Sleep-induced apnea and disordered breathing refers to intermittent, cyclical cessations or reductions of airflow, with or without obstructions of the upper airway (OSA). In the presence of an anat...

Pathophysiology of Sleep Apnea

Sleep-related breathing disorders are highly prevalent in patients with established cardiovascular disease. Obstructive sleep apnea (OSA) affects an estimated 15 million adult Americans and is present in a large proportion of patients with hypertension and in those with other cardiovascular disorders, including coronary artery disease, stroke, and atrial fibrillation.1–14 In contrast, central sleep apnea (CSA) occurs mainly in patients with heart failure.15–19 The purpose of this Scientific Statement is to describe the types and prevalence of sleep apnea and its relevance to individuals who either are at risk for or already have established cardiovascular disease. Special emphasis is given to recognizing the patient with cardiovascular disease who has coexisting sleep apnea, to understanding the mechanisms by which sleep apnea may contribute to the progression of the cardiovascular condition, and to identifying strategies for treatment. This document is not intended as a systematic review but rather seeks to highlight concepts and evidence important to understanding the interactions between sleep apnea and cardiovascular disease, with particular attention to more recent advances in patient-oriented research. Implicit in this first American Heart Association/American College of Cardiology Scientific Statement on Sleep Apnea and Cardiovascular Disease is the recognition that, although holding great promise, this general area is in need of a substantially expanded knowledge base. Specific questions include whether sleep apnea is important in initiating the development of cardiac and vascular disease, whether sleep apnea in patients with established cardiovascular disease accelerates disease progression, and whether treatment of sleep apnea results in clinical improvement, fewer cardiovascular events, and reduced mortality.

Experimental approaches directed at addressing these issues are limited by several considerations. First, the close association between obesity and OSA often obscures differentiation between the effects of obesity, the effects of OSA, and the effects of synergies between these conditions. Second, multiple comorbidities, …

Sleep Apnea and Cardiovascular Disease

BACKGROUND Central sleep apnea is associated with poor prognosis and death in patients with heart failure. Adaptive servo-ventilation is a therapy that uses a noninvasive ventilator to treat central sleep apnea by delivering servo-controlled inspiratory pressure support on top of expiratory positive airway pressure. We investigated the effects of adaptive servo-ventilation in patients who had heart failure with reduced ejection fraction and predominantly central sleep apnea. METHODS We randomly assigned 1325 patients with a left ventricular ejection fraction of 45% or less, an apnea–hypopnea index (AHI) of 15 or more events (occurrences of apnea or hypopnea) per hour, and a predominance of central events to receive guideline-based medical treatment with adaptive servo-ventilation or guidelinebased medical treatment alone (control). The primary end point in the time-toevent analysis was the first event of death from any cause, lifesaving cardiovascular intervention (cardiac transplantation, implantation of a ventricular assist device, resuscitation after sudden cardiac arrest, or appropriate lifesaving shock), or unplanned hospitalization for worsening heart failure. RESULTS In the adaptive servo-ventilation group, the mean AHI at 12 months was 6.6 events per hour. The incidence of the primary end point did not differ significantly between the adaptive servo-ventilation group and the control group (54.1% and 50.8%, respectively; hazard ratio, 1.13; 95% confidence interval [CI], 0.97 to 1.31; P = 0.10). All-cause mortality and cardiovascular mortality were significantly higher in the adaptive servo-ventilation group than in the control group (hazard ratio for death from any cause, 1.28; 95% CI, 1.06 to 1.55; P = 0.01; and hazard ratio for cardiovascular death, 1.34; 95% CI, 1.09 to 1.65; P = 0.006). CONCLUSIONS Adaptive servo-ventilation had no significant effect on the primary end point in patients who had heart failure with reduced ejection fraction and predominantly central sleep apnea, but all-cause and cardiovascular mortality were both increased with this therapy. (Funded by ResMed and others; SERVE-HF ClinicalTrials.gov number, NCT00733343.) abstr act

https://www.nejm.org/doi/pdf/10.1056/NEJMoa1506459

Adaptive Servo-Ventilation for Central Sleep Apnea in Systolic Heart Failure

This review summarizes the recent literature on the epidemiology of adult obstructive sleep apnea (OSA) from various population-based studies. Despite methodologic differences, comparisons have yielded similar prevalence rates of the OSA syndrome in various geographic regions and across a number of ethnic groups. Risk factors for OSA including obesity, aging, gender, menopause and ethnicity, are analyzed. We also provide discussion on adverse medical conditions associated with OSA, including hypertension, stroke, coronary artery disease, congestive heart failure, cardiovascular mortality, insulin resistance and neurocognitive dysfunction. Finally, with the progression of the global obesity epidemic, we focus on the economic healthcare burden of OSA and the importance of recognizing the largely undiagnosed OSA population, with an emphasis on strategies to improve access to diagnostic resources.

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Epidemiology of Obstructive Sleep Apnea: a Population-based Perspective.

J-STAGE Advance Publication released online September 10, 2019 Mailing address: Scientific Committee of the Japanese Circulation Society, 18F Imperial Hotel Tower, 1-1-1 Uchisaiwai-cho, Chiyoda-ku, Tokyo 100-0011, Japan. E-mail: meeting@j-circ.or.jp This English language document is a revised digest version of Guidelines for the Diagnosis and Treatment of Acute and Chronic Heart Failure (JCS 2017/JHFS 2017) reported at the Japanese Circulation Society Joint Working Groups performed in 2017 (Website: http://www.j-circ.or.jp/guideline/pdf/JCS2017_tsutsui_d.pdf). Joint Working Groups: The Japanese Circulation Society; the Japanese Heart Failure Society; the Japanese Association for Thoracic Surgery; the Japanese Society of Hypertension; the Japanese Society of Echocardiography; the Japanese Society for Cardiovascular Surgery; the Japanese College of Cardiology; the Japanese Association of Cardiac Rehabilitation; the Japan Society of Ultrasonics in Medicine; the Japan Diabetes Society; the Japanese Heart Rhythm Society; “the Study Group on Idiopathic Cardiomyopathy” supported by the Health and Labor Sciences Research Grant on Intractable Diseases; and “the Study Group on the Multi-center Observational Study of Dilatedphase Hypertrophic Cardiomyopathy”, supported by the “Practical Research Project for Rare/ intractable Diseases by the Japan Agency for Medical Research and Development”. ISSN-1346-9843 All rights are reserved to the Japanese Circulation Society. For permissions, please e-mail: cj@j-circ.or.jp JCS 2017/JHFS 2017 Guideline on Diagnosis and Treatment of Acute and Chronic Heart Failure ― Digest Version ―

/pdf/jcs-2017-jhfs-2017-guideline-on-diagnosis-and-treatment-of-2ndrq4hiod.pdf

JCS 2017/JHFS 2017 Guideline on Diagnosis and Treatment of Acute and Chronic Heart Failure ― Digest Version ―

Aim: Evaluation of the prevalence and nature of sleep-disordered breathing (SDB) in patients with symptomatic chronic heart failure (CHF) receiving therapy according to current guidelines. Methods and results: We prospectively screened 700 patients with CHF (NYHA class ≥II, LV-EF ≤40%) for SDB using cardiorespiratory polygraphy (Embletta™). Furthermore, echocardiography, cardiopulmonary exercise and 6-min walk testing were performed. Medication included ACE-inhibitors and/or AT1-receptor blockers in at least 94%, diuretics in 87%, β-blockers in 85%, digitalis in 61% and spironolactone in 62% of patients. SDB was present in 76% of patients (40% central (CSA), 36% obstructive sleep apnoea (OSA)). CSA patients were more symptomatic (NYHA class 2.9±0.5 vs. no SDB 2.57±0.5 or OSA 2.57±0.5; pb0.05) and had a lower LV-EF (27.4±6.6% vs. 29.3±2.6%, pb0.05) than OSA patients. Oxygen uptake (VO2) was lowest in CSA patients: predicted peak VO2 57±16% vs. 64±18% in OSA and 63±17% in no SDB, pb0.05. 6-min walking distances were 331±111 m in CSA, 373±108 m in OSA and 377±118 m in no SDB (pb0.05). Conclusions: This study confirms the high prevalence of SDB, particularly CSA in CHF patients. CSA seems to be a marker of heart failure severity.

https://onlinelibrary.wiley.com/doi/pdf/10.1016/j.ejheart.2006.08.003

Volker Topfer

Papers

Sleep-disordered breathing in patients with symptomatic heart failure: a contemporary study of prevalence in and characteristics of 700 patients.

Sleep related breathing disorders in chronic heart failure: diagnosis, prevalence, and predictors