CONTINUOUS positive airway pressure (CPAP) treatment reduces major cardiovascular and cerebrovascular events in patients with high-risk obstructive sleep apnoea (OSA), while it may cause harm in those with low-risk OSA, a new study has shown.
Obstructive sleep apnoea disrupts breathing during sleep and is linked to heightened cardiovascular risks such as heart attacks and strokes. Although CPAP is a common therapy for OSA, previous trials showed mixed results regarding its cardiovascular benefits. This large multi-trial analysis aimed to clarify whether CPAP’s protective effects are more pronounced in patients classified as having high-risk OSA, defined by specific heart rate and oxygen desaturation measures during sleep.
The study pooled data from 3,549 participants across three randomized trials, comparing CPAP treatment with usual care. High-risk OSA was identified by heart rate increases exceeding 9.4 beats per minute or hypoxic burden above 87.1 per cent minutes per hour. Overall, 16.6% of CPAP users and 16.3% of usual care patients reached the primary endpoint of major adverse cardiovascular and cerebrovascular events (MACCE), which included cardiovascular death, myocardial infarction, and stroke. However, in those with high-risk OSA, CPAP reduced MACCE risk significantly (interaction hazard ratio 0.69; 95% confidence interval 0.50–0.95). This protective effect was stronger in patients without excessive sleepiness (iHR 0.59) or without elevated blood pressure (iHR 0.54). Notably, CPAP was associated with harm in low-risk OSA patients, which may offset benefits observed at the population level.
These results suggest CPAP should be targeted to patients with high-risk OSA to improve cardiovascular outcomes effectively. Clinicians should consider OSA severity markers when prescribing CPAP and monitor patient response carefully. Future research is needed to refine risk stratification and understand mechanisms behind differential CPAP effects to guide personalised treatment strategies.
Reference
Azarbarzin A et al. Cardiovascular benefit of continuous positive airway pressure according to high-risk obstructive sleep apnoea: a multi-trial analysis. European Heart Journal. 2025;ehaf447.
