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Clinical Question

Does positive airway pressure (PAP) for adults with sleep apnea reduce cardiovascular (CV) disease morbidity and mortality?

Bottom Line

The use of PAP for adults with sleep apnea does not reduce adverse CV events or mortality. Patients who experience daytime fatigue at baseline benefit from reduced sleepiness and improved physical and mental well-being. Order sleep testing only in patients with signs or symptoms of sleep apnea who also experience clinically significant symptoms of daytime fatigue. No one else will benefit. (Level of Evidence = 1a)

Synopsis

These investigators thoroughly searched multiple databases including Medline, Embase, and the Cochrane Library, as well as reference lists from clinical trials, review articles, conference abstracts, and the clinicaltrials.gov website. Eligible studies included randomized clinical trials that assessed the use of PAP compared with standard care or sham PAP among adults, 18 years or older, with obstructive sleep apnea (OSA) or central sleep apnea (CSA). No language restrictions were applied. Two individuals independently assessed studies for inclusion criteria and for methodologic quality using a standard risk of bias assessment tool. Disagreements were resolved by consensus.

A total of 10 studies that assessed the use of PAP in adults (N = 7,266) with OSA and CSA met the inclusion criteria—nine evaluated continuous PAP and one evaluated adaptive servo-ventilation. The overall risk of bias was low to medium; all studies concealed allocation assignment and masked outcomes assessment. No significant associations occurred between the use of PAP and major adverse CV events, CV mortality, or all-cause mortality in patients with OSA or CSA. In addition, there was no significant association with length of follow-up, adherence with using PAP, and baseline apnea-hypopnea index. The use of PAP was significantly associated with improvements in sleepiness and quality of life. A formal analysis found no evidence of publication bias and minimal heterogeneity of assessed outcomes.

Study design: Meta-analysis (randomized controlled trials)

Funding source: Government

Setting: Various (meta-analysis)

Reference:YuJZhouZMcEvoyRDet alAssociation of positive airway pressure with cardiovascular events and death in adults with sleep apnea: a systematic review and meta-analysis. JAMA2017;318(2):156–166.

POEMs (patient-oriented evidence that matters) are provided by Essential Evidence Plus, a point-of-care clinical decision support system published by Wiley-Blackwell. For more information, see http://www.essentialevidenceplus.com. Copyright Wiley-Blackwell. Used with permission.

For definitions of levels of evidence used in POEMs, see http://www.essentialevidenceplus.com/product/ebm_loe.cfm?show=oxford.

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This series is coordinated by Sumi Sexton, MD, editor-in-chief.

A collection of POEMs published in AFP is available at https://www.aafp.org/afp/poems.

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