Observational studies versus RCTs in sleep apnoea treatment: towards a more pragmatic and less ideological approach

Extract The association between obstructive sleep apnoea (OSA) and cardiovascular disease has long been recognised, but the role of positive airway pressure (PAP) therapy in modifying cardiovascular risk remains controversial [1–7]. Over the past decade, large randomised controlled trials (RCTs) such as SAVE, ISAACC and RICCADSA have consistently reported neutral results with respect to major adverse cardiovascular events (MACEs) [8–10]. These findings have led to scepticism about the capacity of PAP therapy to improve cardiovascular outcomes beyond symptomatic relief, particularly in non-sleepy patients or those with pre-existing cardiovascular disease. Yet, as with many questions in clinical medicine, trial design, adherence issues, and follow-up duration have clouded interpretation [11, 12].