CPAP alternative may be better for lowering blood pressure in sleep apnea, hypertension

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Key takeaways:

  • Mandibular advancement devices were as effective for blood pressure lowering as CPAP devices for patients with obstructive sleep apnea and hypertension.
  • The difference may be due to better adherence.

A mandibular advancement device may be better for blood pressure lowering compared with continuous positive airway pressure devices for people with obstructive sleep apnea and hypertension, researchers reported.

Mandibular advancement devices are not considered as effective a treatment for obstructive sleep apnea as continuous positive airway pressure (CPAP) devices, but they may be better tolerated and are an alternative for patients who do not want to use a CPAP device, according to a press release from the American College of Cardiology.

Sleep apnea CPAP_273497611
Mandibular advancement devices trended toward superiority for blood pressure lowering vs. CPAP devices for patients with obstructive sleep apnea and hypertension. Image: Adobe Stock

For the CRESCENT trial, presented at the ACC Scientific Session and simultaneously published in the Journal of the American College of Cardiology, Chi-Hang Ronald Lee, MBBS, MD, professor of medicine at Yong Loo Lin School of Medicine, National University of Singapore and senior consultant in the department of cardiology at National University Heart Centre, Singapore, and colleagues randomly assigned 220 patients with moderate to severe obstructive sleep apnea, defined as apnea-hypopnea index of at least 15 events per hour, hypertension and elevated CV risk to receive a mandibular advancement device or a CPAP device. Mandibular advancement devices keep the airway open by repositioning the lower jaw and moving the tongue forward, whereas CPAP devices deliver pressurized air through the mouth and nose to keep the airway open, according to the release.

Chi-Hang Ronald Lee

“Over 400 million people globally have moderate to severe obstructive sleep apnea, and it is underdiagnosed and may be a contributing factor to their high blood pressure,” Lee said. “Especially for patients whose blood pressure is hard to control or who have a lot of excessive daytime sleepiness, [it is important to] go see a physician about sleep apnea and get treated if necessary.”

Differences in BP lowering

The primary outcome was 6-month change in mean 24-hour arterial BP.

At 6 months, mean 24-hour arterial BP declined in the mandibular advancement device group by –2.5 mm Hg (P = .003) but did not change in the CPAP group (P = .374), and mandibular advancement devices were noninferior to CPAP devices for BP lowering (between-group difference, –1.6 mm Hg; 95% CI, –3.51 to 0.24; P for noninferiority < .001), according to the researchers.

“Looking at the totality of evidence available in the literature, it is still reasonable to say that CPAP is the first-line treatment until we have more data on the [mandibular advancement device],” Lee said in the release. “However, for patients who truly cannot tolerate or accept using a CPAP, we should be more open minded in looking for an alternative therapy such as a [mandibular advancement device], which based on our study, numerically had a better blood pressure reduction in patients compared with a CPAP.”

In addition, 6-month reduction of the following secondary BP measures was greater in the mandibular advancement device group than in the CPAP group: 24-hour systolic BP (P = .002), 24-hour diastolic BP (P < .001), 24-hour pulse pressure (P = .002), mean awake BP (P = .005), awake systolic BP (P = .009), awake diastolic BP (P = .007), awake pulse pressure (P = .008), mean asleep BP (P = .001), asleep systolic BP (P = .005) and asleep diastolic BP (P = .001), Lee said during the presentation. There was no difference between the groups in change in asleep pulse pressure.

Adherence may be factor

“The [mandibular advancement device] patients simply used the device longer,” Lee said in the release. “That also might explain why the blood pressure reduction at nighttime, when the patients are actually using it, had a better reduction in the [mandibular advancement device] arm.”

In a related editorial published in JACC, Michele Emdin, MD, PhD, FESC, FHFA, director of the cardiology division at Fondazione G. Monasterio and professor of cardiovascular diseases at the Scuola Superiore Sant’Anna, Pisa, Italy, and colleagues wrote that “poor adherence to CPAP might explain the absence of a relevant effect [on hypertension], particularly in asymptomatic or mildly symptomatic patients.”

“Although the population consisted of hypertensive patients (with up to 20% taking three antihypertensive drugs), blood pressure values were generally well controlled at baseline, with mean values falling in the range of normality in both arms. Nonetheless, the slightly greater reduction in mean blood pressure observed with mandibular advancement devices will deserve further attention and underscores the need for assessing the efficacy of this therapy even on clinical endpoints,” Emdin and colleagues wrote.

References:

PERSPECTIVE

It was good to see there is an alternative option to a therapy that is not very well-tolerated or adhered to. The alternative option for sleep apnea treatment showed significant reductions in BP and apnea-hypopnea index. Especially in the United States, where sleep apnea is underdiagnosed and undertreated, CPAP does not get great adherence over the long term. This has important implications for CV health, especially in people with known heart disease or risk factors. What many would consider a less invasive or cumbersome option is effective in delivering results.

For people who are CPAP-resistant or CPAP-adverse for whatever reason, this significantly easier-to-use technology has an important place in the landscape of sleep apnea treatment.

Alexander J. Blood, MD, MSc, FACC

Associate Director, Accelerator for Clinical Transformation

Mass General Brigham

Attending Physician in Cardiovascular Medicine and Critical Care

Brigham and Womens Hospital

Newton-Wellesley Hospital

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