BACKGROUND: Data regarding the effect of positive airway pressure (PAP) therapy for obstructive sleep apnoea (OSA) on all-cause mortality are inconsistent. We aimed to conduct a systematic review and meta-analysis to test the hypothesis that PAP therapy is associated with reduced all-cause and cardiovascular mortality in people with OSA.
METHODS: For this systematic review and meta-analysis, we searched PubMed, Embase, and the Cochrane Central Register of Controlled Trials, from database inception to Aug 22, 2023 (updated Sept 9, 2024), with no language or geographical restrictions. Reference lists of eligible studies and recent conference abstracts (2022-23) were also reviewed. We included outpatient studies (randomised controlled trials [RCTs] or confounder-adjusted, non-randomised controlled studies [NRCSs]) assessing the incidence of all-cause mortality, cardiovascular mortality, or both in adults (aged =18 years) with OSA who were treated versus not treated with PAP; other study types and studies that evaluated only PAP adherence were excluded. Abstracts of all retrieved publications were independently screened by two of three researchers (BS, SRB, and KCW), with disagreements resolved by adjudication from another researcher (SHM). The AutoLit feature of the Nested Knowledge platform was used for the review and data-extraction phases. We analysed each log-transformed hazard ratio (HR) and SE using a linear random-effects model to estimate overall HRs and 95% CIs. To evaluate the risk of bias, we used the Cochrane Risk of Bias tool for RCTs and the Newcastle-Ottawa Scale for NRCSs. This study was registered with PROSPERO, CRD42023456627.
FINDINGS: Of 5484 records identified by our search, 435 were assessed for eligibility and 30 studies were included in the systematic review and meta-analysis (ten RCTs and 20 NRCSs). These studies included 1 175 615 participants, of whom 905 224 (77%) were male and 270 391 (23%) were female (SE 1·9), with a mean age of 59·5 (SE 1·4) years and a mean follow-up of 5·1 (0·5) years. The risk of bias was low to moderate. The risk of all-cause mortality (HR 0·63, 95% CI 0·56-0·72; p<0·0001) and cardiovascular mortality (0·45, 0·29-0·72; p<0·0001) was significantly lower in the PAP group than in the no-PAP group, and the clinically relevant benefit of PAP therapy increased with use.
INTERPRETATION: Our results are consistent with a potentially beneficial effect of PAP therapy on all-cause and cardiovascular mortality in patients with OSA. Patients should be made aware of this effect of their treatment, which could result in greater acceptance of treatment initiation and greater adherence, leading to a higher likelihood of improved outcomes.
FUNDING: ResMed.
| Discipline Area | Score |
|---|---|
| Family Medicine (FM)/General Practice (GP) |  |
| General Internal Medicine-Primary Care(US) | |
| Cardiology | |
| Respirology/Pulmonology | |
Great meta-analysis and systematic review with good evidence supporting PAP.
A large meta-analysis confirming an association of PAP use with lower cardiovascular and all-cause mortality. It's important to note that studies have not yet demonstrated a direct link between PAP use and improved mortality.
Known benefits from PAP therapy on mortality but this study does it on a large scale.
This meta-analysis finds that in patients with obstructive sleep apnea, treatment with positive airway pressure was associated with reduced all-cause and cardiovascular mortality. The meta-analysis pooled RCTs and observational studies and the results are strongly driven by the latter, which contributed more weight and showed much stronger effects (as usual) that RCTs, which on their own were unable to confirm reductions in mortality. Pooling was therefore likely inappropriate and there is no reporting of statistical heterogeneity (P values for interaction are not the best way to analyze this). Otherwise, all of this is known already by most clinicians
The knowledge gained by reviewing this analysis improves my advice when encouraging my patients to remain compliant with home PAP therapy.
The statistical methodology never translates into useful clinical information. How many people need treatment to save one life, for how many years, and at what total cost to prevent one death? Totally useless for clinicians.
