A large urban health system study suggests that COVID-19 may leave a lasting impact on sleep-breathing, with a higher risk of new-onset OSA even among patients who were never hospitalized.
Study: Risk of new-onset obstructive sleep apnea up to 4.5 years after COVID-19 in the urban population. Image Credit: PeopleImages / Shutterstock
A recent study published in the journal Scientific Reports suggests that people may develop obstructive sleep apnea (OSA) up to 4.5 years after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection.
Analyzing more than 910,000 individuals, including hospitalized and non-hospitalized individuals, researchers found that SARS-CoV-2 infection was independently associated with a higher risk of new-onset OSA after adjustment for medical comorbidities and vaccination status. Among participants who developed OSA, coronavirus disease 2019 (COVID-19) patients admitted to hospitals were also more likely to develop pulmonary hypertension and heart failure.
These findings suggest that clinicians should consider targeted screening for OSA symptoms in higher-risk people with a prior COVID-19 history. If symptoms are detected early, clinicians could offer earlier diagnostic referral and treatment strategies in these individuals.
OSA refers to a commonly observed sleep disorder in which the upper airways of people repeatedly collapse while a person is sleeping. As a result, affected individuals experience intermittent periods of hypoxia and fragmented sleep. If left untreated, OSA may increase the risk of hypertension, arrhythmias, diabetes, stroke, and cognitive decline. Researchers are therefore seeking ways to identify high-risk individuals to facilitate prompt treatment of OSA.
Scientists have found that COVID-19 has been associated with persistent systemic inflammation, autonomic dysregulation, and central nervous system involvement. Taken together, these effects could affect breathing and sleep patterns. Nevertheless, whether SARS-CoV-2 infection can make people more vulnerable to OSA remains unclear.
About the Study
In this study, researchers investigated the potential impact of SARS-CoV-2 infection on the likelihood of incident OSA. To do so, they analyzed electronic medical records from the Montefiore Health System, including data from outpatient clinics and hospitals. They also investigated whether sociodemographic factors, comorbidities, hospitalization, and COVID-19 vaccinations influence the risk.
The study included adults who underwent SARS-CoV-2 polymerase chain reaction (PCR) testing between 1 March 2020 and 17 August 2024. These participants were divided into hospitalized COVID-positive, non-hospitalized COVID-positive, and COVID-negative groups to assess the impact of COVID-19 on individual susceptibility to OSA.
For individuals with a history of COVID-19, follow-up commenced upon receipt of the first SARS-CoV-2-positive test result. For those without a documented positive SARS-CoV-2 PCR test in the health system, follow-up began after the initial healthcare visit in March 2020.
The researchers conducted follow-ups until OSA diagnosis, the last clinical visit, or death through 17 August 2024. The study excluded individuals with pre-existing OSA and those who could not be followed up within a month of entering the study.
The team determined OSA using International Classification of Diseases, 10th Revision (ICD-10) diagnostic codes only, because sleep-study or other objective OSA assessments were not uniformly available. They estimated hazard ratios (HRs) for incident OSA using Cox regression analyses. The researchers performed inverse probability weighting (IPW) to adjust for sociodemographic variables, vaccination status, and clinical factors. Study variables included sex, age, ethnicity, race, household income, and insurance type.
The team additionally used Poisson regression to evaluate new-onset secondary outcomes after OSA diagnosis, such as obesity, hypertension, arrhythmia, stroke, heart failure, myocardial infarction, pulmonary hypertension, and diabetes. They also validated the findings by using a historical control cohort of 621,046 individuals from the same healthcare system having index dates before COVID-19 onset, from January 2016 to December 2019.
Results
The sample population comprised 910,393 individuals. Among these participants, non-hospitalized and hospitalized COVID-positive individuals showed greater risks of developing OSA than COVID-negative individuals, with adjusted HR values of 1.33 and 1.41, respectively.
The researchers obtained similar findings using the historical cohort. Because this was an observational electronic health record study, the findings indicate association rather than causation. Even in non-hospitalized cases, COVID-19 may be linked to altered respiratory functions and sleep systems, increasing OSA vulnerability.
The team observed that the association between hospitalized COVID-19 and new-onset OSA was stronger in separate subgroup analyses of Black individuals, patients younger than 60 years, and those with asthma.
Among those with COVID-19 history who were not hospitalized, stronger associations were observed separately among females, Hispanic patients, and those with major comorbidities. These subgroup hazard ratios were not adjusted for potential confounders, so they should be interpreted cautiously. Vaccination status was not associated with a significant difference in incident OSA risk in these groups.
Among participants who developed OSA, the hospitalized COVID-positive group also showed a higher adjusted risk of developing pulmonary hypertension and heart failure, while the non-hospitalized group of COVID-positive individuals showed a higher adjusted risk of obesity. Importantly, COVID-19 showed an independent association with OSA risk, supporting targeted OSA screening among high-risk individuals.
The authors noted several limitations, including reliance on ICD-10 codes rather than uniform sleep testing, potential detection bias from more frequent healthcare encounters after COVID-19, potential misclassification of COVID-negative patients tested outside the health system or at home, and the single health system design.
Conclusion
The findings demonstrate that people who have been diagnosed with SARS-CoV-2 infection could be more prone to developing OSA than those without a documented positive diagnosis. This risk may be particularly higher in separate subgroup analyses involving younger individuals, racial and ethnic minority groups, and people living with medical conditions such as asthma.
These findings suggest that clinicians should be more vigilant for OSA-associated symptoms and predisposing factors while examining people who have a history of COVID-19, particularly those who were hospitalized for the disease. However, the results should be interpreted as associative, not causal.
In future studies, researchers should include objective sleep assessments, such as polysomnography, and explore biological mechanisms linking COVID-19 and OSA to develop more targeted treatments.
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