Chest

Chest

Volume 150, Issue 6, December 2016, Pages 1291-1301
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Original Research: Antithrombotic Therapy
OSA Is a Risk Factor for Recurrent VTE

https://doi.org/10.1016/j.chest.2016.07.011Get rights and content

Background

OSA is a risk factor for a first episode of pulmonary embolism (PE), although its impact on the risk of thromboembolism recurring is uncertain. Our objective was to explore the prognostic value of OSA after the discontinuation of oral anticoagulation (OAC) in patients with a first episode of PE.

Methods

In 120 consecutive patients who had stopped OAC for a first episode of PE, we performed home respiratory polygraphy and recorded sleep characteristics, classic risk factors for PE, blood pressure measurements, spirometric parameters, physical activity, and levels of D-dimer and prothrombin fragment 1+2 (F1+2). Patients were followed for 5 to 8 years, and the main end point was PE recurrence. Restarting OAC for any thromboembolic event was evaluated as a secondary end point.

Results

During the follow-up period, 19 patients had a PE recurrence, and 16 of them had an apnea-hypopnea index (AHI) ≥ 10 h–1. In a multivariate Cox regression model, an AHI ≥ 10 h–1 (hazard ratio [HR], 20.73; 95% CI, 1.71-251.28), mean nocturnal oxygen saturation (nSao2) (HR, 0.39; 95% CI, 0.20-0.78), time with Sao2 < 90% (CT90%) (HR, 0.90; 95% CI, 0.82-0.98), and D-dimer level (HR, 1.001; 95% CI, 1.00-1.002) were identified as independent risk factors for recurrent PE. Twenty-four patients resumed OAC, and AHI ≥ 10 h–1 (HR, 20.66; 95% CI, 2.27-188.35), mean nSao2 (HR, 0.54; 95% CI, 0.32-0.94), and Epworth Sleepiness Scale (ESS) (HR, 0.73; 95% CI, 0.56-0.97) were retained as independent risk factors for the resumption of OAC.

Conclusions

After a first episode of PE, OSA is an independent risk factor for PE recurrence or restarting OAC for a new thromboembolic event.

Section snippets

Subjects, Design, and Ethics

We performed a prospective study (University Hospital Son Espases, Palma de Mallorca and University Hospital La Paz, Madrid, Spain). Eligible cases were all consecutive patients with a previous (6-12 months) PE episode diagnosed by CT pulmonary angiography who had completed at least 3 months of OAC with a vitamin K antagonist. All subjects were included when they stopped OAC, the withdrawal of which was decided by physicians not involved in the study. They were included in the study from

General Characteristics and Sleep Study Variables

One hundred twenty patients with a first episode of PE who had received at least 3 months of OAC were included in the study. The description of demographic characteristics, comorbidities, classic risk factors for thromboembolic disease, physical activity level, D-dimer and F1+2 levels, as well as sleep parameters are summarized in Table 1. Overall, 71 patients with PE (59.2%) had OSA (AHI > 10 h–1), and 33 (27.5%) of these cases were severe (AHI > 30 h–1). In contrast, daytime sleepiness was

Discussion

The main finding in this study is that after a first episode of PE, patients with OSA had a higher risk of recurrent PE than did those without OSA. Moreover, AHI and nocturnal hypoxemia, assessed by the mean nSao2 and CT90%, are independent risk factors for PE recurrence and for resuming anticoagulation because of a new thromboembolic event.

We have previously found a significant association between OSA and PE. In fact, for every 10-unit rise in AHI, the PE risk increased by 45%.3 Some other

Acknowledgments

Author contributions: A. A-F. and F. G-R. had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. A. A-F. served as principal author. A. A-F., F. G-R., and J. S. contributed to the study concept and design. A. A-F., A. G. S., M. D. P., R. C., E. M-C., M. C., C. F-C., and F. G-R. contributed to data collection and interpretation. F. G-R. performed the statistical analyses. All authors, including A. B. and J. P.,

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    FUNDING/SUPPORT: This research was partially supported by grants from Direcció General d'Avaluació i Acreditació, Conselleria de Salut i Consum. Illes Balears 2009, Neumomadrid 2009, SEPAR 2008 [820], SEPAR-2010-820 and Comunidad de Madrid [S2010/BMD-2542], and Ministerio de Economía y Competitividad [PI10/00495].

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