Sleep apnea in heart failure
S. Javaheri , M.D
Professor Emeritus of Medicine
University of Cincinnati, College of Medicine
Medical Director Sleepcare Diagnostics
Cincinnati, Ohio
Breathe Conference, Kings Island
October 21st, 2011
javaheri@snorenomore.com
Prevalence of
Heart Failure in U.S.
• 2% of population (6 million)
• 6–10% of population >65 y old
• Leading cause of hospitalization in people > 65 y
The crystal ball
Poor survival in heart
failure in the era of beta blockers
“Despite our many successes in the
treatment of heart failure, our current
drug regimens probably prolong
survival only about 9 to 18 months
relative to where we were in 1985”
GS Francis, JACC, 2006
Current estimates of 5 y survival:
30 to 35%
Sleep apnea and heart failure
Identification and effective treatment of comorbidities which contribute to the
progression of heart failure is of utmost
importance.
Sleep Medicine Physician Board Review
OSA in heart failure occurs
in subjects with compromised airway
Sleep Medicine Physician Board Review
SLEEP APNEA INCREASES LV
TRANSMURAL PRESSURE
Normal
Hypertension
100
Ppl
Ppl
Ppl
140
0.0
LVTm
100
140
100
Pr
UAO
0.0
100 - (0.0) = 100
100
-40
140 - (0.0) = 140
Sleep Medicine Physician Board Review
100 - (- 40) = 140
Prevalence of sleep apnea in Systolic Heart Failure
100 out of 114 consecutive patients
68% with AHI ≥ 5/h
49% with AHI ≥ 15/h
Javaheri et al:
Ann Intern Med 1995
Circulation
1998
Int J Cardiol
2006
Prevalence of sleep apnea in
recent prospective studies of SHF
Country
(year)
n
% AHI≥15/hr
%
CSA
%
OSA
* USA (06)
100
49
37
12
USA (08)
108
61
31
30
*Canada (07)
287
47
21
26
*UK (07)
55
53
38
15
Germany (07)
700
52
33
19
*Germany (09)
50
64
44
20
*Germany (10)
273
64
50
14
*Portugal (10)
103
46
n/a
n/a
China (07)
126
71
46
25
Germany (07)
203
71
28
43
Germany (07)
102
54
37
17
France (09)
316
81
25
56
% AHI≥10/hr
Prevalence of sleep apnea in
recent prospective studies of SHF
54% (897/1676)
34% (541/1573)
20% (308/1573)
Prevalence of sleep apnea in
Heart Failure with PEF
• n = 244 consecutive patients (87 women)
• Mean age 65
• Echocardiogram, Polygraphy,
and R and L heart catheterization
• Cause of DHF:
- HTN (44%)
- CAD (33%)
- Hypertrophic/Restrictive (23%)
Bitter T, 2009 EJHF
Prevalence of Sleep Apnea in
Heart Failure with PEF
How frequently patients
with HF are tested for SA?
A retrospective cohort study used the
2004-2005 Medicare Standard Analytical Files (SAFs).
SAFs contain a 5 % sample of randomly selected
Medicare beneficiaries.
The study population included newly diagnosed HF
patients in the first quarter of 2004 without prior
diagnosis of SA.
Sleep Medicine Physician Board Review
Under-diagnosis of sleep apnea
in patients with heart failure
Study Cohort
N=30,719
SA tested
N=572 (2%)
SA Dx: N=553 (97%)
tested, diagnosed,
not treated
N=295
Not SA tested
N=30,147 (98%)
No SA Dx N=19 (3%)
tested, diagnosed,
treated
N=258
Javaheri et al. Am J Respir Crit Care Med 2011
Sleep Medicine Physician Board Review
The mystery of the lack of
subjective EDS in patients with SHF
Most studies show no difference in
subjective EDS in patients with systolic heart
failure with or without sleep apnea.
However, when tested objectively, by
MSLT or Osler test, heart failure patients with
sleep apnea are sleeper than those without
sleep apnea.
No difference in subjective EDS
among the 3 groups(n=100)
90
No SA
CSA
OSA
80
70
60
50
p=0.8
40
30
Javaheri et al:
1998, 2006
20
10
0
Patients (n)
EDS (%)
*vs. Group I
Group II
†vs.
Clinical impact of lack of subjective EDS in SHF
1.Under diagnosis of sleep apnea in systolic
heart failure
2. Inadequate long-term CPAP adherence could
diminish its effectiveness in maximizing LVEF
and survival both for OSA and CSA
Sleep Medicine Physician Board Review
Sleep Apnea in Heart Failure:
Then what should the primary care
physicians and the cardiologists look
for to suspect presence of sleep apnea
in their patients with systolic heart
failure?
The phenotype depends differs in OSA
and CSA
Hallmarks of OSA in SHF
90
Group I
*†
80
Group II
p=0.02
p=0.1
70
Group III
p=0.1
60
50
p=0.1
p<0.001
40
*†
p=0.8
30
20
10
0
Patients
(n)
Age
(y)
Ht
(in)
BMI
(kg/m2)
Snoring
(%)
*vs. Group I
Group II
†vs.
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EDS
(%)
Apnea
(%)
Hallmarks of CSA in SHF
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Treatment of OSA in CHF
•
•
•
•
•
•
•
•
Promote sleep hygiene
Avoid ETOH, benzodiazepines, opioids, and Viagra
Weight loss
Positive airway pressure devices: CPAP, bilevel,
Provent
Mandibular advancement devices
Upper airway procedures
Hypoglossal N stimulation
Nocturnal use of supplemental oxygen
Sleep Medicine Physician Board Review
Provent
Effects of PAP therapy on LVEF in RCT OSA/SHF
Kaneko
Open
Mansfield
Open
Egea
DB
Smith
DB
Khayat
Open
Khayat
Open
n
12
19
20
23
11
13
AHI, n/h
40
25
44
36
30
34
LVEF, %
25
35
29
30
29
26
Change in
LVEF, %
9*
5*
2.2*
0.0
0.5
8.5*
Duration
4w
3m
3m
6w
3m
3m
PAP
titration
CPAP
yes
CPAP
yes
CPAP
yes
Auto
no
CPAP
yes
Bilevel
yes
6.2
5.6
NR
3.5
3.6
4.5
Compliance
OSA as Cause of Mortality in SHF
• 218 patients with LVEF<45%
• 45 with CSA (21%)
• 113 control group, AHI < 15, mean = 7/h
• 41 untreated OSA, AHI ≥15/hr, mean = 33/h
Wang et al; JAAC, 2007
Wang H et al. J Am Coll Cardiol. 2007; 49: 1632
Worsening Survival of Patients
With Heart Failure and OSA
AHI<15, mean = 7/h
(n=113;14 deaths)
100
Survival (%)
95
90
85
H.R. = 2.81
80
75
AHI ≥ 15/hr, mean = 33/h
(n=41; 9 deaths)
p = 0.029†
70
0
20
40
60
80
Time (months)
M-NSA=mild to no sleep apnea
OSA=obstructive sleep apnea
†
After adjusting for left ventricular ejection fraction,
NYHA functional class, age
Wang H et al. J Am Coll Cardiol. 2007; 49: 1632
Under-diagnosis of sleep apnea
in patients with heart failure
Study Cohort
N=30,719
SA tested
N=572 (2%)
SA Dx: N=553 (97%)
tested, diagnosed, not
treated
N=295
Not SA tested
N=30,147 (98%)
No SA Dx N=19 (3%)
tested, diagnosed,
treated
N=258
Javaheri et al. Am J Respir Crit Care Med 2011
Sleep Medicine Physician Board Review
Kaplan-Meier Survival Curves, Adjusted
by Age, Gender, and Charlson Comorbidity Index, 2004-2005
Percent of Cohort Alive
100%
Tested, Diagnosed, Treated, N=258
90%
Not Tested, Not Treated, N=30,065
80%
70%
Hazard ratio = .33 (95% CI = .21-.51), P <.0001
60%
Baseline 1
2
3
4
5
6
Quarters after HF Onset
Javaheri et al. Am J Respir Crit Care Med 2011
Sleep Medicine Physician Board Review
7
8
Cumulative event-free survival in
CPAP-treated and untreated patients
Cumulative Event Free Survival (%)
100
80
N=65
AHI: 45 /hr
LVEF: 36 %
60
40
Treated
N=23
Untreated
20
HR 2.03 (1.07-3.68) P=0.03
AHI: 38 /hr
LVEF: 35 %
0
0
Kasai T, et al. Chest, 2008
12
24
36
Months
Sleep Medicine Physician Board Review
48
60
Cumulative event-free survival by compliance status
Cumulative Event Free Survival (%)
100
N=32
AHI: 46 /hr
LVEF: 37 %
80
60
N=33
(6.0 hr/night)
40
AHI: 44 /hr
LVEF: 35 %
(3.5 hr/night)
20
HR 4.02 (1.33-12.2) P=0.014
0
0
Kasai T, et al. Chest, 2008
12
24
36
Months
Sleep Medicine Physician Board Review
48
60
OSA Patients Die During Sleep
Gami et al, NEJM, 2006
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If I can choose……
Dr, are you telling me that if I
use my CPAP I will die during
daytime while awake!
I know you mean good, but I
prefer to die during sleep
Sleep Medicine Physician Board Review
Author
year
n
Age
year
LVEF
%
Mortality
Statistical
significance
Hanly
(96)
16
64
23
↑
Yes
Lanfranchi
(99)
62
57
23
↑
Yes
Sin
(00)
66
59
22
↑
Yes
Bradley
(03)
258
63
25
↑
Yes
Leite
(03)
84
42
34
↑
Yes
Corra
(06)
133
58
23
↑
Yes
Javaheri
(07)
88
62
25
↑
Yes
Brack
(07)
60
58
29
↑
Yes
La Rovere
(07)
380
52
25
↑
Yes
Andreas
(98)
36
55
20
↑
No
Roebuck
(04)
78
53
20
→
No
Jilek
(11)
176
65
34
↑
Yes
CSA is an independent
predictor of mortality in SHF
•
•
•
•
N = 114 eligible
N = 100 Enrolled
N = 12 with OSA Excluded
N = 88
32 with AHI <5/hr ( mean = 2 )
56 with AHI ≥5/hr ( mean = 34 ; CAI = 23)
• Median F/U : 51 months
Javaheri et al , J Am Coll Cardiol (May, 2007)
Sleep Medicine Physician Board Review
CSA is a Predictor of Mortality in SHF
100
90
AHI < 5/h (n=32)
80
AHI ≥5/h (n=56)
Survival %
70
60
50
40
30
20
Hazard ratio=2.14
10
P=0.02
0
0
10
20
30
40
50
60
70 80
90 100 110 120 130 140 150 160 170
Months
Sleep Medicine Physician Board Review
Javaheri S et al. J Am Coll Cardiol 2007
The predictors of poor survival in SHF
Three variables, AHI , RVEF and DBP
independently correlated with
survival :
AHI (HR=2.14, P=0.02)
RVEF (HR=0.97, P=0.003)
DBP (HR=0.96, P=0.02)
Javaheri, JACC, 2007
Sleep Medicine Physician Board Review
poor
Heart-Transplantation-Free Survival
Transplantation-free
Survival (%)
100
80
CPAP group
60
Control group
40
20
P=0.54
0
0
12
24
36
48
60
Time from Enrollment (mo)
Bradley TD et al., N Engl J Med 2005
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Treatment of sleep apnea with CPAP in SHF
In regard to therapy with CPAP,
how does CSA differ from OSA?
Sleep Medicine Physician Board Review
CSA in SHF
Prevalence of CPAP-responders and nonresponders
Patients
n
21
Responders
Non-responders
43%
AHI(36 to 4/h)
57%
AHI(62 to 62)
Javaheri, Circulation, 2000
Sleep Medicine Physician Board Review
Baseline Polysomnogram: HCSB
CPAP
Reasons why CPAP increased mortality
1. CPAP- nonresponders (43 % up to 57%)
2. Adverse hemodynamic consequences of
CPAP:
CPAP increases intrathoracic P and
decreases venous return to R ventricle
Javaheri , JCSM, 2006
Sleep Medicine Physician Board Review
The predictors of poor survival in SHF
Three variables, AHI , RVEF and DBP
independently correlated with
survival :
AHI
RVEF
DBP
poor
HR=2.14, P=0.02
HR=0.97, P=0.003
HR=0.96, P=0.02
Sleep Medicine Physician Board Review
Javaheri, JACC, 2007
Reasons why CPAP increased mortality
1. CPAP- nonresponders
2. Adverse hemodynamic consequences of
CPAP:
CPAP increases intrathoracic P and
decreases venous return to R ventricle
Javaheri , JCSM, 2006
Sleep Medicine Physician Board Review
Reasons why CPAP increased mortality
If my statements are correct, then:
1. CPAP responders should have a better
survival than the control group, and
2. CPAP non-responders should have a
poorer survival than the control group
Sleep Medicine Physician Board Review
Heart-Transplantation-Free Survival
100
Transplantation-free
Survival (%)
CPAP group, n=128
80
60
Control group
40
20
P=0.54
0
0
12
24
36
48
Time from Enrollment (mo)
Bradley TD et al., N Engl J Med 2005
Sleep Medicine Physician Board Review
60
Transplant-free survival in SHF patients
according to effect of CPAP on CSA (Artz, Circ, 2007)
CPAP responders*
(AHI at 3 months < 15/hr, n = 57)
Transplant-free survival (%)
100
80
60
Control
CPAP non-responders
(AHI at 3 months  15/hr, n = 43)
40
20
* vs. control: HR=0.36, p=0.040
0
0
6
12 18 24
30 36 42 48
54 60
Time from enrollment (months)
Sleep Medicine Physician Board Review
Transplant-free survival (%)
Transplant-free survival
according to effect of CPAP on CSA
CPAP responders*
(AHI at 3 months < 15/hr, n = 57)
100
80
Control
60
CPAP non-responders
(AHI at 3 months  15/hr, n =
43)
40
Control
20
*versus control: HR=0.36,
0
0
6
12 18 24
p=0.040
30 36 42 48
54 60
Time from enrollment (months)
Sleep Medicine Physician Board Review
CSA in SHF
Prevalence of CPAP-responders and non-responders
Potential Therapeutic Role of PSSV Devices
Patients
Javaheri (1st night)
(Circulation,2000)
Artz (at 3 m)
(Circulation,2007)
n
Responders
Non-responders
21
43%
AHI (36 to 4/h)
57%
AHI (62 to 62)
(lowPCO2)
100
57%
AHI (34 to 6.5)
43%
AHI (47 to 35)
Sleep Medicine Physician Board Review
Regarding CPAP in CSA/SHF
2 important concerns:
1. CPAP non-responders
2. Poor adherence with CPAP in
responders
Sleep Medicine Physician Board Review
ASV devices
• VPAP Adapt ASV Enhanced
• BiPAP AutoSV Advanced
Sleep Medicine Physician Board Review
General operation of ASV devices
Hyperpnea
Hypopnea
Patients
Airflow
Device
Inspiratory
pressure
support
Expiratory
pressure
Inspiratory support decreasing during hyperpnea and increasing during hypopnea
Operation of BiPap auto SV Advanced
EP increased from 4 to7 cm H2O
during obstructive disordered breathing events
AHI comparative data across various nights (N=37)
Javaheri et al, Sleep 2011, In Press
100
90
80
70
60
53.1
50
40
34.5
30
20
10.4
10
6.1
0
vs. Dx_PSG
vs. autoSV
Advanced
Dx_PSG
-----
CPAP
<0.001
autoSV
<0.001
autoSV Advanced
<0.001
<0.001
<0.001
0.0354
-----
Effects of PAP treatment on survival
in patients with SHF and severe sleep apnea
Jilek et al. EJHF, 2011
100
PAP treated; AHI=49/h
Survival, %
80
16 events, 18%
60
untreated ; AHI=42
44 events, 52%
40
adjusted HR 0.3 (95%CI: 0.2 – 0.6, p=0.001)
20
0
20
40
60
80
months
Sleep Medicine Physician Board Review
100
Thanks for your attention
Ref: S. Javaheri,
Heart Failure
in:
Principles and Practice of Sleep Medicine, 2010
A patient with HCSB on VPAP Adapt Enhanced
Sleep Medicine Physician Board Review
• Cardiovascular changes in NREM & REM sleep
NREM Sleep:
–
Sympathetic and Parasympathetic Activity
–
HR & BP
–
Ventilation
–
– Phasic REM sleep
HR and BP
• NREM sleep is peaceful for CV system
• Phasic REM sleep is not peaceful for CV system
Differences of ESS Score between HF patients (University of
Toronto) and the GP (Madison Sleep Cohort) according to the
AHI †
Subjective Sleepiness
(ESS Score)
11
†
GP
10
†
9
8
†
†
HF
7
6
(† p<0.05, †† p<0.01)
5
4
AHI < 5
AHI  5-15
Arzt M et al. Arch Int Med 2006
Sleep Medicine Physician Board Review
AHI  15
Long-term CPAP adherence in OSA
one year use of CPAP in
nonsleepy OSA patients in the
Spanish trial
Adherence: 4.7 ± 2 hrs
Barbe et al, Am J Respir Crit Care, 2010
Sleep Medicine Physician Board Review
Kaplan-Meier Survival Curves, Adjusted
by Age, Gender, and Charlson Comorbidity Index, 2004-2005
100%
Percent of
Cohort Alive
Tested, Diagnosed and Treated
N=258
Tested, Diagnosed and Not treated
N=295
90%
Hazard ratio =.49 (95% CI= .29-.84), P=0.009
80%
Baseline
1
2
3
4
5
Quarters after HF
Javaheri et al. Am J Respir Crit Care Med 2011
Sleep Medicine Physician Board Review
6
7
8
Future direction
2 RCT,
one with VPAP Adapt Enhanced
one with BiPap AutoSV Advanced
are in progress in systolic heart failure
Sleep Medicine Physician Board Review
Prevalence of sleep apnea
in Systolic Heart Failure
100 out of 114 consecutive patients
10% on beta blockers
Javaheri et al :
Ann Intern Med
Circulation
Int J Cardiol
AHI ≥ 15/h
1995
1998
2006
49%
Sleep Medicine Physician Board Review
Prevalence of sleep apnea in 6 recent
prospective PSG studies of SHF
%AHI≥15/hr
70
%CSA
%OSA
60
50
40
30
20
10
0
USA
(06)
Canada
(07)
UK
(07)
Germany
(09)
Germany
(10)
Prevalence of sleep apnea in 6 recent
prospective PSG studies of SHF
Country
(year)
n
AHI≥15/hr
USA (06)
100
Canada (07)
CSA
OSA
49
37
12
287
135
60
75
UK (07)
55
29
21
8
Germany (09)
50
32
22
10
Germany (10)
273
175
137
38
Portugal (10)
103
46
n/a
n/a
Total
868
466
277
143
Prevalence of sleep apnea in 6 recent
prospective studies of SHF
Prevalence of sleep apnea in 12 recent prospective
studies of 2,423 consecutive patients with SHF
Country
(year)
n
*USA (06)
AHI≥10/hr
(n)
AHI≥15/hr
(n)
CSA
(n)
OSA
(n)
100
49
37
12
USA (08)
108
66
33
32
*Canada (07)
287
135
60
75
China (07)
126
58
32
*UK (07)
55
29
21
8
Germany (07)
700
364
231
133
Germany (07)
203
144
57
87
Germany (07)
102
55
38
17
France (09)
316
256
79
177
*Germany (09)
50
32
22
10
*Germany (10)
273
175
137
38
*Portugal (10)
103
46
n/a
n/a
Total
2,423
896
773
621
89
544
Prevalence of sleep apnea in
recent prospective studies of SHF
Country
(year)
n
%
AHI≥10/hr
%
CSA
%
OSA
%
β blockers
China (07)
126
71
46
25
80
Germany (07)
203
71
28
43
90
Germany (07)
102
54
37
17
80
France (09)
316
81
25
56
82
Total
747
73
31
42
84
Prevalence of sleep apnea in
recent prospective studies of SHF
Country
(year)
n
%
AHI≥15/hr
%
CSA
%
OSA
%
β blockers
* USA (06)
100
49
37
12
10
USA (08)
108
61
31
30
82
*Canada (07)
287
47
21
26
80
*UK (07)
55
53
38
15
78
Germany (07)
700
52
33
19
85
*Germany (09)
50
64
44
20
100
*Germany (10)
273
64
50
14
88
*Portugal (10)
103
46
n/a
n/a
90
Total
1676
54
34
20
81
Prevalence of sleep apnea in SHF
(blue=EEG/red=no EEG)
Prevalence of sleep apnea in 2 recent
polygraphy studies of SHF (n=808)
AHI≥15/hr
CSA
OSA
Prevalence of Sleep Apnea in
Recent Prospective Studies of SHF
n
Country (y)
US (06)
US(08)
Canada (07)
China (07)
UK (07)
126
55
700
Germany (07)
203
102
%
AHI
≥ 15/hr
49
61
47
100
108
287
Germany (07)
Germany (07)
%
AHI
≥ 10/hr
%
β blocke
10
82
80
80
71
53
52
78
85
71
90
54
80
Prevalence of Sleep Apnea in SHF
The World Series
n = 431
n = 1250
AHI ≥10
AHI ≥15
Prevalence of CSA in Systolic Heart Failure
100 out of 114 consecutive patients
49% with AHI ≥ 15/h
37% CSA
Javaheri et al:
Ann Intern Med 1995
Circulation
1998
Int J Cardiol
2006
Prevalence of Sleep Apnea in
Recent Prospective Studies of SHF
n
Country (y)
US (06)
US(08)
Canada (07)
China (07)
UK (07)
126
55
700
Germany (07)
203
102
%
%
AHI
≥ 15/hr CSA
%
β blocke
37
31
21
10
82
80
46
80
38
78
33
85
71
28
90
54
37
80
49
61
47
100
108
287
Germany (07)
Germany (07)
%
AHI
≥ 10/hr
71
53
52
Prevalence of CSA in SHF
The World Series
40
35%
31%
35
30
25
%
n = 431
n = 1250
20
15
10
5
0
AHI ≥10
AHI ≥15
Prevalence of CSA in Systolic Heart Failure
100 out of 114 consecutive patients
49% with AHI ≥ 15/h
12% OSA
Javaheri et al:
Ann Intern Med 1995
Circulation
1998
Int J Cardiol
2006
Prevalence of OSA in SHF
Recent Studies
n
Country (y)
US (06)
%
AHI
≥ 10/hr
%
AHI
≥ 15/hr
49
100
Canada (07) 287
55
UK (07)
%
OSA
12
26
47
53
52
Germany (07) 700
15
19
43
Germany (07) 203
71
Germany (07)102
54
17
China (07)
71
25
126
%
β blocke
10
80
78
85
90
80
80
Prevalence of OSA in SHF
The World Series
35
30
32
n = 431
25
%
20
20
n = 1250
15
10
5
0
AHI ≥ 10
AHI ≥ 15
World wide prevalence of sleep
apnea in systolic heart failure
Author,
Country (y)
n
AHI > 15/hr
%
B blockers
%
Javaheri,
USA (06)
100
49
10
MacDonald,
USA (08)
108
61
82
Wang,
Canada (07)
287
47
80
Vazir,
UK (07)
55
53
78
Oldenburg,
Germany (07)
700
52
85
Worldwide prevalence of sleep
apnea in 1250 consecutive patients with SHF
60
52
50
40
%
31
30
21
20
10
0
AHI ≥15
CSA
OSA
Sleep Medicine Physician Board Review
Prevalence of Sleep Apnea in
Heart Failure with PEF(n=244)
AHI≥15/hr
Prevalence of sleep apnea in 6 recent
prospective PSG studies of SHF
54% (467/868)
36% (277/765)
19% (143/765)
Prevalence of Sleep Apnea in
Heart Failure with PEF
• Patients with SA performed worse on exercise test
and 6 minute walk
• With increasing impairment of diastolic dysfunction
the prevalence of SA, and CSA in particular
increased
• Patients with CSA had lower PCO₂,
higher NT-proBNP, LVEDP, PCWP, and PAP
Sleep Medicine Physician Board Review
How frequently patients
with HF are tested for SA?
Among a population of 30,719 newly diagnosed HF
patients, only 1,263 (4%) were clinically
suspected to have SA.
Of these, 553 (only 2% of the total cohort) were
tested for SA.
Javaheri et al, AJRCCM, 2011
Sleep Medicine Physician Board Review
How frequently patients with
HF are tested for SA?
A retrospective cohort study used the
2004-2005 Medicare Standard Analytical Files (SAFs).
SAFs contain a 5 % sample of randomly selected
Medicare beneficiaries.
The study population included newly diagnosed HF
patients in the first quarter of 2004 without prior
diagnosis of SA.
Javaheri et al. Am J Respir Crit Care Med 2011.
Sleep Medicine Physician Board Review
Phenotype of heart failure patients
with and without sleep apnea
90
NO SA
CSA
OSA
*†
80
p=0.02
p=0.1
70
p=0.1
60
50
p<0.001
40
*†
p=0.8
30
20
10
0
Patients
(n)
*vs. Group I
Group II
†vs.
Age
(y)
Ht
BMI
Snoring
(in)
(kg/m2)
(%)
Sleep Medicine Physician Board Review
EDS
(%)
PAP devices decreases LV afterload
Normal
Hypertension
100
Ppl
100
Pr
LVTm
Ppl
100 - (0.0) = 100
Ppl
-40
140 - (0.0) = 140
100
100
140
0.0
CPAP
100
140
Ppl
0.0
UAO
100
+10
100 - (-40) = 140
100 - (+10) = 90
OSA , HF and CPAP
1.CPAP titration in OSA with heart failure is the
same as OSA without HF
2. Generally, OSA is eliminated with overnight
CPAP titration
3.Occasionally central apneas may occur
during titration with CPAP
4.In most patients, OSA is controlled with low
pressure
What is critical is long-term adherence
Sleep Medicine Physician Board Review
CPAP adherence in OSA
What is a major determinant of
long-term adherence to CPAP
in OSA patients ?
Sleep Medicine Physician Board Review
Optimize Therapy of Heart Failure
ACEI; ß-Blockers; Diuretics; Digoxin; CRT
SRBD
Eliminated
Follow-up
Clinically
Cardiac
Transplantation
Nocturnal Nasal
Oxygen
Medications
Theophylline
Persistent
SRBD
Consider
Treatment
Phrenic Nerve
Stimulation
Acetazolamide
Positive Airway
Pressure Devices
CPAP
Bilevel
ASV
Changes in AHI with low flow nasal O2 in CSA patients
with heart failure and systolic dysfunction
80
70
p<0.0001
Room Air
Oxygen
Apnea-Hypopnea Index (n/hr)
MeansSD
60
p=0.01
p<0.05
p<0.001
50
p<0.01
p=0.02
40
30
20
10
0
N=9
Hanly
N=7
Walsh
N=11
Staniforth
N=7
Franklin
N=22
Andreas
N=29
Javaheri
RCT : Theophylline Improves CSA
Baseline Placebo Theo
Variable
15
15
15
N
15/0
15/0
15/0
Gender, M/F
66
66
66
Age, y
175
175
175
Ht, cm
89
88
88
Wt, kg
ND
ND
11
Theo, ug/ml
Javaheri et al., NEJM, 1996
Values are means; ND=not detectable
RCT:Theophylline improves CSA in HF
Variable Baseline Placebo Theo
37
18*
AHI, n/h
47
26
6*
CAI, n/h
26
2
2
OAI, n/h
2
2
1
MAI, n/h
2
17
8*
DBArI, n/h
24
Javaheri et al., NEJM, 1996, 335, 562-7
Values are means; * p < 0.05
RCT: Disordered breathing events of 12 SHF
patients with CSA treated with single dose of
acetazolamide before bedtime
Variable Baseline
AHI, n/h
55
CAI, n/h
44
OAI, n/h
1
DBArI, n/h 25
Placebo
57
49
1
20
Actz
34*†
23*†
2
13
p < 0.05 versus baseline † = p < 0.05 versus placebo
Javaheri, Am J Respir Crit Care Med, 2006
p
0.002
0.004
0.6
0.06
Long-term CPAP adherence in SHF
is inadequate (Arzt, Circulation, 2007)
AHI (n/hr)
CPAP-CSA
suppressed
n=57
6
CPAP-CSA
unsuppressed
n=43
35
P (cm H2O)
9
9
CPAP use
at 3 m (hr)
CPAP use
at 12 m (hr)
4.6
4.2
3.6
3.6
Bi-level
Pressure
cm/H₂O
20
Fixed inspiratory pressure
15
Fixed inspiratory support = IPAP - EPAP
10
Fixed expiratory pressure
5
0
VPAP Adapt SV Enhanced
Pressure
cm/H₂O
25
18
Variable inspiratory pressure support
Max inspiratory P = 25
Default min
pressure
support 3
Default max
pressure
support 5
7
4
Fixed expiratory pressure
(Manually adjusted)
0
BiPAP Auto SV Advanced
Pressure
cm/H₂O
25
Max inspiratory P = 25
18
11
4
0
Min expiratory P = 4 with
automatic adjustment
Variable inspiratory pressure support
Min inspiratory support = 0
Max pressure support =
25 – instantaneous EPAP
Features of ASV devices
EP to eliminate obstructive events.
– Back up rate to abort any impending
apnea
– Variable inspiratory support which
with hypopneas and with hyperpneas
–
Sleep Medicine Physician Board Review