Background— There is a paucity of data from large cohort studies examining the prognostic significance of obstructive sleep apnea (OSA) in patients with coronary artery disease. We hypothesized that OSA predicts subsequent major adverse cardiac and cerebrovascular events (MACCEs) in patients undergoing percutaneous coronary intervention. Methods and Results— The Sleep and Stent Study was a prospective, multicenter registry of patients successfully treated with percutaneous coronary intervention in 5 countries. Between December 2011 and April 2014, 1748 eligible patients were prospectively enrolled. The 1311 patients who completed a sleep study within 7 days of percutaneous coronary intervention formed the cohort for this analysis. Drug-eluting stents were used in 80.1% and bioresorbable vascular scaffolds in 6.3% of the patients, and OSA, defined as an apnea-hypopnea index of ≥15 events per hour, was found in 45.3%. MACCEs, a composite of cardiovascular mortality, nonfatal myocardial infarction, nonfatal stroke, and unplanned revascularization, occurred in 141 patients during the median follow-up of 1.9 years (interquartile range, 0.8 years). The crude incidence of an MACCEs was higher in the OSA than the non-OSA group (3-year estimate, 18.9% versus 14.0%; p =0.001). Multivariate Cox regression analysis indicated that OSA was a predictor of MACCEs, with an adjusted hazard ratio of 1.57 (95% confidence interval, 1.10–2.24; P =0.013), independently of age, sex, ethnicity, body mass index, diabetes mellitus, and hypertension. Conclusions— OSA is independently associated with subsequent MACCEs in patients undergoing percutaneous coronary intervention. Evaluation of therapeutic approaches to mitigate OSA-associated risk is warranted. Clinical Trial Registration— URL: http://www.clinicaltrials.gov . Unique identifier: NCT01306526.

C a s e R e p o r t e31 I NTRO D U C TIO NOrtner's syndrome, more commonly known as cardiovocal syndrome, is a clinical entity characterised by hoarseness that is attributable to a cardiovascular disease resulting in left recurrent laryngeal nerve palsy. Ortner, in 1897, first described this syndrome in a patient with mitral stenosis and left atrial enlargement.(1) Since its first description, various underlying cardiopulmonary causes resulting in left recurrent laryngeal nerve palsy have been well documented.(2) Herein, we report the case of a patient who presented with atypicalOrtner's syndrome and painless dysphagia. CA S E R EPO RTA 68-year-old Chinese man was admitted for painless dysphagia associated with a six-month history of nausea, malnutrition, weight loss and hoarseness. Right vocal cord palsy was detected during nasoendoscopy. Physical examination revealed that the patient was severely underweight with a body mass index of 14 kg/m 2 . His blood pressure was 115/70 mmHg, and his heart rate was 70 bpm. Both the first and second heart sounds were audible, with pansystolic murmur detected at the apical region.The patient's jugular venous pressure was not elevated, but bibasal crackles were present. Chest radiography demonstrated overall cardiomegaly and signs of left atrial dilatation, as evidenced by an additional right heart border and a prominent bulge in the left heart border ( Fig. 1). The patient's resting 12-lead electrocardiography (ECG) showed sinus rhythm (Fig. 2). The P wave was notched and prolonged, with a duration of more than 110 ms. The biphasic P wave was present in leads V1and V2, with the duration of the negative phase greater than 40 ms. These ECG features are also highly suggestive of left atrial enlargement.Barium swallow revealed an external indentation of the anterior oesophagus at the level of the aortic arch, with resultant dilatation of the proximal oesophagus (Fig. 3). This was attributed to either cardiomegaly or an unfolded aorta.

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