1 The Ottawa Hospital Research Institute, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada.
2 Institute for Clinical Evaluative Sciences, Ontario, Canada.
Ann Am Thorac Soc. 2019 Jan;16(1):71-81. doi: 10.1513/AnnalsATS.201802-136OC.
The combined impact of chronic obstructive pulmonary disease (COPD) and obstructive sleep apnea (OSA) on cardiovascular outcomes remains controversial.
We determined whether the combined presence of COPD and severe OSA defined by the apnea-hypopnea index (AHI) or degree of nocturnal hypoxemia is associated with increased hazards of cardiovascular events and mortality.
Prospectively collected data from adults with suspected OSA who underwent sleep study between 1994 and 2010 were linked to provincial administrative data to determine a presence of COPD and composite outcome. Exposures of interest were: 1) AHI greater than 30, and 2) 10 or more minutes of sleep time spent with oxygen saturation (Sa) less than 90%. The primary outcome was a composite of hospitalization due to myocardial infarction, stroke, congestive heart failure, cardiac revascularization procedures, or death from any cause. Using Cox regression and controlling for confounders, hazards were compared between four groups: AHI greater than 30 with COPD, AHI greater than 30 without COPD, AHI less than or equal to 30 with COPD, and AHI less than or equal to 30 without COPD (reference). A similar approach was used for the degree of nocturnal hypoxemia. Relative excess risk due to interaction (RERI) was calculated. To adjust for the effect of positive airway pressure treatment, given that information on its acceptance, but not adherence, was available, a separate analysis was conducted only on untreated individuals who never claimed a positive airway pressure device.
Among 10,149 participants, 30% had AHI greater than 30, 25% spent at least 10 minutes of sleep with Sa less than 90%, and 12% had COPD. Over a median of 9.4 years, 16.4% developed an outcome. In the total sample, a greater hazard of outcome was observed in individuals with COPD who spent at least 10 minutes of sleep with Sa less than 90% (hazard ratio, 1.91; 95% confidence interval [CI], 1.60 to 2.28) but not with AHI greater than 30; a synergistic effect was found in women (RERI, 1.18; 95% CI, 0.05 to 2.30), but not men (RERI, -0.08; 95% CI, -0.47 to 0.32). The highest hazard of outcome was associated with the co-occurrence of AHI greater than 30 and COPD in untreated individuals (hazard ratio, 2.01; 95% CI, 1.55 to 2.62); a synergistic effect was not found.
In adults with suspected OSA, the co-occurrence of nocturnal hypoxemia and COPD was associated with an increased hazard of cardiovascular events and mortality with a synergistic effect found only in women.
慢性阻塞性肺疾病（COPD）和阻塞性睡眠呼吸暂停（OSA）对心血管结局的综合影响仍存在争议。
我们旨在确定 COPD 和严重 OSA（定义为呼吸暂停-低通气指数（AHI）或夜间低氧血症程度）的合并存在是否与心血管事件和死亡率的增加风险相关。
前瞻性收集了 1994 年至 2010 年间疑似 OSA 患者的睡眠研究数据，并与省级行政数据相关联，以确定 COPD 的存在和复合结局。感兴趣的暴露因素为：1）AHI 大于 30，2）10 分钟或更长时间的睡眠期间，氧饱和度（Sa）小于 90%。主要结局是因心肌梗死、中风、充血性心力衰竭、心脏血运重建手术或任何原因导致的死亡而住院的复合结局。使用 Cox 回归并控制混杂因素，在四个组之间比较风险：AHI 大于 30 合并 COPD、AHI 大于 30 无 COPD、AHI 小于或等于 30 合并 COPD 和 AHI 小于或等于 30 无 COPD（参考）。对于夜间低氧血症的程度，采用了类似的方法。计算相对超额风险比交互作用（RERI）。由于可以获得关于接受程度但不了解依从性的信息，因此为了调整正压通气治疗的效果，仅对从未声称使用过正压通气设备的未治疗个体进行了单独分析。
在 10149 名参与者中，30%的人 AHI 大于 30，25%的人至少有 10 分钟的睡眠 Sa 小于 90%，12%的人患有 COPD。在中位数为 9.4 年的随访期间，16.4%的人出现了该结局。在整个样本中，与 AHI 大于 30 相比，Sa 小于 90%的睡眠时间至少 10 分钟的 COPD 患者发生该结局的风险更高（风险比，1.91；95%置信区间[CI]，1.60 至 2.28）；在女性中发现了协同作用（RERI，1.18；95%CI，0.05 至 2.30），但在男性中未发现（RERI，-0.08；95%CI，-0.47 至 0.32）。与未治疗个体中 AHI 大于 30 和 COPD 的共同发生相关的结局风险最高（风险比，2.01；95%CI，1.55 至 2.62）；未发现协同作用。
在疑似 OSA 的成年人中，夜间低氧血症和 COPD 的共同发生与心血管事件和死亡率的增加风险相关，仅在女性中发现了协同作用。
