Effect of Positive Airway Pressure on Cardiovascular Outcomes in Coronary Artery Disease Patients with Nonsleepy Obstructive Sleep Apnea. The RICCADSA Randomized Controlled Trial

TLDR

Obstructive sleep apnea is common among coronary artery disease patients, many of whom do not experience daytime sleepiness. This study aimed to evaluate whether continuous positive airway pressure reduces long‑term cardiovascular events in CAD patients with nonsleepy OSA. In a single‑center, prospective, randomized controlled trial, 244 newly revascularized CAD patients with AHI ≥ 15/h and Epworth Sleepiness Scale < 10 were assigned to auto‑titrating CPAP or no positive airway pressure, with a median follow‑up of 57 months and a primary endpoint of repeat revascularization, myocardial infarction, stroke, or cardiovascular death. Intention‑to‑treat analysis showed no significant difference in the primary endpoint (18.1 % vs 22.1 %, HR 0.80, p = 0.449), but on‑treatment analysis revealed a significant cardiovascular risk reduction for CPAP use ≥4 h/night (HR 0.29, p = 0.026) after adjusting for baseline comorbidities and compliance. The trial is registered at clinicaltrials.gov (NCT00519597).

Abstract

Obstructive sleep apnea (OSA) is common in patients with coronary artery disease (CAD), many of whom do not report daytime sleepiness. First-line treatment for symptomatic OSA is continuous positive airway pressure (CPAP), but its value in patients without daytime sleepiness is uncertain.To determine the effects of CPAP on long-term adverse cardiovascular outcome risk in patients with CAD with nonsleepy OSA.This single-center, prospective, randomized, controlled, open-label, blinded evaluation trial was conducted between December 2005 and November 2010. Consecutive patients with newly revascularized CAD and OSA (apnea-hypopnea index ≥15/h) without daytime sleepiness (Epworth Sleepiness Scale score <10) were randomized to auto-titrating CPAP (n = 122) or no positive airway pressure (n = 122).The primary endpoint was the first event of repeat revascularization, myocardial infarction, stroke, or cardiovascular mortality. Median follow-up was 57 months. The incidence of the primary endpoint did not differ significantly in patients who did versus did not receive CPAP (18.1% vs. 22.1%; hazard ratio, 0.80; 95% confidence interval, 0.46-1.41; P = 0.449). Adjusted on-treatment analysis showed a significant cardiovascular risk reduction in those who used CPAP for ≥4 versus <4 hours per night or did not receive treatment (hazard ratio, 0.29; 95% confidence interval, 0.10-0.86; P = 0.026).Routine prescription of CPAP to patients with CAD with nonsleepy OSA did not significantly reduce long-term adverse cardiovascular outcomes in the intention-to-treat population. There was a significant reduction after adjustment for baseline comorbidities and compliance with the treatment. Clinical trial registered with www.clinicaltrials.gov (NCT 00519597).