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Review
. 2024 Sep 24;84(13):1224-1240.
doi: 10.1016/j.jacc.2024.07.024.

Treatment of OSA and its Impact on Cardiovascular Disease, Part 2: JACC State-of-the-Art Review

Shahrokh Javaheri  1 , Sogol Javaheri  2 , David Gozal  3 , Francisco Campos-Rodriguez  4 , Miguel Angel Martinez-Garcia  5 , Babak Mokhlesi  6 , Reena Mehra  7 , Walter T McNicholas  8 , Virend K Somers  9 , Phyllis C Zee  10 , Peter Cistulli  11 , Atul Malhotra  2
Affiliations
Review

Treatment of OSA and its Impact on Cardiovascular Disease, Part 2: JACC State-of-the-Art Review

Shahrokh Javaheri et al. J Am Coll Cardiol. .

Abstract

Many studies have shown an association of obstructive sleep apnea (OSA) with incident cardiovascular diseases, particularly when comorbid with insomnia, excessive sleepiness, obesity hypoventilation syndrome, and chronic obstructive pulmonary disease. Randomized controlled trials (RCTs) have demonstrated that treatment of OSA with positive airway pressure devices (CPAP) improves systemic hypertension, particularly in those with resistant hypertension who are adherent to CPAP. However, large RCTs have not shown long-term benefits of CPAP on hard cardiovascular outcomes, but post hoc analyses of these RCTs have demonstrated improved hard outcomes in those who use CPAP adequately. In theory, low CPAP adherence and patient selection may have contributed to neutral results in intention-to-treat analyses. Only by further research into clinical, translational, and basic underlying mechanisms is major progress likely to continue. This review highlights the various treatment approaches for sleep disorders, particularly OSA comorbid with various other disorders, the potential reasons for null results of RCTs treating OSA with CPAP, and suggested approaches for future trials.

Keywords: CPAP; OSA; hypoventilation syndrome; noninvasive ventilation; obesity.

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Conflict of interest statement

Funding Support and Author Disclosures ResMed provided a philanthropic donation to UC San Diego. Dr Shahrokh Javaheri has received income related to medical education from Res Med, Jazz, Idorsia, Eli Lilly, and Avadel Pharmaceutical; and is a consultant to Zoll-Respicardia. Dr Sogol Javaheri has received grant funding from Zoll and the Massachusetts Technology Collaborative; and is supported by an internal health equity grant from Harvard Medical School. Dr Mehra has received an honorarium from the American Academy of Sleep Medicine; has received funds for service on the American Board of Internal Medicine writing group; has received NIH funding; and has received royalties from Up to Date. Dr Somers is supported by National Institutes of Health (NIH) grant HL65176; has served as a consultant for Bayer, Jazz Pharmaceuticals, Huxley, Apnimed, ResMed, Lilly, and Respicardia; and is on the Sleep Number Scientific Advisory Board. Dr Zee is a consultant to Eisai, Idorsia, Jazz, and Harmony; and has received institutional grants from Vanda and Sleep Number. Dr Cistulli has an appointment to an endowed academic Chair at the University of Sydney that was established from ResMed funding; has received research support from ResMed and SomnoMed; is a consultant to ResMed, SomnoMed, Signifier Medical Technologies, Bayer, and Sunrise Medical; and has a pecuniary interest in SomnoMed related to a role in research and development (2004). Dr Malhotra is funded by the NIH; and has received income related to medical education from Powell Mansfield, Livanova, Eli Lilly, and Zoll. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Figures

CENTRAL ILLUSTRATION
CENTRAL ILLUSTRATION. Phenotypic Therapeutic Options in Obstructive Sleep Apnea
The figure depicts various mechanisms which could be target of therapy in obstructive sleep apnea. Although continuous positive airway pressure (CPAP) device is the most effective therapeutic option, other variables could also be targeted as depicted. HGN = hypoglossal nerve.
FIGURE 1
FIGURE 1. Effect of CPAP Therapy on BP in Patients With Resistant Hypertension
The figure includes the results of the randomized controlled trials published to date. Positive figures mean improvement in blood pressure (BP) level with continuous positive airway pressure (CPAP) treatment (net changes). From Javaheri et al. DBP = diastolic blood pressure; SBP = systolic blood pressure.
FIGURE 2
FIGURE 2. Prevalence and Evolution of PH in the Pickwick Trial
This figure shows a significant drop in the prevalence of pulmonary hypertension (PH), which was sustained through the 3-year follow-up. Adapted from Masa et al and Mokhlesi et al. CPAP = continuous positive airway pressure; NIV = noninvasive ventilation.
FIGURE 3
FIGURE 3. CPAP Treatment of OSA in the Overlap Syndrome Improves Survival
Long-term outcome study showing that patients with overlap syndrome and moderate or severe obstructive sleep apnea (OSA) treated with continuous positive airway pressure (CPAP) have similar survival rates to those with chronic obstructive pulmonary disease (COPD) alone, whereas those patients with overlap syndrome (COPD with OSA) not treated with CPAP had higher mortality, especially from cardiovascular disease. Adapted with permission of the American Thoracic Society.
FIGURE 4
FIGURE 4. Effective Use of CPAP Improves Cerebrocardiovascular Outcomes and All-Cause Mortality
The y-axis shows the risk ratio (RR) with 95% CI; the x-axis shows the different types of individual and composite cardiovascular (CV) events. *P < 0.05. Reprinted with permission of the American Thoracic Society. AMI = acute myocardial infarction; CCVE = cardiocerebrovascular event; CPAP = continuous positive airway pressure; HF = heart failure; MACCE = major adverse cardiocerebrovascular events; TIA = transient ischemic attack.
See this image and copyright information in PMC

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