Differential Effects of Sleep Respiratory Event Types on Heart Rate Variability: Central Apnea as the Most...

Background: Sleep-disordered breathing (SDB) is frequently accompanied by autonomic nervous system (ANS) dysfunction, which is closely associated with an increased incidence of cardiovascular diseases and elevated mortality risk. Heart rate variability (HRV) serves as a classic metric for evaluating sympathovagal balance; however, the specific impacts of four distinct types of respiratory events-obstructive apnea (OA), central apnea (CA), mixed apnea (MA), and hypopnea (HYP)-on HRV remain underinvestigated. Utilizing ultra-short-term HRV analysis, this study aimed to evaluate the immediate effects of different respiratory events on ANS function, while further exploring the modulatory roles of arousal, Apnea-Hypopnea Index (AHI) severity and sleep stages (non-rapid eye movement [NREM] vs. rapid eye movement [REM]). Methods: A total of 108 patients with SDB undergoing overnight polysomnography (PSG) were included. A total of 19,862 respiratory events, including obstructive apnea (OA), central apnea (CA), mixed apnea (MA), and hypopnea (HYP), were analyzed using 15 s ECG segments. Linear mixed-effects models (LMMs) and estimated marginal means (EMMs) with Sidak-adjusted pairwise comparisons were constructed to evaluate differences in ECG-derived features and to analyze differences between event types. Results: Central apnea (CA) was associated with significantly reduced HRV and heart rate indices, including Standard Deviation of Successive Differences (SDSD), Root Mean Square of the Successive (RMSSD), Standard Deviation 1 (SD1), and heart rate (HR), compared with other respiratory event types (all p < 0.05). Across all event types, HRV metrics exhibited consistent dynamic changes before, during, and after respiratory events (all p < 0.001), characterized by a decrease during the event followed by post-event recovery. In the interaction effect of sleep stage, SDSD was significantly lower in CA compared with both OA (estimate = -11.67, 95% CI -18.78 to -4.59, p < 0.001) and HYP (estimate = -11.38, 95% CI -18.55 to -4.20, p < 0.001) during NREM sleep. No significant differences in HRV parameters, heart rate, or QRS duration were observed between OA and HYP (all p > 0.05). Conclusions: This study is the first to elucidate the differential impacts of four distinct types of sleep respiratory events on ultra-short-term HRV, confirming that CA events exert the most profound effects on autonomic function. These findings suggest that the proportion of CA occurrences could serve as a more precise biomarker for identifying individuals at high risk for cardiovascular diseases within the SDB population.