TABLE VIII.B. 4.c.

PAP after CVA

Study	Year	LOE	Study design	Study groups	Clinical endpoints	Conclusion
Aaronson et al. 1220	2016	1b	Randomized control trial	36 stroke patients who were admitted to a neurorehabilitation unit with OSA were randomly assigned to receive 4 weeks of CPAP therapy (20) or standard of care (16)	Cognitive status measured by neuropsychological examination, and functional status measured by two neurological scales and a measure of activities of daily living (ADL). Recovery rate in the two groups of OSA patients	CPAP treatment significantly improves attention and executive functioning of stroke patients with OSA. CPAP treatment did not significantly improve functional status (neurological and ADL).
Bravata et al.1221	2011	1b	Randomized control trial	70 acute TIA patients were randomized to control (25) or treatment group (45) who received auto-CPAP for two nights and those in treatment group with OSA received auto-CPAP for remaining 90 days	Prevalence of OSA CPAP adherence rate among TIA patients Recurrent vascular events such as recurrent TIA, stroke, hospitalization for CHF, MI, death	OSA is highly prevalent among patients with acute TIA. Increasing auto-CPAP use was not significantly associated with reduced rate of recurrent vascular events.
Bravata et al.599	2017	1b	Randomized control trial	225 points with cerebrovascular disease and HTN from the GoToSleep study at two Veteran Health Affairs centers were randomized to control group or treatment group of auto-CPAP for 1 year	OSA prevalence, OSA treatment as measured by CPAP adherence, and HTN control	There is a high prevalence of OSA among patients with chronic cerebrovascular disease and hypertension. Portable polysomnography and auto-CPAP use improved the diagnosis and the treatment for OSA compared with standard care, but did not lower blood pressure.
Catalan-Serra et al.647	2019	2b	Prospective cohort study	Cohort of 1005 consecutive patients referred to Sleep Units at two Spanish University hospitals who were ≥65 years. They were categorized into four groups based on AHI values from sleep studies and CPAP adherence: 1) control group 2) untreated mild-moderate OSA 3) untreated severe OSA 4) CPAP-treated OSA	Incidence of coronary heart disease and incidence of stroke after adjusting for OSA group, age, BMI, HTN, sex, smoking, ESS, and AF	The incidence of stroke, but not coronary heart disease, is increased in elderly patients with untreated severe OSA.
Gupta et al.1029	2018	1b	RCT	70 patients with OSA and recent stroke randomized to 1. CPAP, 2. non-CPAP	New vascular events. Secondary: clinical stroke outcomes and neuropsycholog- ical parameters	Nonsignificant lower rate of vascular event in CPAP group (3%) vs. non-CPAP group (15%). Significantly improved clinical stroke outcomes (modified Rankin scale) at 12-months in CPAP group.
Khot et al.761	2016	1b	Randomized control trial	Pilot study: 40 patients in stroke rehabilitation who were randomized to APAP or sham CPAP without testing for OSA	Change in Functional Independence Measure (FIM) was assessed between rehabilitation admission and discharge	There were positive trends toward better FIM score improvement with APAP compared to sham CPAP.
Kim et al.1222	2016	2a	Systematic review and meta-analysis	8 studies (one RCT and five cohort and two administrative data) to evaluate effects of CPAP on risk of stroke	Stroke incidence and mortality	Treating with CPAP in patients with OSA might decrease the risk of stroke as seen only in the cohort studies.
McKee et al.1224	2020	2b	Retrospective observational study	527 post-stroke patients at inpatient rehab who underwent overnight oximetry and those at high risk for OSA (3%ODI > 10) were on trial of Auto-CPAP	Recovery measured by changes in functional and cognitive outcomes calculated by functional independence measure (FIM) scores	APAP in high-risk patients was poorly tolerated and did not improve FIM.
Parra et al.1225	2015	1b	Randomized control trial 235 patients <75 years old admitted with ischemic stroke for the first time and with moderate-severe OSA with an AHI ≥20 events randomized to standard care or nasal CPAP during the acute stroke phase	Cardiovascular events: cardiac ischemic events, recurrent stroke, and cardiovascular mortality	Ischemic stroke patients treated with early nasal CPAP improves long-term survival with better neurological recovery compared to the control group.
Parra et al.1226	2011	1b	Randomized control trial	140 patients admitted with first time ischemic stroke and AHI ≥ 20 events/h randomized to early nasal CPAP or standard care during acute stroke phase	Cardiovascular events: cardiac ischemic events, stroke recurrence, and cardiovascular mortality Neurological parameters measured by Barthel index, Canadian scale, Rankin scale, and SF-36	Patients who received nasal CPAP treatment earlier had significantly greater and faster neurological recovery compared to the control group. Stroke patients treated with CPAP experienced less Incident cardiovascular events in the first 24 months compared to control group.
Ryan et al.1227	2011	1b	Randomized control trial	Patients with ischemic or hemorrhagic stroke patients with moderate to severe OSA were assigned to standard rehabilitation alone (22) or to CPAP (22)	Motor, functional, and neurocognitive recovery as measured by Canadian Neurological scale, the 6-min walk test distance, sustained attention response test, and the digit or spatial span-backward	CPAP in stroke patients undergoing rehabilitation improved functional and motor, but not neurocognitive outcomes.
Sánchez-de-la-Torre et al.1203	2020	1b	Randomized control trial	2551 patients admitted with acute coronary syndrome (ACS) symptoms who had a respiratory polygraphy within 24–72 h of admission. Patients had a sleep study and those with OSA were randomized to either CPAP with standard care or standard care alone. Those ACS patients without OSA were the control group	Prevalence of cardiovascular events: cardiovascular death or non-fatal events [acute myocardial infarction, non-fatal stroke, hospital admission for heart failure, and new hospitalizations for unstable angina or transient ischemic attack]	The prevalence of cardiovascular events was not significantly associated with CPAP use in patients with ACS and OSA compared to standard care treatment. Moreover, OSA diagnosis was not associated with worse prognosis in ACS patients.