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Noise in the signal or bad vibrations?

1193 Editorial—Rice The debate continues about whether snoring, independent of frank obstructive sleep apnea (OSA), poses risk for cardiovascular disease (CVD). Animal models show convincing data that vibrations from snoring affect the carotid artery1 via localized endothelial dysfunction2 and lead to reduced baroreceptor sensitivity.3 One human study of objectively measured snoring showed dramatically higher rates of carotid plaque in those with heavy snoring compared to those without.4 OSA has been confirmed as an independent risk factor for CVD in multiple cohorts.5-7 But snoring, which usually accompanies OSA, is not recognized as part of the known pathophysiology of OSA. The current paradigm suggests that intermittent hypoxia, fragmented sleep, and large negative intrathoracic pressure swings due to OSA lead to the development of CVD.8,9 Epidemiologic data where OSA is measured suggest that self-reported snoring without OSA is not associated with excess CVD risk,5 but longitudinal data on objectively measured snoring is nonexistent in the current literature.10 To address this gap, Marshall and colleagues11 have gone back to the original data collected as part of the Busselton Health Study in 1990. The four-channel home portable monitor used to quantify OSA utilized a microphone encased in plastic that was taped next to the participants’ larynx. Snoring events were scored based on the power spectra recorded, yielding a percentage of epochs spent snoring during the night. They also examined the time above a threshold for “loud snoring.” In this way they defined one’s exposure to snoring at baseline, to examine the long term impact of snoring on mortality, cardiovascular events, and strokes. In their fully adjusted analyses that controlled for OSA, Marshall and colleagues11 found no increase in mortality, cardiovascular events, or stroke across quartiles of their snoring severities or with any other snoring quantification. It should be noted that their earlier work showed a strong association between OSA and all-cause mortality with a greater than 6-fold fully adjusted risk of death at 17 years in those with moderate to severe OSA.12 This suggests that their characterization of disordered breathing during sleep is accurate and argues against any role for snoring leading to death, CVD, or stroke, after accounting for OSA. EDITORIAL