CPAP for Nonsleepy Obstructive Sleep Apnea?

Summary and Comment |
September 8, 2016

CPAP for Nonsleepy Obstructive Sleep Apnea?

  1. Kirsten E. Fleischmann, MD, MPH

Continuous positive airway pressure relieves daytime sleepiness, but it might not improve CV outcomes.

  1. Kirsten E. Fleischmann, MD, MPH

In a recent trial of 2717 patients with obstructive sleep apnea (OSA) and cardiovascular (CV) disease, treatment with continuous positive airway pressure (CPAP) did not improve cardiovascular outcomes but did improve snoring, daytime sleepiness, quality of life, and mood (NEJM JW Gen Med Oct 1 2016 and N Engl J Med 2016 Aug 28; [e-pub]). That trial excluded patients with severe daytime sleepiness but permitted enrollment of nonsleepy or mild-to-moderately sleepy patients. Now, researchers have conducted a trial in which 244 patients with recently revascularized coronary disease and OSA (apnea-hypopnea index ≥15/hour) — but exclusively without daytime sleepiness — received CPAP or no CPAP.

After median follow-up of 57 months, incidence of the primary composite CV endpoint (repeat revascularization, myocardial infarction, stroke, or cardiovascular-related mortality) was similar in the CPAP and no-CPAP groups (18 vs. 22%; P=0.45). However, those who used CPAP ≥4 hours nightly had significantly lower CV risk than those who did not receive treatment or who used CPAP <4 hours nightly (hazard ratio, 0.29). Of note, 30 participants in the CPAP group returned their devices within 3 months of enrollment.

Comment

Among OSA patients without daytime sleepiness, CPAP showed no significant benefit for cardiovascular outcomes. Although participants who adhered to CPAP therapy did seem to benefit, the authors caution that the on-treatment analysis should be interpreted with caution, because adherence to CPAP could be a marker for other factors associated with better outcomes. Importantly, in the above-mentioned much-larger trial, CPAP did not improve CV outcomes regardless of adherence, and the mean Epworth sleepiness score in that trial (7.4, on a 24-point scale) was not so different from that of the current study (5.5). Editorialists note that interventions are needed to optimize adherence and to study OSA therapies other than CPAP (e.g., mandibular advancement devices). At least for now, OSA treatment should be prescribed to improve daytime sleepiness and other symptoms of OSA, but it might not improve CV outcomes.

Editor Disclosures at Time of Publication

  • Disclosures for Kirsten E. Fleischmann, MD, MPH at time of publication Grant / Research support NIH/NHLBI; Bluefield Project to Cure Frontotemporal Dementia Leadership positions in professional societies American College of Cardiology and American Heart Association (Vice Chair, Writing Committee for Guidance on Cardiovascular Evaluation and Care for Noncardiac Surgery)

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