Table of Contents    
Year : 2020  |  Volume : 11  |  Issue : 2  |  Page : 164-168  

The prevalence and related risk factors of obstructive sleep apnea in heart failure patients at the indonesian referral hospital for respiratory diseases

1 Department of Pulmonology and Respiratory Medicine, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
2 Department of Cardiology, Persahabatan Hospital, Jakarta, Indonesia
3 Department of Pulmonology and Respiratory Medicine, Faculty of Medicine, Universitas Indonesia; Department of Nutrition, Faculty of Medicine, Universitas Indonesia, Dr. Cipto Mangunkusumo Hospital, Jakarta, Indonesia

Date of Submission28-Aug-2019
Date of Decision10-Nov-2019
Date of Acceptance26-Dec-2019
Date of Web Publication22-Jul-2020

Correspondence Address:
Agus Dwi Susanto
Department of Pulmonology and Respiratory Medicine, Faculty of Medicine, Universitas Indonesia, Persahabatan Hospital, Jalan Persahabatan Raya No. 1, Rawamangun, Jakarta 13230
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jnsbm.JNSBM_176_19

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Background: Obstructive sleep apnea (OSA) is closely associated with metabolic diseases such as hypertension and dyslipidemia. OSA is also frequently found in patients with heart failure. This study aims to determine the prevalence and factors which affect the incidence of OSA in patients with heart failure. Methods: This cross-sectional study was conducted on 70 samples of patients with heart failure in the cardiac outpatient clinic and inpatient ward of the Persahabatan Hospital, Jakarta, Indonesia. Results: Using the Berlin Questionnaire, 42 patients (60%) were found to be at high risk of OSA. Using the Chi-square test, it was found that age (P = 0.988), gender (P = 0.678), body mass index (P = 0.170), neck circumference (P = 0.605), abdominal circumference (P = 0.189), blood pressure (P = 0.922), and smoking (P = 0.678) factors did not have a significant correlation with OSA risk in patients with heart failure. While the tonsil size was found to have a significant correlation (P = 0.005). Conclusions: Patients with heart failure were at risk of having OSA, and tonsil size was significantly correlated with OSA incidence in patients with heart failure.

Keywords: Berlin Questionnaire, heart failure, obstructive sleep apnea, polysomnography, tonsils

How to cite this article:
Susanto AD, Harahap RA, Antariksa B, Basalamah MA, Nurwidya F. The prevalence and related risk factors of obstructive sleep apnea in heart failure patients at the indonesian referral hospital for respiratory diseases. J Nat Sc Biol Med 2020;11:164-8

How to cite this URL:
Susanto AD, Harahap RA, Antariksa B, Basalamah MA, Nurwidya F. The prevalence and related risk factors of obstructive sleep apnea in heart failure patients at the indonesian referral hospital for respiratory diseases. J Nat Sc Biol Med [serial online] 2020 [cited 2021 Mar 4];11:164-8. Available from:

   Introduction Top

Obstructive sleep apnea (OSA) is closely linked to stroke, chronic renal failure, and heart diseases such as heart failure.[1],[2] It has been reported that 36% of 700 patients with a functional class (FC) I-II heart failure suffer from OSA in Europe.[3],[4]

OSA is characterized by recurrent incidences of decreased or cessation of airflow although breathing efforts are seen to be caused by partial or complete obstruction of the upper airway.[5] Apnea is defined as a reduction in peak sensitivity of the amplitude to heat ±90% of baseline for ±10 s. The severity of OSA can be determined polysomnography (PSG) examination and Berlin criteria questionnaire. Apnea–Hypopnea Index (AHI) is the number of apnea and hypopnea per hour of sleep, a standard used for the quantitative assessment of OSA severity. In OSA, the AHI score is ≥5–10 events/h. The diagnosis of OSAS was made through an AHI score >5–10 events/h of OSA, and the patient has excessive symptoms of drowsy at daytime, unrefreshing sleep, or chronic fatigue.[4],[5] This study aims to determine the prevalence of OSA risk in patients with congestive heart failure (CHF) based on the Berlin Questionnaire and to find the risk factors for OSA.

   Methods Top

This cross-sectional study was conducted in the cardiac outpatient and inpatient ward of the National Referral Hospital for Respiratory Diseases, Persahabatan Hospital, Jakarta, Indonesia, from July to October 2015, and patients were recruited by consecutive sampling until the sample size was reached. The inclusion criteria were patients of stage I–II CHF, both men and women aged 40–70 years who came to the cardiac outpatient clinic with FC I-II CHF. The patients underwent history taking, physical examination, and echocardiography. Patients with ejection fraction (EF) <50% underwent PSG examination in the inpatient ward. OSA patients were treated by continuous positive airway pressure. Exclusion criteria were OSA patients with a history of stroke and chronic obstructive pulmonary disease, patients without FC I-II CHF. Patients who were willing to participate in the study were required to complete and sign the informed consent.

The data collection in this study was conducted by interview using questionnaires based on Berlin criteria [Table 1],[1] and other questions regarding the history of FC I-II CHF through anamnesis, physical examination, and laboratory examination including blood glucose examination, HbA1C, and C-reactive protein. The patient then underwent an echocardiography examination continued with PSG examination in the inpatient ward.[6],[7],[8] The Berlin Questionnaire consists of ten questions about sleep disturbances, which can be used for screening patients who are at risk for the occurrence of sleep disorders. Patients are considered high-risk OSA if two or more categories are positive and low-risk OSA if only one or no positive category.[1] The PSG used in this study is the portable-type Alice PDX (Philips Co, Andover, USA).[9] This study has been approved by the Institutional Review Board of the Faculty of Medicine, Universitas Indonesia.
Table 1: Berlin Questionnaire

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Bivariate analysis was performed using the Chi-square test. Multivariate analysis was performed on independent variables to determine the OSA risk factors in heart failure patients. Statistical analysis was performed in the obtained data using the Statistical Package for the Social Sciences (SPSS) software program version 20 (IBM Corp, Armonk, NY, USA). P < 0.05 was considered to be statistically significant.

   Results Top

This study was conducted from August to October 2015 at the Persahabatan Hospital in patients with FC I-II CHF with EF <50%. The total sample in this study was 70 patients. Each patient was given the Berlin Questionnaire. From the questionnaire, the study found 42 patients (60%) had a risk for OSA, which have a score of 2 or more. Further, examination with PSG was performed for patients with the risk of OSA.

Most of the patients were aged 50–59 years, male, hypertensive heart disease as the etiology of CHF, normal weight, had neck circumference above the cut off value, hypertension, smokers, and high-risk OSA as seen in [Table 2].
Table 2: Characteristics of study patients

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Of the 42 patients with high-risk OSA, 26 patients were randomly selected to undergo PSG examination. From the 26 patients examined with PSG, patients with mild OSA (AHI 5–15) were seven patients (26.7%), moderate OSA (AHI 15–30) were nine patients (34.5%), and severe OSA (AHI >30) were ten patients (38.8%). Symptoms of OSA in patients with heart failure include snoring, choking, and breathing efforts which cause the patient to wake up and feel fatigued when awake from the sleep [Table 3].
Table 3: Symptoms of obstructive sleep apnea in heart failure patients

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We then analyze the association between various factors with OSA in heart failure patients. Age was not significantly associated with OSA severity level (P = 0.988). The association between gender factor with OSA severity was also not statistically significant (P = 0.678). Although severe OSA was more prevalent in patients with obesity, which was found in 22 from 32 obese patients; however, body mass index (BMI) was not significantly associated with the severity of OSA (P = 0.170). The association of the neck circumference with OSA was not statistically significant (P = 0.605). There was a significant association (P = 0.005) between tonsil size and the severity of OSA in patients with heart failure.

In this study, severe OSA was more common in patients with high blood pressure (hypertension) as many as 22 from 37 patients with hypertension; however, the correlation between blood pressure factors and OSA severity was not statistically significant (P = 0.922). The association between a smoking factor and OSA severity was not statistically significant (P = 0.678). In this study, severe OSA was more common in patients with an EF of <40%, which was found in 29 from 43 patients; however, the association between EF and OSA severity was not statistically significant (P = 0.109).

Finally, we performed multivariate analysis using logistic regression test for variables with P < 0.25, which are BMI (0.170), abdominal circumference (P = 0.189), tonsil size (P = 0.007), and EF (P = 0.109). Based on logistic regression test results, there were no variables associated with OSA in patients with CHF, as described in [Table 4].
Table 4: Multivariate analysis of obstructive sleep apnea risk factors in heart failure patients

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   Discussion Top

OSA is frequently found in CHF patients. In this study, we determined the prevalence and factors which affect the incidence of OSA in patients with CHF. This study found that patients with high-risk of OSA (score >2) based on the Berlin Questionnaire were 42 patients (60%). The previous report by Javaheri et al. found that 11% of 81 heart failure patients had OSA on PSG screening.[10] According to the literature, patients suffering from OSA usually have narrowed airway in the pharynx or tonsil hypertrophy. OSA can also be caused by cardiac vascular diseases such as heart failure. In patients with heart failure, fluid accumulation of the lower limbs remain in the lower limb during the day due to posture effect, but this fluid will shift toward the neck when sleeping, especially during the night. This fluid shifting will cause neck and vein congestion and edematous of the pharynx connective tissue, resulting in increased pressure on the pharynx and airway obstruction.[11]

This study found symptoms experienced in heart failure patients with OSA such as snoring, fatigue after waking, and sleep deprivation. A study by Nieto et al. involved 6132 patients and they found that the prevalence of snoring symptoms was present in 33.9% of the patients.[12] Snoring in OSA caused by pharyngeal collapse with the tongue, uvula, and soft palate toward the posterior covering the airway at the larynx area. It can also be caused by the upper airway collapse leading to decreased air volume capacity in the lungs, thus affecting ventilation control systems which cause the airway to collapse partly or completely.[11]

Patients with OSA were more prevalent at the age of 50–59 years, and this is consistent with cross-sectional studies conducted by Pahlesia et al.[13] and with a prospective study conducted by Mannarino et al.[14] This finding is different from a quasi-experimental study by Susanto et al. who found that the patients mostly aged 31–40 years,[15] and with a study by Knecht et al. involving elderly heart failure patients with age range 68–70 years.[16] Sin et al. study found that age was significantly associated with OSA incidence in female patients with heart failure, and Odds ratio for age >60 years was 6.04 (95% confidence interval: 1.75–20.0).[17] Left ventricular hypertrophy in patients with CHF is closely related to changes in blood pressure during sleep compared to waking, and increased blood pressure may also be aggravated by the OSA.[18]

This study found that the BMI factor has no significant correlation with the incidence of OSA. Meanwhile, a study conducted by Wiadnyana et al. found that OSA was more common in patients with a BMI >25.[19] Furthermore, Punjabi et al. found that 58% of cases of adult patients with OSA are closely related to BMI ≥25 kg/m2.[20] Obesity can cause changes in the airways causing the size of the pharynx to shrink. Fat deposition in the neck can cause the pads on the pharynx-surrounding tissue and lateral pharynx muscle thickened, thus causing the airways to narrow and cause apnea in OSA patients with heart failure who have risk factors for obesity. Obesity is also an early cause of hypertension and insulin-resistant diabetes mellitus, which can cause endothelial vascular disorders. These events are the initial occurrence of heart failure in patients with OSA.[18]

There was no significant correlation between neck circumference and OSA incidence. Evidence suggests that the neck circumference does not affect OSA in heart failure because OSA that occurs in patients with heart failure is due to fluid shifts to the neck area at the time of lying down or sleeping position, especially at night when the fluid accumulation is supposed to be in the lower limb.[11]

In this study, OSA patients with a Berlin Questionnaire score of >2 were significantly associated with enlarged tonsils. This result is also in accordance with a study by Cahali et al.,[21] which found that the size of the tonsils did have a significant correlation with AHI (P = 0.04). The tonsil grade is closely related to the volume of true connective tissue with varying sizes according to the age and BMI.[21]

This study found that blood pressure and OSA occurrence did not have a significant correlation. In contrast, Mannarino et al. found that 64 patients with moderate-to-severe OSH have persistent hypertension.[14] Furthermore, Young et al. found that blood pressure will increase linearly along with the increase of AHI with P = 0.003 for systolic blood pressure and P = 0.01 for diastolic blood pressure.[22]

In this study, patients at high risk of OSA from the Berlin Questionnaire were more common in severe CHF patients with low EF (<40%) although it was not statistically significant. The direct mechanism of OSA can occur because of increased blood pressure may reduce the left ventricular EF.[23]

   Conclusions Top

This study found heart failure patients with high-risk OSA based on Berlin Questionnaires is 60%. Twenty-six patients at high risk of OSA underwent PSG examination with the result of patients with mild OSA (AHI score 5–15) – seven patients (26.7%), moderate OSA (AHI score 15–30) –nine patients (34.5%), and severe OSA (AHI >30) –ten patients (38.8%). Tonsil size was found to have a significant correlation with the incidence of OSA in patients with heart failure.

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Conflicts of interest

There are no conflicts of interest.

   References Top

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  [Table 1], [Table 2], [Table 3], [Table 4]


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