CPAP Treatment and Cardiovascular Prevention

Evaluate the Relationship Between Obstructive Sleep Apnea and Metabolic Syndrome in Real-World Data

Objective

Obstructive sleep apnea (OSA) is a disorder characterized by disruption in breathing and hypoventilation. In parallel, metabolic syndrome (MetS) mainly co-occur with OSA, however, their association has not been fully elucidated. Therefore, this study aimed to reveal the relationship between OSA and MetS using data from the National Health And Nutrition Examination Survey (NHANES) database and pooled data from Genome-Wide Association Studies (GWAS).

Material and Methods

Data from the National Health and Nutrition Examination Survey and pooled data from genome-wide association analysis (GWAS) were used univariate and multivariate logistic regression analyses were carried out to evaluate the correlation between OSA and MetS, and multivariate logistic regression models were utilized for adjusting for potential confounders. Two-sample Mendelian randomization (MR) was used to assess the causal relationship between OSA and MetS. The variance-weighted inverse method was employed as the main method of analysis.

Results

A positive relationship of OSA with Mets was evidenced by multivariate logistic regression analysis, and OSA was associated with higher incidence rates of all-cause and cardiovascular mortality. OSA is strongly associated with abdominal obesity, hypertension, hyperglycemia, high triglycerides, and low HDL. Furthermore, except for hypertriglyceridemia, MR analysis indicated that genetically driven OSA was causally associated with a higher risk of MetS.

Conclusion

The positive relationship of OSA with Mets was revealed, and higher incidence rates of all-cause mortality and cardiovascular mortality were noted to be correlated with OSA. MR analysis further confirmed the causal relationship of OSA with MetS and cardiovascular disease.

Positive Airway Pressure Therapy Predicts Lower Mortality and Major Adverse Cardiovascular Events Incidence in Medicare Beneficiaries with Obstructive Sleep Apnea

Background

Obesity is associated with obstructive sleep apnea (OSA) and cardiovascular risk. Positive airway pressure (PAP) is the first line treatment for OSA, but evidence on its beneficial effect on major adverse cardiovascular events (MACE) prevention is limited. Using claims data, the effects of PAP on mortality and incidence of MACE among Medicare beneficiaries with OSA were examined.

Methods

A cohort of Medicare beneficiaries with ≥2 distinct OSA claims was defined from multi-state, state-wide, multi-year (2011-2020) Medicare fee-for-service claims data. Evidence of PAP initiation and utilization was based on PAP claims after OSA diagnosis. MACE was 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 estimated treatment effects controlling for sociodemographic and clinical factors.

Results

Among 888,835 beneficiaries with OSA (median age 73 years; 43.9% women; median follow-up 1,141 days), those with evidence of PAP initiation (32.6%) had significantly lower all-cause mortality (HR [95%CI]: 0.53 [0.52-0.54]) and MACE incidence risk (0.90 [0.89-0.91]). Higher quartiles of annual PAP claims were progressively associated with lower mortality (Q2: 0.84 [0.81-0.87], Q3: 0.76 [0.74-0.79], Q4: 0.74 [0.72-0.77]) and MACE incidence risk (Q2: 0.92 [0.89-0.95], Q3: 0.89 [0.86-0.91], Q4: 0.87 [0.85-0.90]).

Conclusion

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

Positive airway pressure therapy adherence and outcomes in obstructive sleep apnea: An exploratory longitudinal retrospective randomized chart review

Background

Positive airway pressure (PAP) therapy is prescribed to patients with obstructive sleep apnea (OSA). A commonly used definition for PAP therapy adherence is based upon the minimum requirements to receive Medicare coverage in the US, defined as PAP usage of four or more hours per night on 70 percent of nights for at least 30 consecutive days. However, little evidence exists to support this definition for PAP therapy adherence. Therefore, the present study sought to determine the efficacy of the present definition of PAP therapy adherence on longitudinal outcomes in patients with OSA, using objectively measured PAP device usage time.

Methods

An exploratory longitudinal, retrospective, randomized chart review was done to assess clinical outcomes between patients with OSA who were defined as PAP therapy adherent (n=50) and non-adherent (n=50) during an eight-year observation period.

Results

No significant differences were shown between groups for mortality, hospitalizations, or development of co-morbidities during the observation period. However, logistic regression showed significantly higher odds of adherence in male patients compared to female patients (OR=8.519; 95%CI=1.301-55.756; p=0.025) and significantly lower odds of adherence in patients with higher normal (OR=0.039; 95%CI=0.005-0.392; p=0.003), mild excessive (OR=0.039; 95%CI=0.003-0.517; p=0.014), and severe excessive (OR=0.088; 95%CI=0.012-0.635; p=0.016) daytime sleepiness compared to patients with lower normal daytime sleepiness. An increasing number of hospitalizations also corresponded with a significant decrease in odds of being adherent (OR=0.741; 95%CI=0.551-0.995; p=0.046).

Conclusion

The present study supports a steadily growing body of literature calling for more consideration and evidence to support a definition of PAP therapy adherence that is clinically meaningful.

Clinical Application of the Multicomponent Grading System for Sleep Apnea Classification and Incident Cardiovascular Mortality

Objective  To evaluate the clinical utility of the Baveno classification in predicting incident cardiovascular mortality after five years of follow-up in a clinic-based cohort of patients with obstructive sleep apnea (OSA). Materials and Methods  We evaluated the reproducibility of the Baveno classification using data from the Santiago Obstructive Sleep Apnea (SantOSA) study. The groups were labeled Baveno A (minor symptoms and comorbidities), B (severe symptoms and minor comorbidities), C (minor symptoms and severe comorbidities), and D (severe symptoms and comorbidities). Within-group comparisons were performed using analysis of variance (ANOVA) and post hoc tests. The associations between groups and incident cardiovascular mortality were determined through the Mantel-Cox and Cox proportional hazard ratios (HRs) adjusted by covariables. Results  A total of 1,300 OSA patients were included (Baveno A: 27.7%; B: 28%; C: 16.8%; and D: 27.5%). The follow-up was of 5.4 years. Compared to Baveno A, the fully-adjusted risk of cardiovascular mortality with Baveno B presented an HR of 1.38 (95% confidence interval [95%CI]: 0.14-13.5; p  = 0.78); with Baveno C, it was of 1.71 (95%CI: 0.18-16.2; p  = 0.63); and, with Baveno D, of 1.04 (95%CI: 0.12-9.2; p  = 0.98). We found no interactions involving Baveno group, sex and OSA severity. Discussion  Among OSA patients, the Baveno classification can describe different subgroups. However, its utility in identifying incident cardiovascular mortality is unclear. Long-term follow-up studies and the inclusion of demographic variables in the classification could improve its ability to detect a high-risk phenotype associated with cardiovascular mortality. Conclusion  The Baveno classification serves as a valuable method for categorizing varying groups of patients afflicted with OSA. Nevertheless, its precision in identifying occurrence of cardiovascular mortality is still unclear.

Hypoxic burden to guide CPAP treatment allocation in patients with obstructive sleep apnoea: a post hoc study of the ISAACC trial

BACKGROUND

Hypoxic burden (HB) has emerged as a strong predictor of cardiovascular risk in obstructive sleep apnoea (OSA). We aimed to assess the potential of HB to predict the cardiovascular benefit of treating OSA with continuous positive airway pressure (CPAP).

METHODS

This was a post hoc analysis of the ISAACC trial (ClinicalTrials.gov: NCT01335087) including non-sleepy patients with acute coronary syndrome (ACS) diagnosed with OSA (apnoea-hypopnoea index ≥15 events·h-1) by respiratory polygraphy. Patients were randomised to CPAP or usual care and followed for a minimum of 1 year. HB was calculated as the total area under all automatically identified desaturations divided by total sleep time. Patients were categorised as having high or low baseline HB according to the median value (73.1%min·h-1). Multivariable Cox regression models were used to assess whether the effect of CPAP on the incidence of cardiovascular outcomes was dependent on the baseline HB level.

RESULTS

The population (362 patients assigned to CPAP and 365 patients assigned to usual care) was middle-aged (mean age 59.7 years), overweight/obese and mostly male (84.5%). A significant interaction was found between the treatment arm and the HB categories. In the high HB group, CPAP treatment was associated with a significant reduction in the incidence of cardiovascular events (HR 0.57, 95% CI 0.34-0.96). In the low HB group, CPAP-treated patients exhibited a trend toward a higher risk of cardiovascular outcomes than those receiving usual care (HR 1.33, 95% CI 0.79-2.25). The differential effect of the treatment depending on the baseline HB level followed a dose-response relationship.

CONCLUSION

In non-sleepy ACS patients with OSA, high HB levels were associated with a long-term protective effect of CPAP on cardiovascular prognosis.

Breathless nights and heart flutters: Understanding the relationship between obstructive sleep apnea and atrial fibrillation

There is an extraordinary and increasing global burden of atrial fibrillation (AF) and obstructive sleep apnea (OSA), two conditions that frequently accompany one another and that share underlying risk factors. Whether a causal pathophysiologic relationship connects OSA to the development and/or progression of AF, or whether shared risk factors promote both conditions, is unproven. With increasing recognition of the importance of controlling AF-related risk factors, numerous observational studies now highlight the potential benefits of OSA treatment in AF-related outcomes. Physicians are regularly faced with caring for this important and increasing population of patients despite a paucity of clinical guidance on the topic. Here, we review the clinical epidemiology and pathophysiology of AF and OSA with a focus on key clinical studies and major outstanding questions that should be addressed in future studies.

Prognostic importance of obstructive sleep apnea and CPAP treatment for cardiovascular and mortality outcomes in patients with resistant hypertension: a prospective cohort study

The prognostic importance of obstructive sleep apnea (OSA) severity and other polysomnographic parameters in patients with resistant hypertension (RHT) has never been evaluated. We aimed to assess it in a prospective cohort of 422 individuals with RHT. OSA presence/severity was ascertained by complete polysomnography (PSG) at baseline. Multivariable Cox regressions assessed the risks associated with OSA severity and other PSG parameters (apnea-hypopnea index, sleep duration, nocturnal hypoxemia and periodic limb movements) for the primary (total cardiovascular events [CVEs] and all-cause mortality) and secondary outcomes (major CVEs). In the subgroup of patients with moderate/severe OSA, the risks associated with CPAP treatment were also estimated in relation to untreated individuals. One-hundred and eighty-six participants (44%) had no/mild OSA and 236 (56%) had moderate/severe OSA, and 67 of them were CPAP-treated. Over a mean follow-up of 5 years, there were 46 CVEs (37 major ones) and 44 all-cause deaths. Neither the presence of moderate/severe or severe OSA, nor being untreated during follow-up, was associated with significant excess risks for any outcome in relation to the subgroup with no/mild OSA. Similarly, no other PSG-derived parameter predicted any adverse outcome. Otherwise, CPAP treatment was associated with non-significant risk reductions of 37% for total CVEs, 49% for major CVEs and 63% for all-cause mortality in relation to those who remained untreated during follow-up. In conclusion, the presence/severity of OSA and its related PSG parameters were not associated with worse cardiovascular/mortality prognosis in patients with RHT. However, CPAP treatment might be protective in individuals with moderate/severe OSA.

Electronic health record-derived outcomes in obstructive sleep apnea managed with positive airway pressure tracking systems

STUDY OBJECTIVES

To assess the effectiveness of continuous positive airway pressure (CPAP) management guided by CPAP machine downloads in newly diagnosed patients with obstructive sleep apnea (OSA) using electronic health record-derived health care utilization, biometric variables, and laboratory data.

METHODS

Electronic health record data of patients seen at the University of Utah Sleep Program from 2012-2015 were reviewed to identify patients with new diagnosis of OSA in whom CPAP adherence and residual apnea-hypopnea index as measured by a positive airway pressure adherence tracking device data for ≥ 1 year were available. Biometric data, laboratory data, and system-wide charges were compared in the 1 year before and after CPAP therapy. Subgroups were divided by whether patients met tracking criteria, mean nightly usage, and OSA severity.

RESULTS

976 consecutive, newly diagnosed participants with OSA (median age 55 years, 56.6% male) met inclusion criteria. There was a mean decrease of systolic blood pressure (BP) of 1.2 mm Hg and diastolic BP of 1.0 mm Hg within a year of initiation of CPAP therapy. BP improvements in the subgroup meeting CPAP tracking targets were 1.36 mmHg (systolic) and 1.37 mmHg (diastolic). No significant change was noted in body mass index, glycated hemoglobin, or serum creatinine values within a year of starting CPAP therapy, and health care utilization increased (mean acute care visits 0.22 per year to 0.53 per year; mean charges of $3,997 per year to $8,986 per year).

CONCLUSIONS

An improvement in BP was noted within a year of CPAP therapy in newly diagnosed patients with OSA, with no difference in the magnitude of improvement between those meeting tracking system adherence targets.

CITATION

Locke BW, Neill SE, Howe HE, Crotty MC, Kim J, Sundar KM. Electronic health record-derived outcomes in obstructive sleep apnea managed with positive airway pressure tracking systems. J Clin Sleep Med. 2022;18(3):885-894.

CPAP adherence is associated with reduced inpatient utilization among older adult Medicare beneficiaries with pre-existing cardiovascular disease

STUDY OBJECTIVES

To examine the impact of adherence to continuous positive airway pressure (CPAP) therapy on health care utilization among a nationally representative and sample of older adults with multiple morbidities and pre-existing cardiovascular disease and subsequently diagnosed with obstructive sleep apnea in the United States.

METHODS

Our data source was a random 5% sample of Medicare administrative claims data. All participants (n = 1,921) were of age ≥ 65 years, diagnosed with cardiovascular disease and obstructive sleep apnea, and subsequently began treatment with CPAP between 2009-2013. Based on the number of CPAP machine charges, individuals were categorized as low, partial, or high adherers (ie, < 4, 4-12, and > 12 CPAP charges, respectively). The impact of CPAP adherence status on health care utilization was assessed across multiple points of service, including outpatient encounters, inpatient stays, emergency department visits, and prescription fills over 24 months following CPAP initiation.

RESULTS

Significant differences in demographic and comorbid disease characteristics were observed between low adherers (n = 377), partial adherers (n = 236), and high adherers (n = 1,308). After adjusting for covariates and relative to low adherers, high adherers demonstrated reduced inpatient visits (hazard ratio 0.75; 95% confidence interval 0.57, 0.97).

CONCLUSIONS

In this nationally representative sample of older Medicare beneficiaries with multiple morbidities and relative to low adherers, high adherers demonstrated reduced inpatient utilization.

CITATION

Wickwire EM, Bailey MD, Somers VK, et al. CPAP adherence is associated with reduced inpatient utilization among older adult Medicare beneficiaries with pre-existing cardiovascular disease. J Clin Sleep Med. 2022;18(1):39-45.

Continuous positive airway pressure and adverse cardiovascular events in obstructive sleep apnea: are participants of randomized trials representative of sleep clinic patients?

STUDY OBJECTIVES

Randomized controlled trials (RCTs) have shown no reduction in adverse cardiovascular (CV) events in patients randomized to continuous positive airway pressure (CPAP) therapy for obstructive sleep apnea (OSA). This study examined whether randomized study populations were representative of OSA patients attending a sleep clinic.

METHODS

Sleep clinic patients were 3,965 consecutive adults diagnosed with OSA by in-laboratory polysomnography from 2006 to 2010 at a tertiary hospital sleep clinic. Characteristics of these patients were compared with participants of five recent RCTs examining the effect of CPAP on adverse CV events in OSA. The percentage of patients with severe (apnea-hypopnea index, [AHI] ≥ 30 events/h) or any OSA (AHI ≥ 5 events/h) who met the eligibility criteria of each RCT was determined, and those criteria that excluded the most patients identified.

RESULTS

Compared to RCT participants, sleep clinic OSA patients were younger, sleepier, more likely to be female and less likely to have established CV disease. The percentage of patients with severe or any OSA who met the RCT eligibility criteria ranged from 1.2% to 20.9% and 0.8% to 21.9%, respectively. The eligibility criteria that excluded most patients were preexisting CV disease, symptoms of excessive sleepiness, nocturnal hypoxemia and co-morbidities.

CONCLUSIONS

A minority of sleep clinic patients diagnosed with OSA meet the eligibility criteria of RCTs of CPAP on adverse CV events in OSA. OSA populations in these RCTs differ considerably from typical sleep clinic OSA patients. This suggests that the findings of such OSA treatment-related RCTs are not generalizable to sleep clinic OSA patients.Randomized Intervention with Continuous Positive Airway Pressure in CAD and OSA (RICCADSA) trial, https://clinicaltrials.gov/ct2/show/NCT00519597, ClinicalTrials.gov number, NCT00519597.Usefulness of Nasal Continuous Positive Airway Pressure (CPAP) Treatment in Patients with a First Ever Stroke and Sleep Apnea Syndrome, https://clinicaltrials.gov/ct2/show/NCT00202501, ClinicalTrials.gov number, NCT00202501.Effect of Continuous Positive Airway Pressure (CPAP) on Hypertension and Cardiovascular Morbidity-Mortality in Patients with Sleep Apnea and no Daytime Sleepiness, https://clinicaltrials.gov/ct2/show/NCT00127348, ClinicalTrials.gov number, NCT00127348.Continuous Positive Airway Pressure (CPAP) in Patients with Acute Coronary Syndrome and Obstructive Sleep Apnea (OSA) (ISAACC), https://clinicaltrials.gov/ct2/show/NCT01335087, ClinicalTrials.gov number, NCT01335087.

Impact of continuous positive airway pressure ventilation on cardiovascular outcomes among patients with obstructive sleep apnea: A meta-analysis of randomized trials

Background

The impact of continuous positive airway pressure (CPAP) on cardiovascular outcomes among patients with obstructive sleep apnea (OSA) is controversial.

Objective

To evaluate the impact of CPAP on reducing cardiovascular outcomes in patients with OSA.

Methods

We performed a computerized search of MEDLINE, EMBASE and COCHRANE databases through April 2021 for randomized trials evaluating the impact of CPAP versus control on cardiovascular outcomes in patients with OSA. Summary estimates were reported using both fixed and random effects model. The main study outcome was major adverse cardiac events (MACE).

Results

The final analysis included 8 randomized trials with total of 5684 patients. The weighted mean follow-up was 42.6 months. There was no difference between the CPAP and control groups in the risk of MACE (14.4% versus 14.8%, risk ratio [RR]: 0.97; 95% confidence interval [CI]: 0.85 to 1.10; p = 0.60; I2 = 21%). Subgroup analysis suggested that CPAP was associated with lower MACE (by 36%) in CPAP-adherent patients (≥4 h/night) (Pinteraction = 0.08). There was no difference between the CPAP and control groups in the risk of all-cause mortality, cardiovascular mortality, acute stroke, acute myocardium infarction or hospitalizations for angina.

Conclusions and relevance

CPAP use might not be associated with lower cardiovascular events among patients with OSA. However, patients adherent to CPAP (≥4 h/night) might derive a benefit on cardiovascular outcomes. Future studies are warranted to evaluate the impact of CPAP in reducing cardiovascular events among patients with severe OSA and with optimal adherence rates to CPAP therapy.

A Validation Study of Four Different Cluster Analyses of OSA and the Incidence of Cardiovascular Mortality in a Hispanic Population

BACKGROUND

Previous studies reported a strong association between sleepiness-related symptoms and comorbidities with poor cardiovascular outcomes among patients with moderate to severe OSA (msOSA). However, the validation of these associations in the Hispanic population from South America and the ability to predict incident cardiovascular disease remain unclear.

RESEARCH QUESTION

In Hispanic patients with msOSA, are four different cluster analyses reproducible and able to predict incident cardiovascular mortality?

STUDY DESIGN AND METHODS

Using the SantOSA cohort, we reproduced four cluster analyses (Sleep Heart Health Study [SHHS], Icelandic Sleep Apnea Cohort [ISAC], Sleep Apnea Cardiovascular Endpoints [SAVE], and The Institute de Recherche en Sante Respiratoire des Pays de la Loire [IRSR] cohorts) following a cluster analysis similar to each training dataset. The incidence of cardiovascular mortality was constructed using a Kaplan-Meier (log-rank) model, and Cox proportional hazards models were adjusted by confounders.

RESULTS

Among 780 patients with msOSA in our cohort, two previous cluster analyses (SHHS and ISAC) were reproducible. The SAVE and IRSR cluster analyses were not reproducible in our sample. We identified the following subtypes for SHHS: "minimally symptomatic," "disturbed sleep," "moderate sleepiness," and "severe sleepiness." For ISAC, three different subtypes ("minimally symptomatic," "disturbed sleep," and "excessive sleepiness") were similar to the original dataset. Compared with "minimally symptomatic," we found a significant association between "excessive sleepiness" and cardiovascular mortality after 5 years of follow-up in SantOSA, hazard ratio (HR), 5.47; 95%CI, 1.74-8.29; P < .01; and HR, 3.23; 95%CI, 1.21-8.63; P = .02, using the SHHS and ISAC cluster analyses, respectively.

INTERPRETATION

Among patients with msOSA, a symptom-based approach can validate different OSA patient subtypes, and those with excessive sleepiness have an increased risk of incident cardiovascular mortality in the Hispanic population from South America.

Randomized clinical trials of cardiovascular disease in obstructive sleep apnea: understanding and overcoming bias

Three recent randomized control trials (RCTs) found that treatment of obstructive sleep apnea (OSA) with continuous positive airway pressure (CPAP) did not reduce rates of future cardiovascular events. This article discusses the biases in these RCTs that may explain their negative results, and how to overcome these biases in future studies. First, sample selection bias affected each RCT. The subjects recruited were not patients typically presenting for treatment of OSA. In particular, subjects with excessive sleepiness were excluded due to ethical concerns. As recent data indicate that the excessively sleepy OSA subtype has increased cardiovascular risk, subjects most likely to benefit from treatment were excluded. Second, RCTs had low adherence to therapy. Reported adherence is lower than found clinically, suggesting it is in part related to selection bias. Each RCT showed a CPAP benefit consistent with epidemiological studies when restricting to adherent patients, but was underpowered. Future studies need to include sleepy individuals and maximize adherence. Since it is unethical and impractical to randomize very sleepy subjects to no therapy, alternative designs are required. Observational designs using propensity scores, which are accepted by FDA for studies of medical devices, provide an opportunity. The design needs to ensure covariate balance, including measures assessing healthy user and healthy adherer biases, between regular users of CPAP and non-users. Sensitivity analyses can evaluate the robustness of results to unmeasured confounding, thereby improving confidence in conclusions. Thus, these designs can robustly assess the cardiovascular benefit of CPAP in real-world patients, overcoming biases in RCTs.

Research routes on improved sleep bruxism metrics: Toward a standardised approach

A recent report from the European Sleep Research Society's task force "Beyond AHI" discussed an issue that has been a long-term subject of debate - what are the best metrics for obstructive sleep apnoea (OSA) diagnosis and treatment outcome assessments? In a similar way, sleep bruxism (SB) metrics have also been a recurrent issue for >30 years and there is still uncertainty in dentistry regarding their optimisation and clinical relevance. SB can occur alone or with comorbidities such as OSA, gastroesophageal reflux disorder, insomnia, headache, orofacial pain, periodic limb movement, rapid eye movement behaviour disorder, and sleep epilepsy. Classically, the diagnosis of SB is based on the patient's dental and medical history and clinical manifestations; electromyography is used in research and for complex cases. The emergence of new technologies, such as sensors and artificial intelligence, has opened new opportunities. The main objective of the present review is to stimulate the creation of a collaborative taskforce on SB metrics. Several examples are available in sleep medicine. The development of more homogenised metrics could improve the accuracy and refinement of SB assessment, while moving forward toward a personalised approach. It is time to develop SB metrics that are relevant to clinical outcomes and benefit patients who suffer from one or more possible negative consequences of SB.

Efficacy of continuous positive airway pressure (CPAP) in patients with obstructive sleep apnea (OSA) and resistant hypertension (RH): Systematic review and meta-analysis

Approximately 70-85% of patients with resistant hypertension (RH) report obstructive sleep apnea (OSA). However, whether therapy with continuous positive airway pressure (CPAP) improves blood pressure (BP) in this population is not clear. We performed a systematic review and meta-analysis of randomized controlled trials (RCTs) to determine the efficacy of CPAP in patients with OSA and RH. Two reviewers performed the literature search, risk of bias analysis, and data extraction. The pooled data were analyzed in a meta-analysis using the DerSimonian-Laird method. We calculated the mean difference (MD) in systolic blood pressure (SBP) and diastolic blood pressure (DBP) measured at 24 h and in the daytime and nighttime. We also evaluated changes in aortic stiffness and aldosterone excretion. A total of 10 RCTs and 606 participants were included. CPAP was associated with changes in 24-h SBP (-5.06 mmHg; CI, -7.98, -2.13), 24-h DBP (-4.21 mmHg; CI, -6.5, -1.93), daytime SBP (-2.34 mmHg; CI, -6.94, +2.27), daytime DBP (-2.14 mmHg; CI, -4.96, -0.67), nighttime SBP (-4.15 mmHg; CI, -7.01, -1.29), and nighttime DBP (-1.95 mmHg; CI, -3.32, -0.57). We found no benefit for aortic stiffness, but it did lead to a mild reduction in aldosterone secretion. CPAP therapy improved BP, especially nighttime BP, in this population.

Summary and Update on Behavioral Interventions for Improving Adherence with Positive Airway Pressure Treatment in Adults

Continuous positive airway pressure (PAP) is still the most efficacious treatment for obstructive sleep apnea when used effectively. Since the availability of PAP 39 years ago there have been considerable technological advances, such as quieter, lighter and smaller machines with better humidification. However, adherence to treatment is still a major problem. This article reviews studies published on behavioral interventions aimed at improving the uptake and maintenance of PAP treatment (January 2016-February 2020). It discusses underlying factors in the poor uptake and discontinuation of treatment and the role of qualitative research to better understand the perspective of the patients.

Risk of mortality among patients with moderate to severe obstructive sleep apnea and diabetes mellitus: results from the SantOSA cohort

INTRODUCTION

Patients with obstructive sleep apnea (OSA) and comorbid diabetes mellitus (DM) are reported to have an increased risk of cardiovascular (CV) outcomes; however, data on CV mortality are scant.

AIM

This study aimed to evaluate if patients with comorbid OSA and DM have an increased risk of CV mortality that is higher than the two diseases in isolation.

METHODS

In this prospective cohort study, we included patients referred for a sleep study with and without DM at baseline. We developed four study groups as follows: group 1 (reference group), OSA (-) DM (-); group 2, OSA (-) DM (+); group 3, OSA (+) DM (-); group 4, OSA (+) DM (+). Intergroup differences were evaluated using the t test and χ² test, and multivariate analysis was performed using logistic regression. The incidence rates of CV mortality were calculated using the Kaplan-Meier (log-rank) model, and adjusted HRs were calculated using the Cox regression model.

RESULTS

A total of 1447 patients were included in the analysis-group 1: 441 participants; group 2: 141 participants; group 3: 736 participants; group 4: 151 participants. The mean follow-up was 5 years. The association between OSA + DM showed an independent risk of incident CV mortality (HR 2.37, CI 1.16-4.82, p = 0.02) and an increased prevalence of coronary heart disease (OR 3.44, CI 1.73-5.59, p < 0.01). In addition, T90% was also associated with CV mortality.

CONCLUSION

The coexistence of OSA + DM was associated with an independent risk of CV mortality. In addition, T90% was also associated with CV mortality.

EHR Integration of PAP Devices in Sleep Medicine Implementation in the Clinical Setting

Positive airway pressure (PAP) therapy integration is a component of electronic health record (EHR) sleep medicine optimization. EHR optimization facilitates telehealth in continuous care population health. A coordinated care plan can leverage early telehealth interventions.

Obstructive sleep apnoea, intermittent hypoxia and heart failure with a preserved ejection fraction

Obstructive sleep apnoea (OSA) is recognised to be a potent risk factor for hypertension, coronary heart disease, strokes and heart failure with a reduced ejection fraction. However, the association between OSA and heart failure with a preserved ejection fraction (HFpEF) is less well recognised. Both conditions are very common globally.It appears that there are many similarities between the pathological effects of OSA and other known aetiologies of HFpEF and its postulated pathophysiology. Intermittent hypoxia induced by OSA leads to widespread stimulation of the sympathetic nervous system, renin-angiotensin-aldosterone system and more importantly a systemic inflammatory state associated with oxidative stress. This is similar to the consequences of hypertension, diabetes, obesity and ageing that are the common precursors to HFpEF. The final common pathway is probably via the development of myocardial fibrosis and structural changes in collagen and myocardial titin that cause myocardial stiffening. Thus, considering the pathophysiology of OSA and HFpEF, OSA is likely to be a significant risk factor for HFpEF and further trials of preventive treatment should be considered.

CPAP adherence reduces cardiovascular risk among older adults with obstructive sleep apnea

STUDY OBJECTIVES

To examine (1) the impact of adherence to continuous positive airway pressure (CPAP) therapy on risk for cardiovascular (CVD) events among a nationally representative sample of older adults with obstructive sleep apnea (OSA), and (2) the heterogeneity of this effect across subgroups defined by race, sex, and socioeconomic status.

METHODS

We conducted a retrospective cohort study among Medicare beneficiaries aged ≥ 65 years with OSA (2009-2013). Monthly indicators of CPAP adherence (charges for machines, masks, or supplies) were summed over 25 months to create a CPAP adherence variable. New CVD events (ischemic heart disease, cardiac and peripheral procedures) were modeled as a function of CPAP adherence using generalized estimating equations. Heterogeneity of the effect of CPAP on new CVD events was evaluated based on race, sex, and socioeconomic status.

RESULTS

Among 5024 beneficiaries diagnosed with OSA who initiated CPAP, 1678 (33%) demonstrated new CVD events. Following adjustment for demographic and clinical characteristics, CPAP adherence was associated with reduced risk of new CVD events (hazard ratio 0.95; 95% confidence interval 0.94, 0.96) over 25 months. When analyses were stratified by time since the first CPAP charge, the protective effect remained significant for the 12- and 6-month, but not 3-month, outcome models. No significant differences were observed in the protective effect of CPAP based on race, sex, or socioeconomic status.

CONCLUSIONS

In this national study of older adult Medicare beneficiaries with OSA, CPAP adherence was associated with greatly reduced risk for CVD events. This risk reduction was consistent across race, sex, and socioeconomic subgroups.

Obstructive Sleep Apnoea Syndrome: Continuous Positive Airway Pressure Therapy for Prevention of Cardiovascular Risk

Obstructive sleep apnoea (OSA) syndrome is characterised by the presence of apnoea or obstructive hypopnoea during sleep, accompanied by hypoxia. It is estimated that the syndrome affects approximately 10% of men and 15% of women. Diagnosis and treatment rates have increased in recent years, but the condition remains undiagnosed in a high percentage of patients. Recent evidence suggests that OSA may increase the risk of cardiovascular disease. The relationship between OSA and cardiovascular disease can be explained, at least in part, by the coexistence of cardiovascular risk factors in the two pathologies, such as age, overweight, smoking and sedentary lifestyle. However, OSA has been independently associated with the risk of developing hypertension, cerebrovascular disease, ischaemic heart disease, heart failure and arrhythmias. Clinical trials that have evaluated the efficacy of continuous positive airway pressure (CPAP) treatment in primary and secondary cardiovascular prevention have not demonstrated a significant reduction in the incidence or recurrence of cardiovascular events. This article analyses the relationship between OSA and cardiovascular risk and discusses recent clinical trials on the efficacy of CPAP in primary and secondary cardiovascular prevention.

A CPAP data-based algorithm for automatic early prediction of therapy adherence

OBJECTIVE

Adherence is a critical issue in the treatment of obstructive sleep apnea with continuous positive airway pressure (CPAP). Approximately 40% of patients treated with CPAP are at risk of discontinuation or insufficient use (< 4 h/night). Assuming that the first few days on CPAP are critical for continued treatment, we tested the predictive value at day 14 (D14) of the Philips Adherence Profiler™ (AP) algorithm for adherence at 3 months (D90).

METHOD

The AP™ algorithm uses CPAP machine data hosted in the database of EncoreAnywhere™. This retrospective study involved 457 patients (66% men, 60.0 ± 11.9 years; BMI = 31.2 ± 5.9 kg/m²; AHI = 37.8 ± 19.2; Epworth score = 10.0 ± 4.8) from the Pays de la Loire Sleep Cohort. At D90, 88% of the patients were adherent as defined by a mean daily CPAP use of ≥ 4 h.

RESULTS

In a univariate analysis, the factors significantly associated with CPAP adherence at D90 were older age, lower BMI, CPAP adherence (≥ 4 h/night) at D14, and AP™ prediction at D14. In a multivariate analysis, only older age (OR 2.10 [1.29-3.41], p = 0.003) and the AP™ prediction at D14 (OR 16.99 [7.26-39.75], p < 0.0001) were significant predictors. CPAP adherence at D90 was not associated with device-derived residual events, nor with the levels of pressure or leakage except in the case of very significant leakage when it persisted for 90 days.

CONCLUSION

Automatic telemonitoring algorithms are relevant tools for early prediction of CPAP therapy adherence and may make it possible to focus therapeutic follow-up efforts on patients who are at risk of non-adherence.

Long-term Effect of CPAP Treatment on Cardiovascular Events in Patients With Resistant Hypertension and Sleep Apnea. Data From the HIPARCO-2 Study

BACKGROUND

There is some controversy about the effect of continuous positive airway pressure (CPAP) on the incidence of cardiovascular events (CVE). However, the incidence of CVE among patients with both obstructive sleep apnea (OSA) ans resistant hypertension (HR) has not been evaluated. Our objective was to analyze the long-term effect of CPAP treatment in patients with RH and OSA on the incidence of CVE.

METHODS

Multi-center, observational and prospective study of patients with moderate-severe OSA and RH. All the patients were followed up every 3-6 months and the CVE incidence was measured. Patients adherent to CPAP (at least 4h/day) were compared with those with not adherent or those who had not been prescribed CPAP.

RESULTS

Valid data were obtained from 163 patients with 64 CVE incidents. Treatment with CPAP was offered to 82%. After 58 months of follow-up, 58.3% of patients were adherent to CPAP. Patients not adherent to CPAP presented a non-significant increase in the total CVE incidence (HR:1.6; 95%CI: 0.96-2.7; p=0.07). A sensitivity analysis showed that patients not adherent to CPAP had a significant increase in the incidence of cerebrovascular events (HR: 3.1; CI95%: 1.07-15.1; p=0.041) and hypertensive crises (HR: 5.1; CI95%: 2.2-11.6; p=0.006), but the trend went in the opposite direction with respect to coronary events (HR: 0.22; CI95%: 0.05-1.02; p=0.053).

CONCLUSIONS

In patients with RH and moderate-severe OSA, an uneffective treatment with CPAP showed a trend toward an increase in the incidence of CVE (particularly neurovascular events and hypertensive crises) without any changes with respect to coronary events.

Obstructive sleep apnea and cardiovascular disease, a story of confounders!

Obstructive sleep apnea (OSA) syndrome is increasingly common among middle aged and older adults and is frequently linked to most cardiovascular diseases (CVD). Sleep-disordered breathing and CVD share a number of common risk factors and comorbid conditions including obesity, male gender, advancing age, metabolic syndrome, and hypertension. OSA appears to be associated with worsened CVD outcomes, sleep-related symptoms, quality of life, and risk of motor vehicle accidents. Demonstrating a cause-and-effect relationship between CVD and OSA has been challenging due to shared comorbidities. Strong evidence demonstrating clinically significant benefit for OSA treatments on OSA-related CVD outcomes are limited. In this review, we evaluate potential pathophysiologic mechanisms that link OSA to CVD and focus on specific treatments for OSA, including positive airway pressure (PAP), dental devices, and surgeries with regard to OSA-related CVD outcomes.

The impact of obstructive sleep apnea and PAP therapy on all-cause and cardiovascular mortality based on age and gender - a literature review

BACKGROUND

Obstructive sleep apnea (OSA) is a common sleep disorder which negatively impacts different body systems, especially the cardiovascular system. The correlation between sleep related breathing disorders and cardiovascular diseases has been well studied. However, the impact of OSA on cardiovascular related mortality and the role of positive airway pressure therapy in decreasing mortality is unclear. We reviewed studies investigating the impact of OSA on all-cause and cardiovascular related mortality in both genders, and in different age groups.

METHODS

A literature search (PubMed) using two phrases "obstructive sleep apnea and co-morbidities in males and females" and "obstructive sleep apnea and co-morbidities by age" yielded a total of 214 articles. Nineteen articles met the inclusion criteria.

RESULTS

The studies reviewed showed conflicting results. Some showed that OSA increases all cause and cardiovascular related mortality predominantly in the middle-aged group (40-65) followed by a plateau or a reduction in mortality. Other studies showed a positive linear correlation between OSA and mortality up to the age of 80. The same controversy was noted for gender; some studies did not observe an increase in mortality in females with OSA, while others observed a trend for an increase in mortality in females.

CONCLUSION

There is a debate in the literature regarding the impact of OSA on all-cause and cardiovascular mortality in both genders and in different age groups. However, the variation in results might be related to different study designs and significant epidemiological prevalence of OSA in males and females.