RESUMEN
BACKGROUND: Atrial fibrillation and obstructive sleep apnea are common conditions, but little is known about obstructive sleep apnea and cardiovascular risk among atrial fibrillation patients. METHODS: Using the Truven Health MarketScan databases, we constructed a prospective cohort of atrial fibrillation patients from 2007 to 2014. Atrial fibrillation, obstructive sleep apnea, stroke, myocardial infarction, and confounders were defined using the International Classification of Disease-9-CM codes. We matched individuals with an obstructive sleep apnea diagnosis with up to five individuals without a diagnosis by age, sex, and enrollment date. Cox proportional hazards models adjusted for confounders and high-dimensional propensity scores. We included migraines as a control outcome. Bias analysis used published sensitivities and specificities to generate rate ratios adjusted for obstructive sleep apnea misclassification. RESULTS: We matched 56,969 individuals with an obstructive sleep apnea diagnosis to 323,246 without. During a mean follow-up of 16 months, 3234 incident strokes and 4639 incident myocardial infarctions occurred. After adjustment, obstructive sleep apnea diagnosis was strongly associated with reduced risk of incident stroke (hazard ratio = 0.48, 95% confidence interval = 0.43, 0.53) and myocardial infarction (0.40, [0.37, 0.44]) and a smaller reduced risk of migraines (0.82, [0.68, 0.99]). Bias analysis produced wide-ranging or inestimable rate ratios adjusted for misclassification of obstructive sleep apnea. CONCLUSIONS: Obstructive sleep apnea diagnosis in atrial fibrillation patients was strongly associated with reduced risk of incident cardiovascular disease. We discuss misclassification, selection bias, and residual confounding as potential explanations.
Asunto(s)
Fibrilación Atrial/epidemiología , Isquemia Encefálica/epidemiología , Infarto del Miocardio/epidemiología , Apnea Obstructiva del Sueño/epidemiología , Accidente Cerebrovascular/epidemiología , Anciano , Enfermedades Cardiovasculares/epidemiología , Estudios de Cohortes , Factores de Confusión Epidemiológicos , Bases de Datos Factuales , Femenino , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Modelos de Riesgos Proporcionales , Estudios Prospectivos , Riesgo , Sesgo de Selección , Apnea Obstructiva del Sueño/diagnóstico , Estados Unidos/epidemiologíaRESUMEN
OBJECTIVE: Conditional cash transfer programs are popular internationally and represent a large investment in child health. Evidence of their impact on child nutrition status remains weak and inconsistent, particularly for Bolsa Família, the Brazilian conditional cash transfer program and one of the world's largest. Our objective was to estimate the effect of the Brazilian conditional cash transfer program, Bolsa Família (BF), on child nutritional status as measured by length-for-age z-score (LAZ) and weight-for-age z-score (WAZ) at 24 months. METHODS: We analyzed the 1703 children eligible for BF from the 2004 Pelotas Birth Cohort. Children were divided into three exposure groups by total amount of money their household received from BF in 24 months: no BF, low BF (≤R$1000) and high BF (>R$1000). Using a doubly robust semiparametric estimation method we estimated the effect of receiving low and high levels of BF on LAZ and WAZ at 24 months. RESULTS: After adjustment for measured confounders, the expected difference in LAZ between children that received low or high levels of BF compared to no BF was -0.14 [95% confidence interval (CI): -0.27, -0.02] and -0.20 (95% CI: -0.33, -0.08) respectively. For WAZ the estimated differences were -0.04 (95% CI: -0.17, 0.08) for low levels versus no BF and -0.18 (95% CI: -0.30, -0.05) for high levels versus no BF. The expected difference in population LAZ had all eligible households received it and population LAZ under no BF was -0.15 (95% CI: -0.26, -0.04). Sensitivity analyses suggested only a strong confounder could explain away these results. CONCLUSIONS: Among participants of the 2004 Pelotas Birth Cohort, BF was associated with a reduction in LAZ and WAZ in 24 month old children.