In Reply We agree with Dr Hunasikatti that the exclusion of excessively sleepy patients from randomized trials of the management of OSA for secondary prevention of cardiovascular disease may well have contributed to the null findings of these studies, as mentioned in our Review.1 Although it is not known whether treatment of sleepy patients with OSA reduces cardiovascular risk, control of symptoms is a sufficient rationale for treatment of these patients, whether the treatment is PAP or any of the variety of alternative treatment options. These alternatives include weight loss and exercise, which have known cardiovascular and metabolic benefits in addition to their effect on OSA. We appreciate the likelihood that other subgroups of asymptomatic or minimally symptomatic patients with OSA, in addition to those with resistant hypertension, may receive long-term health benefits from management of OSA. Although it is possible that patients with comorbid OSA and obstructive lung diseases are one such group, observational studies such as those cited by Hunasikatti should be considered hypothesis generating rather than a sound basis for therapeutic decision-making. Because adherence to therapy is itself a strong predictor of reduced mortality, even when it is adherence to placebo,2 studies that compare adherent vs nonadherent patients provide at best weak evidence of a treatment effect. Therefore, prior to making a general recommendation in favor of treatment for any particular group of asymptomatic patients, randomized clinical trials should be undertaken to demonstrate a clinical benefit.
Gottlieb DJ, Punjabi NM. Benefits of Treating Obstructive Sleep Apnea—Reply. JAMA. 2020;324(11):1110–1111. doi:10.1001/jama.2020.11856
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