Cardiovascular benefit of continuous positive airway pressure according to high-risk obstructive sleep apnoea : a multi-trial analysis
(2026) In European Heart Journal 47(17). p.2077-2089- Abstract
Background and Aims: Randomized trials of continuous positive airway pressure (CPAP) treatment for obstructive sleep apnoea (OSA) in patients with cardiovascular disease have not detected reduced risk of major adverse cardiovascular and cerebrovascular events (MACCEs). This study tested whether the cardiovascular benefit of CPAP occurs preferentially in high-risk OSA, characterized by greater OSA-related heart rate acceleration or hypoxaemia. Methods: In a post hoc analysis of pooled Randomized Intervention with Continuous Positive Airway Pressure in Coronary Artery Disease and Obstructive Sleep Apnoea, Impact of Continuous Positive Airway Pressure on Patients with Acute Coronary Syndrome and Nonsleepy Obstructive Sleep Apnoea, and... (More)
Background and Aims: Randomized trials of continuous positive airway pressure (CPAP) treatment for obstructive sleep apnoea (OSA) in patients with cardiovascular disease have not detected reduced risk of major adverse cardiovascular and cerebrovascular events (MACCEs). This study tested whether the cardiovascular benefit of CPAP occurs preferentially in high-risk OSA, characterized by greater OSA-related heart rate acceleration or hypoxaemia. Methods: In a post hoc analysis of pooled Randomized Intervention with Continuous Positive Airway Pressure in Coronary Artery Disease and Obstructive Sleep Apnoea, Impact of Continuous Positive Airway Pressure on Patients with Acute Coronary Syndrome and Nonsleepy Obstructive Sleep Apnoea, and Sleep Apnoea Cardiovascular Endpoints Study randomized trials; outcomes were stratified by high-risk OSA status, defined by heart rate response following OSA respiratory events >9.4 b.p.m. (third tertile) or oxygen desaturation area under baseline (hypoxic burden) > 87.1% min/h (third tertile). Cox mixed models quantified the CPAP treatment effect on MACCE (including cardiovascular mortality, myocardial infarction, and stroke) within high-risk OSA and the difference vs low-risk status (primary test). Secondary analyses examined participants without excessive sleepiness (Epworth <11 points) or without increased blood pressure (systolic/diastolic <140/90 mmHg). Results: In 3549 participants, 16.6% and 16.3% reached the MACCE endpoint with CPAP (n = 1778) and usual care (n = 1771), respectively. The CPAP treatment effect was greater in participants with vs without high-risk OSA [interaction hazard ratio (iHR) .69, 95% confidence interval (CI) .50–.95, Pinteraction = .024; Nhigh-risk = 1832]. The differential effect was stronger in those without excessive sleepiness (iHR .59, 95% CI .41–.84; Nhigh-risk = 1509), or without increased blood pressure (iHR .54, 95% CI .36–.81; Nhigh-risk = 1244). Continuous positive airway pressure benefits in high-risk OSA were observed alongside harm in low-risk OSA. Conclusions: Continuous positive airway pressure preferentially improves cardiovascular outcomes in high-risk OSA, while harm in low-risk OSA may counteract this effect. These findings provide a pathway to identify patients likely to benefit.
(Less)
- author
- organization
- publishing date
- 2026-05-01
- type
- Contribution to journal
- publication status
- published
- subject
- keywords
- Heart rate response, Hypoxic burden, MACCE, Obstructive sleep apnoea, Phenotype, Precision medicine
- in
- European Heart Journal
- volume
- 47
- issue
- 17
- pages
- 13 pages
- publisher
- Oxford University Press
- external identifiers
-
- scopus:105037864316
- pmid:40794640
- ISSN
- 0195-668X
- DOI
- 10.1093/eurheartj/ehaf447
- language
- English
- LU publication?
- yes
- additional info
- Publisher Copyright: © The Author(s) 2025. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/pages/standard-publication-reuse-rights)
- id
- b756e225-4468-4511-804f-815871b9d3ea
- date added to LUP
- 2026-07-16 14:38:18
- date last changed
- 2026-08-27 20:54:13
@article{b756e225-4468-4511-804f-815871b9d3ea,
abstract = {{<p>Background and Aims: Randomized trials of continuous positive airway pressure (CPAP) treatment for obstructive sleep apnoea (OSA) in patients with cardiovascular disease have not detected reduced risk of major adverse cardiovascular and cerebrovascular events (MACCEs). This study tested whether the cardiovascular benefit of CPAP occurs preferentially in high-risk OSA, characterized by greater OSA-related heart rate acceleration or hypoxaemia. Methods: In a post hoc analysis of pooled Randomized Intervention with Continuous Positive Airway Pressure in Coronary Artery Disease and Obstructive Sleep Apnoea, Impact of Continuous Positive Airway Pressure on Patients with Acute Coronary Syndrome and Nonsleepy Obstructive Sleep Apnoea, and Sleep Apnoea Cardiovascular Endpoints Study randomized trials; outcomes were stratified by high-risk OSA status, defined by heart rate response following OSA respiratory events >9.4 b.p.m. (third tertile) or oxygen desaturation area under baseline (hypoxic burden) > 87.1% min/h (third tertile). Cox mixed models quantified the CPAP treatment effect on MACCE (including cardiovascular mortality, myocardial infarction, and stroke) within high-risk OSA and the difference vs low-risk status (primary test). Secondary analyses examined participants without excessive sleepiness (Epworth <11 points) or without increased blood pressure (systolic/diastolic <140/90 mmHg). Results: In 3549 participants, 16.6% and 16.3% reached the MACCE endpoint with CPAP (n = 1778) and usual care (n = 1771), respectively. The CPAP treatment effect was greater in participants with vs without high-risk OSA [interaction hazard ratio (iHR) .69, 95% confidence interval (CI) .50–.95, P<sub>interaction</sub> = .024; N<sub>high-risk</sub> = 1832]. The differential effect was stronger in those without excessive sleepiness (iHR .59, 95% CI .41–.84; N<sub>high-risk</sub> = 1509), or without increased blood pressure (iHR .54, 95% CI .36–.81; N<sub>high-risk</sub> = 1244). Continuous positive airway pressure benefits in high-risk OSA were observed alongside harm in low-risk OSA. Conclusions: Continuous positive airway pressure preferentially improves cardiovascular outcomes in high-risk OSA, while harm in low-risk OSA may counteract this effect. These findings provide a pathway to identify patients likely to benefit.</p>}},
author = {{Azarbarzin, Ali and Vena, Daniel and Esmaeili, Neda and Wellman, Andrew and Pinilla, Lucía and Messineo, Ludovico and Zinchuk, Andrey and Alex, Raichel and Baumert, Mathias and Loffler, Kelly A. and Anderson, Craig S. and White, David P. and Redline, Susan and Gottlieb, Daniel J. and Barbé, Ferran and Peker, Yuksel and Sánchez-de-la-Torre, Manuel and McEvoy, Doug and Sands, Scott A.}},
issn = {{0195-668X}},
keywords = {{Heart rate response; Hypoxic burden; MACCE; Obstructive sleep apnoea; Phenotype; Precision medicine}},
language = {{eng}},
month = {{05}},
number = {{17}},
pages = {{2077--2089}},
publisher = {{Oxford University Press}},
series = {{European Heart Journal}},
title = {{Cardiovascular benefit of continuous positive airway pressure according to high-risk obstructive sleep apnoea : a multi-trial analysis}},
url = {{http://dx.doi.org/10.1093/eurheartj/ehaf447}},
doi = {{10.1093/eurheartj/ehaf447}},
volume = {{47}},
year = {{2026}},
}