Positive airway pressure therapy and all-cause and cardiovascular mortality in people with obstructive sleep apnoea: a systematic review and meta-analysis of randomised controlled trials and confounder-adjusted, non-randomised controlled studies.

Summary

Across 30 studies (10 RCTs and 20 adjusted NRCSs; 1,175,615 participants; mean follow-up 5.1 years), PAP therapy in OSA was associated with a 37% reduction in all-cause mortality and a 55% reduction in cardiovascular mortality, with benefits increasing with use. Bias was low to moderate, supporting clinical messaging to initiate and adhere to PAP.

Key Findings

• PAP therapy was associated with lower all-cause mortality (HR 0.63) and cardiovascular mortality (HR 0.45).
• The meta-analysis included 30 studies (10 RCTs and 20 adjusted NRCSs) with 1,175,615 participants and mean follow-up of 5.1 years.
• Clinical benefit increased with greater PAP use; overall risk of bias was low to moderate.

Clinical Implications

Discuss mortality benefits when counseling OSA patients, prioritize PAP initiation, monitor adherence, and tailor strategies (e.g., behavioral support) to sustain use and maximize benefit.

Limitations

• Inclusion of NRCSs raises potential for residual confounding despite adjustment
• Industry funding (ResMed) may introduce perceived bias; heterogeneity in PAP adherence across studies

Future Directions

Individual patient data meta-analyses to model adherence-dose–response, pragmatic trials in diverse populations, and cost-effectiveness evaluations to inform policy.