Risk of new-onset obstructive sleep apnea up to 4.5 years after COVID-19 in the urban population

Rationale Obstructive sleep apnea (OSA) is linked to cardiovascular, metabolic, and cognitive morbidity. Although COVID-19 has been associated with long-term respiratory and neurological sequelae, its role in precipitating new-onset OSA remains unclear. Objectives To evaluate whether SARS-CoV-2 infection increases risk of developing OSA up to 4.5 years post-infection and how risk varies by hospitalization status, demographics, comorbidities, and vaccination status. Methods This retrospective cohort study used electronic health records from the Montefiore Health System in the Bronx. Adults tested for SARS-CoV-2 between March 1, 2020, and August 17, 2024, were classified as hospitalized COVID+, non-hospitalized COVID+, or COVID−. Patients with prior OSA or inadequate follow-up were excluded. Inverse probability weighting adjusted for demographic, clinical, socioeconomic, and vaccination covariates. New-onset OSA was assessed using weighted Cox proportional hazards models. Secondary outcomes including hypertension, myocardial infarction, heart failure, stroke, arrhythmia, pulmonary hypertension, type 2 diabetes, and obesity were evaluated with Poisson regression. Sensitivity analysis used a pre-pandemic control cohort. Results Among 910,393 eligible patients, hospitalized [HR 1.41 (95% CI 1.14-1.73)] and non-hospitalized [HR 1.33 (95% CI 1.22-1.46)] COVID+ patients had higher adjusted risk of new-onset OSA versus COVID− controls. Similar findings were observed using historical controls (n=621046). After OSA onset, hospitalized COVID+ patients had higher risks of heart failure and pulmonary hypertension, while non-hospitalized COVID+ patients had higher risk of obesity vs COVID− patients. Conclusions SARS-CoV-2 infection is independently associated with increased risk of new-onset OSA. These findings support targeted screening in post-COVID populations. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement The author(s) received no specific funding for this work. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: This retrospective cohort study was approved by the Einstein-Montefiore Institutional Review Board (2021-13658), which granted a waiver of obtaining informed consent. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes Data can be provided upon reasonable request. tim.duong{at}einsteinmed.edu