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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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Bradley TD, Logan AG, Lorenzi Filho G, Kimoff RJ, Durán Cantolla J, Arzt M, Redolfi S, Parati G, Kasai T, Dunlap ME, Delgado D, Yatsu S, Bertolami A, Pedrosa R, Tomlinson G, Marin Trigo JM, Tantucci C, Floras JS. Adaptive servo-ventilation for sleep-disordered breathing in patients with heart failure with reduced ejection fraction (ADVENT-HF): a multicentre, multinational, parallel-group, open-label, phase 3 randomised controlled trial. THE LANCET. RESPIRATORY MEDICINE 2024; 12:153-166. [PMID: 38142697 DOI: 10.1016/s2213-2600(23)00374-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 09/21/2023] [Accepted: 09/28/2023] [Indexed: 12/26/2023]
Abstract
BACKGROUND In patients with heart failure and reduced ejection fraction, sleep-disordered breathing, comprising obstructive sleep apnoea (OSA) and central sleep apnoea (CSA), is associated with increased morbidity, mortality, and sleep disruption. We hypothesised that treating sleep-disordered breathing with a peak-flow triggered adaptive servo-ventilation (ASV) device would improve cardiovascular outcomes in patients with heart failure and reduced ejection fraction. METHODS We conducted a multicentre, multinational, parallel-group, open-label, phase 3 randomised controlled trial of peak-flow triggered ASV in patients aged 18 years or older with heart failure and reduced ejection fraction (left ventricular ejection fraction ≤45%) who were stabilised on optimal medical therapy with co-existing sleep-disordered breathing (apnoea-hypopnoea index [AHI] ≥15 events/h of sleep), with concealed allocation and blinded outcome assessments. The trial was carried out at 49 hospitals in nine countries. Sleep-disordered breathing was stratified into predominantly OSA with an Epworth Sleepiness Scale score of 10 or lower or predominantly CSA. Participants were randomly assigned to standard optimal treatment alone or standard optimal treatment with the addition of ASV (1:1), stratified by study site and sleep apnoea type (ie, CSA or OSA), with permuted blocks of sizes 4 and 6 in random order. Clinical evaluations were performed and Minnesota Living with Heart Failure Questionnaire, Epworth Sleepiness Scale, and New York Heart Association class were assessed at months 1, 3, and 6 following randomisation and every 6 months thereafter to a maximum of 5 years. The primary endpoint was the cumulative incidence of the composite of all-cause mortality, first admission to hospital for a cardiovascular reason, new onset atrial fibrillation or flutter, and delivery of an appropriate cardioverter-defibrillator shock. All-cause mortality was a secondary endpoint. Analysis for the primary outcome was done in the intention-to-treat population. This trial is registered with ClinicalTrials.gov (NCT01128816) and the International Standard Randomised Controlled Trial Number Register (ISRCTN67500535), and the trial is complete. FINDINGS The first and last enrolments were Sept 22, 2010, and March 20, 2021. Enrolments terminated prematurely due to COVID-19-related restrictions. 1127 patients were screened, of whom 731 (65%) patients were randomly assigned to receive standard care (n=375; mean AHI 42·8 events per h of sleep [SD 20·9]) or standard care plus ASV (n=356; 43·3 events per h of sleep [20·5]). Follow-up of all patients ended at the latest on June 15, 2021, when the trial was terminated prematurely due to a recall of the ASV device due to potential disintegration of the motor sound-abatement material. Over the course of the trial, 41 (6%) of participants withdrew consent and 34 (5%) were lost to follow-up. In the ASV group, the mean AHI decreased to 2·8-3·7 events per h over the course of the trial, with associated improvements in sleep quality assessed 1 month following randomisation. Over a mean follow-up period of 3·6 years (SD 1·6), ASV had no effect on the primary composite outcome (180 events in the control group vs 166 in the ASV group; hazard ratio [HR] 0·95, 95% CI 0·77-1·18; p=0·67) or the secondary endpoint of all-cause mortality (88 deaths in the control group vs. 76 in the ASV group; 0·89, 0·66-1·21; p=0·47). For patients with OSA, the HR for all-cause mortality was 1·00 (0·68-1·46; p=0·98) and for CSA was 0·74 (0·44-1·23; p=0·25). No safety issue related to ASV use was identified. INTERPRETATION In patients with heart failure and reduced ejection fraction and sleep-disordered breathing, ASV had no effect on the primary composite outcome or mortality but eliminated sleep-disordered breathing safely. FUNDING Canadian Institutes of Health Research and Philips RS North America.
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Affiliation(s)
- T Douglas Bradley
- University Health Network Toronto Rehabilitation Institute (KITE), Toronto, ON, Canada; Toronto General Hospital, Toronto, ON, Canada.
| | - Alexander G Logan
- Toronto General Hospital, Toronto, ON, Canada; Mount Sinai Hospital, Toronto, ON, Canada
| | | | - R John Kimoff
- McGill University Health Centre, Montreal, QC, Canada
| | | | - Michael Arzt
- Universitaetskinikum Regensburg, Regensburg, Germany
| | | | - Gianfranco Parati
- IRCCS, Istituto Auxologico Italiano, Milan, Italy; University of Milano-Bicocca, Milan, Italy
| | | | - Mark E Dunlap
- MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | | | - Shoichiro Yatsu
- University Health Network Toronto Rehabilitation Institute (KITE), Toronto, ON, Canada; Toronto General Hospital, Toronto, ON, Canada
| | | | | | | | | | | | - John S Floras
- Toronto General Hospital, Toronto, ON, Canada; Mount Sinai Hospital, Toronto, ON, Canada
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Tamisier R, Pepin J, Cowie MR, Wegscheider K, Vettorazzi E, Suling A, Angermann C, d'Ortho M, Erdmann E, Simonds AK, Somers VK, Teschler H, Lévy P, Woehrle H. Effect of adaptive servo ventilation on central sleep apnea and sleep structure in systolic heart failure patients: polysomnography data from the SERVE-HF major sub study. J Sleep Res 2022; 31:e13694. [PMID: 35840352 PMCID: PMC9787165 DOI: 10.1111/jsr.13694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 06/23/2022] [Accepted: 06/23/2022] [Indexed: 12/30/2022]
Abstract
This SERVE-HF (Treatment of Predominant Central Sleep Apnea by Adaptive Servo Ventilation in Patients With Heart Failure) sub study analysis evaluated polysomnography (PSG) data in patients with heart failure with reduced ejection fraction (HFrEF) and predominant central sleep apnea (CSA) randomised to guideline-based medical therapy, with or without adaptive servo ventilation (ASV). Patients underwent full overnight PSG at baseline and at 12 months. All PSG recordings were analysed by a core laboratory. Only data for patients with baseline and 3- or 12-month values were included. The sub study included 312 patients; the number with available PSG data differed for each variable (94-103 in the control group, 77-99 in the ASV group). After 12 months, baseline-adjusted respiratory measures were significantly better in the ASV group versus control. Although some between-group differences in sleep measures were seen at 12 months (e.g., better sleep efficiency in the ASV group), these were unlikely to be clinically significant. The number of periodic leg movements during sleep (PLMS) increased in the ASV group (p = 0.039). At 12 months, the respiratory arousal index was significantly lower in the ASV versus control group (p < 0.001), whilst the PLMS-related arousal index was significantly higher in the ASV group (p = 0.04 versus control). ASV attenuated the respiratory variables characterising sleep apnea in patients with HFrEF and predominant CSA in SERVE-HF. Sleep quality improvements during ASV therapy were small and unlikely to be clinically significant. The increase in PLMS and PLMS-related arousals during ASV warrants further investigation, particularly relating to their potential association with increased cardiovascular risk.
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Affiliation(s)
- Renaud Tamisier
- University Grenoble Alpes, Inserm, HP2 Laboratory, Pole Thorax et VaisseauxCHU Grenoble AlpesGrenobleFrance
| | - Jean‐Louis Pepin
- University Grenoble Alpes, Inserm, HP2 Laboratory, Pole Thorax et VaisseauxCHU Grenoble AlpesGrenobleFrance
| | | | - Karl Wegscheider
- Department of Medical Biometry and EpidemiologyUniversity Medical Center Hamburg‐EppendorfHamburgGermany
| | - Eik Vettorazzi
- Department of Medical Biometry and EpidemiologyUniversity Medical Center Hamburg‐EppendorfHamburgGermany
| | - Anna Suling
- Department of Medical Biometry and EpidemiologyUniversity Medical Center Hamburg‐EppendorfHamburgGermany
| | - Christiane Angermann
- Department of Medicine IUniversity and University Hospital WürzburgWürzburgGermany
| | - Marie‐Pia d'Ortho
- Hôpital Bichat, Explorations Fonctionnelles ‐ Sleep Centre, AP‐HPUniversité de ParisParisFrance
| | | | - Anita K. Simonds
- Royal Brompton and Harefield NHS Foundation Trust HospitalLondonUK
| | | | - Helmut Teschler
- Department of Pneumology, Ruhrlandklinik, West German Lung CenterUniversity Hospital Essen, University Duisburg‐EssenEssenGermany
| | | | - Holger Woehrle
- Sleep and Ventilation Center Blaubeuren, Respiratory Center UlmUlmGermany
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Pinto ACPN, Rocha A, Pachito DV, Drager LF, Lorenzi-Filho G. Non-invasive positive pressure ventilation for central sleep apnoea in adults. Cochrane Database Syst Rev 2022; 10:CD012889. [PMID: 36278514 PMCID: PMC9590003 DOI: 10.1002/14651858.cd012889.pub2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Central sleep apnoea (CSA) is characterised by abnormal patterns of ventilation during sleep due to a dysfunctional drive to breathe. Consequently, people with CSA may present poor sleep quality, sleep fragmentation, inattention, fatigue, daytime sleepiness, and reduced quality of life. OBJECTIVES To assess the effectiveness and safety of non-invasive positive pressure ventilation (NIPV) for the treatment of adults with CSA. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and Scopus on 6 September 2021. We applied no restrictions on language of publication. We also searched clinical trials registries for ongoing and unpublished studies, and scanned the reference lists of included studies to identify additional studies. SELECTION CRITERIA We included randomised controlled trials (RCTs) reported in full text, those published as abstract only, and unpublished data. DATA COLLECTION AND ANALYSIS Two review authors independently selected studies for inclusion, extracted data, and assessed risk of bias of the included studies using the Cochrane risk of bias tool version 1.0, and the certainty of the evidence using the GRADE approach. In the case of disagreement, a third review author was consulted. MAIN RESULTS We included 15 RCTs with a total of 1936 participants, ranging from 10 to 1325 participants. All studies had important methodological limitations. We assessed most studies (11 studies) as at high risk of bias for at least one domain, and all studies as at unclear risk of bias for at least two domains. The trials included participants aged > 18 years old, of which 70% to 100% were men, who were followed from one week to 60 months. The included studies assessed the effects of different modes of NIPV and CSA. Most participants had CSA associated with chronic heart failure. Because CSA encompasses a variety of causes and underlying clinical conditions, data were carefully analysed, and different conditions and populations were not pooled. The findings for the primary outcomes for the seven evaluated comparisons are presented below. Continuous positive airway pressure (CPAP) plus best supportive care versus best supportive care in CSA associated with chronic heart failure In the short term, CPAP plus best supportive care may reduce central apnoea hypopnoea index (AHI) (mean difference (MD) -14.60, 95% confidence interval (CI) -20.11 to -9.09; 1 study; 205 participants). However, CPAP plus best supportive care may result in little to no difference in cardiovascular mortality compared to best supportive care alone. The evidence for the effect of CPAP plus best supportive care on all-cause mortality is very uncertain. No adverse effects were observed with CPAP, and the results for adverse events in the best supportive care group were not reported. Adaptive servo ventilation (ASV) versus CPAP in CSA associated with chronic heart failure The evidence is very uncertain about the effect of ASV versus CPAP on quality of life evaluated in both the short and medium term. Data on adverse events were not reported, and it is not clear whether data were sought but not found. ASV versus bilevel ventilation in CSA associated with chronic heart failure In the short term, ASV may result in little to no difference in central AHI. No adverse events were detected with ASV, and the results for adverse events in the bilevel ventilation group were not reported. ASV plus best supportive care versus best supportive care in CSA associated with chronic heart failure In the medium term, ASV plus best supportive care may reduce AHI compared to best supportive care alone (MD -20.30, 95% CI -28.75 to -11.85; 1 study; 30 participants). In the long term, ASV plus best supportive care likely increases cardiovascular mortality compared to best supportive care (risk ratio (RR) 1.25, 95% CI 1.04, 1.49; 1 study; 1325 participants). The evidence suggests that ASV plus best supportive care may result in little to no difference in quality of life in the short, medium, and long term, and in all-cause mortality in the medium and long term. Data on adverse events were evaluated but not reported. ASV plus best supportive care versus best supportive care in CSA with acute heart failure with preserved ejection fraction Only adverse events were reported for this comparison, and no adverse events were recorded in either group. ASV versus CPAP maintenance in CPAP-induced CSA In the short term, ASV may slightly reduce central AHI (MD -4.10, 95% CI -6.67 to -1.53; 1 study; 60 participants), but may result in little to no difference in quality of life. Data on adverse events were not reported, and it is not clear whether data were sought but not found. ASV versus bilevel ventilation in CPAP-induced CSA In the short term, ASV may slightly reduce central AHI (MD -8.70, 95% CI -11.42 to -5.98; 1 study; 30 participants) compared to bilevel ventilation. Data on adverse events were not reported, and it is not clear whether data were sought but not found. AUTHORS' CONCLUSIONS CPAP plus best supportive care may reduce central AHI in people with CSA associated with chronic heart failure compared to best supportive care alone. Although ASV plus best supportive care may reduce AHI in people with CSA associated with chronic heart failure, it likely increases cardiovascular mortality in these individuals. In people with CPAP-induced CSA, ASV may slightly reduce central AHI compared to bilevel ventilation and to CPAP. In the absence of data showing a favourable impact on meaningful patient-centred outcomes and defining clinically important differences in outcomes in CSA patients, these findings need to be interpreted with caution. Considering the level of certainty of the available evidence and the heterogeneity of participants with CSA, we could draw no definitive conclusions, and further high-quality trials focusing on patient-centred outcomes, such as quality of life, quality of sleep, and longer-term survival, are needed to determine whether one mode of NIPV is better than another or than best supportive care for any particular CSA patient group.
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Affiliation(s)
- Ana Carolina Pereira Nunes Pinto
- Cochrane Brazil, Health Technology Assessment Center, São Paulo, Brazil
- Biological and Health Sciences Department, Federal University of Amapa, Amapá, Brazil
- Post-graduation program in Evidence-based Health, Department of Medicine, Federal University of São Paulo, São Paulo, Brazil
| | - Aline Rocha
- Cochrane Brazil, Núcleo de Avaliação de Tecnologias em Saúde, São Paulo, Brazil
| | | | - Luciano F Drager
- Unidade de Hipertensão, Disciplina de Nefrologia, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
- Unidade de Hipertensão, Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
- Cardiology Center, Hospital Sírio Libanes, São Paulo, Brazil
| | - Geraldo Lorenzi-Filho
- Laboratorio de Sono, Divisao de Pneumologia, Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
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Matthes S, Randerath W. Assessment of sleep disordered breathing in patients with heart failure. Breathe (Sheff) 2022; 18:220153. [PMID: 36865658 PMCID: PMC9973519 DOI: 10.1183/20734735.0153-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 09/14/2022] [Indexed: 11/16/2022] Open
Abstract
When to look for sleep disturbances in heart failure patients and how best to treat them: a practical and evidence-based expert opinion https://bit.ly/3LpCnNP.
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Affiliation(s)
- Sandhya Matthes
- Institute of Pneumology, University of Cologne, Solingen, Germany,Hospital Bethanien Solingen, Clinic of Pneumology and Allergology, Center for Sleep Medicine and Respiratory Care, Solingen, Germany
| | - Winfried Randerath
- Institute of Pneumology, University of Cologne, Solingen, Germany,Hospital Bethanien Solingen, Clinic of Pneumology and Allergology, Center for Sleep Medicine and Respiratory Care, Solingen, Germany,Corresponding author: Winfried Randerath ()
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Ventrikuläre Arrhythmien bei obstruktiver und zentraler Schlafapnoe. SOMNOLOGIE 2021. [DOI: 10.1007/s11818-021-00319-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Zusammenfassung
Hintergrund
Ventrikuläre Arrhythmien treten mit einer hohen Prävalenz auf und sind mit einer hohen Morbidität und Mortalität assoziiert. Sowohl die obstruktive (OSA) als auch die zentrale (ZSA) Schlafapnoe können auf Grund ihrer Pathophysiologie zu vermehrten ventrikulären Arrhythmien beitragen.
Ziel
Dieser Artikel soll die komplexen Zusammenhänge und Erkenntnisse jüngster Forschungen bezüglich schlafbezogenen Atmungsstörungen (SBAS) und ventrikulärer Arrhythmien und deren Therapiemöglichkeiten beleuchten.
Material und Methoden
Es erfolgte eine Literaturrecherche basierend auf prospektiven, retrospektiven, klinischen und experimentellen Studien sowie Reviews, Metaanalysen und aktuellen Leitlinien, die seit 2014 in der Medline-Datenbank gelistet wurden.
Ergebnisse
Es besteht ein bidirektionaler Zusammenhang zwischen der SBAS und ventrikulären Arrhythmien. Intermittierende Hypoxie, oxidativer Stress, wiederkehrende Arousals, intrathorakale Druckschwankungen und kardiales Remodeling tragen im Rahmen der SBAS zu einer erhöhten ventrikulären Arrhythmieneigung bei. Der Schweregrad der OSA, gemessen mittels Apnoe-Hypopnoe-Index, ist mit der Prävalenz ventrikulärer Arrhythmien assoziiert. Ähnliche Ergebnisse liegen für Patienten mit ZSA und Herzinsuffizienz vor. Studien zu ventrikulären Arrhythmien bei ZSA-Patienten ohne Herzinsuffizienz fehlen. Eine Positivdrucktherapie (PAP) bei OSA- oder ZSA-Patienten führte in verschiedenen Studien zu einer reduzierten Anzahl an ventrikulären Arrhythmien. Dieser Zusammenhang konnte jedoch nicht in allen Studien bestätigt werden. Ventrikuläre Arrhythmien treten bei der OSA gehäuft nachts auf, bei der ZSA gleichmäßig über den Tag verteilt.
Diskussion
Bisherige Studien weisen einen Zusammenhang zwischen der OSA bzw. der ZSA und ventrikulären Arrhythmien trotz unterschiedlicher Pathophysiologie nach. Hinsichtlich des Effektes der PAP auf ventrikuläre Arrhythmien bei Patienten mit OSA und ZSA sind weitere Studien erforderlich.
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Anchouche K, Elharram M, Oulousian E, Razaghizad A, Avram R, Marquis-Gravel G, Randhawa VK, Nkulikiyinka R, Ni W, Fiuzat M, O'Connor C, Psotka MA, Fox J, Tyl B, Kao D, Sharma A. Use of Actigraphy (Wearable Digital Sensors to Monitor Activity) in Heart Failure Randomized Clinical Trials: A Scoping Review. Can J Cardiol 2021; 37:1438-1449. [PMID: 34256087 DOI: 10.1016/j.cjca.2021.07.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Revised: 07/05/2021] [Accepted: 07/05/2021] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Actigraphy-based measurements of physiologic parameters may enable design of patient-centric heart failure (HF) clinical trials. Recently, the Heart Failure Collaboratory focused on recommendations for meaningful change and use of actigraphy as an end point in HF clinical trials. We aimed to evaluate randomized controlled trials (RCTs) that have quantified the impact of HF interventions using actigraphy. METHODS Using a scoping review strategy, we evaluated the use of actigraphy in HF RCTs. Studies were identified through electronic searches of Embase, OVID Medline, PubMed, and Cochrane Review. Data on trial characteristics and results were collected. RESULTS We identified 11 RCTs with a total of 1,455 participants. The risk of bias across the included trials was high overall. All trials had the primary outcomes reflecting measures of either physical activity (n = 8), sleep (n = 2), or both (n = 1). Five trials evaluated response to pharmacologic therapies compared with placebo, 3 evaluated physical activity interventions, 2 evaluated group or cognitive therapy, and 1 evaluated sleep-ventilation strategy. Sample sizes ranged from 30 to 619 participants. There was significant heterogeneity relating to device type, body placement site, and handling of missing actigraphy data. Duration of monitoring ranged from 48 hours to 12 weeks. None of the studies evaluating pharmacologic therapies (n = 5) demonstrated a significant improvement of actigraphy-based primary end point measurements. CONCLUSIONS There is significant heterogeneity in the use, methodology, and results of actigraphy-based HF RCTs. Our results highlight the need to develop, standardize, and validate actigraphy-specific outcomes for use in HF clinical trials.
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Affiliation(s)
- Khalil Anchouche
- Division of Cardiology, McGill University Health Centre, McGill University, Montréal, Québec, Canada; DREAM-CV Lab, McGill University Health Centre, McGill University, Montréal, Québec, Canada
| | - Malik Elharram
- Division of Cardiology, McGill University Health Centre, McGill University, Montréal, Québec, Canada; DREAM-CV Lab, McGill University Health Centre, McGill University, Montréal, Québec, Canada
| | - Emily Oulousian
- Division of Cardiology, McGill University Health Centre, McGill University, Montréal, Québec, Canada; DREAM-CV Lab, McGill University Health Centre, McGill University, Montréal, Québec, Canada
| | - Amir Razaghizad
- Division of Cardiology, McGill University Health Centre, McGill University, Montréal, Québec, Canada; DREAM-CV Lab, McGill University Health Centre, McGill University, Montréal, Québec, Canada
| | - Robert Avram
- Division of Cardiology, Department of Medicine, Ottawa Heart Institute, University of Ottawa, Ottawa, Ontario, Canada; Division of Cardiology, University of California San Francisco, San Francisco, California, USA; Montréal Heart Institute, Université de Montréal, Montréal, Québec, Canada
| | | | - Varinder Kaur Randhawa
- Department of Cardiovascular Medicine, Kaufman Center for Heart Failure, Heart, Vascular and Thoracic Institute, Cleveland, Ohio, USA
| | | | - Wei Ni
- Eli Lilly and Company, Indianapolis, Indiana, USA
| | - Mona Fiuzat
- Division of Cardiology, Duke University, Durham, North Carolina, USA
| | - Christopher O'Connor
- Division of Cardiology, Duke University, Durham, North Carolina, USA; Inova Heart and Vascular Institute, Falls Church, Virginia, USA
| | | | - Jonathan Fox
- Eidos Therapeutics, San Francisco, California, USA
| | - Benoit Tyl
- Center for Therapeutic Innovation Cardiovascular and Metabolic diseases, Institut de Recherches Internationales Servier, Suresnes, France
| | - David Kao
- Department of Medicine, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Abhinav Sharma
- Division of Cardiology, McGill University Health Centre, McGill University, Montréal, Québec, Canada; DREAM-CV Lab, McGill University Health Centre, McGill University, Montréal, Québec, Canada.
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Khandwalla RM, Grant D, Birkeland K, Heywood JT, Fombu E, Owens RL, Steinhubl SR. The AWAKE-HF Study: Sacubitril/Valsartan Impact on Daily Physical Activity and Sleep in Heart Failure. Am J Cardiovasc Drugs 2021; 21:241-254. [PMID: 32978755 DOI: 10.1007/s40256-020-00440-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/03/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND AWAKE-HF evaluated the effect of the initiation of sacubitril/valsartan versus enalapril on activity and sleep using actigraphy in patients who have heart failure with reduced ejection fraction (HFrEF). METHODS In this randomized, double-blind study, patients with HFrEF (n = 140) were randomly assigned to sacubitril/valsartan or enalapril for 8 weeks, followed by an 8-week open-label phase with sacubitril/valsartan. Primary endpoint was change from baseline in mean activity counts during the most active 30 min/day at week 8. The key secondary endpoint was change in mean nightly activity counts/minute from baseline to week 8. Kansas City Cardiomyopathy Questionnaire-23 (KCCQ-23) was an exploratory endpoint. RESULTS There were no detectable differences between groups in geometric mean ratio of activity counts during the most active 30 min/day at week 8 compared with baseline (0.9456 [sacubitril/valsartan:enalapril]; 95% confidence interval [CI] 0.8863-1.0088; P = 0.0895) or in mean change from baseline in activity during sleep (difference: 2.038 counts/min; 95% CI - 0.062 to 4.138; P = 0.0570). Change from baseline to week 8 in KCCQ-23 was 2.89 for sacubitril/valsartan and 4.19 for enalapril, both nonsignificant. CONCLUSIONS In AWAKE-HF, no detectable differences in activity and sleep were observed when comparing sacubitril/valsartan with enalapril in patients with HFrEF using a wearable biosensor. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov, NCT02970669.
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Kolb L, Arzt M, Stadler S, Heider K, Maier LS, Malfertheiner M. Adaptive servo-ventilation in patients with chronic heart failure and sleep disordered breathing: predictors of usage. Sleep Breath 2020; 25:1135-1145. [PMID: 32880808 PMCID: PMC8195885 DOI: 10.1007/s11325-020-02182-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 07/10/2020] [Accepted: 08/21/2020] [Indexed: 11/24/2022]
Abstract
PURPOSE Adaptive servo-ventilation (ASV) is a therapy designed for patients with central sleep apnea (CSA) and Cheyne Stokes respiration. The aim of this study was to find predictors of ASV usage in patients with CSA in a routine sleep clinic cohort. METHODS In this retrospective study, consecutive patients in whom ASV therapy was initiated at the University Hospital Regensburg between 2011 and 2015, were analyzed. Analysis included polysomnographies of diagnostic and ASV initiation nights, a phone questionnaire on ASV usage, readout of the ASV device 1 month after initiation ("early ASV usage," 1 month after ASV initiation), and the readout of the last month before a reappointment date set in 2015 ("late ASV usage," median 17 months after ASV initiation). RESULTS In 69 consecutive patients, the mean early and late ASV usage per night was 4.8 ± 2.5 h and 4.1 ± 3.0 h, respectively. Seventeen months after initiation, 57% of patients used the device ≥ 4 h per night, and of those 91% reported a subjective benefit from ASV therapy. Early ASV usage was significantly associated with late ASV usage (univariable regression: Beta 0.8, 95%CI [0.6; 1.0] p < 0.001). In multivariable regression analysis, short duration of slow wave sleep (N3) during diagnostic polysomnography (Beta - 6.2, 95%CI [- 11.0; - 1.5]; p = 0.011) and subjective benefit from ASV (Beta 174.0, 95%CI [68.6; 279.5]; p = 0.002) were significantly associated with longer late ASV usage. CONCLUSION Early ASV usage predicts late ASV usage. In addition, low slow wave sleep before ASV initiation and subjective benefit from ASV may contribute to higher late ASV usage.
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Affiliation(s)
- Leonie Kolb
- Department of Internal Medicine II, Cardiology and Pneumology, Center for Sleep Medicine, University Medical Center Regensburg, Regensburg, Germany
| | - Michael Arzt
- Department of Internal Medicine II, Cardiology and Pneumology, Center for Sleep Medicine, University Medical Center Regensburg, Regensburg, Germany.
| | - Stefan Stadler
- Department of Internal Medicine II, Cardiology and Pneumology, Center for Sleep Medicine, University Medical Center Regensburg, Regensburg, Germany
| | - Katharina Heider
- Department of Internal Medicine II, Cardiology and Pneumology, Center for Sleep Medicine, University Medical Center Regensburg, Regensburg, Germany
| | - Lars S Maier
- Department of Internal Medicine II, Cardiology and Pneumology, Center for Sleep Medicine, University Medical Center Regensburg, Regensburg, Germany
| | - Maximilian Malfertheiner
- Department of Internal Medicine II, Cardiology and Pneumology, Center for Sleep Medicine, University Medical Center Regensburg, Regensburg, Germany
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Abstract
PURPOSE OF REVIEW Central sleep apnea occurs in up to 50% of heart failure patients and worsens outcomes. Established therapies are limited by minimal supporting evidence, poor patient adherence, and potentially adverse cardiovascular effects. However, transvenous phrenic nerve stimulation, by contracting the diaphragm, restores normal breathing throughout sleep and has been shown to be safe and effective. This review discusses the mechanisms, screening, diagnosis, and therapeutic approaches to CSA in patients with HF. RECENT FINDINGS In a prospective, multicenter randomized Pivotal Trial (NCT01816776) of transvenous phrenic nerve stimulation with the remedē System, significantly more treated patients had a ≥ 50% reduction in apnea-hypopnea index compared with controls, with a 41 percentage point difference between group difference at 6 months (p < 0.0001). All hierarchically tested sleep, quality of life, and daytime sleepiness endpoints were significantly improved in treated patients. Freedom from serious related adverse events at 12 months was 91%. Benefits are sustained to 36 months. Transvenous phrenic nerve stimulation improves quality of life in patients with heart failure and central sleep apnea. Controlled trials evaluating the impact of this therapy on mortality/heart failure hospitalizations and "real world" experience are needed to confirm safety and effectiveness.
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11
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von Haehling S, Arzt M, Doehner W, Edelmann F, Evertz R, Ebner N, Herrmann-Lingen C, Garfias Macedo T, Koziolek M, Noutsias M, Schulze PC, Wachter R, Hasenfuß G, Laufs U. Improving exercise capacity and quality of life using non-invasive heart failure treatments: evidence from clinical trials. Eur J Heart Fail 2020; 23:92-113. [PMID: 32392403 DOI: 10.1002/ejhf.1838] [Citation(s) in RCA: 60] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Accepted: 04/14/2020] [Indexed: 12/28/2022] Open
Abstract
Endpoints of large-scale trials in chronic heart failure have mostly been defined to evaluate treatments with regard to hospitalizations and mortality. However, patients with heart failure are also affected by very severe reductions in exercise capacity and quality of life. We aimed to evaluate the effects of heart failure treatments on these endpoints using available evidence from randomized trials. Interventions with evidence for improvements in exercise capacity include physical exercise, intravenous iron supplementation in patients with iron deficiency, and - with less certainty - testosterone in highly selected patients. Erythropoiesis-stimulating agents have been reported to improve exercise capacity in anaemic patients with heart failure. Sinus rhythm may have some advantage when compared with atrial fibrillation, particularly in patients undergoing pulmonary vein isolation. Studies assessing treatments for heart failure co-morbidities such as sleep-disordered breathing, diabetes mellitus, chronic kidney disease and depression have reported improvements of exercise capacity and quality of life; however, the available data are limited and not always consistent. The available evidence for positive effects of pharmacologic interventions using angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, beta-blockers, and mineralocorticoid receptor antagonists on exercise capacity and quality of life is limited. Studies with ivabradine and with sacubitril/valsartan suggest beneficial effects at improving quality of life; however, the evidence base is limited in particular for exercise capacity. The data for heart failure with preserved ejection fraction are even less positive, only sacubitril/valsartan and spironolactone have shown some effectiveness at improving quality of life. In conclusion, the evidence for state-of-the-art heart failure treatments with regard to exercise capacity and quality of life is limited and appears not robust enough to permit recommendations for heart failure. The treatment of co-morbidities may be important for these patient-related outcomes. Additional studies on functional capacity and quality of life in heart failure are required.
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Affiliation(s)
- Stephan von Haehling
- Department of Cardiology and Pneumology, University of Göttingen Medical Center and German Center for Cardiovascular Research (DZHK), Partner Site Göttingen, Göttingen, Germany
| | - Michael Arzt
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Wolfram Doehner
- BCRT - Berlin Institute of Health Center for Regenerative Therapies, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Department of Internal Medicine and Cardiology, Charité - Universitätsmedizin Berlin, Campus Virchow-Klinikum and German Center for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany
| | - Frank Edelmann
- Department of Internal Medicine and Cardiology, Charité - Universitätsmedizin Berlin, Campus Virchow-Klinikum and German Center for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany
| | - Ruben Evertz
- Department of Cardiology and Pneumology, University of Göttingen Medical Center and German Center for Cardiovascular Research (DZHK), Partner Site Göttingen, Göttingen, Germany
| | - Nicole Ebner
- Department of Cardiology and Pneumology, University of Göttingen Medical Center and German Center for Cardiovascular Research (DZHK), Partner Site Göttingen, Göttingen, Germany
| | - Christoph Herrmann-Lingen
- Department of Psychosomatic Medicine and Psychotherapy, University of Göttingen Medical Center and German Center for Cardiovascular Research (DZHK), Partner Site Göttingen, Göttingen, Germany
| | - Tania Garfias Macedo
- Department of Cardiology and Pneumology, University of Göttingen Medical Center and German Center for Cardiovascular Research (DZHK), Partner Site Göttingen, Göttingen, Germany
| | - Michael Koziolek
- Department of Nephrology and Rheumatology, University of Göttingen Medical Center, Göttingen, Germany
| | - Michel Noutsias
- Mid-German Heart Center, Division of Cardiology, Angiology and Intensive Medical Care, Department of Internal Medicine III, University Hospital Halle, Martin-Luther-University Halle, Halle (Saale), Germany
| | - P Christian Schulze
- Division of Cardiology, Pneumology, Angiology and Intensive Medical Care, Department of Internal Medicine I, University Hospital Jena, Friedrich-Schiller-University Jena, Jena, Germany
| | - Rolf Wachter
- Klinik und Poliklinik für Kardiologie, Universitätsklinikum Leipzig, Leipzig, Germany
| | - Gerd Hasenfuß
- Department of Cardiology and Pneumology, University of Göttingen Medical Center and German Center for Cardiovascular Research (DZHK), Partner Site Göttingen, Göttingen, Germany
| | - Ulrich Laufs
- Klinik und Poliklinik für Kardiologie, Universitätsklinikum Leipzig, Leipzig, Germany
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Sawyer C, Khayat RN. Role of Wearable Technology in the Sleep-Heart Practice—a Conceptual Approach. CURRENT SLEEP MEDICINE REPORTS 2020. [DOI: 10.1007/s40675-020-00167-x] [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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Yamamoto S, Yamaga T, Nishie K, Nagata C, Mori R. Positive airway pressure therapy for the treatment of central sleep apnoea associated with heart failure. Cochrane Database Syst Rev 2019; 12:CD012803. [PMID: 31797360 PMCID: PMC6891032 DOI: 10.1002/14651858.cd012803.pub2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Ischaemic heart disease including heart failure is the most common cause of death in the world, and the incidence of the condition is rapidly increasing. Heart failure is characterised by symptoms such as fatigue and breathlessness during light activity, as well as disordered breathing during sleep. In particular, sleep disordered breathing (SDB), including central sleep apnoea (CSA) and obstructive sleep apnoea (OSA), is highly prevalent in people with chronic heart failure. A previous meta-analysis demonstrated that positive airway pressure (PAP) therapy dramatically increased the survival rate of people with heart failure who had CSA, and thus could contribute to improving the prognosis of these individuals. However, recent trials found that adaptive servo-ventilation (ASV) including PAP therapy had a higher risk of all-cause mortality and cardiovascular mortality. A meta-analysis that included recent trials was therefore needed. OBJECTIVES To assess the effects of positive airway pressure therapy for people with heart failure who experience central sleep apnoea. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library, MEDLINE, Embase, and Web of Science Core Collection on 7 February 2019 with no limitations on date, language, or publication status. We also searched two clinical trials registers in July 2019 and checked the reference lists of primary studies. SELECTION CRITERIA We excluded cross-over trials and included individually randomised controlled trials, reported as full-texts, those published as abstract only, and unpublished data. DATA COLLECTION AND ANALYSIS Two review authors independently extracted outcome data from the included studies. We double-checked that data had been entered correctly by comparing the data presented in the systematic review with study reports. We analysed dichotomous data as risk ratios (RRs) with 95% confidence intervals (CIs) and continuous data as mean difference (MD) or standardised mean difference (SMD) with 95% CIs. Furthermore, we performed subgroup analysis in the ASV group or continuous PAP group separately. We used GRADEpro GDT software to assess the quality of evidence as it relates to those studies that contribute data to the meta-analyses for the prespecified outcomes. MAIN RESULTS We included 16 randomised controlled trials involving a total of 2125 participants. The trials evaluated PAP therapy consisting of ASV or continuous PAP therapy for 1 to 31 months. Many trials included participants with heart failure with reduced ejection fraction. Only one trial included participants with heart failure with preserved ejection fraction. We are uncertain about the effects of PAP therapy on all-cause mortality (RR 0.81, 95% CI 0.54 to 1.21; participants = 1804; studies = 6; I2 = 47%; very low-quality evidence). We found moderate-quality evidence of no difference between PAP therapy and usual care on cardiac-related mortality (RR 0.97, 95% CI 0.77 to 1.24; participants = 1775; studies = 5; I2 = 11%). We found low-quality evidence of no difference between PAP therapy and usual care on all-cause rehospitalisation (RR 0.95, 95% CI 0.70 to 1.30; participants = 1533; studies = 5; I2 = 40%) and cardiac-related rehospitalisation (RR 0.97, 95% CI 0.70 to 1.35; participants = 1533; studies = 5; I2 = 40%). In contrast, PAP therapy showed some indication of an improvement in quality of life scores assessed by all measurements (SMD -0.32, 95% CI -0.67 to 0.04; participants = 1617; studies = 6; I2 = 76%; low-quality evidence) and by the Minnesota Living with Heart Failure Questionnaire (MD -0.51, 95% CI -0.78 to -0.24; participants = 1458; studies = 4; I2 = 0%; low-quality evidence) compared with usual care. Death due to pneumonia (N = 1, 3% of PAP group); cardiac arrest (N = 18, 3% of PAP group); heart transplantation (N = 8, 1% of PAP group); cardiac worsening (N = 3, 9% of PAP group); deep vein thrombosis/pulmonary embolism (N = 1, 3% of PAP group); and foot ulcer (N = 1, 3% of PAP group) occurred in the PAP therapy group, whereas cardiac arrest (N = 16, 2% of usual care group); heart transplantation (N = 12, 2% of usual care group); cardiac worsening (N = 5, 14% of usual care group); and duodenal ulcer (N = 1, 3% of usual care group) occurred in the usual care group across three trials. AUTHORS' CONCLUSIONS The effect of PAP therapy on all-cause mortality was uncertain. In addition, although we found evidence that PAP therapy did not reduce the risk of cardiac-related mortality and rehospitalisation, there was some indication of an improvement in quality of life for heart failure patients with CSA. Furthermore, the evidence was insufficient to determine whether adverse events were more common with PAP than with usual care. These findings were limited by low- or very low-quality evidence. PAP therapy may be worth considering for individuals with heart failure to improve quality of life.
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Affiliation(s)
- Shuhei Yamamoto
- Shinshu University HospitalDepartment of Rehabilitation3‐1‐1 AsahiMatsumotoNaganoJapan
| | - Takayoshi Yamaga
- Health Science UniversityDepartment of Occupational TherapyFujikawaguchiko‐machiJapan
| | - Kenichi Nishie
- Iida Municipal HospitalDepartment of Respiratory Medicine395‐0814 Yawatamachi 438IidaNaganoJapan
| | - Chie Nagata
- National Center for Child Health and DevelopmentDepartment of Education for Clinical Research2‐10‐1 OkuraSetagaya‐kuTokyoJapan157‐8535
| | - Rintaro Mori
- National Center for Child Health and DevelopmentDepartment of Health Policy2‐10‐1 OkuraSetagaya‐kuTokyoTokyoJapan157‐0074
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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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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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16
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Chen C, Wen T, Liao W. Nocturnal supports for patients with central sleep apnea and heart failure: a systemic review and network meta-analysis of randomized controlled trials. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:337. [PMID: 31475207 DOI: 10.21037/atm.2019.06.72] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Sleep apnea probably brings poor outcomes of chronic heart failure (CHF), and some methods show benefit to patients with heart failure (HF) and central sleep apnea (CSA). Our study based on the randomized controlled trials (RCTs) to find out the most beneficial therapy of nocturnal support to decrease the apnea hypopnea index (AHI). Methods The PubMed, and the Web of Science were used to find out the included studies. RevMan 5.3 and Stata 15.1 were performed to this systemic review and network meta-analysis. Results After searching and screening the articles, finally we included 14 articles with total 919 patients, and 4 arms [adaptive servo ventilation (ASV), continuous positive airway pressure (CPAP), oxygen treatment, control]. Compared with the control group, the therapeutic regimens did not show significant difference in AHI. Ranking the different nocturnal supports in the order of estimated probabilities of each treatment by using the network meta-analysis, the result showed that ASV was the best one (87.8%), followed by oxygen (12.2%), CPAP (0%), and control (0%). Conclusions Based on our study, the adoptive servo ventilation is probably the best choice to down the AHI in patients with HF and CSA.
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Affiliation(s)
- Chongxiang Chen
- Department of Intensive Care Unit, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou 510060, China
| | - Tianmeng Wen
- School of Public Health, Sun Yat-sen University, Guangzhou 510060, China
| | - Wei Liao
- Department of Intensive Care Unit, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou 510060, China
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Ren L, Wang K, Shen H, Xu Y, Wang J, Chen R. Effects of continuous positive airway pressure (CPAP) therapy on neurological and functional rehabilitation in Basal Ganglia Stroke patients with obstructive sleep apnea: A prospective multicenter study. Medicine (Baltimore) 2019; 98:e16344. [PMID: 31305423 PMCID: PMC6641828 DOI: 10.1097/md.0000000000016344] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Obstructive sleep apnea (OSA) adversely affects neurological recovery. This study aimed to determine the impact of continuous positive airway pressure (CPAP) and/or rehabilitation in basal ganglia stroke patients with OSA.A prospective controlled trial was conducted in 2015-2018. The subjects received routine rehabilitation training for up to 2 years and were assigned to the intervention and control groups treated with CPAP or without, respectively. Then, treatment effects on sleep parameters, motor function, stroke severity, daily life activities, cognitive function, and psychological states were assessed at different time points.At 6 months, the CPAP group showed significantly lower mean apnea-hypopnea index (AHI), percentage of time with SpO2 at <90% (TS90%), micro-arousal index, and percentages of time in non-rapid eye movement (non-REM) stages 1-2 and REM stage in total sleeping time compared with the control group, and significantly higher mean minimum of peripheral oxygen saturation (L-SaO2%) and percentage of time in stage 3 (P < .001) sleep. The CPAP group showed significant improvements in average the National Institutes of Health Stroke Scale (NIHSS), Fugl-Meyer assessment scale (FMA), Barthel index (BI), Minimental state examination (MMSE), Hamilton anxiety scale (HAMA) and Hamilton depression rating scale for depression (HRSD) scores at different times versus the control group, respectively (P < .05). However, no difference in body mass index (BMI) management was observed (P > .05). Repeated-measures ANOVA revealed significant interactions between the two groups for change in FMA, MMSE, BI, HAMA, and HRSD scores from admission to 24 months (P < .001), but no significant was found for BMI (P = .582).Basal ganglia stroke patients with OSA tend to have significantly greater sleeping, neurological and functional recovery after CPAP, and rehabilitation over 2 years.
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Affiliation(s)
- Lei Ren
- Department of Respiratory Medicine, The Second Affiliated Hospital of Suzhou University, Suzhou, Jiangsu
- Department of Respiratory Rehabilitation, The Fourth Rehabilitation Hospital of Shanghai (Shanghai Jingan Geriatric Hospital)
| | - Kai Wang
- Department of Neurological Rehabilitation, The Fourth Rehabilitation Hospital of Shanghai (Shanghai Jingan Geriatric Hospital), Shanghai, China
| | - Honghua Shen
- Department of Respiratory Rehabilitation, The Fourth Rehabilitation Hospital of Shanghai (Shanghai Jingan Geriatric Hospital)
| | - Yiming Xu
- Department of Respiratory Rehabilitation, The Fourth Rehabilitation Hospital of Shanghai (Shanghai Jingan Geriatric Hospital)
| | - Jing Wang
- Department of Respiratory Medicine, The Second Affiliated Hospital of Suzhou University, Suzhou, Jiangsu
| | - Rui Chen
- Department of Respiratory Medicine, The Second Affiliated Hospital of Suzhou University, Suzhou, Jiangsu
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A System for Monitoring Breathing Activity Using an Ultrasonic Radar Detection with Low Power Consumption. JOURNAL OF SENSOR AND ACTUATOR NETWORKS 2019. [DOI: 10.3390/jsan8020032] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Continuous monitoring of breathing activity plays a major role in detecting and classifying a breathing abnormality. This work aims to facilitate detection of abnormal breathing syndromes, including tachypnea, bradypnea, central apnea, and irregular breathing by tracking of thorax movement resulting from respiratory rhythms based on ultrasonic radar detection. This paper proposes a non-contact, non-invasive, low cost, low power consumption, portable, and precise system for simultaneous monitoring of normal and abnormal breathing activity in real-time using an ultrasonic PING sensor and microcontroller PIC18F452. Moreover, the obtained abnormal breathing syndrome is reported to the concerned physician’s mobile telephone through a global system for mobile communication (GSM) modem to handle the case depending on the patient’s emergency condition. In addition, the power consumption of the proposed monitoring system is reduced via a duty cycle using an energy-efficient sleep/wake scheme. Experiments were conducted on 12 participants without any physical contact at different distances of 0.5, 1, 2, and 3 m and the breathing rates measured with the proposed system were then compared with those measured by a piezo respiratory belt transducer. The experimental results illustrate the feasibility of the proposed system to extract breathing rate and detect the related abnormal breathing syndromes with a high degree of agreement, strong correlation coefficient, and low error ratio. The results also showed that the total current consumption of the proposed monitoring system based on the sleep/wake scheme was 6.936 mA compared to 321.75 mA when the traditional operation was used instead. Consequently, this led to a 97.8% of power savings and extended the battery life time from 8 h to approximately 370 h. The proposed monitoring system could be used in both clinical and home settings.
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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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20
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Schlafapnoe als Komorbidität bei Herzinsuffizienz. Internist (Berl) 2018; 59:428-438. [DOI: 10.1007/s00108-018-0412-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Adaptive servo-ventilation and sleep quality in treatment emergent central sleep apnea and central sleep apnea in patients with heart disease and preserved ejection fraction. Clin Res Cardiol 2018; 107:421-429. [DOI: 10.1007/s00392-018-1203-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Accepted: 01/11/2018] [Indexed: 12/12/2022]
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Zhu B, Vincent C, Kapella MC, Quinn L, Collins EG, Ruggiero L, Park C, Fritschi C. Sleep disturbance in people with diabetes: A concept analysis. J Clin Nurs 2017; 27:e50-e60. [PMID: 28793386 DOI: 10.1111/jocn.14010] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/31/2017] [Indexed: 01/27/2023]
Abstract
AIMS AND OBJECTIVES To clarify the meaning of sleep disturbance in people with diabetes and examine its antecedents, attributes and consequences through concept analysis. BACKGROUND Sleep is crucial for health, and people with diabetes are frequently beset with disturbances in their sleep. The concept of sleep disturbance in people with diabetes has not been clearly defined. The inconsistent use of sleep disturbance has created confusion and impeded our understanding of the sleep in people with diabetes. This analysis will provide a conceptual foundation of sleep disturbance in diabetes, thereby facilitating more effective means for assessment and treatment. DESIGN Concept analysis. METHODS A systematic search without time restriction on the publication year was carried out using PubMed, CINAHL, PsycINFO, Web of Science and ProQuest Dissertations and Theses. Rodgers's method of evolutionary concept analysis guided the analysis. Inductive thematic analysis was conducted to identify the attributes, antecedents and consequences. RESULTS Based on the 26 eligible studies, two major attributes are that sleep disturbance is a symptom and is characterised by impaired sleep quality and/or abnormal sleep duration. Two antecedents are diabetes-related physiological change and psychological well-being. Sleep disturbance can result in impaired daytime functioning, glucose regulation and quality of life. CONCLUSIONS Defining the concept of sleep disturbance in people with diabetes facilitates consistent use and effective communication in both practice and research. Sleep disturbance in people with diabetes is a complex symptom that includes impaired sleep quality and/or abnormal sleep duration. This paper contributes to the current knowledge of sleep in people with diabetes. Future research on antecedents and consequences of sleep disturbance is necessary for further clarifications. RELEVANCE TO CLINICAL PRACTICE Findings from this paper underscore the need for nursing education, clinical assessment and effective management of sleep disturbance in people with diabetes.
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Affiliation(s)
- Bingqian Zhu
- College of Nursing, The University of Illinois at Chicago, Chicago, IL, USA
| | - Catherine Vincent
- College of Nursing, The University of Illinois at Chicago, Chicago, IL, USA
| | - Mary C Kapella
- College of Nursing, The University of Illinois at Chicago, Chicago, IL, USA
| | - Laurie Quinn
- College of Nursing, The University of Illinois at Chicago, Chicago, IL, USA
| | - Eileen G Collins
- College of Nursing, The University of Illinois at Chicago, Chicago, IL, USA
| | - Laurie Ruggiero
- Institute for Health Research and Policy, School of Public Health, The University of Illinois at Chicago, Chicago, IL, USA
| | - Chang Park
- College of Nursing, The University of Illinois at Chicago, Chicago, IL, USA
| | - Cynthia Fritschi
- College of Nursing, The University of Illinois at Chicago, Chicago, IL, USA
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23
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Device Therapy for Sleep-Disordered Breathing in Patients with Cardiovascular Diseases and Heart Failure. Sleep Med Clin 2017; 12:243-254. [DOI: 10.1016/j.jsmc.2017.02.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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Türoff A, Thiem U, Fox H, Spießhöfer J, Bitter T, Tamisier R, Punjabi NM, Horstkotte D, Oldenburg O. Sleep duration and quality in heart failure patients. Sleep Breath 2017; 21:919-927. [PMID: 28389910 DOI: 10.1007/s11325-017-1501-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Revised: 03/19/2017] [Accepted: 04/04/2017] [Indexed: 01/06/2023]
Abstract
PURPOSE Sleep-disordered breathing (SDB) is highly prevalent in patients with heart failure and reduced left ventricular ejection fraction (HF-REF). SDB is classified as predominant obstructive (OSA) or central (CSA) and may alter sleep duration, sleep quality, and quality of life. This study describes sleep quality and duration in well-characterized cohorts of these patients. METHODS Two hundred fifty consecutive patients with HF-REF (NYHA class ≥II, ejection fraction ≤45%) underwent cardiac and pulmonary examination, plus full attended in-hospital overnight polysomnography (PSG). PSG recordings were performed according to current recommendations and underwent independent, blinded analysis at a core laboratory. RESULTS Patients with HF-REF and CSA were older and had more impaired cardiac function compared to those with OSA. With respect to sleep parameters, patients with CSA spent more time in bed than those with OSA (468 ± 52 vs 454 ± 46 min, p = 0.021) while sleep efficiency was lower (67 ± 14 vs 72 ± 13% of total sleep time (TST), p = 0.008). In addition, CSA patients spent more time awake after sleep onset (101 ± 61 vs 71 ± 46 min, p = 0.001) and had more stage N1 (light) sleep (33 ± 19 vs 28 ± 16% of TST, p = 0.017). Overall, the proportion of sleep spent in N3 (slow-wave/deep) sleep in HF-REF patients with SDB was low (4.1 ± 6.3% of TST) compared with healthy adults. CONCLUSIONS HF-REF patients with CSA compared to OSA have worse sleep efficiency and quality. This could result in less restorative sleep, changes in sympathovagal balance, and impaired resetting of important reflexes, which might contribute to worse cardiovascular outcomes in HF-REF patients with SDB.
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Affiliation(s)
- Anke Türoff
- Clinic for Cardiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Georgstrasse 11, 32545, Bad Oeynhausen, Germany
- Emergency Department, Asklepios Klinik Wansbek, Hamburg, Germany
| | - Ulrich Thiem
- Department of Medical Informatics, Biometry and Epidemiology, University of Bochum, Bochum, Germany
| | - Henrik Fox
- Clinic for Cardiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Georgstrasse 11, 32545, Bad Oeynhausen, Germany
| | - Jens Spießhöfer
- Clinic for Cardiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Georgstrasse 11, 32545, Bad Oeynhausen, Germany
- Department of Pulmonology, Hanover Medical School, Hanover, Germany
| | - Thomas Bitter
- Clinic for Cardiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Georgstrasse 11, 32545, Bad Oeynhausen, Germany
| | - Renaud Tamisier
- HP2 Laboratory, Inserm U1042, Grenoble Alps University and Sleep, Exercise and Physiology Laboratory, EFCR, Grenoble University Hospital, Grenoble, France
| | - Naresh M Punjabi
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Dieter Horstkotte
- Clinic for Cardiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Georgstrasse 11, 32545, Bad Oeynhausen, Germany
| | - Olaf Oldenburg
- Clinic for Cardiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Georgstrasse 11, 32545, Bad Oeynhausen, Germany.
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25
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Zhang Y, Wang W, Cai S, Sheng Q, Pan S, Shen F, Tang Q, Liu Y. Obstructive sleep apnea exaggerates cognitive dysfunction in stroke patients. Sleep Med 2017; 33:183-190. [PMID: 28291701 DOI: 10.1016/j.sleep.2016.11.028] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Revised: 11/20/2016] [Accepted: 11/28/2016] [Indexed: 11/17/2022]
Abstract
BACKGROUND Obstructive sleep apnea (OSA) is very common in stroke survivors. It potentially worsens the cognitive dysfunction and inhibits their functional recovery. However, whether OSA independently damages the cognitive function in stroke patients is unclear. A simple method for evaluating OSA-induced cognitive impairment is also missing. METHODS Forty-four stroke patients six weeks after onset and 24 non-stroke patients with snoring were recruited for the polysomnographic study of OSA and sleep architecture. Their cognitive status was evaluated with a validated Chinese version of Cambridge Prospective Memory Test. The relationship between memory deficits and respiratory, sleeping, and dementia-related clinical variables were analyzed with correlation and multiple linear regression tests. RESULTS OSA significantly and independently damaged time- and event-based prospective memory in stroke patients, although it had less power than the stroke itself. The impairment of prospective memory was correlated with increased apnea-hypopnea index, decreased minimal and mean levels of peripheral oxygen saturation, and disrupted sleeping continuity (reduced sleep efficiency and increased microarousal index). The further regression analysis identified minimal levels of peripheral oxygen saturation and sleep efficiency to be the two most important predictors for the decreased time-based prospective memory in stroke patients. CONCLUSIONS OSA independently contributes to the cognitive dysfunction in stroke patients, potentially through OSA-caused hypoxemia and sleeping discontinuity. The prospective memory test is a simple but sensitive method to detect OSA-induced cognitive impairment in stroke patients. Proper therapies of OSA might improve the cognitive function and increase the life quality of stroke patients.
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Affiliation(s)
- Yan Zhang
- Department of Neurology, The Kunshan Affiliated Hospital of Jiangsu University, 215300 Kunshan, China; Department of Neurology, The First People's Hospital of Kunshan, 215300 Kunshan, China.
| | - Wanhua Wang
- Department of Neurology, The Kunshan Affiliated Hospital of Jiangsu University, 215300 Kunshan, China; Department of Neurology, The First People's Hospital of Kunshan, 215300 Kunshan, China
| | - Sijie Cai
- Department of Respiratory Medicine, The Kunshan Affiliated Hospital of Jiangsu University, 215300 Kunshan, China
| | - Qi Sheng
- Department of Respiratory Medicine, The Kunshan Affiliated Hospital of Jiangsu University, 215300 Kunshan, China
| | - Shenggui Pan
- Department of Rehabilitation Medicine, The Kunshan Affiliated Hospital of Jiangsu University, 215300 Kunshan, China
| | - Fang Shen
- Department of Neurology, The Kunshan Affiliated Hospital of Jiangsu University, 215300 Kunshan, China; Department of Neurology, The First People's Hospital of Kunshan, 215300 Kunshan, China
| | - Qing Tang
- Department of Neurology, The Kunshan Affiliated Hospital of Jiangsu University, 215300 Kunshan, China; Department of Neurology, The First People's Hospital of Kunshan, 215300 Kunshan, China
| | - Yang Liu
- Department of Neurology, Saarland University, 66421 Homburg, Germany
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Costanzo MR, Ponikowski P, Javaheri S, Augostini R, Goldberg L, Holcomb R, Kao A, Khayat RN, Oldenburg O, Stellbrink C, Abraham WT. Transvenous neurostimulation for central sleep apnoea: a randomised controlled trial. Lancet 2016; 388:974-82. [PMID: 27598679 DOI: 10.1016/s0140-6736(16)30961-8] [Citation(s) in RCA: 128] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Central sleep apnoea is a serious breathing disorder associated with poor outcomes. The remedé system (Respicardia Inc, Minnetonka, MN, USA) is an implantable device which transvenously stimulates a nerve causing diaphragmatic contraction similar to normal breathing. We evaluated the safety and effectiveness of unilateral neurostimulation in patients with central sleep apnoea. METHODS We recruited patients from 31 hospital-based centres in Germany, Poland, and the USA in this prospective, multicentre, randomised trial. Participants had to have been medically stable for at least 30 days and have received appropriate guideline recommended therapy, be aged at least 18 years, be expected to tolerate study procedures, and willing and able to comply with study requirements. Eligible patients with an apnoea-hypopnoea index (AHI) of at least 20 events per h, tested by a polysomnography, underwent device implantation and were randomly assigned (1:1) by a computer-generated method stratified by site to either stimulation (treatment) or no stimulation (control) for 6 months. The primary effectiveness endpoint in the intention-to-treat population was the comparison of the proportions of patients in the treatment versus control groups achieving a 50% or greater AHI reduction from baseline to 6 months, measured by a full-night polysomnography assessed by masked investigators in a core laboratory. The primary safety endpoint of 12-month freedom from serious adverse events related to the procedure, system, or therapy was evaluated in all patients. This trial is active, but not recruiting, and is registered with ClinicalTrials.gov (NCT01816776). FINDINGS Between April 17, 2013, and May 28, 2015, we randomly assigned 151 eligible patients to the treatment (n=73) or control (n=78) groups. In the analysis of the intention-to-treat population, significantly more patients in the treatment group (35 [51%] of 68) had an AHI reduction from baseline of 50% or greater at 6 months than had those in the control group (eight [11%] of 73; difference between groups 41%, 95% CI 25-54, p<0·0001). 138 (91%) of 151 patients had no serious-related adverse events at 12 months. Seven (9%) cases of related-serious adverse events occurred in the control group and six (8%) cases were reported in the treatment group. Seven patients died (unrelated to implant, system, or therapy), four deaths (two in treatment group and two in control group) during the 6-month randomisation period when neurostimulation was delivered to only the treatment group and was off in the control group, and three deaths between 6 months and 12 months of follow-up when all patients received neurostimulation. 27 (37%) of 73 patients in the treatment group reported non-serious therapy-related discomfort that was resolved with simple system reprogramming in 26 (36%) patients, but was unresolved in one (1%) patient. INTERPRETATION Transvenous neurostimulation significantly reduced the severity of central sleep apnoea, including improvements in sleep metrics, and was well tolerated. The clinically meaningful effects of the therapy are supported by the concordant improvements in oxygenation and quality of life, making transvenous neurostimulation a promising therapeutic approach for central sleep apnoea. FUNDING Respicardia Inc.
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Affiliation(s)
| | - Piotr Ponikowski
- Department of Heart Diseases, Medical University, Military Hospital, Wroclaw, Poland
| | | | | | - Lee Goldberg
- University of Pennsylvania, Philadelphia, PA, USA
| | | | - Andrew Kao
- Mid America Heart Institute, Kansas City, MO, USA
| | | | - Olaf Oldenburg
- Bad Oeynhausen Heart and Diabetes Centre, Bad Oeynhausen, Germany
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27
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Arzt M. Neurostimulation in patients with heart failure and central sleep apnoea. Lancet 2016; 388:938-40. [PMID: 27598663 DOI: 10.1016/s0140-6736(16)31526-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Accepted: 07/22/2016] [Indexed: 11/16/2022]
Affiliation(s)
- Michael Arzt
- Centre of Sleep Medicine, Department of Internal Medicine II, University Medical Centre Regensburg, Regensburg 93053, Germany.
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