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Obstructive sleep apnea and acute myocardial infarction severity: ischemic preconditioning?

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An Erratum to this article was published on 21 December 2012



Obstructive sleep apnea (OSA) is characterized by intermittent hypoxia (IH). In animal models, IH has been shown to protect the myocardium during periods of ischemia by reducing infarct size. However, this phenomenon of “ischemic preconditioning” has not been investigated among OSA patients with acute myocardial infarction (MI). This study investigates the role of OSA on MI severity as measured by cardiac enzymes, specifically troponin-T, among patients with an acute MI.


This is an observational cohort study of patients ≥18 years of age who were hospitalized with an acute MI. Each participant underwent portable sleep monitoring (Apnea Link Plus); OSA was defined as an apnea–hypopnea index ≥5/h. Multivariable regression analysis was conducted to assess the relationship between OSA and highly sensitive troponin-T levels.


In our entire cohort of acute MI patients (n = 136), 77 % of the sample had evidence of sleep disordered breathing, with 35 % of the sample having OSA (i.e., an AHI >5). Higher AHI was associated with lower peak troponin-T levels in partially adjusted models (β = −0.0320, p = 0.0074, adjusted for age, gender, and race) and fully adjusted models (β = −0.0322, p = 0.0085) (additionally adjusted for smoking, hypertension, hyperlipidemia, body mass index, history of prior cardiovascular or cerebrovascular disease, diabetes and baseline admission creatinine levels). The mean value of the log-transformed peak troponin-T variable was used to dichotomize the outcome variable. In both partially (OR 0.949, CI 0.905–0.995, p = 0.03) and fully adjusted (OR 0.918, CI 0.856–0.984, p = 0.0151) logistic regression models, the OR for AHI suggests a protective effect on high troponin-T level.


Our study demonstrates that patients with OSA have less severe cardiac injury during an acute non-fatal MI when compared to patients without OSA. This may suggest a cardioprotective role of sleep apnea during acute MI via ischemic preconditioning.

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  1. Collinson PO (2011) Biochemical estimation of infarct size. Heart 97:169–170

    Article  PubMed  Google Scholar 

  2. Gozal D, Lipton AJ, Jones KL (2002) Circulating vascular endothelial growth factor levels in patients with obstructive sleep apnea. Sleep 25:59–65

    PubMed  Google Scholar 

  3. Imagawa S, Yamaguchi Y, Higuchi M, Neichi T, Hasegawa Y, Mukai HY, Suzuki N, Yamamoto M, Nagasawa T (2001) Levels of vascular endothelial growth factor are elevated in patients with obstructive sleep apnea—hypopnea syndrome. Blood 98:1255–1257

    Article  PubMed  CAS  Google Scholar 

  4. Lavie L, Kraiczi H, Hefetz A, Ghandour H, Perelman A, Hedner J, Lavie P (2002) Plasma vascular endothelial growth factor in sleep apnea syndrome: effects of nasal continuous positive air pressure treatment. Am J Respir Crit Care Med 165:1624–1628

    Article  PubMed  Google Scholar 

  5. Ma J, Xu Y, Zhang Z, Liu H, Xiong W, Xu S (2007) Serum level of vascular endothelial growth factor in patients with obstructive sleep apnea hypopnea syndrome. J Huazhong Univ Sci Technol Med Sci 27:157–160

    Article  PubMed  CAS  Google Scholar 

  6. Martinez D, da Silva RP, Klein C, Fiori CZ, Massierer D, Cassol CM, Bos AJ, Gus M (2012) High risk for sleep apnea in the Berlin questionnaire and coronary artery disease. Sleep Breath 16(1):89–94

    Article  PubMed  Google Scholar 

  7. Martinez D, Klein C, Rahmeier L, da Silva RP, Fiori CZ, Cassol CM, Goncalves SC, Bos AJ (2012) Sleep apnea is a stronger predictor for coronary heart disease than traditional risk factors. Sleep Breath 16(3):695–701

    Article  PubMed  Google Scholar 

  8. Mayr A, Mair J, Klug G, Schocke M, Pedarnig K, Trieb T, Pachinger O, Jaschke W, Metzler B (2011) Cardiac troponin T and creatine kinase predict mid-term infarct size and left ventricular function after acute myocardial infarction: a cardiac MR study. J Magn Reson Imaging 33:847–854

    Article  PubMed  Google Scholar 

  9. Metzler B, Hammerer-Lercher A, Jehle J, Dietrich H, Pachinger O, Xu Q, Mair J (2002) Plasma cardiac troponin T closely correlates with infarct size in a mouse model of acute myocardial infarction. Clin Chim Acta 325:87–90

    Article  PubMed  CAS  Google Scholar 

  10. Murry CE, Jennings RB, Reimer KA (1986) Preconditioning with ischemia: a delay of lethal cell injury in ischemic myocardium. Circulation: 1124-1136

  11. Neckar J, Ostadal B, Kolar F (2004) Myocardial infarct size-limiting effect of chronic hypoxia persists for five weeks of normoxic recovery. Physiol Res 53:621–628

    PubMed  CAS  Google Scholar 

  12. Peker Y, Carlson J, Hedner J (2006) Increased incidence of coronary artery disease in sleep apnoea: a long-term follow-up. Eur Respir J 28:596–602

    Article  PubMed  CAS  Google Scholar 

  13. Reichlin T, Hochholzer W, Bassetti S, Steuer S, Stelzig C, Hartwiger S, Biedert S, Schaub N, Buerge C, Potocki M, Noveanu M, Breidthardt T, Twerenbold R, Winkler K, Bingisser R, Mueller C (2009) Early diagnosis of myocardial infarction with sensitive cardiac troponin assays. N Engl J Med 361(9):858–867

    Article  PubMed  CAS  Google Scholar 

  14. Shah NA, Yaggi HK, Concato J, Mohsenin V (2010) Obstructive sleep apnea as a risk factor for coronary events or cardiovascular death. Sleep Breath 14:131–136

    Article  PubMed  Google Scholar 

  15. Steiner S, Schueller PO, Schulze V, Strauer BE (2010) Occurrence of coronary collateral vessels in patients with sleep apnea and total coronary occlusion. Chest 137:516–520

    Article  PubMed  Google Scholar 

  16. Thygesen K, Alpert JS, Jaffe AS, Simoons ML, Chaitman BR, White HD, Writing Group on behalf of the Joint ESC/ACCF/AHA/WHF Task Force for the Universal Definition of Myocardial Infarction (2012) Third universal definition of myocardial infarction. Circulation 50:2173–2195

    Google Scholar 

  17. Tsukamoto K, Ohara A (2006) Temporal worsening of sleep-disordered breathing in the acute phase of myocardial infarction. Circ J 70:1553–1556

    Article  PubMed  Google Scholar 

  18. Valipour A, Litschauer B, Mittermayer F, Rauscher H, Burghuber OC, Wolzt M (2004) Circulating plasma levels of vascular endothelial growth factor in patients with sleep disordered breathing. Respir Med 98:1180–1186

    Article  PubMed  Google Scholar 

  19. Weinreich G, Armitstead J, Topfer V, Wang YM, Wang Y, Teschler H (2009) Validation of ApneaLink as screening device for Cheyne–Stokes respiration. Sleep 32:553–557

    PubMed  Google Scholar 

  20. Xu WQ, Yu Z, Xie Y, Huang GQ, Shu XH, Zhu Y, Zhou ZN, Yang HT (2011) Therapeutic effect of intermittent hypobaric hypoxia on myocardial infarction in rats. Basic Res Cardiol 106:329–342

    Article  PubMed  CAS  Google Scholar 

  21. Younger JF, Plein S, Barth J, Ridgway JP, Ball SG, Greenwood JP (2007) troponin-I concentration 72 h after myocardial infarction correlates with infarct size and presence of microvascular obstruction. Heart 93(12):1547–1551

    Article  PubMed  CAS  Google Scholar 

  22. Zong P, Setty S, Sun W, Martinez R, Tune JD, Ehrenburg IV, Tkatchouk EN, Mallet RT, Downey HF (2004) Intermittent hypoxic training protects canine myocardium from infarction. Exp Biol Med (Maywood) 229:806–812

    CAS  Google Scholar 

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Dr. Shah has funding support from the American Sleep Medicine Foundation. In addition, pilot funding for purchasing sleep monitors was provided by the Divisions of Pulmonary and Cardiology at Montefiore Medical Center.

The authors would like to express their deepest gratitude to the Department of Respiratory Therapy at Montefiore Medical Center for their assistance in the application of the portable sleep monitors for this study.


The authors have indicated no financial conflicts of interest. A research grant ($2,000) from Resmed was received for scoring and reviewing of sleep studies by independent reviewers with no relationship to Resmed.

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Correspondence to Neomi Shah.

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Shah, N., Redline, S., Yaggi, H.K. et al. Obstructive sleep apnea and acute myocardial infarction severity: ischemic preconditioning?. Sleep Breath 17, 819–826 (2013).

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