CPAP therapy may improve HFpEF-like features in coronary artery disease with obstructive sleep apnea: A randomized controlled trial

Background Obstructive sleep apnea (OSA) frequently coexists with coronary artery disease (CAD) and may contribute to heart failure with preserved ejection fraction (HFpEF). Whether HFpEF-like features are reversible with continuous positive airway pressure (CPAP) therapy remains uncertain. Methods A total of 177 revascularized CAD patients with nonsleepy OSA (Epworth Sleepiness Scale score <10; apnea–hypopnea index [AHI] ≥15/h) from the RICCADSA cohort randomized to CPAP (n = 89) or no CPAP (n = 88) were included. HFpEF-like status was defined using a composite of five echocardiographic and biomarker criteria (≥2 positive). Multivariable logistic regression models were constructed to assess the association between CPAP therapy and HFpEF improvement, adjusting for age, sex, body mass index, AHI, hypertension, diabetes, log-transformed NT-proBNP, and E/e′ ratio. Results HFpEF-like features were present in 126 patients (71.2%), with similar prevalence in the CPAP and no-CPAP groups (69.7% vs 72.7%). Among patients with HFpEF-like status at baseline, improvement at 12 month-follow-up occurred in 24 of 62 patients (38.7%) randomized to CPAP compared with 13 of 64 (20.3%) in the no-CPAP group ( p = 0.023). In multivariable analysis, CPAP remained independently associated with HFpEF improvement (OR 2.85, 95% CI 1.13–7.22; p = 0.027). Higher baseline NT-proBNP was inversely associated with improvement (OR 0.37; p = 0.002), whereas E/e′ was not independently predictive. Conclusions CPAP therapy is independently associated with improvement in HFpEF-like features in patients with CAD and OSA, particularly among those with lower myocardial stress. These findings support the presence of a potentially modifiable HFpEF phenotype responsive to treatment of sleep-disordered breathing. Trial registration ClinicalTrials.gov (NCT00519597) © 2026 The Authors.