The link between obstructive sleep apnoea (OSA) and cardiovascular disease (CVD) is clear. Its well-established association with essential hypertension is thought to link OSA to an increased risk of atherosclerotic and hypertensive sequelae. However, data on the long-term impact of current OSA treatments on CVD outcomes remain limited. Continuous positive airway pressure (CPAP) is the commonest first-line and long-term intervention for OSA but is hampered by atrociously poor adherence and limited understanding of its cardiovascular impact. Fascinating surgical alternatives are available like upper airway stimulation (UAS), which monitors ventilatory effort to stimulate the hypoglossal nerve and initiate tongue protrusion, and soft tissue debulking surgery including uvulopalatopharyngoplasty (UPPP) and tonsillectomy. These have demonstrated positive effects on CVD biomarkers, though their impact on CVD clinical endpoints is less clear. “It’s time to clear the air!” declared Martin and colleagues, as they embarked on a study comparing the long-term CVD outcomes of these treatments. Their retrospective analysis included 9246 patients who underwent sleep surgery (UAS, UPPP and tonsillectomy) and 510,987 patients treated exclusively with CPAP. Outcomes were assessed at five, eight and 20 years following treatment initiation (excluding 20-year follow-up for UAS given its recent FDA approval). At every time point, surgical interventions demonstrated significantly decreased odds and improved survival for CVD morbidity compared to CPAP, though subgroup analysis revealed fewer significant improvements in CVD outcomes for tonsillectomy. This highly powered study provides rich novel data on the long-term cardiovascular outcomes of different OSA treatments, highlighting the potentially transformative impact of UAS. We must be cautious in our interpretation given the potential selection biases favouring healthier surgical patients and the lack of 20-year data for UAS. But, for carefully selected patient cohorts who cannot hack the high flow of CPAP, these results may truly provoke both deep inspiration and tongue protrusion!
Sleep apnoea got your heart in your throat? Perhaps it’s time to ditch the CPAP and fetch the scalpel
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