Abstract Body: Background: Heart failure (HF) remains a leading cause of morbidity and mortality in the United States, with obstructive sleep apnea (OSA) increasingly recognized as a prevalent comorbidity that may exacerbate hemodynamic stress, sympathetic activation, and adverse cardiovascular outcomes. Although OSA affects a large proportion of individuals with HF, it remains underdiagnosed and undertreated. Despite this growing awareness, national mortality trends and disparities in HF-related deaths involving OSA have not been comprehensively characterized.

Hypothesis: We hypothesized that mortality from HF with comorbid OSA has increased over the past two decades and varies significantly by sex, race, urbanization level, and geographic region.

Methods: Mortality records from the CDC WONDER database were analyzed for 7,414 individuals aged >35 years between 1999 and 2020. HF (ICD-10 codes I11.0, I13.0, I13.2, I50) was designated as the underlying cause of death, and OSA (ICD-10 code G47.3) was identified as a contributing cause. Age-adjusted mortality rates (AAMRs) per 1,000,000 population were calculated. Temporal trends were evaluated using Joinpoint regression to estimate the annual percent change (APC).

Results: From 1999 to 2020, the AAMR for HF deaths with OSA increased from 0.7 (95% CI, 0.5–0.8) to 4.4 (95% CI, 4.1–4.7), with an APC of 8.9% (p < 0.001). Cumulative AAMR was higher among males (2.6 [95% CI, 2.5–2.6]) than females (1.5 [95% CI, 1.4–1.5]). By race, African American individuals had the highest AAMR (3.8 [95% CI, 3.6–4.0]), followed by Whites (1.8 [95% CI, 1.7–1.8]), American Indians (1.3 [95% CI, 0.9–1.8]), and Asians (0.5 [95% CI, 0.4–0.6]). Large-fringe metropolitan areas had the lowest AAMR (1.6 [95% CI, 1.5–1.7]), while small-metropolitan (2.3 [95% CI, 2.1–2.4]) and micropolitan-rural (2.3 [95% CI, 2.2–2.5]) areas had the highest. Among U.S. regions, the Midwest and West showed the greatest AAMRs (2.3 [95% CI, 2.2–2.4]), followed by the South (1.9 [95% CI, 1.8–2.0]) and Northeast (1.3 [95% CI, 1.2–1.4]).

Conclusions: Mortality from heart failure with comorbid OSA has increased substantially since 1999, with a disproportionate burden among males, African American individuals, rural communities, and residents of the Midwest and West. These findings underscore the need for integrated strategies that address OSA diagnosis and management in patients with HF, with attention to equity-focused interventions across underserved regions.