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