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Durland J, Angles J, Hoyland F, Hajj JM, Houston BA, Jackson GR. Ventricular assist devices and sleep-disordered breathing-A mechanical heart stimulating a sleepy brain. Artif Organs 2024; 48:191-196. [PMID: 37974550 DOI: 10.1111/aor.14681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 10/11/2023] [Accepted: 11/07/2023] [Indexed: 11/19/2023]
Abstract
Sleep-disordered breathing, including obstructive sleep apnea (OSA) and central sleep apnea (CSA), is common in severe heart failure (HF) patients. There is limited data on the effect of left ventricular assist devices (LVAD) on sleep apnea. We performed a retrospective review of 350 durable LVAD patients and found 5 with a history of pre- and post-LVAD sleep studies. All five patients had OSA, and three had concomitant CSA. We observed reduced apnea-hypopnea index following LVAD placement. This was due to a near abolishment of CSA in three mixed sleep apnea patients-as seen by a central apnea index improvement from an average of 25.9 ± 13.1 to 1.4 ± 2.5 events per hour (p = 0.063). LVAD placement was associated with an increase in thermodilution cardiac output from 2.7 ± 0.6 to 4.1 ± 1.1 L/min (p = 0.014). These findings support chemoreception physiology seen in patients with poor circulation and the effect of restoring this circulation with LVAD support.
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Affiliation(s)
- Justin Durland
- Department of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Jacqueline Angles
- Division of Pulmonary and Sleep Medicine, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Frank Hoyland
- Division of Pulmonary and Sleep Medicine, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Jennifer M Hajj
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Brian A Houston
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Gregory R Jackson
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
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2
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Light MP, Kreitinger KY, Lee E, DeYoung PN, Lakhani A, Siegel B, Daniels LB, Malhotra A, Owens RL. The impact of sleep disordered breathing on cardiac troponin in acutely decompensated heart failure. Sleep Breath 2023; 27:553-560. [PMID: 35641808 PMCID: PMC9708937 DOI: 10.1007/s11325-022-02646-7] [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: 01/10/2022] [Revised: 05/05/2022] [Accepted: 05/17/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE Sleep disordered breathing in decompensated heart failure has physiological consequences (e.g., intermittent hypoxemia) that may predispose to subclinical myocardial injury, yet a temporal relationship between sleep apnea and troponin elevation has not been established. METHODS We assessed the feasibility of performing respiratory polygraphy and measuring overnight high-sensitivity cardiac troponin T change in adults admitted to the hospital with acutely decompensated heart failure. Repeat sleep apnea tests (SATs) were performed to determine response to optimal medical heart failure therapy. Multivariable logistic regression was used to identify associations between absolute overnight troponin change and sleep apnea characteristics. RESULTS Among the 19 subjects with acutely decompensated heart failure, 92% of SATs demonstrated sleep disordered breathing (apnea-hypopnea index [AHI] > 5 events/h). For those with repeat SATs, AHI increased in 67% despite medical management of heart failure. Overnight troponin increase was associated with moderate to severe sleep apnea (vs. no to mild sleep apnea, odds ratio (OR = 18.4 [1.51-224.18]), central apnea index (OR = 1.11 [1.01-1.22]), and predominantly central sleep apnea (vs. obstructive, OR = 22.9 [1.29-406.32]). CONCLUSIONS Sleep apnea severity and a central apnea pattern may be associated with myocardial injury. Respiratory polygraphy with serial biomarker assessment is feasible in this population, and combining this approach with interventions (e.g., positive airway pressure) may help establish if a link exists between sleep apnea and subclinical myocardial injury.
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Affiliation(s)
- Matthew P Light
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of California San Diego (UCSD), 9300 Campus Point Drive #7381, La Jolla, CA, 92037, USA.
| | - Kimberly Y Kreitinger
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of California San Diego (UCSD), 9300 Campus Point Drive #7381, La Jolla, CA, 92037, USA
| | - Euyhyun Lee
- Altman Clinical and Translational Research Institute, University of California San Diego, La Jolla, CA, USA
| | - Pamela N DeYoung
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of California San Diego (UCSD), 9300 Campus Point Drive #7381, La Jolla, CA, 92037, USA
| | - Avni Lakhani
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of California San Diego (UCSD), 9300 Campus Point Drive #7381, La Jolla, CA, 92037, USA
| | - Brent Siegel
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of California San Diego (UCSD), 9300 Campus Point Drive #7381, La Jolla, CA, 92037, USA
| | - Lori B Daniels
- Division of Cardiology, Department of Medicine, University of California San Diego (UCSD), La Jolla, CA, USA
| | - Atul Malhotra
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of California San Diego (UCSD), 9300 Campus Point Drive #7381, La Jolla, CA, 92037, USA
| | - Robert L Owens
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of California San Diego (UCSD), 9300 Campus Point Drive #7381, La Jolla, CA, 92037, USA
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Oku Y. Temporal variations in the pattern of breathing: techniques, sources, and applications to translational sciences. J Physiol Sci 2022; 72:22. [PMID: 36038825 DOI: 10.1186/s12576-022-00847-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Accepted: 08/12/2022] [Indexed: 11/10/2022]
Abstract
The breathing process possesses a complex variability caused in part by the respiratory central pattern generator in the brainstem; however, it also arises from chemical and mechanical feedback control loops, network reorganization and network sharing with nonrespiratory motor acts, as well as inputs from cortical and subcortical systems. The notion that respiratory fluctuations contain hidden information has prompted scientists to decipher respiratory signals to better understand the fundamental mechanisms of respiratory pattern generation, interactions with emotion, influences on the cortical neuronal networks associated with cognition, and changes in variability in healthy and disease-carrying individuals. Respiration can be used to express and control emotion. Furthermore, respiration appears to organize brain-wide network oscillations via cross-frequency coupling, optimizing cognitive performance. With the aid of information theory-based techniques and machine learning, the hidden information can be translated into a form usable in clinical practice for diagnosis, emotion recognition, and mental conditioning.
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Affiliation(s)
- Yoshitaka Oku
- Division of Physiome, Department of Physiology, Hyogo Medical University, Nishinomiya, Hyogo, 663-8501, Japan.
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4
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Toledo C, Díaz-Jara E, Diaz HS, Schwarz KG, Pereyra KV, Las Heras A, Rios-Gallardo A, Andrade DC, Moreira T, Takakura A, Marcus NJ, Del Rio R. Medullary astrocytes mediate irregular breathing patterns generation in chronic heart failure through purinergic P2X7 receptor signalling. EBioMedicine 2022; 80:104044. [PMID: 35533501 PMCID: PMC9097632 DOI: 10.1016/j.ebiom.2022.104044] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Revised: 04/19/2022] [Accepted: 04/20/2022] [Indexed: 11/05/2022] Open
Abstract
Background Breathing disorders (BD) (apnoeas/hypopneas, periodic breathing) are highly prevalent in chronic heart failure (CHF) and are associated with altered central respiratory control. Ample evidence identifies the retrotrapezoid nucleus (RTN) as an important chemosensitivity region for ventilatory control and generation of BD in CHF, however little is known about the cellular mechanisms underlying the RTN/BD relationship. Within the RTN, astrocyte‐mediated purinergic signalling modulates respiration, but the potential contribution of RTN astrocytes to BD in CHF has not been explored. Methods Selective neuron and/or astrocyte-targeted interventions using either optogenetic and chemogenetic manipulations in the RTN of CHF rats were used to unveil the contribution of the RTN on the development/maintenance of BD, the role played by astrocytes in BD and the molecular mechanism underpinning these alterations. Findings We showed that episodic photo-stimulation of RTN neurons triggered BD in healthy rats, and that RTN neurons ablation in CHF animals eliminates BD. Also, we found a reduction in astrocytes activity and ATP bioavailability within the RTN of CHF rats, and that chemogenetic restoration of normal RTN astrocyte activity and ATP levels improved breathing regularity in CHF. Importantly, P"X/ P2X7 receptor (P2X7r) expression was reduced in RTN astrocytes from CHF rats and viral vector-mediated delivery of human P2X7 P2X7r into astrocytes increases ATP bioavailability and abolished BD. Interpretation Our results support that RTN astrocytes play a pivotal role on BD generation and maintenance in the setting CHF by a mechanism encompassing P2X7r signalling. Funding This study was funded by the National Research and Development Agency of Chile (ANID).
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All You Need Is Sleep: the Effects of Sleep Apnea and Treatment Benefits in the Heart Failure Patient. Curr Heart Fail Rep 2021; 18:144-152. [PMID: 33772415 DOI: 10.1007/s11897-021-00506-1] [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] [Accepted: 02/25/2021] [Indexed: 02/05/2023]
Abstract
PURPOSE OF REVIEW Recognition and treatment of sleep apnea is an important but easily overlooked aspect of care in the heart failure patient. This review summarizes the data behind the recommendations in current practice guidelines and highlights recent developments in treatment options. RECENT FINDINGS Neuromodulation using hypoglossal nerve stimulation has been increasingly used for treatment of OSA; however, it has not been studied in the heart failure population. Alternatively, phrenic nerve stimulation for treatment of CSA is effective for heart failure patients, and cardiac resynchronization therapy can be effective in improving CSA in pacing-induced cardiomyopathy. In patients suspected to have sleep apnea, polysomnography is recommended to better understand the prognosis and treatment options. Positive airway pressure is the standard treatment for sleep apnea; however, neurostimulation can be especially effective in those with predominantly central events. Understanding the pathophysiology of sleep apnea can guide further management decisions.
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Bekfani T, Schöbel C, Pietrock C, Valentova M, Ebner N, Döhner W, Schulze PC, Anker SD, von Haehling S. Heart failure and sleep-disordered breathing: susceptibility to reduced muscle strength and preclinical congestion (SICA-HF cohort). ESC Heart Fail 2020; 7:2063-2070. [PMID: 32578399 PMCID: PMC7524208 DOI: 10.1002/ehf2.12798] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 04/28/2020] [Accepted: 05/14/2020] [Indexed: 12/19/2022] Open
Abstract
Aims Increased sympathetic activation in patients with heart failure (HF) and sleep‐disordered breathing (SDB) provokes cardiac decompensation and protein degradation and could lead to muscle wasting and muscle weakness. The aim of this study was to investigate the differences in body composition, muscle function, and the susceptibility of preclinical congestion among patients with HF and SDB compared with those without SDB. Methods and results We studied 111 outpatients with stable HF who were enrolled into the Studies Investigating Co‐morbidities Aggravating Heart Failure. Echocardiography, short physical performance battery (SPPB), cardiopulmonary exercise testing, dual‐energy X‐ray absorptiometry, bioelectrical impedance analysis (BIA), tests of muscle strength, and polygraphy were performed. SDB was defined as apnoea/hypopnoea index (AHI) >5 per hour of sleep. Central sleep apnoea (CSA) and obstructive sleep apnoea (OSA) were defined as AHI >50% of central or obstructive origin, respectively. A total of 74 patients (66.7%) had any form of SDB [CSA (24 patients, 32.4%), OSA (47 patients, 63.5%)]. Patients with SDB showed increased muscle weakness (chair stand), reduced muscle strength, and lower values of SPPB score (P < 0.05). Patients with SDB did not show overt clinical signs of cardiac decompensation compared with those without SDB (P > 0.05) but had increased amounts of water (total body water, intracellular, and extracellular) measured using BIA (P < 0.05). Increased amounts of total body water were associated with the severity of SDB and inversely with muscle strength and exercise capacity measured by anaerobic threshold (P < 0.05). Altogether, 17 patients had muscle wasting. Of these, 11 (65%) patients had SDB (statistically not significant). Conclusions SDB is highly prevalent in patients with HF. Patients with SDB have lower muscle strength and tend to be more susceptible to preclinical congestion.
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Affiliation(s)
- Tarek Bekfani
- Department of Internal Medicine I, Division of Cardiology, Angiology and Intensive Medical Care, University Hospital Magdeburg, Otto von Guericke University, Leipziger Str. 44, Magdeburg, D-39120, Germany
| | - Christoph Schöbel
- Department of Sleep Medicine, Universität Duisburg-Essen, Essen, Germany
| | - Charlotte Pietrock
- Department of Cardiology, Charité Medical School, Campus Virchow-Klinikum, Berlin, Germany
| | - Miroslava Valentova
- Department of Cardiology and Pneumology, Germany and German Centre for Cardiovascular Research (DZHK), partner site Göttingen, University of Göttingen Medical Centre, Göttingen, Germany.,Department of Internal Medicine, Comenius University, Bratislava, Slovak Republic
| | - Nicole Ebner
- Department of Cardiology and Pneumology, Germany and German Centre for Cardiovascular Research (DZHK), partner site Göttingen, University of Göttingen Medical Centre, Göttingen, Germany
| | - Wolfram Döhner
- Department of Cardiology, Charité Medical School, Campus Virchow-Klinikum, Berlin, Germany.,Center for Stroke Research Berlin, Charité Medical School, Berlin, Germany
| | - P Christian Schulze
- Department of Internal Medicine I, Division of Cardiology, Angiology, Pneumology and Intensive Medical Care, University Hospital Jena, Friedrich-Schiller-University, Jena, Germany
| | - Stefan D Anker
- Division of Cardiology and Metabolism - Heart Failure, Cachexia & Sarcopenia, Department of Cardiology, Campus Virchow-Klinikum, Charité - Medical School, Berlin, Germany.,Berlin-Brandenburg Centre for Regenerative Therapies (BCRT), Charité Medical School, Berlin, Germany
| | - Stephan von Haehling
- Department of Cardiology and Pneumology, Germany and German Centre for Cardiovascular Research (DZHK), partner site Göttingen, University of Göttingen Medical Centre, Göttingen, Germany
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Common Co-Morbidities in Heart Failure – Diabetes, Functional Mitral Regurgitation and Sleep Apnoea. ACTA ACUST UNITED AC 2019; 1:25-41. [PMID: 36262740 PMCID: PMC9536668 DOI: 10.36628/ijhf.2019.0004] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Revised: 10/02/2019] [Accepted: 10/03/2019] [Indexed: 02/06/2023]
Abstract
Heart failure (HF) is a condition that carries a considerable burden of disability many now related to co-existing co-morbidities. The drive to find newer effective therapies targeting novel mechanisms has led to a recent emphasis on treating common co-morbidities that are clustered around contemporary HF patients. Here is renewed contemporary co-morbidities that until recently have received little attention but which are now subject of considerable interest and potential therapeutic advance. These include, diabetes, functional mitral regurgitation and sleep disordered breathing. These three contemporary co-morbidities that have recently been subject to major trial evaluation will be reviewed in this paper.
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8
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Management of Sleep-Disordered Breathing in Heart Failure. CURRENT SLEEP MEDICINE REPORTS 2018. [DOI: 10.1007/s40675-018-0126-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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9
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Matsumoto H, Kasai T. Central Sleep Apnea in Heart Failure: Pathogenesis and Management. CURRENT SLEEP MEDICINE REPORTS 2018. [DOI: 10.1007/s40675-018-0125-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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10
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Abstract
Periodic breathing during incremental cardiopulmonary exercise testing is a regularly recurring waxing and waning of tidal volume due to oscillations in central respiratory drive. Periodic breathing is a sign of respiratory control system instability, which may occur at rest or during exercise. The possible mechanisms responsible for exertional periodic breathing might be related to any instability of the ventilatory regulation caused by: (1) increased circulatory delay (i.e., circulation time from the lung to the brain and chemoreceptors due to reduced cardiac index leading to delay in information transfer), (2) increase in controller gain (i.e., increased central and peripheral chemoreceptor sensitivity to arterial partial pressure of oxygen and of carbon dioxide), or (3) reduction in system damping (i.e., baroreflex impairment). Periodic breathing during exercise is observed in several cardiovascular disease populations, but it is a particularly frequent phenomenon in heart failure due to systolic dysfunction. The detection of exertional periodic breathing is linked to outcome and heralds worse prognosis in heart failure, independently of the criteria adopted for its definition. In small heart failure cohorts, exertional periodic breathing has been abolished with several dedicated interventions, but results have not yet been confirmed. Accordingly, further studies are needed to define the role of visceral feedbacks in determining periodic breathing during exercise as well as to look for specific tools for preventing/treating its occurrence in heart failure.
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Abstract
PURPOSE OF REVIEW Sleep plays many roles in maintenance of cardiovascular health. This review summarizes the literature across several areas of sleep and sleep disorders in relation to cardiometabolic disease risk factors. RECENT FINDINGS Insufficient sleep duration is prevalent in the population and is associated with weight gain and obesity, inflammation, cardiovascular disease, diabetes, and mortality. Insomnia is also highly present and represents an important risk factor for cardiovascular disease, especially when accompanied by short sleep duration. Sleep apnea is a well-characterized risk factor for cardiometabolic disease and cardiovascular mortality. Other issues are relevant as well. For example, sleep disorders in pediatric populations may convey cardiovascular risks. Also, sleep may play an important role in cardiovascular health disparities. SUMMARY Sleep and sleep disorders are implicated in cardiometabolic disease risk. This review addresses these and other issues, concluding with recommendations for research and clinical practice.
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12
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Cheyne-Stokes-Atmung. SOMNOLOGIE 2018. [DOI: 10.1007/s11818-017-0142-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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13
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Cheng J, Liu Y, Li G, Zhang Z, Ma L, Yang X, Yang J, Zhang K, Kong J, Dong M, Zhang M, Xu X, Sui W, Wang J, Shang R, Ji X, Zhang Y, Zhang C, Hao P. Noninvasive ventilation improves cardiac function in patients with chronic heart failure. Oncotarget 2018; 7:48918-48924. [PMID: 27391436 PMCID: PMC5226480 DOI: 10.18632/oncotarget.10441] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Accepted: 06/17/2016] [Indexed: 12/14/2022] Open
Abstract
Chronic heart failure (CHF) has been shown to be associated with an increased incidence of sleep-disordered breathing. Whether treatment with noninvasivepositive-pressure ventilation (NPPV), including continuous positive airway pressure, bi-level positive airway pressure and adaptive servo-ventilation, improves clinical outcomes of CHF patients is still debated. 2,832 CHF patients were enrolled in our analysis. NPPV was significantly associated with improvement in left ventricular ejection fraction (39.39% vs. 34.24%; WMD, 5.06; 95% CI, 3.30-6.81; P < 0.00001) and plasma brain natriuretic peptide level (268.23 pg/ml vs. 455.55 pg/ml; WMD, −105.66; 95% CI, [−169.19]-[−42.13]; P = 0.001). However, NPPV did not reduce all-cause mortality (0.26% vs. 0.24%; OR, 1.13; 95% CI, 0.93-1.37; P = 0.22) or re-hospitalization rate (57.86% vs. 59.38%; OR, 0.47; 95% CI, 0.19-1.19; P = 0.02) as compared with conventional therapy. Despite no benefits on hard endpoints, NPPV may improve cardiac function of CHF patients. These data highlight the important role of NPPV in the therapy of CHF.
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Affiliation(s)
- Jing Cheng
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education and Chinese Ministry of Health, Shandong University Qilu Hospital, Jinan, Shandong, China
| | - Yanping Liu
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education and Chinese Ministry of Health, Shandong University Qilu Hospital, Jinan, Shandong, China.,Shandong Key Laboratory of Cardiovascular and Cerebrovascular Disease, Shandong Provincial Medical Imaging Institute, Shandong University, Jinan, Shandong, China
| | - Guishuang Li
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education and Chinese Ministry of Health, Shandong University Qilu Hospital, Jinan, Shandong, China
| | - Zhongwen Zhang
- Shandong Provincial Qianfoshan Hospital, Shandong University, Jinan, Shandong, China
| | - Lianyue Ma
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education and Chinese Ministry of Health, Shandong University Qilu Hospital, Jinan, Shandong, China
| | - Xiaoyan Yang
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education and Chinese Ministry of Health, Shandong University Qilu Hospital, Jinan, Shandong, China
| | - Jianmin Yang
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education and Chinese Ministry of Health, Shandong University Qilu Hospital, Jinan, Shandong, China
| | - Kai Zhang
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education and Chinese Ministry of Health, Shandong University Qilu Hospital, Jinan, Shandong, China
| | - Jing Kong
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education and Chinese Ministry of Health, Shandong University Qilu Hospital, Jinan, Shandong, China
| | - Mei Dong
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education and Chinese Ministry of Health, Shandong University Qilu Hospital, Jinan, Shandong, China
| | - Meng Zhang
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education and Chinese Ministry of Health, Shandong University Qilu Hospital, Jinan, Shandong, China
| | - Xingli Xu
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education and Chinese Ministry of Health, Shandong University Qilu Hospital, Jinan, Shandong, China
| | - Wenhai Sui
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education and Chinese Ministry of Health, Shandong University Qilu Hospital, Jinan, Shandong, China
| | - Jiali Wang
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education and Chinese Ministry of Health, Shandong University Qilu Hospital, Jinan, Shandong, China
| | - Rui Shang
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education and Chinese Ministry of Health, Shandong University Qilu Hospital, Jinan, Shandong, China
| | - Xiaoping Ji
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education and Chinese Ministry of Health, Shandong University Qilu Hospital, Jinan, Shandong, China
| | - Yun Zhang
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education and Chinese Ministry of Health, Shandong University Qilu Hospital, Jinan, Shandong, China
| | - Cheng Zhang
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education and Chinese Ministry of Health, Shandong University Qilu Hospital, Jinan, Shandong, China
| | - Panpan Hao
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education and Chinese Ministry of Health, Shandong University Qilu Hospital, Jinan, Shandong, China
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Central Sleep Apnea with Cheyne-Stokes Breathing in Heart Failure – From Research to Clinical Practice and Beyond. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2018; 1067:327-351. [DOI: 10.1007/5584_2018_146] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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15
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Abstract
Central sleep apnea and Cheyne-Stokes respiration are commonly observed breathing patterns during sleep in patients with congestive heart failure. Common risk factors are male gender, older age, presence of atrial fibrillation, and daytime hypocapnia. Proposed mechanisms include augmented peripheral and central chemoreceptor sensitivity, which increase ventilator instability during both wakefulness and sleep; diminished cerebrovascular reactivity and increased circulation time, which impair the normal buffering of Paco2 and hydrogen ions and delay the detection of changes in Paco2 during sleep; and rostral fluid shifts that predispose to hypocapnia.
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Sleep-Disordered Breathing in Neuromuscular Disease: Diagnostic and Therapeutic Challenges. Chest 2017; 152:880-892. [PMID: 28372949 DOI: 10.1016/j.chest.2017.03.023] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Revised: 02/23/2017] [Accepted: 03/21/2017] [Indexed: 12/11/2022] Open
Abstract
Normal sleep-related rapid eye movement sleep atonia, reduced lung volumes, reduced chemosensitivity, and impaired airway dilator activity become significant vulnerabilities in the setting of neuromuscular disease. In that context, the compounding effects of respiratory muscle weakness and disease-specific features that promote upper airway collapse or cause dilated cardiomyopathy contribute to various sleep-disordered breathing events. The reduction in lung volumes with neuromuscular disease is further compromised by sleep and the supine position, exaggerating the tendency for upper airway collapse and desaturation with sleep-disordered breathing events. The most commonly identified events are diaphragmatic/pseudo-central, due to a decrease in the rib cage contribution to the tidal volume during phasic rapid eye movement sleep. Obstructive and central sleep apneas are also common. Noninvasive ventilation can improve survival and quality of sleep but should be used with caution in the context of dilated cardiomyopathy or significant bulbar symptoms. Noninvasive ventilation can also trigger sleep-disordered breathing events, including ineffective triggering, autotriggering, central sleep apnea, and glottic closure, which compromise the potential benefits of the intervention by increasing arousals, reducing adherence, and impairing sleep architecture. Polysomnography plays an important diagnostic and therapeutic role by correctly categorizing sleep-disordered events, identifying sleep-disordered breathing triggered by noninvasive ventilation, and improving noninvasive ventilation settings. Optimal management may require dedicated hypoventilation protocols and a technical staff well versed in the identification and troubleshooting of respiratory events.
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Kahwash R, Khayat RN. A Practical Approach to the Identification and Management of Sleep-Disordered Breathing in Heart Failure Patients. Sleep Med Clin 2017; 12:205-219. [PMID: 28477775 DOI: 10.1016/j.jsmc.2017.01.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Sleep-disordered breathing (SDB) is a major health problem affecting much of the general population. Although SDB is responsible for rapid progression of heart failure (HF) and the worsening morbidity and mortality, advanced HF state is associated with accelerated development of SDB. In the face of recent developments in SDB treatment and availability of effective therapeutic options known to improve quality of life, exercise tolerance, and heart function, most HF patients with SDB are left unrecognized and untreated. This article provides an overview of SDB in HF with focus on practical approaches intended to facilitate screening and treatment.
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Affiliation(s)
- Rami Kahwash
- Section of Heart Failure and Transplant, Division of Cardiovascular Medicine, Davis Heart & Lung Research Institute, The Ohio State University, 473 West 12th Avenue, Columbus, OH 43210, USA.
| | - Rami N Khayat
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Davis Heart & Lung Research Institute, The Ohio State University, 473 West 12th Avenue, Columbus, OH 43210, USA
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Valika A, Costanzo MR. Sleep-Disordered Breathing During Congestive Heart Failure: To Intervene or Not to Intervene? Card Fail Rev 2017; 3:134-139. [PMID: 29387467 DOI: 10.15420/cfr.2017:7:1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Sleep-disordered breathing is common in heart failure patients and is associated with increased morbidity and mortality. Central sleep apnea occurs more commonly in heart failure-reduced ejection fraction, and obstructive sleep apnea occurs more frequently in heart failure with preserved ejection fraction. Although the two types of sleep-disordered breathing have distinct pathophysiologic mechanisms, both contribute to abnormal cardiovascular consequences. Treatment with continuous positive airway pressure for obstructive sleep apnea in heart failure has been well defined, whereas treatment strategies for central sleep apnea in heart failure continue to evolve. Unilateral transvenous neurostimulation has shown promise for the treatment of central sleep apnea. In this paper, we examine the current state of knowledge of treatment options for sleep-disordered breathing in heart failure.
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Affiliation(s)
- Ali Valika
- Advocate Medical Group - Midwest Heart Specialists, Advocate Heart Institute,Oak Brook, IL, USA
| | - Maria Rosa Costanzo
- Advocate Medical Group - Midwest Heart Specialists, Advocate Heart Institute,Oak Brook, IL, USA
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Seguchi O, Hisamatsu E, Nakano A, Nakajima S, Kuroda K, Watanabe T, Sato T, Sunami H, Yanase M, Hata H, Hamasaki T, Fujita T, Kobayashi J, Nakatani T, Kitakaze M, Fukushima N. Low partial pressure of end-tidal carbon dioxide predicts left ventricular assist device implantation in patients with advanced chronic heart failure. Int J Cardiol 2016; 230:40-46. [PMID: 28038817 DOI: 10.1016/j.ijcard.2016.12.102] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Revised: 12/03/2016] [Accepted: 12/17/2016] [Indexed: 01/07/2023]
Abstract
BACKGROUND This study aimed to clarify the prognostic impact of partial pressure of end-tidal carbon dioxide (PETCO2) in patients with advanced chronic heart failure (HF). METHODS Forty-eight patients (mean age 43.1±11.9years, 32 males) with chronic HF (44 with non-ischemic and 4 with ischemic cardiomyopathy) were prospectively enrolled. Echocardiography, blood tests, pulmonary function testing, and PETCO2 measurements were performed as noninvasive tests, whereas right heart catheterization and arterial blood gas analysis were conducted as invasive tests. The primary end point of this study was left ventricular assist device (LVAD) implantation or cardiac death. RESULTS Eighteen patients underwent LVAD implantation at the Interagency Registry for Mechanically Circulatory Support (INTERMACS) profile 3 during the follow-up period, and no patient died. PETCO2 was significantly lower in a stepwise manner with New York Heart Association functional class (class I or II, 34.2±9.3mmHg vs. class III or IV, 27.7±2.5mmHg; p<0.001). Univariate and multivariate Cox proportional hazard models and time-dependent receiver operating characteristic curve analysis revealed that PETCO2≤31mmHg is an independent noninvasive predictor of LVAD implantation. Univariable and multivariable linear regression analyses showed that pulmonary arterial pressure was independently and highly correlated with PETCO2 (r2=-0.512, p<0.001). CONCLUSIONS Among various noninvasive clinical parameters investigated, PETCO2 was the independent predictor of LVAD implantation at the INTERMACS profile 3 in patients with chronic HF. Pulmonary congestion may significantly contribute to decreases in PETCO2 in patients with HF.
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Affiliation(s)
- Osamu Seguchi
- Department of Transplantation,National Cerebral and Cardiovascular Center, Osaka, Japan.
| | - Eriko Hisamatsu
- Department of Transplantation,National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Atsushi Nakano
- Department of Clinical Research, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Seiko Nakajima
- Department of Transplantation,National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Kensuke Kuroda
- Department of Transplantation,National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Takuya Watanabe
- Department of Transplantation,National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Takuma Sato
- Department of Transplantation,National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Haruki Sunami
- Department of Transplantation,National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Masanobu Yanase
- Department of Transplantation,National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Hiroki Hata
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Toshimitsu Hamasaki
- Department of Data Science, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Tomoyuki Fujita
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Junjiro Kobayashi
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Takeshi Nakatani
- Department of Transplantation,National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Masafumi Kitakaze
- Department of Clinical Research, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Norihide Fukushima
- Department of Transplantation,National Cerebral and Cardiovascular Center, Osaka, Japan
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Abstract
PURPOSE OF REVIEW Sleep-disordered breathing, which includes both obstructive and central sleep apnoea (OSA and CSA, respectively), is highly prevalent in patients with heart failure. In this review, we outline our current understanding of the bidirectional relationship between these disorders and heart failure. We also explore the role of recent advances in therapeutics. RECENT FINDINGS Although early studies suggest promise of adaptive servoventilation in treating sleep-disordered breathing, particularly CSA with associated Cheyne-Stokes respiration, the recent clinical trial in the heart failure patient population has demonstrated worse cardiovascular outcome in symptomatic patients. SUMMARY Both OSA and CSA are highly prevalent in patients with heart failure. Effective treatment of OSA with continuous positive airway pressure can improve cardiovascular outcome in these patients. However, recent evidence suggests that adaptive servoventilation cannot be safely recommended as a therapy for CSA in the context of heart failure, as a result of increased risk of cardiovascular mortality.
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21
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Sands SA, Edwards BA, Kee K, Stuart-Andrews C, Skuza EM, Roebuck T, Turton A, Hamilton GS, Naughton MT, Berger PJ. Control theory prediction of resolved Cheyne−Stokes respiration in heart failure. Eur Respir J 2016; 48:1351-1359. [DOI: 10.1183/13993003.00615-2016] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Accepted: 06/19/2016] [Indexed: 11/05/2022]
Abstract
Cheyne–Stokes respiration (CSR) foretells deleterious outcomes in patients with heart failure. Currently, the size of therapeutic intervention is not guided by the patient's underlying pathophysiology. In theory, the intervention needed to resolve CSR, as a control system instability (loop gain >1), can be predicted knowing the baseline loop gain and how much it falls with therapy.In 12 patients with heart failure, we administered an inspiratory carbon dioxide fraction of 1–3% during CSR (n=95 interventions) as a means to reduce loop gain. We estimated the loop gain on therapy (LGtherapy), using the baseline loop gain (using hyperpnoea length/cycle length) and its expected reduction (18% per 1% inspired carbon dioxide), and tested the specific hypothesis that LGtherapypredicts CSR persistence (LGtherapy>1)versusresolution (LGtherapy<1).As predicted, when LGtherapy>1.0, CSR continued during therapy in 23 out of 25 (92%) trials. A borderline loop gain zone (0.8<LGtherapy<1) yielded an unpredictable outcome, while LGtherapy<0.8 consistently yielded CSR resolution (37 out of 37 trials). A threshold of LGtherapy=0.9 determined outcome in 76 out of 95 (80%) trials.We establish proof-of-concept that control theory provides predictive insight into CSR resolution in heart failure. Thus, we now have a means to calculate the size of interventions needed to ameliorate CSR on a patient-by-patient basis.
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22
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Bekfani T, Abraham WT. Current and future developments in the field of central sleep apnoea. Europace 2016; 18:1123-34. [DOI: 10.1093/europace/euv435] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2015] [Accepted: 11/23/2015] [Indexed: 12/22/2022] Open
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Niewinski P. Carotid body modulation in systolic heart failure from the clinical perspective. J Physiol 2016; 595:53-61. [PMID: 26990354 DOI: 10.1113/jp271692] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2015] [Accepted: 03/10/2016] [Indexed: 01/30/2023] Open
Abstract
Augmented sensitivity of peripheral chemoreceptors (PChS) is a common finding in systolic heart failure (HF). It is related to lower left ventricle systolic function, higher plasma concentrations of natriuretic peptides, worse exercise tolerance and greater prevalence of atrial fibrillation compared to patients with normal PChS. The magnitude of ventilatory response to the activation of peripheral chemoreceptors is proportional to the level of heart rate (tachycardia) and blood pressure (hypertension) responses. All these responses can be measured non-invasively in a safe and reproducible fashion using different methods employing either hypoxia or hypercapnia. Current interventions aimed at modulation of peripheral chemoreceptors in HF are focused on carotid bodies (CBs). There is a clear link between afferent signalling from CBs and sympathetic overactivity, which remains the priority target of modern HF treatment. However, CB modulation therapies may face several potential obstacles: (1) As evidenced by HF trials, an excessive inhibition of sympathetic system may be harmful. (2) Proximity of critical anatomical structures (important vessels and nerves) makes surgical and transcutaneous interventions on CB technically demanding. (3) Co-existence of atherosclerosis in the area of carotid artery bifurcation increases the risk of central embolic events related to CB modulation. (4) The relative contribution of CBs vs. aortic bodies to sympathetic activation in HF patients is unclear. (5) Choosing optimal candidates for CB modulation from the population of HF patients may be problematic. (6) There is a risk of nocturnal hypoxia following CB ablation - mostly after bilateral procedures and in patients with concomitant obstructive sleep apnoea.
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Affiliation(s)
- Piotr Niewinski
- Cardiology Department, Centre for Heart Diseases, Military Hospital, Wroclaw, Poland
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24
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Dhakal BP, Lewis GD. Exercise oscillatory ventilation: Mechanisms and prognostic significance. World J Cardiol 2016; 8:258-266. [PMID: 27022457 PMCID: PMC4807314 DOI: 10.4330/wjc.v8.i3.258] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Accepted: 12/18/2015] [Indexed: 02/06/2023] Open
Abstract
Alteration in breathing patterns characterized by cyclic variation of ventilation during rest and during exercise has been recognized in patients with advanced heart failure (HF) for nearly two centuries. Periodic breathing (PB) during exercise is known as exercise oscillatory ventilation (EOV) and is characterized by the periods of hyperpnea and hypopnea without interposed apnea. EOV is a non-invasive parameter detected during submaximal cardiopulmonary exercise testing. Presence of EOV during exercise in HF patients indicates significant impairment in resting and exercise hemodynamic parameters. EOV is also an independent risk factor for poor prognosis in HF patients both with reduced and preserved ejection fraction irrespective of other gas exchange variables. Circulatory delay, increased chemosensitivity, pulmonary congestion and increased ergoreflex signaling have been proposed as the mechanisms underlying the generation of EOV in HF patients. There is no proven treatment of EOV but its reversal has been noted with phosphodiesterase inhibitors, exercise training and acetazolamide in relatively small studies. In this review, we discuss the mechanistic basis of PB during exercise and the clinical implications of recognizing PB patterns in patients with HF.
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25
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Pathophysiology of central sleep apneas. Sleep Breath 2016; 20:467-82. [DOI: 10.1007/s11325-015-1290-z] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2015] [Revised: 11/10/2015] [Accepted: 11/23/2015] [Indexed: 11/26/2022]
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Anker SD, von Haehling S, Germany R. Sleep-disordered breathing and cardiovascular disease. Indian Heart J 2015; 68 Suppl 1:S69-76. [PMID: 27056657 PMCID: PMC4824338 DOI: 10.1016/j.ihj.2015.11.018] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2015] [Accepted: 11/05/2015] [Indexed: 11/17/2022] Open
Abstract
Sleep-disordered breathing (SDB) is a common comorbidity in a number of cardiovascular diseases, and mounting clinical evidence demonstrates that it has important implications in the long-term outcomes of patients with cardiovascular disease (CVD). While recognition among clinicians of the role of SDB in CVD is increasing, it too often remains neglected in the routine care of patients with CVD, and therefore remains widely undiagnosed and untreated. In this article, we provide an overview of SDB and its relationship to CVD, with the goal of helping cardiovascular clinicians better recognize and treat this important comorbidity in their patients. We will describe the two major types of SDB and discuss the pathophysiologic, diagnostic, and therapeutic considerations of SDB in patients with CVD.
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Affiliation(s)
- Stefan D Anker
- Innovative Clinical Trials, University Medical Centre Göttingen, Göttingen, Germany.
| | - Stephan von Haehling
- Innovative Clinical Trials, University Medical Centre Göttingen, Göttingen, Germany
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Miyamoto T, Nakahara H, Ueda S, Manabe K, Kawai E, Inagaki M, Kawada T, Sugimachi M. Periodic Breathing in Heart Failure Explained by Dynamic and Static Properties of Respiratory Control. CLINICAL MEDICINE INSIGHTS-CARDIOLOGY 2015; 9:133-42. [PMID: 26561001 PMCID: PMC4629632 DOI: 10.4137/cmc.s18761] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2015] [Revised: 06/18/2015] [Accepted: 07/01/2015] [Indexed: 12/12/2022]
Abstract
OBJECTIVE The respiratory operating point is determined by the interplay between the controller and plant subsystem elements within the respiratory chemoreflex feedback system. This study aimed to establish the methodological basis for quantitative analysis of the open-loop dynamic properties of the human respiratory control system and to apply the results to explore detailed mechanisms of the regulation of respiration and the possible mechanism of periodic breathing in chronic heart failure. METHODS AND RESULTS In healthy volunteers, we measured arterial CO2 partial pressure (PaCO2) and minute ventilation
(V˙E) to estimate the dynamic properties of the controller (
PaCO2→V˙E relation) and plant (
V˙E→PaCO2 relation). The dynamic properties of the controller and plant approximated first- and second-order exponential models, respectively, and were described using parameters including gain, time constant, and lag time. We then used the open-loop transfer functions to simulate the closed-loop respiratory response to an exogenous disturbance, while manipulating the parameter values to deviate from normal values but within physiological ranges. By increasing both the product of gains of the two subsystem elements (total loop gain) and the lag time, the condition of system oscillation (onset of periodic breathing) was satisfied. CONCLUSION When abnormality occurs in a part of the respiratory chemoreflex system, instability of the control system is amplified and may result in the manifestation of respiratory abnormalities such as periodic breathing.
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Affiliation(s)
- Tadayoshi Miyamoto
- Graduate School of Health Sciences, Morinomiya University of Medical Sciences, Osaka City, Osaka, Japan
| | - Hidehiro Nakahara
- Graduate School of Health Sciences, Morinomiya University of Medical Sciences, Osaka City, Osaka, Japan
| | - Shinya Ueda
- Graduate School of Health Sciences, Morinomiya University of Medical Sciences, Osaka City, Osaka, Japan
| | - Kou Manabe
- Graduate School of Health Sciences, Morinomiya University of Medical Sciences, Osaka City, Osaka, Japan
| | - Eriko Kawai
- Graduate School of Health Sciences, Morinomiya University of Medical Sciences, Osaka City, Osaka, Japan
| | - Masashi Inagaki
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center, Suita City, Osaka, Japan
| | - Toru Kawada
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center, Suita City, Osaka, Japan
| | - Masaru Sugimachi
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center, Suita City, Osaka, Japan
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28
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Cundrle I, Somers VK, Johnson BD, Scott CG, Olson LJ. Exercise end-tidal CO2 predicts central sleep apnea in patients with heart failure. Chest 2015; 147:1566-1573. [PMID: 25742609 DOI: 10.1378/chest.14-2114] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Increased CO2 chemosensitivity and augmented exercise ventilation are characteristic of patients with heart failure (HF) with central sleep apnea (CSA). The aim of this study was to test the hypothesis that decreased end-tidal CO2 by cardiopulmonary exercise testing predicts CSA in patients with HF. METHODS Consecutive ambulatory patients with New York Heart Association II to III HF were prospectively evaluated by CO2 chemosensitivity by rebreathe, cardiopulmonary exercise testing, and polysomnography (PSG). Subjects were classified as having either CSA (n = 20) or no sleep apnea (n = 13) by PSG; a central apnea-hypopnea index (AHI) ≥ 5 was used to define CSA. Subgroups were compared by t test or Mann-Whitney test and data summarized as mean ± SD. P < .05 was considered significant. RESULTS At rest, subjects with CSA had higher central CO2 chemosensitivity (Δminute ventilation [V.e]/Δpartial pressure of end-tidal CO2 [Petco2], 2.3 ± 1.0 L/min/mm Hg vs 1.6 ± 0.4 L/min/mm Hg, P = .02) and V.e (15 ± 7 L/min vs 10 ± 3 L/min, P = .02) and lower Petco2 (31 ± 4 mm Hg vs 35 ± 4 mm Hg, P < .01) than control subjects. At peak exercise, the ventilatory equivalents per expired CO2 (V.e/V.co2) was higher (43 ± 9 vs 33 ± 6, P < .01) and Petco2 lower (29 ± 6 mm Hg vs 36 ± 5 mm Hg, P < .01) in subjects with CSA. In addition, CO2 chemosensitivity, peak exercise V.e/V.co2, and Petco2 were independently correlated with CSA severity as quantified by the AHI (P < .05). Peak exercise Petco2 was most strongly associated with CSA (OR, 1.29; 95% CI, 1.08-1.54; P = .01; area under the curve, 0.88). CONCLUSIONS In patients with HF and CSA, ventilatory drive is increased while awake at rest and during exercise and associated with heightened CO2 chemosensitivity and decreased arterial CO2 set point.
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Affiliation(s)
- Ivan Cundrle
- International Clinical Research Center and Department of Anesthesiology and Intensive Care, Faculty of Medicine, Masaryk University, Brno, Czech Republic; St. Anna's University Hospital Brno, and Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Virend K Somers
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | - Bruce D Johnson
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | - Christopher G Scott
- Department of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
| | - Lyle J Olson
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN.
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29
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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.
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Spießhöfer J, Heinrich J, Lehmann R, Efken C, Fox H, Bitter T, Körber B, Horstkotte D, Oldenburg O. Respiratory effects of adaptive servoventilation therapy in patients with heart failure and Cheyne-Stokes respiration compared to healthy volunteers. Respiration 2015; 89:374-82. [PMID: 25871423 DOI: 10.1159/000375312] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2013] [Accepted: 12/30/2014] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Nocturnal adaptive servoventilation (ASV) therapy is now frequently used to treat Cheyne-Stokes respiration (CSR), which is highly prevalent in patients with moderate-to-severe heart failure (HF) and characterized by periodical breathing (hyperventilation). OBJECTIVES This study analyzed and compared the acute effects of a novel ASV device on carbon dioxide pressure (pCO2) and oxygen saturation (SaO2) in HF patients with CSR and healthy volunteers. The influence of being asleep or awake on the ASV algorithm was also determined. METHODS All subjects underwent ASV (PaceWave™, ResMed) for 1 h. Transcutaneous pCO2 (PtcCO2) and SaO2 were assessed transcutaneously, while wakefulness was analyzed using EEG recordings. Assessments were made 30 min before and after ASV, and during 1 h of ASV. RESULTS Twenty HF patients (19 male; age 79 ± 12 years) and 15 volunteers (13 male, age 25 ± 4 years) were included. When awake, ASV was associated with a trend towards a decrease in PtcCO2 and an increase in SaO2 versus baseline in HF patients (34.4 ± 3.2 to 33.7 ± 3.8 mm Hg and 93.8 ± 2.6 to 94.9 ± 2.6%, respectively) and volunteers (39.5 ± 3.0 to 38.2 ± 3.8 mm Hg and 96.9 ± 1.3 to 97.8 ± 0.9%). While asleep during ASV, PtcCO2 increased to 36.3 ± 3.8 mm Hg and SaO2 decreased to 93.8 ± 2.6% in HF patients, with similar changes in volunteers (PtcCO2 41.7 ± 3.0 mm Hg, SaO2 97.1 ± 1.2). All comparisons were statistically significant (p ≤ 0.05, except the PtcCO2 decrease in both groups when awake). CONCLUSIONS ASV therapy might result in hyperventilation when subjects are awake, but while asleep, PtcCO2 increased to mid-normal values, effects that would be favorable in HF patients with CSR.
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Affiliation(s)
- Jens Spießhöfer
- Department of Cardiology, Heart and Diabetes Centre North Rhine-Westphalia, Ruhr University Bochum, Bad Oeynhausen, Germany
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Costanzo MR, Khayat R, Ponikowski P, Augostini R, Stellbrink C, Mianulli M, Abraham WT. Mechanisms and clinical consequences of untreated central sleep apnea in heart failure. J Am Coll Cardiol 2015; 65:72-84. [PMID: 25572513 PMCID: PMC4391015 DOI: 10.1016/j.jacc.2014.10.025] [Citation(s) in RCA: 64] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2014] [Revised: 09/22/2014] [Accepted: 10/15/2014] [Indexed: 01/08/2023]
Abstract
Central sleep apnea (CSA) is a highly prevalent, though often unrecognized, comorbidity in patients with heart failure (HF). Data from HF population studies suggest that it may present in 30% to 50% of HF patients. CSA is recognized as an important contributor to the progression of HF and to HF-related morbidity and mortality. Over the past 2 decades, an expanding body of research has begun to shed light on the pathophysiologic mechanisms of CSA. Armed with this growing knowledge base, the sleep, respiratory, and cardiovascular research communities have been working to identify ways to treat CSA in HF with the ultimate goal of improving patient quality of life and clinical outcomes. In this paper, we examine the current state of knowledge about the mechanisms of CSA in HF and review emerging therapies for this disorder.
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Affiliation(s)
| | - Rami Khayat
- Division of Pulmonary, Critical Care and Sleep, The Ohio State University, Columbus, Ohio
| | - Piotr Ponikowski
- Cardiac Department, 4th Military Hospital, Wroclaw, Poland; Cardiac Department, Medical University, Wroclaw, Poland
| | - Ralph Augostini
- Division of Cardiovascular Medicine, The Ohio State University, Columbus, Ohio
| | - Christoph Stellbrink
- Department of Cardiology and Intensive Care Medicine, Bielefeld Medical Center, Bielefeld, Germany
| | | | - William T Abraham
- Division of Cardiovascular Medicine, The Ohio State University, Columbus, Ohio
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32
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Miyamoto T, Bailey DM, Nakahara H, Ueda S, Inagaki M, Ogoh S. Manipulation of central blood volume and implications for respiratory control function. Am J Physiol Heart Circ Physiol 2014; 306:H1669-78. [DOI: 10.1152/ajpheart.00987.2013] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The respiratory operating point (ventilatory or arterial Pco2 response) is determined by the intersection point between the controller and plant subsystem elements within the respiratory control system. However, to what extent changes in central blood volume (CBV) influence these two elements and the corresponding implications for the respiratory operating point remain unclear. To examine this, 17 apparently healthy male participants were exposed to water immersion (WI) or lower body negative pressure (LBNP) challenges to manipulate CBV and determine the corresponding changes. The respiratory controller was characterized by determining the linear relationship between end-tidal Pco2 (PetCO2) and minute ventilation (V̇e) [V̇e = S × (PetCO2 − B)], whereas the plant was determined by the hyperbolic relationship between V̇e and PetCO2 (PetCO2 = A/V̇e + C). Changes in V̇e at the operating point were not observed under either WI or LBNP conditions despite altered PetCO2 ( P < 0.01), indicating a moving respiratory operating point. An increase (WI) and a decrease (LBNP) in CBV were shown to reset the controller element (PetCO2 intercept B) rightward and leftward, respectively ( P < 0.05), without any change in S, whereas the plant curve remained unaltered at the operating point. Collectively, these findings indicate that modification of the controller element rather than the plant element is the major factor that contributes toward an alteration of the respiratory operating point during CBV shifts.
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Affiliation(s)
- Tadayoshi Miyamoto
- Graduate School of Health Sciences, Morinomiya University of Medical Sciences, Osaka City, Osaka, Japan
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center Research Institute, Suita City, Osaka, Japan
| | - Damian Miles Bailey
- Neurovascular Research Laboratory, Faculty of Life Sciences and Education, University of South Wales, Wales, United Kingdom; and
| | - Hidehiro Nakahara
- Graduate School of Health Sciences, Morinomiya University of Medical Sciences, Osaka City, Osaka, Japan
| | - Shinya Ueda
- Graduate School of Health Sciences, Morinomiya University of Medical Sciences, Osaka City, Osaka, Japan
| | - Masashi Inagaki
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center Research Institute, Suita City, Osaka, Japan
| | - Shigehiko Ogoh
- Department of Biomedical Engineering, Toyo University, Kawagoe City, Saitama, Japan
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The Relationship between Nocturnal Hypoxemia and Left Ventricular Ejection Fraction in Congestive Heart Failure Patients. SLEEP DISORDERS 2014; 2014:978358. [PMID: 24693442 PMCID: PMC3945920 DOI: 10.1155/2014/978358] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/08/2013] [Accepted: 11/19/2013] [Indexed: 11/26/2022]
Abstract
Congestive heart failure (CHF) is a major cause of mortality and morbidity. Among patients with heart failure, sleep disordered breathing (SDB) is a common problem. Current evidence suggests that SDB, particularly central SDB, is more prevalent in patients with CHF than in the general population, but it is underdiagnosed as SDB symptoms that are less prevalent in CHF. The main aims of this study were to determine the relationship between nocturnal hypoxemia and left ventricular ejection fraction in patients with chronic heart failure. By means of echocardiography, 108 patients with left ventricular ejection fraction ≤45% were divided into mild, moderate, and severe CHF. Hypoxemia was recorded overnight in the hospital and was measured by portable pulse oximetry. In the 108 patients with CHF, 44 (40.7%) were severe, 17 (15.7%) moderate, and 47 (43.6%) mild CHF. 95 (88%) of patients with CHF had abnormal patterns of nocturnal hypoxemia suggestive of Cheyne-Stokes respiration. Ejection fraction correlated negatively with dip frequency. There was no correlation between nocturnal hypoxemia with BMI and snoring. This study confirms strong associations between sleep apnea and heart disease in patients with CHF. Overnight oximetry is a useful screening test for Cheyne-Stokes respiration in patients with known heart failure.
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Solaiman AZ, Feehan RP, Chabitnoy AM, Leuenberger UA, Monahan KD. Ventilatory responses to chemoreflex stimulation are not enhanced by angiotensin II in healthy humans. Auton Neurosci 2014; 183:72-9. [PMID: 24556416 DOI: 10.1016/j.autneu.2014.01.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2013] [Revised: 11/18/2013] [Accepted: 01/16/2014] [Indexed: 10/25/2022]
Abstract
The chemoreflexes exert significant control over respiration and sympathetic outflow. Abnormalities in chemoreflex function may contribute to various disease processes. Based on prior animal studies, we developed the hypothesis that acutely elevating circulating angiotensin II levels into the pathophysiological range increases chemoreflex responsiveness in healthy humans. Eighteen adults were studied before (Pre) and during (Post) low (protocol 1; 2ng/kg/min; n=9) or high (protocol 2; 5ng/kg/min; n=9) dose angiotensin II infusion (study day 1). Chemoreflex responses were quantified by the pure nitrogen breathing method [slope of the minute ventilation vs. arterial oxygen saturation plot generated during a series (n=10) of 100% inspired nitrogen exposures (1-8 breaths)] and by measuring responses to hypercapnia (7% inspired carbon dioxide). Responses to a non-chemoreflex stimulus were also determined (cold pressor test). Measurements were repeated on a subsequent day (study day 2) before and during infusion of a control vasoconstrictor (phenylephrine) infused at a dose (0.6-1.2μg/kg/min) sufficient to increase blood pressure to the same degree as that achieved during angiotensin II infusion. We found that despite increasing plasma angiotensin II levels to pathophysiological levels responses to pure nitrogen breathing, hypercapnia, and the cold pressor test were unchanged by low (2ng/kg/min) and high dose (5ng/kg/min) angiotensin II infusion (protocols 1 and 2). Similarly, responses measured during phenylephrine infusion (Post) were unchanged (from Pre). These findings indicate that acutely increasing plasma angiotensin II levels to levels observed in disease states, such as human heart failure, do not increase chemoreflex responsiveness in healthy humans.
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Affiliation(s)
- Adil Z Solaiman
- Penn State Heart and Vascular Institute, Pennsylvania State University College of Medicine, Hershey, PA 17033, United States
| | - Robert P Feehan
- Penn State Heart and Vascular Institute, Pennsylvania State University College of Medicine, Hershey, PA 17033, United States
| | - Amy M Chabitnoy
- Penn State Heart and Vascular Institute, Pennsylvania State University College of Medicine, Hershey, PA 17033, United States
| | - Urs A Leuenberger
- Penn State Heart and Vascular Institute, Pennsylvania State University College of Medicine, Hershey, PA 17033, United States
| | - Kevin D Monahan
- Penn State Heart and Vascular Institute, Pennsylvania State University College of Medicine, Hershey, PA 17033, United States.
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Vanhecke TE, Franklin BA, Ajluni SC, Sangal RB, McCullough PA. Cardiorespiratory fitness and sleep-related breathing disorders. Expert Rev Cardiovasc Ther 2014; 6:745-58. [DOI: 10.1586/14779072.6.5.745] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Abstract
Neurophysiologically, central apnea is due to a temporary failure in the pontomedullary pacemaker generating breathing rhythm. As a polysomnographic finding, central apneas occur in many pathophysiological conditions. Depending on the cause or mechanism, central apneas may not be clinically significant, for example, those that occur normally at sleep onset. In contrast, central apneas occur in a number of disorders and result in pathophysiological consequences. Central apneas occur commonly in high-altitude sojourn, disrupt sleep, and cause desaturation. Central sleep apnea also occurs in number of disorders across all age groups and both genders. Common causes of central sleep apnea in adults are congestive heart failure and chronic use of opioids to treat pain. Under such circumstances, diagnosis and treatment of central sleep apnea may improve quality of life, morbidity, and perhaps mortality. The mechanisms of central sleep apnea have been best studied in congestive heart failure and hypoxic conditions when there is increased CO2 sensitivity below eupnea resulting in lowering eupneic PCO2 below apneic threshold causing cessation of breathing until the PCO2 rises above the apneic threshold when breathing resumes. In many other disorders, the mechanism of central sleep apnea (CSA) remains to be investigated.
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Affiliation(s)
- S Javaheri
- University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.
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Khayat R, Small R, Rathman L, Krueger S, Gocke B, Clark L, Yamokoski L, Abraham WT. Sleep-disordered breathing in heart failure: identifying and treating an important but often unrecognized comorbidity in heart failure patients. J Card Fail 2013; 19:431-44. [PMID: 23743494 DOI: 10.1016/j.cardfail.2013.04.005] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2012] [Revised: 04/09/2013] [Accepted: 04/18/2013] [Indexed: 01/29/2023]
Abstract
Sleep-disordered breathing (SDB) is the most common comorbidity in patients with heart failure (HF) and has a significant impact on quality of life, morbidity, and mortality. A number of therapeutic options have become available in recent years that can improve quality of life and potentially the outcomes of HF patients with SDB. Unfortunately, SDB is not part of the routine evaluation and management of HF, so it remains untreated in most HF patients. Although recognition of the role of SDB in HF is increasing, clinical guidelines for the management of SDB in HF patients continue to be absent. This article provides an overview of SDB in HF and proposes a clinical care pathway to help clinicians to better recognize and treat SDB in their HF patients.
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Affiliation(s)
- Rami Khayat
- Ohio State University, Division of Pulmonary, Critical Care and Sleep, Columbus, OH 43210, USA.
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Wahab R, Basner RC. Nocturnal non-invasive ventilation for cardio-respiratory disorders in adults. Expert Rev Respir Med 2013; 7:615-29. [PMID: 24175738 DOI: 10.1586/17476348.2013.839246] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Following the classic 'iron lung' non-invasive negative pressure ventilator, non-invasive positive pressure ventilation (NIPPV), particularly used 'nocturnally' has developed a broad role in both the acute hospital setting and domiciliary long-term use for many cardio-respiratory disorders associated with acute and chronic ventilatory failure. This role is based in part upon the perceived relative ease of application and discontinuation of NIPPV, ability to avoid intubation or tracheostomy and their associated morbidities and availability of increasingly portable pressure and volume cycled NIPPV devices. Nevertheless, the many methodologies necessary for optimal NIPPV use are often underappreciated by health care workers and patients alike. This review focuses on the rationale, practice, and future directions for 'nocturnal' use of non-invasive positive pressure ventilation (nNIV) in cardio-respiratory disorders in adults which are commonly associated with sleep-related apnea, hypoventilation and hypoxemia: congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), obesity hypoventilation syndrome (OHS), cystic fibrosis (CF) and neuromuscular disorders.
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Affiliation(s)
- Romina Wahab
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University College of Physicians and Surgeons, 622 West 168th Street, NY 10032, USA
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Plataki M, Sands SA, Malhotra A. Clinical consequences of altered chemoreflex control. Respir Physiol Neurobiol 2013; 189:354-63. [PMID: 23681082 DOI: 10.1016/j.resp.2013.04.020] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2013] [Revised: 04/19/2013] [Accepted: 04/25/2013] [Indexed: 01/28/2023]
Abstract
Control of ventilation dictates various breathing patterns. The respiratory control system consists of a central pattern generator and several feedback mechanisms that act to maintain ventilation at optimal levels. The concept of loop gain has been employed to describe its stability and variability. Synthesizing all interactions under a general model that could account for every behavior has been challenging. Recent insight into the importance of these feedback systems may unveil therapeutic strategies for common ventilatory disturbances. In this review we will address the major mechanisms that have been proposed as mediators of some of the breathing patterns in health and disease that have raised controversies and discussion on ventilatory control over the years.
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Affiliation(s)
- Maria Plataki
- Department of Internal Medicine, Bridgeport Hospital, Yale New Haven Health, Bridgeport, CT, USA
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Ramos RP, Alencar MCN, Treptow E, Arbex F, Ferreira EMV, Neder JA. Clinical usefulness of response profiles to rapidly incremental cardiopulmonary exercise testing. Pulm Med 2013; 2013:359021. [PMID: 23766901 PMCID: PMC3666297 DOI: 10.1155/2013/359021] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2012] [Revised: 12/17/2012] [Accepted: 01/15/2013] [Indexed: 02/06/2023] Open
Abstract
The advent of microprocessed "metabolic carts" and rapidly incremental protocols greatly expanded the clinical applications of cardiopulmonary exercise testing (CPET). The response normalcy to CPET is more commonly appreciated at discrete time points, for example, at the estimated lactate threshold and at peak exercise. Analysis of the response profiles of cardiopulmonary responses at submaximal exercise and recovery, however, might show abnormal physiologic functioning which would not be otherwise unraveled. Although this approach has long been advocated as a key element of the investigational strategy, it remains largely neglected in practice. The purpose of this paper, therefore, is to highlight the usefulness of selected submaximal metabolic, ventilatory, and cardiovascular variables in different clinical scenarios and patient populations. Special care is taken to physiologically justify their use to answer pertinent clinical questions and to the technical aspects that should be observed to improve responses' reproducibility and reliability. The most recent evidence in favor of (and against) these variables for diagnosis, impairment evaluation, and prognosis in systemic diseases is also critically discussed.
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Affiliation(s)
- Roberta P. Ramos
- Pulmonary Function and Clinical Exercise Physiology Unit (SEFICE), Division of Respiratory Diseases, Department of Medicine, Federal University of Sao Paulo (UNIFESP), Rua Francisco de Castro 54, Vila Mariana, 04020-050 São Paulo, SP, Brazil
| | - Maria Clara N. Alencar
- Pulmonary Function and Clinical Exercise Physiology Unit (SEFICE), Division of Respiratory Diseases, Department of Medicine, Federal University of Sao Paulo (UNIFESP), Rua Francisco de Castro 54, Vila Mariana, 04020-050 São Paulo, SP, Brazil
| | - Erika Treptow
- Pulmonary Function and Clinical Exercise Physiology Unit (SEFICE), Division of Respiratory Diseases, Department of Medicine, Federal University of Sao Paulo (UNIFESP), Rua Francisco de Castro 54, Vila Mariana, 04020-050 São Paulo, SP, Brazil
| | - Flávio Arbex
- Pulmonary Function and Clinical Exercise Physiology Unit (SEFICE), Division of Respiratory Diseases, Department of Medicine, Federal University of Sao Paulo (UNIFESP), Rua Francisco de Castro 54, Vila Mariana, 04020-050 São Paulo, SP, Brazil
| | - Eloara M. V. Ferreira
- Pulmonary Function and Clinical Exercise Physiology Unit (SEFICE), Division of Respiratory Diseases, Department of Medicine, Federal University of Sao Paulo (UNIFESP), Rua Francisco de Castro 54, Vila Mariana, 04020-050 São Paulo, SP, Brazil
| | - J. Alberto Neder
- Pulmonary Function and Clinical Exercise Physiology Unit (SEFICE), Division of Respiratory Diseases, Department of Medicine, Federal University of Sao Paulo (UNIFESP), Rua Francisco de Castro 54, Vila Mariana, 04020-050 São Paulo, SP, Brazil
- Division of Respiratory and Critical Care Medicine, Department of Medicine, Queen's University and Kingston General Hospital, Richardson House, 102 Stuart Street, Kingston, ON, Canada K7L 2V6
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Dumitrascu R, Tiede H, Eckermann J, Mayer K, Reichenberger F, Ghofrani HA, Seeger W, Heitmann J, Schulz R. Sleep apnea in precapillary pulmonary hypertension. Sleep Med 2013; 14:247-51. [DOI: 10.1016/j.sleep.2012.11.013] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2012] [Revised: 10/19/2012] [Accepted: 11/15/2012] [Indexed: 11/26/2022]
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Fukuma N, Hayashi H, Sugaya J, Aida T, Kato M, Kato K, Kato Y, Takahashi H, Mizuno K. Sleep-disordered breathing with nighttime hypocapnia relates to daytime enhanced ventilatory response to exercise in patients with heart disease. J NIPPON MED SCH 2013; 79:409-15. [PMID: 23291838 DOI: 10.1272/jnms.79.409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Sleep-disordered breathing (SDB) induces nighttime disturbance of arterial gases, such as carbon dioxide. However, it is still unclear whether nighttime SDB-related gas abnormality is related to respiratory dysregulation in daytime. Therefore, we examined the relationship between the arterial partial pressure of carbon dioxide (PaCO(2)) at nighttime and the respiratory response to exercise in daytime. METHODS Eighteen men (age, mean ± SD; 55 ± 11 years) with heart disease underwent multichannel respiratory monitoring through the night with transdermal measurement of PaCO(2) (PtcCO(2)) reflecting PaCO(2) and a cardiopulmonary exercise test in daytime. The ventilatory equivalent (VE)/carbon dioxide production (VCO(2)) slope as an index of ventilatory response to exercise and peak oxygen consumption (VO(2)) were obtained with a cardiopulmonary exercise test. RESULTS Of the 18 patients, 10 patients had obstructive SDB, 5 had central SDB, and 3 patients did not have SDB. The mean apnea-hypopnea index was 21 ± 17. Minimum nighttime saturation of O(2) was positively correlated with peak VO(2), but not with VE/VCO(2). Nighttime PtcCO(2) was not correlated with peak VO(2) but was negatively correlated with the VE/VCO(2) slope of the daytime cardiopulmonary exercise test (r=-0.53). CONCLUSION Nighttime lowering of PaCO(2) in SDB is related to an abnormal ventilatory response to exercise testing in the daytime. This finding suggests that nighttime hyperventilation in SDB alters both nighttime and daytime pathophysiological conditions in patients with heart disease.
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Affiliation(s)
- Nagaharu Fukuma
- Division of Cardiology, Department of Internal Medicine, Nippon Medical School, Tokyo, Japan.
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Abstract
Irregular breathing characterized by cyclic variation of ventilation with a period of approximately 1 min has been recognized in patients with heart failure for almost two centuries. Periodic breathing during exercise is a noninvasive parameter that is easily recognizable during submaximal cardiopulmonary exercise testing. Recent studies have established that periodic breathing during exercise not only signals significant impairment in resting and exercise hemodynamic parameters but also potently predicts adverse events in heart failure patients. This article reviews the mechanistic basis of periodic breathing and the clinical utility of discerning patterns of irregular breathing in patients with heart failure.
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Affiliation(s)
- Bishnu P Dhakal
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
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Edwards BA, O'Driscoll DM, Ali A, Jordan AS, Trinder J, Malhotra A. Aging and sleep: physiology and pathophysiology. Semin Respir Crit Care Med 2010; 31:618-33. [PMID: 20941662 DOI: 10.1055/s-0030-1265902] [Citation(s) in RCA: 95] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Aging effects on sleep are important to consider for the practicing pulmonologist due to the increase in prevalence of major respiratory disorders as well as the normal changes that occur in sleep patterns with aging. Typically, aging is associated with decreases in the amount of slow wave sleep and increases in stage 1 and 2 non-rapid eye movement sleep, often attributed to an increased number of spontaneous arousals that occur in the elderly. Elderly individuals tend to go to sleep earlier in the evening and wake earlier due to a phase advance in their normal circadian sleep cycle. Furthermore the development of sleep-related respiratory disorders such as obstructive sleep apnea (OSA) and central sleep apnea or Cheyne-Stokes respiration (CSA-CSR) associated with congestive heart failure (CHF) occur with increasing prevalence in the elderly. The development of such disorders is often of major concern because they are associated with systemic hypertension and cardiovascular disease, metabolic disorders such as diabetes, and impaired neurocognition. The present review reflects the current understanding of the normal changes in sleep patterns and sleep needs with advancing age, in addition to the effect that aging has on the predisposition to and consequences of OSA and CSA-CSR associated with CHF.
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Affiliation(s)
- Bradley A Edwards
- Division of Sleep Medicine, Brigham and Women's Hospital and Harvard Medical School, 221 Longwood Ave., Boston, MA 02115, USA.
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Abstract
Central apnea is caused by temporary failure in the pontomedullary pacemaker generating breathing rhythm, which results in the loss of ventilatory effort, and if it lasts 10 seconds or more it is defined as central apnea. This article reviews current knowledge on central sleep apnea.
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Affiliation(s)
- S Javaheri
- Department of Medicine, University of Cincinnati College of Medicine, 4780 Socialville Fosters Road, Mason, OH 45040, USA.
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Abstract
About half of the patients suffering from heart failure present with sleep-disordered breathing. In most cases obstructive and central breathing disturbances (including Cheyne-Stokes respiration [CSR]) coexist. CSR is defined by a waxing and waning pattern of the tidal volume. While its pathophysiology has not been elucidated completely, increased ventilatory sensitivity for CO2 and therefore an imbalance of the respiratory drive and effort, a chronic hyperventilatory state, and changes of the apnoeic threshold are considered to play a relevant role. However, CSR in heart failure impairs survival and quality of life of the patients and is therefore a major challenge of respiratory sleep medicine. If CSR persists despite optimal medical and interventional therapy of the underlying cardiac disorder, oxygen supply, continuous positive airway pressure (CPAP), and bilevel pressure are often trialled. However, there is insufficient evidence to recommend oxygen or bilevel treatment. CPAP has proven to improve left ventricular function. In addition, retrospective analyses suggested a reduction of mortality under CPAP in heart failure patients with CSR. However, these findings could not be reproduced in the prospective controlled CanPAP trial. More recently, adaptive servoventilation (ASV) has been introduced for treatment of CSR or coexisting sleep-related breathing disorders. ASV devices aim at counterbalancing the ventilatory overshoot and undershoot by applying variable pressure support with higher tidal volume (TV) during hypoventilation and reduced TV during hyperventilation. ASV has proven to be superior to CPAP but the long-term efficacy and the influences on cardiac parameters and survival are still under investigation.
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Affiliation(s)
- Winfried J. Randerath
- Institute of Pneumology at the University Witten/Herdecke, Clinic for Pneumology and Allergology, Center of Sleep Medicine and Respiratory Care, Bethanien Hospital, Aufderhöherstraße 169-175, 42699 Solingen, Germany,
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Balady GJ, Arena R, Sietsema K, Myers J, Coke L, Fletcher GF, Forman D, Franklin B, Guazzi M, Gulati M, Keteyian SJ, Lavie CJ, Macko R, Mancini D, Milani RV. Clinician's Guide to cardiopulmonary exercise testing in adults: a scientific statement from the American Heart Association. Circulation 2010; 122:191-225. [PMID: 20585013 DOI: 10.1161/cir.0b013e3181e52e69] [Citation(s) in RCA: 1298] [Impact Index Per Article: 92.7] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Koo BB, Strohl KP, Gillombardo CB, Jacono FJ. Ventilatory patterning in a mouse model of stroke. Respir Physiol Neurobiol 2010; 172:129-35. [PMID: 20472101 DOI: 10.1016/j.resp.2010.05.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2009] [Revised: 05/06/2010] [Accepted: 05/06/2010] [Indexed: 10/19/2022]
Abstract
Cheyne-Stokes respiration (CSR) is a breathing pattern characterized by waxing and waning of breath volume and frequency, and is often recognized following stroke, when causal pathways are often obscure. We used an animal model to address the hypothesis that cerebral infarction is a mechanism for producing breathing instability. Fourteen male A/J mice underwent either stroke (n=7) or sham (n=7) procedure. Ventilation was measured using whole body plethysmography. Respiratory rate (RR), tidal volume (V(T)) and minute ventilation (V(e)) mean values and coefficient of variation were computed for ventilation and oscillatory behaviors. In addition, the ventilatory data were computationally fit to models to quantify autocorrelation, mutual information, sample entropy and a nonlinear complexity index. At the same time post-procedure, stroke when compared to sham animal breathing consisted of a lower RR and autocorrelation, higher coefficient of variation for V(T) and higher coefficient of variation for V(e). Mutual information and the nonlinear complexity index were higher in breathing following stroke which also demonstrated a waxing/waning pattern. The absence of stroke in the sham animals was verified anatomically. We conclude that ventilatory pattern following cerebral infarction demonstrated increased variability with increased nonlinear patterning and a waxing/waning pattern, consistent with CSR.
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Affiliation(s)
- Brian B Koo
- Department of Neurology, Case Western Reserve University School of Medicine, Louis Stokes Veterans Affairs Medical Center, Cleveland, OH 44106, USA.
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Cheyne-Stokes Respiration in Patients with Heart Failure. Lung 2009; 188:5-14. [DOI: 10.1007/s00408-009-9200-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2009] [Accepted: 11/12/2009] [Indexed: 11/27/2022]
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