Adherence to CPAP Treatment and the Risk of Recurrent Cardiovascular Events: A Meta-Analysis

Effect of CPAP Treatment on Cardiovascular Outcomes

INTRODUCTION

Randomized controlled trials (RCT) have not demonstrated a role for continuous positive airway pressure (CPAP) on the secondary prevention of major cardiovascular events in obstructive sleep apnea (OSA) patients. However, participants in RCTs are substantially different from real-world patients. Therefore, we aimed to assess the effect of CPAP treatment on major cardiovascular events in real-world OSA patients.

METHODS

Population-based longitudinal observational study including all OSA patients with an active CPAP prescription at the beginning of 2011 in Catalonia, Spain, that terminated CPAP treatment during 2011 and did not have CPAP prescriptions between 2012-2015; and propensity-score-matched OSA patients that continued CPAP treatment until the end of 2015 or death. Adjusted hazard ratios were used to assess the association between CPAP treatment and overall and cardiovascular mortality, cardiovascular hospitalizations, or major adverse cardiovascular events (MACEs).

RESULTS

3638 CPAP terminators and 10,914 propensity-score-matched continuators were included (median age 67 [57-77] years, 71.4% male). During a median follow-up of 47.9 months CPAP continuators showed a lower risk of cardiovascular death than terminators (hazard ratio [HR]: 0.61; 95% confidence interval [CI]: 0.50-0.75) after adjusting by age, sex and key comorbidities. Similar results were found for cardiovascular hospitalizations (HR: 0.87; 95% CI: 0.76-0.99) and MACEs (HR: 0.84; 95% CI: 0.75-0.95).

CONCLUSION

CPAP treatment continuation could be associated with a significantly lower risk of major cardiovascular events in real-world OSA patients. This result highlights the importance of including real-world patients in studies on OSA.

The impact of continuous positive airway pressure therapy on cardiovascular events in patients with obstructive sleep apnoea: an updated systematic review and meta-analysis

OBJECTIVE

Obstructive sleep apnoea (OSA) is positively associated with cardiovascular diseases, and continuous positive airway pressure (CPAP) is a common treatment for such patients. This study aimed to explore the impact of CPAP on cardiovascular outcomes and prognosis in patients with OSA.

METHODS

A search was conducted in the PubMed, Embase and CENTRAL databases for relevant studies published up to March 2024. Two independent reviewers screened the studies based on inclusion and exclusion criteria, and data were synthesised using RevMan 5.3 software. Heterogeneity was assessed using the Cochran Q test and the I2 statistic.

RESULTS

A total of 10 randomised controlled trials and 3 observational studies, comprising 13,832 patients, were included. Compared with standard treatment, the use of CPAP did not significantly reduce the risk of major adverse cardiovascular events (MACE) (risk ratio [RR]: 0.73, 95% confidence interval [CI]: 0.52-1.03; p = 0.07; I2 = 66%), all-cause mortality (RR: 0.92, 95% CI: 0.72-1.16; p = 0.48; I2 = 0%), cardiovascular mortality (RR: 0.63, 95% CI: 0.33-1.19; p = 0.15; I2 = 70%) or non-cardiovascular mortality (RR: 0.81, 95% CI: 0.57-1.15; p = 0.23; I2 = 0%). Similarly, there were no significant differences in the incidence of myocardial infarction, stroke, hospitalisation due to unstable angina or heart failure or atrial fibrillation among those using CPAP. However, when CPAP adherence was ≥ 4 h, CPAP significantly reduced the risk of MACE and cardiovascular mortality.

CONCLUSION

Although CPAP's cardiovascular benefits in patients with OSA are not confirmed, it may be that bias risks, CPAP adherence and characteristics of the study population may attenuate the perceived benefits of CPAP. Further research is needed to optimise CPAP therapy.

Treatment of OSA and its Impact on Cardiovascular Disease, Part 2: JACC State-of-the-Art Review

Many studies have shown an association of obstructive sleep apnea (OSA) with incident cardiovascular diseases, particularly when comorbid with insomnia, excessive sleepiness, obesity hypoventilation syndrome, and chronic obstructive pulmonary disease. Randomized controlled trials (RCTs) have demonstrated that treatment of OSA with positive airway pressure devices (CPAP) improves systemic hypertension, particularly in those with resistant hypertension who are adherent to CPAP. However, large RCTs have not shown long-term benefits of CPAP on hard cardiovascular outcomes, but post hoc analyses of these RCTs have demonstrated improved hard outcomes in those who use CPAP adequately. In theory, low CPAP adherence and patient selection may have contributed to neutral results in intention-to-treat analyses. Only by further research into clinical, translational, and basic underlying mechanisms is major progress likely to continue. This review highlights the various treatment approaches for sleep disorders, particularly OSA comorbid with various other disorders, the potential reasons for null results of RCTs treating OSA with CPAP, and suggested approaches for future trials.

Predicting the risk of cardiovascular and cerebrovascular event in systemic lupus erythematosus: a Chinese SLE treatment and research group study XXVI

OBJECTIVE

Patients with systemic lupus erythematosus (SLE) have an increased risk of cardiovascular and cerebrovascular events (CCEs). Furthermore, CCE was a significant factor contributing to mortality in patients with SLE. However, no clinical model exists that can predict which patients are at high risk. The purpose of this study was to develop a practical model for predicting the risk of CCE in people with SLE.

METHODS

This study was based on the Chinese SLE Treatment and Research Group cohort. A total of 2399 patients, who had a follow-up period of over 3 years and were diagnosed with SLE for less than 1 year at the start of the study, were included. Cox proportional hazards regression and least absolute shrinkage and selection operator regression were used to establish the model. Internal validation was performed, and the predictive power of the model was evaluated.

RESULTS

During the follow-up period, 93 patients had CCEs. The prediction model included nine variables: male gender, smoking, hypertension, age of SLE onset >40, cutaneous involvement, arthritis, anti-β2GP1 antibody positivity, high-dose glucocorticoids and hydroxychloroquine usage. The model's C index was 0.801. Patients with a prognostic index over 0.544 were classified into the high-risk group.

CONCLUSION

We have developed a predictive model that uses clinical indicators to assess the probability of CCE in patients diagnosed with SLE. This model has the ability to precisely predict the risk of CCE in patients with SLE. We recommended using this model in the routine assessment of patients with SLE.

Influence of Comorbidity and Obesity on the Occurrence of Vascular Events in Obstructive Apnoea Treated with CPAP

BACKGROUND

Obesity has increased cardiovascular morbidity and mortality. It is the leading risk factor for obstructive sleep apnoea (OSA). The relationship between obesity-OSA and vascular disease seems clear. There is no consensus on whether CPAP (continuous positive airway pressure) treatment prevents vascular events.

OBJECTIVE

The aim of this study was to determine the effect of comorbidity and obesity on the risk of vascular events in patients with OSA treated with CPAP.

METHOD

This study was a prospective study of historical cohorts of adult patients with OSA and CPAP. The sample was 3017 patients. Descriptive, survival (Kaplan-Meier) and Cox regression analyses were performed, calculating crude and adjusted association relationships to explain the risk of vascular events.

RESULTS

A total of 1726 patients were obese, 782 were diabetics, and 1800 were hypertensive. The mean adherence was 6.2 (±1.8 h/day), and the mean follow-up time was 2603 days (±953.3). In the COX regression analysis, the event-related variables were baseline age (HR: 1.025: 1.012-1.037; p < 0.001), pre-treatment vascular event (HR; 2.530: 1.959-3.266; p < 0.001), hypertension (HR; 1.871: 1.187-2.672; p = 0.005) and abbreviated Charlson comorbidity index (HR; 1.289: 1.100-1.510; p = 0.002).

CONCLUSIONS

The occurrence of vascular events in OSA patients on CPAP treatment is related to hypertension, having a vascular event before treatment, age at the start of CPAP use and abbreviated Charlson comorbidity index.

Positive Airway Pressure, Mortality, and Cardiovascular Risk in Older Adults With Sleep Apnea

Importance

Positive airway pressure (PAP) is the first-line treatment for obstructive sleep apnea (OSA), but evidence on its beneficial effect on major adverse cardiovascular events (MACE) and mortality prevention is limited.

Objective

To determine whether PAP initiation and utilization are associated with lower mortality and incidence of MACE among older adults with OSA living in the central US.

Design, Setting, and Participants

This retrospective clinical cohort study included Medicare beneficiaries with 2 or more distinct OSA claims identified from multistate, statewide, multiyear (2011-2020) Medicare fee-for-service claims data. Individuals were followed up until death or censoring on December 31, 2020. Analyses were performed between December 2021 and December 2023.

Exposures

Evidence of PAP initiation and utilization based on PAP claims after OSA diagnosis.

Main Outcomes and Measures

All-cause mortality and MACE, defined as a composite of myocardial infarction, heart failure, stroke, or coronary revascularization. Doubly robust Cox proportional hazards models with inverse probability of treatment weights were used to estimate treatment effect sizes controlling for sociodemographic and clinical factors.

Results

Among 888 835 beneficiaries with OSA included in the analyses (median [IQR] age, 73 [69-78] years; 390 598 women [43.9%]; 8115 Asian [0.9%], 47 122 Black [5.3%], and 760 324 White [85.5%] participants; median [IQR] follow-up, 3.1 [1.5-5.1] years), those with evidence of PAP initiation (290 015 [32.6%]) had significantly lower all-cause mortality (hazard ratio [HR], 0.53; 95% CI, 0.52-0.54) and MACE incidence risk (HR, 0.90; 95% CI, 0.89-0.91). Higher quartiles (Q) of annual PAP claims were progressively associated with lower mortality (Q2 HR, 0.84; 95% CI, 0.81-0.87; Q3 HR, 0.76; 95% CI, 0.74-0.79; Q4 HR, 0.74; 95% CI, 0.72-0.77) and MACE incidence risk (Q2 HR, 0.92; 95% CI, 0.89-0.95; Q3 HR, 0.89; 95% CI, 0.86-0.91; Q4 HR, 0.87; 95% CI, 0.85-0.90).

Conclusions and Relevance

In this cohort study of Medicare beneficiaries with OSA, PAP utilization was associated with lower all-cause mortality and MACE incidence. Results might inform trials assessing the importance of OSA therapy toward minimizing cardiovascular risk and mortality in older adults.

Phenotypes of obstructive sleep apnea in women: A real-life cohort study

OBJECTIVE

Obstructive sleep apnea (OSA) is a complex, heterogeneous disease. Categorizing the disorder into phenotypes can help us better understand its pathology and guide us toward more personalized treatment approaches. Nevertheless, most of the previous cluster analysis (CA) studies in OSA predominantly included middle-aged to older men and may not adequately represent the heterogeneity of OSA phenotypes in women. Our aim is to identify these phenotypes in women using an extensive, exclusively female cohort.

METHODS

Cross-sectional study of 1886 women diagnosed with OSA (apnea-hypopnea index >5 events/h) by PSG (polysomnography) and RP (respiratory polygraphy) at a tertiary hospital Sleep Unit. A CA was performed including general data, clinical variables, comorbidities and sleep study results.

RESULTS

Four phenotypic subtypes were identified: Cluster 1 "Middle-aged paucisymptomatic women without cardiovascular risk factors" (507 patients, 27 %); Cluster 2 "Older paucisymptomatic women with established cardiovascular disease and severe OSA" (228 patients, 12 %); Cluster 3 "Middle-aged women with "classic" symptoms and cardiovascular risk factors" (892 patients, 47 %), and Cluster 4 ″Middle-aged women with mood disorders, nonrestorative sleep and cardiovascular risk factors" (259 patients, 14 %).

CONCLUSIONS

Conducting a CA exclusively within a female cohort reveals a heterogeneous presentation of OSA in women, similar to what has been previously reported in the literature for men. The "classical" presentation is notably the most prevalent, while the "atypical" presentation, which was previously more frequently associated with women, is less prevalent. Additionally, paucisymptomatic presentations, with or without associated comorbidities, are also present.

Educational video demonstrating collapsibility of the upper airway during sleep improves initial acceptance of CPAP in patients with severe obstructive sleep apnea: a retrospective study

STUDY OBJECTIVES

We investigated whether an audiovisual educational video demonstrating collapsibility of the upper airway during sleep would influence initial continuous positive airway pressure (CPAP) acceptance among patients with severe obstructive sleep apnea.

METHODS

Between January 2017 and December 2018, a single-center retrospective study was conducted. We implemented an educational video demonstrating upper airway collapsibility during sleep in February 2018. We analyzed the medical records from 145 consecutive patients diagnosed with severe obstructive sleep apnea who underwent in-laboratory polysomnography both before and after implementing the educational video. Among them, 76 patients received standard care before the video's introduction (standard care group), and another 69 patients were managed after its implementation (video group).

RESULTS

Baseline characteristics including age, body mass index, educational level, occupation category, comorbidities, Mallampati score, Epworth Sleepiness Scale score, apnea-hypopnea index, and sleep time with SpO2 below 90% were not significantly different between the 2 groups. Acceptance of CPAP following an in-laboratory overnight titration study was significantly higher in the video group (80%) than in the standard care group (57%) (P = .003). Multivariate regression analyses revealed that watching the video was a strong predictor of initial CPAP acceptance (odds ratio, 4.162; 95% confidence interval, 1.627-10.646; P = .004). Both sleep time with SpO2 below 90% (odds ratio, 1.020; 95% confidence interval, 1.002-1.038; P = .029) and sleep efficiency (odds ratio, 1.052; 95% confidence interval, 1.023-1.083; P < .001) were weak predictors for initial CPAP acceptance. At 12 months, adherence among those who accepted the CPAP treatment was similar between the 2 groups (78% vs 74%; P = .662). However, within the initial cohorts, a significantly higher proportion of patients in the video group (62%) were using CPAP at 12 months compared with the standard care group (42%) (P = .015).

CONCLUSIONS

Among patients with severe obstructive sleep apnea, an educational video demonstrating upper airway collapsibility during sleep improved initial CPAP acceptance rates when compared with standard care.

CITATION

Tselepi C, Tsirves G, Exarchos K, et al. Educational video demonstrating collapsibility of the upper airway during sleep improves initial acceptance of CPAP in patients with severe obstructive sleep apnea: a retrospective study. J Clin Sleep Med. 2024;20(9):1423-1433.

Sex differences in sleep and sleep-disordered breathing

PURPOSE OF REVIEW

There is increasing evidence for relevant sex differences in pathophysiology, symptom presentation and outcomes in obstructive sleep apnoea (OSA). However, research on sex differences and sex-specific phenotypes in sleep-disordered breathing (SDB) is still in its infancy and data on sex differences in other SDB is still very scarce.

RECENT FINDINGS

While OSA is more common in men than in premenopausal women, the prevalence of OSA doubles postmenopausally and becomes comparable to that of men. Women have a lower collapsibility of the upper airway and a lower arousal threshold. In addition, the rapid eye movement (REM)-apnoea-hypopnoea index (AHI) is typically higher in women than in men, but the non-REM-AHI and thus the total AHI is often lower. Women are often symptomatic at lower AHI and present more frequently with symptoms of sleep fragmentation and poor sleep quality. Both certain forms of OSA (e.g. REM-OSA) and certain phenotypes (e.g. COMISA) are more common in women. Men have a higher risk of high loop gain central sleep apnoea.

SUMMARY

For a better understanding of sex-typical phenotypes with the aim of a more targeted treatment approach of SDB, adequately powered studies on sex differences in SDB should be conducted.

Factors predictive of extensive use of CPAP treatment in obstructive sleep apnoea

AIM

In patients with obstructive sleep apnoea (OSA), the benefits of continuous positive airway pressure (CPAP) therapy are increased for every additional hour of daily CPAP usage. However, the data of predictors of extensive usage is scarce, if any. Therefore, we evaluated potential predictors affecting extensive treatment usage.

METHODS

In this retrospective study, we compiled an institutional cohort of consecutive patients diagnosed with who started CPAP therapy 1999-2022 and were included in a wireless telemonitoring system in May 2022 (N = 14,394). Patients using CPAP device ≥ 9 h/d were stratified into a younger (< 65 years; N = 124) and an older group (≥ 65 years; N = 131).

RESULTS

We found 255 patients (male 61%) eligible for our study, with a median age of 65 (interquartile range, IQR 55-73) years, and mean body mass index (BMI) of 36 ± 6.9 kg/m2. Median CPAP use was 10 h/d (IQR 10-11). BMI and depressive symptoms (DEPS) in the younger group were higher than in the older group (37.9 ± 7 vs. 34.6 ± 6.4 kg/m2, p < 0.001 and 11 (IQR 5-20) vs. 7 (IQR 5-14), p = 0.01, respectively). During follow-up, the BMI of the younger group increased (39.9 ± 12.5 kg/m2 vs. 37.9 ± 7 kg/m2, p = 0.009). DEPS values decreased in the younger group and became comparable between the groups. In multivariate models, the baseline BMI independently predicted extensive CPAP use among the younger age group, and the mask leak among the older group.

CONCLUSION

BMI at baseline in the younger and mask leak in the older group could be independent predictive factors for extensive use of CPAP.

Association of positive airway pressure termination with mortality and non-fatal cardiovascular events in patients with obstructive sleep apnoea

BACKGROUND AND AIMS

The recurrence of obstructive sleep apnoea (OSA) after positive airway pressure (PAP) therapy termination has physiological consequences that may increase cardiovascular (CV) risk. We aimed to determine whether PAP termination is associated with an increased incidence of major adverse CV events (MACE) compared with adherent PAP continuation.

METHODS

Data from the Pays de la Loire Sleep Cohort were linked to the French national health insurance database to identify incident MACE (composite outcome of mortality, stroke and cardiac diseases), and CV active drug (lipid-lowering, antihypertensive and antiplatelet drugs, beta-blockers) adherence (medication possession ratio ≥80%). The association of PAP termination with MACE was evaluated using a time-dependent survival Cox model, with adjustment for confounders including CV active drug status.

RESULTS

After a median follow-up of 8 years, 969 of 4188 included patients (median age 58 years, 69.6% men) experienced MACE, 1485 had terminated PAP while 2703 continued PAP with at least 4 hours/night use. 38% of patients were adherent to all CV drugs in the PAP continuation group versus 28% in the PAP termination group (p<0.0001). After adjustment for confounders, PAP termination was associated with an increased risk of MACE (HR (95% CI): 1.39 (1.20 to 1.62); p<0.0001). PAP termination was not associated with incident heart failure and coronary artery disease.

CONCLUSIONS

In this multicentre clinical-based cohort involving 4188 patients with OSA, PAP termination compared with adherent PAP continuation was associated with an increased risk of MACE. More research is needed to determine whether support programmes on PAP adherence could improve CV outcomes.

Obstructive sleep apnea and cardiovascular risk

Patients with obstructive sleep apnea (OSA) experience repetitive episodes of upper airway obstruction due to recurrent collapse during sleep. This leads to intermittent hypoxia episodes, which, through complex pathophysiological mechanisms, trigger sympathetic overactivation, endothelial dysfunction, hypercoagulation, and metabolic dysregulation. Consequently, other cardiovascular risk factors such as hypertension, metabolic syndrome, and diabetes are induced. Furthermore, this enhances target organ damage, affecting the heart, arteries, and kidneys, leading to an increased risk of cardiovascular morbidity and mortality. Among the various treatments for OSA, Continuous Positive Airway Pressure (CPAP) has been extensively studied. To date, this treatment has shown mild benefits in reducing blood pressure, particularly noticeable in patients with resistant hypertension. Furthermore, CPAP treatment appears to reduce cardiovascular events, both in primary and secondary prevention, though this benefit is limited to individuals with good compliance (CPAP use ≥4h/night). Future research perspectives in OSA seem to focus on identifying patients in whom the condition significantly influences cardiovascular risk, thus determining those who would benefit the most from treatment in the reduction of cardiovascular risk.

Heterogeneous Effects of Continuous Positive Airway Pressure in Non-Sleepy Obstructive Sleep Apnea on Cardiovascular Disease Outcomes: Post Hoc Machine Learning Analysis of the ISAACC Trial (ECSACT Study)

Rationale: Randomized controlled trials of continuous positive airway pressure (CPAP) therapy for cardiovascular disease (CVD) prevention among patients with obstructive sleep apnea (OSA) have been largely neutral. However, given that OSA is a heterogeneous disease, there may be unidentified subgroups demonstrating differential treatment effects. Objectives: We sought to apply a novel data-drive approach to identify nonsleepy OSA subgroups with heterogeneous effects of CPAP on CVD outcomes within the Impact of Sleep Apnea Syndrome in the Evolution of Acute Coronary Syndrome (ISAACC) study. Methods: Participants were randomly partitioned into two datasets. One for training (70%) our machine-learning model and a second (30%) for validation of significant findings. Model-based recursive partitioning was applied to identify subgroups with heterogeneous treatment effects. Survival analysis was conducted to compare treatment (CPAP vs. usual care [UC]) outcomes within subgroups. Results: A total of 1,224 nonsleepy OSA participants were included. Of 55 features entered into our model, only two appeared in the final model (i.e., average OSA event duration and hypercholesterolemia). Among participants at or below the model-derived average event duration threshold (19.5 s), CPAP was protective for a composite of CVD events (training hazard ratio [HR], 0.46; P = 0.002). For those with longer event duration (>19.5 s), an additional split occurred by hypercholesterolemia status. Among participants with longer event duration and hypercholesterolemia, CPAP resulted in more CVD events compared with UC (training HR, 2.24; P = 0.011). The point estimate for this harmful signal was also replicated in the testing dataset (HR, 1.83; P = 0.118). Conclusions: We discovered subgroups of nonsleepy OSA participants within the ISAACC study with heterogeneous effects of CPAP. Among the training dataset, those with longer OSA event duration and hypercholesterolemia had nearly 2.5 times more CVD events with CPAP compared with UC, whereas those with shorter OSA event duration had roughly half the rate of CVD events if randomized to CPAP.

Links Between Obstructive Sleep Apnea and Myocardial Blood Flow Changes Impacting Adverse Cardiovascular Disease-related Outcomes

PURPOSE OF REVIEW

Recent studies have demonstrated an association between obstructive sleep apnea (OSA) and abnormal myocardial blood flow (MBF), myocardial flow reserve (MFR), and coronary microvascular dysfunction (CMD). Here, we review the evidence and describe the potential underlying mechanisms linking OSA to abnormal MBF. Examining relevant studies, we assess the impact of OSA-specific therapy, such as continuous positive airway pressure (CPAP), on MBF.

RECENT FINDINGS

Recent studies suggest an association between moderate to severe OSA and abnormal MBF/MFR. OSA promotes functional and structural abnormalities of the coronary microcirculation. OSA also promotes the uncoupling of MBF to cardiac work. In a handful of studies with small sample sizes, CPAP therapy improved MBF/MFR. Moderate to severe OSA is associated with abnormal MFR, suggesting an association with CMD. Evidence suggests that CPAP therapy improves MBF. Future studies must determine the clinical impact of improved MBF with CPAP.

The causality between leisure sedentary behaviors, physical activity and obstructive sleep apnea: a bidirectional Mendelian randomization study

Background

Previous observational studies have shown a correlation between leisure sedentary behaviors (LSB) and physical activity (PA) with the incidence of obstructive sleep apnea (OSA). However, the causal associations remain unknown. Therefore, our study used bidirectional two-sample Mendelian randomization (MR) to identify potential causal relationships between LSB/PA and OSA.

Methods

We sourced genetic variation data for LSB and PA from the UK Biobank, while data on OSA were collected from the FinnGen study. The primary analysis method employed was the inverse variance weighted (IVW) approach, complemented by the weighted median and MR-Egger methods. For sensitivity analyses, we conducted Cochran's Q test, the MR-Egger intercept test, the MR-PRESSO global test, and the leave-one-out analysis.

Results

IVW analyses showed that genetically predicted leisure television watching (odds ratio [OR] = 1.38, 95% confidence interval [CI] = 1.09-1.75, p = 0.007) and computer use (OR = 1.48, 95% CI = 1.15-1.92, p = 0.002) significantly increased the risk of OSA. Conversely, self-reported vigorous physical activity (VPA) (OR = 0.33, 95% CI = 0.11-0.98, p = 0.046) may reduce the risk of OSA. No causal effects on OSA risk were observed for driving or self-reported moderate-to-vigorous physical activity. Furthermore, the reverse MR analysis indicated no significant causal relationship between OSA and any LSB/PA phenotype. Sensitivity tests showed no significant heterogeneity or horizontal pleiotropy.

Conclusion

This study suggests that leisurely television watching and computer use are risk factors for OSA, while VPA may be a protective factor. Additionally, OSA does not affect PA or LSB levels. We recommend reducing sedentary activities, particularly television watching and computer use, and prioritizing VPA to reduce the risk of OSA. Further research in diverse populations and settings is needed to validate these findings.

National Implementation of CPAP Telemonitoring and a Pay-for-performance Scheme for Homecare Providers in France Leads to Prioritisation of Resources to Individuals with Low Therapy Adherence: The IMPACT-PAP Cohort Study

INTRODUCTION

Long-term adherence to continuous positive airway pressure (CPAP) therapy for obstructive sleep apnoea remains suboptimal and low adherence increases healthcare costs. This study investigated relationships between CPAP adherence and the intensity of support provided by homecare providers after implementation of telemonitoring and pay-for-performance reimbursement for CPAP in France.

METHODS

Adults who started CPAP in 2018/2019, used telemonitoring, and had ≥1 year of homecare provider data were eligible. The main objective was to determine associations between CPAP adherence at 1 month (low [<2h/night], intermediate [2 to <4h/night], high [≥4h/night]) and the number/type of homecare provider interactions (home visits, phone calls, mask change) during the first year.

RESULTS

Eleven thousand, one hundred sixty-six individuals were included (mean age 59.8±12.7 years, 67% male). The number of homecare provider interactions per person increased significantly as 1-month CPAP usage decreased (7.65±4.3, 6.5±4.0, 5.4±3.4 in low, intermediate and high adherence groups; p<0.01). There was marked improvement in device usage over the first 5-6 months of therapy in the low and intermediate adherence subgroups (p<0.05 after adjustment for age, sex, initial CPAP adherence, and number of interactions). After adjustment for age, sex and 1-month adherence, having 3-4 interactions was significantly associated with better 1-year adherence (odds ratio 1.24, 95% confidence interval 1.05-1.46), while having >7 interactions was significantly associated with worse 1-year adherence.

CONCLUSIONS

The telemonitoring/reimbursement scheme in France had a positive impact on CPAP adherence and facilitated a more personalised approach to therapy management, focusing resources on patients with low and intermediate adherence.

The PAP-RES algorithm: Defining who, why and how to use positive airway pressure therapy for OSA

Obstructive sleep apnea (OSA) is a common condition that is increasing in prevalence worldwide. Untreated OSA has a negative impact on health-related quality of life and is an independent risk factor for cardiovascular diseases. Despite available data suggesting that cardiovascular risk might differ according to clinical phenotypes and comorbidities, current approaches to OSA treatment usually take a "one size fits all" approach. Identification of cardiovascular vulnerability biomarkers and clinical phenotypes associated with response to positive airway pressure (PAP) therapy could help to redefine the standard treatment paradigm. The new PAP-RES (PAP-RESponsive) algorithm is based on the identification of OSA phenotypes that are likely to impact therapeutic goals and modalities. The paradigm shift is to propose a simplified approach that defines therapeutic goals based on OSA phenotype: from a predominantly "symptomatic phenotype" (individuals with high symptom burden that negatively impacts on daily life and/or accident risk or clinically significant insomnia) to a "vulnerable cardiovascular phenotype" (individuals with comorbidities [serious cardiovascular or respiratory disease or obesity] that have a negative impact on cardiovascular prognosis or a biomarker of hypoxic burden and/or autonomic nervous system dysfunction). Each phenotype requires a different PAP therapy care pathway based on differing health issues and treatment objectives.

Sleep Apnea and Stroke: A Narrative Review

TOPIC IMPORTANCE

Stroke is the second-leading cause of death worldwide. OSA is an independent risk factor for stroke and is associated with multiple vascular risk factors. Poststroke OSA is prevalent and closely linked with various stroke subtypes, including cardioembolic stroke and cerebral small vessel disease. Observational studies have shown that untreated poststroke OSA is associated with an increased risk of recurrent stroke, mortality, poorer functional recovery, and longer hospitalizations.

REVIEW FINDINGS

Poststroke OSA tends to be underdiagnosed and undertreated, possibly because stroke patients with OSA present atypically compared with the general population with OSA. Objective testing, such as the use of ambulatory sleep testing or in-laboratory polysomnography, is recommended for diagnosing OSA. The gold standard for treating OSA is CPAP therapy. Randomized controlled trials (RCTs) have shown that treatment of poststroke OSA using CPAP improves nonvascular outcomes such as cognition and neurologic recovery. However, findings from RCTs that have evaluated the effect of CPAP on recurrent stroke risk and mortality have been largely negative.

SUMMARY

There is a need for high-quality RCTs in poststroke OSA that may provide evidence to support the utility of CPAP (and/or other treatment modalities) in reducing recurrent vascular events and mortality. This goal may be achieved by examining treatment strategies that have yet to be trialed in poststroke OSA, tailoring interventions according to poststroke OSA endotypes and phenotypes, selecting high-risk populations, and using metrics that reflect the physiological abnormalities that underlie the harmful effects of OSA on cardiovascular outcomes.

Development and application of a machine learning-based predictive model for obstructive sleep apnea screening

Objective

To develop a robust machine learning prediction model for the automatic screening and diagnosis of obstructive sleep apnea (OSA) using five advanced algorithms, namely Extreme Gradient Boosting (XGBoost), Logistic Regression (LR), Support Vector Machine (SVM), Light Gradient Boosting Machine (LightGBM), and Random Forest (RF) to provide substantial support for early clinical diagnosis and intervention.

Methods

We conducted a retrospective analysis of clinical data from 439 patients who underwent polysomnography at the Affiliated Hospital of Xuzhou Medical University between October 2019 and October 2022. Predictor variables such as demographic information [age, sex, height, weight, body mass index (BMI)], medical history, and Epworth Sleepiness Scale (ESS) were used. Univariate analysis was used to identify variables with significant differences, and the dataset was then divided into training and validation sets in a 4:1 ratio. The training set was established to predict OSA severity grading. The validation set was used to assess model performance using the area under the curve (AUC). Additionally, a separate analysis was conducted, categorizing the normal population as one group and patients with moderate-to-severe OSA as another. The same univariate analysis was applied, and the dataset was divided into training and validation sets in a 4:1 ratio. The training set was used to build a prediction model for screening moderate-to-severe OSA, while the validation set was used to verify the model's performance.

Results

Among the four groups, the LightGBM model outperformed others, with the top five feature importance rankings of ESS total score, BMI, sex, hypertension, and gastroesophageal reflux (GERD), where Age, ESS total score and BMI played the most significant roles. In the dichotomous model, RF is the best performer of the five models respectively. The top five ranked feature importance of the best-performing RF models were ESS total score, BMI, GERD, age and Dry mouth, with ESS total score and BMI being particularly pivotal.

Conclusion

Machine learning-based prediction models for OSA disease grading and screening prove instrumental in the early identification of patients with moderate-to-severe OSA, revealing pertinent risk factors and facilitating timely interventions to counter pathological changes induced by OSA. Notably, ESS total score and BMI emerge as the most critical features for predicting OSA, emphasizing their significance in clinical assessments. The dataset will be publicly available on my Github.

The Future of Telemedicine for Obstructive Sleep Apnea Treatment: A Narrative Review

Obstructive sleep apnea is a common type of sleep-disordered breathing associated with multiple comorbidities. Nearly a billion people are estimated to have obstructive sleep apnea, which carries a substantial economic burden, but under-diagnosis is still a problem. Continuous positive airway pressure (CPAP) is the first-line treatment for OSAS. Telemedicine-based interventions (TM) have been evaluated to improve access to diagnosis, increase CPAP adherence, and contribute to easing the follow-up process, allowing healthcare facilities to provide patient-centered care. This narrative review summarizes the evidence available regarding the potential future of telemedicine in the management pathway of OSA. The potential of home sleep studies to improve OSA diagnosis and the importance of remote monitoring for tracking treatment adherence and failure and to contribute to developing patient engagement tools will be presented. Further studies are needed to explore the impact of shifting from teleconsultations to collaborative care models where patients are placed at the center of their care.

Sleep-disordered breathing in heart failure

PURPOSE OF REVIEW

This review addresses the evolving intersection of sleep-disordered breathing (SDB) and heart failure, a topic of increasing clinical significance due to the high prevalence of SDB in heart failure patients and its impact on morbidity and mortality. It reflects recent advancements in diagnostic methodologies and therapeutic strategies. It emphasizes the need for heightened awareness among healthcare providers about the complex relationship between SDB and various forms of heart failure.

RECENT FINDINGS

Recent studies underscore the high incidence of SDB in heart failure patients, varying with the cause of heart failure. Emerging diagnostic tools, including home sleep tests and advanced inpatient screening methods, have improved the early detection and accurate diagnosis of SDB. Novel treatment modalities, like hypoglossal and phrenic nerve stimulation, are promising, especially where conventional therapies are inadequate. The review also discusses the complexities of managing SDB in the context of different heart failure subtypes.

SUMMARY

Findings from recent literature suggest that improved screening, diagnosis, and innovative treatment of SDB in heart failure patients can reduce morbidity, mortality, and healthcare costs. This review emphasizes the need for personalized treatment approaches tailored to individual patient profiles, highlighting the potential of new technologies and multidisciplinary strategies in clinical practice.

The association between the effective apnea-hypopnea index and blood pressure reduction efficacy following CPAP/oxygen treatment

BACKGROUND

The effect of sleep apnea treatment on reducing cardiovascular disease risk remains inconclusive. This study aims to assess if the effective apnea hypopnea index (eAHI), a measure of residual sleep apnea burden post-treatment, is a factor in determining blood pressure (BP) response to continuous positive airway pressure therapy. The eAHI integrates time on therapy, residual apnea, and % of sleep time untreated.

METHODS

A secondary analysis of the Heart Biomarker Evaluation in Apnea Treatment (HeartBEAT) study, a randomized, controlled, parallel group assessment of continuous positive airway pressure (CPAP), oxygen and sleep hygiene. The Delta-AHI (▲AHI) was defined as the difference between baseline AHI and effective AHI at 12 weeks. Logistic and linear regression models estimated the predictors for nocturnal systolic BP change following sleep apnea therapy.

RESULTS

One hundred and sixty-nine subjects with a mean age of 62.82 ± 6.99 years were included in the final analysis. Fifty subjects had ▲AHI ≤8/hour of sleep and 119 subjects were higher. After adjustment, baseline mean nighttime systolic blood pressure (OR 1.036, 95% CI 1.015-1.058, p: 0.001) and ▲AHI ≥8/hour (OR 2.406, 95% CI 1.116-5.185, p:0.025) were independent predictors for mean nighttime systolic blood pressure change >3 mm Hg. The higher effective AHI was negatively related with BNP (β: -2.564, SE: 1.167, p: 0.029) and positively related with troponin change (β: 0.703, SE: 0.256, p: 0.007).

CONCLUSION

The ▲AHI was an independent predictor of the blood pressure response to sleep apnea treatment.

REGISTER NUMBER

NCT01086800.

Pulmonology: What You May Have Missed in 2023

The field of pulmonology saw significant advances in 2023. The publications highlighted in this article address advances and changes in practice related to asthma, chronic obstructive pulmonary disease (COPD), interstitial lung disease, pleural disorders, and sleep-disordered breathing. One article reviews data examining the efficacy of vaccination against respiratory syncytial virus, a respiratory viral illness that has had devastating effects globally. Four studies evaluate the role of various therapies in COPD, including dupilumab, ensifentrine, pulmonary rehabilitation programs, and lung volume reduction versus endobronchial valves. Another study explores the effect on vascular events of positive-pressure ventilation in patients with sleep-disordered breathing and recent stroke. The use of combination therapy with rituximab and mycophenolate mofetil on progression-free survival in patients with nonspecific interstitial pneumonia is the topic of another study. We also highlight an update of clinical recommendations for the evaluation of patients with pleural disorders and a systematic review analyzing the effectiveness of inhaled corticosteroids as a supplement to dual therapy for COPD.

Cardiovascular disease and risk in COPD: a state of the art review

INTRODUCTION

Chronic Obstructive Pulmonary Disease (COPD) and cardiovascular diseases (CVD) commonly co-exist. Outcomes of people living with both conditions are poor in terms of symptom burden, receiving evidence-based treatment and mortality. Increased understanding of the underlying mechanisms may help to identify treatments to relieve this disease burden. This narrative review covers the overlap of COPD and CVD with a focus on clinical presentation, mechanisms, and interventions. Literature up to December 2023 are cited.

AREAS COVERED

1. What is COPD 2. The co-existence of COPD and cardiovascular disease 3. Mechanisms of cardiovascular disease in COPD. 4. Populations with COPD are at risk of CVD 5. Complexity in the co-diagnosis of COPD in those with cardiovascular disease. 6. Therapy for COPD and implications for cardiovascular events and risk. 7. Cardiovascular risk and exacerbations of COPD. 8. Pro-active identification and management of CV risk in COPD.

EXPERT OPINION

The prospective identification of co-morbid COPD in CVD patients and of CVD and CV risk in people with COPD is crucial for optimizing clinical outcomes. This includes the identification of novel treatment targets and the design of clinical trials specifically designed to reduce the cardiovascular burden and mortality associated with COPD. Databases searched: Pubmed, 2006-2023.

Causal association of gastroesophageal reflux disease with obstructive sleep apnea and sleep-related phenotypes: a bidirectional two-sample Mendelian randomization study

Background

The interactions and associations between obstructive sleep apnea (OSA), sleep-related phenotypes (SRPs), and gastroesophageal reflux disease (GERD) are complex, thus it is hard to explore the effect and direction of causalities.

Study objectives

A bidirectional Mendelian randomization (MR) study was performed to explore causal associations of GERD with OSA and SRPs (including insomnia, morningness, sleep duration, ease of getting up, daytime napping, daytime dozing, and snoring).

Methods

First, we gathered summary statistics from publicly available databases. Subsequently, we identified single-nucleotide polymorphisms without strong linkage (r2 ≤ 0.001) by referencing relevant genome-wide association studies that met genome-wide significance criteria. Our primary analysis relied on inverse variance weighted to estimate the causal relationship. To ensure the validity of our findings, we also conducted several sensitivity analyses. These included MR Pleiotropy RESidual Sum and Outlier to detect and correct for potential pleiotropic effects, MR-Egger to assess directional pleiotropy, and weighted median analysis to further evaluate heterogeneity and pleiotropy. For the initial MR analysis, when causality was indicated by the results, instrumental variables that were significantly linked to the aforementioned confounding factors were removed. We will re-analyze the data after excluding outcome-related single nucleotide polymorphisms to confirm that the results are still consistent with the previous results.

Results

GERD was found to increase the risk of OSA (OR = 1.53, 95% CI = 1.37-1.70, p = 5.3 × 10-15), insomnia (OR = 1.14, 95% CI = 1.10-1.19, p = 1.3 × 10-10), snoring (OR = 1.09, 95% CI = 1.04-1.13, p = 6.3 × 10-5) and less sleep duration (OR = 0.94, 95% CI = 0.91-0.97, p = 3.7 × 10-4). According to the reverse-direction analysis, there is an elevated risk of GERD associated with OSA (OR = 1.07, 95% CI = 1.02-1.12, p = 0.005), insomnia (OR = 1.95, 95% CI = 1.60-2.37, p = 1.92 × 10-11) and snoring (OR = 1.74, 95% CI = 1.37-2.21, p = 4.4 × 10-6).

Conclusion

Genetic susceptibility to GERD can elevate the likelihood of experiencing insomnia, snoring, and OSA, in addition to diminishing sleep duration. Conversely, a reverse MR analysis indicates that ameliorating any one of insomnia, snoring, or OSA can mitigate the risk of developing GERD.