TABLE VII.A.6a.

Association between OSA and heart failure

Study	Year	LOE	Study design	Study group	Relevant clinical endpoint	Conclusion
Gottlieb et al.641	2010	2b	Prospective cohort 4422 subjects Followed for a median of 8.7 years	Participants had OSA on PSG and no coronary heart disease or heart failure at baseline	Incident CHF CHF-free survival	Incidence of CHF increased with increasing severity of OSA After adjustment for age, race, smoking, and BMI, AHI was associated with CHF in men but not women
Hla et al.645	2015	2b	Prospective cohort of people in South-Central Wisconsin 1546 participants	Participants had OSA on PSG and no documented CHD or CHF at baseline CHD and CHF was self-reported	Composite outcome of incident CHD or heart failure	After adjustment for age, sex, smoking, and BMI, OSA was associated with increased incidence of CHD or heart failure Association of OSA with incident CHD or CHF was attenuated when participants who reported using CPAP were included in the analysis
Kasai et al.754	2008	2b	Prospective cohort in Tokyo, Japan 88 patients followed for mean of 25.3 ± 15.3 months	Moderate to severe OSA with AHI≥15 LVEF<50% and NYHA class II or greater symptoms 65 were treated with CPAP and 23 were untreated	Event-free survival	Cumulative event-free survival was higher in patients w/OSA on CPAP vs. patients w/OSA not on CPAP Cumulative event-free survival was significantly lower in patients with poor compliance than in those with good compliance
Wang et al.742	2007	2b	Prospective, single-center, observational cohort Patients referred to Mount Sinai Hospital in Toronto 218 subjects were followed for a mean of 2.9 ± 2.2 years 164 had complete data	Heart failure for at least 6 months LVEF ≤ 45% at rest NYHA class II-IV dyspnea All underwent PSG and were divided into categories: AHI < 15 and AHI ≥ 15 Those with central sleep apnea were excluded Patients with OSA were divided into “treated” and “untreated” groups	Cumulative rate of death	Mortality was higher in those with untreated OSA compared to treated OSA after adjusting for LVEF, NYHA class, and age
Kaneko et al.743	2003	1b	RCT 24 patients	Heart failure for at least 6 months LVEF≤45% at rest NYHA class II-IV dyspnea No exacerbations within 3 months Optimal medical therapy OSA with AHI of ≥20 with >50% obstructive events Half of the patients were treated with CPAP, the other half were treated only with medical therapy	Cardiovascular physiologic parameters as measured by trans-thoracic echocardiography: LVEF, LVEDV, LVESV	Nocturnal CPAP improves daytime left ventricular systolic function in patients with heart failure and OSA

Abbreviations: CHD, coronary heart disease; CHF, congestive heart failure; LVEDV, left ventricular end diastolic volume; LVEF, left ventricular ejection fraction; LVESV, left ventricular end systolic volume; OSA, obstructive sleep apnea; PSG, polysomnogram.