Impact of continuous positive airway pressure therapy for obstructive sleep apnea on atrial fibrillation recurrence following catheter ablation: a comprehensive systematic review and meta-analysis

Background Obstructive sleep apnea (OSA) is common in patients with atrial fibrillation (AF) and contributes to atrial remodeling and post-ablation recurrence. Continuous positive airway pressure (CPAP) therapy may improve rhythm outcomes; however, its overall efficacy and impact across clinical subgroups remain uncertain. We performed a systematic review and meta-analysis to clarify this association. Purpose To evaluate the impact of continuous positive airway pressure therapy on atrial fibrillation recurrence following catheter ablation through a systematic review and meta-analysis. Methods We systematically searched PubMed, Embase, and Cochrane Library through January 2026 for studies evaluating CPAP therapy in patients with obstructive sleep apnea undergoing AF ablation. Effect estimates were pooled using random-effects models in Stata 18.0. Risk of bias was assessed using the ROBINS-I tool, with prespecified subgroup analyses. Results Thirty-two studies (n = 8,964 patients; mean age 63.8 years; 72% male; mean follow-up 18.4 months) were included. The primary endpoint, AF recurrence after catheter ablation, was significantly reduced with CPAP therapy compared with untreated OSA (HR 0.62; 95% CI 0.54–0.71; I² = 38%). Greater benefit was observed in moderate–severe OSA (HR 0.56; 95% CI 0.48–0.66) and with high CPAP adherence ≥4 hours/night (HR 0.49; 95% CI 0.40–0.60), whereas low adherence showed no significant effect (HR 0.87; 95% CI 0.71–1.06). Secondary outcomes demonstrated reduced repeat ablation (RR 0.71; 95% CI 0.58–0.87), a non-significant trend toward lower stroke risk (HR 0.76; 95% CI 0.55–1.04), and improvement in left atrial volume index (WMD −4.2 mL/m²; 95% CI −7.8 to −0.6). Regarding safety, CPAP did not increase serious adverse events (RR 0.97; 95% CI 0.72–1.31), treatment discontinuation (RR 1.18; 95% CI 0.89–1.56), device intolerance (RR 1.24; 95% CI 0.92–1.68), cardiovascular hospitalization (RR 0.93; 95% CI 0.70–1.24), all-cause mortality (HR 0.89; 95% CI 0.60–1.32), therapy-related withdrawal (RR 1.15; 95% CI 0.84–1.57), mask discomfort (RR 1.29; 95% CI 0.96–1.73), nasal congestion (RR 1.21; 95% CI 0.90–1.63), skin irritation (RR 1.17; 95% CI 0.82–1.66), or aerophagia (RR 1.14; 95% CI 0.79–1.64), with low heterogeneity across safety outcomes (I² < 25%). Conclusion CPAP therapy significantly reduces atrial fibrillation recurrence after catheter ablation, with greater benefit in moderate–severe OSA and in patients with high treatment adherence. It lowers repeat ablation risk and improves left atrial remodeling without increasing adverse events, supporting OSA treatment as an integral component of rhythm control strategy.