A Validation Study of Four Different Cluster Analyses of OSA and the Incidence of Cardiovascular Mortality in a Hispanic Population


      Previous studies reported a strong association between sleepiness-related symptoms and comorbidities with poor cardiovascular outcomes among patients with moderate to severe OSA (msOSA). However, the validation of these associations in the Hispanic population from South America and the ability to predict incident cardiovascular disease remain unclear.

      Research Question

      In Hispanic patients with msOSA, are four different cluster analyses reproducible and able to predict incident cardiovascular mortality?

      Study Design and Methods

      Using the SantOSA cohort, we reproduced four cluster analyses (Sleep Heart Health Study [SHHS], Icelandic Sleep Apnea Cohort [ISAC], Sleep Apnea Cardiovascular Endpoints [SAVE], and The Institute de Recherche en Sante Respiratoire des Pays de la Loire [IRSR] cohorts) following a cluster analysis similar to each training dataset. The incidence of cardiovascular mortality was constructed using a Kaplan-Meier (log-rank) model, and Cox proportional hazards models were adjusted by confounders.


      Among 780 patients with msOSA in our cohort, two previous cluster analyses (SHHS and ISAC) were reproducible. The SAVE and IRSR cluster analyses were not reproducible in our sample. We identified the following subtypes for SHHS: “minimally symptomatic,” “disturbed sleep,” “moderate sleepiness,” and “severe sleepiness.” For ISAC, three different subtypes (“minimally symptomatic,” “disturbed sleep,” and “excessive sleepiness”) were similar to the original dataset. Compared with “minimally symptomatic,” we found a significant association between “excessive sleepiness” and cardiovascular mortality after 5 years of follow-up in SantOSA, hazard ratio (HR), 5.47; 95% CI, 1.74-8.29; P < .01; and HR, 3.23; 95% CI, 1.21-8.63; P = .02, using the SHHS and ISAC cluster analyses, respectively.


      Among patients with msOSA, a symptom-based approach can validate different OSA patient subtypes, and those with excessive sleepiness have an increased risk of incident cardiovascular mortality in the Hispanic population from South America.

      Graphical Abstract

      Key Words


      BIC (Bayesian information criterion), CA (cluster analysis), CHD (coronary heart disease), ESS (Epworth Sleepiness Scale), HR (hazard ratio), HSAT (home sleep apnea test), HTN (hypertension), IRSR (The Institute de Recherche en Sante Respiratoire des Pays de la Loire), ISAC (Icelandic Sleep Apnea Cohort), msOSA (moderate to severe OSA), RDI (respiratory disturbance index), SantOSA (OSA in Santiago), SAVE (Sleep Apnea Cardiovascular Endpoints), SHHS (Sleep Heart Health Study), Spo2 (oxygen saturation), T90% (total time with oxyhemoglobin saturation below 90%)
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