51
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Perger E, Inami T, Lyons OD, Alshaer H, Smith S, Floras JS, Logan AG, Arzt M, Duran Cantolla J, Delgado D, Fitzpatrick M, Fleetham J, Kasai T, Kimoff RJ, Leung RST, Lorenzi Filho G, Mayer P, Mielniczuk L, Morrison DL, Parati G, Parthasarathy S, Redolfi S, Ryan CM, Series F, Tomlinson GA, Woo A, Bradley TD. Distinct Patterns of Hyperpnea During Cheyne-Stokes Respiration: Implication for Cardiac Function in Patients With Heart Failure. J Clin Sleep Med 2017; 13:1235-1241. [PMID: 29065956 DOI: 10.5664/jcsm.6788] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Accepted: 08/16/2017] [Indexed: 01/06/2023]
Abstract
STUDY OBJECTIVES In heart failure (HF), we observed two patterns of hyperpnea during Cheyne-Stokes respiration with central sleep apnea (CSR-CSA): a positive pattern where end-expiratory lung volume remains at or above functional residual capacity, and a negative pattern where it falls below functional residual capacity. We hypothesized the negative pattern is associated with worse HF. METHODS Patients with HF underwent polysomnography. During CSR-CSA, hyperpnea, apnea-hyperpnea cycle, and lung to finger circulation times (LFCT) were measured. Plasma N-terminal prohormone of brain natriuretic peptide (NT-proBNP) concentration and left ventricular ejection fraction (LVEF) were assessed. RESULTS Of 33 patients with CSR-CSA (31 men, mean age 68 years), 9 had a negative hyperpnea pattern. There was no difference in age, body mass index, and apnea-hypopnea index between groups. Patients with a negative pattern had longer hyperpnea time (39.5 ± 6.4 versus 25.8 ± 5.9 seconds, P < .01), longer cycle time (67.8 ± 15.9 versus 51.7 ± 9.9 seconds, P < .01), higher NT-proBNP concentrations (2740 [6769] versus 570 [864] pg/ml, P = .01), and worse New York Heart Association class (P = .02) than those with a positive pattern. LFCT and LVEF did not differ between groups. CONCLUSIONS Patients with HF and a negative CSR-CSA pattern have evidence of worse cardiac function than those with a positive pattern. Greater positive expiratory pressure during hyperpnea is likely generated during the negative pattern and might support stroke volume in patients with worse cardiac function. COMMENTARY A commentary on this article appears in this issue on page 1227. CLINICAL TRIAL REGISTRATION The trial is registered with Current Controlled Trials (www.controlled-trials.com; ISRCTN67500535) and Clinical Trials (www.clinicaltrials.gov; NCT01128816).
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Affiliation(s)
- Elisa Perger
- University Health Network/Mount Sinai Hospital, Toronto, Ontario, Canada.,Centre for Sleep Medicine and Circadian Biology of the University of Toronto, Toronto, Ontario, Canada
| | - Toru Inami
- University Health Network/Mount Sinai Hospital, Toronto, Ontario, Canada.,Centre for Sleep Medicine and Circadian Biology of the University of Toronto, Toronto, Ontario, Canada
| | - Owen D Lyons
- University Health Network/Mount Sinai Hospital, Toronto, Ontario, Canada.,Centre for Sleep Medicine and Circadian Biology of the University of Toronto, Toronto, Ontario, Canada
| | - Hisham Alshaer
- University Health Network/Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Stephanie Smith
- University Health Network/Mount Sinai Hospital, Toronto, Ontario, Canada
| | - John S Floras
- University Health Network/Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Alexander G Logan
- University Health Network/Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Michael Arzt
- Universitätsklinikum Regensburg, Regensburg, Germany
| | | | - Diego Delgado
- University Health Network/Mount Sinai Hospital, Toronto, Ontario, Canada
| | | | - John Fleetham
- Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | | | - R John Kimoff
- McGill University Health Centre, Montreal, Quebec, Canada
| | | | | | - Pierre Mayer
- Hôpital Hôtel-Dieu du CHUM, Université de Montréal, Montreal, Quebec, Canada
| | - Lisa Mielniczuk
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | | | | | | | | | - Clodagh M Ryan
- University Health Network/Mount Sinai Hospital, Toronto, Ontario, Canada.,Centre for Sleep Medicine and Circadian Biology of the University of Toronto, Toronto, Ontario, Canada
| | - Frederic Series
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec City, Quebec, Canada
| | - George A Tomlinson
- University Health Network/Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Anna Woo
- University Health Network/Mount Sinai Hospital, Toronto, Ontario, Canada
| | - T Douglas Bradley
- University Health Network/Mount Sinai Hospital, Toronto, Ontario, Canada.,Centre for Sleep Medicine and Circadian Biology of the University of Toronto, Toronto, Ontario, Canada
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52
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Floras JS. Ambulatory Apnea Monitoring in Heart Failure. J Am Coll Cardiol 2017; 70:1365-1367. [DOI: 10.1016/j.jacc.2017.07.761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Accepted: 07/28/2017] [Indexed: 11/25/2022]
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53
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Abstract
Central sleep apnea and Cheyne-Stokes respiration are commonly observed breathing patterns during sleep in patients with congestive heart failure. Common risk factors are male gender, older age, presence of atrial fibrillation, and daytime hypocapnia. Proposed mechanisms include augmented peripheral and central chemoreceptor sensitivity, which increase ventilator instability during both wakefulness and sleep; diminished cerebrovascular reactivity and increased circulation time, which impair the normal buffering of Paco2 and hydrogen ions and delay the detection of changes in Paco2 during sleep; and rostral fluid shifts that predispose to hypocapnia.
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54
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Sleep-Disordered Breathing in Neuromuscular Disease: Diagnostic and Therapeutic Challenges. Chest 2017; 152:880-892. [PMID: 28372949 DOI: 10.1016/j.chest.2017.03.023] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Revised: 02/23/2017] [Accepted: 03/21/2017] [Indexed: 12/11/2022] Open
Abstract
Normal sleep-related rapid eye movement sleep atonia, reduced lung volumes, reduced chemosensitivity, and impaired airway dilator activity become significant vulnerabilities in the setting of neuromuscular disease. In that context, the compounding effects of respiratory muscle weakness and disease-specific features that promote upper airway collapse or cause dilated cardiomyopathy contribute to various sleep-disordered breathing events. The reduction in lung volumes with neuromuscular disease is further compromised by sleep and the supine position, exaggerating the tendency for upper airway collapse and desaturation with sleep-disordered breathing events. The most commonly identified events are diaphragmatic/pseudo-central, due to a decrease in the rib cage contribution to the tidal volume during phasic rapid eye movement sleep. Obstructive and central sleep apneas are also common. Noninvasive ventilation can improve survival and quality of sleep but should be used with caution in the context of dilated cardiomyopathy or significant bulbar symptoms. Noninvasive ventilation can also trigger sleep-disordered breathing events, including ineffective triggering, autotriggering, central sleep apnea, and glottic closure, which compromise the potential benefits of the intervention by increasing arousals, reducing adherence, and impairing sleep architecture. Polysomnography plays an important diagnostic and therapeutic role by correctly categorizing sleep-disordered events, identifying sleep-disordered breathing triggered by noninvasive ventilation, and improving noninvasive ventilation settings. Optimal management may require dedicated hypoventilation protocols and a technical staff well versed in the identification and troubleshooting of respiratory events.
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55
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Kahwash R, Khayat RN. A Practical Approach to the Identification and Management of Sleep-Disordered Breathing in Heart Failure Patients. Sleep Med Clin 2017; 12:205-219. [PMID: 28477775 DOI: 10.1016/j.jsmc.2017.01.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Sleep-disordered breathing (SDB) is a major health problem affecting much of the general population. Although SDB is responsible for rapid progression of heart failure (HF) and the worsening morbidity and mortality, advanced HF state is associated with accelerated development of SDB. In the face of recent developments in SDB treatment and availability of effective therapeutic options known to improve quality of life, exercise tolerance, and heart function, most HF patients with SDB are left unrecognized and untreated. This article provides an overview of SDB in HF with focus on practical approaches intended to facilitate screening and treatment.
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Affiliation(s)
- Rami Kahwash
- Section of Heart Failure and Transplant, Division of Cardiovascular Medicine, Davis Heart & Lung Research Institute, The Ohio State University, 473 West 12th Avenue, Columbus, OH 43210, USA.
| | - Rami N Khayat
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Davis Heart & Lung Research Institute, The Ohio State University, 473 West 12th Avenue, Columbus, OH 43210, USA
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56
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Rey de Castro J, Liendo A, Ortiz O, Rosales-Mayor E, Liendo C. Ventilatory Cycle Measurements and Loop Gain in Central Apnea in Mining Drivers Exposed to Intermittent Altitude. J Clin Sleep Med 2017; 13:27-32. [PMID: 27707449 DOI: 10.5664/jcsm.6380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2015] [Accepted: 08/30/2016] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES By measuring the apnea length, ventilatory phase, respiratory cycle length, and loop gain, we can further characterize the central apneas of high altitude (CAHA). METHODS Sixty-three drivers of all-terrain vehicles, working in a Peruvian mine located at 2,020 meters above sea level (MASL), were evaluated. A respiratory polygraph was performed in the first night they slept at high altitude. None of the subjects were exposed to oxygen during the test or acetazolamide in the preceding days of the test. RESULTS Sixty-three respiratory polygraphs were performed, and 59 were considered for analysis. Forty-six (78%) were normal, 6 (10%) had OSA, and 7 (12%) had CAHA. Key data from subjects include: residing altitude: 341 ± 828 MASL, Lake Louise scoring: 0.4 ± 0.8, Epworth score: 3.4 ± 2.7, apneahypopnea index: 35.7 ± 19.3, CA index: 13.4 ± 14.2, CA length: 14.4 ± 3.6 sec, ventilatory length: 13.5 ± 2.9 sec, cycle length: 26.5 ± 4.0 sec, ventilatory length/CA length ratio 0.9 ± 0.3 and circulatory delay 13.3 ± 2.9 sec. Duty ratio media [ventilatory duration/cycle duration] was 0.522 ± 0 0.128 [0.308-0.700] and loop gain was calculated from the duty ratio utilizing this formula: LG = 2π / [(2πDR-sin(2πDR)]. All subjects have a high loop gain media 2.415 ± 1.761 [1.175-6.260]. Multiple correlations were established with loop gain values, but the only significant correlation detected was between central apnea index and loop gain. CONCLUSIONS Twelve percent of the studied population had CAHA. Measurements of respiratory cycle in workers with CAHA are more similar to idiopathic central apneas rather than Hunter-Cheyne-Stokes respiration. Also, there was a high degree of correlation between severity of central apnea and the degree of loop gain. The abnormal breathing patterns in those subjects could affect the sleep quality and potentially increase the risk for work accidents.
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Affiliation(s)
- Jorge Rey de Castro
- Clínica Anglo Americana, Lima-Perú, School Medicine Professor, Universidad Peruana Cayetano Heredia, Lima-Perú
| | - Alicia Liendo
- University of Medicine and Health Sciences-St. Kitts, WI
| | - Oswaldo Ortiz
- Individual Member of the International Council of Occupational Health
| | - Edmundo Rosales-Mayor
- CIBERES, IDIBAPS, Respiratory Disease Department, Instituto Clínic del Tórax, Hospital Clínic de Barcelona, Barcelona, Spain
| | - César Liendo
- Multidisciplinary Sleep Clinic, Louisiana State University, Shreveport, LA; Clinical and Sleep Laboratory Director VAMC, Shreveport, LA
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57
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Valika A, Costanzo MR. Sleep-Disordered Breathing During Congestive Heart Failure: To Intervene or Not to Intervene? Card Fail Rev 2017; 3:134-139. [PMID: 29387467 DOI: 10.15420/cfr.2017:7:1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Sleep-disordered breathing is common in heart failure patients and is associated with increased morbidity and mortality. Central sleep apnea occurs more commonly in heart failure-reduced ejection fraction, and obstructive sleep apnea occurs more frequently in heart failure with preserved ejection fraction. Although the two types of sleep-disordered breathing have distinct pathophysiologic mechanisms, both contribute to abnormal cardiovascular consequences. Treatment with continuous positive airway pressure for obstructive sleep apnea in heart failure has been well defined, whereas treatment strategies for central sleep apnea in heart failure continue to evolve. Unilateral transvenous neurostimulation has shown promise for the treatment of central sleep apnea. In this paper, we examine the current state of knowledge of treatment options for sleep-disordered breathing in heart failure.
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Affiliation(s)
- Ali Valika
- Advocate Medical Group - Midwest Heart Specialists, Advocate Heart Institute,Oak Brook, IL, USA
| | - Maria Rosa Costanzo
- Advocate Medical Group - Midwest Heart Specialists, Advocate Heart Institute,Oak Brook, IL, USA
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58
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Naughton MT, Kee K. Sleep apnoea in heart failure: To treat or not to treat? Respirology 2016; 22:217-229. [PMID: 27998040 DOI: 10.1111/resp.12964] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Accepted: 10/26/2016] [Indexed: 01/28/2023]
Abstract
Heart failure (HF) and sleep apnoea are common disorders which frequently coexist. Two main types of apnoea occur: one is obstructive which, through recurring episodes of snoring, hypoxaemia, large negative intra-thoracic pressures and arousals from sleep leading to downstream inflammatory and autonomic nervous system changes, is thought to be a causative factor to the development of systemic hypertension and HF. The other type of apnoea, Cheyne-Stokes respiration with central sleep apnoea (CSR-CSA), is characterized by an oscillatory pattern of ventilation with a prevailing hyperventilation-induced hypocapnia, often in the absence of significant hypoxaemia and snoring, and is thought to be a consequence of advanced HF-related low cardiac output, high sympathetic nervous system activation and pulmonary congestion. CSR-CSA may be a compensatory response to advanced HF. Rostral fluid shift during sleep may play an important role in the pathogenesis of both obstructive sleep apnoea (OSA) and CSA. Studies of positive airway pressure (PAP) treatment of OSA and CSA in HF have shown short-term improvements in cardiac and autonomic function; however, there is no evidence of improved survival. Loop gain may provide useful marker of continuous PAP (CPAP) responsiveness in patients with central apnoea. A greater understanding of the pathophysiology of the interaction between obstructive and central apnoea and the various types of HF, and the mechanisms of therapies, such as PAP, is required to develop new strategies to overcome the disabling symptoms, and perhaps improve the mortality, that accompany HF with sleep apnoea.
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Affiliation(s)
- Matthew T Naughton
- Department of Respiratory Medicine, Alfred Hospital, Melbourne, Victoria, Australia.,Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Kirk Kee
- Department of Respiratory Medicine, Alfred Hospital, Melbourne, Victoria, Australia.,Central Clinical School, Monash University, Melbourne, Victoria, Australia
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59
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Hermand E, Lhuissier FJ, Voituron N, Richalet JP. Ventilatory oscillations at exercise in hypoxia: A mathematical model. J Theor Biol 2016; 411:92-101. [PMID: 27743839 DOI: 10.1016/j.jtbi.2016.10.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Revised: 09/01/2016] [Accepted: 10/04/2016] [Indexed: 10/20/2022]
Abstract
We evaluated the mechanisms responsible for the instability of ventilation control system under simultaneous metabolic (exercise) and environmental (hypoxia) stresses, promoting the genesis of periodic breathing. A model following the main concepts of ventilatory control has been tested, including cardiovascular and respiratory parameters, characteristics of peripheral and central chemoreceptors, at mild exercise in hypoxia (FIO2=0.145). Interaction between O2 and CO2 sensing was introduced following three different modalities. A sensitivity and multivariate regression analyses closely matched with physiological data for magnitude and period of oscillations. Low FIO2 and long circulatory delay from lungs to peripheral chemoreceptors (DeltaTp) lengthen the period of oscillations, while high peripheral and central chemoresponses to O2 and CO2, low FIO2 and high DeltaTp increased their magnitude. Peripheral and central O2/CO2 interactions highlight the role of CO2 on peripheral gain to O2 and the contribution of peripheral afferences on central gain to CO2. Our model supports the key role of peripheral chemoreceptors in the genesis of ventilatory oscillations. Differences in the dynamics of central and peripheral components might be determinant for the system stability.
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Affiliation(s)
- Eric Hermand
- Université Paris 13, Sorbonne Paris Cité, Laboratoire "Hypoxie et poumons", EA2363, 74 rue Marcel Cachin, 93017 Bobigny Cedex, France.
| | - François J Lhuissier
- Université Paris 13, Sorbonne Paris Cité, Laboratoire "Hypoxie et poumons", EA2363, 74 rue Marcel Cachin, 93017 Bobigny Cedex, France
| | - Nicolas Voituron
- Université Paris 13, Sorbonne Paris Cité, Laboratoire "Hypoxie et poumons", EA2363, 74 rue Marcel Cachin, 93017 Bobigny Cedex, France
| | - Jean-Paul Richalet
- Université Paris 13, Sorbonne Paris Cité, Laboratoire "Hypoxie et poumons", EA2363, 74 rue Marcel Cachin, 93017 Bobigny Cedex, France.
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60
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May AM, Blackwell T, Stone PH, Stone KL, Cawthon PM, Sauer WH, Varosy PD, Redline S, Mehra R. Central Sleep-disordered Breathing Predicts Incident Atrial Fibrillation in Older Men. Am J Respir Crit Care Med 2016; 193:783-91. [PMID: 26595380 DOI: 10.1164/rccm.201508-1523oc] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
RATIONALE Although research supports a sleep-disordered breathing and atrial fibrillation association, prospective data examining sleep-disordered breathing predicting incident atrial fibrillation are lacking. OBJECTIVES To investigate sleep-disordered breathing indices as predictors of incident atrial fibrillation. METHODS A cohort (n = 843) of ambulatory older men without prevalent atrial fibrillation was assessed for baseline sleep indices: apnea-hypopnea index, central sleep apnea (central apnea index, ≥5 vs. <5), central sleep apnea or Cheyne-Stokes respiration, obstructive apnea-hypopnea index, and percentage of sleep time with less than 90% oxygen saturation. Incident clinically symptomatic adjudicated or self-reported atrial fibrillation outcome was ascertained (mean follow-up, 6.5 ± 0.7 yr). We used logistic regression models adjusted for age, race, body mass index, cardiopulmonary disease, alcohol use, pacemaker, cholesterol, cardiac medications, and alternate apnea type for obstructive and central apnea. Age interaction terms and median age-stratified analyses were performed. MEASUREMENTS AND MAIN RESULTS Central sleep apnea (odds ratio [OR], 2.58; 95% confidence interval [CI], 1.18-5.66) and Cheyne-Stokes respiration with central sleep apnea (OR, 2.27; 95% CI, 1.13-4.56), but not obstructive apnea or hypoxemia, predicted incident atrial fibrillation. Central apnea, Cheyne-Stokes respiration, and sleep-disordered breathing-age interaction terms were significant (P < 0.05). Unlike the case with younger participants, among participants aged 76 years or older (albeit with small atrial fibrillation counts), atrial fibrillation was related to central apnea (OR, 9.97; 95% CI, 2.72-36.50), Cheyne-Stokes respiration with central apnea (OR, 6.31; 95% CI, 1.94-20.51), and apnea-hypopnea index (OR, 1.22; 95% CI, 1.08-1.39 [per 5-unit increase]). CONCLUSIONS In older men, central apnea and Cheyne-Stokes respiration predicted increased atrial fibrillation risk, with findings being strongest in older participants in whom overall sleep-disordered breathing also increased atrial fibrillation risk.
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Affiliation(s)
- Anna M May
- 1 Division of Pulmonary, Critical Care and Sleep Medicine, University Hospitals Case Medical Center, Cleveland, Ohio
| | - Terri Blackwell
- 2 California Pacific Medical Center Research Institute, San Francisco, California
| | - Peter H Stone
- 3 Brigham and Women's Hospital, Boston, Massachusetts
| | - Katie L Stone
- 2 California Pacific Medical Center Research Institute, San Francisco, California
| | - Peggy M Cawthon
- 2 California Pacific Medical Center Research Institute, San Francisco, California
| | | | - Paul D Varosy
- 4 University of Colorado at Denver, Denver, Colorado
| | - Susan Redline
- 3 Brigham and Women's Hospital, Boston, Massachusetts.,5 Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts; and
| | - Reena Mehra
- 6 Sleep Center, Neurological Institute, Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio
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61
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Bekfani T, Abraham WT. Current and future developments in the field of central sleep apnoea. Europace 2016; 18:1123-34. [DOI: 10.1093/europace/euv435] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2015] [Accepted: 11/23/2015] [Indexed: 12/22/2022] Open
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62
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A novel therapeutic approach for central sleep apnea: Phrenic nerve stimulation by the remedē® System. Int J Cardiol 2016; 206 Suppl:S28-34. [DOI: 10.1016/j.ijcard.2016.02.121] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Accepted: 02/21/2016] [Indexed: 11/18/2022]
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63
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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: 80] [Impact Index Per Article: 10.0] [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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64
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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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65
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Rittayamai N, Wilcox E, Drouot X, Mehta S, Goffi A, Brochard L. Positive and negative effects of mechanical ventilation on sleep in the ICU: a review with clinical recommendations. Intensive Care Med 2016; 42:531-541. [PMID: 26759012 DOI: 10.1007/s00134-015-4179-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2015] [Accepted: 12/06/2015] [Indexed: 01/03/2023]
Abstract
PURPOSE Sleep is an essential physiologic process that helps to restore normal body homeostasis. Sleep disturbances have been shown to be associated with poor clinical outcomes, such as a greater risk of cardiovascular disease and increasing mortality. Critically ill patients, particularly those receiving mechanical ventilation, may be more susceptible to sleep disruption. METHODS AND RESULTS Mechanical ventilation is an important factor influencing sleep in critically ill patients as it may have positive or negative effects, depending on patient population, mode, and specific settings. Other causes of sleep disruption include the acute illness itself, the daily routine care, and the effects of medications. Improving sleep in patients admitted to an intensive care unit has the potential to improve both short- and long-term clinical outcomes. In this article we review the specific aspects of sleep in critically ill mechanically ventilated patients, including abnormal sleep patterns and loss of circadian rhythm, as well as the effects of mechanical ventilation and intravenous sedatives on sleep quality and quantity. CONCLUSIONS We provide recommendations for clinicians regarding optimal ventilatory settings and discuss fields for future research.
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Affiliation(s)
- Nuttapol Rittayamai
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.,Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond St, Toronto, ON, M5B 1W8, Canada.,Division of Respiratory Diseases and Tuberculosis, Department of Medicine, Faculty of Medicine Siriraj Hospital, Bangkok, Thailand
| | - Elizabeth Wilcox
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.,Department of Medicine, University of Toronto, Toronto, Canada.,Division of Respirology (Critical Care), Department of Medicine, University Health Network, Toronto, Canada
| | - Xavier Drouot
- CHU de Poitiers, Service de Neurophysiologie Clinique, Poitiers, France.,Faculté de Médecine et de Pharmacie, Université de Poitiers, Poitiers, France.,INSERM CIC 1402, Poitiers, France
| | - Sangeeta Mehta
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.,Department of Medicine, University of Toronto, Toronto, Canada.,Department of Medicine, Mount Sinai Hospital, Toronto, Canada
| | - Alberto Goffi
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.,Department of Medicine, University of Toronto, Toronto, Canada.,Division of Respirology (Critical Care), Department of Medicine, University Health Network, Toronto, Canada
| | - Laurent Brochard
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada. .,Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond St, Toronto, ON, M5B 1W8, Canada. .,Department of Medicine, University of Toronto, Toronto, Canada.
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66
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Oldenburg O, Wellmann B, Buchholz A, Bitter T, Fox H, Thiem U, Horstkotte D, Wegscheider K. Nocturnal hypoxaemia is associated with increased mortality in stable heart failure patients. Eur Heart J 2015; 37:1695-703. [DOI: 10.1093/eurheartj/ehv624] [Citation(s) in RCA: 186] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Accepted: 10/27/2015] [Indexed: 11/14/2022] Open
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67
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Kwon Y, Van't Hof J, Roy SS, Bache RJ, Das G. A Novel Method for Assessing Cardiac Output With the Use of Oxygen Circulation Time. J Card Fail 2015; 22:921-924. [PMID: 26571148 DOI: 10.1016/j.cardfail.2015.10.021] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Revised: 09/03/2015] [Accepted: 10/22/2015] [Indexed: 11/26/2022]
Abstract
BACKGROUND We investigated whether a simple breath hold would yield dynamic oxygen (O2) saturation change and whether the derived circulation time would be useful in assessing cardiac function. METHODS AND RESULTS Patients undergoing right heart catheterization for clinical indications (n = 48), including heart failure (HF; n = 24), were prospectively recruited. Each subject was instructed to hold their breath for 20-40 seconds. Lung to finger circulation time (LFCT), defined as the time from the point of rebreathing to nadir O2 desaturation, was correlated with cardiac output. Among 48 subjects recruited, 37 manifested ≥3% O2 desaturation allowing for an LFCT measurement. Mean LFCT was 38.5 ± 17.5 seconds (range 18.9-94.7 s). LFCT in patients with a clinical diagnosis of HF was significantly longer than those without (45.9 ± 19.9 s vs 31.5 ± 11.5 s; P = .01). Overall, the LFCT was inversely correlated with cardiac output (Fick: r = -0.56; P < .001 [n = 37]; thermodilution: r = -0.6; P = .001 [n = 27]). CONCLUSIONS LFCT is prolonged in low cardiac output. LFCT is a novel method that may be useful to noninvasively assess cardiac function in HF.
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Affiliation(s)
- Younghoon Kwon
- Department of Medicine, Cardiovascular Division, University of Minnesota Medical School, Minneapolis, Minnesota.
| | - Jeremy Van't Hof
- Department of Medicine, Cardiovascular Division, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Samit S Roy
- Department of Medicine, Cardiovascular Division, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Robert J Bache
- Department of Medicine, Cardiovascular Division, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Gladwin Das
- Department of Medicine, Cardiovascular Division, University of Minnesota Medical School, Minneapolis, Minnesota
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68
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Tomita Y, Kasai T. Effectiveness of adaptive servo-ventilation. World J Respirol 2015; 5:112-125. [DOI: 10.5320/wjr.v5.i2.112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2015] [Revised: 04/16/2015] [Accepted: 06/11/2015] [Indexed: 02/06/2023] Open
Abstract
Adaptive servo-ventilation (ASV) has been developed as a specific treatment for sleep-disordered breathing, in particular Cheyne-Stokes respiration with central sleep apnea (CSA). Heart failure patients often have sleep-disordered breathing, which consists of either obstructive sleep apnea (OSA) or CSA. Other medical conditions, such as stroke, acromegaly, renal failure, and opioid use may be associated with CSA. Continuous positive airway pressure (CPAP) therapy is widely used for patients with OSA, but some of these patients develop CSA on CPAP, which is called treatment-emergent CSA. CPAP can be useful as a treatment for these various forms of CSA, but it is insufficient to eliminate respiratory events in approximately half of patients with CSA. As compared to CPAP, ASV may be a better option to treat CSA, with sufficient alleviation of respiratory events as well as improvement of cardiac function in heart failure patients. In patients without heart failure, ASV can also alleviate CSA and relieve their symptom. Recently, ASV has been widely used for patients with various forms of CSA. ASV may be also used in the setting without CSA, but it should be assessed more carefully. Clinicians should have a better understanding of the indications for ASV in each setting.
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69
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Aboussouan LS. Sleep-disordered Breathing in Neuromuscular Disease. Am J Respir Crit Care Med 2015; 191:979-89. [DOI: 10.1164/rccm.201412-2224ci] [Citation(s) in RCA: 81] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Costanzo MR, Khayat R, Ponikowski P, Augostini R, Stellbrink C, Mianulli M, Abraham WT. Mechanisms and clinical consequences of untreated central sleep apnea in heart failure. J Am Coll Cardiol 2015; 65:72-84. [PMID: 25572513 PMCID: PMC4391015 DOI: 10.1016/j.jacc.2014.10.025] [Citation(s) in RCA: 64] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2014] [Revised: 09/22/2014] [Accepted: 10/15/2014] [Indexed: 01/08/2023]
Abstract
Central sleep apnea (CSA) is a highly prevalent, though often unrecognized, comorbidity in patients with heart failure (HF). Data from HF population studies suggest that it may present in 30% to 50% of HF patients. CSA is recognized as an important contributor to the progression of HF and to HF-related morbidity and mortality. Over the past 2 decades, an expanding body of research has begun to shed light on the pathophysiologic mechanisms of CSA. Armed with this growing knowledge base, the sleep, respiratory, and cardiovascular research communities have been working to identify ways to treat CSA in HF with the ultimate goal of improving patient quality of life and clinical outcomes. In this paper, we examine the current state of knowledge about the mechanisms of CSA in HF and review emerging therapies for this disorder.
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Affiliation(s)
| | - Rami Khayat
- Division of Pulmonary, Critical Care and Sleep, The Ohio State University, Columbus, Ohio
| | - Piotr Ponikowski
- Cardiac Department, 4th Military Hospital, Wroclaw, Poland; Cardiac Department, Medical University, Wroclaw, Poland
| | - Ralph Augostini
- Division of Cardiovascular Medicine, The Ohio State University, Columbus, Ohio
| | - Christoph Stellbrink
- Department of Cardiology and Intensive Care Medicine, Bielefeld Medical Center, Bielefeld, Germany
| | | | - William T Abraham
- Division of Cardiovascular Medicine, The Ohio State University, Columbus, Ohio
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71
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Hosokawa K, Ando SI, Tohyama T, Kiyokawa T, Tanaka Y, Otsubo H, Nakamura R, Kadokami T, Fukuyama T. Estimation of nocturnal cardiac output by automated analysis of circulation time derived from polysomnography. Int J Cardiol 2014; 181:14-6. [PMID: 25479531 DOI: 10.1016/j.ijcard.2014.11.211] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2014] [Accepted: 11/26/2014] [Indexed: 10/24/2022]
Affiliation(s)
- Kazuya Hosokawa
- Department of Cardiovascular Medicine, Kyushu University Hospital, Fukuoka, Japan
| | - Shin-Ichi Ando
- Sleep Apnea Center, Kyushu University Hospital, Fukuoka, Japan.
| | - Takeshi Tohyama
- Department of Cardiovascular Medicine, Kyushu University Hospital, Fukuoka, Japan
| | - Tomomi Kiyokawa
- Clinical Physiological Laboratory, Saiseikai Futsukaichi Hospital, Fukuoka, Japan
| | - Yumi Tanaka
- Department of Cardiovascular Medicine, Saiseikai Futsukaichi Hospital, Fukuoka, Japan
| | - Hideki Otsubo
- Department of Cardiovascular Medicine, Saiseikai Futsukaichi Hospital, Fukuoka, Japan
| | - Ryo Nakamura
- Department of Cardiovascular Medicine, Saiseikai Futsukaichi Hospital, Fukuoka, Japan
| | - Toshiaki Kadokami
- Department of Cardiovascular Medicine, Saiseikai Futsukaichi Hospital, Fukuoka, Japan
| | - Takaya Fukuyama
- Department of Cardiovascular Medicine, Saiseikai Futsukaichi Hospital, Fukuoka, Japan
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72
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Terrill PI, Edwards BA, Nemati S, Butler JP, Owens RL, Eckert DJ, White DP, Malhotra A, Wellman A, Sands SA. Quantifying the ventilatory control contribution to sleep apnoea using polysomnography. Eur Respir J 2014; 45:408-18. [PMID: 25323235 DOI: 10.1183/09031936.00062914] [Citation(s) in RCA: 171] [Impact Index Per Article: 17.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Elevated loop gain, consequent to hypersensitive ventilatory control, is a primary nonanatomical cause of obstructive sleep apnoea (OSA) but it is not possible to quantify this in the clinic. Here we provide a novel method to estimate loop gain in OSA patients using routine clinical polysomnography alone. We use the concept that spontaneous ventilatory fluctuations due to apnoeas/hypopnoeas (disturbance) result in opposing changes in ventilatory drive (response) as determined by loop gain (response/disturbance). Fitting a simple ventilatory control model (including chemical and arousal contributions to ventilatory drive) to the ventilatory pattern of OSA reveals the underlying loop gain. Following mathematical-model validation, we critically tested our method in patients with OSA by comparison with a standard (continuous positive airway pressure (CPAP) drop method), and by assessing its ability to detect the known reduction in loop gain with oxygen and acetazolamide. Our method quantified loop gain from baseline polysomnography (correlation versus CPAP-estimated loop gain: n=28; r=0.63, p<0.001), detected the known reduction in loop gain with oxygen (n=11; mean±sem change in loop gain (ΔLG) -0.23±0.08, p=0.02) and acetazolamide (n=11; ΔLG -0.20±0.06, p=0.005), and predicted the OSA response to loop gain-lowering therapy. We validated a means to quantify the ventilatory control contribution to OSA pathogenesis using clinical polysomnography, enabling identification of likely responders to therapies targeting ventilatory control.
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Affiliation(s)
- Philip I Terrill
- Division of Sleep Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA School of Information Technology and Electrical Engineering, The University of Queensland, Brisbane, Australia
| | - Bradley A Edwards
- Division of Sleep Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Shamim Nemati
- Division of Sleep Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - James P Butler
- Division of Sleep Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Robert L Owens
- Division of Sleep Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Danny J Eckert
- Division of Sleep Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA Neuroscience Research Australia and the School of Medical Sciences, University of New South Wales, Sydney, Australia
| | - David P White
- Division of Sleep Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Atul Malhotra
- Division of Sleep Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA Division of Pulmonary and Critical Care, University of Southern California San Diego, La Jolla, CA, USA
| | - Andrew Wellman
- Division of Sleep Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Scott A Sands
- Division of Sleep Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA Central Clinical School, The Alfred and Monash University, Melbourne, Australia
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73
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A 77-Year-Old Man with Nocturnal Epilepsy. Ann Am Thorac Soc 2014; 11:1332-4. [DOI: 10.1513/annalsats.201312-449cc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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74
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Kwon Y, Khan T, Pritzker M, Iber C. Circulation time measurement from sleep studies in patients with obstructive sleep apnea. J Clin Sleep Med 2014; 10:759-65, 765A. [PMID: 25024653 DOI: 10.5664/jcsm.3866] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
INTRODUCTION Lung to finger circulation time (LFCT) can be estimated from polysomnography (PSG) in the presence of an apneic event by using oxygen as an indicator and a finger as the site of detection. The purpose of this study was to refine the methodology of LFCT measurement and to compare LFCT in patients with obstructive sleep apnea (OSA) with and without heart failure (HF). METHODS In a retrospective manner, 10 LFCT measurements per patient were made from the PSG in 171 consecutive patients with a diagnosis of OSA who were divided into two groups: (a) those with a clinical history of underlying HF (N = 42) and (b) those without HF (N = 129). Mean values were compared between the two groups. We also examined associations of LFCT with various factors in each group and the combined group separately using multiple regression analysis. RESULTS Gender and age were significantly associated with LFCT in patients with OSA alone. Use of β-blockers was associated with LFCT in the group with OSA with HF. Among the entire cohort, HF, β-blocker, gender, and age were found to be significantly associated with LFCT. The presence of HF was the strongest predictor of a prolonged LFCT (adjusted mean LFCT: OSA only = 18.5 [95% CI: 17.2-19.7 sec] vs. OSA with HF = 26.1 [95% CI: 24.3-28.0 sec], p < 0.0001). CONCLUSION LFCT can be reliably measured and is prolonged in patients with OSA and underlying HF. LFCT based on PSG may be a useful marker for detection of coexisting HF in patients with OSA.
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Affiliation(s)
- Younghoon Kwon
- Hennepin County Medical Center, Minneapolis, MN ; University of Minnesota, Minneapolis, MN
| | - Talha Khan
- Medical College of Wisconsin, Milwaukee, WI
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75
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Ding N, Ni BQ, Zhang XL, Zha WJ, Hutchinson SZ, Lin W, Huang M, Zhang SJ, Wang H. Elimination of central sleep apnea by cardiac valve replacement: a continuous follow-up study in patients with rheumatic valvular heart disease. Sleep Med 2014; 15:880-6. [PMID: 24938583 DOI: 10.1016/j.sleep.2014.02.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2013] [Revised: 02/10/2014] [Accepted: 02/13/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND Recent studies have suggested that cardiac surgery may affect sleep-disordered breathing (SDB) in chronic heart failure patients. However, the dynamic changes in sleep apnea and heart function after cardiac surgery and the mechanisms responsible for these changes remain unknown. METHODS Patients with rheumatic valvular heart disease (RVHD) and SDB were enrolled and followed up at three, six and 12 months after cardiac valve replacement (CVR). Baseline and follow-up clinical data consisting of NYHA classification, 6min walk distance (6-MWD), medications, echocardiography, electrocardiography, chest X-ray, arterial blood gas, lung-to-finger circulation time (LFCT), and sleep data were collected and evaluated. RESULTS Twenty-four central sleep apnea (CSA) patients and 15 obstructive sleep apnea (OSA) patients completed three follow-up assessments. Comparison of the baseline parameters between OSA patients and CSA patients showed that CSA patients had a worse baseline cardiac function assessed by higher NYHA class, shorter 6-MWD, larger left atrial diameter, longer LFCT, and enhanced chemosensitivity (higher pH and lower arterial carbon dioxide tension (PaCO2)). A continuous significant elevation in 6-MWD and left ventricular ejection fraction and decrease in NYHA class, plasma BNP, and left atrial diameter were found in both CSA and OSA patients. When comparing CSA and OSA patients, the CSA indices were remarkably reduced at month 3 post CVR and sustained throughout the trial, whereas there were no significant decreases in OSA index and hypopnea index. pH values and LFCT were markedly decreased and PaCO2 markedly increased in patients with CSA at the end of the third months following CVR. These changes were sustained until the end of the trial. CONCLUSIONS CSA patients with RVHD had a worse baseline cardiac function, enhanced chemosensitivity and disordered hemodynamic as compared with OSA patients with RVHD. CSA were eliminated after CVR; however, there were no changes in OSA. The elimination of CSA, post CVR, is associated with the combined efficacies of improvement of cardiac function, normalized chemosensitivity, and stabilized hemodynamic.
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Affiliation(s)
- Ning Ding
- Department of Respiratory Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Bu-Qing Ni
- Department of Cardiothoracic Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Xi-Long Zhang
- Department of Respiratory Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Wang-Jian Zha
- Department of Respiratory Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | | | - Wei Lin
- Department of Geriatric Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Mao Huang
- Department of Respiratory Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Shi-Jiang Zhang
- Department of Cardiothoracic Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China.
| | - Hong Wang
- Department of Respiratory Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
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76
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Minic M, Granton JT, Ryan CM. Sleep disordered breathing in group 1 pulmonary arterial hypertension. J Clin Sleep Med 2014; 10:277-83. [PMID: 24634625 PMCID: PMC3927433 DOI: 10.5664/jcsm.3528] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
STUDY OBJECTIVES To determine the prevalence and clinical predictors of sleep disordered breathing (SDB) and impact on outcomes in a cohort of patients with WHO group 1 pulmonary arterial hypertension (PAH). METHODS A retrospective, cross-sectional review of 52 consecutive subjects with known WHO group 1 PAH referred for assessment of possible SDB. Subjects had overnight polysomnography within 6 months of right heart catheterization performed as part of a routine clinical protocol. RESULTS SDB was present in 71% of the PAH patients: 56% had OSA and 44% CSA. Older age and subjective sleepiness as assessed by the Epworth Sleepiness Scale score > 10 were predictive of SDB. A high prevalence of OSA occurred in both male (50%) and female (60%) subjects. No differences in cardiopulmonary hemodynamics or survival between those with and without SDB were observed. CONCLUSIONS This high prevalence of SDB in the PAH population suggests that systematic screening and testing is important in this group. Further studies are necessary to determine the pathophysiological effect of SDB and potential impact of SDB treatment in this population. CITATION Minic M; Granton JT; Ryan CM. Sleep disordered breathing in group 1 pulmonary arterial hypertension.
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Affiliation(s)
- Milan Minic
- Royal College of Surgeons in Ireland, Dublin, Ireland
| | - John T. Granton
- Department of Medicine, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Clodagh M. Ryan
- Department of Medicine, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
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Mansukhani MP, Kolla BP, Ramar K. International Classification of Sleep Disorders 2 and American Academy of Sleep Medicine Practice Parameters for Central Sleep Apnea. Sleep Med Clin 2014. [DOI: 10.1016/j.jsmc.2013.10.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Abstract
Neurophysiologically, central apnea is due to a temporary failure in the pontomedullary pacemaker generating breathing rhythm. As a polysomnographic finding, central apneas occur in many pathophysiological conditions. Depending on the cause or mechanism, central apneas may not be clinically significant, for example, those that occur normally at sleep onset. In contrast, central apneas occur in a number of disorders and result in pathophysiological consequences. Central apneas occur commonly in high-altitude sojourn, disrupt sleep, and cause desaturation. Central sleep apnea also occurs in number of disorders across all age groups and both genders. Common causes of central sleep apnea 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 perhaps mortality. The mechanisms of central sleep apnea have been best studied in congestive heart failure and hypoxic conditions when there is increased CO2 sensitivity below eupnea resulting in lowering eupneic PCO2 below apneic threshold causing cessation of breathing until the PCO2 rises above the apneic threshold when breathing resumes. In many other disorders, the mechanism of central sleep apnea (CSA) remains to be investigated.
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Affiliation(s)
- S Javaheri
- University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.
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80
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Khayat R, Small R, Rathman L, Krueger S, Gocke B, Clark L, Yamokoski L, Abraham WT. Sleep-disordered breathing in heart failure: identifying and treating an important but often unrecognized comorbidity in heart failure patients. J Card Fail 2013; 19:431-44. [PMID: 23743494 DOI: 10.1016/j.cardfail.2013.04.005] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2012] [Revised: 04/09/2013] [Accepted: 04/18/2013] [Indexed: 01/29/2023]
Abstract
Sleep-disordered breathing (SDB) is the most common comorbidity in patients with heart failure (HF) and has a significant impact on quality of life, morbidity, and mortality. A number of therapeutic options have become available in recent years that can improve quality of life and potentially the outcomes of HF patients with SDB. Unfortunately, SDB is not part of the routine evaluation and management of HF, so it remains untreated in most HF patients. Although recognition of the role of SDB in HF is increasing, clinical guidelines for the management of SDB in HF patients continue to be absent. This article provides an overview of SDB in HF and proposes a clinical care pathway to help clinicians to better recognize and treat SDB in their HF patients.
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Affiliation(s)
- Rami Khayat
- Ohio State University, Division of Pulmonary, Critical Care and Sleep, Columbus, OH 43210, USA.
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81
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Zhu K, Kharboutly H, Ma J, Bouzit M, Escourrou P. Bench test evaluation of adaptive servoventilation devices for sleep apnea treatment. J Clin Sleep Med 2013; 9:861-71. [PMID: 23997698 PMCID: PMC3746713 DOI: 10.5664/jcsm.2982] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
RATIONALE Adaptive servoventilation devices are marketed to overcome sleep disordered breathing with apneas and hypopneas of both central and obstructive mechanisms often experienced by patients with chronic heart failure. The clinical efficacy of these devices is still questioned. STUDY OBJECTIVES This study challenged the detection and treatment capabilities of the three commercially available adaptive servoventilation devices in response to sleep disordered breathing events reproduced on an innovative bench test. METHODS The bench test consisted of a computer-controlled piston and a Starling resistor. The three devices were subjected to a flow sequence composed of central and obstructive apneas and hypopneas including Cheyne-Stokes respiration derived from a patient. The responses of the devices were separately evaluated with the maximum and the clinical settings (titrated expiratory positive airway pressure), and the detected events were compared to the bench-scored values. RESULTS The three devices responded similarly to central events, by increasing pressure support to raise airflow. All central apneas were eliminated, whereas hypopneas remained. The three devices responded differently to the obstructive events with the maximum settings. These obstructive events could be normalized with clinical settings. The residual events of all the devices were scored lower than bench test values with the maximum settings, but were in agreement with the clinical settings. However, their mechanisms were misclassified. CONCLUSION The tested devices reacted as expected to the disordered breathing events, but not sufficiently to normalize the breathing flow. The device-scored results should be used with caution to judge efficacy, as their validity depends upon the initial settings.
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Affiliation(s)
- Kaixian Zhu
- Department Explorations Fonctionnelles Multidisciplinaires, AP-HP Antoine-Béclère Hospital, Clamart, France.
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Maestri R, Bruschi C, Olmetti F, La Rovere MT, Pinna GD. Assessment of the peripheral ventilatory response to CO2in heart failure patients: reliability of the single-breath test. Physiol Meas 2013; 34:1123-32. [DOI: 10.1088/0967-3334/34/9/1123] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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83
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Ding N, Ni BQ, Zhang XL, Huang HP, Su M, Zhang SJ, Wang H. Prevalence and risk factors of sleep disordered breathing in patients with rheumatic valvular heart disease. J Clin Sleep Med 2013; 9:781-7. [PMID: 23946708 DOI: 10.5664/jcsm.2920] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES Sleep disordered breathing (SDB) is common in patients with chronic heart failure secondary to non-valvular heart disease; however, the prevalence and characteristics of SDB in patients with rheumatic valvular heart disease (RVHD) are unclear. This study was designed to determine the prevalence, characteristics, and risk factors for SDB in RVHD patients. METHODS A cross-sectional study was conducted in 260 RVHD patients. The following data were recorded: types of heart valve lesions, electrocardiographic, echocardiographic, arterial blood gas analysis findings, baseline medication, 6-minute walk test (6MWT) distance, and sleep parameters. RESULTS Compared to patients with single leftsided valve lesions, patients with left- and rightsided valve lesions had a higher prevalence of SDB (46.2% vs. 31.2%, p = 0.013); the increased prevalence of SDB only involved central sleep apnea (CSA) (31.1% vs. 14.1%, p = 0.001). Patients with obstructive sleep apnea (OSA) or CSA were older and had a shorter 6MWT distance, lower left ventricle ejection fraction and PaO₂, a longer lung-to-finger circulation time, and a higher prevalence of atrial fibrillation (AF) and hypertension (all p < 0.05) as compared with patients without SDB. Multinomial logistic regression analysis showed that PaO2 ≤ 85 mm Hg was the only risk factor for OSA. Male gender, AF, 6MWT distance ≤ 300 m, PaO₂ ≤ 85 mmHg, and PaCO₂ ≤ 40 mm Hg were risk factors for CSA. CONCLUSIONS Patients with RVHD had a high prevalence of SDB (predominantly CSA). RVHD patients with SDB, particularly those who had CSA, manifested more severe symptoms and greater impairment of cardiac function. Assessments of clinical manifestations of cardiac dysfunction may be important for predicting the risk factors for SDB.
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Affiliation(s)
- Ning Ding
- Department of Respiratory Medicine, the First Affiliated Hospital of Nanjing Medical University, China
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84
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Simms T, Brijbassi M, Montemurro LT, Bradley TD. Differential timing of arousals in obstructive and central sleep apnea in patients with heart failure. J Clin Sleep Med 2013; 9:773-9. [PMID: 23946707 PMCID: PMC3716668 DOI: 10.5664/jcsm.2918] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
STUDY OBJECTIVES In obstructive sleep apnea (OSA), arousals generally occur at apnea termination and help restore airflow. However, timing of arousals in central sleep apnea (CSA) has not been objectively quantified, and since arousals can persist even when CSA is alleviated, may not play the same defensive role as they do in OSA. We hypothesized that arousals following central events would occur longer after event termination than following obstructive events and would be related to circulation time. METHODS We examined polysomnograms from 20 patients with heart failure (HF) (left ventricular ejection fraction ≤ 45%): 10 with OSA and 10 with CSA (apneahypopnea index ≥ 15). Twenty central or obstructive apneas or hypopneas were analyzed in each patient. RESULTS Compared to the OSA group in whom arousals generally occurred at obstructive event termination, in the CSA group they occurred longer after central event termination (0.9 ± 1.1 versus 8.0 ± 4.1 s, p < 0.0001), but before peak hyperpnea. Time from arousal to peak hyperpnea did not differ between groups (4.3 ± 1.1 vs 4.8 ± 1.6 s, p = 0.416). Unlike the OSA group, latency from apnea termination to arousal correlated with circulation time in the CSA group (r = 0.793, p = 0.006). CONCLUSIONS In HF patients with CSA, apnea-to-arousal latency is longer than in those with OSA, and arousals usually follow resumption of airflow. These observations provide evidence that arousals are less likely to act as a protective mechanism to facilitate resumption of airflow following apneas in CSA than in OSA.
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Affiliation(s)
- Taryn Simms
- Sleep Research Laboratories of the University Health Network Toronto Rehabilitation Institute and Toronto General Hospital, Toronto, ON, Canada
| | - Melissa Brijbassi
- Sleep Research Laboratories of the University Health Network Toronto Rehabilitation Institute and Toronto General Hospital, Toronto, ON, Canada
| | - Luigi Taranto Montemurro
- Sleep Research Laboratories of the University Health Network Toronto Rehabilitation Institute and Toronto General Hospital, Toronto, ON, Canada
| | - T. Douglas Bradley
- Sleep Research Laboratories of the University Health Network Toronto Rehabilitation Institute and Toronto General Hospital, Toronto, ON, Canada
- Centre for Sleep Medicine and Circadian Biology of the University of Toronto, Toronto, ON, Canada
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85
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Strey KA, Baertsch NA, Baker-Herman TL. Inactivity-induced respiratory plasticity: protecting the drive to breathe in disorders that reduce respiratory neural activity. Respir Physiol Neurobiol 2013; 189:384-94. [PMID: 23816599 DOI: 10.1016/j.resp.2013.06.023] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2013] [Revised: 06/04/2013] [Accepted: 06/24/2013] [Indexed: 12/25/2022]
Abstract
Multiple forms of plasticity are activated following reduced respiratory neural activity. For example, in ventilated rats, a central neural apnea elicits a rebound increase in phrenic and hypoglossal burst amplitude upon resumption of respiratory neural activity, forms of plasticity called inactivity-induced phrenic and hypoglossal motor facilitation (iPMF and iHMF), respectively. Here, we provide a conceptual framework for plasticity following reduced respiratory neural activity to guide future investigations. We review mechanisms giving rise to iPMF and iHMF, present new data suggesting that inactivity-induced plasticity is observed in inspiratory intercostals (iIMF) and point out gaps in our knowledge. We then survey conditions relevant to human health characterized by reduced respiratory neural activity and discuss evidence that inactivity-induced plasticity is elicited during these conditions. Understanding the physiological impact and circumstances in which inactivity-induced respiratory plasticity is elicited may yield novel insights into the treatment of disorders characterized by reductions in respiratory neural activity.
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Affiliation(s)
- K A Strey
- Department of Comparative Biosciences, University of Wisconsin, Madison, WI 53706, USA.
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86
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McGee S. Cheyne-stokes breathing and reduced ejection fraction. Am J Med 2013; 126:536-40. [PMID: 23541375 DOI: 10.1016/j.amjmed.2013.01.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2012] [Revised: 01/08/2013] [Accepted: 01/09/2013] [Indexed: 10/27/2022]
Abstract
BACKGROUND The accuracy of Cheyne-Stokes breathing as a sign of left ventricular dysfunction and its overall prognostic significance are unknown. METHODS Between 2001 and 2006, the author examined 386 inpatients at a Department of Veterans Affairs Medical Center and compared the finding of Cheyne-Stokes breathing and its cycle length with the patients' echocardiographic ejection fraction (EF) and 5-year survival. RESULTS A total of 45 of 386 patients (11.7%) had Cheyne-Stokes breathing. Two variables were independently associated with Cheyne-Stokes breathing: reduced EF (P<.001) and age>80 years (P=.006). The presence of Cheyne-Stokes breathing increased the probability of a markedly reduced EF (ie, EF<40%; likelihood ratio, 5.3; 95% confidence interval, 3.1-9), especially in patients aged≤80 years (likelihood ratio, 7.8; 95% confidence interval, 3.9-15.5). The finding was present in 1 of 3 affected patients (sensitivity=34%). The correlation between cycle length and EF was poor (r=0.23, P=.14). The 5-year survival of patients with Cheyne-Stokes breathing (37.2%) was similar to that of patients without the finding (42.9%, P=.18, log-rank test). CONCLUSIONS In hospitalized patients, Cheyne-Stokes breathing increases the probability of left ventricular dysfunction. It is present in 1 of 3 patients with markedly reduced EF. When detected during physical examination, Cheyne-Stokes breathing does not indicate worse prognosis.
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Affiliation(s)
- Steven McGee
- General Medical Service, Department of Veterans Affairs Medical Center, Seattle, WA 98108, USA.
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87
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Camargo S, Riedl M, Anteneodo C, Kurths J, Wessel N. Diminished heart beat non-stationarities in congestive heart failure. Front Physiol 2013; 4:107. [PMID: 23720631 PMCID: PMC3654225 DOI: 10.3389/fphys.2013.00107] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2013] [Accepted: 04/26/2013] [Indexed: 11/13/2022] Open
Abstract
Studies on heart rate variability (HRV) have become popular and the possibility of diagnosis based on non-invasive techniques compels us to overcome the difficulties originated on the environmental changes that can affect the signal. We perform a non-parametric segmentation which consists of locating the points where the signal can be split into stationary segments. By finding stationary segments we are able to analyze the size of these segments and evaluate how the signal changes from one segment to another, looking at the statistical moments given in each patch, for example, mean and variance. We analyze HRV data for 15 patients with congestive heart failure (CHF; 11 males, 4 females, age 56±11 years), 18 elderly healthy subjects (EH; 11 males, 7 females, age 50±7 years), and 15 young healthy subjects (YH; 11 females, 4 males, age 31±6 years). Our results confirm higher variance for YH, and EH, while CHF displays diminished variance with p-values <0.01, when compared to the healthy groups, presenting higher HRV in healthy subjects. Moreover, it is possible to distinguish between YH and EH with p < 0.05 through the segmentation outcomes. We found high correlations between the results of segmentation and standard measures of HRV analysis and a connection to results of detrended fluctuation analysis (DFA). The segmentation applied to HRV studies detects aging and pathological conditions effects on the non-stationary behavior of the analyzed groups, promising to contribute in complexity analysis and providing risk stratification measures.
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Affiliation(s)
- Sabrina Camargo
- Department of Physics, Humboldt-Universität zu Berlin Berlin, Germany ; Department of Physics, PUC-Rio Rio de Janeiro, Brazil
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88
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Plataki M, Sands SA, Malhotra A. Clinical consequences of altered chemoreflex control. Respir Physiol Neurobiol 2013; 189:354-63. [PMID: 23681082 DOI: 10.1016/j.resp.2013.04.020] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2013] [Revised: 04/19/2013] [Accepted: 04/25/2013] [Indexed: 01/28/2023]
Abstract
Control of ventilation dictates various breathing patterns. The respiratory control system consists of a central pattern generator and several feedback mechanisms that act to maintain ventilation at optimal levels. The concept of loop gain has been employed to describe its stability and variability. Synthesizing all interactions under a general model that could account for every behavior has been challenging. Recent insight into the importance of these feedback systems may unveil therapeutic strategies for common ventilatory disturbances. In this review we will address the major mechanisms that have been proposed as mediators of some of the breathing patterns in health and disease that have raised controversies and discussion on ventilatory control over the years.
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Affiliation(s)
- Maria Plataki
- Department of Internal Medicine, Bridgeport Hospital, Yale New Haven Health, Bridgeport, CT, USA
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89
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White LH, Bradley TD. Role of nocturnal rostral fluid shift in the pathogenesis of obstructive and central sleep apnoea. J Physiol 2013; 591:1179-93. [PMID: 23230237 PMCID: PMC3607865 DOI: 10.1113/jphysiol.2012.245159] [Citation(s) in RCA: 185] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2012] [Accepted: 12/06/2012] [Indexed: 12/25/2022] Open
Abstract
Obstructive sleep apnoea (OSA) is common in the general population and increases the risk of motor vehicle accidents due to hypersomnolence from sleep disruption, and risk of cardiovascular diseases owing to repetitive hypoxia, sympathetic nervous system activation, and systemic inflammation. In contrast, central sleep apnoea (CSA) is rare in the general population. Although their pathogenesis is multifactorial, the prevalence of both OSA and CSA is increased in patients with fluid retaining states, especially heart failure, where they are associated with increased mortality risk. This observation suggests that fluid retention may contribute to the pathogenesis of both OSA and CSA. According to this hypothesis, during the day fluid accumulates in the intravascular and interstitial spaces of the legs due to gravity, and upon lying down at night redistributes rostrally, again owing to gravity. Some of this fluid may accumulate in the neck, increasing tissue pressure and causing the upper airway to narrow, thereby increasing its collapsibility and predisposing to OSA. In heart failure patients, with increased rostral fluid shift, fluid may additionally accumulate in the lungs, provoking hyperventilation and hypocapnia, driving below the apnoea threshold, leading to CSA. This review article will explore mechanisms by which overnight rostral fluid shift, and its prevention, can contribute to the pathogenesis and therapy of sleep apnoea.
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Affiliation(s)
- Laura H White
- Department of Medicine, University Health Network Toronto General Hospital, Rehabilitation Institute, University of Toronto, Ontario, Canada
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90
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Varoneckas G, Podlipskyte A, Alonderis A, Martinkenas A. Sleep disordered breathing in coronary heart disease patients with mild and moderate heart failure. Health (London) 2013. [DOI: 10.4236/health.2013.58a2006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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91
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Berry RB, Budhiraja R, Gottlieb DJ, Gozal D, Iber C, Kapur VK, Marcus CL, Mehra R, Parthasarathy S, Quan SF, Redline S, Strohl KP, Davidson Ward SL, Tangredi MM. Rules for scoring respiratory events in sleep: update of the 2007 AASM Manual for the Scoring of Sleep and Associated Events. Deliberations of the Sleep Apnea Definitions Task Force of the American Academy of Sleep Medicine. J Clin Sleep Med 2012; 8:597-619. [PMID: 23066376 DOI: 10.5664/jcsm.2172] [Citation(s) in RCA: 3288] [Impact Index Per Article: 274.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The American Academy of Sleep Medicine (AASM) Sleep Apnea Definitions Task Force reviewed the current rules for scoring respiratory events in the 2007 AASM Manual for the Scoring and Sleep and Associated Events to determine if revision was indicated. The goals of the task force were (1) to clarify and simplify the current scoring rules, (2) to review evidence for new monitoring technologies relevant to the scoring rules, and (3) to strive for greater concordance between adult and pediatric rules. The task force reviewed the evidence cited by the AASM systematic review of the reliability and validity of scoring respiratory events published in 2007 and relevant studies that have appeared in the literature since that publication. Given the limitations of the published evidence, a consensus process was used to formulate the majority of the task force recommendations concerning revisions.The task force made recommendations concerning recommended and alternative sensors for the detection of apnea and hypopnea to be used during diagnostic and positive airway pressure (PAP) titration polysomnography. An alternative sensor is used if the recommended sensor fails or the signal is inaccurate. The PAP device flow signal is the recommended sensor for the detection of apnea, hypopnea, and respiratory effort related arousals (RERAs) during PAP titration studies. Appropriate filter settings for recording (display) of the nasal pressure signal to facilitate visualization of inspiratory flattening are also specified. The respiratory inductance plethysmography (RIP) signals to be used as alternative sensors for apnea and hypopnea detection are specified. The task force reached consensus on use of the same sensors for adult and pediatric patients except for the following: (1) the end-tidal PCO(2) signal can be used as an alternative sensor for apnea detection in children only, and (2) polyvinylidene fluoride (PVDF) belts can be used to monitor respiratory effort (thoracoabdominal belts) and as an alternative sensor for detection of apnea and hypopnea (PVDFsum) only in adults.The task force recommends the following changes to the 2007 respiratory scoring rules. Apnea in adults is scored when there is a drop in the peak signal excursion by ≥ 90% of pre-event baseline using an oronasal thermal sensor (diagnostic study), PAP device flow (titration study), or an alternative apnea sensor, for ≥ 10 seconds. Hypopnea in adults is scored when the peak signal excursions drop by ≥ 30% of pre-event baseline using nasal pressure (diagnostic study), PAP device flow (titration study), or an alternative sensor, for ≥ 10 seconds in association with either ≥ 3% arterial oxygen desaturation or an arousal. Scoring a hypopnea as either obstructive or central is now listed as optional, and the recommended scoring rules are presented. In children an apnea is scored when peak signal excursions drop by ≥ 90% of pre-event baseline using an oronasal thermal sensor (diagnostic study), PAP device flow (titration study), or an alternative sensor; and the event meets duration and respiratory effort criteria for an obstructive, mixed, or central apnea. A central apnea is scored in children when the event meets criteria for an apnea, there is an absence of inspiratory effort throughout the event, and at least one of the following is met: (1) the event is ≥ 20 seconds in duration, (2) the event is associated with an arousal or ≥ 3% oxygen desaturation, (3) (infants under 1 year of age only) the event is associated with a decrease in heart rate to less than 50 beats per minute for at least 5 seconds or less than 60 beats per minute for 15 seconds. A hypopnea is scored in children when the peak signal excursions drop is ≥ 30% of pre-event baseline using nasal pressure (diagnostic study), PAP device flow (titration study), or an alternative sensor, for ≥ the duration of 2 breaths in association with either ≥ 3% oxygen desaturation or an arousal. In children and adults, surrogates of the arterial PCO(2) are the end-tidal PCO(2) or transcutaneous PCO(2) (diagnostic study) or transcutaneous PCO(2) (titration study). For adults, sleep hypoventilation is scored when the arterial PCO(2) (or surrogate) is > 55 mm Hg for ≥ 10 minutes or there is an increase in the arterial PCO(2) (or surrogate) ≥ 10 mm Hg (in comparison to an awake supine value) to a value exceeding 50 mm Hg for ≥ 10 minutes. For pediatric patients hypoventilation is scored when the arterial PCO(2) (or surrogate) is > 50 mm Hg for > 25% of total sleep time. In adults Cheyne-Stokes breathing is scored when both of the following are met: (1) there are episodes of ≥ 3 consecutive central apneas and/or central hypopneas separated by a crescendo and decrescendo change in breathing amplitude with a cycle length of at least 40 seconds (typically 45 to 90 seconds), and (2) there are five or more central apneas and/or central hypopneas per hour associated with the crescendo/decrescendo breathing pattern recorded over a minimum of 2 hours of monitoring.
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Affiliation(s)
- Richard B Berry
- University of Florida Health Science Center, Gainesville, FL 32610, USA.
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92
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Abstract
Irregular breathing characterized by cyclic variation of ventilation with a period of approximately 1 min has been recognized in patients with heart failure for almost two centuries. Periodic breathing during exercise is a noninvasive parameter that is easily recognizable during submaximal cardiopulmonary exercise testing. Recent studies have established that periodic breathing during exercise not only signals significant impairment in resting and exercise hemodynamic parameters but also potently predicts adverse events in heart failure patients. This article reviews the mechanistic basis of periodic breathing and the clinical utility of discerning patterns of irregular breathing in patients with heart failure.
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Affiliation(s)
- Bishnu P Dhakal
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
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93
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Abstract
The classification of sleep disorders is necessary to discriminate between disorders and to facilitate an understanding of symptoms, etiology, and pathophysiology that allows for appropriate treatment. The earliest classification systems, largely organized according to major symptoms (insomnia, excessive sleepiness, and abnormal events that occur during sleep), were unable to be based on pathophysiology because the cause of most sleep disorders was unknown. These 3 symptom-based categories are easily understood by physicians and are therefore useful for developing a differential diagnosis. The International Classification of Sleep Disorders, version 2, published in 2005 and currently undergoing revision, combines a symptomatic presentation (e.g., insomnia) with 1 organized in part on pathophysiology (e.g., circadian rhythms) and in part on body systems (e.g., breathing disorders). This organization of sleep disorders is necessary because of the varied nature and because the pathophysiology for many of the disorders is still unknown. The International Classification of Sleep Disorders, version 2 provides relevant diagnostic and epidemiological information on sleep disorders to more easily differentiate between the disorders.
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Affiliation(s)
- Michael J Thorpy
- Montefiore Medical Center and the Albert Einstein College of Medicine, Bronx, New York, NY, USA.
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94
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Sinha AM. [Sleep-disordered breathing and cardiac resynchronization therapy]. Herzschrittmacherther Elektrophysiol 2012; 23:5-8. [PMID: 22410756 DOI: 10.1007/s00399-012-0168-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Patients with progressive heart failure often suffer from sleep-disordered breathing (SDB). Upon receiving cardiac resynchronization therapy (CRT), there is an improvement of cardiac function and central sleep apnea syndrome (CSA) with Cheyne-Stokes respiration; however, effects of CRT on obstructive sleep apnea syndrome seemed to be without clinical relevance. Likewise, additional atrial overdrive pacing did not improve CRT effects relevantly in CSA patients. During CRT, there is an improvement in sleep parameters, sleep quality by reduction of depressive syndromes, and in long-term survival. Therefore, all patients with chronic heart failure and indication for CRT should be monitored regarding SDB before and after CRT device implantation.
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Affiliation(s)
- A-M Sinha
- Klinik für Kardiologie, Pneumologie und Internistische Intensivmedizin, Sana Klinikum Hof, Eppenreuther Str. 9, 95032, Hof, Deutschland.
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95
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Brack T, Randerath W, Bloch KE. Cheyne-Stokes Respiration in Patients with Heart Failure: Prevalence, Causes, Consequences and Treatments. Respiration 2012; 83:165-76. [DOI: 10.1159/000331457] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2011] [Accepted: 08/02/2011] [Indexed: 12/12/2022] Open
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96
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Passino C, Giannoni A, Mannucci F, Prontera C, Filipponi F, Carrai P, Emdin M, Catapano G. Abnormal hyperventilation in patients with hepatic cirrhosis: Role of enhanced chemosensitivity to carbon dioxide. Int J Cardiol 2012; 154:22-6. [DOI: 10.1016/j.ijcard.2010.08.066] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2010] [Revised: 08/11/2010] [Accepted: 08/19/2010] [Indexed: 11/28/2022]
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97
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Mechanisms of sleep-disordered breathing: causes and consequences. Pflugers Arch 2011; 463:213-30. [DOI: 10.1007/s00424-011-1055-x] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2011] [Revised: 10/14/2011] [Accepted: 10/26/2011] [Indexed: 11/27/2022]
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98
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Murphy RM, Shah RV, Malhotra R, Pappagianopoulos PP, Hough SS, Systrom DM, Semigran MJ, Lewis GD. Exercise oscillatory ventilation in systolic heart failure: an indicator of impaired hemodynamic response to exercise. Circulation 2011; 124:1442-51. [PMID: 21875912 DOI: 10.1161/circulationaha.111.024141] [Citation(s) in RCA: 84] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Exercise oscillatory ventilation (EOV) is a noninvasive parameter that potently predicts outcomes in systolic heart failure (HF). However, mechanistic insights into EOV have been limited by the absence of studies relating EOV to invasive hemodynamic measurements and blood gases performed during exercise. METHODS AND RESULTS Fifty-six patients with systolic HF (mean±SEM age, 59±2 years; left ventricular ejection fraction, 30±1%) and 19 age-matched control subjects were studied with incremental cardiopulmonary exercise testing. Fick cardiac outputs, filling pressures, and arterial blood gases were measured at 1-minute intervals during exercise. We detected EOV in 45% of HF (HF+EOV) patients and in none of the control subjects. The HF+EOV group did not differ from the HF patients without EOV (HF-EOV) in age, sex, body mass index, left ventricular ejection fraction, or origin of HF. Univariate predictors of the presence of EOV in HF, among measurements performed during exercise, included higher right atrial pressure and pulmonary capillary wedge pressure and lower cardiac index (CI) but not Paco2 or Pao2. Multivariate logistic regression identified that low exercise CI is the strongest predictor of EOV (odds ratio, 1.39 for each 1.0-L · min(-1) · m(-2) decrement in CI; 95% confidence interval, 1.14-1.70; P=0.001). Among HF patients with EOV, exercise CI was inversely related to EOV cycle length (R=-0.71) and amplitude (R=-0.60; both P<0.001). In 11 HF+EOV subjects treated with 12 weeks of sildenafil, EOV cycle length and amplitude decreased proportionately to increases in CI. CONCLUSION Exercise oscillatory ventilation is closely related to reduced CI and elevated filling pressures during exercise and may be an important surrogate for exercise-induced hemodynamic impairment in HF patients. Clinical Trial Registration- URL: http://www.clinicaltrials.gov. Unique identifier: NCT00309790.
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Affiliation(s)
- Ryan M Murphy
- Cardiology Division, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
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99
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Westhoff M, Arzt M, Litterst P. Prevalence and treatment of central sleep apnoea emerging after initiation of continuous positive airway pressure in patients with obstructive sleep apnoea without evidence of heart failure. Sleep Breath 2011; 16:71-8. [PMID: 21347650 DOI: 10.1007/s11325-011-0486-0] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2010] [Revised: 12/27/2010] [Accepted: 01/13/2011] [Indexed: 12/19/2022]
Abstract
BACKGROUND This study aimed to assess the prevalence of complex sleep apnoea (CompSA), defined as central sleep apnoea (CSA) emerging after the initiation of continuous positive airway pressure (CPAP) therapy for obstructive sleep apnoea (OSA), in patients with normal brain natriuretic peptide (BNP) levels, along with assessing the prevalence of CSA persisting in such patients after the onset of CPAP therapy. We hypothesised that the prevalence of CompSA and persistent CSA after CPAP initiation would be low in patients with OSA and normal BNP levels. MATERIAL AND METHODS Between April 2004 and July 2007, CPAP was initiated for all patients with OSA for two nights using a standardised protocol. The prevalence of CompSA syndrome (CompSAS) and persisting CSA [central apnoea index (CAI) >5/h and apnoea-hypopnoea index (AHI) >15/h with >50% central events during CPAP therapy] was prospectively assessed in patients with normal BNP levels. Patients with CompSAS or persisting CSA upon CPAP treatment received adaptive servoventilation (ASV). RESULTS Of 1,776 patients with OSA receiving CPAP, 28 patients (1.57%) had CSA at the time of CPAP therapy and normal BNP levels. Additionally, 10 patients had CompSAS (0.56%) and 18 patients (1.01%) had persisting CSA. In patients with CompSA or persisting CSA, the AHI was significantly lower with CPAP therapy than at the time of diagnosis (34 ± 15/h vs. 47 ± 20/h, p = 0.005). The CAI increased from 10 ± 10/h to 18/h ± 13/h (p = 0.009) upon initiation of CPAP therapy. ASV reduced the AHI to 6 ± 12/h (p < 0.001) during the first night of use. CONCLUSION The prevalence of CompSA or persisting CSA in patients with OSA and normal BNP levels who are receiving CPAP therapy is low (1.57%). ASV is an effective treatment for these patients.
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Affiliation(s)
- Michael Westhoff
- Department of Pulmonary, Critical Care and Sleep Medicine, Hemer Lung Clinic, Hemer, Germany.
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100
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Tamura A, Ando S, Goto Y, Kawano Y, Shinozaki K, Kotoku M, Kadota J. Washout Rate of Cardiac Iodine-123 Metaiodobenzylguanidine is High in Chronic Heart Failure Patients With Central Sleep Apnea. J Card Fail 2010; 16:728-33. [DOI: 10.1016/j.cardfail.2010.04.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2009] [Revised: 04/15/2010] [Accepted: 04/29/2010] [Indexed: 01/08/2023]
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