Efficacy of Positive Airway Pressure Therapy in Managing Heart Failure Exacerbations in OSA Patients: A Systematic Review

Authors

Hyder Osman Mirghani¹, Nada Sulaiman Eid Alatawi², ALQARNI ,Ibrahim Mohammed I³, Azizah Saeed Albalawi⁴, Abrar Mohammad S Alhawiti⁵, Amal Sulaiman Salem Alamri⁶, Saleh Ahmed S Alimam⁷, Rakan Hamad M Alshamrani⁸, Jomana Nasser Alkhraisi⁹, Shahad Himyan G Almutairi¹⁰, Joud Ali H Albati¹¹, Abdulkhaliq Eisa Alotaibi¹², Bader Naif M Alsubaie ¹³

Keywords

Obstructive sleep apnea; Heart failure; Positive airway pressure; CPAP; HFrEF; HFpEF.

Abstract

Background: Obstructive sleep apnea (OSA) and heart failure (HF) frequently coexist, with untreated OSA contributing to
HF progression through hemodynamic stress and inflammation. Evidence for positive airway pressure (PAP) therapy in this
population remains conflicting following neutral results from major randomized trials.
Methods: A systematic search of PubMed, Embase, Cochrane CENTRAL, and Web of Science (2021–2026) identified
studies evaluating PAP therapy in adults with moderate-to-severe OSA and HF, reporting HF exacerbations
(hospitalizations, emergency visits, or composite events). Risk of bias was assessed using Cochrane RoB 2.0 and ROBINS
I tools. Results: Six studies (7,843 patients) met inclusion criteria: one RCT and five observational studies. PAP-adherent
patients demonstrated significant reductions in healthcare utilization, including a 24% reduction in emergency visits for
HFrEF and a 57% decrease in hospitalizations for HFpEF. Unsuppressed sleep apnea on CPAP was associated with
increased risk of death or HF hospitalization (HR 2.30, 95% CI 1.21–4.38). LVEF improved from 37.2% to 43.2% after one
month of CPAP. Most studies showed moderate risk of bias.
Conclusion: PAP therapy with adequate adherence is associated with meaningful reductions in HF exacerbations across
both HF phenotypes. The discordance between observational and RCT evidence likely reflects the critical importance of
adherence and trial design limitations. These findings support prioritizing OSA diagnosis and adherence optimization in HF
management.

Author Information

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Professor of Internal Medicine and Endocrine, Department of Internal Medicine, Faculty of Medicine,
University of Tabuk, Tabuk, Saudi Arabia, Email: h.mirghani@ut.edu.sa
Internal Medicine Department, King Salman Armed Forces Hospital, Tabuk, Saudi Arabia
Email: Nada22sadfan@gmail.com
Medical Intern, Faculty of Medicine, University of Tabuk, Tabuk, Saudi Arabia
Email: Ibrahim2026mq@gmail.com
Medical Student, Faculty of Medicine, University of Tabuk, Tabuk, Saudi Arabia
Email: Aziiza8288@gmail.com
Medical Intern, Faculty of Medicine, University of Tabuk, Tabuk, Saudi Arabia
Email: Abraralhowiti@gmail.com
Medical Student, Faculty of Medicine, University of Tabuk, Tabuk, Saudi Arabia
Email: Amalalaamrei@gmail.com
Medical Student, Faculty of Medicine, University of Tabuk, Tabuk, Saudi Arabia
Email: Salehemam14@gmail.com
Medical Student, Faculty of Medicine, University of Tabuk, Saudi Arabia
Email: Hrakan101@gmail.com
Medical Student, Faculty of Medicine, University of Tabuk, Saudi Arabia
Email: Jomanakhr@gmail.com
10 Medical Intern, Faculty of Medicine, University of Tabuk, Tabuk, Saudi Arabia
Email: Mters300@gmail.com
11 Medical Student, Faculty of Medicine, University of Riyadh, Riyadh, Saudi Arabia
Email: A7lajood77666@hotmail.com
12 Medical Student, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
Email: Abdulkhaliqeisa@gmail.com
13 Medical Intern, Faculty of Medicine, University of Tabuk, Tabuk, Saudi Arabia
Email: Badr.alsubei@gmail.com
Corresponding author: Nada Sulaiman Eid Alatawi, Email: Nada22sadfan@gmail.com

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