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Vazir A, Kapelios CJ. Sleep-disordered breathing and cardiovascular disease: who and why to test and how to intervene? Heart 2023; 109:1864-1870. [PMID: 37607811 DOI: 10.1136/heartjnl-2019-316375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/24/2023] Open
Abstract
Sleep-disordered breathing (SDB) is common in individuals with established cardiovascular disease (CVD), particularly those with heart failure (HF). There are two main types of SDB, central sleep apnoea (CSA) and obstructive sleep apnoea (OSA) which frequently overlap as mixed SDB. Investigating for SDB could be considered in patients with excessive daytime sleepiness, male sex, high body mass index, low ejection fraction, atrial fibrillation (AF), in patients with no dipping blood pressure pattern, recurrent paroxysms of nocturnal dyspnoea or when an apnoea is witnessed. Excessive daytime sleepiness is less likely to be reported by patients with HF than by the general population. In patients with CVD and OSA, continuous positive airway pressure (CPAP) ventilation for over 4 hours daily reduced the risk of major adverse cardiovascular events, but there was no reduction in mortality. In patients with AF and OSA treated with AF ablation, CPAP use was associated with a reduced risk of recurrence of AF. In patients with HF and OSA, small studies have demonstrated that CPAP improves symptoms, brain natriuretic peptide levels and ejection fraction, but data on survival are lacking. Treatment remains unclear in patients with HF and CSA. The presence of CSA may be a defensive adaptive response to HF, and effectively treating CSA as demonstrated in a randomised clinical trial of adaptive servo-ventilation caused more harm than benefit when compared to optimal medical therapy. Thus, the focus of treating CSA should remain on improving the underlying HF by optimising medical therapy and, if indicated, cardiac resynchronisation therapy.
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Affiliation(s)
- Ali Vazir
- Royal Brompton and Harfield Hospitals, Part of Guys and St Thomas' NHS Foundation Trust, London UK and Honorary Clinical Senior Lecturer Imperial College London, London, UK
| | - Chris J Kapelios
- Department of Cardiology, National and Kapodistrian University of Athens, Athens, Greece
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Luo YM, Chen YY, Liang SF, Wu LG, Wellman A, McEvoy RD, Steier J, Eckert DJ, Polkey MI. Central sleep apnea treated by a constant low-dose CO 2 supplied by a novel device. J Appl Physiol (1985) 2023; 135:977-984. [PMID: 37675475 DOI: 10.1152/japplphysiol.00312.2023] [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: 05/15/2023] [Revised: 09/05/2023] [Accepted: 09/06/2023] [Indexed: 09/08/2023] Open
Abstract
CO2 inhalation has been previously reported as a treatment for central sleep apnea both when associated with heart failure or where the cause is unknown. Here, we evaluated a novel CO2 supply system using a novel open mask capable of comfortably delivering a constantly inspired fraction of CO2 ([Formula: see text]) during sleep. We recruited 18 patients with central sleep apnea (13 patients with cardiac disease, and 5 patients idiopathic) diagnosed by diaphragm electromyogram (EMG) recordings made during overnight full polysomnography (PSG) (night 1). In each case, the optimal [Formula: see text] was determined by an overnight manual titration with PSG (night 2). Titration commenced at 1% CO2 and increased by 0.2% increments until central sleep apnea (CSA) disappeared. Patients were then treated on the third night (night 3) with the lowest therapeutically effective concentration of CO2 derived from night 2. Comparing night 1 and night 3, both apnea-hypopnea index (AHI; 31 ± 14 vs. 6 ± 3 events/h, P < 0.01) and arousal index (22 ± 8 vs. 15 ± 8 events/h, P < 0.01) were significantly improved during CO2 treatment. Sleep efficiency improved from 71 ± 18 to 80 ± 11%, P < 0.05, and sleep latency was shorter (23 ± 18 vs. 10 ± 10 min, P < 0.01). Heart rate was not different between night 1 and night 3. Our data confirm the feasibility of our CO2 delivery system and indicate that individually titrated CO2 supplementation with a novel device including a special open mask can reduce sleep disordered breathing severity and improve sleep quality. Randomized controlled studies should now be undertaken to assess therapeutic benefit for patients with CSA.NEW & NOTEWORTHY A novel device using a special mask was developed and proved that CO2 therapy using the device could eliminate central sleep apnea (CSA) events and improve sleep quality including reducing arousal index in patients with heart failure. The device would become a useful clinical treatment for heart failure patients with CSA.
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Affiliation(s)
- Yuan-Ming Luo
- State Key Laboratory of Respiratory Disease, Guangzhou Medical University, Guangzhou, People's Republic of China
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, United States
- College of Medicine and Public Health, Adelaide Institute for Sleep Health, Flinders University, Adelaide, South Australia, Australia
| | - Yong-Yi Chen
- State Key Laboratory of Respiratory Disease, Guangzhou Medical University, Guangzhou, People's Republic of China
| | - Shan-Feng Liang
- State Key Laboratory of Respiratory Disease, Guangzhou Medical University, Guangzhou, People's Republic of China
| | - Lu-Guang Wu
- State Key Laboratory of Respiratory Disease, Guangzhou Medical University, Guangzhou, People's Republic of China
| | - Andrew Wellman
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, United States
| | - R Doug McEvoy
- College of Medicine and Public Health, Adelaide Institute for Sleep Health, Flinders University, Adelaide, South Australia, Australia
| | - Joerg Steier
- Lane Fox Respiratory Unit/Sleep Disorders Centre, London, United Kingdom
| | - Danny J Eckert
- College of Medicine and Public Health, Adelaide Institute for Sleep Health, Flinders University, Adelaide, South Australia, Australia
| | - Michael I Polkey
- Royal Brompton Hospital, Guy's and St. Thomas' NHS Foundation Trust, London, United Kingdom
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3
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Ni YN, Holzer RC, Thomas RJ. Acute and long-term effects of acetazolamide in presumed high loop gain sleep apnea. Sleep Med 2023; 107:137-148. [PMID: 37178545 DOI: 10.1016/j.sleep.2023.04.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 03/22/2023] [Accepted: 04/11/2023] [Indexed: 05/15/2023]
Abstract
BACKGROUND The acute effect during positive pressure titration and long term efficacy of acetazolamide (AZT) in high loop gain sleep apnea (HLGSA) is inadequately assessed. We predicted that AZT may improve HLGSA in both conditions. METHODS A retrospective analysis of polysomnograms from patients with presumed HLGSA and residual respiratory instability administered AZT (125 or 250 mg) about 3 h into an initially drug-free positive pressure titration. A responder was defined as ≥ 50% reduction of the apnea hypopnea index(AHI 3% or arousal) before and after AZT. A multivariable logistic regression model estimated responder predictors. Long term efficacy of AZT was assessed by comparing both auto-machine (aREIFLOW) and manually scored respiratory events (sREIFLOW) extracted from the ventilator, prior to and after 3 months of AZT, in a subset. RESULTS Of the 231 participants (median age of 61[51-68] years) and 184 (80%) males in the acute effect testing: 77 and 154 patients were given 125 mg and 250 mg AZT. Compared to PAP alone, PAP plus AZT was associated with a lower breathing related arousal index (8 [3-16] vs. 5 [2-10], p < 0.001), and AHI3% (19 [7-37] vs. 11 [5-21], p < 0.001); 98 patients were responders. The non-rapid eye movement sleep (NREM) AHI3% (OR 1.031, 95%CI [1.016-1.046], p < 0.001) was a strong predictor for responder status with AZT exposure. In the 109 participants with 3-month data, both aREIFLOW and sREIFLOWwere significantly reduced after AZT. CONCLUSIONS AZT acutely and chronically reduced residual sleep apnea in presumed HLGSA; NREM AHI3% is a response predictor. AZT was well tolerated and beneficial for at least 3 months.
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Affiliation(s)
- Yue-Nan Ni
- Department of Respiratory and Critical Care Medicine, West China School of Medicine and West China Hospital, Sichuan University, 610041, China.
| | - Rena C Holzer
- Division of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.
| | - Robert Joseph Thomas
- Division of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.
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Piccirillo F, Crispino SP, Buzzelli L, Segreti A, Incalzi RA, Grigioni F. A State-of-the-Art Review on Sleep Apnea Syndrome and Heart Failure. Am J Cardiol 2023; 195:57-69. [PMID: 37011555 DOI: 10.1016/j.amjcard.2023.02.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 02/19/2023] [Accepted: 02/25/2023] [Indexed: 04/05/2023]
Abstract
Heart failure (HF) affects many patients worldwide every year. It represents a leading cause of hospitalization and still, today, mortality remains high, albeit the progress in treatment strategies. Several factors contribute to the development and progression of HF. Among these, sleep apnea syndrome represents a common but still underestimated factor because its prevalence is substantially higher in patients with HF than in the general population and is related to a worse prognosis. This review summarizes the current knowledge about sleep apnea syndrome coexisting with HF in terms of morbidity and mortality to provide actual and future perspectives about the diagnosis, evaluation, and treatment of this association.
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Affiliation(s)
- Francesco Piccirillo
- Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200 - 00128 Roma, Italy; Research Unit of Cardiovascular Sciences, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21 - 00128 Roma, Italy.
| | - Simone Pasquale Crispino
- Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200 - 00128 Roma, Italy; Research Unit of Cardiovascular Sciences, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21 - 00128 Roma, Italy
| | - Lorenzo Buzzelli
- Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200 - 00128 Roma, Italy; Research Unit of Cardiovascular Sciences, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21 - 00128 Roma, Italy
| | - Andrea Segreti
- Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200 - 00128 Roma, Italy; Department of Movement, Human and Health Sciences, University of Rome "Foro Italico", Rome, Italy; Department of Movement, Human and Health Sciences, University of Rome "Foro Italico", Rome, Italy
| | - Raffaele Antonelli Incalzi
- Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200 - 00128 Roma, Italy; Research Unit of Geriatrics, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21 - 00128 Roma, Italy
| | - Francesco Grigioni
- Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200 - 00128 Roma, Italy; Research Unit of Cardiovascular Sciences, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21 - 00128 Roma, Italy
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Rocha A, Pinto ACPN, Pachito DV, Drager LF, Lorenzi-Filho G, Atallah ÁN. Pharmacological treatment for central sleep apnoea in adults. Cochrane Database Syst Rev 2023; 2:CD012922. [PMID: 36861808 PMCID: PMC9981303 DOI: 10.1002/14651858.cd012922.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/03/2023]
Abstract
BACKGROUND The term central sleep apnoea (CSA) encompasses diverse clinical situations where a dysfunctional drive to breathe leads to recurrent respiratory events, namely apnoea (complete absence of ventilation) and hypopnoea sleep (insufficient ventilation) during sleep. Studies have demonstrated that CSA responds to some extent to pharmacological agents with distinct mechanisms, such as sleep stabilisation and respiratory stimulation. Some therapies for CSA are associated with improved quality of life, although the evidence on this association is uncertain. Moreover, treatment of CSA with non-invasive positive pressure ventilation is not always effective or safe and may result in a residual apnoea-hypopnoea index. OBJECTIVES To evaluate the benefits and harms of pharmacological treatment compared with active or inactive controls for central sleep apnoea in adults. SEARCH METHODS We used standard, extensive Cochrane search methods. The latest search date was 30 August 2022. SELECTION CRITERIA We included parallel and cross-over randomised controlled trials (RCTs) that evaluated any type of pharmacological agent compared with active controls (e.g. other medications) or passive controls (e.g. placebo, no treatment or usual care) in adults with CSA as defined by the International Classification of Sleep Disorders 3rd Edition. We did not exclude studies based on the duration of intervention or follow-up. We excluded studies focusing on CSA due to periodic breathing at high altitudes. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods. Our primary outcomes were central apnoea-hypopnoea index (cAHI), cardiovascular mortality and serious adverse events. Our secondary outcomes were quality of sleep, quality of life, daytime sleepiness, AHI, all-cause mortality, time to life-saving cardiovascular intervention, and non-serious adverse events. We used GRADE to assess certainty of evidence for each outcome. MAIN RESULTS We included four cross-over RCTs and one parallel RCT, involving a total of 68 participants. Mean age ranged from 66 to 71.3 years and most participants were men. Four trials recruited people with CSA associated with heart failure, and one study included people with primary CSA. Types of pharmacological agents were acetazolamide (carbonic anhydrase inhibitor), buspirone (anxiolytic), theophylline (methylxanthine derivative) and triazolam (hypnotic), which were given for between three days and one week. Only the study on buspirone reported a formal evaluation of adverse events. These events were rare and mild. No studies reported serious adverse events, quality of sleep, quality of life, all-cause mortality, or time to life-saving cardiovascular intervention. Carbonic anhydrase inhibitors versus inactive control Results were from two studies of acetazolamide versus placebo (n = 12) and acetazolamide versus no acetazolamide (n = 18) for CSA associated with heart failure. One study reported short-term outcomes and the other reported intermediate-term outcomes. We are uncertain whether carbonic anhydrase inhibitors compared to inactive control reduce cAHI in the short term (mean difference (MD) -26.00 events per hour, 95% CI -43.84 to -8.16; 1 study, 12 participants; very low certainty). Similarly, we are uncertain whether carbonic anhydrase inhibitors compared to inactive control reduce AHI in the short term (MD -23.00 events per hour, 95% CI -37.70 to 8.30; 1 study, 12 participants; very low certainty) or in the intermediate term (MD -6.98 events per hour, 95% CI -10.66 to -3.30; 1 study, 18 participants; very low certainty). The effect of carbonic anhydrase inhibitors on cardiovascular mortality in the intermediate term was also uncertain (odds ratio (OR) 0.21, 95% CI 0.02 to 2.48; 1 study, 18 participants; very low certainty). Anxiolytics versus inactive control Results were based on one study of buspirone versus placebo for CSA associated with heart failure (n = 16). The median difference between groups for cAHI was -5.00 events per hour (IQR -8.00 to -0.50), the median difference for AHI was -6.00 events per hour (IQR -8.80 to -1.80), and the median difference on the Epworth Sleepiness Scale for daytime sleepiness was 0 points (IQR -1.0 to 0.00). Methylxanthine derivatives versus inactive control Results were based on one study of theophylline versus placebo for CSA associated with heart failure (n = 15). We are uncertain whether methylxanthine derivatives compared to inactive control reduce cAHI (MD -20.00 events per hour, 95% CI -32.15 to -7.85; 15 participants; very low certainty) or AHI (MD -19.00 events per hour, 95% CI -30.27 to -7.73; 15 participants; very low certainty). Hypnotics versus inactive control Results were based on one trial of triazolam versus placebo for primary CSA (n = 5). Due to very serious methodological limitations and insufficient reporting of outcome measures, we were unable to draw any conclusions regarding the effects of this intervention. AUTHORS' CONCLUSIONS There is insufficient evidence to support the use of pharmacological therapy in the treatment of CSA. Although small studies have reported positive effects of certain agents for CSA associated with heart failure in reducing the number of respiratory events during sleep, we were unable to assess whether this reduction may impact the quality of life of people with CSA, owing to scarce reporting of important clinical outcomes such as sleep quality or subjective impression of daytime sleepiness. Furthermore, the trials mostly had short-term follow-up. There is a need for high-quality trials that evaluate longer-term effects of pharmacological interventions.
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Affiliation(s)
- Aline Rocha
- Cochrane Brazil. Núcleo de Avaliação Tecnologica em Saúde, São Paulo, Brazil; Universidade Federal de São Paulo (UNIFESP). Disciplina de Medicina de Urgência e Medicina Baseada em Evidências, São Paulo, Brazil
| | - Ana Carolina Pereira Nunes Pinto
- Cochrane Brazil. Núcleo de Avaliação Tecnologica em Saúde, São Paulo, Brazil; Biological and Health Sciences Department, Universidade Federal do Amapá, Sao Paulo, Brazil
| | | | - Luciano F Drager
- Unidades de Hipertensao, Instituto do Coraçao (InCor) e Disciplina de Nefrologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Sao Paulo, Brazil
- Centro de Cardiologia, Hospital Sírio Libanês, São Paulo, Brazil
| | - Geraldo Lorenzi-Filho
- Laboratório do Sono, Divisão de Pneumologia, Instituto Incor do Coração (INCOR), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Sao Paulo, Brazil
| | - Álvaro N Atallah
- Universidade Federal de São Paulo (UNIFESP). Disciplina de Medicina de Urgência e Medicina Baseada em Evidências, São Paulo, Brazil; Cochrane Brazil. Núcleo de Avaliação Tecnologica em Saúde, São Paulo, Brazil
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Langner-Hetmańczuk A, Tubek S, Niewiński P, Ponikowski P. The Role of Pharmacological Treatment in the Chemoreflex Modulation. Front Physiol 2022; 13:912616. [PMID: 35774285 PMCID: PMC9237514 DOI: 10.3389/fphys.2022.912616] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 05/19/2022] [Indexed: 12/20/2022] Open
Abstract
From a physiological point of view, peripheral chemoreceptors (PCh) are the main sensors of hypoxia in mammals and are responsible for adaptation to hypoxic conditions. Their stimulation causes hyperventilation—to increase oxygen uptake and increases sympathetic output in order to counteract hypoxia-induced vasodilatation and redistribute the oxygenated blood to critical organs. While this reaction promotes survival in acute settings it may be devastating when long-lasting. The permanent overfunctionality of PCh is one of the etiologic factors and is responsible for the progression of sympathetically-mediated diseases. Thus, the deactivation of PCh has been proposed as a treatment method for these disorders. We review here physiological background and current knowledge regarding the influence of widely prescribed medications on PCh acute and tonic activities.
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Affiliation(s)
- Anna Langner-Hetmańczuk
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
- Institute of Heart Diseases, University Hospital, Wroclaw, Poland
| | - Stanisław Tubek
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
- Institute of Heart Diseases, University Hospital, Wroclaw, Poland
- *Correspondence: Stanisław Tubek,
| | - Piotr Niewiński
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
- Institute of Heart Diseases, University Hospital, Wroclaw, Poland
| | - Piotr Ponikowski
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
- Institute of Heart Diseases, University Hospital, Wroclaw, Poland
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7
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Sleep Breathing Disorders in Heart Failure. Cardiol Clin 2022; 40:183-189. [DOI: 10.1016/j.ccl.2021.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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8
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Wang Y, Schöbel C, Penzel T. Management of Obstructive Sleep Apnea in Patients With Heart Failure. Front Med (Lausanne) 2022; 9:803388. [PMID: 35252246 PMCID: PMC8894657 DOI: 10.3389/fmed.2022.803388] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 01/27/2022] [Indexed: 12/14/2022] Open
Abstract
Sleep apnea is traditionally classified as obstructive sleep apnea (OSA), which occurs when the upper airway collapses due to the relaxation of oropharyngeal musculature, and central sleep apnea occurs when the brainstem cannot stimulate breathing. Most sleep apnea in patients with heart failure (HF) results from coexisting OSA and central sleep apnea (CSA), or complex sleep apnea syndrome. OSA and CSA are common in HF and can be involved in its progression by exposure to the heart to intermittent hypoxia, increased preload and afterload, activating sympathetic, and decreased vascular endothelial function. A majority of treatments have been investigated in patients with CSA and HF; however, less or short-term randomized trials demonstrated whether treating OSA in patients with HF could improve morbidity and mortality. OSA could directly influence the patient's recovery. This review will focus on past and present studies on the various therapies for OSA in patients with HF and summarize CSA treatment options for reasons of reference and completeness. More specifically, the treatment covered include surgical and non-surgical treatments and reported the positive and negative consequences for these treatment options, highlighting possible implications for clinical practice and future research directions.
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Affiliation(s)
- Youmeng Wang
- Sleep Medicine Center, Charité-Universitätsmedizin, Berlin, Germany
- *Correspondence: Youmeng Wang
| | - Christoph Schöbel
- Universitätsmedizin Essen, Ruhrlandklinik - Westdeutsches Lungenzentrum am Universitätsklinikum Essen GmbH, Essen, Germany
| | - Thomas Penzel
- Sleep Medicine Center, Charité-Universitätsmedizin, Berlin, Germany
- Thomas Penzel
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Sleep Disordered Breathing and Cardiovascular Disease: JACC State-of-the-Art Review. J Am Coll Cardiol 2021; 78:608-624. [PMID: 34353537 DOI: 10.1016/j.jacc.2021.05.048] [Citation(s) in RCA: 90] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 05/11/2021] [Indexed: 12/23/2022]
Abstract
Sleep disordered breathing causes repetitive episodes of nocturnal hypoxemia, sympathetic nervous activation, and cortical arousal, often associated with excessive daytime sleepiness. Sleep disordered breathing is common in people with, or at risk of, cardiovascular (CV) disease including those who are obese or have hypertension, coronary disease, heart failure, or atrial fibrillation. Current therapy of obstructive sleep apnea includes weight loss (if obese), exercise, and positive airway pressure (PAP) therapy. This improves daytime sleepiness. Obstructive sleep apnea is associated with increased CV risk, but treatment with PAP in randomized trials has not been shown to improve CV outcome. Central sleep apnea (CSA) is not usually associated with daytime sleepiness in heart failure or atrial fibrillation and is a marker of increased CV risk, but PAP has been shown to be harmful in 1 randomized trial. The benefits of better phenotyping, targeting of higher-risk patients, and a more personalized approach to therapy are being explored in ongoing trials.
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10
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Ni YN, Yang H, Thomas RJ. The role of acetazolamide in sleep apnea at sea level: a systematic review and meta-analysis. J Clin Sleep Med 2021; 17:1295-1304. [PMID: 33538687 DOI: 10.5664/jcsm.9116] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
STUDY OBJECTIVES The recognition of specific endotypes as drivers of sleep apnea suggests the need of therapies targeting individual mechanisms. Acetazolamide is known to stabilize respiration at high altitude but benefits at sea level are less well understood. METHODS All controlled studies of acetazolamide in obstructive sleep apnea and/or central sleep apnea (CSA) were evaluated. The primary outcome was the apnea-hypopnea index. RESULTS Fifteen trials with a total of 256 patients were pooled in our systematic review. Acetazolamide reduced the overall apnea-hypopnea index (mean difference [MD] -15.82, 95% CI: -21.91 to -9.74, P < .00001) in central sleep apnea (MD -22.60, 95% CI: -29.11 to -16.09, P < .00001), but not in obstructive sleep apnea (MD -10.29, 95% CI: -33.34 to 12.77, P = .38). Acetazolamide reduced the respiratory related arousal index (MD -0.82, 95% CI: -1.56 to -0.08, P = .03), improved partial arterial of oxygen (MD 11.62, 95% CI: 9.13-14.11, P < .00001), mean oxygen saturation (MD 1.78, 95% CI: 0.53-3.04, P = .005), total sleep time (MD 25.74, 95% CI: 4.10-47.38, P = .02), N2 sleep (MD 3.34, 95% CI: 0.12-6.56, P = .04) and sleep efficiency (MD 4.83, 95% CI: 0.53-9.13, P = .03). CONCLUSIONS Acetazolamide improves the apnea-hypopnea index and several sleep metrics in central sleep apnea. The drug may be of clinical benefit in patients with high loop gain apnea of various etiologies and patterns. The existence of high heterogeneity is an important limitation in applicability of our analysis. SYSTEMATIC REVIEW REGISTRATION Registry: PROSPERO; Name: The effect of acetazolamide in patients with sleep apnea at sea level: a systematic review and meta analysis; URL: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020163316; Identifier: CRD42020163316.
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Affiliation(s)
- Yue-Nan Ni
- Division of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts.,Department of Respiratory and Critical Care Medicine, West China School of Medicine and West China Hospital, Sichuan University, China
| | - Huan Yang
- Department of Respiratory and Critical Care Medicine, West China School of Medicine and West China Hospital, Sichuan University, China
| | - Robert Joseph Thomas
- Division of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
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11
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Schmickl CN, Owens RL, Orr JE, Edwards BA, Malhotra A. Side effects of acetazolamide: a systematic review and meta-analysis assessing overall risk and dose dependence. BMJ Open Respir Res 2021; 7:7/1/e000557. [PMID: 32332024 PMCID: PMC7204833 DOI: 10.1136/bmjresp-2020-000557] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Revised: 02/22/2020] [Accepted: 02/29/2020] [Indexed: 02/04/2023] Open
Abstract
Introduction Acetazolamide (AZM) is used for various conditions (eg, altitude sickness, sleep apnoea, glaucoma), but therapy is often limited by its side effect profile. Our objective was to estimate the risk of commonly reported side effects based on meta-analyses. We hypothesised that these risks are dose-dependent. Methods We queried MEDLINE/EMBASE (Medical Literature Analysis and Retrieval System Online/Excerpta Medica dataBASE) up until 04/10/2019, including any randomised placebo-controlled trial in which adults received oral AZM versus placebo reporting side effects. Eligibility assessment was performed by two independent reviewers. Data were abstracted by one reviewer who verified key entries at a second time point. For side effects reported by >3 studies a pooled effect estimate was calculated, and heterogeneity assessed via I2; for outcomes reported by >5 studies effect modification by total daily dose (EMbyTDD; <400 mg/d, 400–600 mg/d, >600 mg/d) was assessed via meta-regression. For pre-specified, primary outcomes (paraesthesias, taste disturbances, polyuria and fatigue) additional subgroup analyses were performed using demographics, intervention details, laboratory changes and risk of bias. Results We included 42 studies in the meta-analyses (Nsubjects=1274/1211 in AZM/placebo groups). AZM increased the risk of all primary outcomes (p<0.01, I2 ≤16% and low-to-moderate quality of evidence for all)—the numbers needed to harm (95% CI; nStudies) for each were: paraesthesias 2.3 (95% CI 2 to 2.7; n=39), dysgeusia 18 (95% CI 10 to 38, n=22), polyuria 17 (95% CI 9 to 49; n=22), fatigue 11 (95% CI 6 to 24; n=14). The risk for paraesthesias (beta=1.8 (95% CI 1.1 to 2.9); PEMbyTDD=0.01) and dysgeusia (beta=3.1 (95% CI 1.2 to 8.2); PEMbyTDD=0.02) increased with higher AZM doses; the risk of fatigue also increased with higher dose but non-significantly (beta=2.6 (95% CI 0.7 to 9.4); PEMbyTDD=0.14). Discussion This comprehensive meta-analysis of low-to-moderate quality evidence defines risk of common AZM side effects and corroborates dose dependence of some side effects. These results may inform clinical decision making and support efforts to establish the lowest effective dose of AZM for various conditions.
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Affiliation(s)
- Christopher N Schmickl
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of California San Diego, La Jolla, California, USA
| | - Robert L Owens
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of California San Diego, La Jolla, California, USA
| | - Jeremy E Orr
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of California San Diego, La Jolla, California, USA
| | - Bradley A Edwards
- Sleep and Circadian Medicine Laboratory, Department of Physiology, Monash University, Clayton, Victoria, Australia.,School of Psychological Sciences and Monash Institute of Cognitive and Clinical Neurosciences, Monash University, Clayton, Victoria, Australia
| | - Atul Malhotra
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of California San Diego, La Jolla, California, USA
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Medvedeva EA, Shumeyko AA, Korostovtseva LS, Bochkarev MV, Sviryaev YV. [Sleep disordered breathing in patients with chronic heart failure: prognosis and management]. Zh Nevrol Psikhiatr Im S S Korsakova 2020; 120:85-90. [PMID: 33076651 DOI: 10.17116/jnevro202012009285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Sleep disordered breathing is a frequent comorbidity (50-75%) in patients with chronic heart failure, but it is usually underestimated. This review analyzes sleep disordered breathing in patients with chronic heart failure, demonstrates pathogenetic relationships and the prognostic role of sleep apnea. The authors present modern treatment options for sleep apnea in this cohort (from non-invasive ventilation to implantable devices), highlight the role of drug therapy and outline perspectives of different treatment approaches. This clinical problem is designated as multidisciplinary, which requires a dialogue between researchers and doctors of various specialties to organize comprehensive effective care for this cohort of patients.
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Affiliation(s)
- E A Medvedeva
- Almazov National Medical Research Centre, St-Petersburg, Russia
| | - A A Shumeyko
- Almazov National Medical Research Centre, St-Petersburg, Russia
| | | | - M V Bochkarev
- Almazov National Medical Research Centre, St-Petersburg, Russia
| | - Yu V Sviryaev
- Almazov National Medical Research Centre, St-Petersburg, Russia
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13
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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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Acetazolamide for OSA and Central Sleep Apnea: A Comprehensive Systematic Review and Meta-Analysis. Chest 2020; 158:2632-2645. [PMID: 32768459 DOI: 10.1016/j.chest.2020.06.078] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Revised: 06/09/2020] [Accepted: 06/26/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Therapy options for OSA and central sleep apnea (CSA) are limited, thus many patients remain untreated. Clinically, acetazolamide is sometimes used for CSA; however, given overlapping pathophysiologic properties of OSA and CSA, we hypothesized that acetazolamide is equally effective for both types. Prior reviews focused on specific subtypes of sleep apnea, study designs, and languages, thus including few studies (typically ≤3) limiting insights. RESEARCH QUESTION How efficacious is acetazolamide for sleep apnea, and is its effect modified by sleep apnea type or acetazolamide dose? STUDY DESIGN AND METHODS We queried MEDLINE, EMBASE, and ClinicalTrials.gov from inception until March 11, 2019. Any study in which adults with OSA/CSA received oral acetazolamide vs no acetazolamide (control) that reported sleep apnea-related outcomes was eligible, independent of study design or language. Two reviewers independently assessed eligibility and abstracted data. Primary outcomes were apnea-hypopnea index (AHI) and oxygen saturation nadir. Quality of evidence (QoE) was rated with the use of Grades of Recommendation Assessment, Development and Evaluation methods. RESULTS We included 28 studies (13 OSA/15 CSA; NSubjects,Acetazolamide = 542; NSubjects,Control = 553) that enabled meta-analyses for 24 outcomes. Acetazolamide doses ranged from 36 to 1000 mg/d and treatment duration from 1 to 90 d (median, 6 d). Overall, acetazolamide vs control lowered the AHI by -0.7 effect sizes (95% CI, -0.83 to -0.58; I2 = 0%; moderate QoE) that corresponded to a reduction of 37.7% (95% CI, -44.7 to -31.3) or 13.8/h (95% CI, -16.3 to -11.4; AHIControl = 36.5/h). The AHI reduction was similar in OSA vs CSA, but significantly greater with higher doses (at least up to 500 mg/d). Furthermore, acetazolamide improved oxygen saturation nadir by +4.4% (95% CI, 2.3 to 6.5; I2 = 63%; no evidence of effect modification; very low QoE) and several secondary outcomes that included sleep quality measures and BP (mostly low QoE). INTERPRETATION Short-term acetazolamide improved both OSA and CSA. Rigorous studies with long-term follow up are warranted to assess Acetazolamide's value for the chronic treatment of patients with sleep apnea. CLINICAL TRIAL REGISTRATION PROSPERO (CRD42019147504).
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15
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Voigt J, Emani S, Gupta S, Germany R, Khayat R. Meta-Analysis Comparing Outcomes of Therapies for Patients With Central Sleep Apnea and Heart Failure With Reduced Ejection Fraction. Am J Cardiol 2020; 127:73-83. [PMID: 32430162 DOI: 10.1016/j.amjcard.2020.04.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 04/14/2020] [Accepted: 04/16/2020] [Indexed: 12/18/2022]
Abstract
Patients with heart failure with reduced ejection fraction and predominant central sleep apnea pose treatment challenges. A system review and meta-analysis of randomized controlled trials (RCTs) were undertaken. Electronic searches of digital repositories, journals, specialty society and manufacturer websites, manual searches of reference sections of RCTs, and published clinical guidelines were performed. Studies were graded for bias. Meta-analytic random effects models were used. Outcomes of interest included: sleep, cardiovascular, mortality, and quality of life (QoL). Grading of recommendations assessment, development and evaluation was performed. Nineteen randomized studies were identified that met the inclusion criteria of apnea hypopnea index (AHI) ≥10, predominant central sleep apnea (CSA), and heart failure with reduced ejection fraction (HFrEF) ≤50%. Most trials examined adaptive servo ventilation (ASV) (8 studies) and continuous positive airway pressure (CPAP) (9 studies). Bias existed in that: 15 of 19 (79%) of the trials lacked blinding, 10 of 19 were manufacturer funded, and with attrition in 8 of 19 studies. In meta-analysis, ASV performed better than control on sleep but not on QoL or cardiovascular outcomes, including mortality. CPAP demonstrated positive short-term outcomes on sleep, cardiovascular, and QoL (3 months). Longer-term cardiovascular and mortality data did not show benefit. Drug therapies demonstrated a positive clinical effect short term on sleep outcomes only. Transvenous phrenic nerve stimulation (TPNS) demonstrated positive treatment outcomes on sleep and QoL at 6 months. Evidence suggests improvement in cardiovascular outcomes with TPNS. In conclusion, ASV and CPAP therapies improve sleep, but long-term QoL or cardiovascular benefit was lacking. TPNS exhibited positive outcomes on sleep and QoL at 6 months with positive trends in CV outcomes.
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16
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Javaheri S, Brown LK, Khayat RN. Update on Apneas of Heart Failure With Reduced Ejection Fraction: Emphasis on the Physiology of Treatment. Chest 2020; 157:1637-1646. [DOI: 10.1016/j.chest.2019.12.020] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 12/17/2019] [Accepted: 12/31/2019] [Indexed: 02/07/2023] Open
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Ginter G, Sankari A, Eshraghi M, Obiakor H, Yarandi H, Chowdhuri S, Salloum A, Badr MS. Effect of acetazolamide on susceptibility to central sleep apnea in chronic spinal cord injury. J Appl Physiol (1985) 2020; 128:960-966. [PMID: 32078469 DOI: 10.1152/japplphysiol.00532.2019] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Spinal cord injury (SCI) is an established risk factor for central sleep apnea. Acetazolamide (ACZ), a carbonic anhydrase inhibitor, has been shown to decrease the frequency of central apnea by inducing mild metabolic acidosis. We hypothesized that ACZ would decrease the propensity to develop hypocapnic central apnea and decrease the apneic threshold. We randomized 16 participants with sleep-disordered breathing (8 SCI and 8 able-bodied controls) to receive ACZ (500 mg twice a day for 3 days) or placebo with a 1-wk washout before crossing over to the other drug arm. Study nights included polysomnography and determination of the hypocapnic apneic threshold and CO2 reserve using noninvasive ventilation. For participants with spontaneous central apnea, CO2 was administered until central apnea was abolished, and CO2 reserve was measured as the difference in end-tidal Pco2 (PETCO2) before and after. Steady-state plant gain, the response of end-tidal Pco2 to changes in ventilation, was calculated from PETCO2 and V̇e ratio during stable sleep. Controller gain, the response of ventilatory drive to changes in end-tidal Pco2, was defined as the ratio of change in V̇e between control and hypopnea to the ΔCO2 during stable non-rapid eye movement sleep. Treatment with ACZ for three days resulted in widening of the CO2 reserve (-4.0 ± 1.2 vs. -3.0 ± 0.7 mmHg for able-bodied, -3.4 ± 1.9 vs. -2.2 ± 2.2 mmHg for SCI, P < 0.0001), and a corresponding decrease in the hypocapnic apnea threshold (28.3 ± 5.2 vs. 37.1 ± 5.6 mmHg for able-bodied, 29.9 ± 5.4 vs. 34.8 ± 6.9 mmHg for SCI, P < 0.0001), respectively. ACZ significantly reduced plant gain when compared with placebo (4.1 ± 1.7 vs. 5.4 ± 1.8 mmHg/L min for able-bodied, 4.1 ± 2.0 vs. 5.1 ± 1.7 mmHg·L-1·min for SCI, P < 0.01). Acetazolamide decreased apnea-hypopnea index (28.8 ± 22.9 vs. 39.3 ± 24.1 events/h; P = 0.05), central apnea index (0.6 ± 1.5 vs. 6.3 ± 13.1 events/h; P = 0.05), and oxyhemoglobin desaturation index (7.5 ± 8.3 vs. 19.2 ± 15.2 events/h; P = 0.01) compared with placebo. Our results suggest that treatment with ACZ decreases susceptibility to hypocapnic central apnea due to decreased plant gain. Acetazolamide may attenuate central sleep apnea and improve nocturnal oxygen saturation, but its clinical utility requires further investigation in a larger sample of patients.NEW & NOTEWORTHY Tetraplegia is a risk factor for central sleep-disordered breathing (SDB) and is associated with narrow CO2 reserve (a marker of susceptibility to central apnea). Treatment with high-dose acetazolamide for 3 days decreased susceptibility to hypocapnic central apnea and reduced the frequency of central respiratory events during sleep. Acetazolamide may play a therapeutic role in alleviating central SDB in patients with cervical spinal cord injury, but larger clinical trials are needed.
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Affiliation(s)
- Geoffrey Ginter
- John D. Dingell Veterans Affairs Medical Center, Detroit, Michigan.,Wayne State University, Detroit, Michigan
| | - Abdulghani Sankari
- John D. Dingell Veterans Affairs Medical Center, Detroit, Michigan.,Wayne State University, Detroit, Michigan
| | - Mehdi Eshraghi
- John D. Dingell Veterans Affairs Medical Center, Detroit, Michigan.,Wayne State University, Detroit, Michigan
| | - Harold Obiakor
- John D. Dingell Veterans Affairs Medical Center, Detroit, Michigan.,Wayne State University, Detroit, Michigan
| | | | - Susmita Chowdhuri
- John D. Dingell Veterans Affairs Medical Center, Detroit, Michigan.,Wayne State University, Detroit, Michigan
| | - Anan Salloum
- John D. Dingell Veterans Affairs Medical Center, Detroit, Michigan.,Wayne State University, Detroit, Michigan
| | - M Safwan Badr
- John D. Dingell Veterans Affairs Medical Center, Detroit, Michigan.,Wayne State University, Detroit, Michigan
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19
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The effect of acetazolamide on the improvement of central apnea caused by abusing opioid drugs in the clinical trial. Sleep Breath 2019; 24:1417-1425. [PMID: 31808012 DOI: 10.1007/s11325-019-01968-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Revised: 09/25/2019] [Accepted: 10/25/2019] [Indexed: 01/12/2023]
Abstract
PURPOSE Acetazolamide is utilized as a treatment which falls effective in treating some type of CSA. Hence, it might be effective as far as opium addicts who suffer from CSA are concerned. MATERIALS AND METHOD The current study was a double-blind, placebo-controlled, cross-over study ( clinicalTrials.gov ID: NCT02371473). The whole procedures were identical for both placebo and acetazolamide phases of clinical research. There were 14 CSA more than 5/h and more than 50% of apnea-hypopnea index (AHI). Out of these 14 patients, 10 volunteered to participate in the study. Fast Fourier transformation was used to separate heart rate variability (HRV) into its component VLF (very low frequency band), LF (low frequency band), and HF (high frequency band) rhythms that operate within different frequency ranges. RESULT There are significant results in terms of decreased mix apnea and central apnea together due to acetazolamide compared with placebo (P < 0.023). Time of SatO2 < 90% is decreased as well (P < 0.1). There is also decrease of SDNN and NN50 after treatment with acetazolamide respectively (P < 0.001). Regarding fast Fourier transformation, there is increase of pHF and decrease of pLF after acetazolamide treatment (P < 0.001). CONCLUSION Acetazolamide seems to be effective in improving oxygenation and a decrease of mixed and central apnea events together. In HRV analysis section, LF power has decreased significantly, which may more likely improve prognosis of the patients.
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20
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Spiesshoefer J, Linz D, Skobel E, Arzt M, Stadler S, Schoebel C, Fietze I, Penzel T, Sinha AM, Fox H, Oldenburg O. Sleep – the yet underappreciated player in cardiovascular diseases: A clinical review from the German Cardiac Society Working Group on Sleep Disordered Breathing. Eur J Prev Cardiol 2019; 28:189-200. [PMID: 33611525 DOI: 10.1177/2047487319879526] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Accepted: 09/10/2019] [Indexed: 11/16/2022]
Abstract
Abstract
Patients with a wide variety of cardiovascular diseases, including arterial and pulmonary hypertension, arrhythmia, coronary artery disease and heart failure, are more likely to report impaired sleep with reduced sleep duration and quality, and also, sometimes, sleep interruptions because of paroxysmal nocturnal dyspnoea or arrhythmias. Overall, objective short sleep and bad sleep quality (non-restorative sleep) and subjective long sleep duration are clearly associated with major cardiovascular diseases and fatal cardiovascular outcomes. Sleep apnoea, either obstructive or central in origin, represents the most prevalent, but only one, of many sleep-related disorders in cardiovascular patients. However, observations suggest a bidirectional relationship between sleep and cardiovascular diseases that may go beyond what can be explained based on concomitant sleep-related disorders as confounding factors. This makes sleep itself a modifiable treatment target. Therefore, this article reviews the available literature on the association of sleep with cardiovascular diseases, and discusses potential pathophysiological mechanisms. In addition, important limitations of the current assessment, quantification and interpretation of sleep in patients with cardiovascular disease, along with a discussion of suitable study designs to address future research questions and clinical implications are highlighted. There are only a few randomised controlled interventional outcome trials in this field, and some of the largest studies have failed to demonstrate improved survival with treatment (with worse outcomes in some cases). In contrast, some recent pilot studies have shown a benefit of treatment in selected patients with underlying cardiovascular diseases.
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Affiliation(s)
- Jens Spiesshoefer
- Institute of Life Sciences, Scuola Superiore Sant Anna, Pisa, Italy
- Respiratory Physiology Laboratory, Department of Neurology with Institute for Translational Neurology, University of Muenster, Muenster, Germany
| | - Dominik Linz
- Centre for Heart Rhythm Disorders (CHRD), South Australian Health and Medical Research Institute (SAHMRI), University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | - Erik Skobel
- Medical Care Unit Pneumology, Sleep Medicine, Allergology and Cardiology, Luisenhospital Aachen, Aachen, Germany
| | - Michael Arzt
- Department of Internal Medicine II, University Medical Center Regensburg, Regensburg, Germany
| | - Stefan Stadler
- Department of Internal Medicine II, University Medical Center Regensburg, Regensburg, Germany
| | - Christoph Schoebel
- Interdisciplinary Sleep Medicine Center, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Ingo Fietze
- Interdisciplinary Sleep Medicine Center, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Thomas Penzel
- Interdisciplinary Sleep Medicine Center, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | | | - Henrik Fox
- Clinic for Cardiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Olaf Oldenburg
- Ludgerus-Kliniken Münster, Clemenshospital, Department of Cardiology, Münster, Germany
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Teppema LJ, Boulet LM, Hackett HK, Dominelli PB, Cheyne WS, Dominelli GS, Swenson ER, Foster GE. Influence of methazolamide on the human control of breathing: A comparison to acetazolamide. Exp Physiol 2019; 105:293-301. [PMID: 31595565 DOI: 10.1113/ep088058] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Accepted: 10/04/2019] [Indexed: 01/15/2023]
Abstract
NEW FINDINGS What is the central question of this study? Acetazolamide and methazolamide both reduce hypoxic pulmonary vasoconstriction equally, but methazolamide does not impair skeletal muscle function. The effect of methazolamide on respiratory control in humans is not yet known. What is the main finding and its importance? Similar to acetazolamide after chronic oral administration, methazolamide causes a metabolic acidosis and shifts the ventilatory CO2 response curve leftwards without reducing O2 sensitivity. The change in ventilation over the change in log P O 2 provides a more accurate measure of hypoxic sensitivity than the change in ventilation over the change in arterial oxyhaemoglobin saturation. ABSTRACT Acetazolamide is used to prevent/treat acute mountain sickness and both central and obstructive sleep apnoea. Methazolamide, like acetazolamide, reduces hypoxic pulmonary vasoconstriction, but has fewer side-effects, including less impairment of skeletal muscle function. Given that the effects of methazolamide on respiratory control in humans are unknown, we compared the effects of oral methazolamide and acetazolamide on ventilatory control and determined the ventilation-log P O 2 relationship in humans. In a double-blind, placebo-controlled, randomized cross-over design, we studied the effects of acetazolamide (250 mg three times daily), methazolamide (100 mg twice daily) and placebo in 14 young male subjects who were exposed to 7 min of normoxic hypercapnia and to three levels of eucapnia and hypercapnic hypoxia. With placebo, methazolamide and acetazolamide, the CO2 sensitivities were 2.39 ± 1.29, 3.27 ± 1.82 and 2.62 ± 1.79 l min-1 mmHg-1 (n.s.) and estimated apnoeic thresholds 32 ± 3, 28 ± 3 and 26 ± 3 mmHg, respectively (P < 0.001, placebo versus methazolamide and acetazolamide). The relationship between ventilation ( V ̇ I ) and log P O 2 (using arterialized venous P O 2 in hypoxia) was linear, and neither agent influenced the relationship between hypoxic sensitivity ( Δ V ̇ I / Δ log P O 2 ) and arterial [H+ ]. Using Δ V ̇ I / Δ log P O 2 rather than Δ V ̇ I /Δ arterial oxyhaemoglobin saturation enables a more accurate estimation of oxygenation and ventilatory control in metabolic acidosis/alkalosis when right- or leftward shifts of the oxyhaemoglobin saturation curve occur. Given that acetazolamide and methazolamide have similar effects on ventilatory control, methazolamide might be preferred for indications requiring the use of a carbonic anhydrase inhibitor, avoiding some of the negative side-effects of acetazolamide.
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Affiliation(s)
- Luc J Teppema
- Department of Anesthesiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Lindsey M Boulet
- Centre for Heart, Lung, and Vascular Health, School of Health and Exercise Science, University of British Columbia, Kelowna, BC, Canada
| | - Heather K Hackett
- Centre for Heart, Lung, and Vascular Health, School of Health and Exercise Science, University of British Columbia, Kelowna, BC, Canada
| | - Paolo B Dominelli
- Centre for Heart, Lung, and Vascular Health, School of Health and Exercise Science, University of British Columbia, Kelowna, BC, Canada.,Department of Kinesiology, University of Waterloo, Waterloo, ON, Canada
| | - William S Cheyne
- Centre for Heart, Lung, and Vascular Health, School of Health and Exercise Science, University of British Columbia, Kelowna, BC, Canada
| | - Giulio S Dominelli
- Southern Medical Program, University of British Columbia, Kelowna, BC, Canada
| | - Erik R Swenson
- Division of Pulmonary & Critical Care Medicine, VA Puget Sound Health Care System, University of Washington, Seattle, WA, USA
| | - Glen E Foster
- Centre for Heart, Lung, and Vascular Health, School of Health and Exercise Science, University of British Columbia, Kelowna, BC, Canada
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Unilateral phrenic nerve stimulation in the therapeutical algorithm of central sleep apnoea in heart failure. Curr Opin Pulm Med 2019; 25:561-569. [PMID: 31313744 DOI: 10.1097/mcp.0000000000000606] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
PURPOSE OF REVIEW Central sleep apnoea (CSA) is highly prevalent in patients with heart failure and substantially impairs survival. If optimal cardiac treatment fails, alternative therapeutical options, including positive airway pressure (PAP) therapies, drugs or application of oxygen and carbon dioxide are considered to suppress CSA which interfere with the complex underlying pathophysiology. Most recently, unilateral phrenic nerve stimulation (PNS) has been studied in these patients. Therefore, there is an urgent need to critically evaluate efficacy, potential harm and positioning of PNS in current treatment algorithms. RECENT FINDINGS Data from case series and limited randomized controlled trials demonstrate the feasibility of the invasive approach and acceptable peri-interventional adverse events. PNS reduces CSA by 50%, a figure comparable with continuous PAP or oxygen. However, PNS cannot improve any comorbid upper airways obstruction. A number of fatalities due to malignant cardiac arrhythmias or other cardiac events have been reported, although the association with the therapy is unclear. SUMMARY PNS offers an additional option to the therapeutical portfolio. Intervention-related adverse events and noninvasive alternatives need clear discussion with the patient. The excess mortality in the SERVE-HF study has mainly been attributed to sudden cardiac death. Therefore, previous cardiac fatalities under PNS urge close observation in future studies as long-term data are missing.
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Wongboonsin J, Thongprayoon C, Bathini T, Ungprasert P, Aeddula NR, Mao MA, Cheungpasitporn W. Acetazolamide Therapy in Patients with Heart Failure: A Meta-Analysis. J Clin Med 2019; 8:jcm8030349. [PMID: 30871038 PMCID: PMC6463174 DOI: 10.3390/jcm8030349] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 03/04/2019] [Accepted: 03/08/2019] [Indexed: 02/07/2023] Open
Abstract
Background and objectives: Fluid overload and central sleep apnea are highly prevalent in patients with heart failure (HF). We performed this meta-analysis to assess the effects of acetazolamide therapy on acid/base balance and apnea indexes. Methods: A literature search was conducted using EMBASE, MEDLINE, and Cochrane Database from inception through 18 November 2017 to identify studies evaluating the use of acetazolamide in HF. Study results were analyzed using a random effects model. The protocol for this systematic review is registered with PROSPERO (International Prospective Register of Systematic Reviews; no. CRD42017065401). Results: Nine studies (three randomized controlled trials and six cohort studies) with a total of 229 HF patients were enrolled. After acetazolamide treatment, there were significant decreases in serum pH (mean difference (MD) of −0.04 (95% CI, −0.06 to −0.02)), pCO2 (MD of −2.06 mmHg (95% CI, −3.60 to −0.53 mmHg)), and serum bicarbonate levels (MD of −6.42 mmol/L (95% CI, −10.05 to −2.79 mmol/L)). When compared to a placebo, acetazolamide significantly increased natriuresis (standardized mean difference (SMD) of 0.67 (95% CI, 0.08 to 1.27)), and decreased the apnea-hypopnea index (AHI) (SMD of −1.06 (95% CI, −1.75 to −0.36)) and central apnea index (CAI) (SMD of −1.10 (95% CI, −1.80 to −0.40)). Egger’s regression asymmetry tests revealed no publication bias with p = 0.20, 0.75 and 0.59 for analysis of the changes in pH, pCO2, and serum bicarbonate levels with use of acetazolamide in HF patients. Conclusion: Our study demonstrates significant reduction in serum pH, increase in natriuresis, and improvements in apnea indexes with use of acetazolamide among HF patients.
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Affiliation(s)
- Janewit Wongboonsin
- Department of Medicine, University of Minnesota, Minneapolis, MN 55455, USA.
- Division of Nephrology, Department of Internal Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand.
| | - Charat Thongprayoon
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN 55905, USA.
| | - Tarun Bathini
- Department of Internal Medicine, University of Arizona, Tucson, AZ 85721, USA.
| | - Patompong Ungprasert
- Clinical Epidemiology Unit, Department of Research and Development, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand.
| | - Narothama Reddy Aeddula
- Division of Nephrology, Department of Medicine, Deaconess Health System, Evansville, IN 47747, USA.
| | - Michael A Mao
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN 55905, USA.
| | - Wisit Cheungpasitporn
- Division of Nephrology, Department of Medicine, University of Mississippi Medical Center, Jackson, MS 39216, USA.
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24
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Abstract
Sleep-disordered breathing (SDB) is highly prevalent in heart failure (HF). The presence of SDB in patients with HF appears to be associated with increased risk of cardiovascular morbidity and mortality. In this article, we describe the types, pathophysiology, and consequences of SDB and discuss ways in which SDB can be diagnosed. We also lay emphasis on the recent randomized controlled trials that have had a major impact on how SDB is managed and highlight the complex relationship between SDB and outcomes.
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Affiliation(s)
- Ali Vazir
- Department of Cardiology, Royal Brompton Hospital, Royal Brompton and Harefield NHS Foundation Trust, Sydney Street, London SW3 6NP, UK; Royal Brompton Hospital, National Heart and Lung Institute, Imperial College London, Dovehouse Street, London SW3 6LR, UK.
| | - Varun Sundaram
- Department of Cardiology, Royal Brompton Hospital, Royal Brompton and Harefield NHS Foundation Trust, Sydney Street, London SW3 6NP, UK; Royal Brompton Hospital, National Heart and Lung Institute, Imperial College London, Dovehouse Street, London SW3 6LR, UK; Case Western Reserve University School of Medicine, 2109 Adelbert Rd, Cleveland, Ohio 44106, USA
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25
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Matsumoto H, Kasai T. Central Sleep Apnea in Heart Failure: Pathogenesis and Management. CURRENT SLEEP MEDICINE REPORTS 2018. [DOI: 10.1007/s40675-018-0125-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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26
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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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27
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Oates CP, Ananthram M, Gottlieb SS. Management of Sleep Disordered Breathing in Patients with Heart Failure. Curr Heart Fail Rep 2018; 15:123-130. [PMID: 29616491 DOI: 10.1007/s11897-018-0387-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
PURPOSE OF REVIEW This paper reviews treatment options for sleep disordered breathing (SDB) in patients with heart failure. We sought to identify therapies for SDB with the best evidence for long-term use in patients with heart failure and to minimize uncertainties in clinical practice by examining frequently discussed questions: what is the role of continuous positive airway pressure (CPAP) in patients with heart failure? Is adaptive servo-ventilation (ASV) safe in patients with heart failure? To what extent is SDB a modifiable risk factor? RECENT FINDINGS Consistent evidence has demonstrated that the development of SDB in patients with heart failure is a poor prognostic indicator and a risk factor for cardiovascular mortality. However, despite numerous available interventions for obstructive sleep apnea and central sleep apnea, it remains unclear what effect these therapies have on patients with heart failure. To date, all major randomized clinical trials have failed to demonstrate a survival benefit with SDB therapy and one major study investigating the use of adaptive servo-ventilation demonstrated harm. Significant questions persist regarding the management of SDB in patients with heart failure. Until appropriately powered trials identify a treatment modality that increases cardiovascular survival in patients with SDB and heart failure, a patient's heart failure management should remain the priority of medical care.
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Affiliation(s)
- Connor P Oates
- School of Medicine, University of Maryland, Baltimore, MD, USA
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28
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Eskandari D, Zou D, Grote L, Hoff E, Hedner J. Acetazolamide Reduces Blood Pressure and Sleep-Disordered Breathing in Patients With Hypertension and Obstructive Sleep Apnea: A Randomized Controlled Trial. J Clin Sleep Med 2018; 14:309-317. [PMID: 29510792 DOI: 10.5664/jcsm.6968] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Accepted: 10/30/2017] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES The carbonic anhydrase inhibitor acetazolamide (AZT) modulates blood pressure at high altitude and reduces sleep-disordered breathing in patients with obstructive sleep apnea (OSA). We aimed to investigate the treatment effect of AZT and in combination with continuous positive airway pressure (CPAP) on blood pressure in patients with hypertension and OSA. METHODS In a prospective, randomized, three-way crossover study, 13 male patients with hypertension and moderate to severe OSA (age 64 ± 7 years, body mass index 29 ± 4 kg/m2, and mean apnea-hypopnea index 37 ± 23 events/h) received AZT, CPAP, or AZT plus CPAP for 2-week periods. Antihypertensive medication was washed out. Office and 24-hour blood pressure, arterial stiffness, polygraphic sleep study data, and blood chemistry were compared. RESULTS AZT alone and AZT plus CPAP, but not CPAP alone, reduced office mean arterial pressure compared to baseline (-7 [95% CI -11 to -4], -7 [95% CI -11 to -4] and -1 [95% CI -5 to 4] mmHg, respectively; repeated- measures analysis of variance (RM-ANOVA; P = .015). Aortic systolic pressure and augmentation index, assessed by radial artery oscillatory tonometry, were unaffected by CPAP but decreased after AZT and AZT plus CPAP (RM-ANOVA P = .030 and .031, respectively). The apnea-hypopnea index was significantly reduced in all three treatment arms, most prominently by AZT plus CPAP (RM-ANOVA P = .003). The reduction of venous bicarbonate concentration following AZT was correlated with the change of apnea-hypopnea index (r = 0.66, P = .013). CONCLUSIONS AZT reduced blood pressure, vascular stiffness, and sleep-disordered breathing in patients with OSA and comorbid hypertension. Carbonic anhydrase inhibition may constitute a potential target for drug therapy in patients with sleep apnea and comorbid hypertension. CLINICAL TRIAL REGISTRATION Registry: ClinicalTrials.gov; Identifier: NCT02220803; Title: A Short Term Open, Randomized Cross-over Trial Exploring the Effect of Carbonic Anhydrase Inhibition by Acetazolamide on Sleep Apnea Associated Hypertension and Vascular Dysfunction; URL: https://clinicaltrials.gov/ct2/show/NCT02220803 and Registry: EU Clinical Trials Register; EudraCT Number: 2013-004866-33; Title: A short term open, randomized cross over trial exploring the effect of carbonic anhydrase inhibition by acetazolamide on sleep apnea associated hypertension; URL: https://www.clinicaltrialsregister.eu/ctr-search/search?query=2013-004866-33.
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Affiliation(s)
- Davoud Eskandari
- Center for Sleep and Vigilance Disorders, Department of Internal Medicine and Clinical Nutrition, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Ding Zou
- Center for Sleep and Vigilance Disorders, Department of Internal Medicine and Clinical Nutrition, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Ludger Grote
- Center for Sleep and Vigilance Disorders, Department of Internal Medicine and Clinical Nutrition, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Sleep Disorders Center, Pulmonary Department, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Erik Hoff
- Center for Sleep and Vigilance Disorders, Department of Internal Medicine and Clinical Nutrition, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Sleep Disorders Center, Pulmonary Department, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Jan Hedner
- Center for Sleep and Vigilance Disorders, Department of Internal Medicine and Clinical Nutrition, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Sleep Disorders Center, Pulmonary Department, Sahlgrenska University Hospital, Gothenburg, Sweden
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29
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Abstract
PURPOSE OF REVIEW The bidirectional relationships that have been demonstrated between heart failure (HF) and central sleep apnea (CSA) demand further exploration with respect to the implications that each condition has for the other. This review discusses the body of literature that has accumulated on these relationships and how CSA and its potential treatment may affect outcomes in patients with CSA. RECENT FINDINGS Obstructive sleep apnea (OSA) can exacerbate hypertension, type 2 diabetes, obesity, and atherosclerosis, which are known predicates of HF. Conversely, patients with HF more frequently exhibit OSA partly due to respiratory control system instability. These same mechanisms are responsible for the frequent association of HF with CSA with or without a Hunter-Cheyne-Stokes breathing (HCSB) pattern. Just as is the case with OSA, patients with HF complicated by CSA exhibit more severe cardiac dysfunction leading to increased mortality; the increase in severity of HF can in turn worsen the degree of sleep disordered breathing (SDB). Thus, a bidirectional relationship exists between HF and both phenotypes of SDB; moreover, an individual patient may exhibit a combination of these phenotypes. Both types of SDB remain significantly underdiagnosed in patients with HF and hence undertreated. Appropriate screening for, and treatment of, OSA is clearly a significant factor in the comprehensive management of HF, while the relevance of CSA remains controversial. Given the unexpected results of the Treatment of Sleep-Disordered Breathing with Predominant Central Sleep Apnea by Adaptive Servo Ventilation in Patients with Heart Failure trial, it is now of paramount importance that additional analysis of these data be expeditiously reported. It is also critical that ongoing and proposed prospective studies of this issue proceed without delay.
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30
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Abstract
The majority of patients with heart failure have sleep-disordered breathing (SDB)—with central (rather than obstructive) sleep apnoea becoming the predominant form in those with more severe disease. Cyclical apnoeas and hypopnoeas are associated with sleep disturbance, hypoxaemia, haemodynamic changes, and sympathetic activation. Such patients have a worse prognosis than those without SDB. Mask-based therapies of positive airway pressure targeted at SDB can improve measures of sleep quality and partially normalise the sleep and respiratory physiology, but recent randomised trials of cardiovascular outcomes in central sleep apnoea have been neutral or suggested the possibility of harm, likely from increased sudden death. Further randomised outcome studies (with cardiovascular mortality and hospitalisation endpoints) are required to determine whether mask-based treatment for SDB is appropriate for patients with chronic systolic heart failure and obstructive sleep apnoea, for those with heart failure with preserved ejection fraction, and for those with decompensated heart failure. New therapies for sleep apnoea—such as implantable phrenic nerve stimulators—also require robust assessment. No longer can the surrogate endpoints of improvement in respiratory and sleep metrics be taken as adequate therapeutic outcome measures in patients with heart failure and sleep apnoea.
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31
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Javaheri S, Brown LK. Positive Airway Pressure Therapy for Hyperventilatory Central Sleep Apnea: Idiopathic, Heart Failure, Cerebrovascular Disease, and High Altitude. Sleep Med Clin 2017; 12:565-572. [PMID: 29108611 DOI: 10.1016/j.jsmc.2017.07.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Central sleep apnea (CSA) and Hunter-Cheyne-Stokes breathing (HCSB) are caused by failure of the pontomedullary pacemaker generating breathing rhythm. CSA/HCSB may complicate several disorders causing recurrent arousals and desaturations. Common causes of CSA in adults are congestive heart failure, stroke, and chronic use of opioids; opioids have hypoventilatory effects. Diagnosis and treatment of hyperventilatory CSA may improve quality of life, and, when associated with heart failure or cerebrovascular disease, reduce morbidity and perhaps mortality.
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Affiliation(s)
- Shahrokh Javaheri
- Sleep Laboratory, Bethesda North Hospital, 10535 Montgomery Road, Suite 200, Cincinnati, OH 45242, USA; The University of Cincinnati, Cincinnati, OH, USA; The Ohio University Medical School, Columbus, OH, USA.
| | - Lee K Brown
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, University of New Mexico School of Medicine, University of New Mexico Sleep Disorders Center, 1101 Medical Arts Avenue Northeast, Building #2, Albuquerque, NM 87102, USA; Department of Electrical and Computer Engineering, University of New Mexico School of Engineering, University of New Mexico Sleep Disorders Center, 1101 Medical Arts Avenue Northeast, Building #2, Albuquerque, NM 87102, USA
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32
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Borrelli C, Aimo A, Mirizzi G, Passino C, Vergaro G, Emdin M, Giannoni A. How to take arms against central apneas in heart failure. Expert Rev Cardiovasc Ther 2017; 15:743-755. [PMID: 28777017 DOI: 10.1080/14779072.2017.1364626] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Introduction Despite being a risk mediator in several observational studies, central apneas are currently orphan of treatment in heart failure. After the neutral effects on survival of two randomized controlled trials (RCTs) based on the use of positive airway pressure (the CANPAP and SERVE-HF trials), two alternative hypotheses have been formulated: 1) Periodic breathing/Cheyne-Stokes respiration (PB/CSR) in HF is protective. Indeed, the Naughton's hypothesis assumes that hyperventilation leads to increased cardiac output, lung volume, oxygen storage and reduced muscle sympathetic nerve activity, while central apnea to respiratory muscle rest and hypoxia-induced erythropoiesis. 2) The use of positive airway pressure is just a wrong treatment for PB/CSR. If this is the case, the search for novel potential alternative treatment approaches is mandatory in HF. Areas covered This review will focus on the crucial issue of whether PB/CSR should be treated or not in HF, first by outlining the ideal design of pathophysiological studies to test the Naughton's hypothesis and second by summarizing the treatment strategies so far proposed for PB/CSR in HF and identifying the most promising options to be tested in future RCTs. Expert commentary It is likely that PB/CSR may be compensatory in some cases, but after a certain threshold (to be defined) it becomes maladaptive with negative prognostic meaning in HF. The development of a pathophysiologically based treatment targeting feedback resetting and neurohormonal activation underlying PB/CSR is likely to be the best option to obtain survival benefits in HF.
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Affiliation(s)
- Chiara Borrelli
- a Cardiology and Cardiovascular Medicine Department , Fondazione Toscana Gabriele Monasterio , Pisa , Italy
| | - Alberto Aimo
- b Cardiology Division , University of Pisa , Pisa , Italy
| | - Gianluca Mirizzi
- a Cardiology and Cardiovascular Medicine Department , Fondazione Toscana Gabriele Monasterio , Pisa , Italy.,c Institute of Life Sciences , Scuola Superiore Sant'Anna , Pisa , Italy
| | - Claudio Passino
- a Cardiology and Cardiovascular Medicine Department , Fondazione Toscana Gabriele Monasterio , Pisa , Italy.,c Institute of Life Sciences , Scuola Superiore Sant'Anna , Pisa , Italy
| | - Giuseppe Vergaro
- a Cardiology and Cardiovascular Medicine Department , Fondazione Toscana Gabriele Monasterio , Pisa , Italy
| | - Michele Emdin
- a Cardiology and Cardiovascular Medicine Department , Fondazione Toscana Gabriele Monasterio , Pisa , Italy.,c Institute of Life Sciences , Scuola Superiore Sant'Anna , Pisa , Italy
| | - Alberto Giannoni
- a Cardiology and Cardiovascular Medicine Department , Fondazione Toscana Gabriele Monasterio , Pisa , Italy.,c Institute of Life Sciences , Scuola Superiore Sant'Anna , Pisa , Italy
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33
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Lachowska K, Gruchała M, Narkiewicz K, Hering D. Sympathetic Activation in Chronic Heart Failure: Potential Benefits of Interventional Therapies. Curr Hypertens Rep 2017; 18:51. [PMID: 27193773 DOI: 10.1007/s11906-016-0660-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Heart failure (HF) is a major and growing public health problem. This condition is associated with poor prognosis, a high rate of mortality, frequent hospitalization and increasing costs to health care systems. Pharmacological approaches aimed at reducing morbidity and mortality in HF have primarily focused on inhibition of the renin-angiotensin-aldosterone system (RAAS) and the sympathetic nervous system (SNS), both of which have been associated with disease development, progression and adverse cardiovascular (CV) outcomes. The increasing number of hospitalizations for HF decompensation suggests the failure of available treatment options, indicating the necessity for alternative therapeutic approaches. Alongside pharmacological and cardiac resynchronization therapies in selected patients with arrhythmia, recent advancements in the management of HF have been directed at inhibiting relevant neurogenic pathways underlying disease development and progression. Initial evidence regarding the safety and effectiveness of interventional procedures suggests that HF patients may benefit from novel adjunctive therapies. Here we review the critical role of sympathetic activation in HF and the rationale for therapeutic interventions including device-based and interventional approaches aimed at restoring autonomic neural balance in this condition.
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Affiliation(s)
- Kamila Lachowska
- First Department of Cardiology, Medical University of Gdansk, Gdansk, Poland
| | - Marcin Gruchała
- First Department of Cardiology, Medical University of Gdansk, Gdansk, Poland
| | - Krzysztof Narkiewicz
- Department of Hypertension and Diabetology, Medical University of Gdansk, Gdansk, Poland
| | - Dagmara Hering
- Dobney Hypertension Centre, School of Medicine and Pharmacology-Royal Perth Hospital Unit, The University of Western Australia, Level 3 MRF Building, Rear 50 Murray Street, Perth, WA, 6000, MDBP: M570, Australia.
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34
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Abstract
Sleep-disordered breathing (SDB) is frequently observed in patients with heart failure (HF), and complex pathologic conditions exist between both conditions. In this review article, we describe the characteristics of SDB complicated with HF, the prognostic impact of SDB in HF patients, and the favorable effects of positive airway pressure in HF patients with SDB.
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Affiliation(s)
- Akiomi Yoshihisa
- Department of Cardiovascular Medicine, Fukushima Medical University
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35
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Abstract
Neurophysiologically, central apnea is due to a temporary cessation of respiratory rhythmogenesis in medullary respiratory networks. Central apneas occur in several disorders and result in pathophysiological consequences, including arousals and desaturation. The 2 most common causes in adults are congestive heart failure and chronic use of opioids to treat pain. Under such circumstances, diagnosis and treatment of central sleep apnea may improve quality of life, morbidity, and mortality. This article discusses recent developments in the treatment of central sleep apnea in heart failure and opioids use.
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Affiliation(s)
- Shahrokh Javaheri
- Bethesda North Hospital, 10535 Montgomery Road, Suite 200, Cincinnati, OH 45242, USA.
| | - Robin Germany
- Section of Cardiology, University of Oklahoma College of Medicine, Oklahoma City, OK, USA
| | - John J Greer
- University of Alberta, Edmonton, Alberta, Canada
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36
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Randerath W, Verbraecken J, Andreas S, Arzt M, Bloch KE, Brack T, Buyse B, De Backer W, Eckert DJ, Grote L, Hagmeyer L, Hedner J, Jennum P, La Rovere MT, Miltz C, McNicholas WT, Montserrat J, Naughton M, Pepin JL, Pevernagie D, Sanner B, Testelmans D, Tonia T, Vrijsen B, Wijkstra P, Levy P. Definition, discrimination, diagnosis and treatment of central breathing disturbances during sleep. Eur Respir J 2016; 49:13993003.00959-2016. [DOI: 10.1183/13993003.00959-2016] [Citation(s) in RCA: 169] [Impact Index Per Article: 21.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Accepted: 08/25/2016] [Indexed: 02/07/2023]
Abstract
The complexity of central breathing disturbances during sleep has become increasingly obvious. They present as central sleep apnoeas (CSAs) and hypopnoeas, periodic breathing with apnoeas, or irregular breathing in patients with cardiovascular, other internal or neurological disorders, and can emerge under positive airway pressure treatment or opioid use, or at high altitude. As yet, there is insufficient knowledge on the clinical features, pathophysiological background and consecutive algorithms for stepped-care treatment. Most recently, it has been discussed intensively if CSA in heart failure is a “marker” of disease severity or a “mediator” of disease progression, and if and which type of positive airway pressure therapy is indicated. In addition, disturbances of respiratory drive or the translation of central impulses may result in hypoventilation, associated with cerebral or neuromuscular diseases, or severe diseases of lung or thorax. These statements report the results of an European Respiratory Society Task Force addressing actual diagnostic and therapeutic standards. The statements are based on a systematic review of the literature and a systematic two-step decision process. Although the Task Force does not make recommendations, it describes its current practice of treatment of CSA in heart failure and hypoventilation.
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37
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S3-Leitlinie Nicht erholsamer Schlaf/Schlafstörungen – Kapitel „Schlafbezogene Atmungsstörungen“. SOMNOLOGIE 2016. [DOI: 10.1007/s11818-016-0093-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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38
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Sands SA, Edwards BA, Kee K, Stuart-Andrews C, Skuza EM, Roebuck T, Turton A, Hamilton GS, Naughton MT, Berger PJ. Control theory prediction of resolved Cheyne−Stokes respiration in heart failure. Eur Respir J 2016; 48:1351-1359. [DOI: 10.1183/13993003.00615-2016] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Accepted: 06/19/2016] [Indexed: 11/05/2022]
Abstract
Cheyne–Stokes respiration (CSR) foretells deleterious outcomes in patients with heart failure. Currently, the size of therapeutic intervention is not guided by the patient's underlying pathophysiology. In theory, the intervention needed to resolve CSR, as a control system instability (loop gain >1), can be predicted knowing the baseline loop gain and how much it falls with therapy.In 12 patients with heart failure, we administered an inspiratory carbon dioxide fraction of 1–3% during CSR (n=95 interventions) as a means to reduce loop gain. We estimated the loop gain on therapy (LGtherapy), using the baseline loop gain (using hyperpnoea length/cycle length) and its expected reduction (18% per 1% inspired carbon dioxide), and tested the specific hypothesis that LGtherapypredicts CSR persistence (LGtherapy>1)versusresolution (LGtherapy<1).As predicted, when LGtherapy>1.0, CSR continued during therapy in 23 out of 25 (92%) trials. A borderline loop gain zone (0.8<LGtherapy<1) yielded an unpredictable outcome, while LGtherapy<0.8 consistently yielded CSR resolution (37 out of 37 trials). A threshold of LGtherapy=0.9 determined outcome in 76 out of 95 (80%) trials.We establish proof-of-concept that control theory provides predictive insight into CSR resolution in heart failure. Thus, we now have a means to calculate the size of interventions needed to ameliorate CSR on a patient-by-patient basis.
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Anastasopoulos DL, Chalkias A, Iakovidou N, Xanthos T. Effect of cardiac pacing on sleep-related breathing disorders: a systematic review. Heart Fail Rev 2016; 21:579-90. [PMID: 27112558 DOI: 10.1007/s10741-016-9558-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Sleep-related breathing disorders are commonly encountered in the middle-aged population, negatively affecting quality of life. Central sleep apnea is associated with congestive heart failure, whereas obstructive sleep apnea is related to different pathophysiologic mechanisms, such as the total or partial occlusion of upper airway tract. Both sleep-related disorders have been associated with increased morbidity, and hence, they have been a target of several treatment strategies. The aim of this systematic review is to evaluate the effect of different types of cardiac pacing on sleep-related breathing disorders in patients with or without heart failure. The PubMed and Cochrane Central Register of Controlled Trials were examined from April 2015 to January 2016. Of the initial 360 studies, 22 eligible trials were analyzed. The included studies were classified according to the type of sleep disorder and the intervention undertaken. The evidence shows that cardiac resynchronization therapy but not atrial overdrive pacing can reduce apneic events in central sleep apnea patients. However, their effect on obstructive sleep apnea is controversial. It can be assumed that pacing cannot be used alone as treatment of sleep-related breathing disorders. Further research is needed in order to elucidate the effect of these interventions in sleep apnea patients.
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Affiliation(s)
- Dimitrios L Anastasopoulos
- National and Kapodistrian University of Athens, Medical School, MSc "Cardiopulmonary Resuscitation", Athens, Greece.
- Hellenic Society of Cardiopulmonary Resuscitation, Athens, Greece.
| | - Athanasios Chalkias
- National and Kapodistrian University of Athens, Medical School, MSc "Cardiopulmonary Resuscitation", Athens, Greece
- Hellenic Society of Cardiopulmonary Resuscitation, Athens, Greece
| | - Nicoletta Iakovidou
- National and Kapodistrian University of Athens, Medical School, MSc "Cardiopulmonary Resuscitation", Athens, Greece
- Hellenic Society of Cardiopulmonary Resuscitation, Athens, Greece
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40
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Randerath W, Javaheri S. Sleep-Disordered Breathing in Patients with Heart Failure. CURRENT SLEEP MEDICINE REPORTS 2016. [DOI: 10.1007/s40675-016-0047-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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41
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Pearse SG, Cowie MR. Sleep-disordered breathing in heart failure. Eur J Heart Fail 2016; 18:353-61. [PMID: 26869027 DOI: 10.1002/ejhf.492] [Citation(s) in RCA: 84] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2015] [Revised: 01/04/2016] [Accepted: 01/05/2016] [Indexed: 12/20/2022] Open
Abstract
Sleep-disordered breathing-comprising obstructive sleep apnoea (OSA), central sleep apnoea (CSA), or a combination of the two-is found in over half of heart failure (HF) patients and may have harmful effects on cardiac function, with swings in intrathoracic pressure (and therefore preload and afterload), blood pressure, sympathetic activity, and repetitive hypoxaemia. It is associated with reduced health-related quality of life, higher healthcare utilization, and a poor prognosis. Whilst continuous positive airway pressure (CPAP) is the treatment of choice for patients with daytime sleepiness due to OSA, the optimal management of CSA remains uncertain. There is much circumstantial evidence that the treatment of OSA in HF patients with CPAP can improve symptoms, cardiac function, biomarkers of cardiovascular disease, and quality of life, but the quality of evidence for an improvement in mortality is weak. For systolic HF patients with CSA, the CANPAP trial did not demonstrate an overall survival or hospitalization advantage for CPAP. A minute ventilation-targeted positive airway therapy, adaptive servoventilation (ASV), can control CSA and improves several surrogate markers of cardiovascular outcome, but in the recently published SERVE-HF randomized trial, ASV was associated with significantly increased mortality and no improvement in HF hospitalization or quality of life. Further research is needed to clarify the therapeutic rationale for the treatment of CSA in HF. Cardiologists should have a high index of suspicion for sleep-disordered breathing in those with HF, and work closely with sleep physicians to optimize patient management.
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Affiliation(s)
- Simon G Pearse
- Imperial College London and Royal Brompton Hospital, London, UK
| | - Martin R Cowie
- Imperial College London and Royal Brompton Hospital, London, UK
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42
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Pathophysiology of central sleep apneas. Sleep Breath 2016; 20:467-82. [DOI: 10.1007/s11325-015-1290-z] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2015] [Revised: 11/10/2015] [Accepted: 11/23/2015] [Indexed: 11/26/2022]
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43
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Li Y, Daniels LB, Strollo PJ, Malhotra A. Should All Congestive Heart Failure Patients Have a Routine Sleep Apnea Screening? Con. Can J Cardiol 2015; 31:940-4. [PMID: 26112304 PMCID: PMC4506310 DOI: 10.1016/j.cjca.2015.04.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2015] [Revised: 04/20/2015] [Accepted: 04/20/2015] [Indexed: 11/23/2022] Open
Abstract
Sleep-disordered breathing (SDB) is one of the most common comorbidities in people with congestive heart failure (CHF). Although SDB has major cardiometabolic consequences, the attributable risk of SDB in asymptomatic CHF patients remains unclear. Whether early intervention using positive airway pressure would improve the prognosis in CHF patients is uncertain. As yet, there is insufficient evidence that routine polysomnography screening is cost-effective for asymptomatic CHF patients. Careful clinical risk evaluation and thoughtful use of limited-channel home sleep testing should be considered before the application of routine polysomnography in all CHF patients.
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Affiliation(s)
- Yanru Li
- Beijing Tongren Hospital, Capital Medical University, Department of Otolaryngology Head and Neck Surgery, Beijing, China
| | - Lori B Daniels
- University of California at San Diego, Division of Cardiology, Sulpizio Cardiovascular Center, La Jolla, California, USA
| | - Patrick J Strollo
- UPMC Sleep Medicine Center, Division of Pulmonary, Allergy, and Critical Care Medicine, Pittsburgh, Pennsylvania, USA
| | - Atul Malhotra
- University of California at San Diego, Chief of Division of Pulmonary, Critical Care and Sleep Medicine, La Jolla, California, USA.
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Hermand E, Lhuissier FJ, Larribaut J, Pichon A, Richalet JP. Ventilatory oscillations at exercise: effects of hyperoxia, hypercapnia, and acetazolamide. Physiol Rep 2015; 3:3/6/e12446. [PMID: 26109194 PMCID: PMC4510637 DOI: 10.14814/phy2.12446] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Periodic breathing has been found in patients with heart failure and sleep apneas, and in healthy subjects in hypoxia, during sleep and wakefulness, at rest and, recently, at exercise. To unravel the cardiorespiratory parameters liable to modulate the amplitude and period of ventilatory oscillations, 26 healthy subjects were tested under physiological (exercise) and environmental (hypoxia, hyperoxia, hyperoxic hypercapnia) stresses, and under acetazolamide (ACZ) treatment. A fast Fourier transform spectral analysis of breath-by-breath ventilation evidenced an increase in peak power under hypercapnia (vs. normoxia and hyperoxia, P < 0.001) and a decrease under ACZ (vs. placebo, P < 0.001), whereas it was not modified in hyperoxia. period was shortened by exercise in all conditions (vs. rest, P < 0.01) and by hypercapnia (vs. normoxia, P < 0.05) but remained unchanged under ACZ (vs. placebo). peak power was positively related to cardiac output () and in hyperoxia (P < 0.01), in hypercapnia (P < 0.001) and under ACZ (P < 0.001). period was negatively related to and in hyperoxia (P < 0.01 and P < 0.001, respectively), in hypercapnia (P < 0.05 and P < 0.01, respectively) and under ACZ (P < 0.05 and P < 0.01, respectively). Total respiratory cycle time was the main factor responsible for changes in period. In conclusion, exercise, hypoxia, and hypercapnia increase ventilatory oscillations by increasing and , whereas ACZ decreases ventilatory instability in part by a contrasting action on O2 and CO2 sensing. An intrinsic oscillator might modulate ventilation through a complex system where peripheral chemoreflex would play a key role.
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Affiliation(s)
- Eric Hermand
- Université Paris 13 Sorbonne Paris Cité Laboratoire "Hypoxie et poumon", Bobigny, France
| | - François J Lhuissier
- Université Paris 13 Sorbonne Paris Cité Laboratoire "Hypoxie et poumon", Bobigny, France Assistance Publique-Hôpitaux de Paris, Hôpital Avicenne Service de Physiologie explorations fonctionnelles et médecine du sport, Bobigny, France
| | - Julie Larribaut
- Université Paris 13 Sorbonne Paris Cité Laboratoire "Hypoxie et poumon", Bobigny, France
| | - Aurélien Pichon
- Université Paris 13 Sorbonne Paris Cité Laboratoire "Hypoxie et poumon", Bobigny, France
| | - Jean-Paul Richalet
- Université Paris 13 Sorbonne Paris Cité Laboratoire "Hypoxie et poumon", Bobigny, France Assistance Publique-Hôpitaux de Paris, Hôpital Avicenne Service de Physiologie explorations fonctionnelles et médecine du sport, Bobigny, France
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Respiratory Determinants of Diurnal Hypercapnia in Obesity Hypoventilation Syndrome. What Does Weight Have to Do with It? Ann Am Thorac Soc 2014; 11:945-50. [DOI: 10.1513/annalsats.201403-099oc] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Orr J, Javaheri S, Malhotra A. Comparative effectiveness research in complex sleep apnea. Sleep 2014; 37:833-4. [PMID: 24790259 DOI: 10.5665/sleep.3638] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Affiliation(s)
- Jeremy Orr
- Division of Pulmonary and Critical Care Medicine, University of California, San Diego, CA
| | - Shahrokh Javaheri
- Emeritus Professor of Medicine, University of Cincinnati, Cincinnati, OH
| | - Atul Malhotra
- Division of Pulmonary and Critical Care Medicine, University of California, San Diego, CA
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