Neighborhood Disadvantage Association with Sleep Apnea and Longitudinal Cardiovascular Events and Mortality

Rationale Neighborhood socioeconomic disadvantage is associated with adverse cardiovascular outcomes, but its relationship with obstructive sleep apnea (OSA) severity and sleep-related hypoxemia is not well defined. Objective To assess the association of Area Deprivation Index (ADI) with OSA and major adverse cardiovascular events (MACE). Methods We conducted an observational cohort study of adults in a large institutional sleep registry who underwent polysomnography (PSG) or type III sleep testing. Neighborhood disadvantage was quantified using Area Deprivation Index (ADI) quintiles (ADI-Q1 least disadvantaged; ADI-Q5 most disadvantaged). Associations between ADI, OSA severity (apnea–hypopnea index [AHI]), sleep hypoxemia (percentage of sleep time with oxygen saturation<90%, T90), and incident MACE (heart failure, stroke, atrial fibrillation, coronary artery disease, or death) were assessed using multivariable models adjusted for demographics, comorbidities, smoking, and cardiovascular medications. Measurements and Main Results Among 72,443 adults (52,874 PSG;19,569 type III testing), greater neighborhood deprivation was associated with more severe sleep-related hypoxia (higher T90 and lower oxygen saturation nadir; p < 0.0001) but not with AHI. Over median follow-up of 5.6 years (PSG) and 2.8 years (type III), residence in the most disadvantaged neighborhoods was associated with increased risk of MACE or death (PSG ADI-Q5 vs Q1:HR1.22,95%CI1.13–1.33; type III ADI-Q4 vs Q1:HR1.41,95%CI1.12–1.78). In the type III cohort, hypoxia modified the association between ADI and outcomes (interaction p = 0.025). Conclusions Neighborhood disadvantage is associated with greater sleep-related hypoxia and worse cardiovascular outcomes among patients evaluated for OSA, independent of apnea frequency. Incorporating measures of sleep-related hypoxia and neighborhood disadvantage into cardiovascular risk stratification may play a role in the identification of high-risk populations.