Patients with both severe and nonsevere COVID-19 infections are at higher risk for both new-onset obstructive sleep apnea (OSA) and related serious complications than their uninfected peers, Albert Einstein College of Medicine researchers report in a study published this week on the preprint server medRxiv.
The retrospective study, which has not been peer-reviewed, involved 910,393 patients tested for COVID-19 at Montefiore Health System in the Bronx from March 2020 to August 2024. Follow-up lasted for up to 4.5 years. Of the 910,393 patients, 57,206 tested positive for COVID-19, and 853,187 tested negative.
OSA is estimated to affect 10% to 30% of adults worldwide. It’s characterized by repeated upper-airway collapse during sleep, which leads to intermittent low oxygen levels, poor sleep, and sympathetic nervous system overactivation (“fight or flight mode”).
The study authors noted OSA’s link to cardiovascular, metabolic, and cognitive disease. Likewise, “hospitalization due to COVID-19 often entails prolonged immobilization, corticosteroid use, and weight gain, which are known risk factors for OSA,” they wrote. “Even among non-hospitalized individuals, post-acute sequelae of COVID-19 (“long COVID”) may impair respiratory function and sleep architecture, potentially precipitating the emergence of OSA.”
Apnea risk didn’t vary by vaccination status
After weighting, hospitalized and non-hospitalized COVID-19 patients were 41% and 33%, respectively, more likely to be diagnosed as having OSA than uninfected controls within the next 4.5 years.
After an OSA diagnosis, hospitalized COVID-19 patients had a statistically significant higher risk of heart failure (hazard ratio [HR], 2.33) and pulmonary hypertension (HR, 1.98) than controls, while nonhospitalized COVID patients were significantly more likely than controls to develop obesity (HR, 1.16).
Analyses of demographic subgroups suggested that the link between hospitalized COVID-19 patients and new-onset OSA was stronger in patients with asthma and those who were younger than 60 years, and in Black patients compared with White patients.
Taken together, these findings underscore the need for multidisciplinary surveillance and risk stratification in post-COVID care.
The association between non-hospitalized COVID-19 patients and new-onset OSA was stronger in women than in men, Hispanic versus non-Hispanic patients, and those with major underlying illnesses. Vaccinated and unvaccinated hospitalized and nonhospitalized patients were at similar risk for new-onset OSA.
Hospitalized and nonhospitalized COVID-19 patients also had higher odds of new-onset OSA than an historical cohort of 621,046 patients (HR, 2.09 and 1.56, respectively).
Targeted apnea screening may be warranted
The authors said that, among other possible mechanisms, low-grade systemic inflammation after COVID-19 infection may reduce upper-airway neuromuscular control and weaken pharyngeal muscle tone, leading to airway collapse during sleep. Likewise, higher levels of inflammatory cytokines often seen in long-COVID patients can affect respiratory drive and upper-airway stability, factors central to OSA.
“Taken together, these findings underscore the need for multidisciplinary surveillance and risk stratification in post-COVID care,” the researchers wrote. “Screening for OSA should be considered in patients presenting with persistent fatigue, insomnia, neurocognitive dysfunction, or cardiopulmonary symptoms, even in the absence of classic OSA risk factors such as obesity.”
“Given the long-term consequences of untreated OSA and the elevated risk observed even in non-hospitalized individuals, targeted screening in post-COVID patients, particularly among women, racial and ethnic minorities, and those with comorbidities, may be warranted,” they concluded.
