Subgroup of patients with high heart rate response and coronary artery disease benefit from CPAP

Several trials found no protective effect of continuous positive airway pressure (CPAP) on adverse cardiovascular outcomes in patients with coronary artery disease. However, a re-analysis of the RICCADSA trial presented during the ATS 2021 meeting demonstrated that the subgroup of patients with a high heart-rate response to obstructive events experienced a >50% risk reduction for a cardiovascular event when treated with CPAP.

Previous studies have found no protective effect of CPAP on adverse cardiovascular outcomes in patients with coronary artery disease and non-sleepy obstructive sleep apnoea (OSA) [1-3]. “Our previous study showed that those with non-sleepy OSA who demonstrated a greater respiratory event-related pulse rate response (ΔHR) are at increased risk of cardiovascular morbidity and mortality,” Prof. Ali Azarbarzin (Harvard Medical School, MA, USA) explained [4]. This was the rationale to test the hypothesis that patients with a higher pre-treatment ΔHR might benefit more from CPAP regarding cardiovascular outcomes. Therefore, Prof. Azarbarzin and his colleagues re-analysed data from the RICCADSA clinical trial (NCT00519597) of cardiovascular risk for non-sleepy OSA patients with heart disease [5]. ∆HR was measured from the oximetry pulse rate signals collected during baseline polysomnography of the RICCADSA trial. The primary outcome of this analysis was a composite of repeat revascularisation, myocardial infarction, stroke, and cardiovascular mortality. In the original study, the OSA effect on cardiovascular disease was similar across subgroups. The researchers now analysed whether the effect of the CPAP treatment on the primary outcome was influenced by ∆HR. “If this were true, then we would expect to see a preferential benefit from using CPAP on cardiac outcomes in those with higher ∆HR,” said Prof. Azarbarzin. “Indeed, this is what we found: the greater the ∆HR, the greater the calculated treatment benefit of CPAP.”

∆HR measures were obtained in 92% of patients, and 48 composite events were recorded over a 57-month median follow-up. A significant interaction between treatment and ∆HR was observed. CPAP provided protection from cardiac events in non-sleepy OSA patients whose pulse rates rose significantly during sleep apnoea events. Patients with the highest ∆HR of 10 beats per minute experienced a >50% reduction of risk for a cardiovascular event when treated with CPAP (see Figure).

Figure: Patients with high ∆HR experience a more than 50% risk reduction for cardiovascular events with CPAP [5]



OSA, obstructive sleep apnoea; CVD, cardiovascular disease; ∆HR, pulse rate response.

“Our study provides novel evidence that a greater heart rate responsiveness to obstructive airway events is an identifiable, deleterious, and potentially reversible risk factor that could be used to select patients most likely to exhibit long-term cardiovascular benefit from CPAP therapy,” Prof. Azarbarzin concluded.

1. McEvoy RD, et al. New Engl J Med 2016;375:919-31.
2. Peker Y, et al. Am J Respir Crit Care Med 2016;194(5):613-20.
3. Sánchez-de-la-Torre M, et al. Lancet Respir Med 2013:1(1): 61-72.
4. Azarbarzin A, et al. Am J Respir Crit Care Med 2021 Jan 6 [e-pub ahead of print].
5. Azarbarzin A, et al. Cardiovascular benefit of CPAP is modified by the Sleep Apnea related pulse rate response in coronary artery disease patients with nonsleepy OSA: Findings from the RICCADSA randomized controlled trial. Session B14: Pathophysiology, cardiovascular disease, and COVID – what´s happening in sleep research right now. ATS 2021 International conference, 14-19 May 2021.

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Posted on 5 July 202117 May 2024