Sex-specific pathways linking sleep-disordered breathing to cardiometabolic risk: real-world evidence from a nurse-led digital platform enhanced clinic

Background Sleep-disordered breathing (SDB) represents an underrecognized but modifiable cardiovascular risk factor in primary prevention populations. Despite growing evidence linking sleep apnoea to cardiometabolic dysfunction, systematic screening remains absent from most preventive programmes. Sex-specific pathways connecting SDB to metabolic risk remain poorly characterised, thereby limiting personalized prevention strategies. Purpose We characterised sleep-disordered breathing prevalence and sex-specific cardiometabolic associations within a next-generation nurse-led digital platform enhanced preventive medicine clinic providing comprehensive cardiovascular prevention in real-world clinical practice. Methods The clinic conducted systematic cardiovascular assessments of 199 adults seeking primary prevention in the Czech Republic (Central Europe). By the time of this analysis, complete sleep data were available for 110 participants (49 males and 61 females; mean age 43.9 ± 10.9 years old). Assessments included home sleep apnoea testing (apnoea-hypopnoea index, AHI), visceral fat measurement by bioimpendance, and comprehensive metabolic profiling. We performed sex-stratified correlation analyses and multivariable regression analyses with interaction terms. Results Nearly half (45.5%) of prevention-seeking participants had clinically significant SDB (AHI ≥5 events/hour). Males demonstrated substantially higher sleep apnoea severity than females (8.9±7.4 vs 4.8±3.7 events/hour, p<0.001), with 61% versus 33% meeting OSA criteria (OR 3.27, p=0.003). A striking sex paradox emerged (Figure 1): males showed a strong AHI-visceral fat correlation (ρ=0.617, p<0.0001) while females demonstrated a weak, non-significant association (ρ=0.188, p=0.15). Multivariable regression (Figure 2) confirmed a significant sex×AHI interaction (p=0.033). In males, each 1-unit increase in AHI predicted a 3.0-unit increase in visceral fat (β=2.98, p<0.001, R²=0.442), while females showed no AHI effect (β=0.83, p=0.348, R²=0.187). Overall, AHI correlated significantly with BMI (ρ=0.487), waist circumference (ρ=0.499), and atherogenic dyslipidaemia (ρ=0.372), all p<0.001. Conclusion Systematic sleep screening via nurse-led digital platforms reveals a high prevalence of unrecognised SDB with profound sex-specific associations with cardiometabolic risk. The observed sex paradox—strong linkage with visceral fat in males but absence of such linkage in females—suggests distinct mechanistic pathways requiring sex-tailored screening algorithms and intervention strategies, and demonstrates the real-world feasibility of next-generation, scalable prevention approaches.