TOPLINE

In a large cohort of patients with moderate-to-severe obstructive sleep apnea (OSA), the combination of sleep apnea-specific hypoxic burden (SASHB) and event-related heart rate response (eHR) identified a high-risk group, in whom adherence to positive airway pressure (PAP) therapy was associated with a greater reduction in the incidence of major adverse cardiovascular events (MACEs) than that seen in the low-risk group.

METHODOLOGY

• Researchers conducted a retrospective study to determine whether cardiovascular risk status — defined by a combination of SASHB and eHR values — modified the association between PAP adherence and mortality or cardiovascular events.
• They included 3370 patients (median age, 57 years; 69.3% men; median apnea-hypopnea index, 37 events/h) from a French sleep-clinic cohort. All had moderate-to-severe OSA and initiated PAP therapy between May 2007 and December 2018.
• Patients were classified as high risk when SASHB exceeded 40.6%·min/h or eHR exceeded 21.7 beats/min.
• PAP adherence was defined as an average use of at least 4 hours per night; those who discontinued PAP or used it for less than 4 hours per night were classified as nonadherent.
• The primary composite outcome was MACE — the first occurrence of hospitalization for coronary heart disease, stroke, or heart failure exacerbation, or death from any cause — over a median follow-up of 9 years.

TAKEAWAY

• MACEs occurred in 740 patients, including 251 deaths and 489 nonfatal cardiovascular events.
• Overall, 71.7% of the cohort was identified as having a high-risk status, among whom adherence to PAP was associated with a substantially lower incidence of MACEs than nonadherence (absolute difference, -1.94 per 100 person-years; P < .001), translating to roughly 19 fewer MACEs per 1000 person-years. 
• The difference was negligible in the low-risk group.
• The stronger association between PAP adherence and MACEs in patients who were at high risk than in those at low risk was consistent in subgroup analyses; the interaction appeared stronger among patients without excessive daytime sleepiness (interaction hazard ratio, 0.49; P = .002) than among those with excessive daytime sleepiness.

IN PRACTICE

"Biomarker-based risk stratification could support more personalized treatment decisions, including prioritization of high-risk patients for intensive adherence-support programs, closer CV [cardiovascular] follow-up, and aggressive management of modifiable CV risk factors," the authors wrote.

SOURCE

The study was led by Sébastien Bailly, University Grenoble Alpes, Grenoble, France. It was published online on September 3, 2026, in the European Respiratory Journal.

LIMITATIONS

Given the observational nature of the study, the findings should be interpreted with caution. Patients who were adherent to PAP may have engaged in other healthy behaviors that the analysis could not capture. Because biomarker cutoffs were derived using an outcome-oriented data-driven procedure, they should be considered exploratory, rather than validated clinical decision thresholds.

DISCLOSURES

The data for this study came from a cohort supported by a grant from the Pays de la Loire Respiratory Health Research Institute. One author reported being a former employee of a company involved in manufacturing PAP devices. Several authors reported receiving grants, consulting fees, speaker fees, honoraria, or travel support from various sources.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.