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From Sleep-Disordered Breathing to Increased Left Ventricular Wall Stress in Heart FailureSleep-Disordered Breathing and High Wall Stress FREE TO VIEW

Peter Alter, MD; Jörg Heitmann, MD; Heinz Rupp, PhD
Author and Funding Information

From the Department of Internal Medicine-Cardiology (Drs Alter and Rupp), Philipps University of Marburg; and Department of Internal Medicine-Lung Center (Dr Heitmann), University of Giessen.

Correspondence to: Peter Alter, MD, Internal Medicine-Cardiology, Philipps University of Marburg, Baldingerstrasse, D-35033 Marburg, Germany; e-mail: alter@staff.uni-marburg.de


Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2012;142(3):813. doi:10.1378/chest.12-1057
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To the Editor:

Sleep-disordered breathing (SDB) frequently occurs in patients with congestive heart failure (CHF). Both entities seem to be inherently associated, but mechanisms causally linking SDB with CHF still remain uncertain. Thus, in an issue of CHEST (March 2012), Carr et al1 reviewed acute cardiopulmonary failure resulting from SDB.

Central sleep apnea is associated with increased circulation time in CHF due to a reduced stroke volume and is closely linked to the sympathetic tone. We showed that the severity of SDB is associated with increased end-diastolic and end-systolic left ventricular wall stress, but not with pump function.2 Thus, the question arises of whether cardiac function is indeed the key determinant.

Left ventricular wall stress is predominantly influenced by ventricular volume, myocardial mass, and the transmural pressure gradient. Ventricular wall stress is frequently increased in dilative CHF, since cardiac hypertrophy is not appropriate to compensate for ventricular dilatation.3,4 Increased ventricular wall stress was associated with an altered autonomic tone.5 In obstructive sleep apnea, upper airways obstruction increases the negative intrathoracic pressure, which transmits increased distending forces on the left ventricle and thereby increases wall stress. Increased left ventricular wall stress was identified as the missing link between CHF and SDB and should not be underrated.2 These considerations also provide a rationale for the benefits of positive airway pressure ventilation therapy in CHF.2

It has been suggested that repetitive nocturnal hypoxias interfere with an adequate ventricular hypertrophy in SDB, which enhances further wall stress and ventricular dilatation with worse prognosis.4 Increased left ventricular wall stress is associated with decreased heart rate variability with unfavorable consequences.5 Increased wall stress leads to the opening of stretch-activated cation channels, which increases the risk of sudden cardiac death. Wall stress is also associated with myocardial oxygen consumption, that is, increased wall stress can worsen wall motion abnormalities, further deteriorating cardiac function. We recommend, therefore, that ventricular wall stress should be considered as a diagnostic criterion in SDB and CHF.2 Normalization of high wall stress remains, however, an as-yet unmet therapeutic target.

Carr GE, Mokhlesi B, Gehlbach BK. Acute cardiopulmonary failure from sleep-disordered breathing. Chest. 2012;141(3):798-808. [PubMed] [CrossRef]
 
Alter P, Apelt S, Figiel JH, Rominger MB, Rupp H, Heitmann J. The missing link between heart failure and sleep disordered breathing: increased left ventricular wall stress. Int J Cardiol. 2012;157(2):294-297. [PubMed] [CrossRef]
 
Alter P, Rupp H, Rominger MB, et al. B-type natriuretic peptide and wall stress in dilated human heart. Mol Cell Biochem. 2008;314(1-2):179-191. [PubMed] [CrossRef]
 
Alter P, Rupp H, Stoll F, et al. Increased enddiastolic wall stress precedes left ventricular hypertrophy in dilative heart failure-use of the volume-based wall stress index. Int J Cardiol. 2012;157(2):233-238. [PubMed] [CrossRef]
 
Alter P, Rupp H, Rominger MB, et al. Depression of heart rate variability in patients with increased ventricular wall stress. Pacing Clin Electrophysiol. 2009;32(suppl 1):S26-S31. [PubMed] [CrossRef]
 

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References

Carr GE, Mokhlesi B, Gehlbach BK. Acute cardiopulmonary failure from sleep-disordered breathing. Chest. 2012;141(3):798-808. [PubMed] [CrossRef]
 
Alter P, Apelt S, Figiel JH, Rominger MB, Rupp H, Heitmann J. The missing link between heart failure and sleep disordered breathing: increased left ventricular wall stress. Int J Cardiol. 2012;157(2):294-297. [PubMed] [CrossRef]
 
Alter P, Rupp H, Rominger MB, et al. B-type natriuretic peptide and wall stress in dilated human heart. Mol Cell Biochem. 2008;314(1-2):179-191. [PubMed] [CrossRef]
 
Alter P, Rupp H, Stoll F, et al. Increased enddiastolic wall stress precedes left ventricular hypertrophy in dilative heart failure-use of the volume-based wall stress index. Int J Cardiol. 2012;157(2):233-238. [PubMed] [CrossRef]
 
Alter P, Rupp H, Rominger MB, et al. Depression of heart rate variability in patients with increased ventricular wall stress. Pacing Clin Electrophysiol. 2009;32(suppl 1):S26-S31. [PubMed] [CrossRef]
 
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