CPAP vs Mandibular Advancement Devices and Blood Pressure in Patients With Obstructive Sleep Apnea A Systematic Review and Meta-analysis

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 Datawere 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. RESULTS Of 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 2.5mmHg (95% CI, 1.5 to 3.5mmHg; P < .001) and in DBP of 2.0mmHg (95% CI, 1.3 to 2.7mmHg; P < .001). A 1-hour-per-night increase in mean CPAP use was associated with an additional reduction in SBP of 1.5mmHg (95% CI, 0.8 to 2.3mmHg; P < .001) and an additional reduction in DBP of 0.9mmHg (95% CI, 0.3 to 1.4mm Hg; P = .001). Compared with an inactive control, MADs were associated with a reduction in SBP of 2.1mmHg (95% CI, 0.8 to 3.4mmHg; P = .002) and in DBP of 1.9mmHg (95% CI, 0.5 to 3.2mmHg; P = .008). There was no significant difference between CPAP and MADs in their association with change in SBP (-0.5mmHg [95% CI, -2.0 to 1.0mmHg]; P = .55) or in DBP (-0.2mmHg [95% CI, -1.6 to 1.3mmHg]; P = .82). CONCLUSIONS AND RELEVANCE Among 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.