Part 2: Symptoms and comorbidities in the Swedish treatment matrix

In this interview, Professor Grote explores how symptoms are assessed within the Swedish treatment matrix, the management of non-sleepy patients and the nuances of sex differences in obstructive sleep apnea (OSA). He also highlights the role of comorbidities in guiding treatment.

Q: In the Swedish guidelines, symptoms are reviewed alongside the apnea-hypopnea index (AHI) as criteria in diagnosing and stratifying OSA. How are symptoms evaluated?

Professor Grote: Most clinics use questionnaires that cover important symptoms, but there is no national or centralized standard. Healthcare providers reporting to the Swedish sleep apnea registry (SESAR) have called for a unified Swedish OSA questionnaire, and we are now working on defining or developing one.

The Sleep Revolution project is also contributing by developing a European Sleep Questionnaire to comprehensively assess different components of sleep health and capture the “bothersomeness” of symptoms from the patient’s perspective. This is an important step toward better identifying treatable traits in OSA patients.

Properly evaluating symptoms requires time for an in-depth patient interview. Some clinics avoid this and improve their accessibility, while those who take the time for detailed assessments often face longer waiting times. Accessibility is definitely a significant challenge, but personalized medicine requires this depth, even if it means waiting longer.

Questionnaires like the European Sleep Questionnaire, when combined with good visualization of results, may help strike a balance.

Q. There are ongoing discussions in the sleep community about non-sleepy patients with OSA. Would these patients be treated or not with the new Swedish matrix?

Professor Grote: The matrix requires thorough symptom assessment. Yes, everyone deserves a better quality of life, better sleep and better daytime functioning. But if symptoms are absent or unclear, the indication for treatment becomes weaker.

In practice, however, more non-sleepy patients are actually being treated, possibly because of non-comprehensive coverage of the Epworth Sleepiness Scale, or because of growing societal awareness of sleep health. With so many sleep monitoring apps and devices, and papers, articles and reports emphasizing sleep and snoring risks, more non-sleepy individuals are seeking medical help due to concern about their sleep health status.

It is also possible that our tools and practice miss important symptoms, since there is still no standardization in questionnaires.

Q. Women with OSA often present with lower AHI values and different symptom profiles than men. How does the Swedish matrix account for these differences?

Professor Grote: This is likely a weakness of our work so far. We have not fully addressed or emphasized sex differences in symptomatology, and they are not covered in the matrix.

That said, the matrix does not exclude any symptom profile. It does not explicitly differentiate between men and women, but it does make clear that symptom assessment must be individualized. In this sense, it is open enough to accommodate different presentations and just provides a framework for clinicians on how to think about diagnosis and management.

Importantly, we avoid labeling women’s symptoms as “atypical” because they make up half, or even more, of the population. Evidence on how to tailor treatment by sex is still limited, so further efforts are needed to avoid the misperception of treatable traits.

Q. How accurately do you think women report their symptoms? Do you find they are generally aware of OSA symptoms, or do you need to dig more deeply when you meet them?

Professor Grote: I have a selection bias because the women I meet have been referred for evaluation to our tertiary sleep center. We also accept a lot of women for consultation based on well-prepared self-referrals without requiring a primary care visit. We keep the threshold low and focus on the initial help request and the degree of symptom troublesomeness for the individual patient.

So, among women who reach evaluation, it is not difficult to uncover their symptoms. The challenge is in determining, with mild OSA, what the cause of the problem is, and it is often multifactorial.

Q. OSA risk increases after menopause, yet the Swedish matrix deprioritizes patients over 65. Does this mean post-menopausal women may not receive treatment?

Professor Grote: There is currently a lot of discussion about post-menopausal women with OSA and their increased risk of ischemic heart disease. This is an important topic, and in the matrix, we tried to mirror the evidence available today.

For example, if a woman over 65 has difficult-to-treat hypertension but no OSA symptoms, then hypertension itself becomes the main treatment indication and could be classified as “red” in the matrix. Blood pressure must then be followed up closely. But if symptoms from the OSA-related spectrum are present alongside the harder-to-control blood pressure, our matrix clearly suggests a treatment indication, for example with positive airway pressure (PAP) therapy or mandibular advancement treatment.

I am not aware that PAP therapy offers stronger primary or secondary prevention in women compared to men, and this understanding shaped our decisions. The guideline makes clear that if cardiovascular risk reduction is the main treatment goal, this risk profile should be re-evaluated after 6–12 months. If high PAP therapy use does not improve blood pressure or symptoms, then the rationale for continuing PAP therapy must be reconsidered in that case. That said, in many situations, OSA treatment does provide clear benefits for blood pressure and sleep health.

Q. In the Swedish treatment matrix, you prioritize based on controlled or uncontrolled cardiometabolic comorbidities. Which conditions are given higher priority, and why?

Professor Grote: We prioritized conditions based on the strength of their causal relationship with OSA and the benefits of OSA treatment for them.

Hypertension is listed first, as its association with OSA is the strongest. This is followed by heart failure, atrial fibrillation and stroke, which also have very strong associations. Diabetes and hyperlipidemia are included, though the evidence is less solidly established. Obesity is both a risk factor and a complication, and we know that many sleep apnea patients continue to gain weight even under treatment.

Psychiatric comorbidities are mentioned in the guidelines, but the evidence on the causal relationship to OSA and the treatment effects of CPAP is on the weaker side. We also missed the opportunity to fully address chronic obstructive pulmonary disorder (COPD) overlap, which is very important.

Q. Since comorbidities strongly influence treatment decisions, how should this information be collected most efficiently? Should investigations be led by the sleep physician, or done in collaboration with primary care and cardiology?

Professor Grote: It depends on who is primarily responsible for the referral. Hypertension is usually managed in primary care, while some patients come directly from cardiologists. Sleep centers cannot perform all the types of comorbidity assessments required, but they should try to collect information on them. At a minimum, documentation of these factors and results should be required.

Sleep recordings can also uncover previously undiagnosed conditions. Central sleep apnea may point to heart failure, an irregular nocturnal pulse can indicate atrial fibrillation, and profound nocturnal hypoxia may be caused by COPD. In such cases, the sleep center should refer the patient to the appropriate specialist.

To learn more about the Swedish treatment matrix¹ and how it has been received by physicians and sleep medicine specialists, read the first part of this three-part interview series with Professor Ludger Grote.