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Association of Positive Airway Pressure With Cardiovascular Events and Death in Adults With Sleep Apnea: A Systematic Review and Meta-analysis.
JAMA 2017; 318(2):156-166JAMA

Abstract

Importance

Sleep apnea (obstructive and central) is associated with adverse cardiovascular risk factors and increased risks of cardiovascular disease. Positive airway pressure (PAP) provides symptomatic relief, whether delivered continuously (CPAP) or as adaptive servo-ventilation (ASV), but the associations with cardiovascular outcomes and death are unclear.

Objective

To assess the association of PAP vs control with cardiovascular events and death in patients with sleep apnea.

Data Sources and Study Selection

MEDLINE, EMBASE, and the Cochrane Library were systematically searched from inception date to March 2017 for randomized clinical trials that included reporting of major adverse cardiovascular events or deaths.

Data Extraction and Synthesis

Two authors independently extracted data using standardized forms. Summary relative risks (RRs), risk differences (RDs) and 95% CIs were obtained using random-effects meta-analysis.

Main Outcomes and Measures

The main outcomes were a composite of acute coronary syndrome (ACS) events, stroke, or vascular death (major adverse cardiovascular events); cause-specific vascular events; and death.

Results

The analyses included data from 10 trials (9 CPAP; 1 ASV) of patients with sleep apnea (N = 7266; mean age, 60.9 [range, 51.5 to 71.1] years; 5847 [80.5%] men; mean [SD] body mass index, 30.0 [5.2]. Among 356 major adverse cardiovascular events and 613 deaths recorded, there was no significant association of PAP with major adverse cardiovascular events (RR, 0.77 [95% CI, 0.53 to 1.13]; P = .19 and RD, -0.01 [95% CI, -0.03 to 0.01]; P = .23), cardiovascular death (RR, 1.15 [95% CI, 0.88 to 1.50]; P = .30 and RD -0.00 [95% CI, -0.02 to 0.02]; P = .87), or all-cause death (RR, 1.13 [95% CI, 0.99 to 1.29]; P = .08 and RD, 0.00 [95% CI, -0.01 to 0.01]; P = .51). The same was true for ACS, stroke, and heart failure. There was no evidence of different associations for CPAP vs ASV (all P value homogeneity >.24), and meta-regressions identified no associations of PAP with outcomes for different levels of apnea severity, follow-up duration, or adherence to PAP (all P values > .13).

Conclusions and Relevance

The use of PAP, compared with no treatment or sham, was not associated with reduced risks of cardiovascular outcomes or death for patients with sleep apnea. Although there are other benefits of treatment with PAP for sleep apnea, these findings do not support treatment with PAP with a goal of prevention of these outcomes.

Authors+Show Affiliations

Department of Cardiology, Peking University Third Hospital, Key Laboratory of Cardiovascular Molecular Biology and Regulatory Peptides, Ministry of Health, Key Laboratory of Molecular Cardiovascular Sciences, Ministry of Education, Beijing, People's Republic of China2The George Institute for Global Health, Faculty of Medicine, UNSW Sydney, Sydney, New South Wales, Australia.The George Institute for Global Health, Faculty of Medicine, UNSW Sydney, Sydney, New South Wales, Australia3Department of Radiology, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, People's Republic of China.Adelaide Institute for Sleep Health, Flinders University, Adelaide, South Australia, Australia.The George Institute for Global Health, Faculty of Medicine, UNSW Sydney, Sydney, New South Wales, Australia5The George Institute China, Peking University Health Science Center, Beijing, People's Republic of China6Neurology Department, Royal Prince Alfred Hospital, Sydney Health Partners, Sydney, New South Wales, Australia.The George Institute for Global Health, Faculty of Medicine, UNSW Sydney, Sydney, New South Wales, Australia.The George Institute for Global Health, Faculty of Medicine, UNSW Sydney, Sydney, New South Wales, Australia.The George Institute for Global Health, Faculty of Medicine, UNSW Sydney, Sydney, New South Wales, Australia7The Charles Perkins Centre, University of Sydney, Sydney, New South Wales, Australia8Division of Epidemiology and Biostatistics, Imperial College London, London, United Kingdom.

Pub Type(s)

Journal Article
Meta-Analysis
Review
Systematic Review

Language

eng

PubMed ID

28697252

Citation

Yu, Jie, et al. "Association of Positive Airway Pressure With Cardiovascular Events and Death in Adults With Sleep Apnea: a Systematic Review and Meta-analysis." JAMA, vol. 318, no. 2, 2017, pp. 156-166.
Yu J, Zhou Z, McEvoy RD, et al. Association of Positive Airway Pressure With Cardiovascular Events and Death in Adults With Sleep Apnea: A Systematic Review and Meta-analysis. JAMA. 2017;318(2):156-166.
Yu, J., Zhou, Z., McEvoy, R. D., Anderson, C. S., Rodgers, A., Perkovic, V., & Neal, B. (2017). Association of Positive Airway Pressure With Cardiovascular Events and Death in Adults With Sleep Apnea: A Systematic Review and Meta-analysis. JAMA, 318(2), pp. 156-166. doi:10.1001/jama.2017.7967.
Yu J, et al. Association of Positive Airway Pressure With Cardiovascular Events and Death in Adults With Sleep Apnea: a Systematic Review and Meta-analysis. JAMA. 2017 Jul 11;318(2):156-166. PubMed PMID: 28697252.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Association of Positive Airway Pressure With Cardiovascular Events and Death in Adults With Sleep Apnea: A Systematic Review and Meta-analysis. AU - Yu,Jie, AU - Zhou,Zien, AU - McEvoy,R Doug, AU - Anderson,Craig S, AU - Rodgers,Anthony, AU - Perkovic,Vlado, AU - Neal,Bruce, PY - 2017/7/12/entrez PY - 2017/7/12/pubmed PY - 2017/7/20/medline SP - 156 EP - 166 JF - JAMA JO - JAMA VL - 318 IS - 2 N2 - Importance: Sleep apnea (obstructive and central) is associated with adverse cardiovascular risk factors and increased risks of cardiovascular disease. Positive airway pressure (PAP) provides symptomatic relief, whether delivered continuously (CPAP) or as adaptive servo-ventilation (ASV), but the associations with cardiovascular outcomes and death are unclear. Objective: To assess the association of PAP vs control with cardiovascular events and death in patients with sleep apnea. Data Sources and Study Selection: MEDLINE, EMBASE, and the Cochrane Library were systematically searched from inception date to March 2017 for randomized clinical trials that included reporting of major adverse cardiovascular events or deaths. Data Extraction and Synthesis: Two authors independently extracted data using standardized forms. Summary relative risks (RRs), risk differences (RDs) and 95% CIs were obtained using random-effects meta-analysis. Main Outcomes and Measures: The main outcomes were a composite of acute coronary syndrome (ACS) events, stroke, or vascular death (major adverse cardiovascular events); cause-specific vascular events; and death. Results: The analyses included data from 10 trials (9 CPAP; 1 ASV) of patients with sleep apnea (N = 7266; mean age, 60.9 [range, 51.5 to 71.1] years; 5847 [80.5%] men; mean [SD] body mass index, 30.0 [5.2]. Among 356 major adverse cardiovascular events and 613 deaths recorded, there was no significant association of PAP with major adverse cardiovascular events (RR, 0.77 [95% CI, 0.53 to 1.13]; P = .19 and RD, -0.01 [95% CI, -0.03 to 0.01]; P = .23), cardiovascular death (RR, 1.15 [95% CI, 0.88 to 1.50]; P = .30 and RD -0.00 [95% CI, -0.02 to 0.02]; P = .87), or all-cause death (RR, 1.13 [95% CI, 0.99 to 1.29]; P = .08 and RD, 0.00 [95% CI, -0.01 to 0.01]; P = .51). The same was true for ACS, stroke, and heart failure. There was no evidence of different associations for CPAP vs ASV (all P value homogeneity >.24), and meta-regressions identified no associations of PAP with outcomes for different levels of apnea severity, follow-up duration, or adherence to PAP (all P values > .13). Conclusions and Relevance: The use of PAP, compared with no treatment or sham, was not associated with reduced risks of cardiovascular outcomes or death for patients with sleep apnea. Although there are other benefits of treatment with PAP for sleep apnea, these findings do not support treatment with PAP with a goal of prevention of these outcomes. SN - 1538-3598 UR - https://www.unboundmedicine.com/medline/citation/28697252/Association_of_Positive_Airway_Pressure_With_Cardiovascular_Events_and_Death_in_Adults_With_Sleep_Apnea:_A_Systematic_Review_and_Meta_analysis_ L2 - https://jamanetwork.com/journals/jama/fullarticle/10.1001/jama.2017.7967 DB - PRIME DP - Unbound Medicine ER -