Published date: July 28, 2025
Professor Winfried Randerath is active at the Bethanien Hospital in Solingen, Germany and has for years been one of the leading experts within the European sleep world. He is frequently engaged as a speaker and is appreciated for his ability to structure, clarify and tie topics together. He has long held a leading role in the guideline work for the European Respiratory Society and the Baveno classification, the work discussed in this interview and one of his initiatives aimed at structuring and improving sleep care.
Prof. Randerath: In the town of Baveno, sleep physicians from across Europe joined think tanks focused on important topics in sleep medicine to advance research and care, answering questions like, “Where do we stand today?” or “In which direction and how can we move forward?”
In one such think tank meeting in which I participated focused on the reliance on the apnea-hypopnea index (AHI) as a single parameter for stratifying the severity of obstructive sleep apnea (OSA) and determining the associated need to treat. We felt this simple view of the occurrence of respiratory events was too narrow and failed to reflect the full clinical picture and therefore does not do justice to patients. So, we put forth the idea of further development in the form of an expanded view based on multiple factors.
Prof. Randerath: Yes, this colored scheme was deliberately developed with the intention of making it as simple as possible, using this traffic light scheme we all know from many contexts. As the criteria now contains more fields—nine compared to four in the first version—this scheme is a little more complex, but the visual red-yellow-green designations can aid its use in everyday situations. The reality in our clinical day-to-day work, which we saw in the retrospective study, is that only a small portion of the clinical population falls into the green section, i.e. the group for which we would say that therapy makes no sense at that point.
The majority of patients fall into the red group where treatment is clearly indicated. These tend to be the patients with an AHI over 30 and who have established pre-existing conditions. Beyond that, around 20% of patients land in the so-called yellow group, those patients for whom the decision on treatment is left to the joint discretion of the doctor and patient.
Prof. Randerath: The first draft of the Baveno classification simply identified at-risk patients based on the presence of poorly controlled blood pressure, atrial fibrillation or heart failure. We then realized this was too general and needed to make it more precise. So, we looked at how the established scheme of the European Society of Cardiology (ESC) approaches risk and developed an updated multistep system for the modified Baveno classification
On the one hand, we have patients who have already experienced cardiac events or have established diseases—they have already suffered a heart attack or have severe hypertension or heart failure. These patients are automatically in a high-risk group.
Then we have patients who do not fall into this category, but who have other risk factors that indicate the potential to develop cardiac disease over the next 10 years. This is how the ESC guideline proceeds, using the SCORE2 -OP that factors in cardiovascular risk and age. We adapted the categorization, which enables individual risk assessment.
This means that for patients who do not yet have any established pre-existing conditions, we look at this constellation, the SCORE2-OP, which includes factors such as smoking, diabetes, hypertension, body weight, gender and, as a result, presents a certain probability, which then tells us whether we have a moderate risk or a high risk of suffering a cardiovascular event in the next 10 years. And that's how we classify the patients.
SCORE, Systematic Coronary Risk Evaluation, includes both SCORE2 and SCORE2-OP. These are risk prediction algorithms with recommendations for physicians and patients from the 2021 European Society of Cardiology (ESC) Guidelines on Cardiovascular Disease (CVD) Prevention in Clinical Practice.
SCORE2 is used for patients with no known cardiovascular disease or diabetes between 40 – 69 years of age. It incorporates age, sex, smoking status, cholesterol levels and office blood pressure as well as differences in cardiovascular risk between European countries. SCORE2 was converted into Baveno risk level 1 – 3.
SCORE2-OP is a modified version for persons ≥70 years of age.
Prof. Randerath: The three key symptoms are sleepiness, insomnia and fatigue. When it comes to sleepiness, we must not forget that about half of patients may only experience mild sleepiness, be completely asymptomatic or have insomnia, the inability to sleep. In these patients, the focus should be on disturbed sleep characterized not by difficulty falling asleep but rather by difficulty maintaining sleep. In other words, they wake up and cannot fall asleep again. The Epworth Sleepiness Scale or an evaluated insomnia questionnaire can allow a quantified risk assessment using numerical values.
In everyday clinical practice, for decision-making between doctors and patients, I think you can be much more liberal. If the patient complains of sleepiness—that they’re always sleepy or fall asleep at every opportunity—or if they complain of not being able to maintain stable sleep, then that would certainly be enough as a symptom to then discuss the adequate treatment.
This article is the first in a set from our conversation with Professor Randerath. To continue, read “The role of AHI in the modified Baveno classification”.
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