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- Title
Adherence to CPAP Treatment and the Risk of Recurrent Cardiovascular Events: A Meta-Analysis.
- Authors
Sánchez-de-la-Torre, Manuel; Gracia-Lavedan, Esther; Benitez, Ivan D.; Sánchez-de-la-Torre, Alicia; Moncusí-Moix, Anna; Torres, Gerard; Loffler, Kelly; Woodman, Richard; Adams, Robert; Labarca, Gonzalo; Dreyse, Jorge; Eulenburg, Christine; Thunström, Erik; Glantz, Helena; Peker, Yüksel; Anderson, Craig; McEvoy, Doug; Barbé, Ferran
- Abstract
Key Points: Question: Is continuous positive airway pressure (CPAP) treatment for obstructive sleep apnea (OSA) associated with a decreased risk of cardiovascular adverse events in participants with both OSA and established cardiovascular disease? Findings: This systematic review and individual participant data (IPD) meta-analysis of 3 randomized clinical trials including 4186 patients with IPD showed that whereas the IPD meta-analysis based on intention to treat reported no effect of CPAP treatment, the adherent use of CPAP treatment (≥4 hours/day) is associated with a reduced recurrence risk of major adverse cardiac or cerebrovascular events (MACCEs) with a significant hazard ratio of 0.69. Meaning: Patients with established cardiovascular disease and OSA who used CPAP for 4 or more hours per day had a significantly lower risk of MACCEs than those who used CPAP less than 4 hours per day. Importance: The effect of continuous positive airway pressure (CPAP) on secondary cardiovascular disease prevention is highly debated. Objective: To assess the effect of CPAP treatment for obstructive sleep apnea (OSA) on the risk of adverse cardiovascular events in randomized clinical trials. Data Sources: PubMed (MEDLINE), EMBASE, Current Controlled Trials: metaRegister of Controlled Trials, ISRCTN Registry, European Union clinical trials database, CENTRAL (Cochrane Central Register of Controlled Trials), and ClinicalTrials.gov databases were systematically searched through June 22, 2023. Study Selection: For qualitative and individual participant data (IPD) meta-analysis, randomized clinical trials addressing the therapeutic effect of CPAP on cardiovascular outcomes and mortality in adults with cardiovascular disease and OSA were included. Data Extraction and Synthesis: Two reviewers independently screened records, evaluated potentially eligible primary studies in full text, extracted data, and cross-checked errors. IPD were requested from authors of the selected studies (SAVE [NCT00738179], ISAACC [NCT01335087], and RICCADSA [NCT00519597]). Main Outcomes and Measures: One-stage and 2-stage IPD meta-analyses were completed to estimate the effect of CPAP treatment on risk of recurrent major adverse cardiac and cerebrovascular events (MACCEs) using mixed-effect Cox regression models. Additionally, an on-treatment analysis with marginal structural Cox models using inverse probability of treatment weighting was fitted to assess the effect of good adherence to CPAP (≥4 hours per day). Results: A total of 4186 individual participants were evaluated (82.1% men; mean [SD] body mass index, 28.9 [4.5]; mean [SD] age, 61.2 [8.7] years; mean [SD] apnea-hypopnea index, 31.2 [17] events per hour; 71% with hypertension; 50.1% receiving CPAP [mean {SD} adherence, 3.1 {2.4} hours per day]; 49.9% not receiving CPAP [usual care], mean [SD] follow-up, 3.25 [1.8] years). The main outcome was defined as the first MACCE, which was similar for the CPAP and no CPAP groups (hazard ratio, 1.01 [95% CI, 0.87-1.17]). However, an on-treatment analysis by marginal structural model revealed a reduced risk of MACCEs associated with good adherence to CPAP (hazard ratio, 0.69 [95% CI, 0.52-0.92]). Conclusions and Relevance: Adherence to CPAP was associated with a reduced MACCE recurrence risk, suggesting that treatment adherence is a key factor in secondary cardiovascular prevention in patients with OSA. This meta-analysis of 3 randomized clinical trials assesses the effect of continuous positive airway pressure treatment for obstructive sleep apnea on the risk of adverse cardiovascular events.
- Subjects
EUROPEAN Union; CONTINUOUS positive airway pressure; PATIENT compliance; CARDIOVASCULAR diseases; TREATMENT effectiveness; CARDIOVASCULAR diseases risk factors; STATISTICAL models
- Publication
JAMA: Journal of the American Medical Association, 2023, Vol 330, Issue 13, p1255
- ISSN
0098-7484
- Publication type
Article
- DOI
10.1001/jama.2023.17465