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Simionescu K, Łoboda D, Adamek M, Wilczek J, Gibiński M, Gardas R, Biernat J, Gołba KS. Relationships between Heart Chamber Morphology or Function and Respiratory Parameters in Patients with HFrEF and Various Types of Sleep-Disordered Breathing. Diagnostics (Basel) 2023; 13:3309. [PMID: 37958204 PMCID: PMC10648695 DOI: 10.3390/diagnostics13213309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 10/08/2023] [Accepted: 10/24/2023] [Indexed: 11/15/2023] Open
Abstract
Sleep-disordered breathing (SDB), i.e., central sleep apnea (CSA) and obstructive sleep apnea (OSA), affects the prognosis of patients with heart failure with reduced ejection fraction (HFrEF). The study assessed the relationships between heart chamber size or function and respiratory parameters in patients with HFrEF and various types of SDB. The 84 participants were patients aged 68.3 ± 8.4 years (80% men) with an average left ventricular ejection fraction (LVEF) of 25.5 ± 6.85% who qualified for cardioverter-defibrillator implantation with or without cardiac resynchronization therapy. SDB, defined by an apnea-hypopnea index (AHI) ≥ five events/hour, was diagnosed in 76 patients (90.5%); SDB was severe in 31 (36.9%), moderate in 26 (31.0%), and mild in 19 (22.6%). CSA was the most common type of SDB (64 patients, 76.2%). A direct proportional relationship existed only in the CSA group between LVEF or stroke volume (SV) and AHI (p = 0.02 and p = 0.07), and between LVEF or SV and the percentage of total sleep time spent with hemoglobin oxygen saturation < 90% (p = 0.06 and p = 0.07). In contrast, the OSA group was the only group in which right ventricle size showed a positive relationship with AHI (for basal linear dimension [RVD1] p = 0.06), mean duration of the respiratory event (for RVD1 p = 0.03, for proximal outflow diameter [RVOT proximal] p = 0.009), and maximum duration of respiratory event (for RVD1 p = 0.049, for RVOT proximal p = 0.006). We concluded that in HFrEF patients, SDB severity is related to LV systolic function and SV only in CSA, whereas RV size correlates primarily with apnea/hypopnea episode duration in OSA.
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Affiliation(s)
- Karolina Simionescu
- Department of Electrocardiology and Heart Failure, Medical University of Silesia, 40-635 Katowice, Poland; (K.S.); (J.W.); (M.G.); (R.G.); (K.S.G.)
- Department of Electrocardiology, Upper-Silesian Medical Centre, 40-635 Katowice, Poland
| | - Danuta Łoboda
- Department of Electrocardiology and Heart Failure, Medical University of Silesia, 40-635 Katowice, Poland; (K.S.); (J.W.); (M.G.); (R.G.); (K.S.G.)
- Department of Electrocardiology, Upper-Silesian Medical Centre, 40-635 Katowice, Poland
| | - Mariusz Adamek
- Department of Thoracic Surgery, Medical University of Silesia, 40-055 Katowice, Poland;
- 2nd Department of Radiology, Medical University of Gdansk, 80-210 Gdansk, Poland
| | - Jacek Wilczek
- Department of Electrocardiology and Heart Failure, Medical University of Silesia, 40-635 Katowice, Poland; (K.S.); (J.W.); (M.G.); (R.G.); (K.S.G.)
- Department of Electrocardiology, Upper-Silesian Medical Centre, 40-635 Katowice, Poland
| | - Michał Gibiński
- Department of Electrocardiology and Heart Failure, Medical University of Silesia, 40-635 Katowice, Poland; (K.S.); (J.W.); (M.G.); (R.G.); (K.S.G.)
- Department of Electrocardiology, Upper-Silesian Medical Centre, 40-635 Katowice, Poland
| | - Rafał Gardas
- Department of Electrocardiology and Heart Failure, Medical University of Silesia, 40-635 Katowice, Poland; (K.S.); (J.W.); (M.G.); (R.G.); (K.S.G.)
- Department of Electrocardiology, Upper-Silesian Medical Centre, 40-635 Katowice, Poland
| | - Jolanta Biernat
- Department of Electrocardiology, Upper-Silesian Medical Centre, 40-635 Katowice, Poland
| | - Krzysztof S. Gołba
- Department of Electrocardiology and Heart Failure, Medical University of Silesia, 40-635 Katowice, Poland; (K.S.); (J.W.); (M.G.); (R.G.); (K.S.G.)
- Department of Electrocardiology, Upper-Silesian Medical Centre, 40-635 Katowice, Poland
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Giannoni A, Borrelli C, Gentile F, Sciarrone P, Spießhöfer J, Piepoli M, Richerson GB, Floras JS, Coats AJS, Javaheri S, Emdin M, Passino C. Autonomic and respiratory consequences of altered chemoreflex function: clinical and therapeutic implications in cardiovascular diseases. Eur J Heart Fail 2023; 25:642-656. [PMID: 36907827 PMCID: PMC10989193 DOI: 10.1002/ejhf.2819] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 02/10/2023] [Accepted: 02/26/2023] [Indexed: 03/14/2023] Open
Abstract
The importance of chemoreflex function for cardiovascular health is increasingly recognized in clinical practice. The physiological function of the chemoreflex is to constantly adjust ventilation and circulatory control to match respiratory gases to metabolism. This is achieved in a highly integrated fashion with the baroreflex and the ergoreflex. The functionality of chemoreceptors is altered in cardiovascular diseases, causing unstable ventilation and apnoeas and promoting sympathovagal imbalance, and it is associated with arrhythmias and fatal cardiorespiratory events. In the last few years, opportunities to desensitize hyperactive chemoreceptors have emerged as potential options for treatment of hypertension and heart failure. This review summarizes up to date evidence of chemoreflex physiology/pathophysiology, highlighting the clinical significance of chemoreflex dysfunction, and lists the latest proof of concept studies based on modulation of the chemoreflex as a novel target in cardiovascular diseases.
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Affiliation(s)
- Alberto Giannoni
- Health Science Interdisciplinary Center, Scuola Superiore Sant’Anna, Pisa, Italy
- Fondazione Toscana G. Monasterio, Pisa, Italy
| | | | - Francesco Gentile
- Health Science Interdisciplinary Center, Scuola Superiore Sant’Anna, Pisa, Italy
| | | | - Jens Spießhöfer
- Health Science Interdisciplinary Center, Scuola Superiore Sant’Anna, Pisa, Italy
- University of Aachen, Aachen, Germany
| | | | | | - John S Floras
- Division of Cardiology, Mount Sinai Hospital, University of Toronto, Ontario, Canada
| | | | - Shahrokh Javaheri
- Division of Pulmonary and Sleep Medicine, Bethesda North Hospital, Cincinnati, Ohio, Division of Pulmonary, Critical Care and Sleep Medicine, University of Cincinnati, Cincinnati, Ohio, and Division of Cardiology, The Ohio State University, Columbus, Ohio USA
| | - Michele Emdin
- Health Science Interdisciplinary Center, Scuola Superiore Sant’Anna, Pisa, Italy
- Fondazione Toscana G. Monasterio, Pisa, Italy
| | - Claudio Passino
- Health Science Interdisciplinary Center, Scuola Superiore Sant’Anna, Pisa, Italy
- Fondazione Toscana G. Monasterio, Pisa, Italy
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Javaheri S, Rapoport DM, Schwartz AR. Distinguishing central from obstructive hypopneas on a clinical polysomnogram. J Clin Sleep Med 2023; 19:823-834. [PMID: 36661093 PMCID: PMC10071374 DOI: 10.5664/jcsm.10420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 11/22/2022] [Accepted: 11/22/2022] [Indexed: 01/21/2023]
Abstract
Among sleep-related disordered breathing events, hypopneas are the most frequent. Like obstructive and central apneas, hypopneas may be obstructive or central (reduced drive) in origin. Nevertheless, unlike apneas, categorizing hypopneas as either "obstructive" or "central" is often difficult or ambiguous. It has been suggested that hypopneas could be categorized as obstructive when associated with snoring, inspiratory flow limitation, or paradoxical thoraco-abdominal excursions. This approach, however, has not been extensively tested and misclassification of hypopneas is unavoidable. Yet, much rides on the accurate distinction of these events to guide therapy with medical devices or pharmacological therapy in each patient. Additionally, accurate hypopnea classification is critical for design of clinical trials, because therapeutic responses differ depending on the subtype of hypopnea. Correctly classifying hypopneas can also allay concerns about obtaining coverage for therapies that specifically target either central or obstructive sleep-disordered breathing events. The present paper expands on the current criteria for differentiating obstructive from central hypopneas and provides illustrative tracings that can help classify these events. CITATION Javaheri S, Rapoport DM, Schwartz AR. Distinguishing central from obstructive hypopneas on a clinical polysomnogram. J Clin Sleep Med. 2023;19(4):823-834.
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Affiliation(s)
- Shahrokh Javaheri
- Division of Pulmonary and Sleep, Bethesda North Hospital, Cincinnati, Ohio
| | - David M. Rapoport
- Division of Pulmonary, Critical Care and Sleep Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Alan R. Schwartz
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
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Evans AM. Of Mice and Men and Plethysmography Systems: Does LKB1 Determine the Set Point of Carotid Body Chemosensitivity and the Hypoxic Ventilatory Response? Adv Exp Med Biol 2023; 1427:163-173. [PMID: 37322347 DOI: 10.1007/978-3-031-32371-3_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
Our recent studies suggest that the level of liver kinase B1 (LKB1) expression in some way determines carotid body afferent discharge during hypoxia and to a lesser extent during hypercapnia. In short, phosphorylation by LKB1 of an as yet unidentified target(s) determines a set point for carotid body chemosensitivity. LKB1 is the principal kinase that activates the AMP-activated protein kinase (AMPK) during metabolic stresses, but conditional deletion of AMPK in catecholaminergic cells, including therein carotid body type I cells, has little or no effect on carotid body responses to hypoxia or hypercapnia. With AMPK excluded, the most likely target of LKB1 is one or other of the 12 AMPK-related kinases, which are constitutively phosphorylated by LKB1 and, in general, regulate gene expression. By contrast, the hypoxic ventilatory response is attenuated by either LKB1 or AMPK deletion in catecholaminergic cells, precipitating hypoventilation and apnea during hypoxia rather than hyperventilation. Moreover, LKB1, but not AMPK, deficiency causes Cheyne-Stokes-like breathing. This chapter will explore further the possible mechanisms that determine these outcomes.
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Affiliation(s)
- A Mark Evans
- Centre for Discovery Brain Sciences, Hugh Robson Building, University of Edinburgh, Edinburgh, UK.
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Neder JA, Phillips DB, O'Donnell DE, Dempsey JA. Excess ventilation and exertional dyspnoea in heart failure and pulmonary hypertension. Eur Respir J 2022; 60:13993003.00144-2022. [PMID: 35618273 DOI: 10.1183/13993003.00144-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 05/05/2022] [Indexed: 01/11/2023]
Abstract
Increased ventilation relative to metabolic demands, indicating alveolar hyperventilation and/or increased physiological dead space (excess ventilation), is a key cause of exertional dyspnoea. Excess ventilation has assumed a prominent role in the functional assessment of patients with heart failure (HF) with reduced (HFrEF) or preserved (HFpEF) ejection fraction, pulmonary arterial hypertension (PAH) and chronic thromboembolic pulmonary hypertension (CTEPH). We herein provide the key pieces of information to the caring physician to 1) gain unique insights into the seeds of patients' shortness of breath and 2) develop a rationale for therapeutically lessening excess ventilation to mitigate this distressing symptom. Reduced bulk oxygen transfer induced by cardiac output limitation and/or right ventricle-pulmonary arterial uncoupling increase neurochemical afferent stimulation and (largely chemo-) receptor sensitivity, leading to alveolar hyperventilation in HFrEF, PAH and small-vessel, distal CTEPH. As such, interventions geared to improve central haemodynamics and/or reduce chemosensitivity have been particularly effective in lessening their excess ventilation. In contrast, 1) high filling pressures in HFpEF and 2) impaired lung perfusion leading to ventilation/perfusion mismatch in proximal CTEPH conspire to increase physiological dead space. Accordingly, 1) decreasing pulmonary capillary pressures and 2) mechanically unclogging larger pulmonary vessels (pulmonary endarterectomy and balloon pulmonary angioplasty) have been associated with larger decrements in excess ventilation. Exercise training has a strong beneficial effect across diseases. Addressing some major unanswered questions on the link of excess ventilation with exertional dyspnoea under the modulating influence of pharmacological and nonpharmacological interventions might prove instrumental to alleviate the devastating consequences of these prevalent diseases.
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Affiliation(s)
- J Alberto Neder
- Clinical Exercise Physiology and Respiratory Investigation Unit, Division of Respiratory and Critical Care Medicine, Dept of Medicine, Queen's University and Kingston Health Sciences Centre, Kingston, ON, Canada
| | - Devin B Phillips
- Clinical Exercise Physiology and Respiratory Investigation Unit, Division of Respiratory and Critical Care Medicine, Dept of Medicine, Queen's University and Kingston Health Sciences Centre, Kingston, ON, Canada
| | - Denis E O'Donnell
- Clinical Exercise Physiology and Respiratory Investigation Unit, Division of Respiratory and Critical Care Medicine, Dept of Medicine, Queen's University and Kingston Health Sciences Centre, Kingston, ON, Canada
| | - Jerome A Dempsey
- John Rankin Laboratory of Pulmonary Medicine, Dept of Population Health Sciences, University of Wisconsin-Madison, Madison, WI, USA
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Spiesshoefer J, Giannoni A, Borrelli C, Sciarrone P, Husstedt I, Emdin M, Passino C, Kahles F, Dawood T, Regmi B, Naughton M, Dreher M, Boentert M, Macefield VG. Effects of hyperventilation length on muscle sympathetic nerve activity in healthy humans simulating periodic breathing. Front Physiol 2022; 13:934372. [PMID: 36134331 PMCID: PMC9483206 DOI: 10.3389/fphys.2022.934372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 08/10/2022] [Indexed: 11/13/2022] Open
Abstract
Background: Periodic breathing (PB) is a cyclical breathing pattern composed of alternating periods of hyperventilation (hyperpnea, HP) and central apnea (CA). Differences in PB phenotypes mainly reside in HP length. Given that respiration modulates muscle sympathetic nerve activity (MSNA), which decreases during HP and increases during CA, the net effects of PB on MSNA may critically depend on HP length.Objectives: We hypothesized that PB with shorter periods of HP is associated with increased MSNA and decreased heart rate variability.Methods: 10 healthy participants underwent microelectrode recordings of MSNA from the common peroneal nerve along with non-invasive recording of HRV, blood pressure and respiration. Following a 10-min period of tidal breathing, participants were asked to simulate PB for 3 min following a computed respiratory waveform that emulated two PB patterns, comprising a constant CA of 20 s duration and HP of two different lengths: short (20 s) vs long (40 s). Results: Compared to (3 min of) normal breathing, simulated PB with short HP resulted in a marked increase in mean and maximum MSNA amplitude (from 3.2 ± 0.8 to 3.4 ± 0.8 µV, p = 0.04; from 3.8 ± 0.9 to 4.3 ± 1.1 µV, p = 0.04, respectively). This was paralleled by an increase in LF/HF ratio of heart rate variability (from 0.9 ± 0.5 to 2.0 ± 1.3; p = 0.04). In contrast, MSNA response to simulated PB with long HP did not change as compared to normal breathing. Single CA events consistently resulted in markedly increased MSNA (all p < 0.01) when compared to the preceding HPs, while periods of HP, regardless of duration, decreased MSNA (p < 0.05) when compared to normal breathing.Conclusion: Overall, the net effects of PB in healthy subjects over time on MSNA are dependent on the relative duration of HP: increased sympathetic outflow is seen during PB with a short but not with a long period of HP.
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Affiliation(s)
- Jens Spiesshoefer
- Institute of Life Sciences, Scuola Superiore Sant’Anna, Pisa, Italy
- Department of Pneumology and Intensive Care Medicine, University Hospital RWTH Aachen, Aachen, Germany
- *Correspondence: Jens Spiesshoefer,
| | - Alberto Giannoni
- Institute of Life Sciences, Scuola Superiore Sant’Anna, Pisa, Italy
- Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Chiara Borrelli
- Institute of Life Sciences, Scuola Superiore Sant’Anna, Pisa, Italy
| | | | - Imke Husstedt
- Department of Neurology with Institute for Translational Neurology, University of Muenster, Muenster, Germany
| | - Michele Emdin
- Institute of Life Sciences, Scuola Superiore Sant’Anna, Pisa, Italy
- Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Claudio Passino
- Institute of Life Sciences, Scuola Superiore Sant’Anna, Pisa, Italy
- Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Florian Kahles
- Department of Cardiology and Vascular Medicine, University Hospital RWTH Aachen, Aachen, Germany
| | - Tye Dawood
- Human Autonomic Neurophysiology Laboratory, Baker Heart and Diabetes Institute, Melbourne, VIC, Australia
| | - Binaya Regmi
- Department of Pneumology and Intensive Care Medicine, University Hospital RWTH Aachen, Aachen, Germany
| | - Matthew Naughton
- Department of Respiratory Medicine, The Alfred Hospital, Melbourne, VIC, Australia
- Department of Medicine, Monash University, Melbourne, VIC, Australia
| | - Michael Dreher
- Department of Pneumology and Intensive Care Medicine, University Hospital RWTH Aachen, Aachen, Germany
| | - Matthias Boentert
- Fondazione Toscana Gabriele Monasterio, Pisa, Italy
- Department of Medicine, UKM Marienhospital Steinfurt, Steinfurt, Germany
| | - Vaughan G. Macefield
- Human Autonomic Neurophysiology Laboratory, Baker Heart and Diabetes Institute, Melbourne, VIC, Australia
- Department of Anatomy & Physiology, University of Melbourne, Melbourne, VIC, Australia
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Singh J, Zaballa K, Kok H, Fitzgerald N, Uy C, Nuth D, Castro C, Irving C, Waters K, Fitzgerald DA. Cheyne-stokes respiration in children with heart failure. Paediatr Respir Rev 2022; 43:78-84. [PMID: 35459626 DOI: 10.1016/j.prrv.2022.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 03/01/2022] [Indexed: 11/30/2022]
Abstract
Cheyne-Stokes respiration (CSA-CSR) is a form of central sleep apnea characterized by alternating periods of hyperventilation and central apneas or hypopneas. CSA-CSR develops following a cardiac insult resulting in a compensatory increase in sympathetic activity, which in susceptible patients causes hyperventilation and destabilizes respiratory control. The physiological changes that occur in CSA-CSR include hyperventilation, a reduced blood gas buffering capacity, and circulatory delay. In adults, 25% to 50% of patients with heart failure are reported to have CSA-CSR. The development of CSA-CSR in this group of patients is considered a poor prognostic sign. The prevalence, progression, and treatment outcomes of CSA-CSR in children remain unclear with only 11 children being described in the literature. The lack of data is possibly not due to the paucity of children with severe heart failure and CSA-CSR but because they may be under-recognized, compounded by the absence of routine polysomnographic assessment of children with moderate to severe heart failure. Building on much broader experience in the diagnosis and management of CSA-CSR in adult sleep medicine and our limited experience in a pediatric quaternary center, this paper will discuss the prevalence of CSA-CSR, its' treatment options, outcomes in children, and the potential future direction for research in this understudied area of pediatric sleep medicine.
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Affiliation(s)
- Jagdev Singh
- Department of Sleep Medicine, The Children's Hospital at Westmead, Sydney, NSW, Australia; Discipline of Child and Adolescent Health, Sydney Medical School, University of Sydney, Sydney, NSW, Australia.
| | - Katrina Zaballa
- Department of Sleep Medicine, The Children's Hospital at Westmead, Sydney, NSW, Australia
| | - Harvey Kok
- Department of Respiratory and Sleep Medicine, John Hunter Hospital, Newcastle, NSW, Australia
| | - Nicholas Fitzgerald
- Department of Cardiology, The Children's Hospital at Westmead, Sydney, NSW, Australia; Discipline of Child and Adolescent Health, Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Carla Uy
- Department of Sleep Medicine, The Children's Hospital at Westmead, Sydney, NSW, Australia
| | - Dara Nuth
- Department of Sleep Medicine, The Children's Hospital at Westmead, Sydney, NSW, Australia
| | - Chenda Castro
- Department of Sleep Medicine, The Children's Hospital at Westmead, Sydney, NSW, Australia
| | - Claire Irving
- Department of Cardiology, The Children's Hospital at Westmead, Sydney, NSW, Australia; Discipline of Child and Adolescent Health, Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Karen Waters
- Department of Sleep Medicine, The Children's Hospital at Westmead, Sydney, NSW, Australia; Discipline of Child and Adolescent Health, Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Dominic A Fitzgerald
- Department of Sleep Medicine, The Children's Hospital at Westmead, Sydney, NSW, Australia; Discipline of Child and Adolescent Health, Sydney Medical School, University of Sydney, Sydney, NSW, Australia
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Belli-Marin JFC, Bocchi EA, Ayub-Ferreira S, Junior NC, Guimarães GV. Effects of β-blocker therapy on exercise oscillatory ventilation in reduced ejection fraction heart failure patients: A case series study. Biomed Pharmacother 2022; 152:113106. [PMID: 35665667 DOI: 10.1016/j.biopha.2022.113106] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 05/03/2022] [Accepted: 05/10/2022] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Exercise oscillatory ventilation (EOV) is an abnormal breathing pattern that occurs in ~20% of patients with heart failure (HF) and is associated with poor prognosis and exercise intolerance. β-blockers (βb) are prescribed for most HF patients; however, their effect on EOV remains unclear. We evaluated the effect of βb on EOV in HF patients with reduced ejection fraction (HFrEF). METHODS Fifteen patients diagnosed with HF, ejection fraction < 45%, aged from 18 to 65 years, were included before starting βb therapy. Patients underwent clinical evaluation, cardiopulmonary exercise testing, echocardiography, laboratory exams (norepinephrine levels, B type natriuretic peptide) at baseline and after βb therapy optimized for six months. Presence of exercise oscillatory breathing was determined by two experienced observers who were blinded to the moment of the test (pre or post). RESULTS Fifteen patients (1 female), aged 49.5 ± 2.5 years, with HFrEF, NYHA I-III enrolled in the study. The etiologies of the HFrEF were idiopathic (n = 8) and hypertensive (n = 7). LVEF increased after βb therapy from 25.9 ± 2.5% to 33 ± 2.6%, P = 0.02; peak VO2 did not significantly change (21.8 ± 1.7 vs 24.7 ± 1.9, P = 0.4); VE/VCO2 slope changed from 32.1 ± 10.6-27.5 ± 9.1, P = 0.03. Before βb initiation, nine patients (60%) had EOV, but only two (13%) did after optimized therapy. McNemar test was used to evaluate the significance of the association between the two moments (P = 0.02). CONCLUSION In patients with HF, medical therapy with βb can reverse EOV. This may explain why these patients experience symptom improvement after βb therapy.
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Affiliation(s)
| | - Edimar Alcides Bocchi
- Instituto do Coração, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Brazil
| | - Silvia Ayub-Ferreira
- Instituto do Coração, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Brazil
| | - Nelson Carvas Junior
- Instituto do Coração, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Brazil
| | - Guilherme Veiga Guimarães
- Instituto do Coração, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Brazil.
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MacMillan S, Holmes AP, Dallas ML, Mahmoud AD, Shipston MJ, Peers C, Hardie DG, Kumar P, Evans AM. LKB1 is the gatekeeper of carotid body chemosensing and the hypoxic ventilatory response. Commun Biol 2022; 5:642. [PMID: 35768580 DOI: 10.1038/s42003-022-03583-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 06/14/2022] [Indexed: 11/08/2022] Open
Abstract
The hypoxic ventilatory response (HVR) is critical to breathing and thus oxygen supply to the body and is primarily mediated by the carotid bodies. Here we reveal that carotid body afferent discharge during hypoxia and hypercapnia is determined by the expression of Liver Kinase B1 (LKB1), the principal kinase that activates the AMP-activated protein kinase (AMPK) during metabolic stresses. Conversely, conditional deletion in catecholaminergic cells of AMPK had no effect on carotid body responses to hypoxia or hypercapnia. By contrast, the HVR was attenuated by LKB1 and AMPK deletion. However, in LKB1 knockouts hypoxia evoked hypoventilation, apnoea and Cheyne-Stokes-like breathing, while only hypoventilation and apnoea were observed after AMPK deletion. We therefore identify LKB1 as an essential regulator of carotid body chemosensing and uncover a divergence in dependency on LKB1 and AMPK between the carotid body on one hand and the HVR on the other.
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Roberts EG, Raphelson JR, Orr JE, LaBuzetta JN, Malhotra A. The Pathogenesis of Central and Complex Sleep Apnea. Curr Neurol Neurosci Rep 2022. [PMID: 35588042 DOI: 10.1007/s11910-022-01199-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2022] [Indexed: 11/09/2022]
Abstract
Purpose
The purpose of this article is to review the recent literature on central apnea. Sleep disordered breathing (SDB) is characterized by apneas (cessation in breathing), and hypopneas (reductions in breathing), that occur during sleep. Central sleep apnea (CSA) is sleep disordered breathing in which there is an absence or diminution of respiratory effort during breathing disturbances while asleep. In obstructive sleep apnea (OSA), on the other hand, there is an absence of flow despite ongoing ventilatory effort. Recent Findings Central sleep apnea is a heterogeneous disease with multiple clinical manifestations. Summary OSA is by far the more common condition; however, CSA is highly prevalent among certain patient groups. Complex sleep apnea (CompSA) is defined as the occurrence/emergence of CSA upon treatment of OSA. Similarly, there is considerable overlap between CSA and OSA in pathogenesis as well as impacts. Thus, understanding sleep disordered breathing is important for many practicing clinicians.
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Coniglio AC, Mentz RJ. Sleep Breathing Disorders in Heart Failure. Cardiol Clin 2022; 40:183-9. [DOI: 10.1016/j.ccl.2021.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Deep Singh T. Abnormal Sleep-Related Breathing Related to Heart Failure. Sleep Med Clin 2022; 17:87-98. [PMID: 35216764 DOI: 10.1016/j.jsmc.2021.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Sleep-disordered breathing (SDB) is highly prevalent in patients with heart failure (HF). Untreated obstructive sleep apnea (OSA) and central sleep apnea (CSA) in patients with HF are associated with worse outcomes. Detailed sleep history along with polysomnography (PSG) should be conducted if SDB is suspected in patients with HF. First line of treatment is the optimization of medical therapy for HF and if symptoms persist despite optimization of the treatment, positive airway pressure (PAP) therapy will be started to treat SDB. At present, there is limited evidence to prescribe any drugs for treating CSA in patients with HF. There is limited evidence for the efficacy of continuous positive airway pressure (CPAP) or adaptive servo-ventilation (ASV) in improving mortality in patients with heart failure with reduced ejection fraction (HFrEF). There is a need to perform well-designed studies to identify different phenotypes of CSA/OSA in patients with HF and to determine which phenotype responds to which therapy. Results of ongoing trials, ADVENT-HF, and LOFT-HF are eagerly awaited to shed more light on the management of CSA in patients with HF. Until then the management of SDB in patients with HF is limited due to the lack of evidence and guidance for treating SDB in patients with HF.
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Affiliation(s)
- Tripat Deep Singh
- Academy of Sleep Wake Science, #32 St.no-9 Guru Nanak Nagar, near Gurbax Colony, Patiala, Punjab, India 147003.
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Gentile F, Borrelli C, Sciarrone P, Buoncristiani F, Spiesshoefer J, Bramanti F, Iudice G, Vergaro G, Emdin M, Passino C, Giannoni A. Central Apneas Are More Detrimental in Female Than in Male Patients With Heart Failure. J Am Heart Assoc 2022; 11:e024103. [PMID: 35191313 PMCID: PMC9075076 DOI: 10.1161/jaha.121.024103] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Central apneas (CA) are a frequent comorbidity in patients with heart failure (HF) and are associated with worse prognosis. The clinical and prognostic relevance of CA in each sex is unknown. Methods and Results Consecutive outpatients with HF with either reduced or mildly reduced left ventricular ejection fraction (n=550, age 65±12 years, left ventricular ejection fraction 32%±9%, 21% women) underwent a 24‐hour ambulatory polygraphy to evaluate CA burden and were followed up for the composite end point of cardiac death, appropriate implantable cardioverter‐defibrillator shock, or first HF hospitalization. Compared with men, women were younger, had higher left ventricular ejection fraction, had lower prevalence of ischemic etiology and of atrial fibrillation, and showed lower apnea‐hypopnea index (expressed as median [interquartile range]) at daytime (3 [0–9] versus 10 [3–20] events/hour) and nighttime (10 [3–21] versus 23 [11–36] events/hour) (all P<0.001), despite similar neurohormonal activation and HF therapy. Increased chemoreflex sensitivity to either hypoxia or hypercapnia (evaluated in 356 patients, 65%, by a rebreathing test) was less frequent in women (P<0.001), but chemoreflex sensitivity to hypercapnia was a predictor of apnea‐hypopnea index in both sexes. At adjusted survival analysis, daytime apnea‐hypopnea index ≥15 events/hour (hazard ratio [HR], 2.70; 95% CI, 1.06–7.34; P=0.037), nighttime apnea‐hypopnea index ≥15 events/hour (HR, 2.84; 95% CI, 1.28–6.32; P=0.010), and nighttime CA index ≥10 events/hour (HR, 5.01; 95% CI, 1.88–13.4; P=0.001) were independent predictors of the primary end point in women but not in men (all P>0.05), also after matching women and men for possible confounders. Conclusions In chronic HF, CA are associated with a greater risk of adverse events in women than in men.
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Affiliation(s)
- Francesco Gentile
- Fondazione Toscana G. MonasterioCNR-Regione Toscana Pisa Italy.,University Hospital Pisa Italy
| | - Chiara Borrelli
- Fondazione Toscana G. MonasterioCNR-Regione Toscana Pisa Italy.,University Hospital Pisa Italy
| | - Paolo Sciarrone
- Fondazione Toscana G. MonasterioCNR-Regione Toscana Pisa Italy.,University Hospital Pisa Italy
| | | | | | | | - Giovanni Iudice
- Fondazione Toscana G. MonasterioCNR-Regione Toscana Pisa Italy
| | - Giuseppe Vergaro
- Fondazione Toscana G. MonasterioCNR-Regione Toscana Pisa Italy.,Institute of Life Sciences Scuola Superiore Sant'Anna Pisa Italy
| | - Michele Emdin
- Fondazione Toscana G. MonasterioCNR-Regione Toscana Pisa Italy.,Institute of Life Sciences Scuola Superiore Sant'Anna Pisa Italy
| | - Claudio Passino
- Fondazione Toscana G. MonasterioCNR-Regione Toscana Pisa Italy.,Institute of Life Sciences Scuola Superiore Sant'Anna Pisa Italy
| | - Alberto Giannoni
- Fondazione Toscana G. MonasterioCNR-Regione Toscana Pisa Italy.,Institute of Life Sciences Scuola Superiore Sant'Anna Pisa Italy
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Saito K, Takamatsu Y. Cheyne-Stokes Breathing as a Predictive Indicator of Heart Failure in Patients With Obstructive Sleep Apnea; A Retrospective Case Control Study Using Continuous Positive Airway Pressure Remote Monitoring Data. Front Cardiovasc Med 2022; 9:790331. [PMID: 35224039 PMCID: PMC8876318 DOI: 10.3389/fcvm.2022.790331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 01/17/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectiveWe conducted a retrospective case control study to examine whether remote monitoring of Cheyne-Stokes breathing (CSB) was useful for predicting the onset of heart failure (HF) in patients with obstructive sleep apnea (OSA) on continuous positive airway pressure (CPAP).MethodsAmong patients with OSA treated at our hospital, 33 patients with HF that occurred between July 2014 and May 2021 [11 patients with acute HF (AHF); 22 patients with chronic HF (CHF) exacerbation] were included in the HF group. Of the 618 stable patients, 149 patients with a 30-days average CSB rate (CSB%) ≧1% were included in the non-HF control group. The chronologic change of CSB% were compared among the AHF, CHF and Control groups. Furthermore, of the 149 patients in the non-HF control group, 44 patients were matched for CSB%, body mass index, and sex in a ratio of 1:2 to 22 patients with CHF. The average cycle length (CL) of CSB was compared among three groups: CHF in stable period (CHF-stable group), CHF in exacerbation period (CHF-exacerbation group), and control group. In addition, according to the status of HF, receiver operating characteristic (ROC) curves were generated to determine the optimal cut-off points for variation of CSB% and CL.ResultsChronological change in CSB% among the three groups was significantly different. Standard deviation of CSB% (SD CSB%) before onset HF was significantly higher in both the AHF and CHF groups than in the control group. The CL of CSB was significantly longer in the CHF group than in the control group and was longer during the exacerbation period than during the stable period. The optimal cut-off value of CL that could differentiate patients with and without the onset of HF was 68.9 s.ConclusionThe HF group demonstrated greater CSB variations and longer CL than the non-HF control group. Furthermore, the CL was longer during the exacerbation period of HF even in the same patient. These results suggest that remote monitoring of CPAP device data for CSB variations and CL might allow early prediction of the onset and exacerbation of HF.
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Pinna GD, Robbi E, Bruschi C, La Rovere MT, Maestri R. Interaction Between Arousals and Ventilation During Cheyne-Stokes Respiration in Heart Failure Patients: Insights From Breath-by-Breath Analysis. Front Med (Lausanne) 2022; 8:742458. [PMID: 34977056 PMCID: PMC8717813 DOI: 10.3389/fmed.2021.742458] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 11/22/2021] [Indexed: 11/13/2022] Open
Abstract
Study Objectives: Arousals from sleep during the hyperpneic phases of Cheyne-Stokes respiration with central sleep apnea (CSR-CSA) in patients with heart failure are thought to cause ventilatory overshoot and a consequent longer apnea, thereby sustaining and exacerbating ventilatory instability. However, data supporting this model are lacking. We investigated the relationship between arousals, hyperpnea and post-hyperpnea apnea length during CSR-CSA. Methods: Breath-by-breath changes in ventilation associated with the occurrence of arousal were evaluated in 18 heart failure patients with CSR-CSA, apnea-hypopnea index ≥15/h and central apnea index ≥5/h. The change in apnea length associated with the presence of arousal during the previous hyperpnea was also evaluated. Potential confounding variables (chemical drive, sleep stage) were controlled for. Results: Arousals were associated with a large increase in ventilation at the beginning of the hyperpnea (+76 ± 35%, p < 0.0001), that rapidly declined during its crescendo phase. Around peak hyperpnea, the change in ventilation was -8 ± 26% (p = 0.14). The presence of arousal during the hyperpnea was associated with a median increase in the length of the subsequent apnea of +4.6% (Q1, Q2: -0.7%, 20.5%; range: -8.5%, 36.2%) (p = 0.021). The incidence of arousals occurring at the beginning of hyperpnea and mean ventilation in the region around its peak were independent predictors of the change in apnea length (p = 0.004 and p = 0.015, respectively; R2 = 0.78). Conclusions: Arousals from sleep during CSR-CSA in heart failure patients are associated with a rapidly decreasing ventilatory overshoot at the beginning of the hyperpnea, followed by a tendency toward a slight ventilatory undershoot around its peak. On average, arousals are also associated with a modest increase in post-hyperpnea apnea length; however, large increases in apnea length (>20%) occur in about a quarter of the patients.
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Affiliation(s)
- Gian Domenico Pinna
- Laboratory for the Study of Ventilatory Instability, Department of Biomedical Engineering, Montescano Institute - IRCCS, Istituti Clinici Scientifici Maugeri, Montescano, Italy
| | - Elena Robbi
- Sleep and Respiratory Function Unit, Montescano Institute - IRCCS, Istituti Clinici Scientifici Maugeri, Montescano, Italy.,Laboratory for the Study of the Autonomic Nervous System, Department of Cardiology, Montescano Institute - IRCCS, Istituti Clinici Scientifici Maugeri, Montescano, Italy
| | - Claudio Bruschi
- Department of Pneumology, Montescano Institute - IRCCS, Istituti Clinici Scientifici Maugeri, Montescano, Italy
| | - Maria Teresa La Rovere
- Laboratory for the Study of the Autonomic Nervous System, Department of Cardiology, Montescano Institute - IRCCS, Istituti Clinici Scientifici Maugeri, Montescano, Italy
| | - Roberto Maestri
- Laboratory for the Study of Ventilatory Instability, Department of Biomedical Engineering, Montescano Institute - IRCCS, Istituti Clinici Scientifici Maugeri, Montescano, Italy
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16
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Cassady SJ, Glick DR, Williams SR, Lewis GD. Periodic Breathing in Cardiopulmonary Exercise Testing: Exercise Oscillatory Ventilation in Heart Failure. Ann Am Thorac Soc 2022; 19:120-6. [PMID: 34971352 DOI: 10.1513/AnnalsATS.202105-559CC] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Lévy P, Naughton MT, Tamisier R, Cowie MR, Bradley TD. Sleep Apnoea and Heart Failure. Eur Respir J 2021; 59:13993003.01640-2021. [PMID: 34949696 DOI: 10.1183/13993003.01640-2021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 09/07/2021] [Indexed: 11/05/2022]
Abstract
Heart Failure (HF) and Sleep-Disordered-Breathing (SDB) are two common conditions that frequently overlap and have been studied extensively in the past three decades. Obstructive Sleep Apnea (OSA) may result in myocardial damage, due to intermittent hypoxia increased sympathetic activity and transmural pressures, low-grade vascular inflammation and oxidative stress. On the other hand, central sleep apnoea and Cheyne-Stokes respiration (CSA-CSR) occurs in HF, irrespective of ejection fraction either reduced (HFrEF), preserved (HFpEF) or mildly reduced (HFmrEF). The pathophysiology of CSA-CSR relies on several mechanisms leading to hyperventilation, breathing cessation and periodic breathing. Pharyngeal collapse may result at least in part from fluid accumulation in the neck, owing to daytime fluid retention and overnight rostral fluid shift from the legs. Although both OSA and CSA-CSR occur in HF, the symptoms are less suggestive than in typical (non-HF related) OSA. Overnight monitoring is mandatory for a proper diagnosis, with accurate measurement and scoring of central and obstructive events, since the management will be different depending on whether the sleep apnea in HF is predominantly OSA or CSA-CSR. SDB in HF are associated with worse prognosis, including higher mortality than in patients with HF but without SDB. However, there is currently no evidence that treating SDB improves clinically important outcomes in patients with HF, such as cardiovascular morbidity and mortality.
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Affiliation(s)
- Patrick Lévy
- Univ Grenoble Alpes, Inserm, HP2 laboratory, Grenoble, France .,CHU Grenoble Alpes, Physiology, EFCR, Grenoble, France.,All authors contributed equally to the manuscript
| | - Matt T Naughton
- Alfred Hospital, Department of Respiratory Medicine and Monash University, Melbourne, Australia.,All authors contributed equally to the manuscript
| | - Renaud Tamisier
- Univ Grenoble Alpes, Inserm, HP2 laboratory, Grenoble, France.,CHU Grenoble Alpes, Physiology, EFCR, Grenoble, France.,All authors contributed equally to the manuscript
| | - Martin R Cowie
- Royal Brompton Hospital and Faculty of Lifesciences & Medicine, King"s College London, London, UK.,All authors contributed equally to the manuscript
| | - T Douglas Bradley
- Sleep Research Laboratory of the University Health Network Toronto Rehabilitation Institute, Centre for Sleep Medicine and Circadian Biology of the University of Toronto and Department of Medicine of the University Health Network Toronto General Hospital, Canada.,All authors contributed equally to the manuscript
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Abstract
STUDY OBJECTIVES During positive airway pressure (PAP) therapy for sleep apnea syndromes, the machine detected respiratory event index (REIFLOW) is an important method for clinicians to evaluate the beneficial effects of PAP. There are concerns about the accuracy of this detection, which also confounds a related question-how common and severe are residual events on PAP. METHODS Subjects with OSA who underwent a split night polysomnography were recruited prospectively. Those treated with PAP and tracked by the EncoreAnywhere system were analyzed. The ones who stopped PAP within one month were excluded for this analysis. Compliance, therapy data and waveform data were analyzed. Machine detected versus manually scored events were compared at the 1st, 3rd, 6th and 12th month from PAP initiation. Logistic regression was used to determine factors associated with a high REIFLOW difference. RESULTS One hundred and seventy-nine patients with a mean age 59.06 ± 13.97 years old, median body mass index 33.60 (29.75-38.75) kg/m2, and median baseline AHI 46.30 (31.50-65.90) times/hour were included. The difference between the machine detected REIFLOW and manually scored REIFLOW was 10.72 ±8.43 in the first month and remained stable for up to 12 months. Male sex and large leak ≥ 1.5% were more frequent in patients who had an REIFLOW difference of ≥ 5 / hour of use. A titration arousal index ≥ 15/ hour of sleep, and higher ratio of unstable to stable breathing were also associated with an REIFLOW difference ≥ 5 times/hour of use. CONCLUSIONS There is a substantial and sustained difference between manual and automated event estimates during PAP therapy, and some associated factors were identified.
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Affiliation(s)
- Yue-Nan Ni
- Department of Respiratory, Critical Care and Sleep Medicine, West China School of Medicine and West China Hospital, Sichuan University, China
| | - Robert Joseph Thomas
- Division of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, MA
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Tobushi T, Kasai T, Hirose M, Sakai K, Akamatsu M, Ohsawa C, Yoshioka Y, Suda S, Shiroshita N, Nakamura R, Kadokami T, Tohyama T, Funakoshi K, Hosokawa K, Ando SI. Lung-to-finger circulation time can be measured stably with high reproducibility by simple breath holding method in cardiac patients. Sci Rep 2021; 11:15913. [PMID: 34354137 PMCID: PMC8342428 DOI: 10.1038/s41598-021-95192-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 07/09/2021] [Indexed: 11/26/2022] Open
Abstract
Lung to finger circulation time (LFCT) has been used to estimate cardiac function. We developed a new LFCT measurement device using a laser sensor at fingertip. We measured LFCT by measuring time from re-breathing after 20 s of breath hold to the nadir of the difference of transmitted red light and infrared light, which corresponds to percutaneous oxygen saturation. Fifty patients with heart failure were enrolled. The intrasubject stability of the measurement was assessed by the intraclass correlation coefficient (ICC). The ICC calculated from 44 cases was 0.85 (95% confidence interval: 0.77–0.91), which means to have “Excellent reliability.” By measuring twice, at least one clear LFCT value was obtained in 89.1% of patients and the overall measurability was 95.7%. We conducted all LFCT measurements safely. High ICCs were obtained even after dividing patients according to age, cardiac index (CI); 0.85 and 0.84 (≥ 75 or < 75 years group, respectively), 0.81 and 0.84 (N = 26, ≥ or < 2.2 L/min/M2). These results show that our new method to measure LFCT is highly stable and feasible for any type of heart failure patients.
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Affiliation(s)
- Tomoyuki Tobushi
- Department of Cardiovascular Medicine, Saiseikai Futsukaichi Hospital, Chikushino, Japan
| | - Takatoshi Kasai
- Department of Cardiovascular Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan.,Cardiovascular Respiratory Sleep Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Masayuki Hirose
- Center for Clinical and Translational Research, Kyushu University Hospital, Fukuoka, Japan
| | - Kazuhiro Sakai
- Imaging Device Development, Fuji Xerox Co., Ltd., Kanagawa, Japan
| | - Manabu Akamatsu
- Imaging Device Development, Fuji Xerox Co., Ltd., Kanagawa, Japan
| | - Chizuru Ohsawa
- Imaging Device Development, Fuji Xerox Co., Ltd., Kanagawa, Japan
| | - Yasuko Yoshioka
- Sleep Apnea Center, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Shoko Suda
- Department of Cardiovascular Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Nanako Shiroshita
- Cardiovascular Respiratory Sleep Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Ryo Nakamura
- Department of Cardiovascular Medicine, Saiseikai Futsukaichi Hospital, Chikushino, Japan
| | - Toshiaki Kadokami
- Department of Cardiovascular Medicine, Saiseikai Futsukaichi Hospital, Chikushino, Japan
| | - Takeshi Tohyama
- Center for Clinical and Translational Research, Kyushu University Hospital, Fukuoka, Japan
| | - Kouta Funakoshi
- Center for Clinical and Translational Research, Kyushu University Hospital, Fukuoka, Japan
| | - Kazuya Hosokawa
- Department of Cardiovascular Medicine, Kyushu University Hospital, Fukuoka, Japan
| | - Shin-Ichi Ando
- Sleep Apnea Center, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan.
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Abstract
Treatment-emergent central sleep apnea (TECSA) is a specific form of sleep-disordered breathing, characterized by the emergence or persistence of central apneas during treatment for obstructive sleep apnea. The purpose of this review was to summarize the definition, epidemiology, potential mechanisms, clinical characteristics, and treatment of TECSA. We searched for relevant articles up to January 31, 2020, in the PubMed database. The prevalence of TECSA varied widely in different studies. The potential mechanisms leading to TECSA included ventilatory control instability, low arousal threshold, activation of lung stretch receptors, and prolonged circulation time. TECSA may be a self-limited disorder in some patients and could be resolved spontaneously over time with ongoing treatment of continuous positive airway pressure (CPAP). However, central apneas persist even with the regular CPAP therapy in some patients, and new treatment approaches such as adaptive servo-ventilation may be necessary. We concluded that several questions regarding TECSA remain, despite the findings of many studies, and it is necessary to carry out large surveys with basic scientific design and clinical trials for TECSA to clarify these irregularities. Further, it will be vital to evaluate the baseline demographic and polysomnographic data of TECSA patients more carefully and comprehensively.
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Wheeler JA, Tutrow KD, Ebenroth ES, Gaston B, Bandyopadhyay A. Heart failure is not a determinant of central sleep apnea in the pediatric population. Pediatr Pulmonol 2021; 56:1092-1102. [PMID: 33434409 PMCID: PMC8035286 DOI: 10.1002/ppul.25242] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 11/20/2020] [Accepted: 12/13/2020] [Indexed: 11/09/2022]
Abstract
BACKGROUND/OBJECTIVES Adults with heart failure (HF) have high prevalence of central sleep apnea (CSA). While this has been repeatedly investigated in adults, there is a deficiency of similar research in pediatric populations. The goal of this study was to compare prevalence of CSA in children with and without HF and correlate central apneic events with heart function. METHODS Retrospective analysis of data from children with and without HF was conducted. Eligible children were less than 18 years old with echocardiogram and polysomnogram within 6 months of each other. Children were separated into groups with and without HF based on left ventricular ejection fraction (LVEF). Defining CSA as central apnea-hypopnea index (CAHI) more than 1/hour, the cohort was also classified into children with and without CSA for comparative study. RESULTS A total of 120 children (+HF: 19, -HF: 101) were included. The +HF group was younger, with higher prevalence of trisomy 21, muscular dystrophy, oromotor incoordination, and structural heart disease. The +HF group had lower apnea-hypopnea index (median: 3/hour vs. 8.6/hour) and lower central apnea index (CAI) (median: 0.2/hour vs. 0.55/hour). Prevalence of CSA was similar in both groups (p = .195). LogCAHI was inversely correlated to age (Pearson correlation coefficient: -0.245, p = .022). Children with CSA were younger and had higher prevalence of prematurity (40% vs. 5.3%). There was no significant difference in LVEF between children with and without CSA. After excluding children with prematurity, relationship between CAHI and age was no longer sustained. CONCLUSIONS In contrast to adults, there is no difference in prevalence of CSA in children with and without HF. Unlike in adults, LVEF does not correlate with CAI in children. Overall, it appears that central apneic events may be more a function of age and prematurity rather than of heart function.
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Affiliation(s)
| | | | - Eric S. Ebenroth
- Indiana University School of Medicine, Division of Pediatric Cardiology
| | - Benjamin Gaston
- Indiana University School of Medicine, Section of Pediatric Pulmonology, Allergy and Sleep Medicine
| | - Anuja Bandyopadhyay
- Indiana University School of Medicine, Section of Pediatric Pulmonology, Allergy and Sleep Medicine
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Oppersma E, Ganglberger W, Sun H, Thomas RJ, Westover MB. Algorithm for automatic detection of self-similarity and prediction of residual central respiratory events during continuous positive airway pressure. Sleep 2021; 44:5924368. [PMID: 33057718 PMCID: PMC8631077 DOI: 10.1093/sleep/zsaa215] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 10/05/2020] [Indexed: 12/02/2022] Open
Abstract
Study Objectives Sleep-disordered breathing is a significant risk factor for cardiometabolic and neurodegenerative diseases. High loop gain (HLG) is a driving mechanism of central sleep apnea or periodic breathing. This study presents a computational approach that identifies “expressed/manifest” HLG via a cyclical self-similarity feature in effort-based respiration signals. Methods Working under the assumption that HLG increases the risk of residual central respiratory events during continuous positive airway pressure (CPAP), the full night similarity, computed during diagnostic non-CPAP polysomnography (PSG), was used to predict residual central events during CPAP (REC), which we defined as central apnea index (CAI) higher than 10. Central apnea labels are obtained both from manual scoring by sleep technologists and from an automated algorithm developed for this study. The Massachusetts General Hospital sleep database was used, including 2466 PSG pairs of diagnostic and CPAP titration PSG recordings. Results Diagnostic CAI based on technologist labels predicted REC with an area under the curve (AUC) of 0.82 ± 0.03. Based on automatically generated labels, the combination of full night similarity and automatically generated CAI resulted in an AUC of 0.85 ± 0.02. A subanalysis was performed on a population with technologist-labeled diagnostic CAI higher than 5. Full night similarity predicted REC with an AUC of 0.57 ± 0.07 for manual and 0.65 ± 0.06 for automated labels. Conclusions The proposed self-similarity feature, as a surrogate estimate of expressed respiratory HLG and computed from easily accessible effort signals, can detect periodic breathing regardless of admixed obstructive features such as flow limitation and can aid the prediction of REC.
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Affiliation(s)
- Eline Oppersma
- Cardiovascular and Respiratory Physiology Group, TechMed Centre, University of Twente, The Netherlands
| | | | - Haoqi Sun
- Department of Neurology, Massachusetts General Hospital, Boston, MA
| | - Robert J Thomas
- Department of Medicine, Beth Israel Deaconess Medical Center, Division of Pulmonary, Critical Care & Sleep Medicine, Harvard Medical School, Boston, MA
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Orr JE, Ayappa I, Eckert DJ, Feldman JL, Jackson CL, Javaheri S, Khayat RN, Martin JL, Mehra R, Naughton MT, Randerath WJ, Sands SA, Somers VK, Badr MS. Research Priorities for Patients with Heart Failure and Central Sleep Apnea. An Official American Thoracic Society Research Statement. Am J Respir Crit Care Med 2021; 203:e11-e24. [PMID: 33719931 PMCID: PMC7958519 DOI: 10.1164/rccm.202101-0190st] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Background: Central sleep apnea (CSA) is common among patients with heart failure and has been strongly linked to adverse outcomes. However, progress toward improving outcomes for such patients has been limited. The purpose of this official statement from the American Thoracic Society is to identify key areas to prioritize for future research regarding CSA in heart failure. Methods: An international multidisciplinary group with expertise in sleep medicine, pulmonary medicine, heart failure, clinical research, and health outcomes was convened. The group met at the American Thoracic Society 2019 International Conference to determine research priority areas. A statement summarizing the findings of the group was subsequently authored using input from all members. Results: The workgroup identified 11 specific research priorities in several key areas: 1) control of breathing and pathophysiology leading to CSA, 2) variability across individuals and over time, 3) techniques to examine CSA pathogenesis and outcomes, 4) impact of device and pharmacological treatment, and 5) implementing CSA treatment for all individuals Conclusions: Advancing care for patients with CSA in the context of heart failure will require progress in the arenas of translational (basic through clinical), epidemiological, and patient-centered outcome research. Given the increasing prevalence of heart failure and its associated substantial burden to individuals, society, and the healthcare system, targeted research to improve knowledge of CSA pathogenesis and treatment is a priority.
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Abstract
Heart failure with reduced ejection fraction (HFrEF) induces chronic sympathetic activation. This disturbance is a consequence of both compensatory reflex disinhibition in response to lower cardiac output and patient-specific activation of one or more excitatory stimuli. The result is the net adrenergic output that exceeds homeostatic need, which compromises cardiac, renal, and vascular function and foreshortens lifespan. One such sympatho-excitatory mechanism, evident in ~40-45% of those with HFrEF, is the augmentation of carotid (peripheral) chemoreflex ventilatory and sympathetic responsiveness to reductions in arterial oxygen tension and acidosis. Recognition of the contribution of increased chemoreflex gain to the pathophysiology of HFrEF and to patients' prognosis has focused attention on targeting the carotid body to attenuate sympathetic drive, alleviate heart failure symptoms, and prolong life. The current challenge is to identify those patients most likely to benefit from such interventions. Two assumptions underlying contemporary test protocols are that the ventilatory response to acute hypoxic exposure quantifies accurately peripheral chemoreflex sensitivity and that the unmeasured sympathetic response mirrors the determined ventilatory response. This Perspective questions both assumptions, illustrates the limitations of conventional transient hypoxic tests for assessing peripheral chemoreflex sensitivity and demonstrates how a modified rebreathing test capable of comprehensively quantifying both the ventilatory and sympathoneural efferent responses to peripheral chemoreflex perturbation, including their sensitivities and recruitment thresholds, can better identify individuals most likely to benefit from carotid body intervention.
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Affiliation(s)
- Daniel A. Keir
- University Health Network and Mount Sinai Hospital Division of Cardiology and Department of Medicine, University of Toronto, Toronto General Research Institute, Toronto, ON, Canada
- School of Kinesiology, The University of Western Ontario, London, ON, Canada
| | - James Duffin
- Department of Anesthesia and Pain Management, University of Toronto, Toronto, ON, Canada
- Department of Physiology, University of Toronto, Toronto, ON, Canada
- Thornhill Research Inc., Toronto, ON, Canada
| | - John S. Floras
- University Health Network and Mount Sinai Hospital Division of Cardiology and Department of Medicine, University of Toronto, Toronto General Research Institute, Toronto, ON, Canada
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Tobushi T, Matsushita K, Funakoshi K, Sakai K, Akamatsu M, Yoshioka Y, Tohyama T, Hirose M, Nakamura R, Kadokami T, Ando S. Local temperature control improves the accuracy of cardiac output estimation using lung-to-finger circulation time after breath holding. Physiol Rep 2020; 8:e14632. [PMID: 33159838 PMCID: PMC7648652 DOI: 10.14814/phy2.14632] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 09/19/2020] [Accepted: 09/27/2020] [Indexed: 12/17/2022] Open
Abstract
As timely measurement of the cardiac index (CI) is one of the key elements in heart failure management, a noninvasive, simple, and inexpensive method of estimating CI is keenly needed. We attempted to develop a new device that can estimate CI from the data of lung-to-finger circulation time (LFCT) obtained after a brief breath hold in the awake state. First, we attempted to estimate CI from the LFCT value by utilizing the correlation between 1/LFCT and CI estimated with MRI. Although we could obtain LFCT from 45 of 53 patients with cardiovascular diseases, we could not find the anticipated relation between 1/LFCT and CI. However, we realized that when we adopted only LFCT from patients with a finger temperature of ≥31°C, we could obtain a consistent and clear correlation with CI (correlation coefficient, r = .81). Thus, we next measured LFCT before and after warming the forearm. We found that LFCT decreased after the local temperature increased (from 27.5 ± 13.6 to 18.4 ± 5.3 s, p < 0.01). The correlation between the inverse of LFCT and CI improved after warming (1/LFCT vs. CI, from r = .69 to r = .82). The final Bland-Altman analysis between the measured and estimated CI values revealed that the bias and precision were -0.05 and 0.37 L min-1 m-2 , respectively, and the percentage error was 34.3%. This study clarified that estimating CI using a simple measurement of LFCT is feasible in most patients and a low fingertip temperature strongly affects the CI-1/LFCT relationship, causing an error that can be corrected by proper local warming.
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Affiliation(s)
- Tomoyuki Tobushi
- Department of Cardiovascular MedicineSaiseikai Futsukaichi HospitalChikushinoJapan
| | | | - Kouta Funakoshi
- Center for Clinical and Translational ResearchKyushu University HospitalFukuokaJapan
| | - Kazuhiro Sakai
- Imaging Device DevelopmentFuji Xerox Co., Ltd.KanagawaJapan
| | | | | | - Takeshi Tohyama
- Center for Clinical and Translational ResearchKyushu University HospitalFukuokaJapan
| | - Masayuki Hirose
- Center for Clinical and Translational ResearchKyushu University HospitalFukuokaJapan
| | - Ryo Nakamura
- Department of Cardiovascular MedicineSaiseikai Futsukaichi HospitalChikushinoJapan
| | - Toshiaki Kadokami
- Department of Cardiovascular MedicineSaiseikai Futsukaichi HospitalChikushinoJapan
| | - Shin‐ichi Ando
- Sleep Apnea CenterKyushu University HospitalFukuokaJapan
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26
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Kwon Y, Mariani S, Reid M, Jacobs D, Lima J, Kapur V, Punjabi N, Redline S. Lung to finger circulation time in sleep study and coronary artery calcification: the Multi-Ethnic Study of Atherosclerosis. Sleep Med 2020; 75:8-11. [PMID: 32841914 PMCID: PMC7669686 DOI: 10.1016/j.sleep.2020.05.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2020] [Revised: 04/10/2020] [Accepted: 05/25/2020] [Indexed: 01/04/2023]
Abstract
BACKGROUND Lung to finger circulation time (LFCT) measured from sleep studies may represent a novel physiologic marker for cardiovascular risk in patients with sleep disordered breathing (SDB). We hypothesized that sleep study-derived LFCT would improve risk classification of markers of subclinical cardiovascular disease. METHODS We included participants in the Multi-Ethnic Study of Atherosclerosis (MESA) Sleep cohort with moderate-severe SDB (apnea hypopnea index [AHI] ≥ 15/hr) (N = 598). RESULTS Those with average LFCT above the median (19.4 s) (vs. shorter LFCT) tended to be older, more obese and male. In multivariable analysis, no significant associations were found between average LFCT and subclinical cardiovascular markers including coronary artery calcium, carotid intima-media thickness or left ventricular hypertrophy. However, there was modest improvement in risk classification of coronary artery calcification as compared with AHI alone when average LFCT was added to AHI (C statistics 0.53 vs. 0.62, p = 0.0066). CONCLUSIONS In conclusion, LFCT may be a useful addition to conventional SDB metrics to improve cardiovascular risk assessment.
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Affiliation(s)
- Younghoon Kwon
- Department of Medicine, University of Washington, Seattle, WA, USA.
| | - Sara Mariani
- Department of Medicine, Harvard Medical School, Brigham and Women's Hospital, Boston, MA, USA
| | - Michelle Reid
- Department of Medicine, Harvard Medical School, Brigham and Women's Hospital, Boston, MA, USA
| | - David Jacobs
- Division of Epidemiology and Community Health, University of Minnesota, Minneapolis, MN, USA
| | - Joao Lima
- Department of Medicine, Johns Hopkins University, Baltimore, MA, USA
| | - Vishesh Kapur
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - Naresh Punjabi
- Department of Medicine, Johns Hopkins University, Baltimore, MA, USA
| | - Susan Redline
- Department of Medicine, Harvard Medical School, Brigham and Women's Hospital, Boston, MA, USA
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27
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Kwon Y, Sands SA, Stone KL, Taranto-Montemurro L, Alex RM, White DP, Wellman A, Redline S, Azarbarzin A. Prolonged Circulation Time Is Associated With Mortality Among Older Men With Sleep-Disordered Breathing. Chest 2021; 159:1610-20. [PMID: 33069723 DOI: 10.1016/j.chest.2020.10.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 10/05/2020] [Accepted: 10/08/2020] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Conventional metrics to evaluate sleep-disordered breathing (SDB) have many limitations, including their inability to identify subclinical markers of cardiovascular (CV) dysfunction. RESEARCH QUESTION Does sleep study-derived circulation time (Ct) predict mortality, independent of CV risks and SDB severity? STUDY DESIGN AND METHODS We derived average lung to finger Ct (LFCt) from sleep studies in older men enrolled in the multicenter Osteoporotic Fractures in Men (MrOS) Sleep study. LFCt was defined as the average time between end of scored respiratory events and nadir oxygen desaturations associated with those events. We calculated the hazard ratio (HRs) for the CV and all-cause mortality by LFCt quartiles, adjusting for the demographic characteristics, body habitus, baseline CV risk, and CV disease (CVD). Additional models included apnea-hypopnea index (AHI), time with oxygen saturation as measured by pulse oximetry (SpO2) < 90% (T90), and hypoxic burden. We also repeated analyses after excluding those with CVD at baseline. RESULTS A total of 2,631 men (mean ± SD age, 76.4 ± 5.5 years) were included in this study. LFCt median (interquartile range) was 18 (15-22) s. During an average ± SD follow-up of 9.9 ± 3.5 years, 427 men (16%) and 1,205 men (46%) experienced CV death and all-cause death, respectively. In multivariate analysis, men in the fourth quartile of LFCt (22-52 s) had an HR of 1.36 (95% CI, 1.02-1.81) and 1.35 (95% CI, 1.14-1.60) for CV and all-cause mortality, respectively, when compared with men in the first quartile (4-15 s). The results were similar when additionally adjusting for AHI, T90, or hypoxic burden. Results were stronger among men with no history of CVD at baseline. INTERPRETATION LFCt is associated with both CV and all-cause mortality in older men, independent of baseline CV burden and SDB metrics. LFCt may be a novel physiologic marker for subclinical CVD and adverse outcomes in patients with SDB.
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Abstract
Heart failure is characterized by pathologic hemodynamic derangements, including elevated cardiac filling pressures ("backward" failure), which may or may not coexist with reduced cardiac output ("forward" failure). Even when normal during unstressed conditions such as rest, hemodynamics classically become abnormal during stressors such as exercise in patients with heart failure. This has important upstream and downstream effects on multiple organ systems, particularly with respect to the lungs and kidneys. Hemodynamic abnormalities in heart failure are affected by processes that extend well beyond the cardiac myocyte, including important roles for pericardial constraint, ventricular interaction, and altered venous capacity. Hemodynamic perturbations have widespread effects across multiple heart failure phenotypes, ranging from reduced to preserved ejection fraction, acute to chronic disease, and cardiogenic shock to preserved perfusion states. In the lung, hemodynamic derangements lead to the development of abnormalities in ventilatory control and efficiency, pulmonary congestion, capillary stress failure, and eventually pulmonary vascular disease. In the kidney, hemodynamic perturbations lead to sodium and water retention and worsening renal function. Improved understanding of the mechanisms by which altered hemodynamics in heart failure affect the lungs and kidneys is needed in order to design novel strategies to improve clinical outcomes.
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Affiliation(s)
- Frederik H Verbrugge
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (F.H.V., B.A.B.).,Biomedical Research Institute, Faculty of Medicine and Life Sciences, Hasselt University, Belgium (F.H.V.)
| | - Marco Guazzi
- Cardiology University Department, Heart Failure Unit, University of Milano, IRCCS Policlinico San Donato, Milan, Italy (M.G.)
| | - Jeffrey M Testani
- Section of Cardiovascular Medicine, Yale University, New Haven, CT (J.M.T.)
| | - Barry A Borlaug
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (F.H.V., B.A.B.)
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29
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Linz D, Loffler KA, Sanders P, Catcheside P, Anderson CS, Zheng D, Quan W, Barnes M, Redline S, McEvoy RD, Baumert M. Low Prognostic Value of Novel Nocturnal Metrics in Patients With OSA and High Cardiovascular Event Risk: Post Hoc Analyses of the SAVE Study. Chest 2020; 158:2621-2631. [PMID: 32679239 DOI: 10.1016/j.chest.2020.06.072] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Revised: 06/05/2020] [Accepted: 06/10/2020] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Traditional methods for the quantification of OSA severity may not encapsulate potential relationships between hypoxemia in OSA and cardiovascular risk. RESEARCH QUESTION Do novel nocturnal oxygen saturation (Spo2) metrics have prognostic value in patients with OSA and high cardiovascular event risk? STUDY DESIGN AND METHODS We conducted post hoc analyses of the Sleep Apnea Cardiovascular Endpoints (SAVE) trial. In 2687 individuals, Cox proportional hazards models that were stratified for treatment allocation were used to determine the associations between clinical characteristics, pulse oximetry-derived metrics that were designed to quantify sustained and episodic features of hypoxemia, and cardiovascular outcomes. Metrics included oxygen desaturation index, time <90% Spo2, average Spo2 for the entire recording (mean Spo2), average Spo2 during desaturation events (desaturation Spo2), average baseline Spo2 interpolated across episodic desaturation events (baseline Spo2), episodic desaturation event duration and desaturation/resaturation-time ratio, and mean and SD of pulse rate. RESULTS Neither apnea-hypopnea index, oxygen desaturation index, nor any of the novel Spo2 metrics were associated with the primary SAVE composite cardiovascular outcome. Mean and baseline Spo2 were associated with heart failure (hazard ratio [HR], 0.81; 95% CI, 0.69-0.95; P = .009; and HR, 0.78; 95% CI, 0.67-0.90; P = .001, respectively) and myocardial infarction (HR, 0.86; 95% CI, 0.77-0.95; P = .003; and HR, 0.81; 95% CI, 0.73-0.90; P < .001, respectively). Desaturation duration and desaturation/resaturation time ratio, with established risk factors, predicted future heart failure (area under the curve, 0.86; 95% CI, 0.79-0.93). INTERPRETATION Apnea-hypopnea index and oxygen desaturation index were not associated with cardiovascular outcomes. In contrast, the pattern of oxygen desaturation was associated with heart failure and myocardial infarction. However, concomitant risk factors remained the predominant determinants for secondary cardiovascular events and thus deserve the most intensive management.
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Affiliation(s)
- Dominik Linz
- Heart Rhythm Disorders (CHRD), South Australian Health and Medical Research Institute (SAHMRI), University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia; Department of Cardiology, Maastricht University Medical Centre, Maastricht, Cardiovascular Research Institute Maastricht (CARIM), University Maastricht, Maastricht, The Netherlands; Department of Cardiology, Radboud University Medical Centre, Nijmegen, The Netherlands.
| | - Kelly A Loffler
- Adelaide Institute for Sleep Health (AISH), College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Prashanthan Sanders
- Heart Rhythm Disorders (CHRD), South Australian Health and Medical Research Institute (SAHMRI), University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | - Peter Catcheside
- Adelaide Institute for Sleep Health (AISH), College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Craig S Anderson
- George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia; Neurology Department, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Danni Zheng
- George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - WeiWei Quan
- George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia; Department of Cardiology, Rui Jin Hospital and Institute of Cardiovascular Diseases, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Mary Barnes
- Flinders Centre for Epidemiology and Biostatistics, Flinders University, Adelaide, Australia
| | - Susan Redline
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - R Doug McEvoy
- Adelaide Institute for Sleep Health (AISH), College of Medicine and Public Health, Flinders University, Adelaide, Australia; Sleep Health Service, Respiratory and Sleep Services, Southern Adelaide Local Health Network, Adelaide, Australia
| | - Mathias Baumert
- School of Electrical and Electronic Engineering, University of Adelaide, Adelaide, Australia
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30
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Tobushi T, Hosokawa K, Abe K, Kon-No S, Kadokami T, Nakamura R, Tsutsui H, Ando SI. Changes in lung to finger circulation time measured via cardiopulmonary polygraphy in patients with varying types of heart disease. Heart Vessels 2020; 36:58-68. [PMID: 32613320 DOI: 10.1007/s00380-020-01657-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 06/26/2020] [Indexed: 12/20/2022]
Abstract
Cardiopulmonary polygraphy (PG) demonstrates not only parameters for sleep disordered breathing (SDB) but also hemodynamics. We previously developed a software that detects lung to fingertip circulation time (LFCT) derived from PG dataset and reported that those LFCT reflected the cardiac output. The purpose of this study is to investigate how the LFCT changes during clinical course and whether reflects the impact of in-hospital treatment on cardiac function. Consecutive patients (N = 89) who admitted to the cardiovascular division, underwent PG at the early and late phase of admission. Parameters for SDB and LFCT were compared between an acute decompensated heart failure (ADHF) group (n = 51) and non-ADHF group (n = 38). ADHF group was further divided into subgroups: preserved ejection fraction (pEF) (EF > 40%) and reduced EF (rEF) (EF ≤ 40%). Using our original algorithm, we obtained LFCT values from all of the patients, though 29.4% of ADHF and 44.7% of non-ADHF had no or mild SDB. LFCT significantly shortened in the ADHF-rEF group, in contrast to ADHF-pEF group or non-ADHF group (ADHF-rEF group: 26.9 ± 7.6 to 24.2 ± 6.1 s, p = 0.01; ADHF-pEF group: 25.3 ± 7.3 to 25.3 ± 6.9 s, p = 0.98; non-ADHF group: 21.5 ± 5.5 to 21.9 ± 5.0 s, p = 0.65). The respiratory disorder index in the ADHF group improved after treatment, irrespective of EF (pEF: 26.9 ± 16.1 to 15.8 ± 11.9/h, p < 0.01; rEF: 27.0 ± 16.5 to 20.7 ± 13.6/h, p = 0.03). Automatic detection of LFCT was feasible in almost all cardiac patients. LFCT value changed according to the heart failure treatment in ADHF-rEF patients and reflected cardiac function. LFCT might be a useful indicator of effective cardiac disease treatment.
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Affiliation(s)
- Tomoyuki Tobushi
- Department of Cardiovascular Medicine, Saiseikai Futsukaichi Hospital, Chikushino, Japan
| | - Kazuya Hosokawa
- Department of Cardiovascular Medicine, Kyushu University Hospital, Fukuoka, Japan
| | - Ko Abe
- Department of Cardiovascular Medicine, Saiseikai Futsukaichi Hospital, Chikushino, Japan
| | - Satomi Kon-No
- Department of Cardiovascular Medicine, Saiseikai Futsukaichi Hospital, Chikushino, Japan
| | - Toshiaki Kadokami
- Department of Cardiovascular Medicine, Saiseikai Futsukaichi Hospital, Chikushino, Japan
| | - Ryo Nakamura
- Department of Cardiovascular Medicine, Saiseikai Futsukaichi Hospital, Chikushino, Japan
| | - Hiroyuki Tsutsui
- Department of Cardiovascular Medicine, Kyushu University Hospital, Fukuoka, Japan
| | - Shin-Ichi Ando
- Sleep Apnea Center, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan.
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Kwon Y, Mariani S, Gadi SR, Jacobs Jr DR, Punjabi NM, Reid ML, Azarbarzin A, Wellman AD, Redline S. Characterization of lung-to-finger circulation time in sleep study assessment: the Multi-Ethnic Study of Atherosclerosis. Physiol Meas 2020; 41:065004. [DOI: 10.1088/1361-6579/ab8e12] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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32
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Inami T, Kasai T, Yumino D, Perger E, Alshaer H, Hummel R, Lyons OD, Floras JS, Bradley TD. Relationship of stroke volume to different patterns of Cheyne-Stokes respiration in heart failure. Sleep 2020; 42:5341673. [PMID: 30946471 DOI: 10.1093/sleep/zsy262] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Revised: 11/20/2018] [Indexed: 12/16/2022] Open
Abstract
STUDY OBJECTIVES In patients with heart failure (HF) and reduced left ventricular ejection fraction (HFrEF), stroke volume (SV) falls during hyperpnea of Cheyne-Stokes respiration with central sleep apnea (CSR-CSA). We have identified two distinct patterns of hyperpnea: positive, in which end-expiratory lung volume (EELV) remains at or above functional residual capacity (FRC), and negative, in which EELV falls below FRC. The increase in expiratory intrathoracic pressure generated by the latter should have effects on the heart analogous to external chest compression. To test the hypotheses that in HFrEF patients, CSR-CSA with the negative pattern has an auto-resuscitation effect such that compared with the positive pattern, it is associated with a smaller fall in SV and a smaller increase in cardiac workload (product of heart rate and systolic blood pressure). METHODS In 15 consecutive HFrEF patients with CSR-CSA during polysomnography, hemodynamic data derived from digital photoplethysmography during positive and negative hyperpneas were compared. RESULTS Compared to the positive, negative hyperpneas were accompanied by reductions in the maximum and mean relative fall in SV of 30% (p = 0.002) and 10% (p = 0.031), respectively, and by reductions in the degree of increases in heart rate and rate pressure product during hyperpnea of 46% (p < 0.001) and 13% (p = 0.007), respectively. CONCLUSIONS Our findings suggest the novel concept that the negative pattern of CSR-CSA may constitute a form of auto-resuscitation that acts as a compensatory mechanism to maintain SV in patients with severe HF.
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Affiliation(s)
- Toru Inami
- Sleep Research Laboratory of the University Health Network Toronto Rehabilitation Institute, Toronto, ON, Canada.,Centre for Sleep Medicine and Circadian Biology of the University of Toronto, Toronto, ON, Canada
| | - Takatoshi Kasai
- Sleep Research Laboratory of the University Health Network Toronto Rehabilitation Institute, Toronto, ON, Canada.,Centre for Sleep Medicine and Circadian Biology of the University of Toronto, Toronto, ON, Canada
| | - Dai Yumino
- Sleep Research Laboratory of the University Health Network Toronto Rehabilitation Institute, Toronto, ON, Canada.,Centre for Sleep Medicine and Circadian Biology of the University of Toronto, Toronto, ON, Canada
| | - Elisa Perger
- Sleep Research Laboratory of the University Health Network Toronto Rehabilitation Institute, Toronto, ON, Canada.,Centre for Sleep Medicine and Circadian Biology of the University of Toronto, Toronto, ON, Canada
| | - Hisham Alshaer
- Sleep Research Laboratory of the University Health Network Toronto Rehabilitation Institute, Toronto, ON, Canada
| | - Richard Hummel
- Sleep Research Laboratory of the University Health Network Toronto Rehabilitation Institute, Toronto, ON, Canada
| | - Owen D Lyons
- Sleep Research Laboratory of the University Health Network Toronto Rehabilitation Institute, Toronto, ON, Canada.,Centre for Sleep Medicine and Circadian Biology of the University of Toronto, Toronto, ON, Canada.,Department of Medicine of Women's College Hospital, Toronto, ON, Canada
| | - John S Floras
- Department of Medicine of the University Health Network Toronto General Hospital and Mt. Sinai Health System, Toronto, ON, Canada
| | - T Douglas Bradley
- Sleep Research Laboratory of the University Health Network Toronto Rehabilitation Institute, Toronto, ON, Canada.,Centre for Sleep Medicine and Circadian Biology of the University of Toronto, Toronto, ON, Canada.,Department of Medicine of the University Health Network Toronto General Hospital and Mt. Sinai Health System, Toronto, ON, Canada
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33
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Naughton MT. Periodic breathing: Fine tuning the phenotype. Respirology 2020; 25:240-241. [DOI: 10.1111/resp.13657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2019] [Accepted: 07/15/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Matthew T. Naughton
- Department of Respiratory Medicine, Alfred HospitalMonash University Melbourne VIC Australia
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35
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Abstract
Synchronization of molecular, metabolic, and cardiovascular circadian oscillations is fundamental to human health. Sleep-disordered breathing, which disrupts such temporal congruence, elicits hemodynamic, autonomic, chemical, and inflammatory disturbances with acute and long-term consequences for heart, brain, and circulatory and metabolic function. Sleep apnea afflicts a substantial proportion of adult men and women but is more prevalent in those with established cardiovascular diseases and especially fluid-retaining states. Despite the experimental, epidemiological, observational, and interventional evidence assembled in support of these concepts, this substantial body of work has had relatively modest pragmatic impact, thus far, on the discipline of cardiology. Contemporary estimates of cardiovascular risk still are derived typically from data acquired during wakefulness. The impact of sleep-related breathing disorders rarely is entered into such calculations or integrated into diagnostic disease-specific algorithms or therapeutic recommendations. Reasons for this include absence of apnea-related symptoms in most with cardiovascular disease, impediments to efficient diagnosis at the population level, debate as to target, suboptimal therapies, difficulties mounting large randomized trials of sleep-specific interventions, and the challenging results of those few prospective cardiovascular outcome trials that have been completed and reported. The objectives of this review are to delineate the bidirectional interrelationship between sleep-disordered breathing and cardiovascular disease, consider the findings and implications of observational and randomized trials of treatment, frame the current state of clinical equipoise, identify principal current controversies and potential paths to their resolution, and anticipate future directions.
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Affiliation(s)
- John S Floras
- From the University Health Network and Sinai Health System Division of Cardiology, Department of Medicine, University of Toronto, Ontario, Canada.
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36
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Spiesshoefer J, Becker S, Tuleta I, Mohr M, Diller GP, Emdin M, Florian AR, Yilmaz A, Boentert M, Giannoni A. Impact of Simulated Hyperventilation and Periodic Breathing on Sympatho-Vagal Balance and Hemodynamics in Patients with and without Heart Failure. Respiration 2019; 98:482-494. [PMID: 31461730 DOI: 10.1159/000502155] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 07/16/2019] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The effects of hyperventilation and hyperventilation in the context of periodic breathing (PB) on sympatho-vagal balance (SVB) and hemodynamics in conditions of decreased cardiac output and feedback resetting, such as heart failure (HF) or pulmonary arterial hypertension (PAH), are not completely understood. OBJECTIVES To investigate the effects of voluntary hyperventilation and simulated PB on hemodynamics and SVB in healthy subjects, in patients with systolic HF and reduced or mid-range ejection fraction (HFrEF and HFmrEF) and in patients with PAH. METHODS Study participants (n = 20 per group) underwent non-invasive recording of diastolic blood pressure, heart rate variability (HRV), baroreceptor-reflex sensitivity (BRS), total peripheral resistance index (TPRI) and cardiac index (CI). All measurements were performed at baseline, during voluntary hyperventilation and during simulated PB with different length of the hyperventilation phase. RESULTS In healthy subjects, voluntary hyperventilation led to a 50% decrease in the mean BRS slope and a 29% increase in CI compared to baseline values (p < 0.01 and p < 0.05). Simulated PB did not alter TPRI or CI and showed heterogeneous effects on BRS, but analysis of dPBV revealed decreased sympathetic drive in healthy volunteers depending on PB cycle length (p < 0.05). In HF patients, hyperventilation did not affect BRS and TPRI but increased the CI by 10% (p < 0.05). In HF patients, simulated PB left all of these parameters unaffected. In PAH patients, voluntary hyperventilation led to a 15% decrease in the high-frequency component of HRV (p < 0.05) and a 5% increase in CI (p < 0.05). Simulated PB exerted neutral effects on both SVB and hemodynamic parameters. CONCLUSIONS Voluntary hyperventilation was associated with sympathetic predominance and CI increase in healthy volunteers, but only with minor hemodynamic and SVB effects in patients with HF and PAH. Simulated PB had positive effects on SVB in healthy volunteers but neutral effects on SVB and hemodynamics in patients with HF or PAH.
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Affiliation(s)
- Jens Spiesshoefer
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy, .,Respiratory Physiology Laboratory, Department of Neurology with Institute for Translational Neurology, University of Muenster, Muenster, Germany,
| | - Sara Becker
- Respiratory Physiology Laboratory, Department of Neurology with Institute for Translational Neurology, University of Muenster, Muenster, Germany
| | - Izabela Tuleta
- Department of Cardiology I, University Hospital Muenster, Muenster, Germany
| | - Michael Mohr
- Department of Medicine A, Hematology, Oncology and Pulmonary Medicine, University Hospital Muenster, Muenster, Germany
| | - Gerhard Paul Diller
- Department of Cardiology III, University Hospital Muenster, Muenster, Germany
| | - Michele Emdin
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy.,Cardiology and Cardiovascular Medicine Division, Fondazione Toscana Gabriele Monasterio, National Research Council, CNR-Regione Toscana, Pisa, Italy
| | | | - Ali Yilmaz
- Department of Cardiology I, University Hospital Muenster, Muenster, Germany
| | - Matthias Boentert
- Respiratory Physiology Laboratory, Department of Neurology with Institute for Translational Neurology, University of Muenster, Muenster, Germany
| | - Alberto Giannoni
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy.,Cardiology and Cardiovascular Medicine Division, Fondazione Toscana Gabriele Monasterio, National Research Council, CNR-Regione Toscana, Pisa, Italy
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Giannoni A, Raglianti V, Taddei C, Borrelli C, Chubuchny V, Vergaro G, Mirizzi G, Valleggi A, Cameli M, Pasanisi E, Emdin M, Passino C. Cheyne-Stokes respiration related oscillations in cardiopulmonary hemodynamics in patients with heart failure. Int J Cardiol 2019; 289:76-82. [DOI: 10.1016/j.ijcard.2019.03.033] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2019] [Accepted: 03/15/2019] [Indexed: 12/26/2022]
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Schoebel C, Fietze I, Penzel T. Effects of optimized heart failure medication on central sleep apnea with Cheyne-Stokes respiration pattern in chronic heart failure with reduced left-ventricular ejection fraction. Annu Int Conf IEEE Eng Med Biol Soc 2019; 2019:5723-5726. [PMID: 31947152 DOI: 10.1109/embc.2019.8857849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Central Sleep Apnea with Cheyne Stokes Respiration (CSA-CSR) is often diagnosed in patients with chronic heart failure (CHF). CSA-CSR displays a periodic breathing pattern with a typical waxing and waning breathing with central sleep apnea phases in between. Optimization of heart failure medication with Angiotensin receptor neprilysin inhibition (ARNi) can effect phenotypic traits of CSA-CSR indicating improvements of both, hemodynamic parameters and central chemosensitivity.
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Giannoni A, Gentile F, Navari A, Borrelli C, Mirizzi G, Catapano G, Vergaro G, Grotti F, Betta M, Piepoli MF, Francis DP, Passino C, Emdin M. Contribution of the Lung to the Genesis of Cheyne-Stokes Respiration in Heart Failure: Plant Gain Beyond Chemoreflex Gain and Circulation Time. J Am Heart Assoc 2019; 8:e012419. [PMID: 31237174 PMCID: PMC6662365 DOI: 10.1161/jaha.119.012419] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Background The contribution of the lung or the plant gain (PG; ie, change in blood gases per unit change in ventilation) to Cheyne‐Stokes respiration (CSR) in heart failure has only been hypothesized by mathematical models, but never been directly evaluated. Methods and Results Twenty patients with systolic heart failure (age, 72.4±6.4 years; left ventricular ejection fraction, 31.5±5.8%), 10 with relevant CSR (24‐hour apnea‐hypopnea index [AHI] ≥10 events/h) and 10 without (AHI <10 events/h) at 24‐hour cardiorespiratory monitoring underwent evaluation of chemoreflex gain (CG) to hypoxia (CGO2) and hypercapnia (CGCO2) by rebreathing technique, lung‐to‐finger circulation time, and PG assessment through a visual system. PG test was feasible and reproducible (intraclass correlation coefficient, 0.98; 95% CI, 0.91–0.99); the best‐fitting curve to express the PG was a hyperbola (R2≥0.98). Patients with CSR showed increased PG, CGCO2 (but not CGO2), and lung‐to‐finger circulation time, compared with patients without CSR (all P<0.05). PG was the only predictor of the daytime AHI (R=0.56, P=0.01) and together with the CGCO2 also predicted the nighttime AHI (R=0.81, P=0.0003) and the 24‐hour AHI (R=0.71, P=0.001). Lung‐to‐finger circulation time was the only predictor of CSR cycle length (R=0.82, P=0.00006). Conclusions PG is a powerful contributor of CSR and should be evaluated together with the CG and circulation time to individualize treatments aimed at stabilizing breathing in heart failure.
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Affiliation(s)
- Alberto Giannoni
- 1 Fondazione Toscana G. Monasterio Pisa Italy.,2 Institute of Life Sciences Scuola Superiore Sant'Anna Pisa Italy
| | | | | | | | | | | | - Giuseppe Vergaro
- 1 Fondazione Toscana G. Monasterio Pisa Italy.,2 Institute of Life Sciences Scuola Superiore Sant'Anna Pisa Italy
| | | | | | - Massimo F Piepoli
- 4 Heart Failure Unit Cardiology Guglielmo da Saliceto Hospital Piacenza Italy
| | - Darrel P Francis
- 5 International Center for Circulatory Health National Heart and Lung Institute Imperial College London London United Kingdom
| | - Claudio Passino
- 1 Fondazione Toscana G. Monasterio Pisa Italy.,2 Institute of Life Sciences Scuola Superiore Sant'Anna Pisa Italy
| | - Michele Emdin
- 1 Fondazione Toscana G. Monasterio Pisa Italy.,2 Institute of Life Sciences Scuola Superiore Sant'Anna Pisa Italy
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Javed F, Tamisier R, Pepin J, Cowie MR, Wegscheider K, Angermann C, d'Ortho M, Erdmann E, Simonds AK, Somers VK, Teschler H, Levy P, Armitstead J, Woehrle H. Association of serious adverse events with Cheyne–Stokes respiration characteristics in patients with systolic heart failure and central sleep apnoea: A SERVE‐Heart Failure substudy analysis. Respirology 2019; 25:305-311. [DOI: 10.1111/resp.13613] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Revised: 05/23/2019] [Accepted: 05/23/2019] [Indexed: 01/03/2023]
Affiliation(s)
- Faizan Javed
- Clinical Science and InnovationResMed Asia Pacific Ltd Sydney NSW Australia
| | - Renaud Tamisier
- Pole Thorax et Vaisseaux CHU Grenoble‐Alpes Grenoble France
- Laboratoire HP2Inserm Université Grenoble‐Alpes Grenoble France
| | - Jean‐Louis Pepin
- Pole Thorax et Vaisseaux CHU Grenoble‐Alpes Grenoble France
- Laboratoire HP2Inserm Université Grenoble‐Alpes Grenoble France
| | | | - Karl Wegscheider
- Department of Medical Biometry and EpidemiologyUniversity Medical Center Eppendorf Hamburg Germany
| | - Christiane Angermann
- Comprehensive Heart Failure CenterUniversity Hospital and University of Würzburg Würzburg Germany
| | - Marie‐Pia d'Ortho
- University Paris Diderot, Sorbonne Paris Cité, Hôpital BichatExplorations Fonctionnelles, DHU, FIRE Paris France
| | | | | | | | - Helmut Teschler
- Department of Pneumology, Ruhrlandklinik, West German Lung Center, University Hospital EssenUniversity Duisburg‐Essen Essen Germany
| | - Patrick Levy
- Pole Thorax et Vaisseaux CHU Grenoble‐Alpes Grenoble France
- Laboratoire HP2Inserm Université Grenoble‐Alpes Grenoble France
| | - Jeff Armitstead
- Clinical Science and InnovationResMed Asia Pacific Ltd Sydney NSW Australia
| | - Holger Woehrle
- Sleep and Ventilation Center Blaubeuren/Lung Center Ulm Ulm Germany
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41
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Stellbrink C, Hansky B, Baumann P, Lawin D. [Transvenous neurostimulation in central sleep apnea associated with heart failure]. Herzschrittmacherther Elektrophysiol 2018; 29:377-382. [PMID: 30306302 DOI: 10.1007/s00399-018-0591-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2018] [Accepted: 09/10/2018] [Indexed: 06/08/2023]
Abstract
Sleep-related breathing disorders can be classified as either obstructive (OSA) or central sleep apnea (CSA). Whereas there is substantial knowledge about the pathophysiology and sound recommendations for the diagnosis and treatment of OSA, the origin of CSA is still incompletely understood, patient identification is difficult and the necessity for specific treatment is under debate. CSA often accompanies heart failure and is associated with an adverse prognosis. Optimized heart failure treatment reduces CSA and is thus the cornerstone of CSA treatment. In contrast to OSA, noninvasive ventilation does not lead to prognostic improvement in CSA and ASV ventilation may even lead to an increase in mortality. Transvenous neurostimuation of the phrenic nerve is currently under clinical investigation as a new therapeutic modality for CSA. Early results demonstrate positive effects on sleep parameters and quality of life without any evidence for a negative impact on mortality. However, these results await confirmation in larger studies before this new approach can be advocated for routine clinical use.
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Affiliation(s)
- Christoph Stellbrink
- Klinik für Kardiologie und Internistische Intensivmedizin, Städtische Kliniken Bielefeld, Lehrkrankenhaus der Westfälischen Wilhelms-Universität Münster, Teutoburger Straße 50, 33604, Bielefeld, Deutschland.
| | - Bert Hansky
- Klinik für Kardiologie und Internistische Intensivmedizin, Städtische Kliniken Bielefeld, Lehrkrankenhaus der Westfälischen Wilhelms-Universität Münster, Teutoburger Straße 50, 33604, Bielefeld, Deutschland
| | - Philipp Baumann
- Klinik für Kardiologie und Internistische Intensivmedizin, Städtische Kliniken Bielefeld, Lehrkrankenhaus der Westfälischen Wilhelms-Universität Münster, Teutoburger Straße 50, 33604, Bielefeld, Deutschland
| | - Dennis Lawin
- Klinik für Kardiologie und Internistische Intensivmedizin, Städtische Kliniken Bielefeld, Lehrkrankenhaus der Westfälischen Wilhelms-Universität Münster, Teutoburger Straße 50, 33604, Bielefeld, Deutschland
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42
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Linz D, Baumert M, Catcheside P, Floras J, Sanders P, Lévy P, Cowie MR, Doug McEvoy R. Assessment and interpretation of sleep disordered breathing severity in cardiology: Clinical implications and perspectives. Int J Cardiol 2018; 271:281-288. [DOI: 10.1016/j.ijcard.2018.04.076] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2017] [Revised: 04/14/2018] [Accepted: 04/17/2018] [Indexed: 10/28/2022]
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Abstract
Sleep-disordered breathing (SDB) is highly prevalent in heart failure (HF). The presence of SDB in patients with HF appears to be associated with increased risk of cardiovascular morbidity and mortality. In this article, we describe the types, pathophysiology, and consequences of SDB and discuss ways in which SDB can be diagnosed. We also lay emphasis on the recent randomized controlled trials that have had a major impact on how SDB is managed and highlight the complex relationship between SDB and outcomes.
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Affiliation(s)
- Ali Vazir
- Department of Cardiology, Royal Brompton Hospital, Royal Brompton and Harefield NHS Foundation Trust, Sydney Street, London SW3 6NP, UK; Royal Brompton Hospital, National Heart and Lung Institute, Imperial College London, Dovehouse Street, London SW3 6LR, UK.
| | - Varun Sundaram
- Department of Cardiology, Royal Brompton Hospital, Royal Brompton and Harefield NHS Foundation Trust, Sydney Street, London SW3 6NP, UK; Royal Brompton Hospital, National Heart and Lung Institute, Imperial College London, Dovehouse Street, London SW3 6LR, UK; Case Western Reserve University School of Medicine, 2109 Adelbert Rd, Cleveland, Ohio 44106, USA
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45
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Orr JE, Heinrich EC, Djokic M, Gilbertson D, Deyoung PN, Anza-Ramirez C, Villafuerte FC, Powell FL, Malhotra A, Simonson T. Adaptive Servoventilation as Treatment for Central Sleep Apnea Due to High-Altitude Periodic Breathing in Nonacclimatized Healthy Individuals. High Alt Med Biol 2018; 19:178-184. [PMID: 29641294 PMCID: PMC6014053 DOI: 10.1089/ham.2017.0147] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2017] [Accepted: 01/20/2018] [Indexed: 12/17/2022] Open
Abstract
Orr, Jeremy E., Erica C. Heinrich, Matea Djokic, Dillon Gilbertson, Pamela N. Deyoung, Cecilia Anza-Ramirez, Francisco C. Villafuerte, Frank L. Powell, Atul Malhotra, and Tatum Simonson. Adaptive servoventilation as treatment for central sleep apnea due to high-altitude periodic breathing in nonacclimatized healthy individuals. High Alt Med Biol. 19:178-184, 2018. AIMS Central sleep apnea (CSA) is common at high altitude, leading to desaturation and sleep disruption. We hypothesized that noninvasive ventilation using adaptive servoventilation (ASV) would be effective at stabilizing CSA at altitude. Supplemental oxygen was evaluated for comparison. METHODS Healthy subjects were brought from sea level to 3800 m and underwent polysomnography on three consecutive nights. Subjects underwent each condition-No treatment, ASV, and supplemental oxygen-in random order. The primary outcome was the effect of ASV on oxygen desaturation index (ODI). Secondary outcomes included oxygen saturation, arousals, symptoms, and comparison to supplemental oxygen. RESULTS Eighteen subjects underwent at least two treatment conditions. There was a significant difference in ODI across the three treatments. There was no statistical difference in ODI between no treatment and ASV (17.1 ± 4.2 vs. 10.7 ± 2.9 events/hour; p > 0.17) and no difference in saturation or arousal index. Compared with no treatment, oxygen improved the ODI (16.5 ± 4.5 events/hour vs. 0.5 ± 0.2 events/hour; p < 0.003), in addition to saturation and arousal index. CONCLUSIONS We found that ASV was not clearly efficacious at controlling CSA in persons traveling to 3800 m, whereas supplemental oxygen resolved CSA. Adjustment in the ASV algorithm may improve efficacy. ASV may have utility in acclimatized persons or at more modest altitudes.
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Affiliation(s)
- Jeremy E. Orr
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of California San Diego, La Jolla, California
| | - Erica C. Heinrich
- Department of Medicine, Division of Physiology, University of California San Diego, La Jolla, California
| | - Matea Djokic
- Department of Medicine, Division of Physiology, University of California San Diego, La Jolla, California
| | - Dillon Gilbertson
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of California San Diego, La Jolla, California
| | - Pamela N. Deyoung
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of California San Diego, La Jolla, California
| | - Cecilia Anza-Ramirez
- Departamento de Ciencias Biológicas y Fisiológicas, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Francisco C. Villafuerte
- Departamento de Ciencias Biológicas y Fisiológicas, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Frank L. Powell
- Department of Medicine, Division of Physiology, University of California San Diego, La Jolla, California
| | - Atul Malhotra
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of California San Diego, La Jolla, California
| | - Tatum Simonson
- Department of Medicine, Division of Physiology, University of California San Diego, La Jolla, California
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Bitter T, Özdemir B, Fox H, Horstkotte D, Oldenburg O. Cycle length identifies obstructive sleep apnea and central sleep apnea in heart failure with reduced ejection fraction. Sleep Breath 2018; 22:1093-1100. [PMID: 29637409 DOI: 10.1007/s11325-018-1652-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Revised: 02/28/2018] [Accepted: 03/01/2018] [Indexed: 11/24/2022]
Abstract
AIM To clarify whether unmasking of central sleep apnea during continuous positive airway pressure (CPAP) initiation can be identified from initial diagnostic polysomnography (PSG) in patients with heart failure with reduced ejection fraction (HFREF) and obstructive sleep apnea (OSA) MATERIALS AND METHODS: Forty-three consecutive patients with obstructive sleep apnea and central sleep apnea (OSA/CSA) in HFREF were matched with 43 HFREF patients with OSA and successful CPAP initiation. Obstructive apneas during diagnostic PSG were then analyzed for cycle length (CL), ventilation length (VL), apnea length (AL), time to peak ventilation (TTPV), and circulatory delay (CD). We calculated duty ratio (DR) as the ratio of VL/CL and mathematic loop gain (LG). RESULTS While AL was similar, CL, VL, TTPV, CD, and DR was significantly longer in patients with OSA/CSA compared to those with OSA, and LG was significantly higher. Receiver operator curves identified optimal cutoff values of 50.2 s for CL (area under the curve (AUC) 0.85, 29.2 s for VL (AUC 0.92), 11.5 s for TTPV (AUC 0.82), 26.4 s for CD (AUC 0.79), and 3.96 (AUC 0.78)) respectively for LG to identify OSA/CSA. CONCLUSION OSA/CSA in HFREF can be identified by longer CL, VL, TTPV, and CD from obstructive events in initial diagnostic PSG. The underlying mechanisms seem to be the presence of an increased LG.
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Affiliation(s)
- Thomas Bitter
- Clinic for Cardiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Georgstraße 11, 32545, Bad Oeynhausen, Germany.
| | - Burak Özdemir
- Clinic for Cardiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Georgstraße 11, 32545, Bad Oeynhausen, Germany
| | - Henrik Fox
- Clinic for Cardiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Georgstraße 11, 32545, Bad Oeynhausen, Germany
| | - Dieter Horstkotte
- Clinic for Cardiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Georgstraße 11, 32545, Bad Oeynhausen, Germany
| | - Olaf Oldenburg
- Clinic for Cardiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Georgstraße 11, 32545, Bad Oeynhausen, Germany
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Abstract
Central sleep apnea (CSA) is common in heart failure (HF) patients. Traditional treatment of CSA, including continuous positive airway pressure (CPAP), adaptive servo ventilation (ASV), oxygen therapy, and CO2 inhalation, has respective limitations. Transvenous phrenic nerve stimulation (PNS), a novel therapeutic approach for CSA, was proved to be effective and safe. The remedē® system and related transvenous PNS methods was approved by FDA in 2017, for treating moderate to severe CSA.
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Affiliation(s)
- Ning Ding
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China
| | - Xilong Zhang
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China
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48
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Terziyski K, Draganova A. Central Sleep Apnea with Cheyne-Stokes Breathing in Heart Failure – From Research to Clinical Practice and Beyond. In: Islam MS, editor. Heart Failure: From Research to Clinical Practice. Cham: Springer International Publishing; 2018. pp. 327-51. [DOI: 10.1007/5584_2018_146] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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Abstract
Introduction Mountaineers exposed to hypobaric hypoxia (HH) show high-altitude periodic
breathing (PB). Objective To analyze high-altitude PB during the ascent of Mount Aconcagua
(Argentina). Materials and Methods Descriptive study in healthy volunteers using respiratory polygraphy (RP) at
different altitudes. Results We studied 8 andinist, mean age: 36 years old (25-51), body mass index (BMI)
of 23.6 (20.9-28.7) and 22.77 (20.9-27.7) upon return,
p<0.01. RP without PB showed a lower Oxygen Desaturation
Index (ODI) and a lower Apnea-Hypopnea-Index (AHI); 5.43 (0 - 20) versus
45.95 (2-122) p<0.001 and 3.9 (0-15.5) versus 44.35
(4-115) p<0.001. AHI increased with altitude at the
expense of central apneas and hypopneas: p<0.05. Conclusion High-altitude PB is frequent above 2,581m.a.s.l. And it is characterized by
short cycles. None of the mountaineers showed PB at baseline; however,
high-altitude PB occurred in all subjects above 4,900 m.a.s.l
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Affiliation(s)
- Alvaro Emilio Ortiz-Naretto
- Hospital Francisco Muñiz, Medicine Respiratory Unit - Buenos Aires City - Buenos Aires - Argentina.,Asociación Andina de Medicina para la Altura, Curso Medicina para la Altura - Mendoza City - Mendoza - Argentina.,Hospital Británico de Buenos Aires, Medicine Respiratory Unit - Buenos Aires City - Buenos Aires - Argentina
| | - Miriam Patricia Pereiro
- Hospital Materno Infantil Ramón Sarda, Central Laboratory - Buenos Aires City - Buenos Aires - Argentina.,Asociación Andina de Medicina para la Altura, Curso Medicina para la Altura - Mendoza City - Mendoza - Argentina
| | - Glenda Ernst
- Hospital Británico de Buenos Aires, Medicine Respiratory Unit - Buenos Aires City - Buenos Aires - Argentina
| | - Eduardo Enrique Borsini
- Hospital Británico de Buenos Aires, Medicine Respiratory Unit - Buenos Aires City - Buenos Aires - Argentina
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50
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Toyama T, Hoshizaki H, Kasama S, Miyaishi Y, Kan H, Yamashita E, Kawaguti R, Adachi H, Ohsima S. Adaptive servo-ventilation therapy improves cardiac sympathetic nerve activity, cardiac function, exercise capacity, and symptom in patients with chronic heart failure and Cheyne-Stokes respiration. J Nucl Cardiol 2017; 24:1926-1937. [PMID: 27387522 DOI: 10.1007/s12350-016-0529-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2015] [Revised: 04/05/2016] [Indexed: 10/21/2022]
Abstract
PURPOSE Adaptive servo-ventilation (ASV) therapy has been reported to be effective for improving central sleep apnea (CSA) and chronic heart failure (CHF). The purpose of this study was to clarify whether ASV is effective for CSA, cardiac sympathetic nerve activity (CSNA), cardiac symptoms/function, and exercise capacity in CHF patients with CSA and Cheyne-Stokes respiration (CSR-CSA). METHODS In this study, 31 CHF patients with CSR-CSA and a left ventricular ejection fraction (LVEF) ≤ 40% were randomized into an ASV group and a conservative therapy (non-ASV) group for 6 month. Nuclear imagings with 123I-Metaiodobenzylguanidine (MIBG) and 99mTc-Sestamibi were performed. Exercise capacity using a specific activity scale (SAS) and the New York Heart Association (NYHA) class were evaluated. CSNA was evaluated by 123I-MIBG imaging, with the delayed heart/mediastinum activity ratio (H/M), delayed total defect score (TDS), and washout rate (WR). RESULTS The ASV group had significantly better (P < .05) results than the non-ASV group with respect to the changes of AHI (-20.8 ± 14.6 vs -0.5 ± 8.1), TDS (-7.9 ± 4.3 vs 1.4 ± 6.0), and H/M(0.16 ± 0.16 vs -0.04 ± 0.10) on 123I-MIBG imaging, as well as the changes of LVEF (5.3 ± 3.9% vs 0.7 ± 32.6%), SAS (1.6 ± 1.4 vs 0.3 ± 0.7), and NYHA class (2.2 ± 0.4 vs 2.7 ± 0.5) after 6-month therapy. CONCLUSIONS Performing ASV for 6 months achieved improvement of CSR-CSA, CSNA, cardiac symptoms/function, and exercise capacity in CHF patients with CSR-CSA.
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Affiliation(s)
- Takuji Toyama
- Toyama Cardiovasucular Clinic, 2-33-9, Aramaki-machi, Maebashi, Gunma, 371-0044, Japan.
| | | | - Shu Kasama
- Department of Cardiovascular Medicine, Gunma University School of Medicine, Maebashi, Japan
| | | | - Hakuken Kan
- Gunma Prefectural Cardiovascular Center, Maebashi, Japan
| | - Eiji Yamashita
- Gunma Prefectural Cardiovascular Center, Maebashi, Japan
| | - Ren Kawaguti
- Gunma Prefectural Cardiovascular Center, Maebashi, Japan
| | - Hitoshi Adachi
- Gunma Prefectural Cardiovascular Center, Maebashi, Japan
| | - Shigeru Ohsima
- Gunma Prefectural Cardiovascular Center, Maebashi, Japan
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