Review: Sleep-Disordered Breathing in Heart Failure Simon G Pearse and Martin R Cowie Imperial College London and Royal Brompton Hospital, London, UK. Key-words: heart failure; sleep disordered breathing; diagnosis; treatment Address for correspondence: Professor Martin R Cowie MD MSc FRCP FRCP (Ed) FESC Professor of Cardiology Imperial College London (Royal Brompton Hospital) Dovehouse Street London SW3 6LY T: +442073518856 F: +442073518148 E: [email protected]1
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Imperial College London€¦ · Web viewTherapy with continuous nocturnal oxygen has been used in those intolerant of CPAP. A meta-analysis of 14 studies concluded that oxygen therapy
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Review: Sleep-Disordered Breathing in Heart Failure
Simon G Pearse and Martin R Cowie
Imperial College London and Royal Brompton Hospital, London, UK.
Professor Martin R Cowie MD MSc FRCP FRCP (Ed) FESCProfessor of CardiologyImperial College London (Royal Brompton Hospital)Dovehouse StreetLondon SW3 6LY
Acknowledgement: MRC’s salary is supported by the NIHR Cardiovascular Biomedical Research Unit at the Royal Brompton Hospital, London.
Declaration of interests: MRC is the co-Principal Investigator of the SERVE-HF Study, funded by ResMed, and has received research grants and honoraria for speaking on sleep disordered breathing from ResMed, and consultancy fees from Respicardia and Sorin. SGP’s salary is funded by Boston Scientific.
stimulates the phrenic nerve via the left pericardiophrenic or right brachiocephalic vein. It can
be implanted percutaneously under sedation in the catheter laboratory. The device unilaterally
stimulates the phrenic nerve when no impulse is sensed for a pre-determined time period,
inducing a breath. A non-randomised study of 57 patients showed a mean reduction of 55% in
AHI over 3 months (49.5±14.6/h to 22.4±13.6/h, p < 0.0001) as well as reductions in
arousals, oxygen desaturation index and improved quality of life indices (67). Device or
procedure-related adverse events occurred in 26% of patients, predominantly due to lead
displacement. A somewhat larger randomized study has completed recruitment to further
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evaluate the effect of this technology on the reduction in CSA events but is not powered to
determine the effect on hospitalization or mortality (NCT01816776). For those with OSA, a
similar device exists which stimulates the hypoglossal nerve in response to apnoea and
hypopnoea. An uncontrolled study has shown a significant mean reduction of 68% in AHI
over 12 months in those treated with this stimulator (68). The impact on cardiovascular
outcomes is not known.
Compliance with Positive Airway Pressure Therapy
An important part of positive airway pressure therapy is the delivery interface: nasal pillows,
nasal mask, or oronasal mask. These should be chosen depending on the patient’s facial
features and preferences, and are best dealt with by a service used to setting up patients so any
early problems are resolved rapidly. For all therapies, current targets are to control SDB so
that the AHI is below 5/hr. Experience in our unit is that 80% of heart failure patients are able
to comply with long-term mask therapy if they are aware of the rationale for treatment, and
they are supported through the first few weeks of treatment. Ideally, the cardiologist should
work with the respiratory or sleep physician to ensure a consistent approach to diagnosis and
treatment.
Conclusions
SDB is found in at least half of patients with HF, and is associated with a worse prognosis.
Pathophysiological abnormalities found in SDB (both obstructive and central types) include
cyclical activation of the sympathetic nervous system and periodic hypoxaemia, which may
accelerate cardiac deterioration and trigger arrhythmia. In-hospital PSG is the current
diagnostic gold standard, but simple screening tests such as overnight oximetry or at-home
PG can easily identify patients with a high probability of SDB. Treatment of OSA with CPAP
improves markers of cardiovascular function and there are observational data suggesting a
survival benefit, but a lack of data from an appropriately sized randomized trial with mortality
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and morbidity outcomes. The optimal treatment of CSA remains uncertain and PAP cannot be
recommended on current evidence. Further research is needed to determine whether CSA is
merely an epiphenomenon, is partially adaptive, or is a risk factor for poor outcome that
requires diagnosis and treatment.
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Figures
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Figure 1.
Fig. 1a. Severe obstructive sleep apnoea on sleep polygraphy. Note the persistence of
respiratory effort during apnoeas and the marked swings in heart rate and oxygen saturation.
Fig. 1b. Severe central sleep apnoea on sleep polygraphy. Note the absence of respiratory
effort during apnoeas.
Figure 2.
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The interplay between sleep-disordered breathing and heart failure. (CSA - central sleep
apnoea, OSA - obstructive sleep apnoea). Reprinted from Brenner S, Angermann C, Berthold
J, Ertl G, Stork S. Sleep-disordered breathing and heart failure: a dangerous liaison. Trends