CPAP provides superior reductions in LDL cholesterol, total cholesterol, and nighttime diastolic blood pressure dipping compared with mandibular advancement devices (MADs), according to a new systematic review and meta-analysis. The findings suggest that continuous positive airway pressure should be the preferred first-line therapy for patients with obstructive sleep apnea who have elevated cardiometabolic risk.
Both CPAP and MADs are well-established treatments for obstructive sleep apnea (OSA), a condition affecting an estimated 936 million adults worldwide. CPAP pneumatically splints the upper airway open during sleep, while MADs reposition the mandible and tongue forward to increase airway patency. Both modalities effectively reduce the apnea-hypopnea index and improve daytime sleepiness, but their comparative effects on downstream cardiometabolic outcomes have remained unclear.
OSA is independently linked to hypertension, dyslipidemia, insulin resistance, and increased cardiovascular morbidity and mortality. Knowing which treatment yields better improvements in these downstream markers carries direct clinical relevance for the millions of patients being managed for OSA worldwide.
A team led by Manasrah et al. sought to clarify the question by conducting a systematic review and meta-analysis of randomized controlled trials that directly compared CPAP and MAD in adults with OSA. The meta-analysis, published June 24 in the Journal of Sleep Research, included 14 RCTs with a total of 1,241 patients and searched the published literature through May 2024. Eligible studies had to report at least one cardiometabolic outcome, including lipid profiles, glucose metabolism markers, or blood pressure parameters measured by ambulatory monitoring.
The primary finding was a consistent CPAP advantage across several lipid parameters. Patients assigned to CPAP showed a mean LDL cholesterol reduction of 15.20 mg/dL greater than those assigned to MAD (95% CI -28.86 to -1.53). Total cholesterol followed a similar pattern, with CPAP producing an additional reduction of 17.10 mg/dL (95% CI -30.15 to -4.05).
On blood pressure, the most notable difference emerged in diastolic blood pressure dipping during sleep. CPAP improved the nocturnal dip in diastolic BP by an additional 3.12 mmHg compared with MAD (95% CI -5.62 to -0.62). Nocturnal BP dipping is a clinically relevant pattern; blunted dipping is independently associated with increased cardiovascular event risk.
Domains Where Treatments Did Not Differ
The meta-analysis found no statistically meaningful differences between CPAP and MAD for several other cardiometabolic markers. Serum glucose, HDL cholesterol, and triglycerides were similar between groups. Ambulatory 24-hour mean blood pressure, systolic and diastolic BP during sleep and wakefulness, and heart rate also did not differ significantly.
These null findings are important. They indicate that while CPAP confers a specific advantage in cholesterol metabolism and nocturnal BP regulation, both treatments produce broadly similar effects on glucose homeostasis and overall 24-hour BP load.
Clinical Implications
The authors conclude that CPAP should be preferred in patients with OSA and elevated cardiometabolic risk, given its superior lipid-improving and diastolic BP-lowering profile. For patients who cannot tolerate CPAP, however, MADs remain a viable and effective alternative for managing OSA.
The choice between CPAP and MAD has real-world significance. CPAP adherence is notoriously variable, with many patients citing mask discomfort, noise, and claustrophobia. Average CPAP usage in clinical studies hovers around 4-5 hours per night, and adherence drops sharply within the first weeks of treatment. MADs are often better tolerated and may be used more consistently, but they can cause jaw pain, dental shifts, or occlusal changes over time. The new data give clinicians an evidence-based rationale to recommend CPAP more strongly when cardiometabolic risk factors are present, even while recognizing that adherence challenges may moderate the real-world effect of either device.
Limitations
The authors caution that the evidence base carries several limitations. The 14 pooled RCTs were relatively small, and heterogeneity across studies was moderate to high for several outcomes, likely reflecting differences in patient populations, OSA severity, device types, and follow-up protocols. Follow-up duration in the included trials was generally short, typically ranging from 4 weeks to 6 months, which limits conclusions about long-term cardiovascular event reduction. Many studies also used older MAD designs; newer adjustable devices that more precisely advance the mandible may yield different results.
Further large-scale, longer-term trials comparing modern MAD devices directly with CPAP, with hard cardiovascular endpoints such as myocardial infarction and stroke rather than surrogate lipid and BP markers, would help solidify these findings and clarify whether the observed CPAP advantages translate into meaningful reductions in clinical events.
Source: Manasrah A, Tanashat M, Ghaly R, et al. Comparative effects of continuous positive airway pressure versus mandibular advancement devices on cardiometabolic outcomes in obstructive sleep apnea: a systematic review and meta-analysis of randomized controlled trials. Journal of Sleep Research. 2026;e70351. DOI: 10.1111/jsr.70351. PMID: 42340217.