact of therapy. 13 research questions were evaluated in a systematic literature search using a stepwise hierarchical approach: first, systematic reviews and meta-analyses; second, primary studies post-dating the systematic reviews/meta-analyses. A total of 445 studies were evaluated and 88 included. Statements were generated regarding current evidence and clinical practice.Severe obstructive sleep apnoea (OSA) doubles the risk for incident stroke, especially in young to middle-aged patients. Continuous positive airway pressure (CPAP) may reduce stroke risk, especially in treatment-compliant patients. The prevalence of OSA is high in stroke patients and can be assessed by polygraphy. Severe OSA is a risk factor for recurrence of stroke and may be associated with stroke mortality, while CPAP may improve stroke outcome. It is not clear if insomnia increases stroke risk, while pharmacotherapy of insomnia may increase it. Periodic limb movements in sleep (PLMS), but not restless limb syndrome (RLS), may be associated with an increased risk of stroke. Preliminary data suggest a high frequency of post-stroke insomnia and RLS and their association with a less favourable stroke outcome, while treatment data are scarce.Overall, the evidence base is best for OSA relationship with stroke and supports active diagnosis and therapy. Research gaps remain especially regarding insomnia and RLS/PLMS relationships with stroke.

Polysomnographic characteristics of severe obstructive sleep apnea vary significantly between hypertensive and normotensive patients of both genders

PURPOSE

Hypertension is a common finding in patients with obstructive sleep apnea (OSA), but it has remained unclear whether or not the amount of disturbed breathing and characteristics of individual respiratory events differ between hypertensive and normotensive patients with severe OSA.

METHODS

Full polysomnographic recordings of 323 men and 89 women with severe OSA were analyzed. Differences in the duration of individual respiratory events, total apnea and hypopnea times, and the percentage of disturbed breathing from total sleep time (AHT%) were compared between normotensive and hypertensive patients separately by genders. Furthermore, differences in the respiratory event characteristics were assessed between three AHT% groups (AHT% ≤ 30%, 30% < AHT% ≤ 45%, and AHT% > 45%).

RESULTS

Hypertensive women had lower percentage apnea time (15.2% vs. 18.2%, p = 0.003) and AHT% (33.5% vs. 36.5%, p = 0.021) when compared with normotensive women. However, these differences were not observed between hypertensive and normotensive men. Percentage hypopnea time was higher in hypertensive men (13.5% vs. 11.2%, p = 0.043) but not in women (15.2% vs. 12.2%, p = 0.130) compared with their normotensive counterparts. The variation in AHI explained 60.5% (ρ = 0.778) and 65.0% (ρ = 0.806) of the variation in AHT% in normotensive and hypertensive patients, respectively. However, when AHT% increased, the capability of AHI to explain the variation in AHT% declined.

CONCLUSIONS

There is a major inter- and intra-gender variation in percentage apnea and hypopnea times between hypertensive and normotensive patients with severe OSA. OSA is an important risk factor for hypertension and thus, early detection and phenotyping of OSA would allow timely treatment of patients with the highest risk of hypertension.

Variability and Misclassification of Sleep Apnea Severity Based on Multi-Night Testing

BACKGROUND

Portable monitoring is a convenient means for diagnosing sleep apnea. However, data on whether one night of monitoring is sufficiently precise for the diagnosis of sleep apnea are limited.

RESEARCH QUESTION

The current study sought to determine the variability and misclassification in disease severity over three consecutive nights in a large sample of patients referred for sleep apnea.

METHODS

A sample of 10,340 adults referred for sleep apnea testing was assessed. A self-applied type III monitor was used for three consecutive nights. The apnea-hypopnea index (AHI) was determined for each night, and a reference AHI was computed by using data from all 3 nights. Pairwise correlations and the proportion misclassified regarding disease severity were computed for each of the three AHI values against the reference AHI.

RESULTS

Strong correlations were observed between the AHI from each of the 3 nights (r = 0.87-0.89). However, substantial within-patient variability in the AHI and significant misclassification in sleep apnea severity were observed based on any 1 night of monitoring. Approximately 93% of the patients with a normal study on the first night and 87% of those with severe sleep apnea on the first night were correctly classified compared with the reference derived from all three nights. However, approximately 20% of the patients with mild and moderate sleep apnea on the first night were misdiagnosed either as not having sleep apnea or as having mild disease, respectively.

CONCLUSIONS

In patients with mild to moderate sleep apnea, one night of portable testing can lead to misclassification of disease severity given the substantial night-to-night variability in the AHI.

Obstructive sleep apnea, cognition and Alzheimer's disease: A systematic review integrating three decades of multidisciplinary research

Increasing evidence links cognitive-decline and Alzheimer's disease (AD) to various sleep disorders, including obstructive sleep apnea (OSA). With increasing age, there are substantial differences in OSA's prevalence, associated comorbidities and phenotypic presentation. An important question for sleep and AD researchers is whether OSA's heterogeneity results in varying cognitive-outcomes in older-adults compared to middle-aged adults. In this review, we systematically integrated research examining OSA and cognition, mild cognitive-impairment (MCI) and AD/AD biomarkers; including the effects of continuous positive airway pressure (CPAP) treatment, particularly focusing on characterizing the heterogeneity of OSA and its cognitive-outcomes. Broadly, in middle-aged adults, OSA is often associated with mild impairment in attention, memory and executive function. In older-adults, OSA is not associated with any particular pattern of cognitive-impairment at cross-section; however, OSA is associated with the development of MCI or AD with symptomatic patients who have a higher likelihood of associated disturbed sleep/cognitive-impairment driving these findings. CPAP treatment may be effective in improving cognition in OSA patients with AD. Recent trends demonstrate links between OSA and AD-biomarkers of neurodegeneration across all age-groups. These distinct patterns provide the foundation for envisioning better characterization of OSA and the need for more sensitive/novel sleep-dependent cognitive assessments to assess OSA-related cognitive-impairment.

Associations Between Sleep Apnea and Subclinical Carotid Atherosclerosis: The Multi-Ethnic Study of Atherosclerosis

Background and Purpose- Many health effects of sleep apnea (SA) may be mediated through accelerated atherosclerosis. We examined the associations of snoring and several measurements of SA with subclinical carotid atherosclerosis in a large multiethnic population sample. Methods- This analysis included 1615 participants (mean age, 68 years) from examination 5 (2010-2013) of the MESA study (Multi-Ethnic Study of Atherosclerosis). Sleep measures including SA (apnea-hypopnea index [4%], ≥15 events/hour) were derived from full in-home polysomnography. Carotid atherosclerosis was measured using high-resolution B-mode ultrasound. Multivariable linear and logistic regression models were used to evaluate the associations between sleep exposures with carotid intima-media thickness and the presence of carotid plaque, respectively. Effect modification by age, sex, and race/ethnicity was examined. Results- In multivariable analysis, SA was associated with an increased odds of carotid plaque presence in individuals aged <68 years (odds ratio, 1.47; 95% CI, 1.05-2.06) but not in older individuals (odds ratio, 0.95; 95% CI, 0.67-1.37; P interaction=0.078). Greater hypoxemia (sleep time <90% saturation) was associated with increasing carotid intima-media thickness in younger (0.028±0.014 mm) but not in older individuals (-0.001±0.013 mm; P interaction=0.106). Self-reported snoring was not associated with carotid atherosclerosis. In assessing race-specific outcomes, greater hypoxemia was associated with increased carotid intima-media thickness in blacks (0.049±0.017 mm; P interaction=0.033). Conclusions- In this large multiethnic population-based sample, sleep disturbances are associated with subclinical carotid atherosclerosis in both men and women, particularly in those <68 years of age. The mechanisms underlying the association between SA and carotid atherosclerosis may differ for carotid plaque and carotid intima-media thickness.

Association of obstructive sleep apnea and cerebral small vessel disease: a systematic review and meta-analysis

Study Objectives

The objective of the present study was to investigate the association between obstructive sleep apnea (OSA) and the presence of various neuroimaging marker of cerebral small vessel disease (CSVD).

Methods

We systematically searched PubMed, Embase, Web of Science, Scopus, and Cochrane library (from inception to May 2019) for studies evaluating the association between OSA and CSVD, which included white matter hyperintensities (WMH), silent brain infarction (SBI), cerebral microbleeds (CMBs), and perivascular spaces (PVS). Pooled odds ratios (ORs) with 95% confidence interval (CIs) were estimated using random-effects meta-analysis.

Results

After screening 7290 publications, 20 studies were finally included involving 6036 subjects. The sample size ranged from 27 to 1763 (median 158, interquartile range: 67–393). The meta-analysis showed that moderate to severe OSA was positively associated with WMH (13 studies, n = 4412, OR = 2.23, 95% CI = 1.53 to 3.25, I2 = 80.3%) and SBI (12 studies, n = 3353, OR 1.54, 95% CI = 1.06 to 2.23, I2 = 52%). There was no association with CMBs (three studies, n = 342, OR = 2.17, 95% CI = 0.61 to 7.73, I2 = 60.2%) or PVS (two studies, n = 267, OR = 1.56, 95% CI = 0.28 to 8.57, I2 = 69.5%). There was no relationship between mild OSA and CSVD.

Conclusion

Current evidence suggests that moderate to severe sleep apnea is positively related to WMH and SBI, but not CMBs or PVS, which suggests that OSA may contribute to the pathogenesis of CSVD. Further large cohort studies should be prioritized to confirm the findings.

Sleep and Stroke: New Updates on Epidemiology, Pathophysiology, Assessment, and Treatment

PURPOSE OF REVIEW

This review aims to discuss the most recent data on sleep disorders and stroke, highlighting relevant findings for the practicing neurologist or health providers who encounter patients with sleep disorders and stroke.

RECENT FINDINGS

Sleep apnea and abnormal sleep duration have the strongest association with stroke risk. Possible mechanisms include non-dipping of blood pressure during sleep, hypoxemia or reoxygenation leading to sympathetic activation, hypertension, atrial fibrillation and impaired cerebral hemodynamics. Treatment studies suggest that continuous positive airway pressure (CPAP) for sleep apnea could improve primary prevention of stroke, but data is equivocal for secondary prevention. However, CPAP could improve functional outcomes after stroke.

SUMMARY

Sleep disorders present an opportunity to improve stroke risk and functional outcomes. However, new strategies are needed to determine the patients at high-risk who would most likely benefit from targeted care. Novel methods for phenotyping sleep disorders could provide personalized stroke care to improve clinical outcomes and public health strategies.