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Multicenter Study
. 2018 Mar 1;41(3):zsx214.
doi: 10.1093/sleep/zsx214.

Recognizable Clinical Subtypes of Obstructive Sleep Apnea Across International Sleep Centers: A Cluster Analysis

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Multicenter Study

Recognizable Clinical Subtypes of Obstructive Sleep Apnea Across International Sleep Centers: A Cluster Analysis

Brendan T Keenan et al. Sleep. .
Free PMC article

Abstract

Study objectives: A recent study of patients with moderate-severe obstructive sleep apnea (OSA) in Iceland identified three clinical clusters based on symptoms and comorbidities. We sought to verify this finding in a new cohort in Iceland and examine the generalizability of OSA clusters in an international ethnically diverse cohort.

Methods: Using data on 972 patients with moderate-severe OSA (apnea-hypopnea index [AHI] ≥ 15 events per hour) recruited from the Sleep Apnea Global Interdisciplinary Consortium (SAGIC), we performed a latent class analysis of 18 self-reported symptom variables, hypertension, cardiovascular disease, and diabetes.

Results: The original OSA clusters of disturbed sleep, minimally symptomatic, and excessively sleepy replicated among 215 SAGIC patients from Iceland. These clusters also generalized to 757 patients from five other countries. The three clusters had similar average AHI values in both Iceland and the international samples, suggesting clusters are not driven by OSA severity; differences in age, gender, and body mass index were also generally small. Within the international sample, the three original clusters were expanded to five optimal clusters: three were similar to those in Iceland (labeled disturbed sleep, minimal symptoms, and upper airway symptoms with sleepiness) and two were new, less symptomatic clusters (labeled upper airway symptoms dominant and sleepiness dominant). The five clusters showed differences in demographics and AHI, although all were middle-aged (44.6-54.5 years), obese (30.6-35.9 kg/m2), and had severe OSA (42.0-51.4 events per hour) on average.

Conclusions: Results confirm and extend previously identified clinical clusters in OSA. These clusters provide an opportunity for a more personalized approach to the management of OSA.

Figures

Figure 1.
Figure 1.
Profiles of the three OSA clusters in Icelandic and International SAGIC samples. The relative differences in symptoms among the three OSA clusters (disturbed sleep, minimally symptomatic, and excessively sleepy) are shown in heatmaps within the Icelandic and International samples, separately, where blue indicates a lower relative prevalence/burden and red a higher relative symptom burden. The heatmaps illustrate both the higher prevalence of reported sleepiness and upper airway symptoms in the excessively sleepy and the higher rates of restless sleep and insomnia symptoms in the disturbed sleep. We also see the relative lower reported symptom burden in the minimally symptomatic cluster. Importantly, note the clear similarities in symptom profiles between the Icelandic and International samples of patients. This strongly supports the notion that these OSA subtypes are reproducible both inside and outside of Iceland.
Figure 2.
Figure 2.
Profiles of the five optimal OSA clusters in the International SAGIC sample. The relative symptom burden is shown in a heatmap for each of the five optimal clusters (disturbed sleep, minimal symptoms, upper airway symptoms with sleepiness, upper airway symptoms dominant, and sleepiness dominant), ranging from low burden (blue) to high burden (red). In addition to illustrating the symptomatic differences among the five clusters, note the similarities between the heatmaps for the disturbed sleep, minimal symptoms, and upper airway symptoms with sleepiness and the corresponding heatmaps for the three-cluster solutions in Figure 1.
Figure 3.
Figure 3.
Distribution of the a priori three–OSA clusters within the five optimal OSA clusters found in the International SAGIC sample. The proportions of patients from the a priori three–cluster solution within each of the optimal five clusters are shown. We note that >80% of the disturbed sleep, minimal symptoms, and upper airway symptoms with sleepiness clusters are made up of patients from the similar group in the three-cluster solution, whereas the new upper airway symptoms dominant and sleepiness dominant clusters consist primarily of a mixture of patients from the minimally symptomatic and excessively sleepy clusters.

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