Abstract
PurposeTo evaluate cardiovascular and psychiatric morbidity in patient visits with obstructive sleep apnea (OSA) with insomnia (OSA+Insomnia) versus OSA without insomnia (OSA-Insomnia) in a nationally representative US sample.MethodsA retrospective case-control study of epidemiologic databases (National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey) representing an estimated ± standard error (SE) 62,253,910±5,274,747 (unweighted count = 7234) patient visits with diagnosis of OSA from 1995–2010, was conducted. An estimated 3,994,104±791,386 (unweighted count = 658) were classified as OSA+Insomnia and an estimated 58,259,806±4,849,800 (unweighted count = 6576) as OSA-Insomnia. Logistic regression analysis was carried out using OSA+Insomnia versus OSA-Insomnia as the dependent variable, and age (>50 years versus ≤50 years), sex, race (‘White’ versus ‘non-White’), essential hypertension, heart failure, ischemic heart disease, cardiac dysrhythmia, cerebrovascular disease, diabetes, obesity, hyperlipidemia, depressive, anxiety, and adjustment disorders (includes PTSD), hypersomnia and all medications used as independent variables. All comorbidities were physician diagnosed using the ICD9-CM.ResultsAmong patient visits with OSA, an estimated 6.4%±0.9% also had insomnia. Logistic regression analysis revealed that the OSA+Insomnia group was significantly more likely to have essential hypertension (all ICD9-CM codes 401) (OR = 1.83, 95% CI 1.27–2.65) and provisionally more likely to have cerebrovascular disease (ICD9-CM codes 430–438) (OR = 6.58, 95% CI 1.66–26.08). The significant OR for cerebrovascular disease was considered provisional because the unweighted count was <30.ConclusionsIn a nationally representative sample, OSA+Insomnia was associated significantly more frequently with essential hypertension than OSA-Insomnia, a finding that has not been previously reported. In contrast to studies that have considered patient self-reports of psychological morbidity, the absence of a significant association with psychiatric disorders in our study may be indicative of the fact that we considered only physician-rated psychiatric syndromes meeting ICD9-CM criteria. Our findings among the OSA+Insomnia group are therefore most likely conservative.
Highlights
Obstructive sleep apnea (OSA) [1] and insomnia [2,3] are two of the most commonly encountered sleep disorders
In this study we examined the frequency of physician diagnosed cardiovascular and psychiatric disorders that are commonly associated with OSA alone, among patient visits with OSA plus insomnia, in a randomly selected, nationally representative sample of patient visits in the US, to doctors’ offices, and hospital outpatient and emergency departments for all possible diagnoses
The logistic regression model indicates that the frequency of patients over age 50 years is no longer significantly higher (Odds ratio or Odds ratios (OR) = 1.23, 95% CI 0.87–1.74) in the OSA+Insomnia group versus the OSA-Insomnia group, after controlling for comorbidities, other demographic and potential confounding factors
Summary
Obstructive sleep apnea (OSA) [1] and insomnia [2,3] are two of the most commonly encountered sleep disorders. Activation of the hypothalamicpituitary-adrenal (HPA) axis is believed to be one of the major mechanisms underlying the pathogenesis of both the cardiovascular and psychiatric disorders that are encountered in OSA and insomnia. Corticotropin releasing factor hyperactivity, due to early-life stress or genetic predisposition, can lead to an amplification of the stress response, followed by prolonged and exaggerated sleep difficulties following stress and the subsequent development of chronic insomnia [20,22]. This chronic hyperarousal puts insomnia patients at risk for cardiovascular disease [23] and mood disorders [20] associated with HPA axis hyperactivity. The shared physiological mechanism of HPA hyperactivity underlying both OSA and insomnia may explain the high comorbidity of these two sleep disorders
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