American Thoracic Society and the European Respiratory Society Publish Policy Statement on Disparities in Respiratory Health

To address the global phenomenon of disparities in respiratory health, the American Thoracic Society and the European Respiratory Society have released an official policy statement in which each pledges its commitment to reducing health disparities between the lowest and highest socioeconomic groups by continuing or initiating work with leaders from governments, academia, and other organizations to promote scientific inquiry and training, disseminate medical information and best practices, and monitor and advocate for public respiratory health.

The statement appears in the October 1 American Journal of Respiratory and Critical Care Medicine.

ATS Past President Dean Schraufnagel, MD, the senior deputy editor of the Annals of the American Thoracic Society, served as lead author of the writing committee. “Respiratory diseases disproportionately affect socioeconomically disadvantaged groups and certain ethnic groups in both the United States and Europe,” Dr. Schraufnagel says. “The morbidity and mortality associated with these disparities takes a huge toll, especially on children.”

Klaus Rabe, MD, writing committee member and a past president of ERS, continued: “The effects of health disparities in Europe on respiratory disease are very pronounced. Individuals in lower social groups are not only more likely to have respiratory diseases, but, compared with other disorders, social inequality is associated with a larger proportion of deaths from these diseases.”   

ATS and ERS efforts to address health disparities include:

• Increasing the numbers of under-represented minorities in adult and pediatric pulmonary and critical care medicine in North America.
• Raising the level of pulmonary specialist education to a uniform, high-level across the European Union.
• Support of programs that educate the public about activities such as smoking and drug-addiction and rare diseases that affect only a portion of the population to improve the access of afflicted individuals to appropriate care.
• Support of broad access of patients with respiratory disease to specialists and greater access to health care and other national programs designed to reduce health care inequalities.
• Support of comprehensive tobacco-control strategies at both the state and national level.
• Advocating for and raising awareness of the importance of clean and safe air and promoting inquiry into the effects of climate change on respiratory health.
• Developing programs to educate professionals and policy-makers to reduce disparities in respiratory health.
• Working with the World Health Organization and other societies, agencies, and organizations to eliminate disparities in respiratory health and other noncommunicable diseases.

“Addressing these inequalities is at the core of the missions of our societies,” says ATS President Patricia Finn, MD, who helped draft the policy.

Sleep Apnea is Associated with Subclinical Myocardial Injury

Obstructive sleep apnea is known to be associated with an increased incidence of cardiovascular disease. Now a new study indicates that OSA is associated with subclinical myocardial injury, as indicated by increased high sensitivity troponin T (hs-TnT) levels. Elevated hs-TnT levels are predictive of both coronary heart disease (CHD) and heart failure (HF) in the general population. This is the first study to demonstrate an independent association between sleep apnea severity and this marker of early myocardial injury.

“Although OSA is associated with increased cardiovascular risk, a causal association has been hard to establish because of the association of OSA with other risk factors,” said researcher Amil M. Shah, MD, MPH, of the Brigham and Women's Hospital in Boston. “In our study, we were able to demonstrate that greater OSA severity is independently associated with higher hs-TnT levels, suggesting a role for subclinical myocardial injury in the relationship between OSA and heart failure.”

The findings were published online ahead of print publication in the American Thoracic Society’s American Journal of Respiratory and Critical Care Medicine.

The study included 1,645 middle-aged and older participants in both the Atherosclerosis Risk in Communities and the Sleep Health Study who were free of CHD and HF at baseline. All subjects underwent overnight home polysomnography. Median follow-up was 12.4 years. OSA severity was categorized as none, mild, moderate, or severe using the respiratory disturbance index.    

Hs-TnT levels, but not N terminal pro B-type natriuretic peptide levels (a marker for increased ventricular wall stress), were significantly associated with OSA after adjustment for 17 potential confounders (p=0.02), including age, gender, body mass index, smoking status, hypertension, diabetes, alcohol intake, pulmonary function variables (FEV1 and FVC), COPD status, systolic blood pressure, total cholesterol, LDL cholesterol, HDL cholesterol, triglycerides, insulin level and estimated glomerular filtration rate (eGFR). In all OSA severity categories, hs-TnT was significantly related to the risk of death or incident heart failure, and this relationship was strongest in the severe OSA group.

Limitations of the study include its cross-sectional design, which precludes conclusions on causality, and a limited number of participants with severe OSA.

“Our results suggest a relationship between subclinical myocardial injury and the increased cardiovascular risk seen in patients with OSA,” said Dr. Shah. “Monitoring of hs-TnT levels in these patients may have prognostic value, particularly in patients with severe OSA.”