Role of Continuous Positive Airway Pressure in the Prevention of Cardiovascular Events in Patients With Obstructive Sleep Apnea: A Systematic Review and Meta-Analysis of Randomized Clinical Trials

Background: Obstructive sleep apnea (OSA) is prevalent among patients with cardiovascular disease and is associated with increased risk of major adverse cardiovascular events (MACE). Continuous positive airway pressure (CPAP) is the standard treatment for OSA, but its impact on cardiovascular outcomes remains uncertain, particularly in randomized controlled trials (RCTs). Objectives: To evaluate the effect of CPAP therapy on cardiovascular outcomes in patients with OSA, and to explore the influence of adherence on treatment efficacy. Methods: We conducted a systematic review and meta-analysis of RCTs comparing CPAP with placebo or usual care in adults with OSA. Databases including PubMed, Scopus, Ovid, and CINAHL were searched from inception to December 2024. Primary outcome was MACE; secondary outcomes included cardiovascular mortality, all-cause mortality, myocardial infarction, stroke, angina, heart failure, and new-onset atrial fibrillation. Subgroup analyses were performed based on CPAP adherence (≥4 hours/night vs/night). Risk ratios (RRs) with 95% confidence intervals (CIs) were pooled using fixed-effects model. Results: Eleven RCTs comprising 6,139 participants were included. Overall, CPAP did not significantly reduce MACE (RR = 1.00; 95% CI: 0.87–1.14) or secondary cardiovascular outcomes. However, in patients adherent to CPAP (≥4 hours/night), MACE was significantly reduced (RR = 0.71; 95% CI: 0.52–0.97), and cardiovascular mortality decreased (RR = 0.36; 95% CI: 0.14–0.91). Subgroup analyses revealed no significant benefits in non-adherent patients. Heterogeneity was low for most outcomes. Conclusion: CPAP therapy does not significantly reduce overall cardiovascular risk in OSA patients, except among adherent individuals. These findings underscore adherence as a critical determinant of CPAP’s cardiovascular efficacy. Future trials should prioritize strategies to optimize adherence to fully evaluate CPAP’s cardioprotective potential.