The Hypoxic Burden of Sleep Apnea Predicts Cardiovascular Outcomes in Patients with Heart Failure
- 1Juntendo University Graduate School of Medicine
Abstract
BackgroundSleep-disordered breathing (SDB) is an established adverse prognostic factor in heart failure (HF). Sleep apnea-specific hypoxic burden (SASHB), which reflects the duration and depth of respiratory event-related oxygen desaturation, has shown stronger prognostic value than the apnea-hypopnea index (AHI) in general populations and patients with coronary artery disease. However, its clinical utility in patients hospitalized due to acute HF remains unclear.
ObjectivesThis study evaluated the prognostic value of SASHB in patients hospitalized for acute HF and compared its performance with AHI for risk stratification and identification of patients who may benefit from positive airway pressure (PAP) therapy.
MethodsThis post hoc analysis included 230 patients from a prospective single-center observational cohort of adults hospitalized for acute HF. The primary analysis included 178 patients who did not receive PAP treatment. Associations of SASHB and AHI with the composite endpoint of cardiovascular death or rehospitalization for worsening HF were evaluated using Cox proportional hazards models. Model improvement after adding SASHB or AHI to a model including established clinical risk factors was assessed using changes in the C index and Brier score, reflecting changes in model discrimination and prediction error, respectively. In the full cohort, the interaction between PAP treatment and SDB metrics was evaluated using the g-formula.
ResultsDuring a median follow-up of 3.7 years, 58 of 178 patients (32.6%) reached the composite endpoint. Both SASHB and AHI were independently associated with the composite outcome after multivariable adjustment. However, only SASHB consistently predicted outcomes across analyses and improved model performance beyond established prognostic factors (bootstrap {Delta}C index, 0.020 [95% CI: 0.008-0.031]; bootstrap {Delta}Brier score, -0.007 [95% CI: -0.014 to -0.001]), whereas AHI did not. In the analysis including PAP-treated patients, both SASHB and AHI showed interaction with PAP treatment.
ConclusionsIn patients hospitalized for acute HF, SASHB showed a consistent independent association with adverse clinical outcomes and provided additional prognostic information beyond AHI. SASHB may improve risk stratification and may help identify patients who are more likely to benefit from PAP therapy.
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BibTeX
@misc{masaki2026hypoxic,
title = {{The Hypoxic Burden of Sleep Apnea Predicts Cardiovascular Outcomes in Patients with Heart Failure}},
author = {M. Masaki and S. Tsumoto and N. Shiroshita and F. Kawana and S. Ishiwata and H. Kitagawa and M. Yanagisawa and T. Kasai},
howpublished = {medRxiv},
year = {2026},
month = sep,
doi = {10.64898/2026.09.29.26364138},
url = {https://www.medrxiv.org/content/10.64898/2026.09.29.26364138v1},
note = {CC BY-NC-ND},
}
RIS
TY - UNPB
TI - The Hypoxic Burden of Sleep Apnea Predicts Cardiovascular Outcomes in Patients with Heart Failure
AU - M. Masaki
AU - S. Tsumoto
AU - N. Shiroshita
AU - F. Kawana
AU - S. Ishiwata
AU - H. Kitagawa
AU - M. Yanagisawa
AU - T. Kasai
PY - 2026
DA - 2026/09/29
PB - medRxiv
DO - 10.64898/2026.09.29.26364138
UR - https://www.medrxiv.org/content/10.64898/2026.09.29.26364138v1
AB - BackgroundSleep-disordered breathing (SDB) is an established adverse prognostic factor in heart failure (HF). Sleep apnea-specific hypoxic burden (SASHB), which reflects the duration and depth of respiratory event-related oxygen desaturation, has shown stronger prognostic value than the apnea-hypopnea index (AHI) in general populations and patients with coronary artery disease. However, its clinical utility in patients hospitalized due to acute HF remains unclear. ObjectivesThis study evaluated the prognostic value of SASHB in patients hospitalized for acute HF and compared its performance with AHI for risk stratification and identification of patients who may benefit from positive airway pressure (PAP) therapy. MethodsThis post hoc analysis included 230 patients from a prospective single-center observational cohort of adults hospitalized for acute HF. The primary analysis included 178 patients who did not receive PAP treatment. Associations of SASHB and AHI with the composite endpoint of cardiovascular death or rehospitalization for worsening HF were evaluated using Cox proportional hazards models. Model improvement after adding SASHB or AHI to a model including established clinical risk factors was assessed using changes in the C index and Brier score, reflecting changes in model discrimination and prediction error, respectively. In the full cohort, the interaction between PAP treatment and SDB metrics was evaluated using the g-formula. ResultsDuring a median follow-up of 3.7 years, 58 of 178 patients (32.6%) reached the composite endpoint. Both SASHB and AHI were independently associated with the composite outcome after multivariable adjustment. However, only SASHB consistently predicted outcomes across analyses and improved model performance beyond established prognostic factors (bootstrap {Delta}C index, 0.020 [95% CI: 0.008-0.031]; bootstrap {Delta}Brier score, -0.007 [95% CI: -0.014 to -0.001]), whereas AHI did not. In the analysis including PAP-treated patients, both SASHB and AHI showed interaction with PAP treatment. ConclusionsIn patients hospitalized for acute HF, SASHB showed a consistent independent association with adverse clinical outcomes and provided additional prognostic information beyond AHI. SASHB may improve risk stratification and may help identify patients who are more likely to benefit from PAP therapy.
ER -