All-cause, cardiovascular mortality risks in OSA fall with positive airway pressure use
Key takeaways:
- Researchers have demonstrated that positive airway pressure therapy for OSA has a mortality benefit.
- The risk for mortality was lower with more hours of PAP use.
Use of positive airway pressure therapy decreased the risk for all-cause and cardiovascular mortality in adults with obstructive sleep apnea, according to findings published in The Lancet Respiratory Medicine.
“This is another key piece of evidence to show health systems, caregivers, people themselves even before they become patients, [OSA] is a really important disorder,” Carlos Nunez, MD, chief medical officer of ResMed, said during a media briefing. “It’s a condition that you should treat, and it’s an easy one to treat because ... nearly 90% of people can do it if they’re just given the right support.”
The mortality findings from this study are “an incentive for people to use [CPAP] treatment if they know it’s going to save lives or prevent heart attacks,” Atul Malhotra, MD, research chief of pulmonary, critical care and sleep medicine at the University of California San Diego School of Medicine, pulmonologist at UC San Diego Health and senior author, said during the briefing.
Healio previously reported on this study when it was presented at the 2024 American Thoracic Society International Conference.
After searching through three databases from inception to Sept. 9, 2024, as well as 2022 and 2023 conference abstracts, Malhotra and colleagues assessed 30 outpatient studies, including 10 randomized controlled trials (RCTs) and 20 confounder-adjusted nonrandomized controlled studies (NRCSs) totaling 1,175,615 adults (mean age, 59.5 years; 77% men) with OSA, to uncover the impact of PAP therapy on risk for mortality.
Studies compared all-cause and/or cardiovascular mortality rates of patients treated with PAP and patients without PAP.
“We know [CPAP] makes people feel better,” Malhotra said. “It’s been associated with improvements in blood pressure and reduced risk of motor vehicle accidents, but in terms of is it saving lives, we didn’t know. That’s why we did this analysis.”
Researchers used the Cochrane Risk of Bias tool to determine this risk in RCTs, whereas the Newcastle-Ottawa Scale was used in NRCSs. These assessments found a low to moderate risk of bias.
When divided by study type, patient sex in the all-cause mortality analysis significantly differed between the RCTs and NRCSs (men, 81.4% vs. 74.1%; P = .041), whereas no significant differences were reported in age (mean, 61.7 years vs. 59.6 years), race (white, 60.4% vs. 82.6%), BMI (29.1 kg/m2 vs. 30.5 kg/m2) and baseline apnea-hypopnea index (AHI; 32.5 events per hour vs. 34.8 events per hour).
In the cardiovascular mortality analysis, the RCTs and NRCSs did not significantly differ by sex (men, 81.4% vs. 77.6%), age (mean, 60.8 years vs. 55.2 years), BMI (29.5 kg/m2 vs. 31.4 kg/m2) or baseline AHI (33.2 events per hour vs. 31.4 events per hour). For race, only one RCT and one NRCS captured this data (white, 25.2% vs. 71%), and no P value was reported, according to the study.
Notably, both mortality analyses showed that NRCSs vs. RCTs had significantly better mean PAP adherence per night (all-cause, 6 hours vs. 3.6 hours; cardiovascular, 6.2 hours vs. 3.8 hours). Additionally, researchers observed that NRCSs had significantly longer average follow-up times (all-cause, 5.8 years vs. 3 years; cardiovascular, 6.9 years vs. 3.8 years).
When including all studies, receipt of PAP therapy significantly reduced the risk for all-cause mortality vs. no PAP (HR = 0.63; 95% CI, 0.56-0.72), and this was also true for the risk for cardiovascular mortality (HR = 0.45; 95% CI, 0.29-0.72), according to the study.
Researchers continued to find that PAP treatment significantly decreased the risk for all-cause mortality (HR = 0.6; 95% CI, 0.52-07) and cardiovascular mortality (HR = 0.35; 95% CI, 0.21-0.58) vs. without PAP when evaluating the NRCSs.
During the assessment of the RCTs, patients treated with vs. without PAP therapy had a non-significant decreased risk for all-cause mortality and cardiovascular mortality, according to the study.
Researchers further found that the risk for all-cause mortality was lower with more hours of PAP use in both the RCTs (2 hours/night, HR = 0.95; 4 hours/night, HR = 0.84; 6 hours/night, HR = 0.74) and the NRCSs (2 hours/night, HR = 0.57; 4 hours/night, HR = 0.5; 6 hours/night, HR = 0.44).
The study highlighted that the same pattern was observed with regard to cardiovascular mortality risk in RCTs (2 hours/night, HR = 0.79; 4 hours/night, HR = 0.78; 6 hours/night, HR = 0.76) and NCRSs (2 hours/night, HR = 0.25; 4 hours/night, HR = 0.24; 6 hours/night, HR = 0.24).
“There’s a billion people with obstructive sleep apnea,” Nunez said during the briefing. “It’s one of the most prevalent conditions in people, and 80% are undiagnosed and not treated.”
According to Nunez, there is currently “a once in a generation opportunity” for sleep apnea awareness due to three factors, one of which is the rise in wearables monitoring and tracking sleep.
“There is now big tech involved in sleep apnea,” Nunez said. “Both Samsung and Apple, the two largest consumer companies in the world, have wearables that you can buy without a prescription that can detect whether or not you’re at risk for sleep apnea.”
On the topic of wearables, Malhotra noted that they are not diagnostic devices but aid in raising awareness.
Nunez’s second factor aligns with the FDA’s approval of Zepbound (tirzepatide, Eli Lilly) for adults with moderate to severe OSA and obesity in December 2024.
“We have new advances in obesity therapy which are shining a light on how obesity and obstructive sleep apnea are connected as conditions,” Nunez said.
The final factor for why there is “a once in a generation opportunity” for sleep apnea awareness is the amount of published data related to treating this disorder, including data from this study, Nunez said.
“Now we have more and more evidence like this showing that treating sleep apnea with the gold standard therapy — CPAP — can help not just save your life but help improve your mortality based on cardiovascular risk,” Nunez said.
References:
- New global study finds: Sleep apnea patients who use CPAP live longer. https://newsroom.resmed.com/news-releases/news-details/2025/New-Global-Study-Finds-Sleep-Apnea-Patients-Who-Use-CPAP-Live-Longer/default.aspx. Published March 19, 2025. Accessed March 19, 2025.
- ResMed media briefing: An urgent wake up call — why sleep health can’t be ignored. March 20, 2025.