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Where a patient lives is associated not with how often breathing pauses during sleep but with how deeply and how long oxygen falls when it does, and that difference is reflected in cardiovascular outcomes years later. Those are the central findings of an observational cohort study published August 31, 2026, in the Annals of the American Thoracic Society, led by Cleveland Clinic investigators with collaborators at MetroHealth and the University of Washington.
The study drew on a large institutional sleep registry of 72,443 adults evaluated for obstructive sleep apnea (OSA), including 52,874 who underwent in-laboratory polysomnography (PSG) and 19,569 who completed type III home sleep testing. Neighborhood disadvantage was measured with the Area Deprivation Index (ADI), a publicly available, address-based index of income, education, employment, and housing quality, and patients were grouped into quintiles from least disadvantaged (Q1) to most disadvantaged (Q5). Investigators examined the apnea-hypopnea index (AHI), the percentage of sleep time spent with oxygen saturation below 90% (T90), and the oxygen saturation nadir. The outcome was a composite of incident heart failure, stroke, atrial fibrillation, coronary artery disease, or death (MACE). Models were adjusted for demographics, comorbidities, smoking, and cardiovascular medications.
Greater neighborhood deprivation was associated with more severe sleep-related hypoxia, with higher T90 and a lower oxygen nadir (P < 0.001), but not with AHI. Patients from more deprived neighborhoods did not show a higher apnea-hypopnea burden, yet spent a larger share of the night desaturated.
Over a median follow-up of 5.6 years in the PSG cohort, residence in the most disadvantaged quintile carried a hazard ratio (HR) of 1.22 for MACE or death compared with the least disadvantaged quintile (95% CI, 1.13-1.33). In the type III cohort, with a median follow-up of 2.8 years, the fourth quintile showed an HR of 1.41 relative to the first (95% CI, 1.12-1.78). Within that home-tested group, hypoxia modified the relationship between ADI and outcomes (interaction P = 0.025).
The AHI remains the measure used to grade OSA severity and to qualify patients for positive airway pressure therapy under Medicare and many commercial coverage policies. The hypoxia measures in this study came from the same recordings that produced the AHI.
The authors conclude that neighborhood disadvantage is associated with greater sleep-related hypoxia and worse cardiovascular outcomes among patients evaluated for OSA, independent of apnea frequency. They suggest that incorporating measures of sleep-related hypoxia and neighborhood disadvantage into cardiovascular risk stratification may play a role in identifying high-risk populations.
