title: OSA and depression are common and independently associated with refractory angina in patients with coronary artery disease.
abstract: OBJECTIVE
  Refractory angina is a severe form of coronary artery disease (CAD) characterized by persistent angina despite optimal medical therapy. OSA and depression are common in patients with stable CAD and may contribute to a poor prognosis. We hypothesized that OSA and depression are more common and more severe in patients with refractory angina than in patients with stable CAD.
  
  
  METHODS
  We used standardized questionnaires and full polysomnography to compare consecutive patients with well-established refractory angina vs consecutive patients with stable CAD evaluated for coronary artery bypass graft surgery.
  
  
  RESULTS
  Patients with refractory angina (n = 70) compared with patients with stable CAD (n = 70) were similar in sex distribution (male, 61.5% vs 75.5%; P = .07) and BMI (29.5 ± 4 kg/m2 vs 28.5 ± 4 kg/m2, P = .06), and were older (61 ± 10 y vs 57 ± 7 y, P = .013), respectively. Patients with refractory angina had significantly more symptoms of daytime sleepiness (Epworth Sleepiness Scale score, 12 ± 6 vs 8 ± 5; P < .001), had higher depression symptom scores (Beck Depression Inventory score, 19 ± 8 vs 10 ± 8; P < .001) despite greater use of antidepressants, had a higher apnea-hypopnea index (AHI) (AHI, 37 ± 30 events/h vs 23 ± 20 events/h; P = .001), higher proportion of oxygen saturation < 90% during sleep (8% ± 13 vs 4% ± 9, P = .04), and a higher proportion of severe OSA (AHI ≥ 30 events/h, 48% vs 27%; P = .009) than patients with stable CAD. OSA (P = .017), depression (P < .001), higher Epworth Sleepiness Scale score (P = .007), and lower sleep efficiency (P = .016) were independently associated with refractory angina in multivariate analysis.
  
  
  CONCLUSIONS
  OSA and depression are independently associated with refractory angina and may contribute to poor cardiovascular outcome.
authors.affiliation: Sleep Laboratory, Pulmonary Division, University of São Paulo Medical School, São Paulo, Brazil.
authors.forename: Glaucylara R
authors.initials: GR
authors.lastname: Geovanini
authors.affiliation: Refractory Angina Research Group, University of São Paulo Medical School, São Paulo, Brazil.
authors.forename: Luis H W
authors.initials: LHW
authors.lastname: Gowdak
authors.affiliation: Refractory Angina Research Group, University of São Paulo Medical School, São Paulo, Brazil.
authors.forename: Alexandre C
authors.initials: AC
authors.lastname: Pereira
authors.affiliation: Sleep Laboratory, Pulmonary Division, University of São Paulo Medical School, São Paulo, Brazil.
authors.forename: Naury de Jesus
authors.initials: NJ
authors.lastname: Danzi-Soares
authors.affiliation: Refractory Angina Research Group, University of São Paulo Medical School, São Paulo, Brazil.
authors.forename: Luciana O C
authors.initials: LOC
authors.lastname: Dourado
authors.affiliation: Refractory Angina Research Group, University of São Paulo Medical School, São Paulo, Brazil.
authors.forename: Nilson T
authors.initials: NT
authors.lastname: Poppi
authors.affiliation: Refractory Angina Research Group, University of São Paulo Medical School, São Paulo, Brazil.
authors.forename: Luiz Antonio Machado
authors.initials: LAM
authors.lastname: Cesar
authors.affiliation: Sleep Laboratory, Pulmonary Division, University of São Paulo Medical School, São Paulo, Brazil; Hypertension Unit, Heart Institute (InCor), University of São Paulo Medical School, São Paulo, Brazil.
authors.forename: Luciano F
authors.initials: LF
authors.lastname: Drager
authors.affiliation: Sleep Laboratory, Pulmonary Division, University of São Paulo Medical School, São Paulo, Brazil. Electronic address: geraldo.lorenzi@gmail.com.
authors.forename: Geraldo
authors.initials: G
authors.lastname: Lorenzi-Filho
mesh_terms: D060050:Angina, Stable / Q000150:complications* / Q000503:physiopathology / Q000523:psychology; D001938:Brazil / Q000453:epidemiology; D003324:Coronary Artery Disease / Q000150:complications* / Q000503:physiopathology / Q000523:psychology; D003863:Depression / Q000453:epidemiology / Q000209:etiology* / Q000523:psychology; D004562:Electrocardiography; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D017286:Polysomnography; D015995:Prevalence; D012189:Retrospective Studies; D020181:Sleep Apnea, Obstructive / Q000150:complications* / Q000503:physiopathology / Q000523:psychology; D011795:Surveys and Questionnaires