PAP adherence was linked to fewer cardiovascular events, most clearly in high-risk sleep apnoea

Design

Clinic cohort linked to French national health database

Population

3,370 PAP-treated adults with moderate-to-severe OSA

Primary outcome

Major adverse cardiovascular events

Effect

Adherence HR 0.53 (95% CI 0.46–0.62); stronger in high-risk (interaction HR 0.61)

This French cohort linked 3,370 patients with moderate-to-severe obstructive sleep apnoea on positive airway pressure to national health data, following them for a median of nine years. Patients were classed as high risk by sleep apnoea-specific hypoxic burden or event-related heart rate response.

Using PAP for at least four hours a night was associated with fewer major adverse cardiovascular events (adjusted HR 0.53, 95% CI 0.46–0.62). The association was stronger in the 71.7% with high-risk status (interaction HR 0.61, 0.43–0.87), and appeared strongest in non-sleepy patients. A simplified version of the markers from a single oximetry signal gave similar results.

Randomised trials of PAP for cardiovascular prevention have been disappointing, partly because adherence was poor and patients unselected. This observational study cannot overcome the healthy-adherer effect, but it suggests who might benefit most and a practical way to find them from oximetry.

• Aim for PAP use of at least four hours a night, every night, and check device data at follow-up.
• Do not dismiss PAP in non-sleepy patients with high hypoxic burden — the association was strongest there.
• Look at oxygen desaturation depth and duration, not just the apnoea-hypopnoea index, when judging severity.
• Treat blood pressure, lipids and glucose alongside sleep apnoea; PAP is not a substitute.

Why it matters

It points to physiological markers that could select the sleep apnoea patients whose hearts PAP may actually protect.

Don't overread it

This is observational; randomised trials have not shown PAP prevents cardiovascular events.

The statistics, in plain English

A hazard ratio of 0.53 means adherent patients had about half the rate of cardiovascular events. But people who use PAP faithfully also tend to take their medicines and look after themselves, so part of this is likely a healthy-adherer effect rather than PAP itself.

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