101
|
Abstract
Sleep-disordered breathing (SDB), which includes obstructive sleep apnea (OSA) as its most extreme variant, is characterized by intermittent episodes of partial or complete obstruction of the upper airway, leading to cessation of breathing while asleep. Cardiac arrhythmias are common problems in OSA patients, although the true prevalence and clinical relevance of cardiac arrhythmias remains to be determined. The presence and complexity of tachyarrhythmias and bradyarrhythmias may influence morbidity, mortality and quality of life for patients with OSA. Although the exact mechanisms underlying the link between OSA and cardiac arrhythmias are not well established, they could be some of the same proposed mechanisms relating OSA to different cardiovascular diseases, such as repetitive pharyngeal collapse during sleep, which leads to markedly reduced or absent airflow, followed by oxyhemoglobin desaturation, persistent inspiratory efforts against an occluded airway and termination by arousal from sleep. These mechanisms elicit a variety of autonomic, hemodynamic, humoral and neuroendocrine responses that evoke acute and chronic changes in cardiovascular function. However, despite substantial research effort, the goals of determining in advance which patients will respond most favorably to certain treatment options (such as continuous positive airway pressure, tracheostomy or cardioversion) and the developing alternative treatments remain largely elusive. Therefore, this literature review aims to summarize a broad array of the pathophysiological mechanisms underlying the relationship between OSA and cardiac arrhythmias and the extent of this association from an epidemiological perspective, thereby attempting to assess the effects of OSA treatment on the presence of cardiac arrhythmias.
Collapse
Affiliation(s)
- Ahmad Salah Hersi
- King Fahad Cardiac Centre, College of Medicine, King Saud University, Riyadh 11472, Saudi Arabia.
| |
Collapse
|
102
|
Koehler U, Augsten M, Apelt S, Boehm P, Noeske S, Groß V, Nell C, Dette F. Autonome Regulation und nächtliche Arrhythmien bei Patienten mit schlafbezogener Atmungsstörung. SOMNOLOGIE 2011. [DOI: 10.1007/s11818-011-0511-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
103
|
McKelvie RS, Moe GW, Cheung A, Costigan J, Ducharme A, Estrella-Holder E, Ezekowitz JA, Floras J, Giannetti N, Grzeslo A, Harkness K, Heckman GA, Howlett JG, Kouz S, Leblanc K, Mann E, O'Meara E, Rajda M, Rao V, Simon J, Swiggum E, Zieroth S, Arnold JMO, Ashton T, D'Astous M, Dorian P, Haddad H, Isaac DL, Leblanc MH, Liu P, Sussex B, Ross HJ. The 2011 Canadian Cardiovascular Society Heart Failure Management Guidelines Update: Focus on Sleep Apnea, Renal Dysfunction, Mechanical Circulatory Support, and Palliative Care. Can J Cardiol 2011; 27:319-38. [DOI: 10.1016/j.cjca.2011.03.011] [Citation(s) in RCA: 97] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2011] [Accepted: 03/15/2011] [Indexed: 10/18/2022] Open
|
104
|
Abstract
Obstructive sleep apnea (OSA) is a form of sleep disordered breathing in which pharyngeal muscle relaxation leads to recurrent nighttime apneas and hypopneas that, through increased afterload, intermittent hypoxia, and excess sympathetic activity, weaken the already failing heart. This review presents the current evidence regarding the complex relationship between OSA and heart failure (HF), including support for OSA as both a cause and consequence of HF. The impact of OSA on other cardiovascular diseases, such as hypertension, ischemic heart disease and arrhythmias, as they relate to HF development or exacerbation, also are reviewed.
Collapse
Affiliation(s)
- Meredith A Brisco
- Cardiovascular Medicine, Heart Failure and Cardiac Transplant Program, University of Pennsylvania, 2 East Perelman Center for Advanced Medicine, 3400 Civic Center Boulevard, Philadelphia, PA 19104, USA
| | | |
Collapse
|
105
|
Yamada S, Sakakibara M, Matsushima S, Saito A, Homma T, Fukushima A, Masaki Y, Watanabe M, Mitsuyama H, Yokoshiki H, Tsutsui H. Successful termination of recurrent ventricular arrhythmias by adaptive servo-ventilation in a patient with heart failure. J Cardiol Cases 2011; 3:e57-e61. [PMID: 30532837 DOI: 10.1016/j.jccase.2011.01.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2010] [Revised: 12/21/2010] [Accepted: 01/04/2011] [Indexed: 11/30/2022] Open
Abstract
A 60-year-old woman who underwent operation due to severe aortic stenosis with left ventricular dysfunction had frequent nonsustained ventricular tachycardia (NSVT) at night. She had an increased apnea-hypopnea index and a reduction in minimum O2 saturation during sleep, which was closely associated with the frequency of NSVT. Adaptive servo-ventilation (ASV) therapy improved sleep disorder breathing (SDB) and also reduced ventricular arrhythmias. These effects were associated with the attenuation of the sympathetic nerve activities by the analysis of heart rate variability. ASV is expected to be effective in the treatment of ventricular tachyarrhythmias in patients with heart failure and SDB.
Collapse
Affiliation(s)
- Shiro Yamada
- Department of Cardiovascular Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Mamoru Sakakibara
- Department of Cardiovascular Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Shouji Matsushima
- Department of Cardiovascular Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Akimichi Saito
- Department of Cardiovascular Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Tsuneaki Homma
- Department of Cardiovascular Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Arata Fukushima
- Department of Cardiovascular Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Yoshihiro Masaki
- Department of Cardiovascular Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Masaya Watanabe
- Department of Cardiovascular Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Hirofumi Mitsuyama
- Department of Cardiovascular Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Hisashi Yokoshiki
- Department of Cardiovascular Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Hiroyuki Tsutsui
- Department of Cardiovascular Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| |
Collapse
|
106
|
Kasai T, Bradley TD. Obstructive Sleep Apnea and Heart Failure. J Am Coll Cardiol 2011; 57:119-27. [PMID: 21211682 DOI: 10.1016/j.jacc.2010.08.627] [Citation(s) in RCA: 258] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2010] [Revised: 06/18/2010] [Accepted: 08/01/2010] [Indexed: 10/18/2022]
|
107
|
|
108
|
Bitter T, Westerheide N, Prinz C, Hossain MS, Vogt J, Langer C, Horstkotte D, Oldenburg O. Cheyne-Stokes respiration and obstructive sleep apnoea are independent risk factors for malignant ventricular arrhythmias requiring appropriate cardioverter-defibrillator therapies in patients with congestive heart failure. Eur Heart J 2010; 32:61-74. [PMID: 20846992 DOI: 10.1093/eurheartj/ehq327] [Citation(s) in RCA: 195] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Thomas Bitter
- Department of Cardiology, Heart and Diabetes Centre North Rhine-Westphalia, Ruhr University Bochum, Georgstasse 11, Bad Oeynhausen, Germany.
| | | | | | | | | | | | | | | |
Collapse
|
109
|
Kee K, Sands SA, Edwards BA, Berger PJ, Naughton MT. Positive Airway Pressure in Congestive Heart Failure. Sleep Med Clin 2010. [DOI: 10.1016/j.jsmc.2010.05.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
|
110
|
Abstract
Cardiovascular disease has been the leading cause of death since 1900. Strategies for cardiovascular disease and prevention have helped to reduce the burden of disease, but it remains an important public health challenge. Therefore, understanding the underlying pathophysiology and developing novel therapeutic approaches for cardiovascular disease is of crucial importance. Recognizing the link between sleep and cardiovascular disease may represent one such novel approach. Obstructive sleep apnea (OSA), a common form of sleep-disordered breathing, has a high and rising prevalence in the general adult population, attributable in part to the emerging epidemic of obesity and enhanced awareness. OSA has been independently linked to specific cardiovascular outcomes such as hypertension, stroke, myocardial ischemia, arrhythmias, fatal and nonfatal cardiovascular events, and all-cause mortality. Treatment of OSA may represent a novel target to reduce cardiovascular health outcomes.
Collapse
Affiliation(s)
- Bernardo Selim
- Division of Pulmonary and Critical Care Medicine, Yale University School of Medicine, 333 Cedar Street, PO Box 208057, New Haven, CT 06520-8057, USA
| | | | | |
Collapse
|
111
|
Abstract
Obstructive sleep apnea (OSA) exerts several effects that may be particularly deleterious in patients with heart failure (HF). OSA should be considered especially in HF patients who are obese or have the metabolic syndrome, systemic hypertension, or pulmonary hypertension. HF patients in whom OSA is suspected should undergo a full evaluation by a sleep specialist, including a polysomnogram, to diagnose OSA and differentiate this disease from central sleep apnea. Those found to have OSA should then receive continuous positive airway pressure and/or other interventions, and standard disease management strategies should be used to maximize compliance. Those who cannot tolerate continuous positive airway pressure may be candidates for mandibular advancement devices or surgical therapies including tracheostomy. Standard HF medications should be used to treat HF, and optimization of fluid balance may help minimize OSA severity. However, it is still unknown whether treatment of OSA in HF patients will reduce hospitalizations or mortality.
Collapse
|
112
|
Heart Failure Society of America. Section 6: Nonpharmacologic Management and Health Care Maintenance in Patients With Chronic Heart Failure. J Card Fail 2010. [DOI: 10.1016/j.cardfail.2010.05.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
|
113
|
Augsten M, Nolte J, Jerrentrup L, Apelt S, Becker H, Koehler U. Kardiale Arrhythmien bei obstruktiver Schlafapnoe. SOMNOLOGIE 2010. [DOI: 10.1007/s11818-010-0453-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
|
114
|
|
115
|
Abstract
Diurnal rhythms influence cardiovascular physiology such as heart rate and blood pressure and the incidence of adverse cardiac events such as heart attack and stroke. For example, shift workers and patients with sleep disturbances, such as obstructive sleep apnea, have an increased risk of heart attack, stroke, and sudden death. Diurnal variation is also evident at the molecular level, as gene expression in the heart and blood vessels is remarkably different in the day as compared to the night. Much of the evidence presented here indicates that growth and renewal (structural remodeling) are highly dependent on processes that occur during the subjective night. Myocardial metabolism is also dynamic with substrate preference also differing day from night. The risk/benefit ratio of some therapeutic strategies and the appearance of biomarkers also vary across the 24-hour diurnal cycle. Synchrony between external and internal diurnal rhythms and harmony among the molecular rhythms within the cell is essential for normal organ biology. Cell physiology is 4 dimensional; the substrate and enzymatic components of a given metabolic pathway must be present not only in the right compartmental space within the cell but also at the right time. As a corollary, we show disrupting this integral relationship has devastating effects on cardiovascular, renal and possibly other organ systems. Harmony between our biology and our environment is vital to good health.
Collapse
Affiliation(s)
- Tami A Martino
- Department of Biomedical Sciences, OVC, University of Guelph, Guelph, ON, Canada, N1G2W1.
| | | |
Collapse
|
116
|
Vitulano N, Giubilato G, Santangeli P, Ierardi C, Pieroni M, Bellocci F, Crea F. Continuous positive airway pressure treatment in addition to optimal medical therapy for ventricular ectopy in a patient with heart failure and sleep-related breathing disorder. J Cardiovasc Med (Hagerstown) 2009; 14:673-6. [PMID: 19996980 DOI: 10.2459/jcm.0b013e3283356e70] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
In this report we describe the case of a 56-year-old man with a medical history of onset of asthenia, palpitations and dyspnoea for mild efforts. After a negative ergometric test for myocardial ischaemia and 24-h Holter monitoring showing frequent ventricular premature beats, but an echocardiogram with significant dilation and dysfunction of the left ventricle, coronary angiography was performed and did not show haemodynamically significant stenosis. Regarding the anamnesis of snoring, daytime sleepiness and the relationship between sleep-related breathing disorder and cardiovascular disease, we performed a cardiorespiratory sleep study that indicated a diagnosis of sleep-related breathing disorder with prevalent obstructive apnoea. In addition to optimal medical therapy for cardiovascular disease, the patient began therapy with continuous positive airway pressure during the night. This showed a considerable decrease in ventricular premature beats (VPBs) during the night, a better control of ventricular ectopy during the day and a better compliance with medical therapy.
Collapse
Affiliation(s)
- Nicola Vitulano
- Department of Cardiology, Catholic University of Rome, Italy.
| | | | | | | | | | | | | |
Collapse
|
117
|
Sleep-disordered breathing and heart failure: focus on obstructive sleep apnea and treatment with continuous positive airway pressure. J Card Fail 2009; 16:164-74. [PMID: 20142029 DOI: 10.1016/j.cardfail.2009.08.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2008] [Revised: 08/11/2009] [Accepted: 08/17/2009] [Indexed: 01/10/2023]
Abstract
BACKGROUND Among patients with heart failure, sleep-disordered breathing is a common problem, with a prevalence ranging from 24% to 76%. Encompassed within the general category of sleep-disordered breathing are 2 types of sleep apnea: obstructive sleep apnea (OSA) occurs when the oropharyngeal musculature relaxes, causing a collapse of the upper airway, and central sleep apnea occurs when the brain stem fails to stimulate breathing. METHODS AND RESULTS This article focuses on the relationship between heart failure and OSA, the treatment of OSA with continuous positive airway pressure (CPAP), and the role of CPAP in improving such effects of heart failure as ejection fraction, blood pressure, sympathetic activity, sleepiness, heart rate, and mortality. CONCLUSIONS It is important to distinguish the type of sleep-disordered breathing a patient may have. Further studies are needed to elucidate the effects of CPAP and other therapies.
Collapse
|
118
|
Stuck B. Der Stellenwert operativer Verfahren in der Therapie der obstruktiven Schlafapnoe des Erwachsenen. SOMNOLOGIE 2009. [DOI: 10.1007/s11818-009-0413-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
|
119
|
Devulapally K, Pongonis R, Khayat R. OSA: the new cardiovascular disease: part II: Overview of cardiovascular diseases associated with obstructive sleep apnea. Heart Fail Rev 2009; 14:155-64. [PMID: 18758946 PMCID: PMC2698954 DOI: 10.1007/s10741-008-9101-2] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2008] [Accepted: 06/30/2008] [Indexed: 12/20/2022]
Abstract
Obstructive sleep apnea (OSA), present in 5-15% of adults, is strongly associated with the incidence and poor outcome of hypertension, coronary artery disease, arrhythmia, heart failure, and stroke. Treatment of OSA completely reverses its cardiovascular consequences. In this review, we discuss the clinical evidence for the strong association between OSA and cardiovascular disease and present an argument for approaching OSA as a cardiovascular disease. We particularly focus on the causative relationship between OSA and hypertension, and on the increasingly recognized relationship between OSA and heart failure.
Collapse
Affiliation(s)
- Kiran Devulapally
- Division of Pulmonary, Critical Care, and Sleep Medicine, Ohio State University, Columbus, OH, USA.
| | | | | |
Collapse
|
120
|
Mehra R, Stone KL, Varosy PD, Hoffman AR, Marcus GM, Blackwell T, Ibrahim OA, Salem R, Redline S. Nocturnal Arrhythmias across a spectrum of obstructive and central sleep-disordered breathing in older men: outcomes of sleep disorders in older men (MrOS sleep) study. ACTA ACUST UNITED AC 2009; 169:1147-55. [PMID: 19546416 DOI: 10.1001/archinternmed.2009.138] [Citation(s) in RCA: 171] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND Rates of cardiac arrhythmias increase with age and may be associated with clinically significant morbidity. We studied the association between sleep-disordered breathing (SDB) with nocturnal atrial fibrillation or flutter (AF) and complex ventricular ectopy (CVE) in older men. METHODS A total of 2911 participants in the Outcomes of Sleep Disorders in Older Men Study underwent unattended polysomnography. Nocturnal AF and CVE were ascertained by electrocardiogram-specific analysis of the polysomnographic data. Exposures were (1) SDB defined by respiratory disturbance index (RDI) quartile (a major index including all apneas and hypopneas), and ancillary definitions incorporating (2) obstructive events, obstructive sleep apnea (OSA; Obstructive Apnea Hypopnea Index quartile), or (3) central events, central sleep apnea (CSA; Central Apnea Index category), and (4) hypoxia (percentage of sleep time with <90% arterial oxygen percent saturation). Multivariable logistic regression analyses were performed. RESULTS An increasing RDI quartile was associated with increased odds of AF and CVE (P values for trend, .01 and <.001, respectively). The highest RDI quartile was associated with increased odds of AF (odds ratio [OR], 2.15; 95% confidence interval [CI], 1.19-3.89) and CVE (OR, 1.43; 95% CI, 1.12-1.82) compared with the lowest quartile. An increasing OSA quartile was significantly associated with increasing CVE (P value for trend, .01) but not AF. Central sleep apnea was more strongly associated with AF (OR, 2.69; 95% CI, 1.61-4.47) than CVE (OR, 1.27; 95% CI, 0.97-1.66). Hypoxia level was associated with CVE (P value for trend, <.001); those in the highest hypoxia category had an increased odds of CVE (OR, 1.62; 95% CI, 1.23-2.14) compared with the lowest quartile. CONCLUSIONS In this large cohort of older men, increasing severity of SDB was associated with a progressive increase in odds of AF and CVE. When SDB was characterized according to central or obstructive subtypes, CVE was associated most strongly with OSA and hypoxia, whereas AF was most strongly associated with CSA, suggesting that different sleep-related stresses may contribute to atrial and ventricular arrhythmogenesis in older men.
Collapse
Affiliation(s)
- Reena Mehra
- Departmentof Medicine, Division of Pulmonary, Case Western Reserve University School of Medicine, Center for Clinical Investigatio, Cleveland, Ohio 44106-6003, USA.
| | | | | | | | | | | | | | | | | |
Collapse
|
121
|
Affiliation(s)
- Richard L Verrier
- Harvard Medical School, Beth Israel Deaconess Medical Center, Department of Medicine, Cardiovascular Institute, Boston, Mass 02115, USA.
| | | |
Collapse
|
122
|
Craig S, Pepperell JCT, Kohler M, Crosthwaite N, Davies RJO, Stradling JR. Continuous positive airway pressure treatment for obstructive sleep apnoea reduces resting heart rate but does not affect dysrhythmias: a randomised controlled trial. J Sleep Res 2009; 18:329-36. [PMID: 19549077 DOI: 10.1111/j.1365-2869.2008.00726.x] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Obstructive sleep apnoea (OSA) is associated with cardiovascular morbidity and may precipitate cardiac dysrhythmias. Uncontrolled reports suggest that continuous positive airway pressure (CPAP) may reduce dysrhythmia frequency and resting heart rate. We undertook a randomised controlled trial of therapeutic CPAP and compared with a subtherapeutic control which included an exploration of changes in dysrhythmia frequency and heart rate. Values are expressed as mean (SD). Eighty-three men [49.5 (9.6) years] with moderate-severe OSA [Oxygen Desaturation Index, 41.2 (24.3) dips per hour] underwent 3-channel 24-h electrocardiograms during normal daily activities, before and after 1 month of therapeutic (n = 43) or subtherapeutic (n = 40) CPAP. Recordings were manually analysed for mean heart rate, pauses, bradycardias, supraventricular and ventricular dysrhythmias. The two groups were well matched for age, body mass index, OSA severity, cardiovascular risk factors and history. Supraventricular ectopics and ventricular ectopics were frequently found in 95.2% and 85.5% of patients, respectively. Less common were sinus pauses (42.2%), episodes of bradycardia (12%) and ventricular tachycardias (4.8%). Compared with subtherapeutic control, CPAP reduced mean 24-h heart rate from 83.0 (11.5) to 79.7 (9.8) (P < 0.002) in the CPAP group compared with a non-significant rise (P = 0.18) from 79.0 (10.4) to 79.9 (10.4) in the subtherapeutic group; this was also the case for the day period analysed separately. There was no significant change in the frequencies of dysrhythmias after CPAP. Four weeks of CPAP therapy reduces mean 24-h heart rate possibly due to reduced sympathetic activation but did not result in a significant decrease in dysrhythmia frequency.
Collapse
Affiliation(s)
- Sonya Craig
- Oxford Centre for Respiratory Medicine, Churchill Hospital, Headington, Oxford OX3 7LJ, United Kingdom.
| | | | | | | | | | | |
Collapse
|
123
|
Gamaldo C, Salas RE, Collop NA. Complex arrhythmia during a sleep study--what to do? J Clin Sleep Med 2009; 5:171-173. [PMID: 19968052 PMCID: PMC2670338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
|
124
|
Abstract
Obstructive sleep apnea (OSA) is present in at least 2% to 4% of the general population. Central sleep apnea (CSA), though less common, is highly prevalent in patients with heart failure. Both forms of sleep apnea exert strong modulatory effects on the autonomic nervous system at night through a number of mechanisms including central respiratory-cardiac coupling in the brainstem, chemoreflex stimulation, baroreflexes, and reflexes relating to lung inflation. Arousals also contribute to the autonomic disturbance. Although sleep is normally a time when parasympathetic modulation of the heart predominates and myocardial electrical stability is enhanced, OSA and CSA disturb this quiescence, creating an autonomic profile in which both profound vagal activity leading to bradyarrhythmias, and sympatho-excitation favoring ventricular ectopy are observed. The resulting tendency toward cardiac arrhythmia may directly contribute to sudden cardiac death and premature mortality in patients with sleep apnea. Therapy consists largely of treatment with continuous positive airway pressure, which has been shown to improve autonomic profile and reduce nocturnal arrhythmias.
Collapse
|
125
|
Prevalence and physiological predictors of sleep apnea in patients with heart failure and systolic dysfunction. J Card Fail 2009; 15:279-85. [PMID: 19398074 DOI: 10.1016/j.cardfail.2008.11.015] [Citation(s) in RCA: 171] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2008] [Revised: 11/20/2008] [Accepted: 11/26/2008] [Indexed: 01/06/2023]
Abstract
BACKGROUND Previous studies reported high prevalences of obstructive and central sleep apnea (OSA and CSA, respectively) in patients with heart failure (HF). However, these preceded widespread use of beta-blockers and spironolactone that might have reduced their prevalences. We therefore determined, in patients with HF, prevalences and predictors of OSA and CSA and the influence of changes in HF therapy on prevalences. METHODS AND RESULTS A total of 218 HF patients with left ventricular ejection fraction (LVEF) <or=45% underwent sleep studies between 1997 and 2004 and were classified as having moderate to severe sleep apnea (apnea-hypopnea index >or=15 hours of sleep, either OSA or CSA), or mild to no sleep apnea. The prevalence of moderate to severe OSA was 26% and of CSA was 21%. Predictors of OSA were older age, male sex, and greater body mass index, and of CSA were older age, male sex, atrial fibrillation, hypocapnia, and diuretic use. Between 1997 and 2004, the prevalences of OSA and CSA did not change significantly (P(trend) =.460, P(trend) =.211, respectively) despite increased use of beta-blockers and spironolactone (P(trend) < .001, P(trend) < .001, respectively), and an increase in LVEF (P(trend)=.005). CONCLUSIONS OSA and CSA remain common in patients with HF, despite increases in beta-blocker and spironolactone use.
Collapse
|
126
|
Abstract
Obstructive sleep apnoea (OSA) is a common disorder in which repetitive apnoeas expose the cardiovascular system to cycles of hypoxia, exaggerated negative intrathoracic pressure, and arousals. These noxious stimuli can, in turn, depress myocardial contractility, activate the sympathetic nervous system, raise blood pressure, heart rate, and myocardial wall stress, depress parasympathetic activity, provoke oxidative stress and systemic inflammation, activate platelets, and impair vascular endothelial function. Epidemiological studies have shown significant independent associations between OSA and hypertension, coronary artery disease, arrhythmias, heart failure, and stroke. In randomised trials, treating OSA with continuous positive airway pressure lowered blood pressure, attenuated signs of early atherosclerosis, and, in patients with heart failure, improved cardiac function. Current data therefore suggest that OSA increases the risk of developing cardiovascular diseases, and that its treatment has the potential to diminish such risk. However, large-scale randomised trials are needed to determine, definitively, whether treating OSA improves cardiovascular outcomes.
Collapse
Affiliation(s)
- T Douglas Bradley
- Sleep Research Laboratory of the Toronto Rehabilitation Institute, Toronto, Canada
| | | |
Collapse
|
127
|
Ruttanaumpawan P, Logan AG, Floras JS, Bradley TD. Effect of continuous positive airway pressure on sleep structure in heart failure patients with central sleep apnea. Sleep 2009; 32:91-8. [PMID: 19189783 PMCID: PMC2625329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023] Open
Abstract
STUDY OBJECTIVES At termination of obstructive apneas, arousal is a protective mechanism that facilitates restoration of upper airway patency and airflow. Treating obstructive sleep apnea (OSA) by continuous positive airway pressure (CPAP) reduces arousal frequency indicating that such arousals are caused by OSA. In heart failure (HF) patients with central sleep apnea (CSA), however, arousals frequently occur several breaths after apnea termination, and there is uncertainty as to whether arousals from sleep are a consequence of CSA. If so, they should diminish in frequency when CSA is attenuated. We therefore sought to determine whether attenuation of CSA by CPAP reduces arousal frequency. DESIGN Randomized controlled clinical trial. PATIENTS AND SETTING We examined data from 205 HF patients with CSA (apnea-hypopnea index [AHI] > or =15, > 50% were central) randomized to CPAP or control who had polysomnograms performed at baseline and 3 months later. MEASUREMENTS AND RESULTS In the control group, there was no change in AHI or frequency of arousals. In the CPAP-treated group, the AHI decreased significantly (from [mean +/- SD] 38.9 +/- 15.0 to 17.6 +/- 16.3, P < 0.001) but neither the frequency of arousals nor sleep structure changed significantly. CONCLUSION These data suggest that attenuation of CSA by CPAP does not reduce arousal frequency in HF patients. We conclude that arousals were not mainly a consequence of CSA, and may not have been acting as a defense mechanism to terminate apneas in the same way they do in OSA.
Collapse
|
128
|
Watanabe MA, Bhalodia R, Lundequam EJ, Domitrovich PP, Steinmeyer BC, Stein PK, Freedland KE, Duntley SP, Carney RM. Increased ventricular premature contraction frequency during rem sleep in patients with coronary artery disease and obstructive sleep apnea. Indian Pacing Electrophysiol J 2008; 8:258-67. [PMID: 18982135 PMCID: PMC2572026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Patients with obstructive sleep apnea are reported to have a peak of sudden cardiac death at night, in contrast to patients without apnea whose peak is in the morning. We hypothesized that ventricular premature contraction (VPC) frequency would correlate with measures of apnea and sympathetic activity. METHODS Electrocardiograms from a sleep study of 125 patients with coronary artery disease were evaluated. Patients were categorized by apnea-hypopnea index (AHI) into Moderate (AHI <15) or Severe (AHI>15) apnea groups. Sleep stages studied were Wake, S1, S2, S34, and rapid eye movement (REM). Parameters of a potent autonomically-based risk predictor for sudden cardiac death called heart rate turbulence were calculated. RESULTS There were 74 Moderate and 51 Severe obstructive sleep apnea patients. VPC frequency was affected significantly by sleep stage (Wake, S2 and REM, F=5.8, p<.005) and by AHI (F=8.7, p<.005). In Severe apnea patients, VPC frequency was higher in REM than in Wake (p=.011). In contrast, patients with Moderate apnea had fewer VPCs and exhibited no sleep stage dependence (p=.19). Oxygen desaturation duration per apnea episode correlated positively with AHI (r(2)=.71, p<.0001), and was longer in REM than in non-REM (p<.0001). The heart rate turbulence parameter TS correlated negatively with oxygen desaturation duration in REM (r(2)=.06, p=.014). CONCLUSIONS Higher VPC frequency coupled with higher sympathetic activity caused by longer apnea episodes in REM sleep may be one reason for increased nocturnal death in apneic patients.
Collapse
Affiliation(s)
- Mari A Watanabe
- Internal Medicine Department, St. Louis University (where the work was performed)
| | - Rajeshkumar Bhalodia
- Internal Medicine Department, St. Louis University (where the work was performed)
| | - Eric J Lundequam
- Internal Medicine Department, St. Louis University (where the work was performed)
| | - Peter P Domitrovich
- Heart Rate Variability Laboratory, Cardiovascular Division, Washington University
| | - Brian C Steinmeyer
- Behavioral Medicine Center, Department of Psychiatry, Washington University
| | - Phyllis K Stein
- Heart Rate Variability Laboratory, Cardiovascular Division, Washington University
| | | | - Stephen P Duntley
- Sleep Research Laboratory, Department of Neurology, Washington University
| | - Robert M Carney
- Behavioral Medicine Center, Department of Psychiatry, Washington University
| |
Collapse
|
129
|
Serizawa N, Yumino D, Kajimoto K, Tagawa Y, Takagi A, Shoda M, Kasanuki H, Hagiwara N. Impact of sleep-disordered breathing on life-threatening ventricular arrhythmia in heart failure patients with implantable cardioverter-defibrillator. Am J Cardiol 2008; 102:1064-8. [PMID: 18929710 DOI: 10.1016/j.amjcard.2008.05.057] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2008] [Revised: 05/30/2008] [Accepted: 05/30/2008] [Indexed: 11/24/2022]
Abstract
It was recognized that sleep-disordered breathing (SDB) is associated with cardiac arrhythmia and sudden cardiac death. However, it was unclear whether the presence of SDB increased the risk of life-threatening ventricular arrhythmia in patients with heart failure (HF) with an implantable cardioverter-defibrillator (ICD). Seventy-one patients with HF and an ICD who were followed up for 180 days after a sleep study were prospectively studied. All patients had an ejection fraction <or=35%. SDB was defined as an apnea-hypopnea index >or=10 events/hour on the sleep study. The frequency of appropriate ICD therapy and the day-night pattern of ICD therapies were compared between patients with and without SDB. SDB was diagnosed in 47 of 71 patients (66%). There were no statistical differences between patients with and without SDB in baseline cardiac function. However, appropriate ICD therapies occurred more frequently in patients with (43%) than without SDB (17%; p = 0.029). On multivariate analysis, the presence of SDB was an independent predictor for appropriate ICD therapy (hazard ratio 4.05, 95% confidence interval 1.20 to 13.65, p = 0.015). Moreover, the rate of total ICD therapy from midnight to 6 A.M. was significantly higher in patients with (34%) than without SDB (13%; p = 0.046). In conclusion, in patients with HF with an ICD, the presence of SDB was common and an independent predictor of life-threatening ventricular arrhythmias that were more likely to occur during sleep.
Collapse
|
130
|
Somers VK, White DP, Amin R, Abraham WT, Costa F, Culebras A, Daniels S, Floras JS, Hunt CE, Olson LJ, Pickering TG, Russell R, Woo M, Young T. Sleep apnea and cardiovascular disease: an American Heart Association/American College of Cardiology Foundation Scientific Statement from the American Heart Association Council for High Blood Pressure Research Professional Education Committee, Council on Clinical Cardiology, Stroke Council, and Council on Cardiovascular Nursing. J Am Coll Cardiol 2008; 52:686-717. [PMID: 18702977 DOI: 10.1016/j.jacc.2008.05.002] [Citation(s) in RCA: 600] [Impact Index Per Article: 37.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
MESH Headings
- Adult
- Arrhythmias, Cardiac/epidemiology
- Cardiovascular Diseases/epidemiology
- Cardiovascular Diseases/physiopathology
- Child
- Comorbidity
- Continuous Positive Airway Pressure
- Death, Sudden, Cardiac
- Disease Progression
- Endothelium, Vascular/physiopathology
- Heart Failure/epidemiology
- Heart Rate/physiology
- Humans
- Hypertension/physiopathology
- Hypertension, Pulmonary/epidemiology
- Hypertension, Pulmonary/physiopathology
- Hypertrophy, Left Ventricular/epidemiology
- Hypoxia/physiopathology
- Insulin Resistance/physiology
- Kidney Failure, Chronic/epidemiology
- Kidney Failure, Chronic/physiopathology
- Myocardial Ischemia/epidemiology
- Myocardial Ischemia/physiopathology
- Obesity/epidemiology
- Oxidative Stress/physiology
- Polysomnography
- Sleep Apnea, Central/diagnosis
- Sleep Apnea, Central/epidemiology
- Sleep Apnea, Central/physiopathology
- Sleep Apnea, Obstructive/diagnosis
- Sleep Apnea, Obstructive/epidemiology
- Sleep Apnea, Obstructive/physiopathology
- Sleep Apnea, Obstructive/therapy
- Stroke/epidemiology
- Sympathetic Nervous System/physiopathology
- Ventricular Dysfunction, Left/epidemiology
Collapse
|
131
|
Sleep-disordered breathing in patients with decompensated heart failure. Heart Fail Rev 2008; 14:183-93. [PMID: 18758944 DOI: 10.1007/s10741-008-9103-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2008] [Accepted: 07/03/2008] [Indexed: 10/21/2022]
Abstract
Sleep-disordered breathing (SDB) has a higher prevalence in patients with heart failure than in the general middle-aged population. Obstructive sleep apnea (OSA), one of the forms of SBD, promotes poorly controlled hypertension, coronary events, and atrial fibrillation events that can lead to acutely decompensated heart failure (ADHF), and evidence suggests that untreated OSA increases mortality in patients with heart failure. Cheyne-Stokes respiration and central sleep apnea (CSA) have long been associated with heart failure and, in many patients, can coexist with OSA. In this article, we propose a systematic approach to diagnose and treat OSA in patients with ADHF based on current evidence.
Collapse
|
132
|
Somers VK, White DP, Amin R, Abraham WT, Costa F, Culebras A, Daniels S, Floras JS, Hunt CE, Olson LJ, Pickering TG, Russell R, Woo M, Young T. Sleep apnea and cardiovascular disease: an American Heart Association/american College Of Cardiology Foundation Scientific Statement from the American Heart Association Council for High Blood Pressure Research Professional Education Committee, Council on Clinical Cardiology, Stroke Council, and Council On Cardiovascular Nursing. In collaboration with the National Heart, Lung, and Blood Institute National Center on Sleep Disorders Research (National Institutes of Health). Circulation 2008. [PMID: 18725495 DOI: 10.1161/circulationaha.107.189420] [Citation(s) in RCA: 801] [Impact Index Per Article: 50.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
|
133
|
Khayat RN, Abraham WT, Patt B, Roy M, Hua K, Jarjoura D. Cardiac effects of continuous and bilevel positive airway pressure for patients with heart failure and obstructive sleep apnea: a pilot study. Chest 2008; 134:1162-1168. [PMID: 18641111 DOI: 10.1378/chest.08-0346] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Obstructive sleep apnea (OSA) is prevalent in patients with heart failure. Treatment with continuous positive airway pressure (CPAP) improves systolic function in patients with heart failure. Bilevel positive airway pressure (PAP) is another treatment modality for OSA. The intermediate-term effect of bilevel PAP on left ventricular ejection fraction (LVEF) in patients with stable heart failure and OSA has not been compared to the effect of CPAP. METHODS In this pilot randomized controlled trial, patients with stable systolic dysfunction and newly diagnosed OSA (n = 24) were randomized to receive either CPAP or bilevel PAP. Titration was done in the sleep laboratory using a CPAP-based algorithm. Primary outcome was the improvement in LVEF after 3 months of treatment. Other measurements included 6-min walk test, Epworth sleepiness scale score, and the Minnesota Living With Heart Failure questionnaire. RESULTS Bilevel PAP increased LVEF 7.9% (LVEF percentage scale) more than CPAP (95% confidence interval [CI], 2.3 to 13.4; p = 0.01). In the bilevel PAP group, LVEF increased 8.5% (95% CI, 3.7 to 13.4; p = 0.002). In the CPAP group, LVEF did not change significantly (0.5%; 95% CI, - 2.7 to 3.7; p = 0.7). The difference in LVEF improvement between the two groups was still significant after adjustment for adherence, level of treatment positive pressure, body mass index, and severity of OSA. CONCLUSION This pilot randomized controlled trial suggests that bilevel PAP is superior to CPAP in improving LVEF in patients with systolic dysfunction and OSA. Larger trials are required to evaluate the mechanism behind this effect.
Collapse
Affiliation(s)
- Rami N Khayat
- Sleep-Heart Program, The Ohio Sate University, Columbus, OH.
| | - William T Abraham
- Division of Cardiovascular Medicine, The Ohio Sate University, Columbus, OH
| | - Brian Patt
- Sleep-Heart Program, The Ohio Sate University, Columbus, OH
| | - Monica Roy
- Sleep-Heart Program, The Ohio Sate University, Columbus, OH
| | - Keding Hua
- Center for Biostatistics and College of Public Health, The Ohio Sate University, Columbus, OH
| | - David Jarjoura
- Center for Biostatistics and College of Public Health, The Ohio Sate University, Columbus, OH
| |
Collapse
|
134
|
Treatment of sleep disordered breathing in congestive heart failure. Heart Fail Rev 2008; 14:195-203. [PMID: 18618242 DOI: 10.1007/s10741-008-9099-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2008] [Accepted: 06/18/2008] [Indexed: 10/21/2022]
Abstract
In patients with congestive heart failure, sleep disordered breathing occurs commonly and is associated with an increased mortality. In addition to central sleep apnea (Cheyne-Stokes respiration), obstructive sleep apnea is more prevalent in patients with congestive heart failure than in the general population. As a result, a number of treatments have been investigated, with varying results. While many therapies may improve the severity of sleep disordered breathing, only positive pressure ventilation has been shown to improve cardiac function. Newer forms of positive pressure ventilation, such as adaptive servo-ventilation, appear to be even more effective at correcting central sleep apnea. Whether any of these treatments have an effect on transplant-free survival is presently unknown and awaits further study.
Collapse
|
135
|
Shaw JE, Punjabi NM, Wilding JP, Alberti KGMM, Zimmet PZ. Sleep-disordered breathing and type 2 diabetes: a report from the International Diabetes Federation Taskforce on Epidemiology and Prevention. Diabetes Res Clin Pract 2008; 81:2-12. [PMID: 18544448 DOI: 10.1016/j.diabres.2008.04.025] [Citation(s) in RCA: 199] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2008] [Revised: 04/28/2008] [Accepted: 04/30/2008] [Indexed: 12/16/2022]
Abstract
Sleep-disordered breathing (SDB) has been associated with insulin resistance and glucose intolerance, and is frequently found in people with type 2 diabetes. SDB not only causes poor sleep quality and daytime sleepiness, but has clinical consequences, including hypertension and increased risk of cardiovascular disease. In addition to supporting the need for further research into the links between SDB and diabetes, the International Diabetes Federation Taskforce on Epidemiology and Prevention strongly recommends that health professionals working in both type 2 diabetes and SDB adopt clinical practices to ensure that a patient presenting with one condition is considered for the other.
Collapse
Affiliation(s)
- Jonathan E Shaw
- International Diabetes Institute, 250 Kooyong Road, Caulfield, Melbourne, VIC 3162, Australia.
| | | | | | | | | |
Collapse
|
136
|
Nocturnal cardiac arrhythmia in patients with obstructive sleep apnea. Sleep Med 2008; 9:475-80. [DOI: 10.1016/j.sleep.2007.08.015] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2007] [Revised: 07/30/2007] [Accepted: 08/19/2007] [Indexed: 11/17/2022]
|
137
|
Grimm W. Arrhythmias in patients with obstructive sleep apnea. Sleep Med 2008; 9:471-2. [DOI: 10.1016/j.sleep.2007.09.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2007] [Accepted: 09/17/2007] [Indexed: 10/22/2022]
|
138
|
Abstract
PURPOSE OF REVIEW As heart failure continues to carry significant morbidity and mortality it is crucial to pursue new lines of therapy. Addressing sleep apnea, which is highly prevalent in these patients, offers just such an avenue. We discuss how sleep apnea may contribute to the propagation of heart failure, and how understanding its effects and reversing these effects might benefit heart failure patients. RECENT FINDINGS Continuous positive airway pressure ventilation, atrial pacing, and chronic resynchronization therapy have all been studied in sleep apnea. Some of these therapies have shown benefits in heart failure. This offers hope for improved outcomes, particularly with respect to mortality. Delineating how these therapies affect the heart's energetics and metabolism may also provide further understanding of the relationship between sleep apnea and heart failure. SUMMARY As both obstructive and central sleep apnea are highly prevalent in heart failure, treating these patients with continuous positive airway pressure, atrial pacing, or chronic resynchronization therapy may offer morbidity and mortality benefits. Much remains to be understood about the relationship between sleep apnea and heart failure, and understanding the interaction between the two at both the myocardial and clinical level is crucial.
Collapse
Affiliation(s)
- Anjali H Anselm
- University of Ottawa Heart Institute, Division of Cardiology, Ottawa, Ontario, Canada
| | | | | | | |
Collapse
|
139
|
Ryan CM, Juvet S, Leung R, Bradley TD. Timing of Nocturnal Ventricular Ectopy in Heart Failure Patients With Sleep Apnea. Chest 2008; 133:934-40. [DOI: 10.1378/chest.07-2595] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
|
140
|
Yamauchi M, Kimura H. Oxidative stress in obstructive sleep apnea: putative pathways to the cardiovascular complications. Antioxid Redox Signal 2008; 10:755-68. [PMID: 18177236 DOI: 10.1089/ars.2007.1946] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Obstructive sleep apnea (OSA) is a major public health problem because of its high prevalence in morbidity and mortality. A growing body of evidence suggests that OSA is an important risk factor for cardiovascular diseases. Although the mechanism for the initiation and aggravation of cardiovascular disease has not been fully elucidated, one theorized mechanism is intermittent hypoxia, which is produced by each sleep-disordered breathing event. This repeated hypoxia and reoxygenation cycle is similar to hypoxia-reperfusion injury, which initiates oxidative stress. Recent studies have suggested that OSA is associated with increased levels of oxidative stress or antioxidant deficiencies or both. Oxidative stress is involved in the activation of redox-sensitive transcription factors, which regulate downstream products such as inflammatory cytokines, chemokines, and adhesion molecules. This pathway may be able to explain the pathogenesis of atherosclerosis, a common pathologic factor underlying all types of cardiovascular disease. In addition, endothelial dysfunction derived from oxidative stress can contribute to cardiovascular diseases. This review summarizes current available evidence for and against the occurrence of oxidative stress in OSA and discusses the putative pathways initiating cardiovascular consequences associated with OSA.
Collapse
Affiliation(s)
- Motoo Yamauchi
- Second Department of Internal Medicine, Nara Medical University, Nara, Japan.
| | | |
Collapse
|
141
|
Barta K, Szabó Z, Kun C, Munkácsy C, Magyar T, Bene O, Csiba L, Lorincz I. [Arrhythmias in patients with obstructive sleep apnea]. Orv Hetil 2008; 149:579-87. [PMID: 18353738 DOI: 10.1556/oh.2008.28258] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
The authors summarize the current knowledge on the types, prevalence, reasons, diagnosis and current therapy of arrhythmias occurring in patients with obstructive sleep apnea. Most of the patients with obstructive sleep apnea have nocturnal bradycardia (5-50%), paroxysmal tachyarrhythmia (atrial 35%; ventricular 0-15%), or both. The frequency of rhythm disturbances associated with the severity of the sleeping disorder. It is important to recognize the factors predisposing to arrhythmias and the early appropriate therapy of patients is essential, in order to protect patients from life threatening arrhythmias which may worsen the clinical outcome.
Collapse
Affiliation(s)
- Kitti Barta
- Debreceni Egyetem, Orvos- és Egészségtudományi Centrum, Altalános Orvostudományi Kar, Belgyógyászati Klinika Debrecen.
| | | | | | | | | | | | | | | |
Collapse
|
142
|
Association of sleep-disordered breathing and ventricular arrhythmias in patients without heart failure. Am J Cardiol 2008; 101:882-6. [PMID: 18328858 DOI: 10.1016/j.amjcard.2007.10.056] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2007] [Revised: 10/25/2007] [Accepted: 10/25/2007] [Indexed: 11/24/2022]
Abstract
The prevalence and characteristics of sleep-disordered breathing (SDB) in patients with ventricular arrhythmias, such as premature ventricular complexes and ventricular tachycardia, are unknown. Therefore, this study was conducted to evaluate the prevalence of SDB in patients with severe ventricular arrhythmias and normal left ventricular (LV) function. Thirty-five patients (63% men, mean age 57.4 +/- 13.8 years) underwent a sleep study. All patients had ventricular tachycardia or frequent premature ventricular complexes (>or=300/hour) and had been referred to the cardiology department for medication, catheter ablation therapy, or the implantation of a cardioverter-defibrillator. Patients with heart failure with LV ejection fractions <50% were excluded; in the remaining patients, the mean LV ejection fraction was 63.9 +/- 8.0%. Twenty-one patients (60%) had SDB with apnea-hypopnea indexes >or=5/hour, and the average apnea-hypopnea index was 22.7 +/- 17.9/hour. Twelve patients (34%) had moderate to severe SDB, with an average apnea-hypopnea index of 33.6 +/- 16.6/hour. Central dominant sleep apnea was evident in 3 patients with SDB. The average age and body mass index were significantly higher in patients with SDB than in those without SDB (age 62.0 +/- 12.8 vs 50.6 +/- 12.7 years, body mass index 26.3 +/- 4.0 vs 21.2 +/- 2.0 kg/m2). In conclusion, this study found a high prevalence of SDB in patients with ventricular arrhythmias and normal LV function.
Collapse
|
143
|
|
144
|
Kasai T, Narui K, Dohi T, Yanagisawa N, Ishiwata S, Ohno M, Yamaguchi T, Momomura SI. Prognosis of patients with heart failure and obstructive sleep apnea treated with continuous positive airway pressure. Chest 2008; 133:690-6. [PMID: 18198253 DOI: 10.1378/chest.07-1901] [Citation(s) in RCA: 153] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Therapy with continuous positive airway pressure (CPAP) provides several benefits for patients with heart failure (HF) complicated by obstructive sleep apnea (OSA). However, the effect on the prognosis of such patients remains unknown. AIMS To determine whether CPAP therapy and compliance affects the prognosis of HF patients with OSA. METHODS We classified 88 patients with HF and moderate-to-severe OSA into a CPAP-treated group (n = 65) and an untreated group (n = 23), and then those treated with CPAP were further subclassified according to CPAP therapy compliance. The frequency of death and hospitalization was analyzed using multivariate analysis. RESULTS During a mean (+/- SD) period of 25.3 +/- 15.3 months, 44.3% of the patients died or were hospitalized. Multivariate analysis showed that the risk for death and hospitalization was increased in the untreated group (hazard ratio [HR], 2.03; 95% confidence interval [CI], 1.07 to 3.68; p = 0.030) and in less compliant CPAP-treated patients (HR, 4.02; 95% CI, 1.33 to 12.2; p = 0.014). CONCLUSION Therapy with CPAP significantly reduced the risk of death and hospitalization among patients with HF and OSA. However, reduced compliance with CPAP therapy was significantly associated with an increased risk of death and hospitalization.
Collapse
Affiliation(s)
- Takatoshi Kasai
- Sleep Center, Toranomon Hospital., 2-2-2 Toranomon, Minato-ku, Tokyo 105-8470, Japan.
| | | | | | | | | | | | | | | |
Collapse
|
145
|
Gilman MP, Floras JS, Usui K, Kaneko Y, Leung RST, Bradley TD. Continuous positive airway pressure increases heart rate variability in heart failure patients with obstructive sleep apnoea. Clin Sci (Lond) 2008; 114:243-9. [PMID: 17824846 DOI: 10.1042/cs20070172] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Patients with heart failure or OSA (obstructive sleep apnoea) have reduced HF-HRV (high-frequency heart rate variability), indicating reduced cardiac vagal modulation, a marker of poor prognosis. CPAP (continuous positive airway pressure) abolishes OSA in patients with heart failure, but effects on daytime HF-HRV have not been determined. We hypothesized that, in patients with heart failure, treatment of coexisting OSA by CPAP would increase morning HF-HRV. In 19 patients with heart failure (left ventricular ejection fraction <45%) and OSA (≥20 apnoeas and hypopnoeas/h of sleep), HF-HRV was quantified before and 1 month after randomization to a control or CPAP-treated group. In the control group (n=7), there were no changes in HF-HRV over the 1 month study during wakefulness in the morning. In the CPAP-treated group (n=12) HF-HRV increased significantly during wakefulness in the morning [from 2.43±0.55 to 2.82±0.50 log(ms2/Hz); P=0.002] due to an increase in transfer function between changes in lung volume and changes in HF-HRV (92.37±96.03 to 219.07±177.14 ms/l; P=0.01). In conclusion, treatment of coexisting OSA by nocturnal CPAP in patients with heart failure increases HF-HRV during morning wakefulness, indicating improved vagal modulation of heart rate. This may contribute to improved prognosis.
Collapse
Affiliation(s)
- Matthew P Gilman
- Sleep and Cardiovascular Physiology Research Laboratories, Mount Sinai Hospital, Toronto, ON, Canada
| | | | | | | | | | | |
Collapse
|
146
|
Tislér A, Logan AG, Akócsi K, Tornóci L, Kiss I. Circadian Variation of Death in Hemodialysis Patients. Am J Kidney Dis 2008; 51:53-61. [DOI: 10.1053/j.ajkd.2007.09.019] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2007] [Accepted: 09/26/2007] [Indexed: 11/11/2022]
|
147
|
|
148
|
Abstract
Positive airway pressure (PAP) is the treatment of choice for patients with moderate-to-severe obstructive sleep apnea (OSA). Randomized controlled trials have demonstrated that PAP can effectively reduce the apnea-hypopnea index and improve subjective and objective sleepiness. Some studies have also demonstrated benefits in sleep quality and quality of life for both the patient and bed partner. Observational studies have shown a reduction in the risk of cardiovascular events in OSA patients treated with PAP compared to untreated patients. Since continuous PAP (CPAP) treatment of OSA was described, additional modes of pressure delivery have been developed (bilevel PAP, autoadjusting PAP, flexible PAP). While none of the variants of PAP improves adherence in unselected patients compared to CPAP, individual patients may respond to a change in pressure mode. Attended PAP titration remains the standard of practice for selecting a treatment pressure. However, use of autotitrating PAP devices in the unattended setting can provide an effective titration alternative with careful patient selection and review of titration results. More choices of mask interface are now available to improve comfort and intervene for mask or mouth leaks. However, despite the increase in PAP treatment options, lack of acceptance and inadequate adherence to PAP therapy remain the major causes of treatment failure. Some studies suggest that heated humidification can improve PAP adherence, especially in patients with nasal congestion or dryness. A systematic approach to PAP treatment including education, objective adherence monitoring, early intervention for side effects, and telephone and clinic support is essential to optimize adherence.
Collapse
Affiliation(s)
- Rahul K Kakkar
- Malcom Randall Veterans Affairs Medical Center 111A, 1601 S Archer Rd, Gainesville, FL 32608, USA
| | | |
Collapse
|
149
|
Abstract
Obstructive sleep apnea (OSA) affects approximately 4% of middle-aged men and 2% of middle-aged women. Cardiac arrhythmias are common problems in patients with OSA, even though the true prevalence and clinical relevance of cardiac arrhythmias remains to be determined. The presence and complexity of both tachyarrhythmias and bradyarrhythmias may influence morbidity, mortality, and the quality of life for OSA patients. Although the exact mechanisms underlying the link between OSA and cardiac arrhythmias are not well established, they could be partially the same proposed mechanisms relating OSA to different cardiovascular diseases. OSA is characterized by repetitive pharyngeal collapse during sleep that leads to markedly reduced or absent airflow, followed by oxyhemoglobin desaturation, persistent inspiratory efforts against an occluded airway, and termination by arousal from sleep. These mechanisms elicit a variety of autonomic, hemodynamic, humoral, and neuroendocrine responses that by themselves evoke acute and chronic changes in cardiovascular function. These effects may lead to the development of cardiac arrhythmias and any other form of cardiovascular disease linked to OSA. The aims of this review are to describe the essential cardiovascular pathophysiological aspects of OSA, to outline the relationship between OSA and both tachyarrhythmias and bradyarrhythmias and their possible influence in the natural history of OSA patients, and to assess the effects of OSA treatment on the presence of cardiac arrhythmias.
Collapse
Affiliation(s)
- Miguel A Arias
- Cardiac Arrhythmia and Electrophysiology Unit, Department of Cardiology, Hospital Virgen de la Salud, Toledo, Spain.
| | | |
Collapse
|
150
|
Dursunoglu D, Dursunoglu N. Effect of CPAP on QT interval dispersion in obstructive sleep apnea patients without hypertension. Sleep Med 2007; 8:478-83. [PMID: 17512787 DOI: 10.1016/j.sleep.2006.08.002] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2006] [Revised: 08/07/2006] [Accepted: 08/08/2006] [Indexed: 12/18/2022]
Abstract
OBJECTIVES Delayed cardiac repolarization leading to prolongation of the QT interval is a well-characterised precursor of arrhythmias. Obstructive sleep apnea (OSA) might cause arrhythmias, since QT corrected interval dispersion (QTcd) is increased in these patients. We aimed to determine the effect of nasal continuous positive airway pressure (CPAP) therapy on QTcd in OSA patients without hypertension. METHODS An overnight polysomnography (PSG) and a standard 12-lead electrocardiogram (ECG) were performed on 49 subjects without hypertension, diabetes mellitus, cardiac or pulmonary disease or any hormonal, hepatic, renal or electrolyte disorders. In 29 moderate-severe OSA (apnea-hypopnea index: AHI15) patients, QTd (defined as the difference between the maximum and minimum QT interval) and QTcd were calculated using the Bazzet formula at baseline and after six months of CPAP therapy. RESULTS Eighteen patients were compliant with nasal CPAP, and mean age was 46.5+/-4.9 years. Patients had high body mass index (BMI: 30.6+/-4.0 kg/m(2)), but there was no change in either BMI or blood pressure after six months. A strong positive correlation was shown between QTcd and AHI (p<0.001, r=0.913). The QTcd at baseline (54.5+/-8.7 ms) significantly decreased after CPAP therapy (35.5+/-4.2 ms, p<0.001), although it did not significantly change in 11 non-compliant patients. CONCLUSION In OSA patients without hypertension, CPAP therapy improves the inhomogeneity of repolarization via a significant decrease in QTcd.
Collapse
Affiliation(s)
- Dursun Dursunoglu
- Pamukkale University Medical Faculty, Department of Cardiology, 20200 Kinikli, Denizli, Turkey.
| | | |
Collapse
|