Central Sleep Apnea in Patients with Heart Failure-How to Screen, How to Treat

Efficacy analysis of non-invasive positive pressure ventilation in elderly patients with heart failure complicated with obstructive sleep apnea syndrome

BACKGROUND

It is recommended to use non-invasive positive pressure ventilation in elderly patients with heart failure combined with obstructive sleep apnea syndrome (OSAS).

OBJECTIVE

To study the therapeutic effect of non-invasive positive pressure ventilation on elderly patients with heart failure complicated with OSAS.

METHODS

Using the random number table method, 119 elderly patients with heart failure complicated with OSAS who were admitted to our hospital from April 2020 to April 2021 were divided into the observation (60 cases) and control (59 cases) groups. On the basis of conventional drug treatment, patients in the observation group were treated with non-invasive positive pressure ventilation, and patients in the control group were treated with low-flow oxygen inhalation. The sleep quality, hemoglobin, red blood cells, erythropoietin, pro-brain natriureticpeptide (pro-BNP) levels and blood pressure were compared.

RESULTS

After treatment, levels of hemoglobin, erythrocytes, erythropoietin, pro-BNP, blood pressure and sleep apnea-hypopnea index in the observation group were lower before treatment and in the control group in the same period. The oxygen saturation was higher before treatment and the control group in the same period (P< 0.05). The overall satisfaction with sleep quality in the observation group was higher (P< 0.05).

CONCLUSION

Non-invasive positive pressure ventilation can improve blood oxygen saturation and sleep quality in elderly patients with heart failure complicated with OSAS, and reduce pro-BNP level.

Heart failure and the heart-brain axis

In heart failure (HF) strong haemodynamic and neuronal signalling feedback interactions between the heart and the central nervous system (CNS) exist that are able to mutually provoke acute or chronic functional impairment. Cerebral injury secondary to HF may include acute stroke, cognitive decline and dementia and depressive disorders. Also brain stem functions are involved in the cardiac-cerebral interaction in HF as neurohormonal control and neuronal reflex circuits are known to be impaired or imbalanced in HF. In turn, impaired cerebral functions may account for direct and indirect myocardial injury and may contribute to symptomatic severity of HF, to disease progression and to increased mortality. Despite the clinical and pathophysiologic significance of the heart-CNS interaction, this relevant field of HF comorbidity is clinically under-recognized with regard to both diagnostic workup and treatment efforts. Here, principal aspects of pathophysiologic heart-CNS interactions related to HF are discussed such as stroke, effects on cognitive function, on depressive disorder and neurovegetative control and neuronal cardiovascular reflex regulation. Aspects of (limited) treatment options for cerebral functional interactions in HF are examined.

Central sleep apnea treatment in patients with heart failure with reduced ejection fraction: a network meta-analysis

PURPOSE

Adaptive servo-ventilation (ASV) is contraindicated for the treatment of central sleep apnea (CSA) in patients with heart failure with reduced ejection fraction (HFrEF), limiting treatment options. Though continuous positive airway pressure (CPAP), bi-level PAP with back-up rate (BPAP-BUR), and transvenous phrenic nerve stimulation (TPNS) are alternatives, not much is known about their comparative efficacies, which formed the basis of conducting this network meta-analysis. We sought to analyze their comparative effectiveness in reducing apnea hypopnea index (AHI). Additionally, we also studied their comparative effectiveness on subjective daytime sleepiness as assessed by Epworth sleepiness score (ESS).

METHODS

Randomized controlled trials (RCTs) from PubMed were analyzed in a network meta-analysis and relative superiority was computed based on P-score ranking and Hasse diagrams.

RESULTS

Network meta-analysis based on 8 RCTs showed that when compared to guideline-directed medical therapy (GDMT-used as a common comparator across trials), reduction in AHI by ASV (- 26.05 [- 38.80; - 13.31]), TPNS (- 24.90 [- 42.88; - 6.92]), BPAP-BUR (- 20.36 [- 36.47; - 4.25]), and CPAP (- 16.01 [- 25.42; - 6.60]) were statistically significant but not between the interventions. Based on 6 RCTs of all the interventions, only TPNS showed a statistically significant decrease in ESS (- 3.70 (- 5.58; - 1.82)) when compared to GDMT, while also showing significant differences when compared with ASV (- 3.20 (- 5.86; - 0.54)), BPAP-BUR (- 4.00 (- 7.33; - 0.68)), and CPAP (- 4.45 (- 7.75; - 1.14)). Ranking of treatments based on Hasse diagram, accounting for both AHI and ESS as outcomes for relative hierarchy showed relative superiority of both ASV and TPNS over BPAP-BUR and CPAP.

CONCLUSIONS

Results indicated relative superiority of TPNS and ASV to BPAP-BUR and CPAP in their effects on AHI and ESS.

Sleep Apnoea and Heart Failure

Heart Failure (HF) and Sleep-Disordered-Breathing (SDB) are two common conditions that frequently overlap and have been studied extensively in the past three decades. Obstructive Sleep Apnea (OSA) may result in myocardial damage, due to intermittent hypoxia increased sympathetic activity and transmural pressures, low-grade vascular inflammation and oxidative stress. On the other hand, central sleep apnoea and Cheyne-Stokes respiration (CSA-CSR) occurs in HF, irrespective of ejection fraction either reduced (HFrEF), preserved (HFpEF) or mildly reduced (HFmrEF). The pathophysiology of CSA-CSR relies on several mechanisms leading to hyperventilation, breathing cessation and periodic breathing. Pharyngeal collapse may result at least in part from fluid accumulation in the neck, owing to daytime fluid retention and overnight rostral fluid shift from the legs. Although both OSA and CSA-CSR occur in HF, the symptoms are less suggestive than in typical (non-HF related) OSA. Overnight monitoring is mandatory for a proper diagnosis, with accurate measurement and scoring of central and obstructive events, since the management will be different depending on whether the sleep apnea in HF is predominantly OSA or CSA-CSR. SDB in HF are associated with worse prognosis, including higher mortality than in patients with HF but without SDB. However, there is currently no evidence that treating SDB improves clinically important outcomes in patients with HF, such as cardiovascular morbidity and mortality.

The smell of lung disease: a review of the current status of electronic nose technology

There is a need for timely, accurate diagnosis, and personalised management in lung diseases. Exhaled breath reflects inflammatory and metabolic processes in the human body, especially in the lungs. The analysis of exhaled breath using electronic nose (eNose) technology has gained increasing attention in the past years. This technique has great potential to be used in clinical practice as a real-time non-invasive diagnostic tool, and for monitoring disease course and therapeutic effects. To date, multiple eNoses have been developed and evaluated in clinical studies across a wide spectrum of lung diseases, mainly for diagnostic purposes. Heterogeneity in study design, analysis techniques, and differences between eNose devices currently hamper generalization and comparison of study results. Moreover, many pilot studies have been performed, while validation and implementation studies are scarce. These studies are needed before implementation in clinical practice can be realised. This review summarises the technical aspects of available eNose devices and the available evidence for clinical application of eNose technology in different lung diseases. Furthermore, recommendations for future research to pave the way for clinical implementation of eNose technology are provided.

Coexistence of cardiovascular risk factors and obstructive sleep apnoea in polysomnography

OBJECTIVES

The objective of the study was to assess the relationship between the coexistence of cardiovascular risk factors (CVRFs) and the incidence and severity of obstructive sleep apnoea (OSA).

METHODS

The study involved 88 people, aged 53.76 ± 12.59 years. A questionnaire, basic anthropometric measurements, blood pressure, standard laboratory tests (total cholesterol, triglycerides and glucose) and polysomnography were performed. Each patient was assessed for the presence of CVRFs: i.e. obesity, arterial hypertension, hypercholesterolemia, hypertriglyceridemia, type 2 diabetes and smoking. OSA was diagnosed based on the apnoea and hypopnea index (AHI) in polysomnography.

RESULTS

It was documented that the mean AHI values were significantly higher in obese patients than in non-obese patients, in patients with arterial hypertension than in patients without hypertension, in patients with hypercholesterolaemia than in patients without hypercholesterolaemia and in patients declaring smoking than in non-smoking patients. The correlation analysis revealed a significant positive linear relationship between the number of CVRFs and the AHI value in polysomnography (r = 0.40, p < 0.05). Based on the regression analysis, it was documented that obesity, arterial hypertension and smoking are independent predictors of higher AHI values.

CONCLUSIONS

In the study group of patients with multiple cardiovascular risk factors, there is a directly proportional relationship between the number of cardiovascular risk factors and the AHI index in polysomnography.

All You Need Is Sleep: the Effects of Sleep Apnea and Treatment Benefits in the Heart Failure Patient

PURPOSE OF REVIEW

Recognition and treatment of sleep apnea is an important but easily overlooked aspect of care in the heart failure patient. This review summarizes the data behind the recommendations in current practice guidelines and highlights recent developments in treatment options.

RECENT FINDINGS

Neuromodulation using hypoglossal nerve stimulation has been increasingly used for treatment of OSA; however, it has not been studied in the heart failure population. Alternatively, phrenic nerve stimulation for treatment of CSA is effective for heart failure patients, and cardiac resynchronization therapy can be effective in improving CSA in pacing-induced cardiomyopathy. In patients suspected to have sleep apnea, polysomnography is recommended to better understand the prognosis and treatment options. Positive airway pressure is the standard treatment for sleep apnea; however, neurostimulation can be especially effective in those with predominantly central events. Understanding the pathophysiology of sleep apnea can guide further management decisions.