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Meta-Analysis of Cardiovascular Outcomes With Continuous Positive Airway Pressure Therapy in Patients With Obstructive Sleep Apnea

https://doi.org/10.1016/j.amjcard.2017.05.042Get rights and content

Obstructive sleep apnea (OSA) is associated with increased cardiovascular morbidity and mortality. Continuous positive airway pressure (CPAP) is the main treatment of OSA. The present study explores the impact of CPAP on cardiovascular outcomes. A systematic search of electronic databases for randomized controlled trials comparing CPAP with medical therapy alone in patients with OSA who reported cardiovascular outcomes of interest was performed. The main outcome was major adverse cardiac events. Other outcomes included cardiac mortality, myocardial infarction, angina pectoris, stroke, and transient ischemic attack. Fixed effect model was used in all analyses except for subgroup analysis in which the random effect DerSimonian and Laird's model was used. Four randomized controlled trials with a total of 3,780 patients were included. Compared with medical therapy alone, CPAP use was not associated with reduced risk of major adverse cardiac events (relative risk [RR] 0.94, 95% confidence interval [CI] 0.78 to 1.15, p = 0.93, I2 = 0%) except in the subgroup that wore CPAP >4 hours (RR 0.70, 95% CI 0.52 to 0.94, p = 0.02, I2 = 0%). Furthermore, no reduction in the risk of cardiac mortality (RR 1.14, 95% CI 0.66 to 1.97, p <0.36, I2 = 2%), myocardial infarction (RR 0.96, 95% CI 0.64 to 1.44, p <0.15, I2 = 47%), angina pectoris (RR 1.16, 95% CI 0.9 to 1.50, p <0.51, I2 = 0%), stroke (RR 1.01, 95% CI 0.73 to 1.38, p <0.0.86, I2 = 0%), and transient ischemic attack (RR 1.36, 95% CI 00.69 to 2.68, p <0.24, I2 = 30%) was observed. Subgroup analysis of CPAP adherence in regards to cardiac outcomes showed that CPAP use is not associated with decreased risk of heart failure (RR 0.91, 95% CI 0.50 to 1.66, p <0.55, I2 = 0%). In conclusion, compared with medical therapy alone, utilization of CPAP in patients with OSA is not associated with improved cardiac outcomes except in patients who wore it for >4 hours.

Section snippets

Methods

We searched electronic databases according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.7 Initially, a systematic review of PubMed, MEDLINE, Embase, and Cochrane Central Register of Controlled Trials, without any language restriction, was performed from inception through December 2016. We used the following keywords: “apnea, obstructive sleep”; “CPAP ventilation”; and “assessments, outcomes” (Figure 1). After eligible trials were retrieved, we

Results

As outlined in Figure 1, our initial electronic database search yielded 680 articles. On further screening, 4 RCTs met our eligibility12, 13, 14, 15 criteria with a total of 3,780 subjects. All trials enrolled exclusively patients with OSA. The primary outcome in all trials was MACE. The weighted mean age was 61 years and 74% were men. The weighted mean Apnea Hypopnea Index was 33.75. Details about the trials' characteristics and patients' baseline demographics are summarized in Table 1.

The

Discussion

In this meta-analysis of 4 multicenter RCTs12, 13, 14, 15 with 3,780 patients, we demonstrated that the use of CPAP therapy in patients with moderate to severe OSA was not associated with improved cardiovascular outcomes compared with general care alone, at a mean follow up of 4 years. This may be because average CPAP usage achieved in most trials has not been sufficient to translate into measurable cardiovascular and/or mortality benefit. It is estimated that 20% to 40% of patients do not use

Disclosures

Dr. Lal has received grant support from Jazz and Invado Pharmaceuticals and is on the advisory board for Cipla. This work was not supported by such grants. The other authors have no conflicts of interest to disclose.

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Abuzaid and Al Ashry contributed equally to this manuscript.

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