Abstract
Mandibular advancement device (MAD) is an alternative therapeutic option for CPAP to treat obstructive sleep apnea (OSA). While MAD showed the better adherence, patients with over moderate OSA have been treated more frequently with CPAP despite increasing positive evidence on the cardiovascular outcome with MAD, even in severe patients. Thus, more information is needed regarding the cardiovascular and symptomatic outcome of MAD treatment objectively compared to CPAP. Forty-five supine-dependent OSA patients (apnea–hypopnea index 20–40/h) were randomized to either CPAP or MAD and treated for 8 weeks and switched to another for 8 weeks. The primary endpoint was improvement in the endothelial function, indexed by the flow-mediated dilatation (FMD), and the secondary endpoint was the sleep-time blood pressure (BP). The duration of MAD use was evaluated objectively by an implanted adherence monitor. Treatment efficacy was also evaluated by home sleep monitor and a questionnaire about the symptoms. The adherence was not significantly different (CPAP vs. MAD: 274.5 ± 108.9 min/night vs. 314.8 ± 127.0 min/night, p = 0.095). FMD and sleep-time mean BP were not markedly changed from the baseline with either approach (CPAP vs. MAD: FMD, + 0.47% ± 3.1% vs. + 0.85% ± 2.6%, p = 0.64; BP, − 1.5 ± 5.7 mmHg vs. − 1.2 ± 7.5 mmHg, p = 0.48), although sleepiness, nocturia, and sleep-related parameters were similarly improved and more patients preferred MAD. As MAD and CPAP showed similar effects on cardiovascular outcome and symptomatic relief even with a comparable length of usage, we might expect MAD as an alternative treatment option for CPAP in this range of OSA group.
Similar content being viewed by others
References
Young T, Palta M, Dempsey J, Skatrud J, Weber S, Badr S (1993) The occurrence of sleep-disordered breathing among middle-aged adults. N Engl J Med 328:1230–1235
Kohler M, Stoewhas AC, Ayers L, Senn O, Bloch KE, Russi EW, Stradling JR (2011) Effects of continuous positive airway pressure therapy withdrawal in patients with obstructive sleep apnea a randomized controlled trial. Am J Respir Crit Care Med 184:1192–1199
Sawatari H, Chishaki A, Nishizaka M, Tokunou T, Adachi S, Yoshimura C, Ohkusa T, Ando SI (2016) Cumulative hypoxemia during sleep predicts vascular endothelial dysfunction in patients with sleep-disordered breathing. Am J Hypertens 29:458–463
Nakabayashi K, Jujo K, Saito K, Oka T, Hagiwara N (2017) Evaluation of the association between sleep apnea and polyunsaturated fatty acids profiles in patients after percutaneous coronary intervention. Heart Vessels 32:1296–1303
Shamsuzzaman ASM, Gersh BJ, Somers VK (2003) Obstructive sleep apnea: implications for cardiac and vascular disease. J Am Med Assoc 290:1906–1914
Akita K, Maekawa Y, Kohno T, Tsuruta H, Murata M, Fukuda K (2017) Ameliorating the severity of sleep-disordered breathing concomitant with heart failure status after percutaneous transluminal septal myocardial ablation for drug-refractory hypertrophic obstructive cardiomyopathy. Heart Vessels 32:1320–1326
Heinzer R, Vat S, Marques-Vidal P, Marti-Soler H, Andries D, Tobback N, Mooser V, Preisig M, Malhotra A, Waeber G, Vollenweider P, Tafti M, Haba-Rubio J (2015) Prevalence of sleep-disordered breathing in the general population: the HypnoLaus study. Lancet Respir Med 3:310–318
Marin JM, Carrizo SJ, Vicente E, Agusti AGN (2005) Long-term cardiovascular outcomes in men with obstructive sleep apnoea-hypopnoea with or without treatment with continuous positive airway pressure: an observational study. Lancet 365:1046–1053
Phillips CL, Grunstein RR, Darendeliler MA, Mihailidou AS, Srinivasan VK, Yee BJ, Marks GB, Cistulli PA (2013) Health outcomes of continuous positive airway pressure versus oral appliance treatment for obstructive sleep apnea: a randomized controlled trial. Am J Respir Crit Care Med 187:879–887
Marklund M, Stenlund H, Franklin KA (2004) Mandibular advancement devices in 630 men and women with obstructive sleep apnea and snoring: tolerability and predictors of treatment success. Chest 125:1270–1278
Gagnadoux F, Fleury B, Vielle B, Pételle B, Meslier N, N’Guyen XL, Trzepizur W, Racineux JL (2009) Titrated mandibular advancement versus positive airway pressure for sleep apnoea. Eur Respir J 34:914–920
Chan ASL, Cistulli PA (2009) Oral appliance treatment of obstructive sleep apnea: an update. Curr Opin Pulm Med 15:591–596
Gagnadoux F, Pépin JL, Vielle B, Bironneau V, Chouet-Girard F, Launois S, Meslier N, Meurice JC, Nguyen XL, Paris A, Priou P, Tamisier R, Trzepizur W, Goupil F, Fleury B (2017) Impact of mandibular advancement therapy on endothelial function in severe obstructive sleep apnea. Am J Respir Crit Care Med 195:1244–1252
Trzepizur W, Gagnadoux F, Abraham P, Rousseau P, Meslier N, Saumet JL, Racineux JL (2009) Microvascular endothelial function in obstructive sleep apnea: impact of continuous positive airway pressure and mandibular advancement. Sleep Med 10:746–752
Hoekema A, Stegenga B, Wijkstra PJ, Van Der Hoeven JH, Meinesz AF, De Bont LGM (2008) Obstructive sleep apnea therapy. J Dent Res 87:882–887
Ramar K, Dort LC, Katz SG, Lettieri CJ, Harrod CG, Thomas SM, Chervin RD (2015) Clinical practice guideline for the treatment of obstructive sleep apnea and snoring with oral appliance therapy: an update for 2015. J Clin Sleep Med 11:773–828
Vanderveken OM, Dieltjens M, Wouters K, De Backer WA, Van De Heyning PH, Braem MJ (2013) Objective measurement of compliance during oral appliance therapy for sleep-disordered breathing. Thorax 68:91–96
Joosten SA, O’Driscoll DM, Berger PJ, Hamilton GS (2014) Supine position related obstructive sleep apnea in adults: pathogenesis and treatment. Sleep Med Rev 18:7–17
Taylor F, Pembrey MS, Beddard AP, French H (1907) Observations upon two cases of Cheyne-stokes’ respiration. Med Chir Trans 90:83–98
Corretti MC, Anderson TJ, Benjamin EJ, Celermajer D, Charbonneau F, Creager MA, Deanfield J, Drexler H, Gerhard-Herman M, Herrington D, Vallance P, Vita J, Vogel R (2002) Guidelines for the ultrasound assessment of endothelial-dependent flow-mediated vasodilation of the brachial artery: a report of the international brachial artery reactivity task force. J Am Coll Cardiol 39:257–265
Woodman RJ, Playford DA, Watts GF, Cheetham C, Reed C, Taylor RR, Puddey IB, Beilin LJ, Burke V, Mori TA, Green D (2001) Improved analysis of brachial artery ultrasound using a novel edge-detection software system. J Appl Physiol 91:929–937
Takegami M, Suzukamo Y, Wakita T, Noguchi H, Chin K, Kadotani H, Inoue Y, Oka Y, Nakamura T, Green J, Johns MW, Fukuhara S (2009) Development of a Japanese version of the Epworth Sleepiness Scale (JESS) based on Item Response Theory. Sleep Med 10:556–565
Berry SJ, Coffey DS, Walsh PC, Ewing LL (1984) The development of human benign prostatic hyperplasia with age. J Urol 132:474–479
Kohler M, Craig S, Pepperell JCT, Nicoll D, Bratton DJ, Nunn AJ, Leeson P, Stradling JR (2013) CPAP improves endothelial function in patients with minimally symptomatic OSA: results from a subset study of the MOSAIC trial. Chest 144:896–902
Ip MSM, Tse HF, Lam B, Tsang KWT, Lam WK (2004) Endothelial function in obstructive sleep apnea and response to treatment. Am J Respir Crit Care Med 169:348–353
Schwarz EI, Puhan MA, Schlatzer C, Stradling JR, Kohler M (2015) Effect of CPAP therapy on endothelial function in obstructive sleep apnoea: a systematic review and meta-analysis. Respirology 20:889–895
Itzhaki S, Dorchin H, Clark G, Lavie L, Lavie P, Pillar G (2007) The effects of 1-year treatment with a herbst mandibular advancement splint on obstructive sleep apnea, oxidative stress, and endothelial function. Chest 131:740–749
Lin CC, Wang HY, Chiu CH, Liaw SF (2015) Effect of oral appliance on endothelial function in sleep apnea. Clin Oral Investig 19:437–444
Kallianos A, Panoutsopoulos A, Mermigkis C, Kostopoulos K, Papamichail C, Kokkonouzis I, Kostopoulos C, Nikolopoulos I, Papaiwannou A, Lampaki S, Organtzis J, Pitsiou G, Zarogoulidis P, Trakada G (2015) Sex differences of continuous positive airway pressure treatment on flow-mediated dilation in patients with obstructive sleep apnea syndrome. Clin Interv Aging 10:1361–1367
Andrén A, Hedberg P, Walker-Engström ML, Wahlén P, Tegelberg A (2013) Effects of treatment with oral appliance on 24-h blood pressure in patients with obstructive sleep apnea and hypertension: a randomized clinical trial. Sleep Breath 17:705–712
Bratton DJ, Gaisl T, Wons AM, Kohler M (2015) CPAP vs mandibular advancement devices and blood pressure in patients with obstructive sleep apnea a systematic review and meta-analysis. JAMA J Am Med Assoc 314:2280–2293
Bazzano LA, Khan Z, Reynolds K, He J (2007) Effect of nocturnal nasal continuous positive airway pressure on blood pressure in obstructive sleep apnea. Hypertension 50:417–423
Baguet JP, Barone-Rochette G, Pépin JL (2009) Hypertension and obstructive sleep apnoea syndrome: current perspectives. J Hum Hypertens 23:431–443
Yamaguchi T, Takata Y, Usui Y, Asanuma R, Nishihata Y, Kato K, Shiina K, Yamashina A (2016) Nocturnal intermittent hypoxia is associated with left ventricular hypertrophy in middle-aged men with hypertension and obstructive sleep apnea. Am J Hypertens 29:372–378
Oldenburg O, Wellmann B, Buchholz A, Bitter T, Fox H, Thiem U, Horstkotte D, Wegscheider K (2016) Nocturnal hypoxaemia is associated with increased mortality in stable heart failure patients. Eur Heart J 37:1695–1703
Drager LF, McEvoy RD, Barbe F, Lorenzi-Filho G, Redline S, Initiative I (2017) Sleep apnea and cardiovascular disease: lessons from recent trials and need for team science. Circulation 136:1840–1850
McEvoy RD, Antic NA, Heeley E, Luo Y, Ou Q, Zhang X, Mediano O, Chen R, Drager LF, Liu Z, Chen G, Du B, McArdle N, Mukherjee S, Tripathi M, Billot L, Li Q, Lorenzi-Filho G, Barbe F, Redline S, Wang J, Arima H, Neal B, White DP, Grunstein RR, Zhong N, Anderson CS (2016) CPAP for prevention of cardiovascular events in obstructive sleep apnea. N Engl J Med 375:919–931
Yu J, Zhou Z, McEvoy R, Anderson CS, Rodgers A, Perkovic V, Neal B (2017) Association of positive airway pressure with cardiovascular events and death in adults with sleep apnea: a systematic review and meta-analysis. JAMA 318:156–166
Sharples LD, Clutterbuck-James AL, Glover MJ, Bennett MS, Chadwick R, Pittman MA, Quinnell TG (2016) Meta-analysis of randomised controlled trials of oral mandibular advancement devices and continuous positive airway pressure for obstructive sleep apnoea-hypopnoea. Sleep Med Rev 27:108–124
Engleman HM, McDonald JP, Graham D, Lello GE, Kingshott RN, Coleman EL, Mackay TW, Douglas NJ (2002) Randomized crossover trial of two treatments for sleep apnea/hypopnea syndrome: continuous positive airway pressure and mandibular repositioning splint. Am J Respir Crit Care Med 166:855–859
Barnes M, McEvoy RD, Banks S, Tarquinio N, Murray CG, Vowles N, Pierce RJ (2004) Efficacy of positive airway pressure and oral appliance in mild to moderate obstructive sleep apnea. Am J Respir Crit Care Med 170:656–664
Almeida FR, Henrich N, Marra C, Lynd LD, Lowe AA, Tsuda H, Fleetham JA, Pliska B, Ayas N (2013) Patient preferences and experiences of CPAP and oral appliances for the treatment of obstructive sleep apnea: a qualitative analysis. Sleep Breath 17:659–666
Hajduk IA, Jasani RR, Strollo PJ Jr, Atwood CW Jr, Sanders MH (2000) Nocturia in sleep disordered breathing. Sleep Med 1:263–271
El-Solh AA, Homish GG, Ditursi G, Lazarus J, Rao N, Adamo D, Kufel T (2017) A randomized crossover trial evaluating continuous positive airway pressure versus mandibular advancement device on health outcomes in veterans with posttraumatic stress disorder. J Clin Sleep Med 13:1327–1335
Masa JF, Corral J, Pereira R, Duran-Cantolla J, Cabello M, Hernández-Blasco L, Monasterio C, Alonso A, Chiner E, Rubio M, Garcia-Ledesma E, Cacelo L, Carpizo R, Sacristan L, Salord N, Carrera M, Sancho-Chust JN, Embid C, Vázquez-Polo FJ, Negrín MA, Montserrat JM (2011) Effectiveness of home respiratory polygraphy for the diagnosis of sleep apnoea and hypopnoea syndrome. Thorax 66:567–573
Durán-Cantolla J, Zamora Almeida G, de Vegas Diaz Guereñu O, Saracho Rotaeche L, Hamdan Alkhraisat M, Durán Carro J, Egea Santaolalla C, Anitua E, on Behalf of the Spanish Sleep N (2017) Validation of a new domiciliary diagnosis device for automatic diagnosis of patients with clinical suspicion of OSA. Respirology 22:378–385
Acknowledgements
We appreciate the help of Chikara Yoshimura, MD, PhD and Sakiko Handa, MD, PhD, in the conduct of the study as well as that of Hiroyuki Sawatari, RN, Sayaka Soda, CT, and Yumiko Kubota, RPSGT, in collecting the data for this study.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of interest
This work was supported by JSPS KAKENHI Grant Number JP17K09555. In this trial, the MAD was provided by SomnoMed, Ltd., without any monetary support, and this study was performed independently of this company in its design, the collection and analysis of the data, and the preparation of the manuscript.
Additional information
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
About this article
Cite this article
Yamamoto, U., Nishizaka, M., Tsuda, H. et al. Crossover comparison between CPAP and mandibular advancement device with adherence monitor about the effects on endothelial function, blood pressure and symptoms in patients with obstructive sleep apnea. Heart Vessels 34, 1692–1702 (2019). https://doi.org/10.1007/s00380-019-01392-3
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00380-019-01392-3