Sleepiness and sleep in patients with both systolic heart failure and obstructive sleep apnea

BACKGROUND: Adverse effects of obstructive sleep apnea (OSA), including sleep deprivation, can contribute to the progression of heart failure. The usual indication to diagnose and treat sleep apnea is subjective sleepiness. Previous studies suggest that patients with both heart failure and obstructive sleep apnea often do not complain of sleepiness, albeit their sleep time may be reduced. Therefore, we tested the hypothesis that patients with heart failure have less sleepiness and sleep less compared with subjects without heart failure for a given severity of OSA. METHODS: Sleepiness assessed with the Epworth Sleepiness Scale and sleep structure measured with polysomnography were compared among 155 consecutive patients with heart failure and from a random community sample (n = 1139) according to categories of the apnea-hypopnea index (<5, no OSA; 5-14, mild OSA; and > or =15, moderate to severe OSA). RESULTS: Compared with the community sample, for any given severity of OSA, patients with heart failure had lower mean +/- SE Epworth Sleepiness Scale scores (7.1 +/- 0.4 vs 8.3 +/- 0.2 [P = .005]; 6.7 +/- 0.7 vs 9.2 +/- 0.3 [P < .001]; and 7.8 +/- 0.7 vs 9.8 +/- 0.4 [P = .01]), indicating less sleepiness despite sleeping less (total sleep time mean +/- SE [in minutes]: 306 +/- 7 vs 384 +/- 2, 295 +/- 19 vs 384 +/- 5, and 285 +/- 13 vs 359 +/- 7 for no, mild, and moderate to severe OSA, respectively; P < .001 for all comparisons). CONCLUSIONS: Patients with heart failure have less subjective daytime sleepiness compared with individuals from a community sample, despite significantly reduced sleep time, whether or not they have OSA. In patients with heart failure, the absence of subjective sleepiness is not a reliable means of ruling out OSA.     

Special characteristics of chronotropic reaction to physical exercise in patients with systolic heart failure and obstructive sleep apnea syndrome

In order to study special characteristics of chronotropic reaction to physical exercise on veloergometer in the presence of obstructive sleep apnea (OSA) we examined 84 patients with manifestations of chronic systolic heart failure (HF). Chronotropic insufficiency was found in 88% of patients predominantly in combination with insufficient lowering of heart rate after exercise. At the same time it was more rarely registered in patients with OSA (56.4%). Insufficient lowering of heart rate by the end of first minute of rest was similarly associated with HF and OSA. CONCLUSION: it is necessary to consider simultaneously chronotropic reserve and character of HR recovery after exercise.     

Diuretics in obstructive sleep apnea with diastolic heart failure

BACKGROUND: Upper airway edema might contribute to pharyngeal collapsibility and account for the high prevalence of obstructive sleep apnea (OSA) in patients with heart disease. The aim of this study was to evaluate if intensive unloading with diuretics improves sleep-disordered breathing and increases pharyngeal caliber in patients with severe OSA and diastolic heart failure. METHODS: Fifteen patients with severe OSA, hypertension, and diastolic heart failure were hospitalized to receive IV furosemide, 20 mg, and spironolactone, 100 mg, bid for 3 days. Polysomnography was performed for assessment of apnea-hypopnea index (AHI), acoustic pharyngometry was performed for assessment of the oropharyngeal junction (OPJ) area, and forced midinspiratory flow (FIF(50)), forced midexpiratory flow (FEF(50))/FIF(50) percentage, and exhaled nitric oxide (FeNO) were measured before and after diuretic treatment. RESULTS: Diuretic treatment produced a significant decrease in body weight, BP, and AHI (from 74.89 +/- 6.95 to 57.17 +/- 5.40/h, p < 0.001), associated with an improvement in OPJ area (from 1.33 +/- 0.10 to 1.78 +/- 0.16 cm(2), p = 0.007), FIF(50) (from 3.16 +/- 0.4 to 3.94 +/- 0.4 L/s, p = 0.006), and FEF(50)/FIF(50) percentage (from 117.9 +/- 11.8 to 93.15 +/- 10.1%, p = 0.002). Weight loss was significantly related to the decrease of AHI (R = 0.602; p = 0.018), to the increase of FIF(50) (R = 0.68; p = 0.005), and to the decrease of FEF(50)/FIF(50) (R = 0.635; p = 0.011). CONCLUSIONS: These findings suggest that pharyngeal edema contributes to sleep-disordered breathing in obese patients with severe OSA, hypertension, and diastolic heart failure. Upper airway edema may contribute to the frequent occurrence of OSA in patients with heart disease.     

Periodicity of obstructive sleep apnea in patients with and without heart failure

STUDY OBJECTIVE: To determine whether the duration of the apnea-hyperpnea cycle is longer in patients with congestive heart failure (CHF) and obstructive sleep apnea (OSA) than in patients with OSA alone, and whether this is related to prolonged circulation time. DESIGN: Retrospective study. SETTING: Sleep laboratory of a university teaching hospital.Patients and intervention: Male patients with OSA and CHF (n = 22) or without CHF (n = 18) underwent overnight polysomnography. MEASUREMENTS AND RESULTS: Hyperpnea duration, time to peak tidal volume (Vt), and lung-to-ear circulation time (LECT) were measured in all patients. Compared to the non-CHF patients, those with CHF had significantly longer hyperpneas (25.7 +/- 7.8 s vs 17.6 +/- 5.6 s, p < 0.001) and LECT (14.9 +/- 3.4 s vs 9.0 +/- 1.8 s, p < 0.001) [mean +/- SD]. There was also a significant relationship between LECT and hyperpnea duration (r = 0.67, p < 0.001). CONCLUSION: In patients with CHF, prolonged lung-to-chemoreceptor circulation time influences the cycling characteristics of OSA such that it prolongs hyperpnea and sculpts a pattern resembling Cheyne-Stokes respiration. These findings further suggest that the increased tendency to periodic breathing in CHF may predispose to, or alter the physiologic manifestations of OSA.     

Influence of obstructive sleep apnea on mortality in patients with heart failure.

OBJECTIVES: This study sought to determine, in patients with heart failure (HF), whether untreated moderate to severe obstructive sleep apnea (OSA) is associated with a higher mortality rate than in patients with mild to no sleep apnea (M-NSA). BACKGROUND: Obstructive sleep apnea is common in patients with HF and exposes the heart and circulation to adverse mechanical and autonomic effects. However, its effect on mortality rates of patients with HF has not been reported. METHODS: In a prospective study involving 164 HF patients with left ventricular ejection fractions (LVEFs) < or =45%, we performed polysomnography and compared death rates between those with M-NSA (apnea-hypopnea index [AHI] <15/h of sleep) and those with untreated OSA (AHI > or =15/h of sleep). RESULTS: During a mean (+/- SD) of 2.9 +/- 2.2 and a maximum of 7.3 years of follow-up, the death rate was significantly greater in the 37 untreated OSA patients than in the 113 M-NSA patients after controlling for confounding factors (8.7 vs. 4.2 deaths per 100 patient-years, p = 0.029). Although there were no deaths among the 14 patients whose OSA was treated by continuous positive airway pressure (CPAP), the mortality rate was not significantly different from the untreated OSA patients (p = 0.070). CONCLUSIONS: In patients with HF, untreated OSA is associated with an increased risk of death independently of confounding factors.     

Left ventricular systolic dysfunction in patients with obstructive sleep apnea syndrome

STUDY OBJECTIVES: Conflicting results have been reported regarding the effects of obstructive sleep apnea syndrome (OSAS) on daytime left ventricular (LV) systolic function. This study aimed to assess the prevalence and causes of LV systolic dysfunction, using radionuclide angiography, in a large group of patients with OSAS. DESIGN AND SETTING: A prospective study in the pneumology department of a university medical center. PATIENTS: One hundred sixty-nine consecutive patients with OSAS diagnosed by polysomnography, hospitalized for the administration of nasal continuous positive airway pressure. Patients with a known cardiac disease were excluded. MEASUREMENTS: LV ejection fraction (LVEF) was measured in all patients, using radionuclide ventriculography with multiple-gated equilibrium cardiac imaging. Myocardial scintigraphy with a dipyridamole stress test and echocardiography were performed in those patients with LV systolic dysfunction, defined by a LVEF < 50%, to detect silent heart disease, especially coronary artery disease. RESULTS: LV systolic dysfunction was observed in 7.7% (13 of 169 patients). In these 13 patients, the mean +/- SD LVEF was 42 +/- 6%, the lowest value of LVEF was 32%, and no silent cardiac disease was revealed. Age, body mass index, apnea-hypopnea index, parameters of nocturnal oxyhemoglobin desaturation, and prevalence of systemic hypertension did not significantly differ between patients with LVEF < 50% and those with LVEF > 50%. In seven patients with LV dysfunction, LVEF was measured following treatment of OSAS and reached normal values. CONCLUSION: OSAS may be a direct cause of daytime LV systolic dysfunction that can resolve following reversal of nocturnal apneas.     

持续正压气道通气在合并阻塞型呼吸暂停的老年收缩性心力衰竭中的应用

目的合并阻塞型呼吸暂停的老年慢性收缩性心力衰竭患者，在常规药物治疗基础上，观察持续正压气道通气方法的临床疗效。方法门诊或住院的老年慢性收缩性心力衰竭患者，夜间多导睡眠诊断合并阻塞型呼吸暂停的患者61例，按照随机方法分为研究组（29例）和对照组（32例），药物治疗病情平稳2周后，研究组加用持续正压气道通气治疗，对照组继续药物治疗，8周后比较两组临床表现、超声心动图指标和血清B型钠尿肽的变化情况。结果与对照组相比，研究组8周治疗后6min步行试验增加（103±93）m（P〈0．01），心率平均下降（7±2）次／min（P〈0．01）、收缩压平均下降（10土3）mmHg（P〈0．05），舒张压变化不明显；左室射血分数明显提高5％（P〈0．05），左室收缩末径下降2mm（P〈0．05），每搏输出量增加4ml／次（P〈0．01），血清B型钠尿肽下降651ng／L（P〈0．01）。结论对于合并阻塞型呼吸暂停的老年慢性收缩性心力衰竭患者，常规药物治疗基础上加用持续正压气道通气方法，有利于改善患者的心功能，改善心肌重塑。     

Central sleep apnea is a predictor of cardiac readmission in hospitalized patients with systolic heart failure

BackgroundHospitalized heart failure patients have a high readmission rate. We sought to determine the independent risk due to central sleep apnea (CSA) of readmission in patients with systolic heart failure (SHF).Methods and ResultsThis was a prospective observational cohort study of hospitalized patients with SHF. Patients underwent sleep studies during their hospitalization and were followed for 6 months to determine their rate of cardiac readmissions; 784 consecutive patients were included; 165 patients had CSA and 139 had no sleep-disordered breathing (SDB); the remainder had obstructive sleep apnea (OSA). The rate ratio for 6 months' cardiac readmissions was 1.53 (95% confidence interval 1.1–2.2; P = .03) in CSA patients compared with no SDB. This rate ratio was adjusted for systolic function, type of cardiomyopathy, age, weight, sex, diabetes, coronary disease, length of stay, admission sodium, creatinine, hemoglobin, blood pressure, and discharge medications. Severe OSA was also an independent predictor of readmissions with an adjusted rate ratio of 1.49 (P = .04).ConclusionIn this first evaluation of the impact of SDB on cardiac readmissions in heart failure, CSA was an independent risk factor for 6 months' cardiac readmissions. The effect size of CSA exceeded that of all known predictors of heart failure readmissions.     

Relationship between the severity of obstructive sleep apnea and impaired glucose metabolism in patients with obstructive sleep apnea

BACKGROUND: The relationship between the severity of obstructive sleep apnea (OSA) and impaired glucose metabolism (IGM) has not yet been fully elucidated in patients with OSA. Accordingly, we sought to clarify this relationship in Japanese patients with OSA. METHODS: The study population consisted of 129 Japanese patients with OSA (apnea-hypopnea index [AHI] >/=5). A 75-g oral glucose tolerance test was performed in all patients who had not been diagnosed as diabetes mellitus (DM). IGM was defined as either diabetes mellitus (DM) or impaired glucose tolerance (IGT). RESULTS: IGM was observed in 78 (60.5%) patients: DM in 39 (30.2%) and IGT in 39 (30.2%). The frequency of IGM was significantly different among patients with AHI >/=30, those with 15 /=5), and the prevalence of IGM increased according to the severity of OSA. Furthermore, the AHI was independently associated with IGM, thus suggesting that OSA may contribute to the development of IGM.     

Cycle length identifies obstructive sleep apnea and central sleep apnea in heart failure with reduced ejection fraction

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.

     

Central sleep apnea in patients with congestive heart failure

Central apnea during sleep represents a manifestation of breathing instability in many clinical conditions of varied etiologies. Central apnea is the result of transient cessation of ventilatory motor output, which represents that inhibitory influences favoring instability predominate over excitatory influence favoring stable breathing. This article will review the determinants of central apnea, the specific features of CHF-related central apnea, and outline a management approach     

APAP therapy does not improve impaired sleep quality and sympatho-vagal balance: a randomized trial in patients with obstructive sleep apnea and systolic heart failure

Sleep and Breathing - In heart failure with reduced ejection fraction (HFrEF), the effects of automatic positive airway pressure therapy (APAP) for obstructive sleep apnea (OSA) on sleep quality...     

Relationship of ventricular ectopy to oxyhemoglobin desaturation in patients with obstructive sleep apnea

Patients with obstructive sleep apnea are considered to be at increased risk of sudden, presumably arrhythmia-related death during sleep. The present study was undertaken to determine the relationship between ventricular ectopy and the severity of oxyhemoglobin desaturation in these patients. Thirty-one male patients with obstructive sleep apnea (mean age, 55 +/- 11 years) underwent overnight polysomnography. Arterial oxyhemoglobin saturation (SaO2) was monitored by ear oximetry, and premature ventricular complexes (PVC) were detected using electrocardiographic leads CC5 and CM5. The data were recorded on electromagnetic tape for subsequent computer-assisted analysis to obtain PVC frequency as a function of decile levels of SaO2. Total sleep time averaged 333 +/- 75 minutes, the apnea index was 44 +/- 26 per hour, and the hypopnea index was 18 +/- 24 per hour. Premature ventricular complexes were observed in 23 (74 percent) of the subjects. By analysis of variance, no significant relationship was found between PVC frequency and decile levels of SaO2 for saturations greater than 60 percent; however, in the 16 subjects with SaO2 below 60 percent, a significant increase in PVC frequency was detected with decreasing SaO2 (p less than 0.01). Ventricular bigeminy was observed with SaO2 below 60 percent in three of these 16 subjects. From these results, we conclude that patients with obstructive sleep apnea are at relatively low risk of developing ventricular arrhythmias provided SaO2 remains greater than 60 percent, while those with SaO2 below 60 percent are at increased risk and should be managed accordingly.     

血栓弹力图在OSAHS并发慢性心力衰竭患者中的应用价值

目的 通过血栓弹力图评估阻塞性睡眠呼吸暂停低通气综合征（obstructive sleep apnea hypopnea syndrome,OSAHS）并发慢性心力衰竭（CHF）患者的血凝状态,探讨血栓弹力图在OSAHS并发CHF患者中的应用价值。 方法 选择确诊为OSAHS并发CHF患者60例,按照2015年我国《阻塞性睡眠呼吸暂停低通气综合征诊治指南（基层版）》诊断标准中的睡眠呼吸指数（AHI）,将OSAHS并发CHF患者分为轻度组（20例,AHI 5~15次/h）、中度组（20例,AHI 16~30次/h）和重度组（20例,AHI>30次/h）。另随机选取同一时段我院健康体检者20例作为正常对照组,所有入组患者均记录一般情况,包括年龄、身高、体质量、性别、高血压病、吸烟史、饮酒史、腰围、睡眠监测结果、血栓弹力图结果（R值、MA值）。 结果 ①随着OSAHS并发CHF患者体质量指数（body mass index,BMI）的升高,AHI相应增大,差异有统计学意义（P<0.05）。②OSAHS并发CHF患者各组与正常对照组比较,R值明显减小,差异有统计学意义（P<0.05）。OSAHS并发CHF患者各组间R值比较,差异有统计学意义（P<0.05）。③OSAHS并发CHF患者各组与正常对照组比较,MA值明显增大,差异有统计学意义（P<0.05,P<0.01）。OSAHS并发CHF患者各组间MA值比较,差异有统计学意义（P<0.05,P<0.01）。 结论 OSAHS并发CHF患者病情越重R值越小、MA值相应增大。