Yu Jie, Zhou Zien, McEvoy R Doug, Anderson Craig S, Rodgers Anthony, Perkovic Vlado, Neal Bruce
Department of Cardiology, Peking University Third Hospital, Key Laboratory of Cardiovascular Molecular Biology and Regulatory Peptides, Ministry of Health, Key Laboratory of Molecular Cardiovascular Sciences, Ministry of Education, Beijing, People's Republic of China2The George Institute for Global Health, Faculty of Medicine, UNSW Sydney, Sydney, New South Wales, Australia.
The George Institute for Global Health, Faculty of Medicine, UNSW Sydney, Sydney, New South Wales, Australia3Department of Radiology, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, People's Republic of China.
JAMA. 2017 Jul 11;318(2):156-166. doi: 10.1001/jama.2017.7967.
Sleep apnea (obstructive and central) is associated with adverse cardiovascular risk factors and increased risks of cardiovascular disease. Positive airway pressure (PAP) provides symptomatic relief, whether delivered continuously (CPAP) or as adaptive servo-ventilation (ASV), but the associations with cardiovascular outcomes and death are unclear.
To assess the association of PAP vs control with cardiovascular events and death in patients with sleep apnea.
MEDLINE, EMBASE, and the Cochrane Library were systematically searched from inception date to March 2017 for randomized clinical trials that included reporting of major adverse cardiovascular events or deaths.
Two authors independently extracted data using standardized forms. Summary relative risks (RRs), risk differences (RDs) and 95% CIs were obtained using random-effects meta-analysis.
The main outcomes were a composite of acute coronary syndrome (ACS) events, stroke, or vascular death (major adverse cardiovascular events); cause-specific vascular events; and death.
The analyses included data from 10 trials (9 CPAP; 1 ASV) of patients with sleep apnea (N = 7266; mean age, 60.9 [range, 51.5 to 71.1] years; 5847 [80.5%] men; mean [SD] body mass index, 30.0 [5.2]. Among 356 major adverse cardiovascular events and 613 deaths recorded, there was no significant association of PAP with major adverse cardiovascular events (RR, 0.77 [95% CI, 0.53 to 1.13]; P = .19 and RD, -0.01 [95% CI, -0.03 to 0.01]; P = .23), cardiovascular death (RR, 1.15 [95% CI, 0.88 to 1.50]; P = .30 and RD -0.00 [95% CI, -0.02 to 0.02]; P = .87), or all-cause death (RR, 1.13 [95% CI, 0.99 to 1.29]; P = .08 and RD, 0.00 [95% CI, -0.01 to 0.01]; P = .51). The same was true for ACS, stroke, and heart failure. There was no evidence of different associations for CPAP vs ASV (all P value homogeneity >.24), and meta-regressions identified no associations of PAP with outcomes for different levels of apnea severity, follow-up duration, or adherence to PAP (all P values > .13).
The use of PAP, compared with no treatment or sham, was not associated with reduced risks of cardiovascular outcomes or death for patients with sleep apnea. Although there are other benefits of treatment with PAP for sleep apnea, these findings do not support treatment with PAP with a goal of prevention of these outcomes.
睡眠呼吸暂停（阻塞性和中枢性）与不良心血管危险因素及心血管疾病风险增加相关。气道正压通气（PAP）无论是持续气道正压通气（CPAP）还是适应性伺服通气（ASV），均可缓解症状，但与心血管结局及死亡的关联尚不清楚。
评估PAP与对照相比对睡眠呼吸暂停患者心血管事件和死亡的影响。
对MEDLINE、EMBASE和Cochrane图书馆从创刊至2017年3月进行系统检索，以查找包含主要不良心血管事件或死亡报告的随机临床试验。
两名作者使用标准化表格独立提取数据。采用随机效应荟萃分析得出汇总相对风险（RRs）、风险差异（RDs）及95%置信区间（CIs）。
主要结局包括急性冠状动脉综合征（ACS）事件、中风或血管性死亡（主要不良心血管事件）的复合指标；特定病因的血管事件；以及死亡。
分析纳入了10项试验（9项CPAP试验；1项ASV试验）中睡眠呼吸暂停患者的数据（N = 7266；平均年龄60.9岁[范围51.5至71.1岁]；5847名[80.5%]男性；平均[标准差]体重指数30.0[5.2]）。在记录的356例主要不良心血管事件和613例死亡中，PAP与主要不良心血管事件（RR，0.77[95%CI，0.53至1.13]；P = 0.19，RD，-0.01[95%CI，-0.03至0.01]；P = 0.23）、心血管死亡（RR，1.15[95%CI，0.88至1.50]；P = 0.30，RD -0.00[95%CI，-0.02至0.02]；P = 0.87）或全因死亡（RR，1.13[95%CI，0.99至1.29]；P = 0.08，RD，0.00[95%CI，-0.01至0.01]；P = 0.51）均无显著关联。ACS、中风和心力衰竭的情况也是如此。没有证据表明CPAP与ASV的关联存在差异（所有P值同质性>.24），荟萃回归分析未发现PAP与不同程度的呼吸暂停严重程度、随访持续时间或PAP依从性的结局存在关联（所有P值>.13）。
与未治疗或假治疗相比，使用PAP对睡眠呼吸暂停患者降低心血管结局或死亡风险并无关联。尽管PAP治疗睡眠呼吸暂停还有其他益处，但这些研究结果并不支持以预防这些结局为目标使用PAP进行治疗。
