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Testelmans D, Kalkanis A, Papadopoulos D, Demolder S, Buyse B. Central sleep apnea: emphasizing recognition and differentiation. Expert Rev Respir Med 2024; 18:309-320. [PMID: 38878064 DOI: 10.1080/17476348.2024.2369256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Accepted: 06/13/2024] [Indexed: 06/19/2024]
Abstract
INTRODUCTION Central sleep apnea (CSA) is a sleep-related breathing disorder in which the effort to breathe is intermittently diminished or absent. CSA is a common disorder among patients with different cardiovascular disorders, including heart failure. In addition, a growing number of medications have been shown to induce CSA and CSA can emerge after initiation of treatment for obstructive sleep apnea. Accumulating evidence shows that CSA is a heterogeneous disorder with individual differences in clinical and biological characteristics and/or underlying pathophysiological mechanisms. AREAS COVERED This narrative review offers an overview of the diagnostic aspects and classification of CSA, with an emphasis on heart failure patients, patients with CSA due to a medication and treatment-emergent CSA. The importance of evaluation of prognostic biomarkers in patients with different types of CSA is discussed. This narrative review synthesizes literature on CSA sourced from the PubMed database up to February 2024. EXPERT OPINION CSA presents a remarkably diverse disorder, with treatment modalities exhibiting potentially varied efficacy across its various phenotypes. This highlights the imperative for tailored management strategies that are rooted in phenotype classification.
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Affiliation(s)
- Dries Testelmans
- Department of Pneumology, Leuven University Center for Sleep and Wake disorders, University Hospitals Leuven, Leuven, Belgium
- Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases and Metabolism, KU Leuven, Leuven, Belgium
| | - Alexandros Kalkanis
- Department of Pneumology, Leuven University Center for Sleep and Wake disorders, University Hospitals Leuven, Leuven, Belgium
| | - Dimitrios Papadopoulos
- Department of Pneumology, Leuven University Center for Sleep and Wake disorders, University Hospitals Leuven, Leuven, Belgium
| | - Saartje Demolder
- Department of Pneumology, Leuven University Center for Sleep and Wake disorders, University Hospitals Leuven, Leuven, Belgium
| | - Bertien Buyse
- Department of Pneumology, Leuven University Center for Sleep and Wake disorders, University Hospitals Leuven, Leuven, Belgium
- Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases and Metabolism, KU Leuven, Leuven, Belgium
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Tamisier R, Damy T, Bailly S, Goutorbe F, Davy JM, Lavergne F, Palot A, Verbraecken JA, d'Ortho MP, Pépin JL, d'Ortho MP, Pépin JL, Davy JM, Damy T, Tamisier R. FACE study: 2-year follow-up of adaptive servo-ventilation for sleep-disordered breathing in a chronic heart failure cohort. Sleep Med 2024; 113:412-421. [PMID: 37612192 DOI: 10.1016/j.sleep.2023.07.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 07/10/2023] [Accepted: 07/14/2023] [Indexed: 08/25/2023]
Abstract
BACKGROUND Sleep-disordered breathing (SDB) is a common comorbidity in patients with heart failure (HF) and is associated with worse prognosis. OBJECTIVES This study evaluated the effects of adaptive servo-ventilation (ASV) on morbidity and mortality in a large heterogeneous population of HF patients with different etiologies/phenotypes. METHODS Consecutive HF patients with predominant central sleep apnea (± obstructive sleep apnea) indicated for ASV were included; the control group included patients who refused or stopped ASV before three months follow-up. Six homogenous clusters were determined using the latent class analysis (LCA) method. The primary endpoint was time to composite first event (all-cause death, lifesaving cardiovascular intervention, or unplanned hospitalization for worsening of chronic HF). RESULTS Of 503 patients at baseline, 324 underwent 2-year follow-up. Compared to control group, 2-year primary endpoint event-free survival was significantly greater in patients in ASV group only in univariable analysis (1.67, 95% [1.12-2.49]; p = 0.01). Secondary endpoints, event-free of cardiovascular death or heart failure-related hospitalization and all-cause death or all-cause hospitalization were positively impacted by ASV (univariate and multivariable analysis). LCA identified two groups, with preserved and mid-range left ventricular ejection fraction (LVEF) and severe hypoxia, in whom ASV increase prognosis benefit. CONCLUSIONS Patients with HF and SDB are a highly heterogeneous group identified using LCA. Systematic deep phenotyping is essential to ensure that ASV is prescribed to those benefit from therapy, as ASV use in patients with severe hypoxic burden and those with HFpEF was associated with a significant reduction in cardiovascular events and mortality. CLINICAL TRIAL REGISTRATION https://clinicaltrials.gov/ct2/show/NCT01831128.
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Affiliation(s)
- Renaud Tamisier
- Univ. Grenoble Alpes, Inserm 1300, HP2, Grenoble, France; Service Hospitalo-Universitaire Pneumologie et Physiologie, Pole Thorax et Vaisseaux, CHU de Grenoble Alpes, Grenoble, France.
| | - Thibaud Damy
- Service de Cardiologie, Centre de Référence Amyloses Cardiaques, GRC ARI, DHU ATVB, AP-HP, Hôpital Henri Mondor, Créteil, France; UFR médecine Université Paris-Est Créteil, France; Unité INSERM U981, Créteil, France
| | - Sébastien Bailly
- Univ. Grenoble Alpes, Inserm 1300, HP2, Grenoble, France; Service Hospitalo-Universitaire Pneumologie et Physiologie, Pole Thorax et Vaisseaux, CHU de Grenoble Alpes, Grenoble, France
| | | | - Jean-Marc Davy
- Service de Cardiologie, CHU, Montpellier, France; UFR Médecine Université Montpellier, France
| | | | | | - Johan A Verbraecken
- Multidisciplinary Sleep Disorders Centre, Antwerp University Hospital and University of Antwerp, Antwerp, Belgium
| | - Marie-Pia d'Ortho
- Université de Paris, Neuro Diderot, Inserm, Paris, France; Département de Physiologie - Explorations Fonctionnelles, AP-HP, Hôpital Bichat, Paris, France
| | - Jean-Louis Pépin
- Univ. Grenoble Alpes, Inserm 1300, HP2, Grenoble, France; Service Hospitalo-Universitaire Pneumologie et Physiologie, Pole Thorax et Vaisseaux, CHU de Grenoble Alpes, Grenoble, France
| | - Marie-Pia d'Ortho
- Université de Paris, Neuro Diderot, Inserm, Paris, France; Département de Physiologie - Explorations Fonctionnelles, AP-HP, Hôpital Bichat, Paris, France
| | - Jean-Louis Pépin
- Univ. Grenoble Alpes, Inserm 1300, HP2, Grenoble, France; Service Hospitalo-Universitaire Pneumologie et Physiologie, Pole Thorax et Vaisseaux, CHU de Grenoble Alpes, Grenoble, France
| | - Jean-Marc Davy
- Service de Cardiologie, CHU, Montpellier, France; UFR Médecine Université Montpellier, France
| | - Thibaud Damy
- Service de Cardiologie, Centre de Référence Amyloses Cardiaques, GRC ARI, DHU ATVB, AP-HP, Hôpital Henri Mondor, Créteil, France; UFR médecine Université Paris-Est Créteil, France; Unité INSERM U981, Créteil, France
| | - Renaud Tamisier
- Univ. Grenoble Alpes, Inserm 1300, HP2, Grenoble, France; Service Hospitalo-Universitaire Pneumologie et Physiologie, Pole Thorax et Vaisseaux, CHU de Grenoble Alpes, Grenoble, France
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Parthasarathy S, Arzt M, Javaheri S. A call for precision medicine: Facing the challenge of sleep-disordered breathing in heart failure. Sleep Med 2023; 112:129-131. [PMID: 37844544 PMCID: PMC10872392 DOI: 10.1016/j.sleep.2023.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2023]
Affiliation(s)
- Sairam Parthasarathy
- University of Arizona Health Sciences, Center for Sleep, Circadian, and Neuroscience Research, University of Arizona, Tucson, AZ, USA
| | - Michael Arzt
- Department of Internal Medicine II, University Hospital Regensburg, Germany
| | - Shahrokh Javaheri
- Division of Pulmonary and Sleep, Bethesda North Hospital, Cincinnati, OH, USA.
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Javaheri S, Rosa Costanzo M. Guest editorial: Phrenic nerve stimulation for treatment of central sleep apnea. Sleep Med Rev 2023; 71:101841. [PMID: 37778155 DOI: 10.1016/j.smrv.2023.101841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 08/22/2023] [Indexed: 10/03/2023]
Affiliation(s)
- Shahrokh Javaheri
- Bethesda Montgomery Sleep Laboratory, Cincinnati, OH, USA; Division of Pulmonary, Sleep and Critical Care Medicine, University of Cincinnati, College of Medicine, Cincinnati, OH, USA; Division of Cardiology, The Ohio State University, Columbus, OH, USA.
| | - Maria Rosa Costanzo
- Heart Failure Program, Midwest Cardiovascular Institute, Naperville, IL, USA
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Sun P, Porter K, Randerath W, Jarjoura D, Khayat R. Adaptive servo-ventilation and mortality in patients with systolic heart failure and central sleep apnea: a single-center experience. Sleep Breath 2023; 27:1909-1915. [PMID: 36920657 PMCID: PMC10539434 DOI: 10.1007/s11325-023-02807-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 01/24/2023] [Accepted: 03/06/2023] [Indexed: 03/16/2023]
Abstract
BACKGROUND Central sleep apnea (CSA) is associated with increased mortality and morbidity in patients with heart failure with reduced ejection fraction (HFrEF). Treatment of CSA with a certain type of adaptive servo-ventilation (ASV) device that targets minute ventilation (ASVmv) was found to be harmful in these patients. A newer generation of ASV devices that target peak flow (ASVpf) is presumed to have different effects on ventilation and airway patency. We analyzed our registry of patients with HFrEF-CSA to examine the effect of exposure to ASV and role of each type of ASV device on mortality. METHODS This is a retrospective cohort study in patients with HFrEF and CSA who were treated with ASV devices between 2008 and 2015 at a single institution. Mortality data were collected through the institutional data honest broker. Usage data were obtained from vendors' and manufacturers' servers. Median follow-up was 64 months. RESULTS The registry included 90 patients with HFrEF-CSA who were prescribed ASV devices. Applying a 3-h-per-night usage cutoff, we found a survival advantage at 64 months for those who used the ASV device above the cutoff (n = 59; survival 76%) compared to those who did not (n = 31; survival 49%; hazard ratio 0.44; CI 95%, 0.20 to 0.97; P = 0.04). The majority (n = 77) of patients received ASVpf devices with automatically adjusting end-expiratory pressure (EPAP) and the remainder (n = 13) received ASVmv devices mostly with fixed EPAP (n = 12). There was a trend towards a negative correlation between ASVmv with fixed EPAP and survival. CONCLUSION In this population of patients with HFrEF and CSA, there was no evidence that usage of ASV devices was associated with increased mortality. However, there was evidence of differential effects of type of ASV technology on mortality.
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Affiliation(s)
- Paulina Sun
- The UCI Sleep Disorders Center, Division of Pulmonary and Critical Care Medicine, University of California-Irvine, 20350 SW Birch Street, Newport Beach, CA, 92660, USA.
| | - Kyle Porter
- The Center for Biostatistics, The Ohio State University, Columbus, OH, USA
| | - Winfried Randerath
- Institute of Pneumology at the University Cologne, Bethanien Hospital, Solingen, Germany
| | - David Jarjoura
- The Center for Biostatistics, The Ohio State University, Columbus, OH, USA
| | - Rami Khayat
- The UCI Sleep Disorders Center, Division of Pulmonary and Critical Care Medicine, University of California-Irvine, 20350 SW Birch Street, Newport Beach, CA, 92660, USA
- Division of Pulmonary and Critical Care Medicine, The Sleep Heart Program, The Ohio State University, Columbus, OH, USA
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Javaheri S, Badr MS. Central sleep apnea: pathophysiologic classification. Sleep 2023; 46:zsac113. [PMID: 35551411 PMCID: PMC9995798 DOI: 10.1093/sleep/zsac113] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 05/05/2022] [Indexed: 11/14/2022] Open
Abstract
Central sleep apnea is not a single disorder; it can present as an isolated disorder or as a part of other clinical syndromes. In some conditions, such as heart failure, central apneic events are due to transient inhibition of ventilatory motor output during sleep, owing to the overlapping influences of sleep and hypocapnia. Specifically, the sleep state is associated with removal of wakefulness drive to breathe; thus, rendering ventilatory motor output dependent on the metabolic ventilatory control system, principally PaCO2. Accordingly, central apnea occurs when PaCO2 is reduced below the "apneic threshold". Our understanding of the pathophysiology of central sleep apnea has evolved appreciably over the past decade; accordingly, in disorders such as heart failure, central apnea is viewed as a form of breathing instability, manifesting as recurrent cycles of apnea/hypopnea, alternating with hyperpnea. In other words, ventilatory control operates as a negative-feedback closed-loop system to maintain homeostasis of blood gas tensions within a relatively narrow physiologic range, principally PaCO2. Therefore, many authors have adopted the engineering concept of "loop gain" (LG) as a measure of ventilatory instability and susceptibility to central apnea. Increased LG promotes breathing instabilities in a number of medical disorders. In some other conditions, such as with use of opioids, central apnea occurs due to inhibition of rhythm generation within the brainstem. This review will address the pathogenesis, pathophysiologic classification, and the multitude of clinical conditions that are associated with central apnea, and highlight areas of uncertainty.
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Affiliation(s)
- Shahrokh Javaheri
- Division of Pulmonary and Sleep Medicine, Bethesda North Hospital, Cincinnati, OH, USA
- Division of Pulmonary Critical Care and Sleep Medicine, University of Cincinnati, Cincinnati, OH, USA
- Division of Cardiology, Department of Medicine, Ohio State University, Columbus, OH, USA
| | - M Safwan Badr
- Department of Internal Medicine, Liborio Tranchida, MD, Endowed Professor of Medicine, Wayne State University School of Medicine, University Health Center, Detroit, MI, USA
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Correia S, Sousa S, Drummond M, Pinto P, Staats R, Brito D, Lousada N, Cardoso JS, Moita J. Diagnostic and therapeutic approach of central sleep apnea in heart failure - the role of adaptive servo-ventilation. A statement of the Portuguese society of pulmonology and the Portuguese sleep association. Pulmonology 2023; 29:138-143. [PMID: 35501278 DOI: 10.1016/j.pulmoe.2021.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 11/30/2021] [Accepted: 12/01/2021] [Indexed: 10/18/2022] Open
Abstract
It is known that patients with heart failure (HF) have an increased risk of developing central sleep apnoea (CSA), with Cheyne-Stokes respiration. The development of servo-ventilation aimed to treat CSA and improve the quality of life (QoL) of these patients. A large randomized clinical study, SERVE-HF, was conducted in order to test this theory in patients with HF and reduced ejection fraction (HFrEF). The results from this trial seemed to indicate that, in these patients, there was no beneficial effect of the assisted ventilation in CSA treatment. More surprisingly, an increased rate of all-cause or cardiovascular mortality was observed. This has led to dramatic changes in clinical practice, with decreased frequency of servo-ventilation prescription across Europe, including Portugal, due to changes in the guidelines. However, SERVE-HF was conducted only in severe systolic HF patients with CSA, and caution must be taken when extrapolating these results to HF patients with preserved ejection fraction or CSA patients without HF. The study also showed poor adherence, methodological and statistical gaps, including study design, patient selection, data collection and analysis, treatment adherence, and group crossovers, which have not been discussed in the trial as potential confounding factors and raise several concerns. Moreover, the adaptive servo-ventilation (ASV) device used in SERVE-HF was unable to lower the minimum support pressure below 3 mm H20, and this has been suggested as one of the probable contributing reasons to the excess mortality observed in this study. This limitation has since been solved, and this ASV device is no longer used. This paper describes the results of a Portuguese Task Force on the treatment of central sleep apnoea in patients with chronic HF.
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Affiliation(s)
- S Correia
- Hospital Pedro Hispano, Porto, Portugal.
| | - S Sousa
- Centro Hospitalar de Setubal, Portugal
| | - M Drummond
- Centro Hospitalar Universitario do Porto, Porto, Portugal
| | - P Pinto
- Centro Hospitalar Universitario Lisboa Norte, Lisboa, Portugal
| | - R Staats
- Centro Hospitalar Universitario Lisboa Norte, Lisboa, Portugal
| | - D Brito
- Centro Hospitalar Universitario Lisboa Norte, Lisboa, Portugal
| | - N Lousada
- Centro Hospitalar Universitario Lisboa Norte, Lisboa, Portugal
| | - J S Cardoso
- Centro Hospitalar Universitário de São João, Portugal
| | - J Moita
- Centro Hospitalar e Universitario de Coimbra, Portugal
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Effects of sacubitril-valsartan on central and obstructive apneas in heart failure patients with reduced ejection fraction. Sleep Breath 2023; 27:283-289. [PMID: 35486312 PMCID: PMC9992232 DOI: 10.1007/s11325-022-02623-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 04/05/2022] [Accepted: 04/15/2022] [Indexed: 10/18/2022]
Abstract
OBJECTIVE This study aimed to evaluate the effect of sacubitril-valsartan (SV) on central apneas (CA) and obstructive apneas (OA) in patients with heart failure with reduced ejection fraction (HFrEF). METHODS In patients with HFrEF, SV initiation was titrated to the highest tolerable dosage. Patients were evaluated with portable apnea monitoring, echocardiography, and cardiopulmonary exercise testing at baseline and 3 months later. RESULTS Of a total of 18 patients, 9 (50%) had OA, 7 (39%) had CA, and 2 (11%) had normal breathing. SV therapy was related to a reduction in NT-pro BNP and an improvement in LV function after 3 months. Portable apnea monitoring revealed a significant decrease of the respiratory event index (REI) after treatment with SV (20 ± 23 events/h to 7 ± 7 events/h, p = 0.003). When subgrouping according to type of apneas, REI, and time spent below 90% saturation (T90) decreased in patients with CA and OA (all p < 0.05). CONCLUSION In this prospective study, SV treatment for 3 months in patients with CA and OA is associated with a significant decrease in REI.
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Lorenzi-Filho G, Drager LF, Bradley TD. Adaptive servo-ventilation for central sleep apnea: What are the lessons learned? Pulmonology 2023; 29:105-107. [PMID: 36710090 DOI: 10.1016/j.pulmoe.2022.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 10/25/2022] [Indexed: 01/30/2023] Open
Affiliation(s)
- G Lorenzi-Filho
- Laboratório do Sono, Divisão de Pneumologia, Instituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Brazil.
| | - L F Drager
- Unidade de Hipertensão, Instituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Brazil
| | - T D Bradley
- KITE Sleep Research Laboratory, University Health Network Toronto Rehabilitation Institute, and Departments of Medicine of the University Health Network Toronto General Hospital and University of Toronto, Toronto, ON, Canada
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Singh J, Zaballa K, Kok H, Fitzgerald N, Uy C, Nuth D, Castro C, Irving C, Waters K, Fitzgerald DA. Cheyne-stokes respiration in children with heart failure. Paediatr Respir Rev 2022; 43:78-84. [PMID: 35459626 DOI: 10.1016/j.prrv.2022.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 03/01/2022] [Indexed: 11/30/2022]
Abstract
Cheyne-Stokes respiration (CSA-CSR) is a form of central sleep apnea characterized by alternating periods of hyperventilation and central apneas or hypopneas. CSA-CSR develops following a cardiac insult resulting in a compensatory increase in sympathetic activity, which in susceptible patients causes hyperventilation and destabilizes respiratory control. The physiological changes that occur in CSA-CSR include hyperventilation, a reduced blood gas buffering capacity, and circulatory delay. In adults, 25% to 50% of patients with heart failure are reported to have CSA-CSR. The development of CSA-CSR in this group of patients is considered a poor prognostic sign. The prevalence, progression, and treatment outcomes of CSA-CSR in children remain unclear with only 11 children being described in the literature. The lack of data is possibly not due to the paucity of children with severe heart failure and CSA-CSR but because they may be under-recognized, compounded by the absence of routine polysomnographic assessment of children with moderate to severe heart failure. Building on much broader experience in the diagnosis and management of CSA-CSR in adult sleep medicine and our limited experience in a pediatric quaternary center, this paper will discuss the prevalence of CSA-CSR, its' treatment options, outcomes in children, and the potential future direction for research in this understudied area of pediatric sleep medicine.
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Affiliation(s)
- Jagdev Singh
- Department of Sleep Medicine, The Children's Hospital at Westmead, Sydney, NSW, Australia; Discipline of Child and Adolescent Health, Sydney Medical School, University of Sydney, Sydney, NSW, Australia.
| | - Katrina Zaballa
- Department of Sleep Medicine, The Children's Hospital at Westmead, Sydney, NSW, Australia
| | - Harvey Kok
- Department of Respiratory and Sleep Medicine, John Hunter Hospital, Newcastle, NSW, Australia
| | - Nicholas Fitzgerald
- Department of Cardiology, The Children's Hospital at Westmead, Sydney, NSW, Australia; Discipline of Child and Adolescent Health, Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Carla Uy
- Department of Sleep Medicine, The Children's Hospital at Westmead, Sydney, NSW, Australia
| | - Dara Nuth
- Department of Sleep Medicine, The Children's Hospital at Westmead, Sydney, NSW, Australia
| | - Chenda Castro
- Department of Sleep Medicine, The Children's Hospital at Westmead, Sydney, NSW, Australia
| | - Claire Irving
- Department of Cardiology, The Children's Hospital at Westmead, Sydney, NSW, Australia; Discipline of Child and Adolescent Health, Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Karen Waters
- Department of Sleep Medicine, The Children's Hospital at Westmead, Sydney, NSW, Australia; Discipline of Child and Adolescent Health, Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Dominic A Fitzgerald
- Department of Sleep Medicine, The Children's Hospital at Westmead, Sydney, NSW, Australia; Discipline of Child and Adolescent Health, Sydney Medical School, University of Sydney, Sydney, NSW, Australia
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Barleben A, Allrich M, Grüning W. [Is ASV therapy a positive airway pressure or ventilation therapy? A comparison of acid-base balance per day and under ASV]. Pneumologie 2022; 76:606-613. [PMID: 36104016 DOI: 10.1055/a-1883-8751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
The aim of this work was to determine whether therapy with adaptive support ventilation (ASV) leads to impairment of acid-base balance, in particular to hypocapnia and alkalosis. For this purpose, we measured the acid-base status (SBH) with carbon dioxide and oxygen partial pressure in arterialized blood (pCO2 and pO2), standard bicarbonate (SBC) and pH under spontaneous breathing during the day and under ASV at night. The trigger for this work was, among other things, the result of the SERVE-HF study, which found an increased risk of mortality in patients with heart failure and left ventricular ejection fraction <45% under ASV. There was a presumption of a device algorithm-based effect. The question was whether the minimum pressure support (PSmin) of 3 cmH2O via respiratory alkalosis has a pro-arrhythmogenic effect (and causes higher mortality). A study of patients with treatment-emergent central sleep apnea (TECSA) and normal cardiac function comparing 4 ASV devices showed significantly higher ventilation with the device used in the study. So, this excessive ventilation could be generated by the device and not by class. METHODS A total of 226 patients who came to the follow-up of the ASV from 10/2018 to 03/2020; age 65.2±11.3 years, BMI 35.7±7.5 kg/m2, service life 5530±5400 h, 5.6±2.5 h/d, PSmin 4.9±1.8 cmH2O. None of the patients had heart failure (EF>45%). The majority underwent ASV because of TECSA, rarely a cardiac or other genesis. RESULTS In 29 patients (12.8%) hypocapnia with pCO2 <36 mmHg was found in the morning. CONCLUSION Under ASV we could not determine any class effect of hypocapnia. 12.8% had hypocapnia, and in half of the cases it was severe necessitating modification of therapy. This can have different causes but there are no clear criteria. As there is a risk of hyperventilation, acid-base balance under ASV should be checked.
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Morgenthaler TI. Large telemonitoring databases: the good, the bad, and the useful. J Clin Sleep Med 2021; 17:2349-2350. [PMID: 34669572 DOI: 10.5664/jcsm.9718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Optimal Noninvasive Medicare Access Promotion: Patients with Central Sleep Apnea A Technical Expert Panel Report from the American College of Chest Physicians, the American Association for Respiratory Care, the American Academy of Sleep Medicine, and the American Thoracic Society. Chest 2021; 160:e419-e425. [PMID: 34339687 DOI: 10.1016/j.chest.2021.07.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 07/10/2021] [Accepted: 07/18/2021] [Indexed: 11/20/2022] Open
Abstract
This document summarizes suggestions of the central sleep apnea (CSA) technical expert panel (TEP) working group. This paper shares our vision for bringing the right device to the right patient at the right time. For patients with CSA, current coverage criteria do not align with guideline treatment recommendations. For example, continuous positive airway pressure (CPAP) and oxygen therapy are recommended but not covered for CSA. On the other hand, BPAP without a backup rate may be a covered therapy for OSA, but it may worsen CSA. Narrow coverage criteria that require near elimination of obstructive breathing events on CPAP or bilevel positive airway pressure in the spontaneous mode , even if at poorly tolerated pressure levels, may preclude therapy with BPAP with backup rate or adaptive servoventilation (ASV), even when those devices provide demonstrably better therapy. CSA is a dynamic disorder that may require different treatments over time, sometimes switching from one device to another, for example from BPAP with backup rate to an ASV with automatic end expiratory pressure adjustments, which may not be covered. To address these challenges we suggest several changes to the coverage determinations, including 1) a single simplified initial and continuing coverage definition of CSA that aligns with obstructive sleep apnea, 2) removal of hypoventilation terminology from coverage criteria for CSA, 3) all effective therapies for CSA should be covered, including oxygen and all PAP devices with or without backup rates or servo-mechanisms, and 4) patients shown to have a suboptimal response to one PAP device should be allowed to add oxygen or change to another PAP device with different capabilities if shown to be effective with testing.
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Tamisier R, Damy T, Bailly S, Davy JM, Verbraecken J, Lavergne F, Palot A, Goutorbe F, d'Ortho MP, Pépin JL. Adaptive servo ventilation for sleep apnoea in heart failure: the FACE study 3-month data. Thorax 2021; 77:178-185. [PMID: 34230094 PMCID: PMC8762030 DOI: 10.1136/thoraxjnl-2021-217205] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 05/18/2021] [Indexed: 11/29/2022]
Abstract
Rationale Adaptive servo ventilation (ASV) is contraindicated in patients with systolic heart failure (HF) who have a left ventricular ejection fraction (LVEF) below 45% and predominant central sleep apnoea (CSA). However, the effects of ASV in other HF subgroups have not been clearly defined. Objective The European, multicentre, prospective, observational cohort trial, FACE, evaluated the effects of ASV therapy on morbidity and mortality in patients with HF with sleep-disordered breathing (SDB); 3-month outcomes in patient subgroups defined using latent class analysis (LCA) are presented. Methods Consecutive patients with HF with predominant CSA (±obstructive sleep apnoea) indicated for ASV were included from 2009 to 2018; the non-ASV group included patients who refused/were noncompliant with ASV. The primary endpoint was time to composite first event (all-cause death, lifesaving cardiovascular intervention or unplanned hospitalisation for worsening of chronic HF). Measurements and main results Baseline assessments were performed in 503 patients, and 482 underwent 3-month follow-up. LCA identified six discrete patient clusters characterised by variations in LVEF, SDB type, age, comorbidities and ASV acceptance. The 3- month rate of primary outcome events was significantly higher in cluster 1 patients (predominantly men, low LVEF, severe HF, CSA; 13.9% vs 1.5%–5% in other clusters, p<0.01). Conclusion For the first time, our data identified homogeneous patient clusters representing clinically relevant subgroups relating to SDB management in patients with HF with different ASV usage, each with a different prognosis. This may improve patient phenotyping in clinical practice and allow individualisation of therapy.
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Affiliation(s)
- Renaud Tamisier
- Université Grenoble Alpes, Laboratoire HP2 Inserm U1300, CHU Grenoble Alpes, Grenoble, France
| | - Thibaud Damy
- Hopital Henri Mondor, Creteil, Île-de-France, France.,Cardiology Department, French Referral Centre for Cardiac Amyloidosis, GRC Amyloid Research Institute, Assistance Publique - Hôpitaux de Paris, Paris, France.,UFR Médecine, Université Paris-Est Créteil, Paris, France
| | - Sebastien Bailly
- Université Grenoble Alpes, Laboratoire HP2 Inserm U1300, CHU Grenoble Alpes, Grenoble, France
| | - Jean-Marc Davy
- CHU Montpellier, Montpellier, Languedoc-Roussillon, France
| | - Johan Verbraecken
- Multidisciplinary Sleep Disorders Centre, University Hospital Antwerp, Antwerp, Belgium.,University of Antwerp, Antwerp, Belgium
| | | | - Alain Palot
- Hopital Saint Joseph, Marseille, Provence-Alpes-Côte d'Azur, France
| | | | - Marie-Pia d'Ortho
- Hôpital Bichat Claude-Bernard, Paris, Île-de-France, France.,Université de Paris, Neurodiderot, INSERM, Paris, France
| | - Jean Louis Pépin
- Université Grenoble Alpes, Laboratoire HP2 Inserm U1300, CHU Grenoble Alpes, Grenoble, France
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15
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Orr JE, Ayappa I, Eckert DJ, Feldman JL, Jackson CL, Javaheri S, Khayat RN, Martin JL, Mehra R, Naughton MT, Randerath WJ, Sands SA, Somers VK, Badr MS. Research Priorities for Patients with Heart Failure and Central Sleep Apnea. An Official American Thoracic Society Research Statement. Am J Respir Crit Care Med 2021; 203:e11-e24. [PMID: 33719931 PMCID: PMC7958519 DOI: 10.1164/rccm.202101-0190st] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Background: Central sleep apnea (CSA) is common among patients with heart failure and has been strongly linked to adverse outcomes. However, progress toward improving outcomes for such patients has been limited. The purpose of this official statement from the American Thoracic Society is to identify key areas to prioritize for future research regarding CSA in heart failure. Methods: An international multidisciplinary group with expertise in sleep medicine, pulmonary medicine, heart failure, clinical research, and health outcomes was convened. The group met at the American Thoracic Society 2019 International Conference to determine research priority areas. A statement summarizing the findings of the group was subsequently authored using input from all members. Results: The workgroup identified 11 specific research priorities in several key areas: 1) control of breathing and pathophysiology leading to CSA, 2) variability across individuals and over time, 3) techniques to examine CSA pathogenesis and outcomes, 4) impact of device and pharmacological treatment, and 5) implementing CSA treatment for all individuals Conclusions: Advancing care for patients with CSA in the context of heart failure will require progress in the arenas of translational (basic through clinical), epidemiological, and patient-centered outcome research. Given the increasing prevalence of heart failure and its associated substantial burden to individuals, society, and the healthcare system, targeted research to improve knowledge of CSA pathogenesis and treatment is a priority.
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16
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Diaz S, Brown LK. Is idiopathic central sleep apnea a separate entity? J Clin Sleep Med 2021; 16:1999-2001. [PMID: 33063658 DOI: 10.5664/jcsm.8926] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
- Shanna Diaz
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico
| | - Lee K Brown
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico
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17
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Costanzo MR, Javaheri S, Ponikowski P, Oldenburg O, Augostini R, Goldberg LR, Stellbrink C, Fox H, Schwartz AR, Gupta S, McKane S, Meyer TE, Abraham WT. Transvenous Phrenic Nerve Stimulation for Treatment of Central Sleep Apnea: Five-Year Safety and Efficacy Outcomes. Nat Sci Sleep 2021; 13:515-526. [PMID: 33953626 PMCID: PMC8092633 DOI: 10.2147/nss.s300713] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 04/09/2021] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND The remedē System Pivotal Trial was a prospective, multi-center, randomized trial demonstrating transvenous phrenic nerve stimulation (TPNS) therapy is safe and effectively treats central sleep apnea (CSA) and improves sleep architecture and daytime sleepiness. Subsequently, the remedē System was approved by FDA in 2017. As a condition of approval, the Post Approval Study (PAS) collected clinical evidence regarding long-term safety and effectiveness in adults with moderate to severe CSA through five years post implant. METHODS Patients remaining in the Pivotal Trial at the time of FDA approval were invited to enroll in the PAS and consented to undergo sleep studies (scored by a central laboratory), complete the Epworth Sleepiness Scale (ESS) questionnaire to assess daytime sleepiness, and safety assessment. All subjects (treatment and former control group) receiving active therapy were pooled; data from both trials were combined for analysis. RESULTS Fifty-three of the original 151 Pivotal Trial patients consented to participate in the PAS and 52 completed the 5-year visit. Following TPNS therapy, the apnea-hypopnea index (AHI), central-apnea index (CAI), arousal index, oxygen desaturation index, and sleep architecture showed sustained improvements. Comparing 5 years to baseline, AHI and CAI decreased significantly (AHI baseline median 46 events/hour vs 17 at 5 years; CAI baseline median 23 events/hour vs 1 at 5 years), though residual hypopneas were present. In parallel, the arousal index, oxygen desaturation index and sleep architecture improved. The ESS improved by a statistically significant median reduction of 3 points at 5 years. Serious adverse events related to implant procedure, device or delivered therapy were reported by 14% of patients which include 16 (9%) patients who underwent a pulse generator reposition or lead revision (primarily in the first year). None of the events caused long-term harm. No unanticipated adverse device effects or related deaths occurred through 5 years. CONCLUSION Long-term TPNS safely improves CSA, sleep architecture and daytime sleepiness through 5 years post implant. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01816776.
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Affiliation(s)
| | - Shahrokh Javaheri
- Bethesda North Hospital, Cincinnati, OH, USA.,The Ohio State University, Columbus, OH, USA
| | - Piotr Ponikowski
- Department of Heart Diseases, Medical University, Military Hospital, Wroclaw, Poland
| | - Olaf Oldenburg
- Ludgerus-Kliniken Münster, Clemens Hospital, Münster, Germany
| | | | - Lee R Goldberg
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | | | - Henrik Fox
- Clinic for General and Interventional Cardiology Angiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Alan R Schwartz
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Sanjaya Gupta
- University of Missouri-Kansas City School of Medicine, Saint Luke's Mid-America Heart Institute, Kansas City, MO, USA
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18
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Patterns of adaptive servo-ventilation settings in a real-life multicenter study: pay attention to volume! : Adaptive servo-ventilation settings in real-life conditions. Respir Res 2020; 21:243. [PMID: 32957983 PMCID: PMC7507637 DOI: 10.1186/s12931-020-01509-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 09/13/2020] [Indexed: 01/03/2023] Open
Abstract
Backgrounds To explain the excess cardiovascular mortality observed in the SERVE-HF study, it was hypothesized that the high-pressure ASV default settings used lead to inappropriate ventilation, cascading negative consequences (i.e. not only pro-arrythmogenic effects through metabolic/electrolyte abnormalities, but also lower cardiac output). The aims of this study are: i) to describe ASV-settings for long-term ASV-populations in real-life conditions; ii) to describe the associated minute-ventilations (MV) and therapeutic pressures for servo-controlled-flow versus servo-controlled-volume devices (ASV-F Philips®-devices versus ASV-V ResMed®-devices). Methods The OTRLASV-study is a cross-sectional, 5-centre study including patients who underwent ASV-treatment for at least 1 year. The eight participating clinicians were free to adjust ASV settings, which were compared among i) initial diagnosed sleep-disordered-breathing (SBD) groups (Obstructive-Sleep-Apnea (OSA), Central-Sleep-Apnea (CSA), Treatment-Emergent-Central-Sleep-Apnea (TECSA)), and ii) unsupervised groups (k-means clusters). To generate these clusters, baseline and follow-up variables were used (age, sex, body mass index (BMI), initial diagnosed Obstructive-Apnea-Index, initial diagnosed Central-Apnea-Index, Continuous-Positive-Airway-Pressure used before ASV treatment, presence of cardiopathy, and presence of a reduced left-ventricular-ejection-fraction (LVEF)). ASV-data were collected using the manufacturer’s software for 6 months. Results One hundred seventy-seven patients (87.57% male) were analysed with a median (IQ25–75) initial Apnea-Hypopnea-Index of 50 (38–62)/h, an ASV-treatment duration of 2.88 (1.76–4.96) years, 61.58% treated with an ASV-V. SDB groups did not differ in ASV settings, MV or therapeutic pressures. In contrast, the five generated k-means clusters did (generally described as follows: (C1) male-TECSA-cardiopathy, (C2) male-mostly-CSA-cardiopathy, (C3) male-mostly-TECSA-no cardiopathy, (C4) female-mostly-elevated BMI-TECSA-cardiopathy, (C5) male-mostly-OSA-low-LVEF). Of note, the male-mostly-OSA-low-LVEF-cluster-5 had significantly lower fixed end-expiratory-airway-pressure (EPAP) settings versus C1 (p = 0.029) and C4 (p = 0.007). Auto-EPAP usage was higher in the male-mostly-TECSA-no cardiopathy-cluster-3 versus C1 (p = 0.006) and C2 (p < 0.001). MV differences between ASV-F (p = 0.002) and ASV-V (p < 0.001) were not homogenously distributed across clusters, suggesting specific cluster and ASV-algorithm interactions. Individual ASV-data suggest that the hyperventilation risk is not related to the cluster nor the ASV-monitoring type. Conclusions Real-life ASV settings are associated with combinations of baseline and follow-up variables wherein cardiological variables remain clinically meaningful. At the patient level, a hyperventilation risk exists regardless of cluster or ASV-monitoring type, spotlighting a future role of MV-telemonitoring in the interest of patient-safety. Trial registration The OTRLASV study was registered on ClinicalTrials.gov (Identifier: NCT02429986). 1 April 2015.
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19
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Brown LK, Javaheri S, Khayat R. A Critical Review of SERVE-HF Follow-Up Studies and Their Impact on Clinical Practice. CURRENT SLEEP MEDICINE REPORTS 2020. [DOI: 10.1007/s40675-020-00177-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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20
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Hetland A, Vistnes M, Haugaa KH, Liland KH, Olseng M, Edvardsen T. Obstructive sleep apnea versus central sleep apnea: prognosis in systolic heart failure. Cardiovasc Diagn Ther 2020; 10:396-404. [PMID: 32695620 DOI: 10.21037/cdt.2020.03.02] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background In chronic heart failure (CHF), obstructive sleep apnea (OSA) and Cheyne-Stokes respiration (CSR) are associated with increased mortality. The present study aimed to evaluate the prognostic effect of CSR compared to OSA, in otherwise similar groups of CHF patients. Methods Screening for sleep-disordered breathing (SDB) was conducted among patients with CHF of New York Heart Association (NYHA) class II-IV, and left ventricular ejection fraction (LVEF) of ≤45%. The study included 43 patients (4 women) with >25% CSR during sleeping time, and 19 patients (2 women) with OSA and an apnea-hypopnea index (AHI) of ≥6. Patients were followed for a median of 1,371 days. The primary endpoint was mortality, and the secondary endpoint was combined mortality and hospital admissions. Results Baseline parameters did not significantly differ between groups, but CSR patients were older and had higher AHI values than OSA patients. Five OSA patients (26%) died, and 14 (74%) met the combined end-point of death or hospitalization. CSR patients had significantly higher risk for both end-points, with 23 (53%) deaths [log-rank P=0.040; HR, 2.70 (1.01-7.22); P=0.047] and 40 (93%) deaths or readmissions [log-rank P=0.029; HR, 1.96 (1.06-3.63); P=0.032]. After adjustment for confounding risk factors, the association between CSR and death remained significant [HR, 4.73 (1.10-20.28); P=0.037], hospital admission rates were not significantly different. Conclusions Among patients with CHF, CSR was associated with higher mortality than OSA independently of age and cardiac systolic function. CSR was also an age-independent predictor of unfavorable outcome, but hospital admission rates were not significantly different between the two groups after adjustment.
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Affiliation(s)
- Arild Hetland
- Department of Cardiology, The Hospital of Oestfold, Oestfold, Norway.,Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Maria Vistnes
- Department of Internal Medicine, Diakonhjemmet Hospital, Oslo, Norway
| | - Kristina H Haugaa
- Faculty of Medicine, University of Oslo, Oslo, Norway.,Department of Cardiology and Center for Cardiological Innovation, Oslo University Hospital, Rikshospitalet Oslo, Oslo, Norway
| | - Kristian Hovde Liland
- Faculty of Science and Technology, Norwegian University of Life Sciences, Ås, Norway
| | - Margareth Olseng
- Department of Cardiology, The Hospital of Oestfold, Oestfold, Norway
| | - Thor Edvardsen
- Faculty of Medicine, University of Oslo, Oslo, Norway.,Department of Cardiology and Center for Cardiological Innovation, Oslo University Hospital, Rikshospitalet Oslo, Oslo, Norway
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21
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Javaheri S, Brown LK, Khayat RN. Update on Apneas of Heart Failure With Reduced Ejection Fraction: Emphasis on the Physiology of Treatment. Chest 2020; 157:1637-1646. [DOI: 10.1016/j.chest.2019.12.020] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 12/17/2019] [Accepted: 12/31/2019] [Indexed: 02/07/2023] Open
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22
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Hunasikatti M. Effect of treatment of central sleep apnea/Cheyne-Stokes respiration on left ventricular ejection fraction in heart failure: a network meta-analysis is not the answer. J Clin Sleep Med 2020; 16:651-652. [DOI: 10.5664/jcsm.8304] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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23
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Collen J, Lettieri C, Wickwire E, Holley A. Obstructive sleep apnea and cardiovascular disease, a story of confounders! Sleep Breath 2020; 24:1299-1313. [PMID: 31919716 DOI: 10.1007/s11325-019-01945-w] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2019] [Revised: 09/10/2019] [Accepted: 09/13/2019] [Indexed: 12/18/2022]
Abstract
Obstructive sleep apnea (OSA) syndrome is increasingly common among middle aged and older adults and is frequently linked to most cardiovascular diseases (CVD). Sleep-disordered breathing and CVD share a number of common risk factors and comorbid conditions including obesity, male gender, advancing age, metabolic syndrome, and hypertension. OSA appears to be associated with worsened CVD outcomes, sleep-related symptoms, quality of life, and risk of motor vehicle accidents. Demonstrating a cause-and-effect relationship between CVD and OSA has been challenging due to shared comorbidities. Strong evidence demonstrating clinically significant benefit for OSA treatments on OSA-related CVD outcomes are limited. In this review, we evaluate potential pathophysiologic mechanisms that link OSA to CVD and focus on specific treatments for OSA, including positive airway pressure (PAP), dental devices, and surgeries with regard to OSA-related CVD outcomes.
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Affiliation(s)
- Jacob Collen
- Uniformed Services University, 4301 Jones Bridge Road, Bethesda, MD, 20814, USA.
| | | | - Emerson Wickwire
- Department of Psychiatry, University of Maryland School of Medicine, Baltimore, MD, USA
- Sleep Disorders Center, Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Aaron Holley
- Uniformed Services University, 4301 Jones Bridge Road, Bethesda, MD, 20814, USA
- Walter Reed National Military Medical Center, 8901 Rockville Pike, Bethesda, MD, 20889, USA
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24
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Tietjens JR, Claman D, Kezirian EJ, De Marco T, Mirzayan A, Sadroonri B, Goldberg AN, Long C, Gerstenfeld EP, Yeghiazarians Y. Obstructive Sleep Apnea in Cardiovascular Disease: A Review of the Literature and Proposed Multidisciplinary Clinical Management Strategy. J Am Heart Assoc 2020; 8:e010440. [PMID: 30590966 PMCID: PMC6405725 DOI: 10.1161/jaha.118.010440] [Citation(s) in RCA: 194] [Impact Index Per Article: 48.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
| | - David Claman
- 1 Department of Medicine University of California San Francisco CA
| | - Eric J Kezirian
- 4 USC Caruso Department of Otolaryngology - Head & Neck Surgery Keck School of Medicine University of Southern California Los Angeles CA
| | - Teresa De Marco
- 1 Department of Medicine University of California San Francisco CA
| | | | - Bijan Sadroonri
- 6 Division of Pulmonary Diseases and Sleep Medicine Holy Family Hospital Methuen MA
| | - Andrew N Goldberg
- 7 Department of Otolaryngology - Head & Neck Surgery University of California San Francisco CA
| | - Carlin Long
- 1 Department of Medicine University of California San Francisco CA
| | | | - Yerem Yeghiazarians
- 1 Department of Medicine University of California San Francisco CA.,2 Eli and Edythe Broad Center of Regeneration Medicine and Stem Cell Research University of California San Francisco CA.,3 Cardiovascular Research Institute University of California San Francisco CA
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25
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Javaheri S, McKane SW, Cameron N, Germany RE, Malhotra A. In patients with heart failure the burden of central sleep apnea increases in the late sleep hours. Sleep 2019; 42:5133062. [PMID: 30325462 DOI: 10.1093/sleep/zsy195] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Indexed: 01/06/2023] Open
Abstract
Study Objectives Periodic breathing with central sleep apnea (CSA) is common in patients with left ventricular systolic dysfunction. Based on the pathophysiological mechanisms underlying CSA, we hypothesized that the frequency of CSA episodes would increase in the late hours of non-rapid eye movement (NREM) of sleep. Methods Forty-one patients with left ventricular ejection fraction <40% underwent full-night-attended polysomnography scored by a central core lab. Because central apneas occur primarily in NREM sleep, total NREM sleep time for each patient was divided into 8 equal duration segments. Segment event counts were normalized to an events/hour index based on sleep segment duration. Results Central apnea index (CAI) varied among sleep segments (p = 0.001). As expected CAI was higher in segment 1 compared to segments 2 and 3, increasing during later segments. The minimum CAI occurred in segment 2 with mean ± SD of 21 ± 3 events/hour and maximum CAI was in segment 8 with 37 ± 4 events/hour. We also determined central apnea duration which varied among segments (p = 0.005), with longer durations later in the night (segment 1: 22 ± 1 seconds; segment 8: 26 ± 1 seconds, p < 0.001). Data were also analyzed including rapid eye movement (REM) sleep, with similar results. Further, comparison of CAI between the first and second half of the night showed a significant increase in the index. Circulation time did not change across the segments (p = 0.073). Conclusions In patients with left ventricular dysfunction and CSA, central apnea burden (number and duration) increases during later hours of sleep. These findings have pathophysiological and therapeutic implications. Clinical Trial Registration NCT01124370.
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Affiliation(s)
- Shahrokh Javaheri
- Bethesda Montgomery Sleep Centre, Bethesda North Hospital, Cincinnati, OH
| | | | | | - Robin E Germany
- Respicardia, Inc., Minnetonka, MN.,Division of Cardiovascular Diseases, University of Oklahoma College of Medicine, Oklahoma City, OK
| | - Atul Malhotra
- Division of Pulmonary, Critical Care and Sleep Medicine, University of California at San Diego, San Diego, CA
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26
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Randerath W, Deleanu O, Schiza S, Pepin JL. Central sleep apnoea and periodic breathing in heart failure: prognostic significance and treatment options. Eur Respir Rev 2019; 28:28/153/190084. [PMID: 31604817 PMCID: PMC9488867 DOI: 10.1183/16000617.0084-2019] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Accepted: 08/30/2019] [Indexed: 12/27/2022] Open
Abstract
Central sleep apnoea (CSA) including periodic breathing is prevalent in more than one-third of patients with heart failure and is highly and independently associated with poor outcomes. Optimal treatment is still debated and well-conducted studies regarding efficacy and impact on outcomes of available treatment options are limited, particularly in cardiac failure with preserved ejection fraction. While continuous positive airway pressure and oxygen reduce breathing disturbances by 50%, adaptive servoventilation (ASV) normalises breathing disturbances by to controlling the underlying mechanism of CSA. Results are contradictory regarding impact of ASV on hard outcomes. Cohorts and registry studies show survival improvement under ASV, while secondary analyses of the large SERVE-HF randomised trial showed an excess mortality in cardiac failure with reduced ejection fraction. The current priority is to understand which phenotypes of cardiac failure patients may benefit from treatment guiding individualised and personalised management.
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Affiliation(s)
- Winfried Randerath
- Institute of Pneumology at the University of Cologne, Bethanien Hospital, Clinic for Pneumology and Allergology, Centre of Sleep Medicine and Respiratory Care, Solingen, Germany
| | - Oana Deleanu
- University of Medicine and Pharmacy "Carol Davila" and Institute of Pneumology "Marius Nasta" Bucharest, Bucharest, Romania
| | - Sofia Schiza
- Sofia Schiza, University of Crete, Heraklion, Greece
| | - Jean-Louis Pepin
- Laboratoire du sommeil explorations fonctionnelle Respire, Centre Hospitalier Universitaire Grenoble, Grenoble, France
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27
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Gunn S, Naik S, Bianchi MT, Thomas RJ. Estimation of adaptive ventilation success and failure using polysomnogram and outpatient therapy biomarkers. Sleep 2019; 41:4868556. [PMID: 29471442 DOI: 10.1093/sleep/zsy033] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2017] [Indexed: 11/14/2022] Open
Abstract
Study Objectives Adaptive servo-ventilation (ASV) devices provide anticyclic pressure support for the treatment of central and/or complex sleep apnea, including heart failure patients. Variability in responses in the clinic and negative clinical trials motivated assessment of standard and novel signal biomarkers for ASV efficacy. Methods Multiple clinical databases were queried to assess potential signal biomarkers of ASV effectiveness, including the following: (1) attended laboratory adaptive ventilation titrations: 108, of which 66 had mainstream ETCO2 measurements; (2) AirView data in 98 participants, (3) complete data, from diagnostic polysomnogram (PSG) through review and prospective analysis of on-therapy data using SleepyHead freeware in 44 participants; and (4) hemodynamic data in the form of beat-to-beat blood pressure during ASV titration, using a Finometer in five participants. Results Signal biomarkers of reduced ASV efficacy were noted as follows: (1) an arousal index which markedly exceeded the respiratory event index during positive pressure titration; (2) persistent pressure cycling during long-term ASV therapy, visible in online review systems or reviewing data using freeware; (3) the ASV-associated pressure cycling induced arousals, sleep fragmentation, and blood pressure surges; and (4) elevated ratios of 95th percentile to median tidal volume, minute ventilation, and respiratory rate were associated with pressure cycling. High intraclass coefficients (>0.8) for machine apnea-hypopnea index and other extractable metrics were consistent with stability of patterns over multiple nights of use. Global clinical outcomes correlated negatively with pressure cycling. Conclusions Potential polysomnographic- and device-related signal biomarkers of ASV efficacy are described and may allow improved estimation of therapeutic effectiveness of adaptive ventilation.
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Affiliation(s)
- Stacey Gunn
- Division of Pulmonary, Critical Care and Sleep, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - Sreelatha Naik
- Division of Pulmonary, Critical Care and Sleep, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - Matt Travis Bianchi
- Division of Sleep Medicine, Department of Neurology, Massachusetts General Hospital, Boston, MA
| | - Robert Joseph Thomas
- Division of Pulmonary, Critical Care and Sleep, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
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28
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Abstract
Synchronization of molecular, metabolic, and cardiovascular circadian oscillations is fundamental to human health. Sleep-disordered breathing, which disrupts such temporal congruence, elicits hemodynamic, autonomic, chemical, and inflammatory disturbances with acute and long-term consequences for heart, brain, and circulatory and metabolic function. Sleep apnea afflicts a substantial proportion of adult men and women but is more prevalent in those with established cardiovascular diseases and especially fluid-retaining states. Despite the experimental, epidemiological, observational, and interventional evidence assembled in support of these concepts, this substantial body of work has had relatively modest pragmatic impact, thus far, on the discipline of cardiology. Contemporary estimates of cardiovascular risk still are derived typically from data acquired during wakefulness. The impact of sleep-related breathing disorders rarely is entered into such calculations or integrated into diagnostic disease-specific algorithms or therapeutic recommendations. Reasons for this include absence of apnea-related symptoms in most with cardiovascular disease, impediments to efficient diagnosis at the population level, debate as to target, suboptimal therapies, difficulties mounting large randomized trials of sleep-specific interventions, and the challenging results of those few prospective cardiovascular outcome trials that have been completed and reported. The objectives of this review are to delineate the bidirectional interrelationship between sleep-disordered breathing and cardiovascular disease, consider the findings and implications of observational and randomized trials of treatment, frame the current state of clinical equipoise, identify principal current controversies and potential paths to their resolution, and anticipate future directions.
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Affiliation(s)
- John S Floras
- From the University Health Network and Sinai Health System Division of Cardiology, Department of Medicine, University of Toronto, Ontario, Canada.
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Unilateral phrenic nerve stimulation in the therapeutical algorithm of central sleep apnoea in heart failure. Curr Opin Pulm Med 2019; 25:561-569. [PMID: 31313744 DOI: 10.1097/mcp.0000000000000606] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
PURPOSE OF REVIEW Central sleep apnoea (CSA) is highly prevalent in patients with heart failure and substantially impairs survival. If optimal cardiac treatment fails, alternative therapeutical options, including positive airway pressure (PAP) therapies, drugs or application of oxygen and carbon dioxide are considered to suppress CSA which interfere with the complex underlying pathophysiology. Most recently, unilateral phrenic nerve stimulation (PNS) has been studied in these patients. Therefore, there is an urgent need to critically evaluate efficacy, potential harm and positioning of PNS in current treatment algorithms. RECENT FINDINGS Data from case series and limited randomized controlled trials demonstrate the feasibility of the invasive approach and acceptable peri-interventional adverse events. PNS reduces CSA by 50%, a figure comparable with continuous PAP or oxygen. However, PNS cannot improve any comorbid upper airways obstruction. A number of fatalities due to malignant cardiac arrhythmias or other cardiac events have been reported, although the association with the therapy is unclear. SUMMARY PNS offers an additional option to the therapeutical portfolio. Intervention-related adverse events and noninvasive alternatives need clear discussion with the patient. The excess mortality in the SERVE-HF study has mainly been attributed to sudden cardiac death. Therefore, previous cardiac fatalities under PNS urge close observation in future studies as long-term data are missing.
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Herkenrath SD, Randerath WJ. More than Heart Failure: Central Sleep Apnea and Sleep-Related Hypoventilation. Respiration 2019; 98:95-110. [PMID: 31291632 DOI: 10.1159/000500728] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Accepted: 05/02/2019] [Indexed: 12/29/2022] Open
Abstract
Central sleep apnea (CSA) comprises a variety of breathing patterns and clinical entities. They can be classified into 2 categories based on the partial pressure of carbon dioxide in the arterial blood. Nonhypercapnic CSA is usually characterized by a periodic breathing pattern, while hypercapnic CSA is based on hypoventilation. The latter CSA form is associated with central nervous, neuromuscular, and rib cage disorders as well as obesity and certain medication or substance intake. In contrast, nonhypercapnic CSA is typically accompanied by an overshoot of the ventilation and often associated with heart failure, cerebrovascular diseases, and stay in high altitude. CSA and hypoventilation syndromes are often considered separately, but pathophysiological aspects frequently overlap. An integrative approach helps to recognize underlying pathophysiological mechanisms and to choose adequate therapeutic strategies. Research in the last decades improved our insights; nevertheless, diagnostic tools are not always appropriately chosen to perform comprehensive sleep studies. This supports misinterpretation and misclassification of sleep disordered breathing. The purpose of this article is to highlight unresolved problems, raise awareness for different pathophysiological components and to discuss the evidence for targeted therapeutic strategies.
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Baillieul S, Revol B, Jullian-Desayes I, Joyeux-Faure M, Tamisier R, Pépin JL. Diagnosis and management of central sleep apnea syndrome. Expert Rev Respir Med 2019; 13:545-557. [PMID: 31014146 DOI: 10.1080/17476348.2019.1604226] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Introduction: Central sleep apnea (CSA) syndrome has gained a considerable interest in the sleep field within the last 10 years. It is overrepresented in particular subpopulations such as patients with stroke or heart failure. Early detection and diagnosis, as well as appropriate treatment of central breathing disturbances during sleep remain challenging. Areas covered: Based on a systematic review of CSA in adults the clinical evidence and polysomnographic patterns useful for discerning central from obstructive events are discussed. Current therapeutic indications of CSA and perspectives are presented, according to the type of respiratory disturbances during sleep, alterations in blood gases and ventilatory control. Expert opinion: The precise identification of central events during polysomnographic recording is mandatory. Therapeutic choices for CSA depend on the typology of respiratory disturbances observed by polysomnography, changes in blood gases and ventilatory control. In CSA with normocapnia and ventilatory instability, adaptive servo-ventilation is recommended. In CSA with hypercapnia and/or rapid-eye movement sleep hypoventilation, non-invasive ventilation is required. Further studies are required as strong evidence is lacking regarding the long-term consequences of CSA and the long-term impact of current treatment strategies.
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Affiliation(s)
- Sébastien Baillieul
- a Grenoble Alpes University , HP2 Laboratory , INSERM U1042, Grenoble , France.,b Pôle Thorax et Vaisseaux , Grenoble Alpes University Hospital , Grenoble , France
| | - Bruno Revol
- a Grenoble Alpes University , HP2 Laboratory , INSERM U1042, Grenoble , France.,b Pôle Thorax et Vaisseaux , Grenoble Alpes University Hospital , Grenoble , France
| | - Ingrid Jullian-Desayes
- a Grenoble Alpes University , HP2 Laboratory , INSERM U1042, Grenoble , France.,b Pôle Thorax et Vaisseaux , Grenoble Alpes University Hospital , Grenoble , France
| | - Marie Joyeux-Faure
- a Grenoble Alpes University , HP2 Laboratory , INSERM U1042, Grenoble , France.,b Pôle Thorax et Vaisseaux , Grenoble Alpes University Hospital , Grenoble , France
| | - Renaud Tamisier
- a Grenoble Alpes University , HP2 Laboratory , INSERM U1042, Grenoble , France.,b Pôle Thorax et Vaisseaux , Grenoble Alpes University Hospital , Grenoble , France
| | - Jean-Louis Pépin
- a Grenoble Alpes University , HP2 Laboratory , INSERM U1042, Grenoble , France.,b Pôle Thorax et Vaisseaux , Grenoble Alpes University Hospital , Grenoble , France
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Abstract
Purpose The purpose of this review is to discuss the pathogenesis, clinical manifestations, diagnosis and treatment, including areas of controversy and uncertainty. Recent Findings Central apnea may be due to hypoventilation or to hypocapnia following hyperventilation. The occurrence of central apnea initiates a cascade of events that perpetuates breathing instability, recurrent central apnea and upper airway narrowing. In fact, breathing instability and upper airway narrowing are key elements of central and obstructive apnea. Clinically, central apnea is noted in association with obstructive sleep apnea, heart failure, atrial fibrillation, cerebrovascular accidents tetraplegia, and chronic opioid use.Management strategy for central apnea aim to eliminate abnormal respiratory events, stabilize sleep and alleviate the underlying clinical condition. Positive pressure therapy (PAP) remains a standard therapy for central as well as obstructive apnea. Other treatment options include adaptive-servo ventilation (ASV), supplemental oxygen, phrenic nerve stimulation, and pharmacologic therapy. However, ASV is contraindicated in patients with central sleep apnea who had heart failure with reduced ejection fraction, owing to increased mortality in this population. Summary There are several therapeutic options for central apnea. Randomized controlled studies are needed to ascertain the long-term effectiveness of individual, or combination, treatment modalities in different types of central apnea.
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Affiliation(s)
- M Safwan Badr
- Department of Internal Medicine, Division of pulmonary, critical; care and sleep medicine
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Perger E, Lyons OD, Inami T, Smith S, Floras JS, Logan AG, Bradley TD. Predictors of 1-year compliance with adaptive servoventilation in patients with heart failure and sleep disordered breathing: preliminary data from the ADVENT-HF trial. Eur Respir J 2019; 53:13993003.01626-2018. [PMID: 30409822 DOI: 10.1183/13993003.01626-2018] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2018] [Accepted: 10/29/2018] [Indexed: 11/05/2022]
Affiliation(s)
- Elisa Perger
- Sleep Research Laboratory of the University Health Network Toronto Rehabilitation Institute, Toronto, ON, Canada.,Centre for Sleep Medicine and Circadian Biology, Toronto, ON, Canada
| | - Owen D Lyons
- Sleep Research Laboratory of the University Health Network Toronto Rehabilitation Institute, Toronto, ON, Canada.,Centre for Sleep Medicine and Circadian Biology, Toronto, ON, Canada.,Dept of Medicine Women's College Hospital, Toronto, ON, Canada
| | - Toru Inami
- Sleep Research Laboratory of the University Health Network Toronto Rehabilitation Institute, Toronto, ON, Canada.,Centre for Sleep Medicine and Circadian Biology, Toronto, ON, Canada
| | - Stephanie Smith
- Sleep Research Laboratory of the University Health Network Toronto Rehabilitation Institute, Toronto, ON, Canada
| | - John S Floras
- The University Health Network and Sinai Health System Dept of Medicine, Toronto, ON, Canada
| | - Alexander G Logan
- The University Health Network and Sinai Health System Dept of Medicine, Toronto, ON, Canada
| | - T Douglas Bradley
- Sleep Research Laboratory of the University Health Network Toronto Rehabilitation Institute, Toronto, ON, Canada.,Centre for Sleep Medicine and Circadian Biology, Toronto, ON, Canada.,The University Health Network and Sinai Health System Dept of Medicine, Toronto, ON, Canada
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Mansukhani MP, Kolla BP, Naessens JM, Gay PC, Morgenthaler TI. Effects of Adaptive Servoventilation Therapy for Central Sleep Apnea on Health Care Utilization and Mortality: A Population-Based Study. J Clin Sleep Med 2019; 15:119-128. [PMID: 30621843 DOI: 10.5664/jcsm.7584] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Accepted: 10/10/2018] [Indexed: 12/15/2022]
Abstract
STUDY OBJECTIVES Adaptive servoventilation (ASV) is the suggested treatment for many forms of central sleep apnea (CSA). We aimed to evaluate the impact of treating CSA with ASV on health care utilization. METHODS In this population-based study using the Rochester Epidemiology Project database, we identified patients over a 9-year period who were diagnosed with CSA (n = 1,237), commenced ASV therapy, and had ≥ 1 month of clinical data before and after ASV initiation. The rates of hospitalizations, emergency department visits (EDV), outpatient visits (OPV) and medications prescribed per year (mean ± standard deviation) in the 2 years pre-ASV and post-ASV initiation were compared. RESULTS We found 309 patients (68.0 ± 14.6 years, 80.3% male, apnea-hypopnea index 41.6 ± 26.5 events/h, 78% with cardiovascular comorbidities, 34% with heart failure) who met inclusion criteria; 65% used ASV ≥ 4 h/night on ≥ 70% nights in their first month. The overall 2-year mortality rate was 9.4% and CSA secondary to cardiac cause was a significant risk factor for mortality (hazard ratio 1.81, 95% CI 1.09-3.01, P = .02). Comparing pre-ASV and post-ASV initiation, there was no change in the rate of hospitalization (0.72 ± 1.63 versus 0.79 ± 1.44, P = .46), EDV (1.19 ± 2.18 versus 1.26 ± 2.08, P = .54), OPV (31.59 ± 112.42 versus 13.60 ± 17.36, P = .22), or number of prescribed medications (6.68 ± 2.0 versus 5.31 ± 5.86, P = .06). No differences in these outcomes emerged after accounting for adherence to ASV, CSA subtype and comorbidities via multiple regression analysis (all P > .05). CONCLUSIONS Our cohort of patients with CSA was quite ill and the use of ASV was not associated with a change in health care utilization.
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Affiliation(s)
| | - Bhanu Prakas Kolla
- Center for Sleep Medicine, Mayo Clinic, Minnesota.,Department of Psychiatry and Psychology, Mayo Clinic, Minnesota
| | - James M Naessens
- Division of Healthcare Policy and Research, Mayo Clinic, Minnesota
| | - Peter C Gay
- Center for Sleep Medicine, Mayo Clinic, Minnesota.,Department of Pulmonary and Critical Care Medicine, Mayo Clinic, Minnesota
| | - Timothy I Morgenthaler
- Center for Sleep Medicine, Mayo Clinic, Minnesota.,Department of Pulmonary and Critical Care Medicine, Mayo Clinic, Minnesota
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Lombardi C, Faini A, La Rovere M, Fanfulla F, Mattaliano P, Caravita S, Contini M, Agostoni P, Perrone-Filardi P, Parati G. Heart failure and sleep related breathing disorders: Data from PROMISES (Progetto Multicentrico Italiano Sonno e Scompenso Cardiaco) study. Int J Cardiol 2018; 271:140-145. [DOI: 10.1016/j.ijcard.2018.05.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Revised: 04/26/2018] [Accepted: 05/02/2018] [Indexed: 02/07/2023]
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Costanzo MR, Ponikowski P, Coats A, Javaheri S, Augostini R, Goldberg LR, Holcomb R, Kao A, Khayat RN, Oldenburg O, Stellbrink C, McKane S, Abraham WT. Phrenic nerve stimulation to treat patients with central sleep apnoea and heart failure. Eur J Heart Fail 2018; 20:1746-1754. [PMID: 30303611 PMCID: PMC6607512 DOI: 10.1002/ejhf.1312] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Revised: 08/07/2018] [Accepted: 08/09/2018] [Indexed: 11/05/2022] Open
Abstract
AIMS The presence of central sleep apnoea (CSA) is associated with poor prognosis in patients with heart failure (HF). The aim of this analysis was to evaluate if using phrenic nerve stimulation to treat CSA in patients with CSA and HF was associated with changes in HF-specific metrics. METHODS AND RESULTS All patients randomized in the remedē System Pivotal Trial and identified at baseline with HF were included (n = 96). Effectiveness data from treatment and former control groups were pooled based on months since therapy activation. Changes from baseline to 6 and 12 months in sleep metrics, Epworth Sleepiness Scale, patient global assessment health-related quality of life, Minnesota Living with Heart Failure Questionnaire (MLHFQ), and echocardiographic parameters are reported. HF hospitalization, cardiovascular death, and the composite of HF hospitalization or cardiovascular death within 6 months are reported by the original randomized group assignment for safety assessment. Sleep metrics and quality of life improved from baseline to 6 and 12 months. At 12 months, MLHFQ scores changed by -6.8 ± 20.0 (P = 0.005). The 6-month rate of HF hospitalization was 4.7% in treatment patients (standard error = 3.3) and 17.0% in control patients (standard error = 5.5) (P = 0.065). Reported adverse events were as expected for a transvenous implantable system. CONCLUSIONS Phrenic nerve stimulation reduces CSA severity in patients with HF. In parallel, this CSA treatment was associated with benefits on HF quality of life.
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Affiliation(s)
| | | | | | | | | | | | | | - Andrew Kao
- Mid America Heart Institute, Kansas City, MO, USA
| | | | - Olaf Oldenburg
- Bad Oeynhausen Heart and Diabetes Center, Bad Oeynhausen, Germany
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Javaheri S, Brown LK, Khayat R. Rebuttal to Naughton. J Clin Sleep Med 2018; 14:923-925. [PMID: 29852919 DOI: 10.5664/jcsm.7150] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Accepted: 04/13/2018] [Indexed: 11/13/2022]
Affiliation(s)
- Shahrokh Javaheri
- Sleep Laboratory, Division of Sleep and Pulmonary Medicine, Bethesda North Hospital, Cincinnati, Ohio.,University of Cincinnati, Cincinnati, Ohio.,Ohio University Medical School, Columbus, Ohio
| | - Lee K Brown
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico.,University of New Mexico Sleep Disorders Center, Albuquerque, New Mexico.,Department of Electrical and Computer Engineering, University of New Mexico School of Engineering, Albuquerque, New Mexico
| | - Rami Khayat
- Division of Pulmonary Critical Care and Sleep, Ohio State University, Columbus, Ohio
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38
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Beneficial effects of adaptive servo-ventilation on natriuretic peptides and diastolic function in acute heart failure patients with preserved ejection fraction and sleep-disordered breathing. Sleep Breath 2018; 23:287-291. [DOI: 10.1007/s11325-018-1681-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Revised: 06/04/2018] [Accepted: 06/06/2018] [Indexed: 12/22/2022]
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Javaheri S, Brown LK, Khayat R. CON: Persistent Central Sleep Apnea/Hunter-Cheyne-Stokes Breathing, Despite Best Guideline-Based Therapy of Heart Failure With Reduced Ejection Fraction, Is Not a Compensatory Mechanism and Should Be Suppressed. J Clin Sleep Med 2018; 14:915-921. [PMID: 29852913 DOI: 10.5664/jcsm.7148] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Accepted: 03/29/2018] [Indexed: 12/18/2022]
Affiliation(s)
- Shahrokh Javaheri
- Sleep Laboratory, Division of Sleep and Pulmonary Medicine, Bethesda North Hospital, Cincinnati, Ohio.,University of Cincinnati, Cincinnati, Ohio.,Ohio University Medical School, Columbus, Ohio
| | - Lee K Brown
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico.,University of New Mexico Sleep Disorders Center, Albuquerque, New Mexico.,Department of Electrical and Computer Engineering, University of New Mexico School of Engineering, Albuquerque, New Mexico
| | - Rami Khayat
- Division of Pulmonary Critical Care and Sleep, Ohio State University, Columbus, Ohio
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40
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Abraham WT, Pleister A, Germany R. Identification and Treatment of Central Sleep Apnoea: Beyond SERVE-HF. Card Fail Rev 2018; 4:50-53. [PMID: 29892478 DOI: 10.15420/cfr.2018:9:1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Central sleep apnoea (CSA) occurs in a large proportion of HF patients. CSA has clear detrimental effects, resulting in intermittent hypoxia and sympathetic activation, and is associated with significant morbidity and mortality. Treatment options are limited following the results of a recent trial in which adaptive servo-ventilation resulted in an increase in cardiovascular mortality. Ongoing studies utilising other forms of positive airway pressure may provide additional insight into the results of this trial. A new neurostimulation therapy, phrenic nerve stimulation, has offered a new physiological approach to the treatment of CSA. This therapy has resulted in improvements in the severity of disease and quality of life.
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Randerath W. Positive Airway Pressure for Sleep-Related Breathing Disorders in Heart Failure—Overview and Discussion of Potential Mechanisms of Harm. CURRENT SLEEP MEDICINE REPORTS 2018. [DOI: 10.1007/s40675-018-0116-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Wolf J, Narkiewicz K. Managing comorbid cardiovascular disease and sleep apnea with pharmacotherapy. Expert Opin Pharmacother 2018; 19:961-969. [PMID: 29792524 DOI: 10.1080/14656566.2018.1476489] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
INTRODUCTION Highly prevalent sleep disordered breathing (SDB) has been recognized as an independent cardiovascular disease (CVD) risk factor. Although these two entities often coexist, there is a shortage of sufficiently-powered studies testing the interplay between the course of sleep apnea and CVD pharmacotherapy. The mutual relationship between treated/untreated obstructive sleep apnea (OSA) with ongoing cardiovascular pharmacotherapies is an evident gap in clinical expertise. AREAS COVERED In this article, the authors review the available evidence and outline future research directions concerning the reciprocal relationship between the pharmacological treatment of CVD and SDB. Several attempts have been made to identify the most efficacious hypotensive agents for patients with both OSA and hypertension. Various cardiovascular drugs are also evaluated in terms of their influence on sleep apnea severity. EXPERT OPINION The question of whether OSA should be included in cardiovascular pharmacotherapy individualization algorithms is a matter of debate and more evidence is needed. Cautious intensification of diuretics with the use of aldosterone receptor antagonists deserves attention when both high blood pressure and sleep apnea coexist.
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Affiliation(s)
- Jacek Wolf
- a Faculty of Medicine, Department of Hypertension and Diabetology , Medical University of Gdańsk , Gdańsk , Poland
| | - Krzysztof Narkiewicz
- a Faculty of Medicine, Department of Hypertension and Diabetology , Medical University of Gdańsk , Gdańsk , Poland
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Adaptive servo-ventilation to treat central sleep apnea in heart failure with reduced ejection fraction: the Bad Oeynhausen prospective ASV registry. Clin Res Cardiol 2018; 107:719-728. [PMID: 29654439 DOI: 10.1007/s00392-018-1239-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Accepted: 04/03/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND Central sleep apnea (CSA) is highly prevalent in heart failure patients with reduced left ventricular ejection fraction (HF-REF). The Bad Oeynhausen Adaptive Servo-ventilation (ASV) registry (NCT01657188) was designed to investigate whether treatment of CSA with ASV improved survival in HF-REF patients; the effects of ASV on symptoms and cardiopulmonary performance were also investigated. METHODS AND RESULTS From January 2004 to October 2013, the registry prospectively enrolled HF-REF patients [NYHA class ≥ II, left ventricular ejection fraction (LVEF) ≤ 45%] with moderate to severe predominant CSA [apnea-hypopnea index (AHI) ≥ 15/h]. ASV-treated patients were followed up at 3, 6, 12 and 24 months, including natriuretic peptide concentrations, blood gas analyses, echocardiography, 6-min walk distance (6MWD), and cardiopulmonary exercise (CPX) testing. 550 patients were included [age 67.7 ± 10 years, 90% male, 52% in NYHA class ≥ III, LVEF 29.9 ± 8%, AHI 35.4 ± 13.6/h, and time with nocturnal oxygen saturation < 90% (T < 90%) 58 ± 73 min]; ASV was prescribed to 224 patients. Over a median follow-up of 6.6 years, 109 (48.7%) ASV-treated patients and 191 (58.6%) controls died (adjusted Cox modelling hazard ratio of 0.95, 95% confidence interval 0.68-1.24; p = 0.740); older age, lower LVEF, impaired renal function, low sodium concentration, and nocturnal hypoxemia were significant predictors of mortality. Patient reported NYHA functional class improved in the ASV group, but LVEF, CPX, 6MWD, natriuretic peptides and blood gases remained unchanged. CONCLUSIONS Long-term ASV treatment of predominant CSA in HF-REF patients included in our registry had no statistically significant effect on survival. ASV improved HF symptoms, but had no significant effects on exercise capacity, LVEF, natriuretic peptide concentrations or blood gases during follow-up as compared to control patients.
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Oates CP, Ananthram M, Gottlieb SS. Management of Sleep Disordered Breathing in Patients with Heart Failure. Curr Heart Fail Rep 2018; 15:123-130. [PMID: 29616491 DOI: 10.1007/s11897-018-0387-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
PURPOSE OF REVIEW This paper reviews treatment options for sleep disordered breathing (SDB) in patients with heart failure. We sought to identify therapies for SDB with the best evidence for long-term use in patients with heart failure and to minimize uncertainties in clinical practice by examining frequently discussed questions: what is the role of continuous positive airway pressure (CPAP) in patients with heart failure? Is adaptive servo-ventilation (ASV) safe in patients with heart failure? To what extent is SDB a modifiable risk factor? RECENT FINDINGS Consistent evidence has demonstrated that the development of SDB in patients with heart failure is a poor prognostic indicator and a risk factor for cardiovascular mortality. However, despite numerous available interventions for obstructive sleep apnea and central sleep apnea, it remains unclear what effect these therapies have on patients with heart failure. To date, all major randomized clinical trials have failed to demonstrate a survival benefit with SDB therapy and one major study investigating the use of adaptive servo-ventilation demonstrated harm. Significant questions persist regarding the management of SDB in patients with heart failure. Until appropriately powered trials identify a treatment modality that increases cardiovascular survival in patients with SDB and heart failure, a patient's heart failure management should remain the priority of medical care.
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Affiliation(s)
- Connor P Oates
- School of Medicine, University of Maryland, Baltimore, MD, USA
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45
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Jaffuel D, Molinari N, Berdague P, Pathak A, Galinier M, Dupuis M, Ricci JE, Mallet JP, Bourdin A, Roubille F. Impact of sacubitril-valsartan combination in patients with chronic heart failure and sleep apnoea syndrome: the ENTRESTO-SAS study design. ESC Heart Fail 2018; 5:222-230. [PMID: 29469206 PMCID: PMC5933955 DOI: 10.1002/ehf2.12270] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Revised: 11/10/2017] [Accepted: 01/09/2018] [Indexed: 12/11/2022] Open
Abstract
Aims Sleep‐disordered breathing (SDB) is a highly prevalent co‐morbidity in patients with chronic heart failure (CHF) and can play a detrimental role in the pathophysiology course of CHF. However, the best way to manage SDB in CHF remains a matter of debate. Sacubitril–valsartan has been included in the 2016 European Society of Cardiology guidelines as an alternative to angiotensin‐converting enzyme inhibitors to further reduce the risk of progression of CHF, CHF hospitalization, and death in ambulatory patients. Sacubitril and valsartan are good candidates for correcting SDB of CHF patients because their known mechanisms of action are likely to counteract the pathophysiology of SDB in CHF. Methods and results The ENTRESTO‐SAS trial is a 3‐month, multicentric, prospective, open‐label real‐life cohort study. Patients eligible for sacubitril–valsartan treatment (i.e. adults with left ventricular ejection fraction ≤35%, who remain symptomatic despite optimal treatment with an angiotensin‐converting enzyme inhibitor, a beta‐blocker, and a mineralocorticoid receptor antagonist) will be evaluated before and after 3 months of treatment (nocturnal ventilatory polygraphy, echocardiography, laboratory testing, and quality‐of‐life and SDB questionnaires). The primary outcome is the change in the Apnoea–Hypopnoea Index, before and after 3 months of treatment. One hundred twenty patients are required to detect a significant 20% improvement of the Apnoea–Hypopnoea Index with a power of 90% at an alpha risk of 5%. Conclusions In the context of the SERVE‐HF study, physicians are waiting for new trials and alternative therapies. We sought to assess in the ENTRESTO‐SAS trial whether sacubitril–valsartan could improve the outcome of SDB in CHF patients.
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Affiliation(s)
- Dany Jaffuel
- Department of Pneumology, Arnaud de Villeneuve, Regional University Hospital of Montpellier, 371 Avenue du Doyen Giraud, 34295, Montpellier Cedex 5, France
| | - Nicolas Molinari
- Department of Medical Information, Montpellier University Hospital, IMAG UMR 5149, Montpellier University, 34090, Montpellier, France
| | - Philippe Berdague
- Department of Cardiology, Béziers Hospital, 2 rue Valentin Haûy, BP 740, 34525, Béziers Cedex, France
| | - Atul Pathak
- Department of Cardiovascular Medicine, Hypertension and Heart Failure Unit, Health Innovation Laboratory, Clinique Pasteur, Avenue de Lombez, 31000, Toulouse, France
| | - Michel Galinier
- Department of Cardiology, University Hospital of Rangueil, 1, Avenue Professeur Jean Poulhès, 31095, Toulouse, France
| | - Marion Dupuis
- Department of Pneumology, Respiratory Tracts Center, Hôpital Larrey, 24, chemin de Pouvourville, TSA 30030, 31059, Toulouse Cedex 9, France
| | - Jean-Etienne Ricci
- Department of Cardiology, University Hospital Caremeau, Place du Pr Robert Debré, 30029, Nimes Cedex 9, France
| | - Jean-Pierre Mallet
- Department of Pneumology, Arnaud de Villeneuve, Regional University Hospital of Montpellier, 371 Avenue du Doyen Giraud, 34295, Montpellier Cedex 5, France
| | - Arnaud Bourdin
- Department of Pneumology, Arnaud de Villeneuve, Regional University Hospital of Montpellier, 371 Avenue du Doyen Giraud, 34295, Montpellier Cedex 5, France
| | - François Roubille
- Department of Cardiology, Regional University Hospital of Montpellier, PhyMedExp, University of Montpellier, INSERM U1046, CNRS UMR, 9214, Montpellier, France
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Abstract
PURPOSE OF REVIEW The bidirectional relationships that have been demonstrated between heart failure (HF) and central sleep apnea (CSA) demand further exploration with respect to the implications that each condition has for the other. This review discusses the body of literature that has accumulated on these relationships and how CSA and its potential treatment may affect outcomes in patients with CSA. RECENT FINDINGS Obstructive sleep apnea (OSA) can exacerbate hypertension, type 2 diabetes, obesity, and atherosclerosis, which are known predicates of HF. Conversely, patients with HF more frequently exhibit OSA partly due to respiratory control system instability. These same mechanisms are responsible for the frequent association of HF with CSA with or without a Hunter-Cheyne-Stokes breathing (HCSB) pattern. Just as is the case with OSA, patients with HF complicated by CSA exhibit more severe cardiac dysfunction leading to increased mortality; the increase in severity of HF can in turn worsen the degree of sleep disordered breathing (SDB). Thus, a bidirectional relationship exists between HF and both phenotypes of SDB; moreover, an individual patient may exhibit a combination of these phenotypes. Both types of SDB remain significantly underdiagnosed in patients with HF and hence undertreated. Appropriate screening for, and treatment of, OSA is clearly a significant factor in the comprehensive management of HF, while the relevance of CSA remains controversial. Given the unexpected results of the Treatment of Sleep-Disordered Breathing with Predominant Central Sleep Apnea by Adaptive Servo Ventilation in Patients with Heart Failure trial, it is now of paramount importance that additional analysis of these data be expeditiously reported. It is also critical that ongoing and proposed prospective studies of this issue proceed without delay.
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Abraham WT, Elizabeth Germany R. Transvenous Phrenic Nerve Stimulation for Central Sleep Apnea. Neuromodulation 2018. [DOI: 10.1016/b978-0-12-805353-9.00110-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Mansukhani MP, Somers VK, Shafazand S. PAP and Cardiovascular Events in Adults With Sleep Apnea: Is PAP Useful? J Clin Sleep Med 2017; 13:1487-1489. [PMID: 29151429 DOI: 10.5664/jcsm.6858] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Accepted: 10/27/2017] [Indexed: 11/13/2022]
Affiliation(s)
- Meghna P Mansukhani
- Mayo Clinic College of Medicine and Science, Center for Sleep Medicine, Mayo Clinic, Rochester, Minnesota
| | - Virend K Somers
- Mayo Clinic College of Medicine and Science, Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Shirin Shafazand
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of Miami Miller School of Medicine, Miami, Florida
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49
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Lairez O, Legallois D, Agostini D. Sympathetic nervous system, systolic heart failure, and central sleep apnea: Are we about to find the missing link? J Nucl Cardiol 2017; 24:1938-1940. [PMID: 27457530 DOI: 10.1007/s12350-016-0584-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Accepted: 04/26/2016] [Indexed: 10/21/2022]
Affiliation(s)
- Olivier Lairez
- Département de Médecine Nucléaire, CHU Rangueil, Toulouse, France
| | - Damien Legallois
- Service de Cardiologie, CHU Côte de Nacre, Caen, France
- Service de Médecine Nucléaire, CHU Côte de Nacre, Caen, France
| | - Denis Agostini
- Service de Médecine Nucléaire, CHU Côte de Nacre, Caen, France.
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50
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Drager LF, McEvoy RD, Barbe F, Lorenzi-Filho G, Redline S. Sleep Apnea and Cardiovascular Disease: Lessons From Recent Trials and Need for Team Science. Circulation 2017; 136:1840-1850. [PMID: 29109195 DOI: 10.1161/circulationaha.117.029400] [Citation(s) in RCA: 318] [Impact Index Per Article: 45.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Emerging research highlights the complex interrelationships between sleep-disordered breathing and cardiovascular disease, presenting clinical and research opportunities as well as challenges. Patients presenting to cardiology clinics have a high prevalence of obstructive and central sleep apnea associated with Cheyne-Stokes respiration. Multiple mechanisms have been identified by which sleep disturbances adversely affect cardiovascular structure and function. Epidemiological research indicates that obstructive sleep apnea is associated with increases in the incidence and progression of coronary heart disease, heart failure, stroke, and atrial fibrillation. Central sleep apnea associated with Cheyne-Stokes respiration predicts incident heart failure and atrial fibrillation; among patients with heart failure, it strongly predicts mortality. Thus, a strong literature provides the mechanistic and empirical bases for considering obstructive sleep apnea and central sleep apnea associated with Cheyne-Stokes respiration as potentially modifiable risk factors for cardiovascular disease. Data from small trials provide evidence that treatment of obstructive sleep apnea with continuous positive airway pressure improves not only patient-reported outcomes such as sleepiness, quality of life, and mood but also intermediate cardiovascular end points such as blood pressure, cardiac ejection fraction, vascular parameters, and arrhythmias. However, data from large-scale randomized controlled trials do not currently support a role for positive pressure therapies for reducing cardiovascular mortality. The results of 2 recent large randomized controlled trials, published in 2015 and 2016, raise questions about the effectiveness of pressure therapies in reducing clinical end points, although 1 trial supported the beneficial effect of continuous positive airway pressure on quality of life, mood, and work absenteeism. This review provides a contextual framework for interpreting the results of recent studies, key clinical messages, and suggestions for future sleep and cardiovascular research, which include further consideration of individual risk factors, use of existing and new multimodality therapies that also address adherence, and implementation of trials that are sufficiently powered to target end points and to support subgroup analyses. These goals may best be addressed through strengthening collaboration among the cardiology, sleep medicine, and clinical trial communities.
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Affiliation(s)
- Luciano F Drager
- From Hypertension Unit (L.F.D.) and Sleep Laboratory, Pulmonary Division (G.L.-F.), Instituto do Coracao, and Hypertension Unit, Renal Division (L.F.D.), University of São Paulo Medical School, Brazil; Adelaide Institute for Sleep Health, College of Medicine and Public Health, and School of Medicine, Faculty of Medicine, Nursing, and Health Sciences, Flinders University, Australia (R.D.M.); Sleep Health Service, Respiratory and Sleep Services, Southern Adelaide Local Health Network, Australia (R.D.M.); Respiratory Department, Institut de Recerca Biomèdica de Lleida, Lleida and Centro de Investigacion Biomedica en Red de Enfermedades Respiratorias, Madrid, Spain (F.B.); and Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (S.R.).
| | - R Doug McEvoy
- From Hypertension Unit (L.F.D.) and Sleep Laboratory, Pulmonary Division (G.L.-F.), Instituto do Coracao, and Hypertension Unit, Renal Division (L.F.D.), University of São Paulo Medical School, Brazil; Adelaide Institute for Sleep Health, College of Medicine and Public Health, and School of Medicine, Faculty of Medicine, Nursing, and Health Sciences, Flinders University, Australia (R.D.M.); Sleep Health Service, Respiratory and Sleep Services, Southern Adelaide Local Health Network, Australia (R.D.M.); Respiratory Department, Institut de Recerca Biomèdica de Lleida, Lleida and Centro de Investigacion Biomedica en Red de Enfermedades Respiratorias, Madrid, Spain (F.B.); and Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (S.R.)
| | - Ferran Barbe
- From Hypertension Unit (L.F.D.) and Sleep Laboratory, Pulmonary Division (G.L.-F.), Instituto do Coracao, and Hypertension Unit, Renal Division (L.F.D.), University of São Paulo Medical School, Brazil; Adelaide Institute for Sleep Health, College of Medicine and Public Health, and School of Medicine, Faculty of Medicine, Nursing, and Health Sciences, Flinders University, Australia (R.D.M.); Sleep Health Service, Respiratory and Sleep Services, Southern Adelaide Local Health Network, Australia (R.D.M.); Respiratory Department, Institut de Recerca Biomèdica de Lleida, Lleida and Centro de Investigacion Biomedica en Red de Enfermedades Respiratorias, Madrid, Spain (F.B.); and Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (S.R.)
| | - Geraldo Lorenzi-Filho
- From Hypertension Unit (L.F.D.) and Sleep Laboratory, Pulmonary Division (G.L.-F.), Instituto do Coracao, and Hypertension Unit, Renal Division (L.F.D.), University of São Paulo Medical School, Brazil; Adelaide Institute for Sleep Health, College of Medicine and Public Health, and School of Medicine, Faculty of Medicine, Nursing, and Health Sciences, Flinders University, Australia (R.D.M.); Sleep Health Service, Respiratory and Sleep Services, Southern Adelaide Local Health Network, Australia (R.D.M.); Respiratory Department, Institut de Recerca Biomèdica de Lleida, Lleida and Centro de Investigacion Biomedica en Red de Enfermedades Respiratorias, Madrid, Spain (F.B.); and Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (S.R.)
| | - Susan Redline
- From Hypertension Unit (L.F.D.) and Sleep Laboratory, Pulmonary Division (G.L.-F.), Instituto do Coracao, and Hypertension Unit, Renal Division (L.F.D.), University of São Paulo Medical School, Brazil; Adelaide Institute for Sleep Health, College of Medicine and Public Health, and School of Medicine, Faculty of Medicine, Nursing, and Health Sciences, Flinders University, Australia (R.D.M.); Sleep Health Service, Respiratory and Sleep Services, Southern Adelaide Local Health Network, Australia (R.D.M.); Respiratory Department, Institut de Recerca Biomèdica de Lleida, Lleida and Centro de Investigacion Biomedica en Red de Enfermedades Respiratorias, Madrid, Spain (F.B.); and Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (S.R.).
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