Positive Airway Pressure, Mortality, and Cardiovascular Risk in Older Adults With Sleep Apnea
Authors: Mazzotti Diego R. , Waitman Lemuel R. , Miller Jennifer , Sundar Krishna M. , Stewart Nancy H. , Gozal David , Song Xing ,   Greater Plains Collaborative, Chandaka Sravani , Anuforo Kelechi (KayCee) , Patel Lav , Budine Daryl , Hensel Nathan , Satyakam Siddharth , Smith Sharla , Ridenour Dennis , Jernigan Cheryl , Early Carol , Stephens Kyle , Jurius Kathy , Sidebottom Abbey , Rodgers Cassandra , Zhong Hong , Raj Vino , Melendez Victor , Hare Angie , Melamed Roman , Anderson Curtis , Schouweile Thomas , Roering Christine , Payne Philip , Gupta Snehil , Newland John , Lai Albert , Balls-Berry Joyce , Parham Janine , Fritschle Evin , Cripps Shanelle , Knowlton Kirk , Hansen Channing , Serezlic Erna , Horne Benjamin , VanWormer Jeff , Hase Judith , Southworth Janet , Larose Eric , Davis Mary , Hoeth Laurel , Strey Sandy , Taylor Brad , Osinski Kris , Haverty April , Stoddard Alex , Cornell Sarah , Do Phoenix , Bailey Lucy , McDonough Beth , Chrischilles Betsy , Carnahan Ryan , Gryzlak Brian , Ryu Gi-Yung , Oaklander Katrina , Bruce Pastor , McDowell Brad , Field Jarrod , Mosa Abu , Lawson Sasha , McClay Jim , Islam Soliman , Mandhadi Vasanthi , Kimminau Kim , Ordway Jeff , Stephens Bill , Waitman Russ , Cassone Deandra , Niu Xiaofan , Royse Lisa , Paka Vyshnavi , Wilcox Lori , Greening Janelle , Geary Carol , Viswanathan Goutham , Svoboda Jim , Campbel Jim , (Annette) Frances , Bah Haddy , Bjorklund Todd , Barlocker Jackson , Spuh Josh , Stark Louisa , Strong Mike , Fahina Otolose , Hess Rachel , Kean Jacob , Mumford Sarah , Huffman Ainsley , Risenmay Annie , Ellsmore Olivia , Persson Lissa , Torres Kayla , Stanford Sandi , Syed Mahanaz , Schofield Rae , Zozus Meredith , Shukwit Brian , Decaro Matthew , Heredia Natalia , Miller Charles , Robinson Alice , Bernstam Elmer , Ashraf Fatima , Antony Shiby , Fong Juliet , Reeder Philip , Kao Cindy , Wilkinson Kate , Greer Tracy , Cowell Lindsay 
Published: September 2024

Importance

Positive airway pressure (PAP) is the first-line treatment for obstructive sleep apnea (OSA), but evidence on its beneficial effect on major adverse cardiovascular events (MACE) and mortality prevention is limited.

Objective

To determine whether PAP initiation and utilization are associated with lower mortality and incidence of MACE among older adults with OSA living in the central US.

Design, Setting, and Participants

This retrospective clinical cohort study included Medicare beneficiaries with 2 or more distinct OSA claims identified from multistate, statewide, multiyear (2011-2020) Medicare fee-for-service claims data. Individuals were followed up until death or censoring on December 31, 2020. Analyses were performed between December 2021 and December 2023.

Exposures

Evidence of PAP initiation and utilization based on PAP claims after OSA diagnosis.

Main Outcomes and Measures

All-cause mortality and MACE, defined as a composite of myocardial infarction, heart failure, stroke, or coronary revascularization. Doubly robust Cox proportional hazards models with inverse probability of treatment weights were used to estimate treatment effect sizes controlling for sociodemographic and clinical factors.

Results

Among 888 835 beneficiaries with OSA included in the analyses (median [IQR] age, 73 [69-78] years; 390 598 women [43.9%]; 8115 Asian [0.9%], 47 122 Black [5.3%], and 760 324 White [85.5%] participants; median [IQR] follow-up, 3.1 [1.5-5.1] years), those with evidence of PAP initiation (290 015 [32.6%]) had significantly lower all-cause mortality (hazard ratio [HR], 0.53; 95% CI, 0.52-0.54) and MACE incidence risk (HR, 0.90; 95% CI, 0.89-0.91). Higher quartiles (Q) of annual PAP claims were progressively associated with lower mortality (Q2 HR, 0.84; 95% CI, 0.81-0.87; Q3 HR, 0.76; 95% CI, 0.74-0.79; Q4 HR, 0.74; 95% CI, 0.72-0.77) and MACE incidence risk (Q2 HR, 0.92; 95% CI, 0.89-0.95; Q3 HR, 0.89; 95% CI, 0.86-0.91; Q4 HR, 0.87; 95% CI, 0.85-0.90).

Conclusions and Relevance

In this cohort study of Medicare beneficiaries with OSA, PAP utilization was associated with lower all-cause mortality and MACE incidence. Results might inform trials assessing the importance of OSA therapy toward minimizing cardiovascular risk and mortality in older adults.