Diagnosis and treatment of sleep apnea in heart disease |
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Authors: | Julio A Barcena James C Fang |
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Institution: | (1) Division of Cardiovascular Medicine, University Hospitals/Case Western Reserve University, 11100 Euclid Avenue, Lakeside 3001, Cleveland, Ohio 44120, USA |
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Abstract: | Opinion statement One of the most common yet unidentified conditions in heart disease is sleep-disordered breathing (SDB). Although it is most
prevalent in patients with heart failure, it has been epidemiologically and pathophysiologically linked to ischemic heart
disease, hypertension, sudden cardiac death, atrial fibrillation, and stroke. There are two primary SDB syndromes: obstructive
sleep apnea (OSA) and central sleep apnea (CSA; also known as Cheyne-Stokes respiration). The pathophysiologic mechanisms
that underlie these disorders appear to be distinct but both involve recurrent cycles of excessive sympathetic activation,
hypoxemias and hypercapnias, and increases in ventricular wall stress. Signs and symptoms may include daytime somnolence,
snoring, difficult-to-control hypertension, and refractory arrhythmias or angina. In heart failure, half of patients will
have SDB and most patients will exhibit evidence of both OSA and CSA, although one or the other may predominate. The current
standard diagnostic method is overnight laboratory polysomnography. Primary therapies for OSA include lifestyle changes, various
facial and oral appliances, head and neck surgery, and continuous positive airway pressure (CPAP). CPAP is the most effective
form of therapy for OSA, with few side effects, but is limited by compliance because of comfort-related issues. In patients
with cardiovascular disease who predominantly suffer from OSA, treatment recommendations should be based on current guidelines
for OSA. For patients with heart failure with predominant CSA, the current cornerstone of therapy is the optimization of medical
therapy and resynchronization therapy when indicated. When SDB persists despite optimal medical management, referral to a
sleep medicine consultant should be considered. |
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