Continuous positive airway pressure (CPAP) therapy is not always beneficial in the prevention of cardiovascular events in patients with obstructive sleep apnoea (OSA), due to low CPAP usage, the inclusion of non-sleepy patients, and the usage of wrong selection criteria. New markers, such as hypoxic burden, are showing potential in stratifying patients with OSA for cardiovascular risk. For non-sleepy patients with OSA, there is a need still for specific cardiovascular-associated markers to demonstrate the benefit of CPAP therapy on cardiovascular risk.
“We should not forget that the main target of CPAP therapy is to treat sleepiness in patients with OSA,” said Prof. Raphael Heinzer (Lausanne University Hospital, Switzerland) at the start of his presentation on the future of sleep science . For this clinical outcome, CPAP has been demonstrated to be an effective therapy . In addition, excessively sleepy patients with OSA are at increased risk for cardiovascular diseases . However, the majority of patients with OSA do not report sleepiness . “So how do we treat the non-sleepy patients? And which patients are likely to benefit from CPAP in terms of cardiovascular risk reduction?”
The SAVE study did not show a clear benefit of CPAP therapy in the secondary prevention of adverse cardiovascular events in patients with OSA . “Why did we not see an effect of this intervention in these patients?” asked Prof. Heinzer. Possible explanations are the low CPAP usage (<3 hours per night) in these trials or the fact that these trials included non-sleepy patients. Irreversible cardiovascular damage and the use of the apnoea hypopnoea index (AHI) as an inadequate selection criterion are other potential explanations. “Indeed, patients with AHI <15/hour and patients with AHI >15/hour did not differ with respect to their risk for cardiovascular incidences,” stated Prof. Heinzer . Fortunately, other markers that might have potential in stratifying patients with OSA for cardiovascular risk are emerging. Hypoxic burden was a significant predictor of cardiovascular death and cardiovascular events in 2 cohorts [7,8]. Next to this measure, the sleep apnoea-specific pulse-rate response as well as pulse-wave amplitude drops have been associated with the risk for cardiovascular events [4,9]. “Pulse-wave amplitude drops reflect peripheral vasoconstriction resulting from sympathetic activation,” clarified Prof. Heinzer. Interestingly, low pulse-wave amplitude drops were linked to a higher incidence of cardiovascular events. Prof. Heinzer argued that endothelial dysfunction or a blunted autonomic reactivity may be the underlying causes that explain this association.
“We need prospective primary prevention studies including patients with OSA stratified to more specific cardiovascular-associated markers, to demonstrate the benefit of CPAP therapy on cardiovascular risk in non-sleepy patients with OSA,” continued Prof. Heinzer. “However, randomised trials are not feasible in primary prevention for ethical reasons.” Follow-up of prospective clinical real-world cohorts appears to be the most suitable study design. Propensity score matching, inverse probability of treatment weighting, and other inventive techniques should be applied to gain reliable well-balanced data.
- Heinzer R, et al. The future of sleep science: what are the correct targets, outcome parameters, innovative studies and methodologies? Session 407, Abstract 3635, ERS International Congress 2022, 4–6 September.
- Sawyer AM, et al. Sleep Med Rev. 2011;15(6):343–356.
- Mazotti DR, et al. Am J Respir Crit Care Med. 2019;200(4):493–506.
- Heinzer R, et al. Lancet Respir Med. 2015;3(4):310–318.
- McEvoy RD, et al. N Engl J Med. 2016;375:919–931.
- Sanchez-de-la-Torre M, et al. Lancet Respi Med. 2020;8(4):359–367.
- Azarbarzin A, et al. Eur Heart Journal. 2019;40(14):1149–1157.
- Trzepizur W, et al. Am J Respir Crit Care Med. 2021;205(1):108–117.
- Azarbarzin A, et al. Am J Respir Crit Care Med. 2021;203:A1103.
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Table of Contents: ERS 2022
Letter from the Editor
ERS 2022 Highlights Podcast
COVID-19: What Is New?
Does vilobelimab reduce mortality in severe COVID-19?
Awake proning not positive in COVID-19
Favipiravir may help patients over 60 years with COVID-19 to recover
Brensocatib fails in severe COVID-19
Inhaled agent under investigation for COVID-19
Accurate voice-based COVID-19 diagnostic test in development
Novel scoring tool for post-COVID syndrome aids clinicians and researchers
COPD: Therapies and Innovations
Icenticaftor achieves results on top of triple inhalation therapy in COPD
STARR2: A new approach for treating COPD exacerbations
COPD medication not effective in symptomatic smokers with preserved spirometry
Do digital tools improve physical activity in COPD?
Hyperpolarised gas MRI ready for clinical use
All About Asthma
Tezepelumab in asthma: mucus plugging down, lung function up
Digital asthma intervention improves health and reduces costs
Digitally enhanced therapy lowers treatment burden and costs in severe asthma
Mepolizumab beneficial for patients with severe eosinophilic asthma
Progress in Paediatrics
Antibiotics cause increased risk of wheezing in severe RSV bronchiolitis
Inhaled corticosteroids useful in preterms with decreased lung function
Fish oil or vitamin D during pregnancy can prevent croup
Encouraging results of nintedanib in children with fibrosing ILD
Focus on Interventional Pulmonology
Head-to-head: lung volume reduction surgery vs endobronchial valves
Durable effect of endobronchial valves in severe emphysema
Cone beam CT-guided ENB improves detection of pulmonary nodules
Confirmatory mediastinoscopy not needed in resectable NSCLC
Sleep and Breathing Disorders
In the spotlight: Cancer trends in obstructive sleep apnoea
Impact of CPAP on cardiac endpoints in OSA
Sustained hypoxaemia predicts unprovoked VTE in OSA
CPAP therapy in the prevention of cardiovascular risk in patients with OSA
Other Remarkable Research
Excellent results for high-flow nasal cannula oxygen therapy in acute respiratory failure
Antifibrotic therapy may slow down FVC decline in RAILD
Intravenous N-acetylcysteine performs well in hospitalised patients
Men and women respond differently to diesel exhaust
New trends in cystic lung diseases
Lung-cancer salvage surgery might help after TKI treatment