Highlight
1. Low arousal threshold (ArTH) is a common pathophysiological endotype in obstructive sleep apnea (OSA) linked to poor adherence to positive airway pressure therapy and now shown to predict hypoglossal nerve stimulation (HGNS) discontinuation.
2. Patients with low ArTH demonstrated a significantly higher rate of transition from adherence at 3 months to nonadherence at 6 months of HGNS therapy.
3. The pattern of disengagement in low ArTH patients reflects missed nights rather than decreased nightly usage or intolerance.
4. Preoperative ArTH endotyping may facilitate personalized counseling and interventions to improve HGNS adherence and clinical outcomes in OSA.
