Role of Positive Airway Pressure Therapy for Obstructive Sleep Apnea in Patients With Stroke: A Randomized Controlled Trial

Abstract

Study Objectives: Obstructive sleep apnea (OSA) is an independent risk factor for stroke. The objective of this study was to assess the effect of continuous positive airway pressure (CPAP) treatment on prevention of new vascular events among patients with stroke and OSA. Methods: Consecutive conscious patients presenting with first imaging-confirmed arterial stroke were included, 6 weeks or more after ictus. All patients underwent clinical and polysomnography (PSG) testing. Patients with an apnea-hypopnea index (AHI) of > 15 events/h were randomized to posttitration nightly CPAP treatment and non-CPAP (received best medical treatment) groups. On follow-up at 3, 6, and 12 months from randomization, evaluation was carried out for any new vascular events as the primary outcome measure, and for clinical stroke outcomes (using the Barthel Index and modified Rankin scale) and neuropsychological parameters as the secondary outcome measures. Results: Among the 679 patients with stroke who were screened, 116 reported for PSG, 83 had AHI > 15 events/h, and 70 (34 in CPAP and 36 in non-CPAP) were randomized. Thirteen patients could not be randomized because of a lack of CPAP devices. Four patients crossed over from the CPAP to the non-CPAP group. Age (mean age 53.41 ± 9.85 in CPAP versus 52.69 ± 13.23 years in non-CPAP, P = .81) and sex distribution (24 males in CPAP versus 33 males in non-CPAP, P = .79) were similar in both groups. At 12-month follow-up, there was 1 vascular event (3.33%) in the CPAP group and 6 events (15%) in the non-CPAP group (P = .23). Modified Rankin scale score improvement by ≥ 1 at 12-month follow-up was found in significantly more patients in the CPAP group than in the non-CPAP group (53% versus 27%). I NTRO DUCTI O NStroke is common, the second leading cause of death and disability, and is the cause of high health care costs.1,2 Important risk factors for stroke are hypertension, atrial fibrillation, diabetes, and smoking. These are well-established intervention targets for stroke's primary and secondary prevention. that leads to oxygen desaturation and sleep fragmentation. This further leads to an increased risk of cardiovascular disease, stroke, and death. [4][5][6] It has been established that OSA is an independent risk factor for stroke 1,7 and also aggravates other risk factors (hypertension, coronary artery disease, diabetes, and atrial fibrillation).1 The prevalence of OSA among patients with stroke is around 50% to 80%. Even with neurological improvement in patients with stroke, their OSA does not remit or improve. [8][9][10] The high prevalence of OSA among patients with stroke is associated with an unfavorable clinical course in terms of early neurological worsening, delirium, BRIEF SUMMARY Current Knowledge/Study Rationale: Stroke is a common cause of death and disability and obstructive sleep apnea (OSA) is an independent risk factor for stroke. The objective of this study was to assess the effect of continuous positive airway pressure (CPAP) treatment in prevention of new vascular ...

EAN/ERS/ESO/ESRS statement on the impact of sleep disorders on risk and outcome of stroke

“…Primary studies: A further two class II quality studies on the impact of CPAP on measures of vascular risk were published after the systematic search finished and were included [122,123].…”

Sleep‐disordered breathing and poststroke outcomes

“…4 Pilot RCTs have evaluated the effect of CPAP on functional and cognitive outcomes, with mixed results. 6,16,18,[20][21][22][23][24] The majority of trials were conducted in stroke rehabilitation units or a limited number of hospitals, with sample sizes ranging from 30 to 252. Our results now suggest that functional and cognitive outcomes are reasonable targets for larger, adequately powered trials of the effectiveness of CPAP in improving stroke outcomes.…”

“…[16][17][18][19][20][21][22][23][24][25] If treatment with CPAP is shown to improve stroke outcomes in a larger, adequately powered clinical trial, treatment of SDB may be a viable, cost-efficient intervention strategy to improve stroke recovery. [16][17][18][19][20][21][22][23][24][25] If treatment with CPAP is shown to improve stroke outcomes in a larger, adequately powered clinical trial, treatment of SDB may be a viable, cost-efficient intervention strategy to improve stroke recovery.…”

“…Small randomized clinical trials (RCTs) have demonstrated that treatment of SDB with continuous positive airway pressure (CPAP) in select groups of stroke/transient ischemic attack (TIA) patients may improve functional outcome, cognitive outcome, neurologic recovery, and depressive symptoms, although results have not been conclusive. [16][17][18][19][20][21][22][23][24][25] If treatment with CPAP is shown to improve stroke outcomes in a larger, adequately powered clinical trial, treatment of SDB may be a viable, cost-efficient intervention strategy to improve stroke recovery. Observational data on the association of SDB with a variety of stroke outcomes could inform the most appropriate endpoints for future recovery trials of SDB treatment in stroke patients.…”

Sleep, Oh Sleep, Where Art Thou?

“…Furthermore, Spannella et al [8] reported that treatment of obstructive sleep apnea improved not only blood pressure, but also the metabolic profile without any change in weight. Obstructive sleep apnea also increases the predisposition to stroke; and the treatment of obstructive sleep apnea has also been found to reduce chances of future stroke [9]. Thus, there is ample evidence that obesity increases the risk for obstructive sleep apnea, which in turn increases the risk for diabetes mellitus, dyslipidemia, cardiovascular and cerebrovascular morbidity and effective treatment of OSA improves these consequences.…”