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Tung P, Levitzky YS, Wang R, Weng J, Quan SF, Gottlieb DJ, Rueschman M, Punjabi NM, Mehra R, Bertisch S, Benjamin EJ, Redline S. Obstructive and Central Sleep Apnea and the Risk of Incident Atrial Fibrillation in a Community Cohort of Men and Women. J Am Heart Assoc 2017; 6:JAHA.116.004500. [PMID: 28668820 PMCID: PMC5586257 DOI: 10.1161/jaha.116.004500] [Citation(s) in RCA: 80] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Previous studies have documented a high prevalence of atrial fibrillation (AF) in individuals with obstructive sleep apnea (OSA). Central sleep apnea (CSA) has been associated with AF in patients with heart failure. However, data from prospective cohorts are sparse and few studies have distinguished the associations of obstructive sleep apnea from CSA with AF in population studies. METHODS AND RESULTS We assessed the association of obstructive sleep apnea and CSA with incident AF among 2912 individuals without a history of AF in the SHHS (Sleep Heart Health Study), a prospective, community-based study of existing ("parent") cohort studies designed to evaluate the cardiovascular consequences of sleep disordered breathing. Incident AF was documented by 12-lead ECG or assessed by the parent cohort. obstructive sleep apnea was defined by the obstructive apnea-hypopnea index (OAHI). CSA was defined by a central apnea index ≥5 or the presence of Cheyne Stokes Respiration. Logistic regression was used to assess the association between sleep disordered breathing and incident AF. Over a mean of 5.3 years of follow-up, 338 cases of incident AF were observed. CSA was a predictor of incident AF in all adjusted models and was associated with 2- to 3-fold increased odds of developing AF (central apnea index ≥5 odds ratio [OR], 3.00, 1.40-6.44; Cheyne-Stokes respiration OR, 1.83, 0.95-3.54; CSA or Cheyne-Stokes respiration OR, 2.00, 1.16-3.44). In contrast, OAHI was not associated with incident AF (OAHI per 5 unit increase OR, 0.97, 0.91-1.03; OAHI 5 to <15 OR, 0.84, 0.59-1.17; OAHI 15 to <30 OR, 0.93, 0.60-1.45; OAHI ≥30 OR, 0.76, 0.42-1.36). CONCLUSIONS In a prospective, community-based cohort, CSA was associated with incident AF, even after adjustment for cardiovascular risk factors.
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Affiliation(s)
| | | | - Rui Wang
- Division of Sleep and Circadian Disorders, Brigham & Women's Hospital, Harvard Medical School, Boston, MA
| | - Jia Weng
- Division of Sleep and Circadian Disorders, Brigham & Women's Hospital, Harvard Medical School, Boston, MA
| | - Stuart F Quan
- Division of Sleep and Circadian Disorders, Brigham & Women's Hospital, Harvard Medical School, Boston, MA.,Arizona Respiratory Center, University of Arizona, Tucson, AZ
| | - Daniel J Gottlieb
- Division of Sleep and Circadian Disorders, Brigham & Women's Hospital, Harvard Medical School, Boston, MA.,VA Boston Healthcare System, Boston, MA
| | - Michael Rueschman
- Division of Sleep and Circadian Disorders, Brigham & Women's Hospital, Harvard Medical School, Boston, MA
| | | | - Reena Mehra
- Sleep Center, Neurologic Institute, Cleveland Clinic, Cleveland, OH.,Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH
| | - Suzie Bertisch
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Emelia J Benjamin
- Boston University School of Medicine, Boston, MA.,Boston University School of Public Health, Boston, MA.,NHLBI's and Boston University's Framingham Heart Study, Framingham, MA
| | - Susan Redline
- Division of Sleep and Circadian Disorders, Brigham & Women's Hospital, Harvard Medical School, Boston, MA.,Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
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Redeker NS, Jeon S, Muench U, Campbell D, Walsleben J, Rapoport DM. Insomnia symptoms and daytime function in stable heart failure. Sleep 2010; 33:1210-6. [PMID: 20857868 PMCID: PMC2938862 DOI: 10.1093/sleep/33.9.1210] [Citation(s) in RCA: 102] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
OBJECTIVES To evaluate insomnia symptoms and the extent to which they are associated with clinical and demographic patient characteristics, daytime symptoms, and functional performance in patients with stable heart failure (HF). DESIGN Cross-sectional, observational. SETTING Five structured HF disease management programs in the Northeastern U.S. PARTICIPANTS 173 stable chronic HF patients INTERVENTIONS N/A. MEASUREMENTS AND RESULTS Full polysomnography was obtained for one night in participants' homes. Participants completed the six-minute walk test, Medical Outcomes Study SF-36, Epworth Sleepiness Scale, Pittsburgh Sleep Quality Index, Multi-Dimensional Assessment of Fatigue Scale, Centers for the Epidemiological Studies of Depression Scale, and questionnaire items eliciting insomnia symptoms (self-reported difficulty initiating and maintaining sleep and waking too early in the morning). Over half of HF patients reported insomnia symptoms. These were associated with increased daytime symptoms (depression, fatigue), excessive daytime sleepiness, and functional performance in models that statistically controlled for clinical and demographic covariates. These relationships were not explained by sleep disordered breathing. CONCLUSIONS Insomnia symptoms are common in patients with stable heart failure and are associated with daytime symptoms and decrements in functional performance.
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Affiliation(s)
- Nancy S Redeker
- Yale University School of Nursing, New Haven, CT 06536-0740, USA.
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Redeker NS, Muench U, Zucker MJ, Walsleben J, Gilbert M, Freudenberger R, Chen M, Campbell D, Blank L, Berkowitz R, Adams L, Rapoport DM. Sleep disordered breathing, daytime symptoms, and functional performance in stable heart failure. Sleep 2010; 33:551-60. [PMID: 20394325 PMCID: PMC2849795 DOI: 10.1093/sleep/33.4.551] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
STUDY OBJECTIVES To evaluate characteristics of sleep disordered breathing (SDB); clinical and demographic correlates of SDB; and the extent to which SDB explains functional performance and symptoms in stable heart failure patients receiving care in structured HF disease management programs. DESIGN Cross-sectional, observational study. SETTING Structured heart failure disease management programs. PARTICIPANTS 170 stable chronic heart failure patients (mean age = 60.3 +/- 16.8 years; n = 60 [35%] female; n = 50 [29%] African American; left ventricular ejection fraction mean = 32 +/- 14.6). INTERVENTIONS N/A. MEASUREMENTS AND RESULTS Full polysomnography was obtained for one night on participants in their homes. Participants completed the 6-minute walk, 3 days of actigraphy, MOS-SF 36, Epworth Sleepiness Scale, Pittsburgh Sleep Quality Index, Multi-Dimensional Assessment of Fatigue Scale, and the Centers for the Epidemiological Studies of Depression Scale. Fifty-one percent had significant SDB; Sixteen (9%) of the total sample had central sleep apnea. Severe SDB was associated with a 4-fold increase in the likelihood of poor self-reported physical function (OR = 4.15, 95%CI = 1.19-14.57) and CSA was associated with low levels of daytime mobility (OR = 4.09, 95%CI = 1.23-13.62) after controlling for clinical and demographic variables. There were no statistically significant relationships between SDB and daytime symptoms or self-reported sleep, despite poorer objective sleep quality in patients with SDB. CONCLUSIONS Severe SDB is associated with poor physical function in patients with stable HF but not with daytime symptoms or self-reported sleep, despite poorer objective sleep quality in patients with SDB.
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Abstract
Central apnea during sleep represents a manifestation of breathing instability in many clinical conditions of varied etiologies. Central apnea is the result of transient cessation of ventilatory motor output, which represents that inhibitory influences favoring instability predominate over excitatory influence favoring stable breathing. This article will review the determinants of central apnea, the specific features of CHF-related central apnea, and outline a management approach
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Nadar S, Prasad N, Taylor RS, Lip GYH. Positive pressure ventilation in the management of acute and chronic cardiac failure: a systematic review and meta-analysis. Int J Cardiol 2005; 99:171-85. [PMID: 15749172 DOI: 10.1016/j.ijcard.2004.03.047] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2003] [Revised: 01/19/2004] [Accepted: 03/03/2004] [Indexed: 10/26/2022]
Abstract
Chronic heart failure (CHF) is a common condition and is associated with excess morbidity and mortality, in spite of the many advances in its treatment. Chronic stable heart failure is also associated with an increased incidence of sleep-related breathing disorders, such as central sleep apnoea (CSA) and Cheyne Stokes respiration (CSR). Continuous positive airways pressure (CPAP) has been shown to alleviate the symptoms of CHF, improve left ventricular function and oxygenation. To a certain extent, CPAP also abolishes sleep-related breathing disorders in patients with chronic heart failure. In patients with acute pulmonary oedema, the use of positive pressure ventilation improves cardiac haemodynamic indices, as well as symptoms and oxygenation, and is associated with a lower need for intubation. However, some studies have cast doubts about its safety and suggest a higher rate of myocardial infarction associated with its use. In our opinion, non-invasive positive pressure ventilation and CPAP offers an adjunctive mode of therapy in patients with acute pulmonary oedema and chronic heart failure, who may not be suitable for intubation and in those not responsive to conventional therapies. Non-invasive ventilation also helps to improve oxygenation in those patients with exhaustion and respiratory acidosis. Many trials are still ongoing and the results of these studies would throw more light on the present role of non-invasive ventilation in the management of CHF.
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Affiliation(s)
- Sunil Nadar
- University Department of Medicine, City Hospital, Birmingham B18 7QH, UK
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Garrigue S, Bordier P, Barold SS, Clementy J. Sleep Apnea:. A New Indication for Cardiac Pacing? PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2004; 27:204-11. [PMID: 14764171 DOI: 10.1111/j.1540-8159.2004.00411.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
In the general adult population, prevalence of sleep apnea syndrome reaches 4% in men and 2% in women. Continuous positive airway pressure is the most efficient treatment. At the present time, although severe atrial bradycardias could occur during sleep apnea episodes, cardiac pacing has not been demonstrated as an efficient treatment for those bradycardias. Treating sleep apnea generally reduces the number of bradyarrhythmias. However, recent studies reported a beneficial effect of atrial pacing on the sleep apnea burden. The mechanisms rely on two phenomena: first to counteract nocturnal hypervagotonia, and second to treat heart failure. By increasing the heart rate, cardiac output improves, which mitigates pulmonary subedema. Consequently, stimulation of the pulmonary afferent vagal fibers is diminished, which reduces central sleep apnea incidence. During nocturnal hypervagotonia, snoring and obstructive apnea episodes are increased, mainly due to an excessive muscular relaxation of the upper airway area inducing cyclical substantial decreases in the airway caliper. In patients with a low heart rate, atrial pacing can counteract hypervagotonia by enhancing the sympathetic tone and modifying the degree of vigilance. Accordingly, in the near future, sleep apnea treatment might potentially rely on atrial pacing in bradycardic patients with hypervagotonia (with or without heart failure). The role of the physician would then be not only to diagnose sleep apnea, but also to identify potential responders to cardiac pacing.
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Affiliation(s)
- Stephany Garrigue
- Clinical Electrophysiology and Cardiac Pacing Department, Hôpital Cardiologique du Haut Lévêque, Pessac, France.
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Garrigue S, Bordier P, Clémenty J. Apnées du sommeil et stimulation cardiaque : mécanismes d’action et perspectives. Ann Cardiol Angeiol (Paris) 2003; 52:239-45. [PMID: 14603705 DOI: 10.1016/s0003-3928(03)00083-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
In an adult population, the prevalence of sleep apnea is 4% for men and 2% for women. Generally, nasal positive pressure ventilation is the best therapeutic option. To date, and in spite of the possible presence of marked brady-arrhythmias during sleep apnea, there is no recognised indication for Pacemaker implantation. However, recent data show the potential benefit of permanent cardiac stimulation in these patients. Increasing heart rate (using atrial pacing) improves cardiac output, and reduces pulmonary congestion and pulmonary vagal afferent nerves are no longer stimulated. The incidence of central sleep apnea is thereby reduced. Excessive nocturnal vagal tone increases snoring and sleep apnea, because of excessive relaxation of the oropharyngeal muscles. In patients with bradycardia, atrial stimulation may oppose increased vagal tone, by stimulating the sympathetic system or maintaining it at a minimal level. It is therefore possible that cardiac stimulation will become part of the treatment of sleep apnea in patients with documented bradycardia and/or heart failure.
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Affiliation(s)
- S Garrigue
- Hôpital cardiologique du Haut-Lévêque, 19, avenue de Magellan, 33600 Bordeaux-Pessac, France.
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Garrigue S, Bordier P, Jaïs P, Shah DC, Hocini M, Raherison C, Tunon De Lara M, Haïssaguerre M, Clementy J. Benefit of atrial pacing in sleep apnea syndrome. N Engl J Med 2002; 346:404-12. [PMID: 11832528 DOI: 10.1056/nejmoa011919] [Citation(s) in RCA: 253] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Many patients with sleep apnea syndrome have nocturnal bradycardia, paroxysmal tachyarrhythmias, or both, which can be prevented by permanent atrial pacing. We evaluated the effect of using cardiac pacing to increase the heart rate during sleep in patients with sleep apnea syndrome. METHODS We studied 15 patients (11 men and 4 women; mean [+/-SD] age, 69+/-9 years) with central or obstructive sleep apnea who had received permanent atrial-synchronous ventricular pacemakers for symptomatic sinus bradycardia. All patients underwent three polysomnographic evaluations on consecutive nights, the first night for base-line evaluation and then, in random order, one night in spontaneous rhythm and one in dual-chamber pacing mode with atrial overdrive (basic rate, 15 beats per minute faster than the mean nocturnal sinus rate). The total duration and number of episodes of central or obstructive sleep apnea or hypopnea were analyzed and compared. RESULTS The mean 24-hour sinus rate during spontaneous rhythm was 57 +/- 5 beats per minute at base line, as compared with 72 +/- 3 beats per minute with atrial overdrive pacing (P<0.001). The total duration of sleep was 321 +/- 49 minutes in spontaneous rhythm, as compared with 331 +/- 46 minutes with atrial overdrive pacing (P=0.48). The hypopnea index (the total number of episodes of hypopnea divided by the number of hours of sleep) was reduced from 9 +/- 4 in spontaneous rhythm to 3 +/-3 with atrial overdrive pacing (P<0.001). For both apnea and hypopnea, the value for the index was 28 +/- 22 in spontaneous rhythm, as compared with 11 +/- 14 with atrial overdrive pacing (P<0.001). CONCLUSIONS In patients with sleep apnea syndrome, atrial overdrive pacing significantly reduces the number of episodes of central or obstructive sleep apnea without reducing the total sleep time.
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Affiliation(s)
- Stephane Garrigue
- Hôpital Cardiologique du Haut-Lévêque, University of Bordeaux, Bordeaux, France.
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