1
|
Xie L, Li S, Yu X, Wei Q, Yu F, Tong J. DAHOS Study: Efficacy of dapagliflozin in treating heart failure with reduced ejection fraction and obstructive sleep apnea syndrome - A 3-month, multicenter, randomized controlled clinical trial. Eur J Clin Pharmacol 2024; 80:771-780. [PMID: 38386021 DOI: 10.1007/s00228-024-03643-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 02/02/2024] [Indexed: 02/23/2024]
Abstract
BACKGROUND The recent discovery of new therapeutic approaches to heart failure with reduced ejection fraction (HFrEF), including sodium-glucose cotransporter-2 (SGLT-2) inhibitors, as well as improved treatment of co-morbidities has provided much needed help to HFrEF. In addition, dapagliflozin, one of the SGLT-2 inhibitors, serves as a promising candidate in treating obstructive sleep apnea (OSA) of HFrEF patients due to its likely mechanism of countering the pathophysiology of OSA of HFrEF. METHODS This 3-month multicenter, prospective, randomized controlled trial enrolled participants with left ventricular ejection fraction (LVEF) less than 40% and apnea-hypopnea index (AHI) greater than 15. Participants were randomized into two groups: the treatment group received optimized heart failure treatment and standard-dose dapagliflozin, while the control group only received optimized heart failure treatment. The primary endpoint was the difference in AHI before and after treatment between the two groups. Secondary endpoints included oxygen desaturation index (ODI), minimum oxygen saturation, longest apnea duration, inflammatory factors (CRP, IL-6), quality of life score, and LVEF. RESULTS A total of 107 patients were included in the final analysis. AHI, LVEF and other baseline data were similar for the dapagliflozin and control groups. After 12 weeks of dapagliflozin treatment, the dapagliflozin group showed significant improvements in sleep parameters including AHI, HI, longest pause time, ODI, time spent with SpO2 < 90%, and average SpO2. Meanwhile, the control group showed no significant changes in sleep parameters, but did demonstrate significant improvements in left ventricular end-diastolic diameter, LVEF, and NT-proBNP levels at 12 weeks. In the experimental group, BMI was significantly reduced, and there were improvements in ESS score, MLHFQ score, and EQ-5D-3L score, as well as significant reductions in CRP and IL-6 levels, while the CRP and IL-6 levels were not improved in the control group. The decrease in LVEF was more significant in the experimental group compared to the control group. There were no significant differences in the magnitude of the decreases between the two groups. CONCLUSIONS Dapagliflozin may be an effective treatment for heart failure complicated with OSA, and could be considered as a potential new treatment for OSA. (Trial registration www.chictr.org.cn , ChiCTR2100049834. Registered 10 August 2021).
Collapse
Affiliation(s)
- Liang Xie
- Department of Cardiology, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Shengnan Li
- School of Medicine, Southeast University, Nanjing, China
| | - Xiaojin Yu
- School of Medicine, Southeast University, Nanjing, China
| | - Qin Wei
- Department of Cardiology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Fuchao Yu
- Department of Cardiology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Jiayi Tong
- Department of Cardiology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China.
| |
Collapse
|
2
|
Butt JH, Jering K, DE Boer RA, Claggett BL, Desai AS, Hernandez AF, Inzucchi SE, Jhund PS, Køber L, Kosiborod MN, Lam CSP, Martinez FA, Ponikowski P, Sabatine MS, Shah SJ, Vaduganathan M, Langkilde AM, Bengtsson O, Petersson M, Sjöstrand M, Wilderäng U, Solomon SD, McMurray JJV. Heart Failure, Investigator-Reported Sleep Apnea and Dapagliflozin: A Patient-Level Pooled Meta-Analysis of DAPA-HF and DELIVER. J Card Fail 2024; 30:436-448. [PMID: 38104937 DOI: 10.1016/j.cardfail.2023.08.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 08/19/2023] [Accepted: 08/22/2023] [Indexed: 12/19/2023]
Abstract
BACKGROUND Sleep apnea is more common in patients with heart failure (HF) than in the general population, but little is known about its association with clinical outcomes in various HF phenotypes or how it might modify the effect of HF therapy. OBJECTIVES To examine the prevalence of sleep apnea, its association with outcomes and the effects of dapagliflozin in patients with HF with and without sleep apnea in a pooled analysis of 2 trials comparing dapagliflozin to placebo in HFrEF (DAPA-HF trial) and HFmrEF/HFpEF (DELIVER trial). METHODS A history of sleep apnea was investigator-reported. The primary outcome was a composite of worsening HF or cardiovascular death. RESULTS The prevalence of sleep apnea was 5.7% and 7.8% in patients with HFrEF and HFmrEF/HFpEF, respectively. The primary outcome occurred at a rate of 16.0 in participants with sleep apnea compared to 10.6 per 100 person-years in those without (adjusted HR 1.29 [95%CI, 1.10-1.52]). Compared with placebo, dapagliflozin reduced the risk of the primary endpoint to the same extent in patients with (HR 0.78 [95% CI, 0.59-1.03]) and without sleep apnea (HR 0.79 [0.72-0.87]) [Pinteraction = 0.93]. The beneficial effects of dapagliflozin on other clinical outcomes and symptom burden, physical function, and quality of life were consistent in participants with and without sleep apnea. CONCLUSIONS In DAPA-HF and DELIVER, the true prevalence of sleep apnea was likely underestimated. An investigator-reported history of sleep apnea was associated with higher rates of worsening HF events. The benefits of dapagliflozin on clinical outcomes were consistent in patients with and without sleep apnea. CLINICAL TRIAL REGISTRATION Unique identifiers: NCT01920711 CONDENSED ABSTRACT: In a pooled analysis of the DAPA-HF and DELIVER trials of more than 11,000 patients with heart failure (HF) across the range of ejection fractions, an investigator-reported history of sleep apnea was associated with higher rates of worsening HF events but not mortality. The beneficial effects of dapagliflozin on clinical outcomes were consistent in patients with and without sleep apnea. These findings provide further evidence for dapagliflozin as a new treatment option for patients with heart failure across the range of ejection fractions.
Collapse
Affiliation(s)
- Jawad H Butt
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK; Department of Cardiology, Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark
| | - Karola Jering
- Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, USA
| | | | - Brian L Claggett
- Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, USA
| | - Akshay S Desai
- Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, USA
| | | | | | - Pardeep S Jhund
- Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, USA
| | - Lars Køber
- Department of Cardiology, Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark
| | - Mikhail N Kosiborod
- Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City, Kansas City, MO, USA
| | - Carolyn S P Lam
- National Heart Centre Singapore & Duke-National University of Singapore, Singapore
| | | | - Piotr Ponikowski
- Center for Heart Diseases, University Hospital, Wroclaw Medical University, Wroclaw, Poland
| | - Marc S Sabatine
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, USA
| | - Sanjiv J Shah
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | - Anna Maria Langkilde
- Late-Stage Development, Cardiovascular, Renal, and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Olof Bengtsson
- Late-Stage Development, Cardiovascular, Renal, and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Magnus Petersson
- Late-Stage Development, Cardiovascular, Renal, and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Mikaela Sjöstrand
- Late-Stage Development, Cardiovascular, Renal, and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Ulrica Wilderäng
- Late-Stage Development, Cardiovascular, Renal, and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Scott D Solomon
- Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, USA
| | - John J V McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK.
| |
Collapse
|
3
|
Felippe ISA, Río RD, Schultz H, Machado BH, Paton JFR. Commonalities and differences in carotid body dysfunction in hypertension and heart failure. J Physiol 2023; 601:5527-5551. [PMID: 37747109 PMCID: PMC10873039 DOI: 10.1113/jp284114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 08/29/2023] [Indexed: 09/26/2023] Open
Abstract
Carotid body pathophysiology is associated with many cardiovascular-respiratory-metabolic diseases. This pathophysiology reflects both hyper-sensitivity and hyper-tonicity. From both animal models and human patients, evidence indicates that amelioration of this pathophysiological signalling improves disease states such as a lowering of blood pressure in hypertension, a reduction of breathing disturbances with improved cardiac function in heart failure (HF) and a re-balancing of autonomic activity with lowered sympathetic discharge. Given this, we have reviewed the mechanisms of carotid body hyper-sensitivity and hyper-tonicity across disease models asking whether there is uniqueness related to specific disease states. Our analysis indicates some commonalities and some potential differences, although not all mechanisms have been fully explored across all disease models. One potential commonality is that of hypoperfusion of the carotid body across hypertension and HF, where the excessive sympathetic drive may reduce blood flow in both models and, in addition, lowered cardiac output in HF may potentiate the hypoperfusion state of the carotid body. Other mechanisms are explored that focus on neurotransmitter and signalling pathways intrinsic to the carotid body (e.g. ATP, carbon monoxide) as well as extrinsic molecules carried in the blood (e.g. leptin); there are also transcription factors found in the carotid body endothelium that modulate its activity (Krüppel-like factor 2). The evidence to date fully supports that a better understanding of the mechanisms of carotid body pathophysiology is a fruitful strategy for informing potential new treatment strategies for many cardiovascular, respiratory and metabolic diseases, and this is highly relevant clinically.
Collapse
Affiliation(s)
- Igor S. A. Felippe
- Manaaki Manawa – The Centre for Heart Research, Department of Physiology, Faculty of Health & Medical Sciences, University of Auckland, Grafton, Auckland, 1023, New Zealand
| | - Rodrigo Del Río
- Department of Physiology, Laboratory of Cardiorespiratory Control, Pontificia Universidad Católica de Chile, Santiago, Chile
- Centro de Excelencia en Biomedicina de Magallanes (CEBIMA), Universidad de Magallanes, Punta Arenas, Chile
- Mechanisms of Myelin Formation and Repair Laboratory, Instituto de Ciencias Biomédicas, Facultad de Ciencias de la Salud, Universidad Autónoma de Chile, Santiago, Chile
- Centro de Envejecimiento y Regeneración (CARE), Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Harold Schultz
- Department of Cellular and Integrative Physiology, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Benedito H. Machado
- Department of Physiology, School of Medicine of Ribeirão Preto, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Julian F. R. Paton
- Manaaki Manawa – The Centre for Heart Research, Department of Physiology, Faculty of Health & Medical Sciences, University of Auckland, Grafton, Auckland, 1023, New Zealand
| |
Collapse
|
4
|
Xie L, Song S, Li S, Wei Q, Liu H, Zhao C, Yu F, Tong J. Efficacy of dapagliflozin in the treatment of HFrEF with obstructive sleep apnea syndrome (DAHOS study): study protocol for a multicentric, prospective, randomized controlled clinical trial. Trials 2023; 24:318. [PMID: 37158922 PMCID: PMC10169325 DOI: 10.1186/s13063-023-07332-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Accepted: 04/28/2023] [Indexed: 05/10/2023] Open
Abstract
BACKGROUND Heart failure with reduced ejection fraction (HFrEF) is associated with sleep dyspnea (SDB), which plays an adverse role in the pathophysiology of the condition. SDB management in HFrEF, however, remains controversial. HFrEF's medical management has recently made significant progress with the discovery of new therapeutic avenues, namely sodia-glucose cotransporter-2 (SGLT-2) inhibitors, and better treatment of co-morbidities. Dapagliflozin, one of the SGLT-2 inhibitors, is a good candidate for correcting SDB of HFrEF patients because their known mechanisms of action are likely to counteract the pathophysiology of SDB in HFrEF. METHODS/DESIGN The trial is a 3-month, multicentric, prospective, randomized controlled clinical study. Patients (i.e., adults with left ventricular ejection fraction ≤ 40%, Apnoea-Hypopnoea Index ≥ 15) will be randomized to receive optimized heart failure therapy plus a standard dose of dapagliflozin, while the control group will receive only optimized heart failure therapy. Patients will be evaluated before and after 3 months (nocturnal ventilatory polygraphy, echocardiography, laboratory testing, and quality-of-life and SDB questionnaires). The primary outcome is the change in the Apnoea-Hypopnoea Index, before and after 3 months of treatment. TRIAL REGISTRATION www.chictr.org.cn , ChiCTR2100049834. Registered 10 August 2021.
Collapse
Affiliation(s)
- Liang Xie
- School of Medicine, Southeast University, Nanjing, China
- Department of Cardiology, Jinling Hospitial, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Songsong Song
- Department of Cardiology, Zhongda Hospital, Nanjing, China
| | - Shengnan Li
- School of Medicine, Southeast University, Nanjing, China
| | - Qin Wei
- Department of Cardiology, Zhongda Hospital, Nanjing, China
| | - Hong Liu
- State Key Laboratory of Bioelectronics, School of Biological Science and Medical Engineering, Southeast University, Nanjing, China
| | - Chao Zhao
- State Key Laboratory of Bioelectronics, School of Biological Science and Medical Engineering, Southeast University, Nanjing, China
| | - Fuchao Yu
- Department of Cardiology, Zhongda Hospital, Nanjing, China
| | - Jiayi Tong
- Department of Cardiology, Zhongda Hospital, Nanjing, China.
| |
Collapse
|
5
|
Tamisier R, Pepin J, Cowie MR, Wegscheider K, Vettorazzi E, Suling A, Angermann C, d'Ortho M, Erdmann E, Simonds AK, Somers VK, Teschler H, Lévy P, Woehrle H. Effect of adaptive servo ventilation on central sleep apnea and sleep structure in systolic heart failure patients: polysomnography data from the SERVE-HF major sub study. J Sleep Res 2022; 31:e13694. [PMID: 35840352 PMCID: PMC9787165 DOI: 10.1111/jsr.13694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 06/23/2022] [Accepted: 06/23/2022] [Indexed: 12/30/2022]
Abstract
This SERVE-HF (Treatment of Predominant Central Sleep Apnea by Adaptive Servo Ventilation in Patients With Heart Failure) sub study analysis evaluated polysomnography (PSG) data in patients with heart failure with reduced ejection fraction (HFrEF) and predominant central sleep apnea (CSA) randomised to guideline-based medical therapy, with or without adaptive servo ventilation (ASV). Patients underwent full overnight PSG at baseline and at 12 months. All PSG recordings were analysed by a core laboratory. Only data for patients with baseline and 3- or 12-month values were included. The sub study included 312 patients; the number with available PSG data differed for each variable (94-103 in the control group, 77-99 in the ASV group). After 12 months, baseline-adjusted respiratory measures were significantly better in the ASV group versus control. Although some between-group differences in sleep measures were seen at 12 months (e.g., better sleep efficiency in the ASV group), these were unlikely to be clinically significant. The number of periodic leg movements during sleep (PLMS) increased in the ASV group (p = 0.039). At 12 months, the respiratory arousal index was significantly lower in the ASV versus control group (p < 0.001), whilst the PLMS-related arousal index was significantly higher in the ASV group (p = 0.04 versus control). ASV attenuated the respiratory variables characterising sleep apnea in patients with HFrEF and predominant CSA in SERVE-HF. Sleep quality improvements during ASV therapy were small and unlikely to be clinically significant. The increase in PLMS and PLMS-related arousals during ASV warrants further investigation, particularly relating to their potential association with increased cardiovascular risk.
Collapse
Affiliation(s)
- Renaud Tamisier
- University Grenoble Alpes, Inserm, HP2 Laboratory, Pole Thorax et VaisseauxCHU Grenoble AlpesGrenobleFrance
| | - Jean‐Louis Pepin
- University Grenoble Alpes, Inserm, HP2 Laboratory, Pole Thorax et VaisseauxCHU Grenoble AlpesGrenobleFrance
| | | | - Karl Wegscheider
- Department of Medical Biometry and EpidemiologyUniversity Medical Center Hamburg‐EppendorfHamburgGermany
| | - Eik Vettorazzi
- Department of Medical Biometry and EpidemiologyUniversity Medical Center Hamburg‐EppendorfHamburgGermany
| | - Anna Suling
- Department of Medical Biometry and EpidemiologyUniversity Medical Center Hamburg‐EppendorfHamburgGermany
| | - Christiane Angermann
- Department of Medicine IUniversity and University Hospital WürzburgWürzburgGermany
| | - Marie‐Pia d'Ortho
- Hôpital Bichat, Explorations Fonctionnelles ‐ Sleep Centre, AP‐HPUniversité de ParisParisFrance
| | | | - Anita K. Simonds
- Royal Brompton and Harefield NHS Foundation Trust HospitalLondonUK
| | | | - Helmut Teschler
- Department of Pneumology, Ruhrlandklinik, West German Lung CenterUniversity Hospital Essen, University Duisburg‐EssenEssenGermany
| | | | - Holger Woehrle
- Sleep and Ventilation Center Blaubeuren, Respiratory Center UlmUlmGermany
| |
Collapse
|
6
|
Sleep Breathing Disorders in Heart Failure. Cardiol Clin 2022; 40:183-189. [DOI: 10.1016/j.ccl.2021.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
|
7
|
Conte M, Petraglia L, Poggio P, Valerio V, Cabaro S, Campana P, Comentale G, Attena E, Russo V, Pilato E, Formisano P, Leosco D, Parisi V. Inflammation and Cardiovascular Diseases in the Elderly: The Role of Epicardial Adipose Tissue. Front Med (Lausanne) 2022; 9:844266. [PMID: 35242789 PMCID: PMC8887867 DOI: 10.3389/fmed.2022.844266] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Accepted: 01/13/2022] [Indexed: 01/08/2023] Open
Abstract
Human aging is a complex phenomenon characterized by a wide spectrum of biological changes which impact on behavioral and social aspects. Age-related changes are accompanied by a decline in biological function and increased vulnerability leading to frailty, thereby advanced age is identified among the major risk factors of the main chronic human diseases. Aging is characterized by a state of chronic low-grade inflammation, also referred as inflammaging. It recognizes a multifactorial pathogenesis with a prominent role of the innate immune system activation, resulting in tissue degeneration and contributing to adverse outcomes. It is widely recognized that inflammation plays a central role in the development and progression of numerous chronic and cardiovascular diseases. In particular, low-grade inflammation, through an increased risk of atherosclerosis and insulin resistance, promote cardiovascular diseases in the elderly. Low-grade inflammation is also promoted by visceral adiposity, whose accumulation is paralleled by an increased inflammatory status. Aging is associated to increase in epicardial adipose tissue (EAT), the visceral fat depot of the heart. Structural and functional changes in EAT have been shown to be associated with several heart diseases, including coronary artery disease, aortic stenosis, atrial fibrillation, and heart failure. EAT increase is associated with a greater production and secretion of pro-inflammatory mediators and neuro-hormones, so that thickened EAT can pathologically influence, in a paracrine and vasocrine manner, the structure and function of the heart and is associated to a worse cardiovascular outcome. In this review, we will discuss the evidence underlying the interplay between inflammaging, EAT accumulation and cardiovascular diseases. We will examine and discuss the importance of EAT quantification, its characteristics and changes with age and its clinical implication.
Collapse
Affiliation(s)
- Maddalena Conte
- Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy.,Casa di Cura San Michele, Maddaloni, Italy
| | - Laura Petraglia
- Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
| | | | | | - Serena Cabaro
- Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
| | - Pasquale Campana
- Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
| | - Giuseppe Comentale
- Department of Advanced Biomedical Science, University of Naples Federico II, Naples, Italy
| | - Emilio Attena
- Department of Cardiology, Monaldi Hospital, Naples, Italy
| | - Vincenzo Russo
- Department of Medical Translational Sciences, Monaldi Hospital, University of Campania Luigi Vanvitelli, Campania, Italy
| | - Emanuele Pilato
- Department of Advanced Biomedical Science, University of Naples Federico II, Naples, Italy
| | - Pietro Formisano
- Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
| | - Dario Leosco
- Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
| | - Valentina Parisi
- Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
| |
Collapse
|
8
|
Gentile F, Borrelli C, Sciarrone P, Buoncristiani F, Spiesshoefer J, Bramanti F, Iudice G, Vergaro G, Emdin M, Passino C, Giannoni A. Central Apneas Are More Detrimental in Female Than in Male Patients With Heart Failure. J Am Heart Assoc 2022; 11:e024103. [PMID: 35191313 PMCID: PMC9075076 DOI: 10.1161/jaha.121.024103] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Central apneas (CA) are a frequent comorbidity in patients with heart failure (HF) and are associated with worse prognosis. The clinical and prognostic relevance of CA in each sex is unknown. Methods and Results Consecutive outpatients with HF with either reduced or mildly reduced left ventricular ejection fraction (n=550, age 65±12 years, left ventricular ejection fraction 32%±9%, 21% women) underwent a 24‐hour ambulatory polygraphy to evaluate CA burden and were followed up for the composite end point of cardiac death, appropriate implantable cardioverter‐defibrillator shock, or first HF hospitalization. Compared with men, women were younger, had higher left ventricular ejection fraction, had lower prevalence of ischemic etiology and of atrial fibrillation, and showed lower apnea‐hypopnea index (expressed as median [interquartile range]) at daytime (3 [0–9] versus 10 [3–20] events/hour) and nighttime (10 [3–21] versus 23 [11–36] events/hour) (all P<0.001), despite similar neurohormonal activation and HF therapy. Increased chemoreflex sensitivity to either hypoxia or hypercapnia (evaluated in 356 patients, 65%, by a rebreathing test) was less frequent in women (P<0.001), but chemoreflex sensitivity to hypercapnia was a predictor of apnea‐hypopnea index in both sexes. At adjusted survival analysis, daytime apnea‐hypopnea index ≥15 events/hour (hazard ratio [HR], 2.70; 95% CI, 1.06–7.34; P=0.037), nighttime apnea‐hypopnea index ≥15 events/hour (HR, 2.84; 95% CI, 1.28–6.32; P=0.010), and nighttime CA index ≥10 events/hour (HR, 5.01; 95% CI, 1.88–13.4; P=0.001) were independent predictors of the primary end point in women but not in men (all P>0.05), also after matching women and men for possible confounders. Conclusions In chronic HF, CA are associated with a greater risk of adverse events in women than in men.
Collapse
Affiliation(s)
- Francesco Gentile
- Fondazione Toscana G. MonasterioCNR-Regione Toscana Pisa Italy.,University Hospital Pisa Italy
| | - Chiara Borrelli
- Fondazione Toscana G. MonasterioCNR-Regione Toscana Pisa Italy.,University Hospital Pisa Italy
| | - Paolo Sciarrone
- Fondazione Toscana G. MonasterioCNR-Regione Toscana Pisa Italy.,University Hospital Pisa Italy
| | | | | | | | - Giovanni Iudice
- Fondazione Toscana G. MonasterioCNR-Regione Toscana Pisa Italy
| | - Giuseppe Vergaro
- Fondazione Toscana G. MonasterioCNR-Regione Toscana Pisa Italy.,Institute of Life Sciences Scuola Superiore Sant'Anna Pisa Italy
| | - Michele Emdin
- Fondazione Toscana G. MonasterioCNR-Regione Toscana Pisa Italy.,Institute of Life Sciences Scuola Superiore Sant'Anna Pisa Italy
| | - Claudio Passino
- Fondazione Toscana G. MonasterioCNR-Regione Toscana Pisa Italy.,Institute of Life Sciences Scuola Superiore Sant'Anna Pisa Italy
| | - Alberto Giannoni
- Fondazione Toscana G. MonasterioCNR-Regione Toscana Pisa Italy.,Institute of Life Sciences Scuola Superiore Sant'Anna Pisa Italy
| |
Collapse
|
9
|
Chuang LP, Pang JHS, Lin SW, Hung KC, Hu HC, Kao KC, Wen MS, Chen NH. Elevated serum matrix metalloproteinase-2 levels in heart failure patients with reduced ejection fraction and Cheyne-Stokes respiration. J Clin Sleep Med 2022; 18:1365-1373. [PMID: 35023473 PMCID: PMC9059589 DOI: 10.5664/jcsm.9870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES Cheyne-Stokes respiration (CSR), a kind of central sleep apnea (CSA), is referred to as a poor prognostic factor in heart failure patients with reduced ejection fraction (HFrEF). Matrix metalloproteinase (MMP) and B-type natriuretic peptide (BNP) play important roles in HFrEF patients and are markers of poor prognosis. However, there is no literature mentioning the changes in MMP and BNP in HFrEF patients with CSR. METHODS From June 2018 to June 2019, 41 adult patients with stable heart failure and left ventricular ejection fraction (LVEF) <50% were enrolled from the cardiology clinic. After history taking and medication review to exclude possible central nervous system or medication related CSA, an overnight polysomnography study was performed, and CSR was identified. The morning serum MMP-2, MMP-9 and BNP levels were determined using enzyme-linked immunosorbent assay and fluorescence immunoassay techniques. A positive airway pressure (PAP) device was applied to 7 patients for 3 months. RESULTS The serum MMP-2 and BNP levels were significantly higher in HFrEF patients with CSR than in patients without CSR. In addition, elevated serum MMP-2 levels correlated well with the severity of sleep apnea and intermittent hypoxia, which were represented as the apnea-hypopnea index and the oxygen-desaturation index. No positive correlation was found between those markers and LVEF. Finally, the treatment of sleep apnea with CPAP for 3 months tended to reduce the elevated serum MMP-2 levels. CONCLUSIONS Higher serum MMP-2 and BNP levels were found in HFrEF patients with CSR. Elevated MMP-2 levels were correlated with the severity of sleep apnea and intermittent hypoxia.
Collapse
Affiliation(s)
- Li-Pang Chuang
- Sleep Center and Department of Pulmonary and Critical Care Medicine, Chang Gung Memorial Hospital, Linkou, Taiwan.,School of Medicine, Chang Gung University, Taoyuan, Taiwan.,Department of Respiratory Therapy, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Jong-Hwei S Pang
- Graduate Institute of Clinical Medical Sciences, Chang Gung University, Taoyuan, Taiwan
| | - Shih-Wei Lin
- Sleep Center and Department of Pulmonary and Critical Care Medicine, Chang Gung Memorial Hospital, Linkou, Taiwan.,Department of Respiratory Therapy, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Kuo-Chun Hung
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Han-Chung Hu
- Sleep Center and Department of Pulmonary and Critical Care Medicine, Chang Gung Memorial Hospital, Linkou, Taiwan.,Department of Respiratory Therapy, Chang Gung Memorial Hospital, Linkou, Taiwan.,Department of Respiratory Therapy, Chang Gung University, Taoyuan, Taiwan
| | - Kuo-Chin Kao
- Sleep Center and Department of Pulmonary and Critical Care Medicine, Chang Gung Memorial Hospital, Linkou, Taiwan.,Department of Respiratory Therapy, Chang Gung Memorial Hospital, Linkou, Taiwan.,Department of Respiratory Therapy, Chang Gung University, Taoyuan, Taiwan
| | - Ming-Shien Wen
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Ning-Hung Chen
- Sleep Center and Department of Pulmonary and Critical Care Medicine, Chang Gung Memorial Hospital, Linkou, Taiwan.,Department of Respiratory Therapy, Chang Gung Memorial Hospital, Linkou, Taiwan
| |
Collapse
|
10
|
Floras JS. The 2021 Carl Ludwig Lecture. Unsympathetic autonomic regulation in heart failure: patient-inspired insights. Am J Physiol Regul Integr Comp Physiol 2021; 321:R338-R351. [PMID: 34259047 DOI: 10.1152/ajpregu.00143.2021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Defined as a structural or functional cardiac abnormality accompanied by symptoms, signs, or biomarkers of altered ventricular pressures or volumes, heart failure also is a state of autonomic disequilibrium. A large body of evidence affirms that autonomic disturbances are intrinsic to heart failure; basal or stimulated sympathetic nerve firing or neural norepinephrine (NE) release more often than not exceed homeostatic need, such that an initially adaptive adrenergic or vagal reflex response becomes maladaptive. The magnitude of such maladaptation predicts prognosis. This Ludwig lecture develops two theses: the elucidation and judiciously targeted amelioration of maladaptive autonomic disturbances offers opportunities to complement contemporary guideline-based heart failure therapy, and serendipitous single-participant insights, acquired in the course of experimental protocols with entirely different intent, can generate novel insight, inform mechanisms, and launch entirely new research directions. I précis six elements of our current synthesis of the causes and consequences of maladaptive sympathetic disequilibrium in heart failure, shaped by patient-inspired epiphanies: arterial baroreceptor reflex modulation, excitation stimulated by increased cardiac filling pressure, paradoxical muscle sympathetic activation as a peripheral neurogenic constraint on exercise capacity, renal sympathetic restraint of natriuresis, coexisting sleep apnea, and augmented chemoreceptor reflex sensitivity and then conclude by envisaging translational therapeutic opportunities.
Collapse
Affiliation(s)
- John S Floras
- University Health Network and Sinai Health Division of Cardiology, Toronto General Hospital Research Institute and Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
11
|
Novel technologies in the management of heart failure with preserved ejection fraction: a promise during the time of disappointment from pharmacological approaches? Curr Opin Cardiol 2021; 36:211-218. [PMID: 33394706 DOI: 10.1097/hco.0000000000000829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Despite numerous attempts, none of a wide variety of tested drugs achieved meaningful improvement in the outcomes of heart failure with preserved ejection fraction (HFpEF), making new therapeutic strategies a major unmet medical need. The medical device industry embraced the challenge, developing novel technologies directed to face specific aspects of the pathophysiology of HFpEF. This review focuses on some of the most promising technologies attaining meaningful clinical progress recently in the field of HFpEF therapy. RECENT FINDINGS Implantable pulmonary artery pressure, monitoring for optimization of medical therapy, proved to be beneficial in heart failure admissions in a large postmarketing clinical study. Investigational devices, such as inter-atrial shunts and transvenous phrenic nerve stimulators for the treatment of central sleep apnea with Cheyne-Stokes breathing, are currently being evaluated in HFpEF cohorts in recent trials. SUMMARY Device-based therapies for HFpEF demonstrated encouraging safety and efficacy results in various stages of the disease. Further efforts are needed to ensure that these devices will reach clinical use and contribute to the management of HFpEF patients.
Collapse
|
12
|
Resano-Barrio MP, Arroyo-Espliguero R, Viana-Llamas MC, Mediano O. Obstructive Sleep Apnoea Syndrome: Continuous Positive Airway Pressure Therapy for Prevention of Cardiovascular Risk. Eur Cardiol 2020; 15:e65. [PMID: 33042228 PMCID: PMC7539148 DOI: 10.15420/ecr.2020.10] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 07/27/2020] [Indexed: 12/13/2022] Open
Abstract
Obstructive sleep apnoea (OSA) syndrome is characterised by the presence of apnoea or obstructive hypopnoea during sleep, accompanied by hypoxia. It is estimated that the syndrome affects approximately 10% of men and 15% of women. Diagnosis and treatment rates have increased in recent years, but the condition remains undiagnosed in a high percentage of patients. Recent evidence suggests that OSA may increase the risk of cardiovascular disease. The relationship between OSA and cardiovascular disease can be explained, at least in part, by the coexistence of cardiovascular risk factors in the two pathologies, such as age, overweight, smoking and sedentary lifestyle. However, OSA has been independently associated with the risk of developing hypertension, cerebrovascular disease, ischaemic heart disease, heart failure and arrhythmias. Clinical trials that have evaluated the efficacy of continuous positive airway pressure (CPAP) treatment in primary and secondary cardiovascular prevention have not demonstrated a significant reduction in the incidence or recurrence of cardiovascular events. This article analyses the relationship between OSA and cardiovascular risk and discusses recent clinical trials on the efficacy of CPAP in primary and secondary cardiovascular prevention.
Collapse
Affiliation(s)
| | | | | | - Olga Mediano
- Department of Respiratory Medicine, University Hospital Guadalajara, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES) Madrid, Spain.,Department of Medicine, University of Alcalá Alcalá de Henares, Madrid, Spain
| |
Collapse
|
13
|
Hetland A, Vistnes M, Haugaa KH, Liland KH, Olseng M, Edvardsen T. Obstructive sleep apnea versus central sleep apnea: prognosis in systolic heart failure. Cardiovasc Diagn Ther 2020; 10:396-404. [PMID: 32695620 DOI: 10.21037/cdt.2020.03.02] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background In chronic heart failure (CHF), obstructive sleep apnea (OSA) and Cheyne-Stokes respiration (CSR) are associated with increased mortality. The present study aimed to evaluate the prognostic effect of CSR compared to OSA, in otherwise similar groups of CHF patients. Methods Screening for sleep-disordered breathing (SDB) was conducted among patients with CHF of New York Heart Association (NYHA) class II-IV, and left ventricular ejection fraction (LVEF) of ≤45%. The study included 43 patients (4 women) with >25% CSR during sleeping time, and 19 patients (2 women) with OSA and an apnea-hypopnea index (AHI) of ≥6. Patients were followed for a median of 1,371 days. The primary endpoint was mortality, and the secondary endpoint was combined mortality and hospital admissions. Results Baseline parameters did not significantly differ between groups, but CSR patients were older and had higher AHI values than OSA patients. Five OSA patients (26%) died, and 14 (74%) met the combined end-point of death or hospitalization. CSR patients had significantly higher risk for both end-points, with 23 (53%) deaths [log-rank P=0.040; HR, 2.70 (1.01-7.22); P=0.047] and 40 (93%) deaths or readmissions [log-rank P=0.029; HR, 1.96 (1.06-3.63); P=0.032]. After adjustment for confounding risk factors, the association between CSR and death remained significant [HR, 4.73 (1.10-20.28); P=0.037], hospital admission rates were not significantly different. Conclusions Among patients with CHF, CSR was associated with higher mortality than OSA independently of age and cardiac systolic function. CSR was also an age-independent predictor of unfavorable outcome, but hospital admission rates were not significantly different between the two groups after adjustment.
Collapse
Affiliation(s)
- Arild Hetland
- Department of Cardiology, The Hospital of Oestfold, Oestfold, Norway.,Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Maria Vistnes
- Department of Internal Medicine, Diakonhjemmet Hospital, Oslo, Norway
| | - Kristina H Haugaa
- Faculty of Medicine, University of Oslo, Oslo, Norway.,Department of Cardiology and Center for Cardiological Innovation, Oslo University Hospital, Rikshospitalet Oslo, Oslo, Norway
| | - Kristian Hovde Liland
- Faculty of Science and Technology, Norwegian University of Life Sciences, Ås, Norway
| | - Margareth Olseng
- Department of Cardiology, The Hospital of Oestfold, Oestfold, Norway
| | - Thor Edvardsen
- Faculty of Medicine, University of Oslo, Oslo, Norway.,Department of Cardiology and Center for Cardiological Innovation, Oslo University Hospital, Rikshospitalet Oslo, Oslo, Norway
| |
Collapse
|
14
|
Tamisier R, Damy T, Davy JM, Verbraecken JA, Bailly S, Lavergne F, Palot A, Goutorbe F, Pépin JL, d'Ortho MP. Cohort profile: FACE, prospective follow-up of chronic heart failure patients with sleep-disordered breathing indicated for adaptive servo ventilation. BMJ Open 2020; 10:e038403. [PMID: 32690535 PMCID: PMC7371028 DOI: 10.1136/bmjopen-2020-038403] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
PURPOSE FACE is a prospective cohort study designed to assess the effect of adding adaptive servoventilation (ASV) to standard care on morbidity and mortality in patients with chronic heart failure (HF) with preserved (HFpEF), mid-range (HFmrEF) or reduced ejection fraction (HFrEF) who have sleep-disordered breathing (SDB) with an indication for ASV. We describe the study design, ongoing data collection and baseline participant characteristics. PARTICIPANTS Consecutive patients with HFpEF, HFmrEF or HFrEF plus SDB with central sleep apnoea (CSA) and indication for ASV were enrolled in the study cohort between November 2009 and December 2018; the ASV group includes those treated with ASV and the control group consists of patients who refused ASV or stopped treatment early. Follow-up is based on standard clinical practice, with visits at inclusion, after 3, 12 and 24 months of follow-up. Primary endpoint is the time to first event: all-cause death or unplanned hospitalisation (or unplanned prolongation of a planned hospitalisation) for worsening of HF, cardiovascular death or unplanned hospitalisation for worsening of HF, and all-cause death or all-cause unplanned hospitalisation. FINDINGS TO DATE 503 patients have been enrolled, mean age of 72 years, 88% male, 31% with HFrEF. HF was commonly of ischaemic origin, and the number of comorbidities was high. SDB was severe (median Apnoea-Hypopnoea Index 42/hour), and CSA was the main indication for ASV (69%). HF was highly symptomatic; most patients were in NYHA class II (38%) or III (29%). FUTURE PLANS Patient follow-up is ongoing. Given the heterogeneous nature of the enrolled population, a decision was made to use latent class analysis to define homogeneous patient subgroups, and then evaluate outcomes by cluster, and in the ASV and control groups (overall and within patient clusters). First analysis will be performed after 3 months, a second analysis at the 2-year follow-up. TRIAL REGISTRATION NUMBER NCT01831128; Pre-results.
Collapse
Affiliation(s)
- Renaud Tamisier
- HP2, Grenoble Alpes University, Grenoble, France
- HP2, Inserm, U1042, Grenoble Alps University Hospital, Grenoble, France
- Clinique Universitaire Pneumologie et Physiologie, Centre Hospitalier Universitaire Grenoble Alpes Hopital Michallon, La Tronche, Rhône-Alpes, France
| | - Thibaud Damy
- Service de cardiologie, Centre de Référence Amyloses Cardiaques, Unité INSERM U981, CHU Henri Mondor, AP-HP, Creteil, France
| | - Jean-Marc Davy
- Service de cardiologie, UFR Médecine Université Montpellier, CHU Montpellier, Montpellier, Languedoc-Roussillon, France
| | - Johan A Verbraecken
- Mutlidisciplinary Sleep Disorders centre, Antwerp University Hospital and University of Antwerp, Antwerp, Belgium
| | - Sébastien Bailly
- HP2, Grenoble Alpes University, Grenoble, France
- HP2, Inserm, U1042, Grenoble Alps University Hospital, Grenoble, France
| | | | - Alain Palot
- pneumology unit, Hôpital Saint Joseph, Marseille, Provence-Alpes-Côte d'Azur, France
| | | | - Jean-Louis Pépin
- HP2, Grenoble Alpes University, Grenoble, France
- HP2, Inserm, U1042, Grenoble Alps University Hospital, Grenoble, France
- Clinique Universitaire Pneumologie et Physiologie, Centre Hospitalier Universitaire Grenoble Alpes Hopital Michallon, La Tronche, Rhône-Alpes, France
| | - Marie-Pia d'Ortho
- Department of Physiology and Functional Exploration - Bichat Hospital, Assistance Publique - Hopitaux de Paris, Paris, Île-de-France, France
- NeuroDiderot, Inserm, Université de Paris, Paris, France
| |
Collapse
|
15
|
Nayak HM, Patel R, McKane S, James KJ, Meyer TE, Germany RE, Stellbrink C, Costanzo MR, Augostini R. Transvenous phrenic nerve stimulation for central sleep apnea is safe and effective in patients with concomitant cardiac devices. Heart Rhythm 2020; 17:2029-2036. [PMID: 32619739 DOI: 10.1016/j.hrthm.2020.06.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 06/17/2020] [Accepted: 06/19/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Central sleep apnea is common in heart failure patients. Transvenous phrenic nerve stimulation (TPNS) requires placing a lead to stimulate the phrenic nerve and activate the diaphragm. Data are lacking concerning the safety and efficacy of TPNS in patients with concomitant cardiovascular implantable electronic devices (CIEDs). OBJECTIVE To report the safety and efficacy of TPNS in patients with concomitant CIEDs. METHODS In the remedē System Pivotal Trial, 151 patients underwent TPNS device implant. This analysis compared patients with concomitant CIEDs to those without with respect to safety, implant metrics, and efficacy of TPNS. Safety was assessed using incidence of adverse events and device-device interactions. A detailed interaction protocol was followed. Implant metrics included overall TPNS implantation success. Efficacy endpoints included changes in the apnea-hypopnea index (AHI) and quality of life. RESULTS Of 151 patients, 64 (42%) had a concomitant CIED. There were no significant differences between the groups with respect to safety. There were 4 CIED oversensing events in 3 patients leading to 1 inappropriate defibrillator shock and delivery of antitachycardia pacing. There was no difference in efficacy between the CIED and non-CIED subgroups receiving TPNS, with both having similar percentages of patients who achieved ≥50% reduction in AHI and quality-of-life improvement. CONCLUSION Concomitant CIED and TPNS therapy is safe. The presence of a concomitant CIED did not seem to impact implant metrics, implantation success, and TPNS efficacy. A detailed interaction protocol should be followed to minimize the incidence of device-device interaction.
Collapse
Affiliation(s)
- Hemal M Nayak
- Center for Arrhythmia Care, Heart and Vascular Center, The University of Chicago Pritzker School of Medicine, Chicago, Illinois.
| | - Raj Patel
- Center for Arrhythmia Care, Heart and Vascular Center, The University of Chicago Pritzker School of Medicine, Chicago, Illinois
| | | | | | | | | | | | | | - Ralph Augostini
- The Ohio State University Wexner Medical Center, Columbus, Ohio
| |
Collapse
|
16
|
Kasai T, Taranto Montemurro L, Yumino D, Wang H, Floras JS, Newton GE, Mak S, Ruttanaumpawan P, Parker JD, Bradley TD. Inverse relationship of subjective daytime sleepiness to mortality in heart failure patients with sleep apnoea. ESC Heart Fail 2020; 7:2448-2454. [PMID: 32608195 PMCID: PMC7524079 DOI: 10.1002/ehf2.12808] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 04/20/2020] [Accepted: 05/14/2020] [Indexed: 12/27/2022] Open
Abstract
Aims Patients with sleep apnoea (SA) and heart failure (HF) are less sleepy than SA patients without HF. HF and SA both increase sympathetic nervous system activity (SNA). SNA can augment alertness. We previously showed that in HF patients, the degree of daytime sleepiness was not related to the severity of SA but was inversely related to SNA. Elevated SNA is associated with increased mortality in HF. Therefore, we hypothesized that in HF patients with SA, the degree of daytime sleepiness will be inversely related to mortality. Methods and results In a prospective cohort study, 218 consecutive patients with systolic HF had overnight polysomnography. Among them, 80 subjects with SA (apnoea–hypopnoea index ≥15) were followed for a mean of 28 months to determine all‐cause mortality rate. Subjective daytime sleepiness was assessed by the Epworth Sleepiness Scale (ESS). During follow‐up, 20 patients died. The 5 year death rate in patients with ESS less than 6 (i.e. less sleepy) was significantly higher than in patients with an ESS at or above the median of 6 (i.e. sleepier) [21.3 deaths/100 patient‐years vs. 6.2 deaths/100 patient‐years, unadjusted hazard ratio (HR) 2.94, 95% confidence interval (CI) 1.20 to 7.20, P = 0.018]. After adjusting for confounding factors that included sex, history of hypertension, and mean arterial oxyhaemoglobin saturation, compared with the sleepier patients, less sleepy patients had greater risk of mortality (HR 2.56, 95% CI 1.01 to 6.47, P = 0.047). As a continuous variable, ESS scores were inversely related to mortality risk (HR 0.86, 95% CI 0.75 to 0.98, P = 0.022). Conclusions In patients with HF and SA, the degree of subjective daytime sleepiness is inversely related to the mortality risk, suggesting that among HF patients with SA, those with the least daytime sleepiness are at greater risk of death. They may therefore have greater potential for mortality benefit from therapy of SA than those with greater daytime sleepiness.
Collapse
Affiliation(s)
- Takatoshi Kasai
- Sleep Research Laboratory of the Toronto Rehabilitation Institute, University of Toronto, Toronto, Ontario, Canada.,Centre for Sleep Medicine and Circadian Biology, University of Toronto, Toronto, Ontario, Canada.,Department of Cardiovascular Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Luigi Taranto Montemurro
- Sleep Research Laboratory of the Toronto Rehabilitation Institute, University of Toronto, Toronto, Ontario, Canada.,Centre for Sleep Medicine and Circadian Biology, University of Toronto, Toronto, Ontario, Canada
| | - Dai Yumino
- Sleep Research Laboratory of the Toronto Rehabilitation Institute, University of Toronto, Toronto, Ontario, Canada.,Centre for Sleep Medicine and Circadian Biology, University of Toronto, Toronto, Ontario, Canada
| | - Hanqiao Wang
- Sleep Research Laboratory of the Toronto Rehabilitation Institute, University of Toronto, Toronto, Ontario, Canada.,Centre for Sleep Medicine and Circadian Biology, University of Toronto, Toronto, Ontario, Canada
| | - John S Floras
- Department of Medicine of the Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada.,Department of Medicine, Toronto General Hospital of the University Health Network, 9N-943, 200 Elizabeth Street, Toronto, Ontario, M5G 2C4, Canada
| | - Gary E Newton
- Department of Medicine of the Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Susanna Mak
- Department of Medicine of the Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Pimon Ruttanaumpawan
- Sleep Research Laboratory of the Toronto Rehabilitation Institute, University of Toronto, Toronto, Ontario, Canada.,Centre for Sleep Medicine and Circadian Biology, University of Toronto, Toronto, Ontario, Canada
| | - John D Parker
- Department of Medicine of the Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada.,Department of Medicine, Toronto General Hospital of the University Health Network, 9N-943, 200 Elizabeth Street, Toronto, Ontario, M5G 2C4, Canada
| | - T Douglas Bradley
- Sleep Research Laboratory of the Toronto Rehabilitation Institute, University of Toronto, Toronto, Ontario, Canada.,Department of Medicine, Toronto General Hospital of the University Health Network, 9N-943, 200 Elizabeth Street, Toronto, Ontario, M5G 2C4, Canada.,Centre for Sleep Medicine and Circadian Biology, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
17
|
Giannoni A, Gentile F, Sciarrone P, Borrelli C, Pasero G, Mirizzi G, Vergaro G, Poletti R, Piepoli MF, Emdin M, Passino C. Upright Cheyne-Stokes Respiration in Patients With Heart Failure. J Am Coll Cardiol 2020; 75:2934-2946. [DOI: 10.1016/j.jacc.2020.04.033] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 04/10/2020] [Accepted: 04/13/2020] [Indexed: 12/28/2022]
|
18
|
|
19
|
Alvi RM, Tariq N, Malhotra A, Awadalla M, Triant VA, Zanni MV, Neilan TG. Sleep Apnea and Heart Failure With a Reduced Ejection Fraction Among Persons Living With Human Immunodeficiency Virus. Clin Infect Dis 2019. [PMID: 29534158 DOI: 10.1093/cid/ciy216] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Background Sleep apnea (SA) is common and has prognostic significance among broad groups of patients with heart failure (HF). There are no data characterizing the presence, associations, and prognostic significance of SA among persons living with human immunodeficiency virus (PLHIV) with HF. Methods We conducted a single-center study of PLHIV with HF with reduced ejection fraction (HFrEF; left ventricular ejection fraction [LVEF] <50%) and analyzed the relationship of SA with 30-day HF hospital readmission rate. Results Our cohort included 1124 individuals admitted with HFrEF; 15% were PLHIV, and 92% were on antiretroviral therapy. SA was noted in 28% of PLHIV and 26% of uninfected controls. Compared to uninfected controls with HFrEF and SA, PLHIV with HFrEF and SA had a lower body mass index, lower LVEF, a higher pulmonary artery systolic pressure (PASP), were more likely to have obstructive rather than central SA (P < .05 for all). In a multivariable model, PASP, low CD4 count, high viral load (VL), and SA parameters (apnea-hypopnea index, CPAP use and duration) were predictors of 30-day HF readmission rate. Each 1-hour increase in CPAP use was associated with a 14% decreased risk of 30-day HF readmission among PLHIV. Conclusions Compared to uninfected controls, PLHIV were more likely to have obstructive SA than central SA. Apnea severity, low CD4 count, high VL, and cocaine use were positively associated with 30-day HF hospital readmission rate, whereas CPAP use and increased duration of CPAP use conferred protection.
Collapse
Affiliation(s)
- Raza M Alvi
- Cardiac MR/PET/CT Program, Department of Radiology and Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Noor Tariq
- Yale New-Haven Hospital of Yale University School of Medicine, Connecticut
| | - Atul Malhotra
- University of California-San Diego Pulmonary, Critical Care and Sleep Medicine Division, La Jolla
| | - Magid Awadalla
- Cardiac MR/PET/CT Program, Department of Radiology and Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Virginia A Triant
- Divisions of General Internal Medicine and Infectious Diseases, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Markella V Zanni
- Program in Nutritional Metabolism, Divisions of General Internal Medicine and Infectious Diseases, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Tomas G Neilan
- Cardiac MR/PET/CT Program, Department of Radiology and Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston
| |
Collapse
|
20
|
Jameria Z, Mokhlesi B, Sauser E, Holloway S, Upadhyay GA, Nayak HM. First report of concomitant subcutaneous defibrillator and phrenic nerve stimulator implantation in a patient with severe central sleep apnea and left ventricular systolic dysfunction. HeartRhythm Case Rep 2019; 6:44-47. [PMID: 31956502 PMCID: PMC6962740 DOI: 10.1016/j.hrcr.2019.10.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Revised: 09/26/2019] [Accepted: 10/14/2019] [Indexed: 11/19/2022] Open
Affiliation(s)
- Zenith Jameria
- Center for Arrhythmia Care, Heart and Vascular Center, The University of Chicago Pritzker School of Medicine, Chicago, Illinois
| | - Babak Mokhlesi
- Department of Medicine, Section of Pulmonary and Critical Care, Sleep Disorders Center, The University of Chicago Pritzker School of Medicine, Chicago, Illinois
| | - Emilie Sauser
- Center for Arrhythmia Care, Heart and Vascular Center, The University of Chicago Pritzker School of Medicine, Chicago, Illinois
| | - Sharon Holloway
- Center for Arrhythmia Care, Heart and Vascular Center, The University of Chicago Pritzker School of Medicine, Chicago, Illinois
| | - Gaurav A. Upadhyay
- Center for Arrhythmia Care, Heart and Vascular Center, The University of Chicago Pritzker School of Medicine, Chicago, Illinois
| | - Hemal M. Nayak
- Center for Arrhythmia Care, Heart and Vascular Center, The University of Chicago Pritzker School of Medicine, Chicago, Illinois
- Address reprint requests and correspondence: Dr Hemal M. Nayak, MD, FHRS, Center for Arrhythmia Care, The University of Chicago Medicine, 5841 S. Maryland Avenue, MC 9024, Chicago, IL 60637.
| |
Collapse
|
21
|
Abstract
Synchronization of molecular, metabolic, and cardiovascular circadian oscillations is fundamental to human health. Sleep-disordered breathing, which disrupts such temporal congruence, elicits hemodynamic, autonomic, chemical, and inflammatory disturbances with acute and long-term consequences for heart, brain, and circulatory and metabolic function. Sleep apnea afflicts a substantial proportion of adult men and women but is more prevalent in those with established cardiovascular diseases and especially fluid-retaining states. Despite the experimental, epidemiological, observational, and interventional evidence assembled in support of these concepts, this substantial body of work has had relatively modest pragmatic impact, thus far, on the discipline of cardiology. Contemporary estimates of cardiovascular risk still are derived typically from data acquired during wakefulness. The impact of sleep-related breathing disorders rarely is entered into such calculations or integrated into diagnostic disease-specific algorithms or therapeutic recommendations. Reasons for this include absence of apnea-related symptoms in most with cardiovascular disease, impediments to efficient diagnosis at the population level, debate as to target, suboptimal therapies, difficulties mounting large randomized trials of sleep-specific interventions, and the challenging results of those few prospective cardiovascular outcome trials that have been completed and reported. The objectives of this review are to delineate the bidirectional interrelationship between sleep-disordered breathing and cardiovascular disease, consider the findings and implications of observational and randomized trials of treatment, frame the current state of clinical equipoise, identify principal current controversies and potential paths to their resolution, and anticipate future directions.
Collapse
Affiliation(s)
- John S Floras
- From the University Health Network and Sinai Health System Division of Cardiology, Department of Medicine, University of Toronto, Ontario, Canada.
| |
Collapse
|
22
|
Sánchez T, Gozal D, Smith DL, Foncea C, Betancur C, Brockmann PE. Association between air pollution and sleep disordered breathing in children. Pediatr Pulmonol 2019; 54:544-550. [PMID: 30719878 DOI: 10.1002/ppul.24256] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2018] [Accepted: 12/10/2018] [Indexed: 11/05/2022]
Abstract
BACKGROUND AND OBJECTIVE Similar to other respiratory diseases, sleep disordered breathing (SDB) may be exacerbated by air contaminants. Air pollution may have an impact on incidence and severity of SDB in children. The aims of this study were to examine potential associations between the exposure to different air pollutants and SDB symptoms in children. METHODS In this cross-sectional study, parents from first grade children of elementary schools throughout Chile were included. Data about clinical and family-related SDB risk factors, and the pediatric sleep questionnaire (PSQ) were obtained. Air pollution and meteorological data were obtained from the Chilean online air quality database. RESULTS A total of 564 children (44.9% males) aged (median) 6 years (5-9 year) were included. Prevalence of SDB based on PSQ was 17.7%. When examining air pollutants and conditions, only higher humidity (β = 0.005, 95%CI 0.001-0.009, P = 0.011) was significantly associated with higher PSQ scores after adjusting for demographic and household variables. Higher ozone (O3 ) levels (OR = 1.693, 95%CI 1.409-2.035, P < 0.001), higher humidity (OR = 1.161, 95%CI 1.041-2.035, P = 0.008) and higher dioxide sulfur (SO2 ) levels (OR = 1.16, 95%CI 1.07-1.94, P < 0.001]) were associated with increased odds of wheezing-related sleep disturbances after adjusting for confounders. Lower temperature was a significant predictor of snoring at least >3 nights/week, following adjustment (OR = 0.865, 95%CI 0.751-0.997, P < 0.05). CONCLUSION Sleep respiratory symptoms (wheezing and snoring) are significantly associated with air pollutants such as O3 and SO2 . In addition, meteorological conditions such as humidity and low temperatures may be also associated with SDB-related symptoms.
Collapse
Affiliation(s)
- Trinidad Sánchez
- Division of Pediatrics, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - David Gozal
- Section of Pediatric Sleep Medicine, Department of Pediatrics, Pritzker School of Medicine, Biological Sciences Division, The University of Chicago, Chicago, Illinois
| | - Dale L Smith
- Department of Public Health Sciences, Biological Sciences Division, The University of Chicago, Chicago, Illinois
| | | | - Carmen Betancur
- Department of Psychiatry and Mental Health, Universidad de Concepción, Concepción, Chile
| | - Pablo E Brockmann
- Pediatric Sleep Center, Department of Pediatric Cardiology and Pulmonology, Division of Pediatrics, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| |
Collapse
|
23
|
Gullvåg M, Gjeilo KH, Fålun N, Norekvål TM, Mo R, Broström A. Sleepless nights and sleepy days: a qualitative study exploring the experiences of patients with chronic heart failure and newly verified sleep-disordered breathing. Scand J Caring Sci 2019; 33:750-759. [PMID: 30866061 DOI: 10.1111/scs.12672] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Accepted: 01/27/2019] [Indexed: 01/18/2023]
Abstract
BACKGROUND Sleep-disordered breathing, including obstructive sleep apnoea and central sleep apnoea, is a common disorder among patients with chronic heart failure. Obstructive sleep apnoea is often treated with continuous positive airway pressure, but central sleep apnoea lacks a clear treatment option. Knowledge of how sleep-disordered breathing is experienced (e.g. difficulties and care needs) and handled (e.g. self-care actions) by the patients is limited, but needed, to provide patient-centred care. AIM To explore how newly verified sleep-disordered breathing is experienced by patients with chronic heart failure. METHODS Data were collected through semi-structured interviews and analysed with qualitative content analysis. Seventeen participants (14 men, three women), mean age 60 years (range 41-80) diagnosed with chronic heart failure and objectively verified sleep-disordered breathing (nine obstructive, seven central and one mixed) were strategically selected from heart failure outpatient clinics at two Norwegian university hospitals. RESULTS Patients with chronic heart failure and newly verified sleep-disordered breathing (SDB) described experiences of poor sleep that had consequences for their daily life and their partners. Different self-care strategies were revealed, but they were based on 'common sense' and were not evidence-based. The awareness of having SDB was varied; for some, it gave an explanation to their trouble while others were surprised by the finding. CONCLUSION Patients with chronic heart failure and sleep-disordered breathing experienced reduced sleep quality, influencing their daily life. Possible underlying causes of disrupted sleep, such as sleep-disordered breathing, should be identified to establish proper patient-centred treatment strategies. There is a need for new strategies to approach patients with chronic heart failure (i.e. those with central sleep apnoea) who are not subject to continuous positive airway pressure treatment for their sleep-disordered breathing.
Collapse
Affiliation(s)
- Marianne Gullvåg
- Department of Cardiology, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway.,Faculty of Health and Social Sciences, Western Norway University of Applied Sciences, Bergen, Norway
| | - Kari Hanne Gjeilo
- Department of Cardiology, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway.,Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway.,Department of Cardiothoracic Surgery, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Nina Fålun
- Faculty of Health and Social Sciences, Western Norway University of Applied Sciences, Bergen, Norway.,Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
| | - Tone M Norekvål
- Faculty of Health and Social Sciences, Western Norway University of Applied Sciences, Bergen, Norway.,Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
| | - Rune Mo
- Department of Cardiology, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway.,Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Anders Broström
- Faculty of Health and Social Sciences, Western Norway University of Applied Sciences, Bergen, Norway.,School of Health Sciences, Jönköping University, Jönköping, Sweden.,Department of Clinical Neurophysiology, Linköping University Hospital, Linköping, Sweden
| |
Collapse
|
24
|
Daubert MA, Whellan DJ, Woehrle H, Tasissa G, Anstrom KJ, Lindenfeld J, Benjafield A, Blase A, Punjabi N, Fiuzat M, Oldenburg O, O'Connor CM. Treatment of sleep-disordered breathing in heart failure impacts cardiac remodeling: Insights from the CAT-HF Trial. Am Heart J 2018; 201:40-48. [PMID: 29910054 DOI: 10.1016/j.ahj.2018.03.026] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Accepted: 03/30/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND Sleep-disordered breathing (SDB), including central and obstructive sleep apnea, is a marker of poor prognosis in heart failure (HF) and may worsen cardiac dysfunction over time. Treatment of SDB with adaptive servoventilation (ASV) may reverse pathologic cardiac remodeling in HF patients. METHODS The Cardiovascular Improvements with Minute Ventilation-targeted Adaptive Servo-Ventilation Therapy in Heart Failure (CAT-HF) trial randomized patients with acute decompensated HF and confirmed SDB to either optimal medical therapy (OMT) or treatment with ASV and OMT. Patients with reduced ejection fraction (HFrEF) or preserved EF (HFpEF) were included. Echocardiograms, performed at baseline and 6 months, assessed cardiac size and function and evaluated cardiac remodeling over time. The CAT-HF trial was stopped early in response to the SERVE-HF trial, which found increased mortality among HFrEF patients with central sleep apnea treated with ASV. RESULTS Of the 126 patients enrolled prior to trial cessation, 95 had both baseline and 6-month echocardiograms (77 HFrEF and 18 HFpEF). Among HFrEF patients, both treatment arms demonstrated a significant increase in EF: +4.3% in the ASV group (.0004) and +4.6% in OMT alone (P = .007) and a significant decrease in LV end-systolic volume index: -9.4 mL/m2 in the ASV group (P = .01) and -8.6 mL/m2 in OMT alone (P = .003). Reductions in left atrial (LA) volume and E/e' were greater in the ASV arm, whereas patients receiving OMT alone demonstrated more improvement in right ventricular function. HFpEF patients treated with ASV also had a decrease in LA size that was greater than those receiving OMT alone. Although there were significant intragroup changes within the ASV + OMT and OMT-alone groups, there were no significant intergroup differences at 6 months. CONCLUSIONS Significant reverse LV remodeling was seen among HFrEF patients with SDB regardless of treatment allocation. Substantial reductions in LA volume among HFrEF and HFpEF patients receiving ASV suggest that ASV treatment may also improve diastolic function and warrant further investigation.
Collapse
|
25
|
Roder F, Strotmann J, Fox H, Bitter T, Horstkotte D, Oldenburg O. Interactions of Sleep Apnea, the Autonomic Nervous System, and Its Impact on Cardiac Arrhythmias. CURRENT SLEEP MEDICINE REPORTS 2018. [DOI: 10.1007/s40675-018-0117-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
|
26
|
Parisi V, Paolillo S, Rengo G, Formisano R, Petraglia L, Grieco F, D'Amore C, Dellegrottaglie S, Marciano C, Ferrara N, Leosco D, Filardi PP. Sleep-disordered breathing and epicardial adipose tissue in patients with heart failure. Nutr Metab Cardiovasc Dis 2018; 28:126-132. [PMID: 29198416 DOI: 10.1016/j.numecd.2017.09.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Revised: 09/11/2017] [Accepted: 09/28/2017] [Indexed: 01/02/2023]
Abstract
BACKGROUND AND AIMS Sleep-disordered breathing (SDB) is common in patients with heart failure (HF), contributes to the progression of cardiac disease, and is associated with adverse prognosis. Previous evidence indicates that epicardial adipose tissue (EAT) is independently associated with sleep apnea in obese individuals. We explored the relationship between SDB and EAT in HF patients. METHODS AND RESULTS EAT thickness was assessed by echocardiography in 66 patients with systolic HF undergoing nocturnal cardiorespiratory monitoring. A significantly higher EAT thickness was found in patients with SDB than in those without SDB (10.7 ± 2.8 mm vs. 8.3 ± 1.8 mm; p = 0.001). Among SDB patients, higher EAT thickness was found in both those with prevalent obstructive sleep apnea (OSA) and those with prevalent central sleep apnea (CSA). Of interest, EAT thickness was significantly higher in CSA than in OSA patients (11.9 ± 2.9 vs. 10.1 ± 2.5 p = 0.022). Circulating plasma norepinephrine levels were higher in CSA than in OSA patients (2.19 ± 1.25 vs. 1.22 ± 0.92 ng/ml, p = 0.019). According to the apnea-hypopnea index (AHI), patients were then stratified in three groups of SDB severity: Group 1, mild SDB; Group 2, moderate SDB; Group 3, severe SDB. EAT thickness progressively and significantly increased from Group 1 to Group 3 (ANOVA p < 0.001). At univariate analysis, only left ventricular ejection fraction and AHI significantly correlated with EAT (p = 0.019 and p < 0.0001, respectively). At multivariate analysis, AHI was the only independent predictor of EAT (β = 0.552, p < 0.001). CONCLUSIONS Our results suggest an association between the presence and severity of sleep apneas and cardiac visceral adiposity in HF patients.
Collapse
Affiliation(s)
- V Parisi
- Department of Translational Medical Sciences, Naples, Italy
| | - S Paolillo
- SDN Foundation, Institute of Diagnostic and Nuclear Development, Naples, Italy
| | - G Rengo
- Department of Translational Medical Sciences, Naples, Italy
| | - R Formisano
- Department of Translational Medical Sciences, Naples, Italy
| | - L Petraglia
- Department of Translational Medical Sciences, Naples, Italy
| | - F Grieco
- Department of Translational Medical Sciences, Naples, Italy
| | - C D'Amore
- Department of Advanced Biomedical Science, Naples, Italy
| | | | - C Marciano
- Istituto Diagnostico Varelli, Naples, Italy
| | - N Ferrara
- Department of Translational Medical Sciences, Naples, Italy
| | - D Leosco
- Department of Translational Medical Sciences, Naples, Italy.
| | - P P Filardi
- Department of Advanced Biomedical Science, Naples, Italy
| |
Collapse
|
27
|
Sleep-disordered breathing in heart failure: The state of the art after the SERVE-HF trial. Rev Port Cardiol 2017; 36:859-867. [PMID: 29162360 DOI: 10.1016/j.repc.2017.06.007] [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] [Received: 10/27/2016] [Revised: 05/14/2017] [Accepted: 06/18/2017] [Indexed: 01/06/2023] Open
Abstract
Heart failure (HF) is one of the most prevalent conditions worldwide and despite therapeutic advances, its prognosis remains poor. Among the multiple comorbidities in HF, sleep-disordered breathing (SDB) is frequent and worsens the prognosis. Preliminary observational studies suggested that treatment of SDB could modify the prognosis of HF, and the issue has gained importance in recent years. The diagnosis of SDB is expensive, slow and suboptimal, and there is thus a need for screening devices that are easier to use and validated in this population. The first-line treatment involves optimization of medical therapy for heart failure. Continuous positive airway pressure (CPAP) is used in patients who mainly suffer from obstructive sleep apnea. In patients with predominantly central sleep apnea, CPAP is not sufficient and adaptive servo-ventilation (ASV), despite promising results in observational studies, showed no benefit in patients with symptomatic HF and reduced ejection fraction in the SERVE-HF randomized trial; on the contrary, there was unexpectedly increased mortality in the ASV group compared to controls, and so ASV is contraindicated in these patients, calling into question the definition and pathogenesis of SDB and risk stratification in these patients. There are many gaps in the evidence, and so further research is needed to better understand this issue: definitions, simple screening methods, and whether and how to treat SDB in patients with HF.
Collapse
|
28
|
Carmo J, Araújo I, Marques F, Fonseca C. Sleep-disordered breathing in heart failure: The state of the art after the SERVE-HF trial. REVISTA PORTUGUESA DE CARDIOLOGIA (ENGLISH EDITION) 2017. [DOI: 10.1016/j.repce.2017.06.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
|
29
|
van Bilsen M, Patel HC, Bauersachs J, Böhm M, Borggrefe M, Brutsaert D, Coats AJS, de Boer RA, de Keulenaer GW, Filippatos GS, Floras J, Grassi G, Jankowska EA, Kornet L, Lunde IG, Maack C, Mahfoud F, Pollesello P, Ponikowski P, Ruschitzka F, Sabbah HN, Schultz HD, Seferovic P, Slart RHJA, Taggart P, Tocchetti CG, Van Laake LW, Zannad F, Heymans S, Lyon AR. The autonomic nervous system as a therapeutic target in heart failure: a scientific position statement from the Translational Research Committee of the Heart Failure Association of the European Society of Cardiology. Eur J Heart Fail 2017; 19:1361-1378. [PMID: 28949064 DOI: 10.1002/ejhf.921] [Citation(s) in RCA: 103] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Revised: 04/23/2017] [Accepted: 05/24/2017] [Indexed: 12/20/2022] Open
Abstract
Despite improvements in medical therapy and device-based treatment, heart failure (HF) continues to impose enormous burdens on patients and health care systems worldwide. Alterations in autonomic nervous system (ANS) activity contribute to cardiac disease progression, and the recent development of invasive techniques and electrical stimulation devices has opened new avenues for specific targeting of the sympathetic and parasympathetic branches of the ANS. The Heart Failure Association of the European Society of Cardiology recently organized an expert workshop which brought together clinicians, trialists and basic scientists to discuss the ANS as a therapeutic target in HF. The questions addressed were: (i) What are the abnormalities of ANS in HF patients? (ii) What methods are available to measure autonomic dysfunction? (iii) What therapeutic interventions are available to target the ANS in patients with HF, and what are their specific strengths and weaknesses? (iv) What have we learned from previous ANS trials? (v) How should we proceed in the future?
Collapse
Affiliation(s)
- Marc van Bilsen
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Hospital, Maastricht, the Netherlands
| | - Hitesh C Patel
- National Institute for Health Research (NIHR) Cardiovascular Biomedical Research Unit, Royal Brompton Hospital, London, UK.,National Heart and Lung Institute, Imperial College London, London, UK.,Baker Heart and Diabetes Institute, Melbourne, Vic, Australia
| | - Johann Bauersachs
- Department of Cardiology and Angiology, Medical School Hannover, Hannover, Germany
| | - Michael Böhm
- Clinic for Internal Medicine III, Cardiology, Angiology and Intensive Internal Medicine, Homburg, Germany
| | - Martin Borggrefe
- First Department of Medicine, Cardiology Division, University Medical Centre Mannheim, Mannheim, Germany.,German Centre for Cardiovascular Research, Mannheim, Germany
| | - Dirk Brutsaert
- Department of Cardiology, Antwerp University, Antwerp, Belgium
| | - Andrew J S Coats
- Department of Medicine, Monash University, Melbourne, Vic, Australia.,Department of Medicine, University of Warwick, Coventry, UK
| | - Rudolf A de Boer
- Department of Cardiology, University Medical Centre Groningen, University of Groningen, Groningen, the Netherlands
| | | | - Gerasimos S Filippatos
- Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Athens University Hospital Attikon, Athens, Greece
| | - John Floras
- University Health Network and Sinai Health System Division of Cardiology, Peter Munk Cardiac Centre, Toronto General and Lunenfeld-Tanenbaum Research Institutes, University of Toronto, Toronto, ON, Canada
| | - Guido Grassi
- Clinica Medica, Department of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy.,IRCCS Multimedica, Milan, Italy
| | - Ewa A Jankowska
- Department of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland.,Centre for Heart Diseases, Military Hospital, Wroclaw, Poland
| | - Lilian Kornet
- Medtronic, Inc., Bakken Research Centre, Maastricht, the Netherlands
| | - Ida G Lunde
- Institute for Experimental Medical Research, Oslo University Hospital, University of Oslo, Oslo, Norway
| | - Christoph Maack
- Clinic for Internal Medicine III, Cardiology, Angiology and Intensive Internal Medicine, Homburg, Germany
| | - Felix Mahfoud
- Clinic for Internal Medicine III, Cardiology, Angiology and Intensive Internal Medicine, Homburg, Germany
| | | | - Piotr Ponikowski
- Department of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland.,Centre for Heart Diseases, Military Hospital, Wroclaw, Poland
| | - Frank Ruschitzka
- University Heart Centre, University Hospital Zurich, Zurich, Switzerland
| | - Hani N Sabbah
- Department of Medicine, Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI, USA
| | - Harold D Schultz
- Department of Cellular and Integrative Physiology, University of Nebraska College of Medicine, Omaha, NE, USA
| | - Petar Seferovic
- Department of Cardiology, Belgrade University Medical Centre, Belgrade, Serbia
| | - Riemer H J A Slart
- Department of Nuclear Medicine and Molecular Imaging, University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands.,Department of Biomedical Photonic Imaging, Faculty of Science and Technology, University of Twente, Enschede, the Netherlands
| | - Peter Taggart
- Department of Cardiovascular Science, University College London, Barts Heart Centre, London, UK
| | - Carlo G Tocchetti
- Department of Translational Medical Sciences, Federico II University, Naples, Italy
| | - Linda W Van Laake
- Department of Cardiology, Heart and Lungs Division, and Regenerative Medicine Centre, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Faiez Zannad
- INSERM, Centre for Clinical Investigation 9501, Unit 961, University Hospital Centre, Nancy, France.,Department of Cardiology, Nancy University, University of the Lorraine, Nancy, France
| | - Stephane Heymans
- Netherlands Heart Institute, Utrecht, the Netherlands.,Department of Cardiovascular Sciences, Leuven University, Leuven, Belgium
| | - Alexander R Lyon
- National Institute for Health Research (NIHR) Cardiovascular Biomedical Research Unit, Royal Brompton Hospital, London, UK.,National Heart and Lung Institute, Imperial College London, London, UK
| |
Collapse
|
30
|
Emdin M, Mirizzi G, Giannoni A, Poletti R, Iudice G, Bramanti F, Passino C. Prognostic Significance of Central Apneas Throughout a 24-Hour Period in Patients With Heart Failure. J Am Coll Cardiol 2017; 70:1351-1364. [PMID: 28882233 DOI: 10.1016/j.jacc.2017.07.740] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Revised: 07/07/2017] [Accepted: 07/09/2017] [Indexed: 12/28/2022]
Abstract
BACKGROUND Large trials using noninvasive mechanical ventilation to treat central apnea (CA) occurring at night ("sleep apnea") in patients with systolic heart failure (HF) have failed to improve prognosis. The prevalence and prognostic value of CA during daytime and over an entire 24-h period are not well described. OBJECTIVES This study evaluated the occurrence and prognostic significance of nighttime, daytime, and 24-h CA episodes in a large cohort of patients with systolic HF. METHODS Consecutive patients receiving guideline-recommended treatment for HF (n = 525; left ventricular ejection fraction [LVEF] of 33 ± 9%; 66 ± 12 years of age; 77% males) underwent prospective evaluation, including 24-h respiratory recording, and were followed-up using cardiac mortality as an endpoint. RESULTS The 24-h prevalence of predominant CAs (apnea/hypopnea index [AHI] ≥5 events/h, with CA of >50%) was 64.8% (nighttime: 69.1%; daytime: 57.0%), whereas the prevalence of predominant obstructive apneas (OA) was 12.8% (AHI ≥5 events/h with OAs >50%; nighttime: 14.7%; daytime: 5.9%). Episodes of CA were associated with neurohormonal activation, ventricular arrhythmic burden, and systolic/diastolic dysfunction (all p < 0.05). During a median 34-month follow-up (interquartile range [IQR]: 17 to 36 months), 50 cardiac deaths occurred. Nighttime, daytime, and 24-h moderate-to-severe CAs were associated with increased cardiac mortality (AHI of </≥15 events/h; log-rank: 6.6, 8.7, and 5.3, respectively; all p < 0.05; central apnea index [CAI] of </≥10 events/h; log-rank 8.9, 11.2, and 10.9, respectively; all p < 0.001). Age, B-type natriuretic peptide level, renal dysfunction, 24-h AHI, CAI, and time with oxygen saturation of <90% were independent predictors of outcome. CONCLUSIONS In systolic HF patients, CAs occurred throughout a 24-h period and were associated with a neurohormonal activation, ventricular arrhythmic burden, and worse prognosis.
Collapse
Affiliation(s)
- Michele Emdin
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy; Fondazione Toscana Gabriele Monasterio, Pisa, Italy.
| | - Gianluca Mirizzi
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy; Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | | | | | | | | | - Claudio Passino
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy; Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| |
Collapse
|
31
|
Strotmann J, Fox H, Bitter T, Schindhelm F, Gutleben KJ, Horstkotte D, Oldenburg O. Predominant obstructive or central sleep apnea in patients with atrial fibrillation: influence of characterizing apneas versus apneas and hypopneas. Sleep Med 2017; 37:66-71. [PMID: 28899542 DOI: 10.1016/j.sleep.2017.06.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Revised: 05/22/2017] [Accepted: 06/12/2017] [Indexed: 10/19/2022]
Abstract
OBJECTIVE/BACKGROUND Sleep-disordered breathing (SDB) is common in patients with atrial fibrillation (Afib). Although a high proportion of respiratory events are hypopneas, previous studies have only used apneas to differentiate obstructive (OSA) from central (CSA) sleep apnea. This study investigated the impact of using apneas and hypopneas versus apneas only to define the predominant type of SDB in Afib patients with preserved ejection fraction. PATIENTS/METHODS This retrospective analysis was based on high-quality cardiorespiratory polygraphy (PG) recordings (07/2007-03/2016) that were re-analyzed using 2012 American Academy of Sleep Medicine criteria, with differentiation of apneas and hypopneas as obstructive or central. Classification of predominant (>50% of events) OSA and CSA was defined based on apneas only (OSAAI and CSAAI) or apneas and hypopneas (OSAAHI and CSAAHI). SDB was defined as an apnea-hypopnea index ≥5/h. RESULTS A total of 211 patients were included (146 male, age 68.7 ± 8.5 y). Hypopneas accounted for >50% of all respiratory events. Based on apneas only, 46% of patients had predominant OSA and 44% had predominant CSA. Based on apneas and hypopneas, the proportion of patients with OSA was higher (56%) and that with CSA was lower (36%). In the subgroup of patients with moderate to severe SDB (AHI ≥ 15/h), the proportion with predominant CSA was 55.2% based on apneas only versus 42.1% with apneas and hypopneas. CONCLUSIONS In hospitalized patients with Afib and SDB, use of apneas and hypopneas versus apneas alone had an important influence on the proportion of patients classified as having predominant OSA or CSA.
Collapse
Affiliation(s)
- Johanna Strotmann
- Herz- und Diabeteszentrum NRW, Department of Cardiology, University Hospital, Ruhr- University Bochum, Georgstraße 11, 32545, Bad Oeynhausen, Germany.
| | - Henrik Fox
- Herz- und Diabeteszentrum NRW, Department of Cardiology, University Hospital, Ruhr- University Bochum, Georgstraße 11, 32545, Bad Oeynhausen, Germany.
| | - Thomas Bitter
- Herz- und Diabeteszentrum NRW, Department of Cardiology, University Hospital, Ruhr- University Bochum, Georgstraße 11, 32545, Bad Oeynhausen, Germany.
| | - Florian Schindhelm
- Herz- und Diabeteszentrum NRW, Department of Cardiology, University Hospital, Ruhr- University Bochum, Georgstraße 11, 32545, Bad Oeynhausen, Germany.
| | - Klaus-Jürgen Gutleben
- Herz- und Diabeteszentrum NRW, Department of Cardiology, University Hospital, Ruhr- University Bochum, Georgstraße 11, 32545, Bad Oeynhausen, Germany.
| | - Dieter Horstkotte
- Herz- und Diabeteszentrum NRW, Department of Cardiology, University Hospital, Ruhr- University Bochum, Georgstraße 11, 32545, Bad Oeynhausen, Germany.
| | - Olaf Oldenburg
- Herz- und Diabeteszentrum NRW, Department of Cardiology, University Hospital, Ruhr- University Bochum, Georgstraße 11, 32545, Bad Oeynhausen, Germany.
| |
Collapse
|
32
|
Woehrle H, Cowie MR, Eulenburg C, Suling A, Angermann C, d'Ortho MP, Erdmann E, Levy P, Simonds AK, Somers VK, Zannad F, Teschler H, Wegscheider K. Adaptive servo ventilation for central sleep apnoea in heart failure: SERVE-HF on-treatment analysis. Eur Respir J 2017; 50:50/2/1601692. [PMID: 28860264 PMCID: PMC5593355 DOI: 10.1183/13993003.01692-2016] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2016] [Accepted: 05/28/2017] [Indexed: 12/24/2022]
Abstract
This on-treatment analysis was conducted to facilitate understanding of mechanisms underlying the increased risk of all-cause and cardiovascular mortality in heart failure patients with reduced ejection fraction and predominant central sleep apnoea randomised to adaptive servo ventilation versus the control group in the SERVE-HF trial.Time-dependent on-treatment analyses were conducted (unadjusted and adjusted for predictive covariates). A comprehensive, time-dependent model was developed to correct for asymmetric selection effects (to minimise bias).The comprehensive model showed increased cardiovascular death hazard ratios during adaptive servo ventilation usage periods, slightly lower than those in the SERVE-HF intention-to-treat analysis. Self-selection bias was evident. Patients randomised to adaptive servo ventilation who crossed over to the control group were at higher risk of cardiovascular death than controls, while control patients with crossover to adaptive servo ventilation showed a trend towards lower risk of cardiovascular death than patients randomised to adaptive servo ventilation. Cardiovascular risk did not increase as nightly adaptive servo ventilation usage increased.On-treatment analysis showed similar results to the SERVE-HF intention-to-treat analysis, with an increased risk of cardiovascular death in heart failure with reduced ejection fraction patients with predominant central sleep apnoea treated with adaptive servo ventilation. Bias is inevitable and needs to be taken into account in any kind of on-treatment analysis in positive airway pressure studies.
Collapse
Affiliation(s)
- Holger Woehrle
- ResMed Science Center, ResMed Germany Inc., Martinsried, Germany .,Sleep and Ventilation Center Blaubeuren, Respiratory Center Ulm, Ulm, Germany
| | | | - Christine Eulenburg
- Department of Epidemiology, University Medical Center Groningen, Groningen, the Netherlands
| | - Anna Suling
- Department of Medical Biometry and Epidemiology, University Medical Center Eppendorf, Hamburg, Germany
| | - Christiane Angermann
- Department of Medicine I and Comprehensive Heart Failure Center, University Hospital and University of Würzburg, Würzburg, Germany
| | - Marie-Pia d'Ortho
- University Paris Diderot, Sorbonne Paris Cité, Hôpital Bichat, Explorations Fonctionnelles, DHU FIRE, AP-HP, Paris, France
| | | | | | | | | | - Faiez Zannad
- INSERM, Université de Lorraine, CHU Nancy, France
| | - Helmut Teschler
- Department of Pneumology, Ruhrlandklinik, West German Lung Center, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Karl Wegscheider
- Department of Medical Biometry and Epidemiology, University Medical Center Eppendorf, Hamburg, Germany
| |
Collapse
|
33
|
Yatsu S, Kasai T, Matsumoto H, Murata A, Kato T, Suda S, Hiki M, Shiroshita N, Kato M, Kawana F, Daida H. Change in type of sleep-disordered breathing from predominant central to obstructive sleep apnea following coronary artery bypass grafting. J Cardiol Cases 2017; 16:93-96. [PMID: 30279806 DOI: 10.1016/j.jccase.2017.05.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Revised: 05/18/2017] [Accepted: 05/26/2017] [Indexed: 10/19/2022] Open
Abstract
We report the case of a 67-year-old overweight man with reduced left ventricular ejection fraction (LVEF) due to myocardial infarction. He had an implantable cardioverter defibrillator (ICD) for frequent episodes of ventricular tachyarrhythmia and was initiated into adaptive-servo ventilation therapy for severe central sleep apnea (CSA), which was not suppressed by continuous positive airway pressure (CPAP). Since he still had several episodes of appropriate ICD therapies, coronary angiogram was performed, and severe three-vessel disease was found. He then underwent coronary artery bypass grafting (CABG). After CABG, his LVEF did not improve (from 29 to 25%); however, the B-type natriuretic peptide level decreased (from 560 to 330 pg/mL). Although the apnea-hypopnea index did not change (49.4 before and 55.1/h after CABG), his CSA converted to predominant obstructive sleep apnea accompanied by a shortening of the lung-to-finger circulation time (from 43 to 29 s) 2 weeks after CABG, which was completely suppressed by CPAP. <Learning objective: Central sleep apnea (CSA) can be alleviated by treatments for heart failure. However, limited data are available regarding resolution of CSA after coronary revascularization. We describe a case whose predominant CSA converted to obstructive sleep apnea after surgical coronary revascularization without any improvements in systolic function. Coronary revascularization can alleviate CSA possibly through altering congestive status and may unmask obstructive phenotype in patients with severe coronary artery disease.>.
Collapse
Affiliation(s)
- Shoichiro Yatsu
- Department of Cardiovascular Medicine, Juntendo University School of Medicine, Tokyo, Japan
| | - Takatoshi Kasai
- Department of Cardiovascular Medicine, Juntendo University School of Medicine, Tokyo, Japan.,Cardiovascular Respiratory Sleep Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Hiroki Matsumoto
- Department of Cardiovascular Medicine, Juntendo University School of Medicine, Tokyo, Japan.,Cardiovascular Respiratory Sleep Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Azusa Murata
- Department of Cardiovascular Medicine, Juntendo University School of Medicine, Tokyo, Japan
| | - Takao Kato
- Department of Cardiovascular Medicine, Juntendo University School of Medicine, Tokyo, Japan
| | - Shoko Suda
- Department of Cardiovascular Medicine, Juntendo University School of Medicine, Tokyo, Japan.,Cardiovascular Respiratory Sleep Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Masaru Hiki
- Department of Cardiovascular Medicine, Juntendo University School of Medicine, Tokyo, Japan
| | - Nanako Shiroshita
- Cardiovascular Respiratory Sleep Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Mitsue Kato
- Cardiovascular Respiratory Sleep Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Fusae Kawana
- Cardiovascular Respiratory Sleep Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Hiroyuki Daida
- Department of Cardiovascular Medicine, Juntendo University School of Medicine, Tokyo, Japan
| |
Collapse
|
34
|
Abstract
Sleep-disordered breathing (SDB) occurs in approximately 50% of patients with reduced left ventricular ejection fraction receiving contemporary heart failure (HF) therapies. Obstructive (OSA) and central sleep apneas (CSA) interrupt breathing by different mechanisms but impose qualitatively similar autonomic, chemical, mechanical, and inflammatory burdens on the heart and circulation. Because contemporary evidence-based drug and device HF therapies have little or no mitigating effect on the acute or long-term consequences of such stimuli, there is a sound mechanistic rationale for targeting SDB to reduce cardiovascular event rates and prolong life. However, the promise of observational studies and randomized trials of small size and duration describing a beneficial effect of treating SDB in HF via positive airway pressure was not realized in 2 recent randomized outcome-driven trials: SAVE, which evaluated the cardiovascular effect of treating OSA in a cohort without HF, and SERVE-HF, which reported the results of a strategy of random allocation of minute-ventilation-triggered adaptive servo-ventilation (ASV) for HF patients with CSA. Whether effective treatment of either OSA or CSA improves the HF trajectory by reducing cardiovascular morbidity or mortality has yet to be definitively established. ADVENT-HF, designed to determine the effect of treating both CSA and non-sleepy OSA HF patients with a peak-airflow triggered ASV algorithm, could resolve this present clinical equipoise concerning the treatment of SDB.
Collapse
Affiliation(s)
- Nobuhiko Haruki
- Division of Cardiovascular Medicine, Department of Molecular Medicine and Therapeutics, Tottori University Faculty of Medicine.,The University Health Network and Sinai Health System Division of Cardiology, Department of Medicine, University of Toronto
| | - John S Floras
- The University Health Network and Sinai Health System Division of Cardiology, Department of Medicine, University of Toronto
| |
Collapse
|
35
|
Salama S, Omar A, Ahmed Y, Abd El Sabour M, Seddik MI, Magdy D. Sleep-disordered breathing in ischemic cardiomyopathy and hypertensive heart failure patients. THE EGYPTIAN JOURNAL OF BRONCHOLOGY 2017. [DOI: 10.4103/ejb.ejb_42_16] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
|
36
|
Patients with Cheyne-Stokes respiration and heart failure: patient tolerance after three-month discontinuation of treatment with adaptive servo-ventilation. Heart Vessels 2017; 32:909-915. [PMID: 28188451 DOI: 10.1007/s00380-017-0951-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Accepted: 01/20/2017] [Indexed: 10/20/2022]
Abstract
The recent SERVE HF study concluded that patients with chronic heart failure (CHF) and Cheyne-Stokes respiration (CSR) have increased mortality when treated with adaptive servo-ventilation (ASV). We, therefore, wanted to explore if these patients tolerated discontinuation of ASV treatment. The study was a prospective post-ASV treatment observational design with a 3-month follow-up period. 14 patients from our outpatient clinic, all male, were originally diagnosed with CHF and Cheyne-Stokes respiration, which is a clinical form of central sleep apnea. Left ventricular ejection fraction (LVEF) was ≤45% when ASV treatment was initiated. Median machine use was 68 (42-78) months when the patients were instructed to terminate ASV treatment. The patients were then followed during conventional CHF treatment for 3 months. Study baseline was set the last ASV treatment day. Sleep data were collected from the machine the last day of use. Apnea-hypopnea index (AHI), LVEF, 6-min walk test and 24-h ambulatory electrocardiogram recordings were performed at baseline and at study end. Life quality data were obtained using The Minnesota Living with Heart Failure Questionaire (MLHFQ). New York Heart Association Functional Classification (NYHA) was registered. An ambulatory sleep screening was performed at study end. AHI increased significantly after 3 months without ASV treatment [from 1.6 (0.8-3.2) to 39.2 (24.3-44.1, p = 0.001)]. Quality of life (QOL) decreased significantly: 30 (13-54) at discontinuation of ASV vs. 46 (24-67) (MLHFQ) at study end, p = 0.04. Though there was no significant change in NYHA functional class, patients especially reported increased shortness of breath, reduced concentration and reduced memory after discontinuation of ASV treatment. There were no significant differences in LVEF, heart rhythm data and physical capacity. Left ventricular function was preserved indicating that discontinuation of ASV in heart failure patients does not affect cardiac capacity. There was a significant decrement in QOL that must be considered in further treatment of these patients.
Collapse
|
37
|
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.
Collapse
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
| |
Collapse
|
38
|
Abstract
Congestive heart failure (CHF) is among the most common causes of admission to hospitals in the United States, especially in those over age 65. Few data exist regarding the prevalence CHF of Cheyne-Stokes respiration (CSR) owing to congestive heart failure in the intensive care unit (ICU). Nevertheless, CSR is expected to be highly prevalent among those with CHF. Treatment should focus on the underlying mechanisms by which CHF increases loop gain and promotes unstable breathing. Few data are available to determine prevalence of CSR in the ICU, or how CSR might affect clinical management and weaning from mechanical ventilation.
Collapse
Affiliation(s)
- Scott A Sands
- Division of Sleep Medicine, Brigham and Women's Hospital and Harvard Medical School, 221 Longwood Avenue, Boston, MA 02115, USA; Department of Allergy, Immunology and Respiratory Medicine and Central Clinical School, Alfred Hospital and Monash University, 55 Commercial Rd, Melbourne, VIC 3004, Australia
| | - Robert L Owens
- Division of Pulmonary and Critical Care Medicine, University of California San Diego, 9300 Campus Point Drive, #7381, La Jolla, CA 92037, USA.
| |
Collapse
|
39
|
Miner SES, Pahal D, Nichols L, Darwood A, Nield LE, Wulffhart Z. Sleep Disruption is Associated with Increased Ventricular Ectopy and Cardiac Arrest in Hospitalized Adults. Sleep 2016; 39:927-35. [PMID: 26715226 DOI: 10.5665/sleep.5656] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2015] [Accepted: 11/26/2015] [Indexed: 11/03/2022] Open
Abstract
STUDY OBJECTIVES To determine whether sleep disruption increases ventricular ectopy and the risk of cardiac arrest in hospitalized patients. METHODS Hospital emergency codes (HEC) trigger multiple hospital-wide overhead announcements. In 2014 an electronic "code white" program was instituted to protect staff from violent patients. This resulted in an increase in nocturnal HEC. Telemetry data was examined between September 14 and October 2, 2014. The frequency of nocturnal announcements was correlated with changes in frequency of premature ventricular complexes per hour (PVC/h). Cardiac arrest data were examined over a 3-y period. All HEC were assumed to have triggered announcements. The relationship between nocturnal HEC and the incidence of subsequent cardiac arrest was examined. RESULTS 2,603 hours of telemetry were analyzed in 87 patients. During nights with two or fewer announcements, PVC/h decreased 33% and remained 30% lower the next day. On nights with four or more announcements, PVC/h increased 23% (P < 0.001) and further increased 85% the next day (P = 0.001). In 2014, following the introduction of the code white program, the frequency of all HEC increased from 1.1/day to 6.2/day (P < 0.05). The frequency of cardiac arrest/24 h rose from 0.46/day in 2012-2013 to 0.62/day in 2014 (P = 0.001). During daytime hours (06:00-22:00), from 2012 through 2014, the frequency of cardiac arrest following zero, one or at least two nocturnal HEC were 0.331 ± 0.03, 0.396 ± 0.04 and 0.471 ± 0.09 respectively (R(2) = 0.99, P = 0.03). CONCLUSIONS Sleep disruption is associated with increased ventricular ectopy and increased frequency of cardiac arrest.
Collapse
Affiliation(s)
- Steven Edward Stuart Miner
- Southlake Regional Health Center, Newmarket, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada
| | - Dev Pahal
- Southlake Regional Health Center, Newmarket, Ontario, Canada
| | - Laurel Nichols
- Southlake Regional Health Center, Newmarket, Ontario, Canada
| | - Amanda Darwood
- Southlake Regional Health Center, Newmarket, Ontario, Canada
| | - Lynne Elizabeth Nield
- University of Toronto, Toronto, Ontario, Canada.,Labatt Heart Center, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Zaev Wulffhart
- Southlake Regional Health Center, Newmarket, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
40
|
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.
Collapse
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
| |
Collapse
|
41
|
Liu WT, Lee KY, Lee HC, Chuang HC, Wu D, Juang JN, Chuang KJ. The association of annual air pollution exposure with blood pressure among patients with sleep-disordered breathing. THE SCIENCE OF THE TOTAL ENVIRONMENT 2016; 543:61-66. [PMID: 26580727 DOI: 10.1016/j.scitotenv.2015.10.135] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Revised: 10/27/2015] [Accepted: 10/27/2015] [Indexed: 06/05/2023]
Abstract
While sleep-disordered breathing (SDB), high blood pressure (BP) and air pollution exposure have separately been associated with increased risk of cardiopulmonary mortality, the association linking air pollution exposure to BP among patients with sleep-disordered breathing is still unclear. We collected 3762 participants' data from the Taipei Medical University Hospital's Sleep Center and air pollution data from the Taiwan Environmental Protection Administration. Associations of 1-year mean criteria air pollutants [particulate matter with aerodynamic diameters ≤10 μm (PM10), particulate matter with aerodynamic diameters ≤2.5 μm (PM2.5), nitrogen dioxide (NO2) and ozone (O3)] with systolic BP (SBP) and diastolic BP (DBP) were investigated by generalized additive models. After controlling for age, sex, body mass index (BMI), temperature and relative humidity, we observed that increases in air pollution levels were associated with decreased SBP and increased DBP. We also found that patients with apnea-hypopnea index (AHI) ≥30 showed a stronger BP response to increased levels of air pollution exposure than those with AHI<30. Stronger effects of air pollution exposure on BP were found in overweight participants than in participants with normal BMI. We concluded that annual exposure to air pollution was associated with change of BP among patients with sleep-disordered breathing. The association between annual air pollution exposure and BP could be modified by AHI and BMI.
Collapse
Affiliation(s)
- Wen-Te Liu
- Division of Pulmonary Medicine, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan; School of Respiratory Therapy, College of Medicine, Taipei Medical University, Taipei, Taiwan; Department of Engineering Science, National Cheng Kung University, Tainan, Taiwan; Sleep Research Center, Taipei Medical University Hospital, Taipei Medical University, Taipei, Taiwan; Sleep Center, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
| | - Kang-Yun Lee
- Division of Pulmonary Medicine, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan; Department of Internal Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Hsin-Chien Lee
- Sleep Research Center, Taipei Medical University Hospital, Taipei Medical University, Taipei, Taiwan; Department of Psychiatry, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
| | - Hsiao-Chi Chuang
- Division of Pulmonary Medicine, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan; School of Respiratory Therapy, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Dean Wu
- Department of Psychiatry, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan; Department of Neurology, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan; Department of Neurology, School of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Jer-Nan Juang
- Department of Engineering Science, National Cheng Kung University, Tainan, Taiwan
| | - Kai-Jen Chuang
- Department of Public Health, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan; School of Public Health, College of Public Health and Nutrition, Taipei Medical University, Taipei, Taiwan.
| |
Collapse
|
42
|
Pearse SG, Cowie MR, Sharma R, Vazir A. Sleep-disordered Breathing in Heart Failure. Eur Cardiol 2015; 10:89-94. [PMID: 30310432 PMCID: PMC6159414 DOI: 10.15420/ecr.2015.10.2.89] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Accepted: 11/03/2015] [Indexed: 11/04/2022] Open
Abstract
Sleep-disordered breathing affects over half of patients with heart failure (HF) and is associated with a poor prognosis. It is an under-diagnosed condition and may be a missed therapeutic target. Obstructive sleep apnoea is caused by collapse of the pharynx, exacerbated by rostral fluid shift during sleep. The consequent negative intrathoracic pressure, hypoxaemia, sympathetic nervous system activation and arousals have deleterious cardiovascular effects. Treatment with continuous positive airway pressure may confer symptomatic and prognostic benefit in this group. In central sleep apnoea, the abnormality is with regulation of breathing in the brainstem, often causing a waxing-waning Cheyne Stokes respiration pattern. Non-invasive ventilation has not been shown to improve prognosis in these patients and the recently published SERVE-HF trial found increased mortality in those treated with adaptive servoventilation. The management of sleep-disordered breathing in patients with HF is evolving rapidly with significant implications for clinicians involved in their care.
Collapse
Affiliation(s)
- Simon G Pearse
- Royal Brompton and Harefield NHS Trust and Imperial College London, London, United Kingdom
| | - Martin R Cowie
- Royal Brompton and Harefield NHS Trust and Imperial College London, London, United Kingdom
| | - Rakesh Sharma
- Royal Brompton and Harefield NHS Trust and Imperial College London, London, United Kingdom
| | - Ali Vazir
- Royal Brompton and Harefield NHS Trust and Imperial College London, London, United Kingdom
| |
Collapse
|
43
|
Gellen B, Canouï-Poitrine F, Boyer L, Drouot X, Le Thuaut A, Bodez D, Covali-Noroc A, D'ortho MP, Guendouz S, Rappeneau S, Kharoubi M, Dubois-Rande JL, Hittinger L, Adnot S, Bastuji-Garin S, Damy T. Apnea-hypopnea and desaturations in heart failure with reduced ejection fraction: Are we aiming at the right target? Int J Cardiol 2015; 203:1022-8. [PMID: 26630630 DOI: 10.1016/j.ijcard.2015.11.108] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Revised: 10/28/2015] [Accepted: 11/16/2015] [Indexed: 01/30/2023]
Abstract
BACKGROUND Sleep disordered breathing (SDB) is common in patients with heart failure with reduced ejection fraction (HFrEF). An increased apnea-hypopnea index (AHI) is associated with poor outcomes. We examined whether an analysis of nocturnal desaturations (NDs) can improve the risk stratification. METHODS Three-hundred seventy-six consecutive patients with stable chronic HFrEF and LVEF ≤ 45% were prospectively screened using polygraphy. Sleep apnea (SA) was defined as an AHI ≥ 15. The mean age was 59 ± 13 years, the mean LVEF was 30 ± 6%, and the median AHI was 18 [IQR: 9.33). The composite end-point of death, heart transplantation or LV assistance occurred in 98 patients (26%) within 3 years. Minimal oxygen saturation (MOS) during sleep, the number of desaturations <90%/h and the time spent with oxygen saturation <90% were significantly associated with adverse events (adjusted HR 1.25 [1.03-1.52], 1.25 [1.03-1.53], and 1.28 [1.04-1.59]), whereas the AHI was not (1.10 [0.86-1.39]). The best MOS cut-off value for poor outcomes was ≤ 88%. The patients with an MOS ≤ 88% had a significantly higher event rate (31.9%) than those with an MOS >88% (15.6%; p<0.01). The risk assessment using an MOS of ≤ 88% in addition to established prognostic markers yielded a net reclassification index (NRI) of nearly 6% and was particularly useful in the subgroup of patients with events (NRI: 8.4%). CONCLUSIONS In HFrEF patients, ND ≤ 88% appears to be predictive of adverse events, independent of the presence of SA. This suggests that the risk assessment in HFrEF should also include ND in top of AHI.
Collapse
Affiliation(s)
- Barnabas Gellen
- Cardiology Department, APHP, Henri-Mondor Hospital, F-94010 Créteil, France; Mondor Institute Biomedical Research (IMRB), INSERM U955, F-94010 Créteil, France; Cardiology Department, Poitiers University Hospital, F-86021 Poitiers, France.
| | - Florence Canouï-Poitrine
- Public Health Department and Clinical Research Unit (URC-Mondor), APHP, Henri-Mondor Hospital, F-94010 Créteil, France; CEpiA (Clinical Epidemiology and Ageing) EA4393, Medical School, UPEC, F-94010 Créteil, France
| | - Laurent Boyer
- Mondor Institute Biomedical Research (IMRB), INSERM U955, F-94010 Créteil, France; Physiology Department, APHP, Henri-Mondor Hospital, F-94010 Créteil, France
| | - Xavier Drouot
- Physiology Department, APHP, Henri-Mondor Hospital, F-94010 Créteil, France; Physiology Department, Poitiers University Hospital, F-86021 Poitiers, France
| | - Aurélie Le Thuaut
- Public Health Department and Clinical Research Unit (URC-Mondor), APHP, Henri-Mondor Hospital, F-94010 Créteil, France; CEpiA (Clinical Epidemiology and Ageing) EA4393, Medical School, UPEC, F-94010 Créteil, France
| | - Diane Bodez
- Cardiology Department, APHP, Henri-Mondor Hospital, F-94010 Créteil, France
| | - Ala Covali-Noroc
- Physiology Department, APHP, Henri-Mondor Hospital, F-94010 Créteil, France
| | | | - Soulef Guendouz
- Cardiology Department, APHP, Henri-Mondor Hospital, F-94010 Créteil, France
| | - Stéphane Rappeneau
- Cardiology Department, APHP, Henri-Mondor Hospital, F-94010 Créteil, France
| | - Mounira Kharoubi
- Cardiology Department, APHP, Henri-Mondor Hospital, F-94010 Créteil, France
| | - Jean-Luc Dubois-Rande
- Cardiology Department, APHP, Henri-Mondor Hospital, F-94010 Créteil, France; Mondor Institute Biomedical Research (IMRB), INSERM U955, F-94010 Créteil, France; CEpiA (Clinical Epidemiology and Ageing) EA4393, Medical School, UPEC, F-94010 Créteil, France
| | - Luc Hittinger
- Cardiology Department, APHP, Henri-Mondor Hospital, F-94010 Créteil, France; Mondor Institute Biomedical Research (IMRB), INSERM U955, F-94010 Créteil, France; CEpiA (Clinical Epidemiology and Ageing) EA4393, Medical School, UPEC, F-94010 Créteil, France
| | - Serge Adnot
- Mondor Institute Biomedical Research (IMRB), INSERM U955, F-94010 Créteil, France; Physiology Department, APHP, Henri-Mondor Hospital, F-94010 Créteil, France
| | - Sylvie Bastuji-Garin
- Public Health Department and Clinical Research Unit (URC-Mondor), APHP, Henri-Mondor Hospital, F-94010 Créteil, France; CEpiA (Clinical Epidemiology and Ageing) EA4393, Medical School, UPEC, F-94010 Créteil, France
| | - Thibaud Damy
- Cardiology Department, APHP, Henri-Mondor Hospital, F-94010 Créteil, France; Mondor Institute Biomedical Research (IMRB), INSERM U955, F-94010 Créteil, France
| |
Collapse
|
44
|
Cowie MR, Woehrle H, Wegscheider K, Angermann C, d'Ortho MP, Erdmann E, Levy P, Simonds AK, Somers VK, Zannad F, Teschler H. Adaptive Servo-Ventilation for Central Sleep Apnea in Systolic Heart Failure. N Engl J Med 2015; 373:1095-105. [PMID: 26323938 PMCID: PMC4779593 DOI: 10.1056/nejmoa1506459] [Citation(s) in RCA: 674] [Impact Index Per Article: 74.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Central sleep apnea is associated with poor prognosis and death in patients with heart failure. Adaptive servo-ventilation is a therapy that uses a noninvasive ventilator to treat central sleep apnea by delivering servo-controlled inspiratory pressure support on top of expiratory positive airway pressure. We investigated the effects of adaptive servo-ventilation in patients who had heart failure with reduced ejection fraction and predominantly central sleep apnea. METHODS We randomly assigned 1325 patients with a left ventricular ejection fraction of 45% or less, an apnea-hypopnea index (AHI) of 15 or more events (occurrences of apnea or hypopnea) per hour, and a predominance of central events to receive guideline-based medical treatment with adaptive servo-ventilation or guideline-based medical treatment alone (control). The primary end point in the time-to-event analysis was the first event of death from any cause, lifesaving cardiovascular intervention (cardiac transplantation, implantation of a ventricular assist device, resuscitation after sudden cardiac arrest, or appropriate lifesaving shock), or unplanned hospitalization for worsening heart failure. RESULTS In the adaptive servo-ventilation group, the mean AHI at 12 months was 6.6 events per hour. The incidence of the primary end point did not differ significantly between the adaptive servo-ventilation group and the control group (54.1% and 50.8%, respectively; hazard ratio, 1.13; 95% confidence interval [CI], 0.97 to 1.31; P=0.10). All-cause mortality and cardiovascular mortality were significantly higher in the adaptive servo-ventilation group than in the control group (hazard ratio for death from any cause, 1.28; 95% CI, 1.06 to 1.55; P=0.01; and hazard ratio for cardiovascular death, 1.34; 95% CI, 1.09 to 1.65; P=0.006). CONCLUSIONS Adaptive servo-ventilation had no significant effect on the primary end point in patients who had heart failure with reduced ejection fraction and predominantly central sleep apnea, but all-cause and cardiovascular mortality were both increased with this therapy. (Funded by ResMed and others; SERVE-HF ClinicalTrials.gov number, NCT00733343.).
Collapse
Affiliation(s)
- Martin R Cowie
- From Imperial College London (M.R.C) and Royal Brompton Hospital (A.K.S.) - both in London; ResMed Science Center, ResMed Germany, Martinsried (H.W.), Sleep and Ventilation Center Blaubeuren, Respiratory Center Ulm, Ulm (H.W.), the Department of Medical Biometry and Epidemiology, University Medical Center Eppendorf, Hamburg (K.W.), the Department of Medicine I and Comprehensive Heart Failure Center, University Hospital and University of Würzburg, Würzburg (C.A.), Heart Center, University of Cologne, Cologne (E.E.), and the Department of Pneumology, Ruhrlandklinik, West German Lung Center, University Hospital Essen, University Duisburg-Essen, Essen (H.T.) - all in Germany; University Paris Diderot, Sorbonne Paris Cité, Hôpital Bichat, Explorations Fonctionnelles, Département Hospitalo-Universitaire Fight Inflammation and Remodeling, Assistance Publique-Hôpitaux de Paris, Paris (M-P.O.), Centre Hospitalier Universitaire (CHU) de Grenoble, Grenoble, (P.L.), and INSERM, Université de Lorraine, CHU de Nancy, Nancy (F.Z.) - all in France; and the Mayo Clinic and Mayo Foundation, Rochester, MN (V.K.S.)
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
45
|
Spießhöfer J, Fox H, Lehmann R, Efken C, Heinrich J, Bitter T, Körber B, Horstkotte D, Oldenburg O. Heterogenous haemodynamic effects of adaptive servoventilation therapy in sleeping patients with heart failure and Cheyne-Stokes respiration compared to healthy volunteers. Heart Vessels 2015; 31:1117-30. [PMID: 26296413 DOI: 10.1007/s00380-015-0717-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Accepted: 07/17/2015] [Indexed: 10/23/2022]
Abstract
This study investigated the haemodynamic effects of adaptive servoventilation (ASV) in heart failure (HF) patients with Cheyne-Stokes respiration (CSR) versus healthy controls. Twenty-seven HF patients with CSR and 15 volunteers were ventilated for 1 h using a new ASV device (PaceWave™). Haemodynamics were continuously and non-invasively recorded at baseline, during ASV and after ventilation. Prior to the actual study, a small validation study was performed to validate non-invasive measurement of Stroke volume index (SVI). Non-invasive measurement of SVI showed a marginal overall difference of -0.03 ± 0.41 L/min/m(2) compared to the current gold standard (Thermodilution-based measurement). Stroke volume index (SVI) increased during ASV in HF patients (29.7 ± 5 to 30.4 ± 6 to 28.7 ± 5 mL/m(2), p < 0.05) and decreased slightly in volunteers (50.7 ± 12 to 48.6 ± 11 to 47.9 ± 12 mL/m(2)). Simultaneously, 1 h of ASV was associated with a trend towards an increase in parasympathetic nervous activity (PNA) in HF patients and a trend towards an increase in sympathetic nervous activity (SNA) in healthy volunteers. Blood pressure (BP) and total peripheral resistance response increased significantly in both groups, despite marked inter-individual variation. Effects were independent of vigilance. Predictors of increased SVI during ASV in HF patients included preserved right ventricular function, normal resting BP, non-ischaemic HF aetiology, mitral regurgitation and increased left ventricular filling pressures. This study confirms favourable haemodynamic effects of ASV in HF patients with CSR presenting with mitral regurgitation and/or increased left ventricular filling pressures, but also identified a number of new predictors. This might be mediated by a shift towards more parasympathetic nervous activity in those patients.
Collapse
Affiliation(s)
- Jens Spießhöfer
- Department of Cardiology, Heart and Diabetes Centre North Rhine-Westphalia, University Hospital, Ruhr University Bochum, Georgstrasse 11, 32545, Bad Oeynhausen, Germany
| | - Henrik Fox
- Department of Cardiology, Heart and Diabetes Centre North Rhine-Westphalia, University Hospital, Ruhr University Bochum, Georgstrasse 11, 32545, Bad Oeynhausen, Germany
| | - Roman Lehmann
- Department of Cardiology, Heart and Diabetes Centre North Rhine-Westphalia, University Hospital, Ruhr University Bochum, Georgstrasse 11, 32545, Bad Oeynhausen, Germany
| | - Christina Efken
- Department of Cardiology, Heart and Diabetes Centre North Rhine-Westphalia, University Hospital, Ruhr University Bochum, Georgstrasse 11, 32545, Bad Oeynhausen, Germany
| | - Jessica Heinrich
- Department of Cardiology, Heart and Diabetes Centre North Rhine-Westphalia, University Hospital, Ruhr University Bochum, Georgstrasse 11, 32545, Bad Oeynhausen, Germany
| | - Thomas Bitter
- Department of Cardiology, Heart and Diabetes Centre North Rhine-Westphalia, University Hospital, Ruhr University Bochum, Georgstrasse 11, 32545, Bad Oeynhausen, Germany
| | - Britta Körber
- Department of Cardiology, Heart and Diabetes Centre North Rhine-Westphalia, University Hospital, Ruhr University Bochum, Georgstrasse 11, 32545, Bad Oeynhausen, Germany
| | - Dieter Horstkotte
- Department of Cardiology, Heart and Diabetes Centre North Rhine-Westphalia, University Hospital, Ruhr University Bochum, Georgstrasse 11, 32545, Bad Oeynhausen, Germany
| | - Olaf Oldenburg
- Department of Cardiology, Heart and Diabetes Centre North Rhine-Westphalia, University Hospital, Ruhr University Bochum, Georgstrasse 11, 32545, Bad Oeynhausen, Germany.
| |
Collapse
|
46
|
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.
Collapse
|
47
|
Li Y, Daniels LB, Strollo PJ, Malhotra A. Should All Congestive Heart Failure Patients Have a Routine Sleep Apnea Screening? Con. Can J Cardiol 2015; 31:940-4. [PMID: 26112304 PMCID: PMC4506310 DOI: 10.1016/j.cjca.2015.04.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2015] [Revised: 04/20/2015] [Accepted: 04/20/2015] [Indexed: 11/23/2022] Open
Abstract
Sleep-disordered breathing (SDB) is one of the most common comorbidities in people with congestive heart failure (CHF). Although SDB has major cardiometabolic consequences, the attributable risk of SDB in asymptomatic CHF patients remains unclear. Whether early intervention using positive airway pressure would improve the prognosis in CHF patients is uncertain. As yet, there is insufficient evidence that routine polysomnography screening is cost-effective for asymptomatic CHF patients. Careful clinical risk evaluation and thoughtful use of limited-channel home sleep testing should be considered before the application of routine polysomnography in all CHF patients.
Collapse
Affiliation(s)
- Yanru Li
- Beijing Tongren Hospital, Capital Medical University, Department of Otolaryngology Head and Neck Surgery, Beijing, China
| | - Lori B Daniels
- University of California at San Diego, Division of Cardiology, Sulpizio Cardiovascular Center, La Jolla, California, USA
| | - Patrick J Strollo
- UPMC Sleep Medicine Center, Division of Pulmonary, Allergy, and Critical Care Medicine, Pittsburgh, Pennsylvania, USA
| | - Atul Malhotra
- University of California at San Diego, Chief of Division of Pulmonary, Critical Care and Sleep Medicine, La Jolla, California, USA.
| |
Collapse
|
48
|
Abstract
Congestive heart failure (CHF) is among the most common causes of admission to hospitals in the United States, especially in those over age 65. Few data exist regarding the prevalence CHF of Cheyne-Stokes respiration (CSR) owing to congestive heart failure in the intensive care unit (ICU). Nevertheless, CSR is expected to be highly prevalent among those with CHF. Treatment should focus on the underlying mechanisms by which CHF increases loop gain and promotes unstable breathing. Few data are available to determine prevalence of CSR in the ICU, or how CSR might affect clinical management and weaning from mechanical ventilation.
Collapse
Affiliation(s)
- Scott A Sands
- Division of Sleep Medicine, Brigham and Women's Hospital and Harvard Medical School, 221 Longwood Avenue, Boston, MA 02115, USA; Department of Allergy, Immunology and Respiratory Medicine and Central Clinical School, Alfred Hospital and Monash University, 55 Commercial Rd, Melbourne, VIC 3004, Australia
| | - Robert L Owens
- Division of Pulmonary and Critical Care Medicine, University of California San Diego, 9300 Campus Point Drive, #7381, La Jolla, CA 92037, USA.
| |
Collapse
|
49
|
Floras JS, Ponikowski P. The sympathetic/parasympathetic imbalance in heart failure with reduced ejection fraction. Eur Heart J 2015; 36:1974-82b. [PMID: 25975657 DOI: 10.1093/eurheartj/ehv087] [Citation(s) in RCA: 168] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2015] [Accepted: 03/06/2015] [Indexed: 12/20/2022] Open
Abstract
Cardiovascular autonomic imbalance, a cardinal phenotype of human heart failure, has adverse implications for symptoms during wakefulness and sleep; for cardiac, renal, and immune function; for exercise capacity; and for lifespan and mode of death. The objectives of this Clinical Review are to summarize current knowledge concerning mechanisms for disturbed parasympathetic and sympathetic circulatory control in heart failure with reduced ejection fraction and its clinical and prognostic implications; to demonstrate the patient-specific nature of abnormalities underlying this common phenotype; and to illustrate how such variation provides opportunities to improve or restore normal sympathetic/parasympathetic balance through personalized drug or device therapy.
Collapse
Affiliation(s)
- John S Floras
- University Health Network and Mount Sinai Hospital Division of Cardiology, University of Toronto, Suite 1614, 600 University Avenue, Toronto, Ontario, Canada M5G 1X5
| | - Piotr Ponikowski
- Department for Heart Disease, Medical University, Clinical Military Hospital, Wroclaw, Poland
| |
Collapse
|
50
|
Heart Failure and Sleep Apnea. Can J Cardiol 2015; 31:898-908. [PMID: 26112300 DOI: 10.1016/j.cjca.2015.04.017] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Revised: 03/23/2015] [Accepted: 04/12/2015] [Indexed: 12/18/2022] Open
Abstract
Obstructive and central sleep apnea are far more common in heart failure patients than in the general population and their presence might contribute to the progression of heart failure by exposing the heart to intermittent hypoxia, increased preload and afterload, sympathetic nervous system activation, and vascular endothelial dysfunction. There is now substantial evidence that supports a role for fluid overload and nocturnal rostral fluid shift from the legs as unifying mechanisms in the pathogenesis of obstructive and central sleep apnea in heart failure patients, such that the predominant type of sleep apnea is related to the relative distribution of fluid from the leg to the neck and chest. Despite advances in therapies for heart failure, mortality rates remain high. Accordingly, the identification and treatment of sleep apnea in patients with heart failure might offer a novel therapeutic target to modulate this increased risk. In heart failure patients with obstructive or central sleep apnea, continuous positive airway pressure has been shown to improve cardiovascular function in short-term trials but this has not translated to improved mortality or reduced hospital admissions in long-term randomized trials. Other forms of positive airway pressure such as adaptive servoventilation have shown promising results in terms of attenuation of sleep apnea and improvement in cardiovascular function in short-term trials. Large scale, randomized trials are required to determine whether treating sleep apnea with various interventions can reduce morbidity and mortality.
Collapse
|