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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.
ImportanceSleep 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.
ObjectiveTo assess the association of PAP vs control with cardiovascular events and death in patients with sleep apnea.
Data Sources and Study SelectionMEDLINE, 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 SynthesisTwo 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 MeasuresThe 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.
ResultsThe 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 RelevanceThe 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.
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.
MeSHAcute Coronary Syndrome
Continuous Positive Airway Pressure
Sleep Apnea Syndromes
Pub Type(s)Journal Article