Prevalence of obstructive sleep apnea in patients with hypertrophic cardiomyopathy and its impact on five-year cardiovascular outcomes

Background Obstructive sleep apnea (OSA) is increasingly recognized as a modifiable cardiovascular risk factor, yet its prevalence and impact on long-term outcomes in hypertrophic cardiomyopathy (HCM) patients remain poorly characterized. Research Question: What proportion of adults with HCM have concomitant OSA, and how does the presence of OSA influence five-year cardiovascular outcomes compared with HCM patients without OSA? Methods We queried the TriNetX Global Collaborative Network for adults aged ≥18 years with HCM between 2015 and 2024. We assessed the prevalence of OSA within the HCM cohort. We performed one-to-one propensity-score matching on demographics, comorbidities, medications, and laboratory indices, yielding 10,673 patients per arm. Primary endpoints included ventricular arrhythmia, major adverse cardiovascular events (MACE; composite of myocardial infarction, cerebral infarction, pulmonary embolism, or cardiac arrest), atrial fibrillation/flutter, and all-cause mortality. Hazard ratios with 95% confidence intervals were computed. Results Among 55,749 HCM patients, OSA prevalence was 23.2%. Prevalence was higher in males than females (25.5% vs 20.8%) and peaked at 28% in those aged 45-54 years. Over five years, HCM patients with OSA had higher rates of ventricular arrhythmia (10.2% vs 9.0%) and MACE (13.4% vs 11.7%) compared to HCM-only patients, though neither difference achieved statistical significance (HR 1.06, 95% CI 0.97-1.17 and HR 1.09, 95% CI 0.998-1.19, respectively). Atrial fibrillation/flutter occurred significantly more frequently in the HCM plus OSA group (16.1% vs 13.3%; HR 1.16, 95% CI 1.06-1.26). Conversely, all-cause mortality was significantly lower among patients with concomitant OSA (11.0% vs 13.2%; HR 0.78, 95% CI 0.72-0.84). Conclusion Nearly one-quarter of adults with HCM carry a concurrent diagnosis of OSA. Over a five-year follow-up period, OSA was associated with a significantly increased risk of atrial fibrillation/flutter, while risks of ventricular arrhythmia and MACE showed non-significant trends toward higher rates. Unexpectedly, all-cause mortality was significantly lower in patients with OSA, potentially reflecting survival bias, more intensive clinical monitoring, or therapeutic benefits of OSA treatment. Given the substantial prevalence of OSA in this population and its cardiovascular implications, systematic screening for OSA and targeted strategies in HCM patients warrant prospective evaluation.