Background

Obstructive sleep apnea (OSA) afflicts 1 billion people and is strongly linked with obesity and cardiovascular (CV) disease. Metabolic surgery (MS) is the most effective treatment for obesity and improves CV risk factors. The aim of this study was to investigate the long-term relationship between MS and incident major adverse cardiovascular events (MACE) in patients with moderate-to-severe OSA.

Methods

A total of 13,657 adult patients including 970 patients in the MS group and 12687 patients in the nonsurgical control group met the inclusion criteria including BMI 35-70 kg/m2 and presence of moderate-to-severe OSA (Apnea Hypopnea Index >15 diagnosed by sleep study tests) at Cleveland Clinic (2004-2018). A doubly robust estimation combining the overlap weighting and multivariable-adjusted Cox regression was used to compare outcomes in surgical and nonsurgical groups with follow-up through September 2022. The primary outcome was the incidence of extended MACE (composite of coronary artery events, cerebrovascular events, heart failure, atrial fibrillation, and mortality).

Results

Distribution of 15 baseline covariates between the study groups was precisely balanced after overlap weighting. The cumulative incidence of MACE at 10 years was 27.3% (95% CI, 21.8%-32.3%) in the MS group and 34.1% (95% CI, 32.2%-35.9%) in the nonsurgical group; adjusted absolute risk difference, 4.2% (95% CI, 2.0%-11.5%); adjusted HR, 0.63 (95% CI, 0.52-0.77), P<0.001 [Figure 1].

Conclusions

MS is associated with 37% lower risk of MACE in patients with OSA. This is the first study reporting a treatment modality that is associated with decreased risk of MACE in patients with OSA.