CPAP vs Mandibular Advancement Devices and Blood Pressure in Patients With Obstructive Sleep Apnea

Abstract

IMPORTANCE Obstructive sleep apnea is associated with higher levels of blood pressure (BP), which can lead to increased cardiovascular risk.OBJECTIVE To compare the association of continuous positive airway pressure (CPAP), mandibular advancement devices (MADs), and inactive control groups (placebo or no treatment) with changes in systolic BP (SBP) and diastolic BP (DBP) in patients with obstructive sleep apnea.DATA SOURCES The databases of MEDLINE, EMBASE, and the Cochrane Library were searched up to the end of August 2015 and study bibliographies were reviewed. STUDY SELECTION Randomized clinical trials comparing the effect of CPAP or MADs (vs each other or an inactive control) on BP in patients with obstructive sleep apnea were selected by consensus. Of 872 studies initially identified, 51 were selected for analysis.DATA EXTRACTION AND SYNTHESIS Data were extracted by one reviewer and checked by another reviewer. A network meta-analysis using multivariate random-effects meta-regression was used to estimate pooled differences between each intervention. Meta-regression was used to assess the association between trial characteristics and the reported effects of CPAP vs inactive control.MAIN OUTCOMES AND MEASURES Absolute change in SBP and DBP from baseline to follow-up. RESULTSOf the 51 studies included in the analysis (4888 patients), 44 compared CPAP with an inactive control, 3 compared MADs with an inactive control, 1 compared CPAP with an MAD, and 3 compared CPAP, MADs, and an inactive control. Compared with an inactive control, CPAP was associated with a reduction in SBP of 2.5 mm Hg (95% CI, 1.5 to 3.5 mm Hg; P < .001) and in DBP of 2.0 mm Hg (95% CI, 1.3 to 2.7 mm Hg; P < .001). A 1-hour-per-night increase in mean CPAP use was associated with an additional reduction in SBP of 1.5 mm Hg (95% CI, 0.8 to 2.3 mm Hg; P < .001) and an additional reduction in DBP of 0.9 mm Hg (95% CI, 0.3 to 1.4 mm Hg; P = .001). Compared with an inactive control, MADs were associated with a reduction in SBP of 2.1 mm Hg (95% CI, 0.8 to 3.4 mm Hg; P = .002) and in DBP of 1.9 mm Hg (95% CI, 0.5 to 3.2 mm Hg; P = .008). There was no significant difference between CPAP and MADs in their association with change in SBP (−0.5 mm Hg [95% CI, −2.0 to 1.0 mm Hg]; P = .55) or in DBP (−0.2 mm Hg [95% CI, −1.6 to 1.3 mm Hg]; P = .82). CONCLUSIONS AND RELEVANCEAmong patients with obstructive sleep apnea, both CPAP and MADs were associated with reductions in BP. Network meta-analysis did not identify a statistically significant difference between the BP outcomes associated with these therapies.

Nocturnal Blood Pressure Is Reduced by a Mandibular Advancement Device for Sleep Apnea in Women: Findings From Secondary Analyses of a Randomized Trial

“…The time and location of the blood pressure measurements varied in the studies that included an average of 20% women. Bratton et al17 report that mandibular advancement device therapy reduces the systolic blood pressure by 2.1 (95% CI, 0.8–3.4) mm Hg and the diastolic blood pressure by 1.9 (95% CI, 0.5–3.2) mm Hg, and a similar effect was found with continuous positive airway pressure. In a recent meta‐analysis, the use of positive airway pressure, compared with sham or no treatment, was not associated with reduced risks of cardiovascular outcomes or death for patients with sleep apnea 20.…”

“…Individually fabricated mandibular advancement devices and continuous positive airway pressure reduce blood pressure when treating sleep apnea, according to meta‐analyses, but the effect varies between studies 17, 18, 19. The time and location of the blood pressure measurements varied in the studies that included an average of 20% women.…”

Quality Assessment of Systematic Reviews on the Efficacy of Oral Appliance Therapy for Adult and Pediatric Sleep-Disordered Breathing

“…Therefore, only 17 articles met the inclusion criteria set for this study (Figure 1). Thirteen reviews were on adult OSA (2 SRs and 11 SRs with MAs), 1,[49][50][51][52][53][54][55][56][57][58][59][60] and four reviews were on pediatric OSA (3 SRs and 1 SR with MA). 12,15,61,62 Key methodological and descriptive characteristics of the included reviews are presented in Tables 2 and 3.…”

“…The search strategies were well showcased in most reviews. Two reviews, 53,54 however, did not report the search dates and four others 49,[58][59][60] did not search the gray literature. There was significant variability in the instruments used for quality assessment among the reviews.…”

Rehabilitation of Cardiovascular Disorders and Sleep Apnea

“…11 There is growing evidence that treatment of coexisting OSA with continuous positive airway pressure (CPAP) or mandibular advancement devices can successfully treat OSA, resulting in improved rehabilitation outcomes and improved health-related quality of life. [12][13][14][15] …”