Obstructive sleep apnea and cardiovascular disease, a story of confounders!

  • Jacob CollenEmail author
  • Christopher Lettieri
  • Emerson Wickwire
  • Aaron Holley
Sleep Breathing Physiology and Disorders • Review


Obstructive sleep apnea (OSA) syndrome is increasingly common among middle aged and older adults and is frequently linked to most cardiovascular diseases (CVD). Sleep-disordered breathing and CVD share a number of common risk factors and comorbid conditions including obesity, male gender, advancing age, metabolic syndrome, and hypertension. OSA appears to be associated with worsened CVD outcomes, sleep-related symptoms, quality of life, and risk of motor vehicle accidents. Demonstrating a cause-and-effect relationship between CVD and OSA has been challenging due to shared comorbidities. Strong evidence demonstrating clinically significant benefit for OSA treatments on OSA-related CVD outcomes are limited. In this review, we evaluate potential pathophysiologic mechanisms that link OSA to CVD and focus on specific treatments for OSA, including positive airway pressure (PAP), dental devices, and surgeries with regard to OSA-related CVD outcomes.


Obstructive sleep apnea Cardiovascular disease Coronary artery disease Atrial fibrillation Hypertension Cerebrovascular disease Cerebrovascular accident Congestive heart failure Pulmonary hypertension Continuous positive airway pressure Positive airway pressure 



American Academy of Sleep Medicine


Atrial fibrillation


Apnea Hypopnea Index


Auto-PAP (auto-adjustable continuous positive airway pressure)


Coronary artery disease, coronary heart disease, atherosclerotic vascular disease


Congestive heart failure


Continuous positive airway pressure


Cerebrovascular accident (cerebrovascular disease)


Cardiovascular disease (umbrella term for AF, CVA, HTN, CHF, PHTN, CAD)


Direct current cardioversion (for atrial fibrillation)


Epworth Sleepiness Scale


Functional Outcomes of Sleep Questionnaire


Fatigue Severity Scale


Hypertension (systemic hypertension)


Mean pulmonary arterial pressure


Oral appliance therapy (refers to custom, adjustable, titratable, oral appliance)


Obstructive sleep apnea


Positive airway pressure


Pulmonary hypertension





All of the study authors contributed equally to writing the manuscript and have reviewed the final manuscript. Dr. Collen is the guarantor of the final article and is responsible for the integrity of the contents of this manuscript from article inception to publication of the final product.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

This article does not contain any studies with animals performed by any of the authors.

Informed consent

Informed consent was not applicable for this manuscript as no data from human participants by the authors is used.


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Copyright information

© This is a U.S. government work and not under copyright protection in the U.S.; foreign copyright protection may apply 2020

Authors and Affiliations

  1. 1.Uniformed Services UniversityBethesdaUSA
  2. 2.Department of PsychiatryUniversity of Maryland School of MedicineBaltimoreUSA
  3. 3.Sleep Disorders Center, Division of Pulmonary and Critical Care Medicine, Department of MedicineUniversity of Maryland School of MedicineBaltimoreUSA
  4. 4.Walter Reed National Military Medical CenterBethesdaUSA

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