Association of Prolonged Nocturnal Hypoxemia with Clinical Worsening in Patients with Chronic Thromboembolic Pulmonary Hypertension Undergoing Pulmonary Endarterectomy

Hang Xu^1,†, Wu Song^1,†, Shanshan Zheng¹, Yige Huyan¹, Jiexu Ma¹, Zhaoji Zhong¹, Sheng Liu^1,*

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¹ Department of Cardiovascular Surgery, Key Laboratory of Pulmonary Vascular Medicine, Fuwai Hospital, National Clinical Research Center for Cardiovascular Diseases, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 100037 Beijing, China

^*Correspondence: liusheng@fuwai.com (Sheng Liu)
^†These authors contributed equally.

Rev. Cardiovasc. Med. 2023, 24(8), 240; https://doi.org/10.31083/j.rcm2408240

Submitted: 27 April 2023 | Revised: 31 May 2023 | Accepted: 16 June 2023 | Published: 18 August 2023

This is an open access article under the CC BY 4.0 license.

Abstract

Background: Obstructive sleep apnea (OSA) is common in patients with chronic thromboembolic pulmonary hypertension (CTEPH), but the pathological determinants of adverse outcomes remain unknown. This study aimed to investigate the prognostic significance of various sleep parameters in patients with CTEPH undergoing pulmonary endarterectomy. Methods: Consecutive patients diagnosed with CTEPH who underwent overnight cardiorespiratory polygraphy for the assessment of OSA were enrolled. Time-to-event analysis was performed investigating cardiorespiratory indices (e.g., apnea-hypopnea index [AHI], time percentage with oxygen saturation below $<$ 90% [T90]) and clinical worsening using the log-rank test, and multivariable Cox proportional hazard models adjusted for multiple confounders. Results: Of the 71 patients with operable CTEPH who underwent overnight cardiorespiratory polygraphy, 36 (50.7%) had OSA (AHI of $\geq$ 5) and 32 (45.1%) had nocturnal hypoxemia (T90 of $\geq$ 30%). A 10% increase in T90 was associated with a 27% greater risk of worse hemodynamics, as quantified by mean pulmonary artery pressure of $\geq$ 46 mmHg (odds ratio: 1.27, 95% confidence interval [CI]: 1.07–1.50, p = 0.006). Clinical worsening (CW) was experienced by 19 (26.8%) patients over a median follow-up of 26.8 months. AHI did not predict a higher risk of CW (hazard ratio [HR]: 1.00, 95% CI: 0.93–1.06, p = 0.906). A higher cumulative incidence of CW was seen in patients with nocturnal hypoxemia than in those with normoxemia (43.8% vs. 12.8%, log-rank p = 0.017). Cox regression analysis revealed the association between nocturnal hypoxemia and an increased risk of CW (HR: 3.27, 95% CI: 1.17–9.13, p = 0.024), and these associations persisted after covariate adjustment. Conclusions: Nocturnal hypoxemia quantified by T90 was a risk predictor of short- and long-term CW events among patients with operable CTEPH.

Keywords

sleep apnea

pulmonary hypertension

clinical worsening

hypoxemia

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Funding

Z201100005520005/Capital clinical diagnosis and treatment technology research and transformation application

2017-I2M-3–003/Chinese Academy of Medical Sciences Innovation Fund for Medical Sciences (CIFMS)

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Fig. 1.

Kaplan–Meier survival analysis of participants stratified by T90. CW, clinical worsening; T90, time percentage with SpO ${}_{2}$ below 90%; SpO ${}_{2}$ , oxygen saturation detected by pulse oximetry; HR, hazard ratio.

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Rev. Cardiovasc. Med. Print ISSN 1530-6550 Electronic ISSN 2153-8174