LAUSR

Epidemiological studies have shown a strong association between sleep disordered breathing (SDB) and increased incidence of cardiovascular morbidity and mortality, however, to date, the variation of SDB across the socioeconomic spectrum and how this variation is associated with major cardiovascular events (MACE) and mortality is unknown. A retrospective cohort study was conducted using the Cleveland Clinic Sleep Laboratory Registry and included MACE-naïve adults who underwent polysomnography or home sleep apnea test. Area Deprivation Index (ADI), a biomarker of neighborhood socioeconomic disadvantage, was calculated by national rank, i.e. 25th, 50th and 75th percentiles; higher quartiles reflecting greater deprivation (ADI-Q1,2,3,4). ANOVA with pairwise testing was used to compare variables across ADI quartiles. Composite of MACE included heart failure, stroke, atrial fibrillation and myocardial Infarction or death. Cox proportional hazard regression models tested the association between ADI and SDB-measures of apnea hypopnea Index (AHI) and sleep-related hypoxia (total sleep time spent< 90%SaO2, T90) with MACE. Covariates included demographics, medications, smoking status, Elixhauser Comorbidity Score, and comorbidities. Censoring was sleep study date or last encounter in the electronic medical record. Asterisk (*) indicates statistical significance after pairwise testing. Interaction testing used competing risk (Fine & Gray method). Of 72,443 patients, those living in ADI-Q4, compared to those living in ADI-Q1, were more likely to be younger (*48.9± 3.9 vs 50.4±14.2), female (*59.9% vs 40.1%), African American (*49% vs 4.9%), with lower AHI (*13.5[5.4, 34.1]vs15.1[6.2,33.1]) and lower degree of hypoxia (T90:*2.9[0.40,19.01] vs 4.4[0.50, 25.6]). Model adjusted risk for MACE or death for those in ADI-Q4 was 79% greater than ADI-Q1 (HR=1.79,95%CI:1.51-2.12,p< 0.0001). Likewise, increased AHI severity and T90 above median were associated with 13% and 21% increased risk of MACE or death (HR=1.13,95%CI:1.07-1.19,p< 0.0001; HR=1.21,95%CI:1.51-1.27,p< 0.001) respectively. Interactions were observed between T90 and ADI with the risk of MACE (p=0.0016) or death (p=0.0051). Living in areas of increasing socioeconomic deprivation confers an increased risk for MACE or death. Moreover, sleep-related hypoxia seems to modify this association. ADI appears to be useful to identify populations at risk for worse cardiovascular outcomes and to inform risk stratification for targeted interventions to decreased sleep-health disparities.