0
Editorials |

A Paradigm Shift in the Treatment of Central Sleep Apnea in Heart FailureCentral Apnea and Heart Failure

Reena Mehra, MD, FCCP; Daniel J. Gottlieb, MD, MPH, FCCP
Author and Funding Information

From the Cleveland Clinic (Dr Mehra), Cleveland Clinic Lerner College of Medicine of Case Western Reserve University; VA Boston Healthcare System (Dr Gottlieb); and Division of Sleep Medicine (Dr Gottlieb), Harvard Medical School.

CORRESPONDENCE TO: Reena Mehra MD, FCCP, Sleep Disorders Research, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, 9500 Euclid Ave, Cleveland, OH 44195; e-mail: mehrar@ccf.org


CONFLICT OF INTEREST: R. M. has received honoraria from the American Academy of Sleep Medicine, positive airway pressure machines and equipment for research from Philips Respironics (Koninklijke Philips NV), and funding from the National Institutes of Health. D. J. G. has served as a consultant for VIVUS Inc and has received research support from Jazz Pharmaceuticals plc.

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


Chest. 2015;148(4):848-851. doi:10.1378/chest.15-1536
Text Size: A A A
Published online

Extract

Periodic breathing with central sleep apnea (CSA), known as Hunter-Cheyne-Stokes respiration, is among the first recognized sleep-related breathing disorders, described in the early 19th century, and is now recognized to be quite common in patients with chronic heart failure (HF). It remains uncertain whether CSA is simply a marker of underlying cardiac dysfunction or, alternatively, whether CSA exerts a detrimental effect on the failing heart (eg, via hypoxia, arousal, and their associated sympathoexcitation) or if it is a beneficial compensatory mechanism (eg, via increased end-expiratory lung volumes improving oxygenation or via promotion of cardioprotective alkalosis).1 Reports that CSA is associated with increased risk for mortality in patients with HF, along with preliminary findings of improved cardiac function and reduced mortality when CSA was treated with CPAP,2-4 prompted a multicenter randomized controlled trial to investigate the effect of CPAP on transplant-free survival in patients with HF with CSA. This trial was prematurely terminated because of low recruitment, reduced mortality due to secular trends in the medical treatment of HF, and early divergence of the survival curves in favor of the control group (hazard ratio [HR] in first 18 months, 1.5; P = .02).5 Beyond 18 months, survival favored the CPAP arm, but the overall difference between treatment groups was not statistically significant, despite sustained improvement in intermediate measures (left ventricular ejection fraction [LVEF], plasma norepinephrine level, 6-min walk distance).5 The power of this study was limited, CPAP had suboptimal effectiveness in reducing CSA burden, and secondary analysis suggested that survival was improved in those in whom CSA was suppressed,6 leading to the design and initiation of two larger, more adequately powered trials using adaptive servoventilation (ASV), a bilevel positive airway pressure modality that is more effective in reversing CSA in patients with HF.7 These include an ongoing trial enrolling patients with either obstructive or central sleep apnea (Effect of Adaptive Servo Ventilation on Survival and Hospital Admissions in Heart Failure [ADVENT-HF])8 and a completed trial enrolling only patients with predominantly CSA (Treatment of Predominant Central Sleep Apnea by Adaptive Servo Ventilation in Patients With Heart Failure [SERVE-HF]),9 with recently publicized results.

First Page Preview

View Large
First page PDF preview

Sign In to Access Full Content

MEMBER & INDIVIDUAL SUBSCRIBER

Want Access?

NEW TO CHEST?

Become a CHEST member and receive a FREE subscription as a benefit of membership.

Individuals can purchase this article on ScienceDirect.

Individuals can purchase a subscription to the journal.

Individuals can purchase a subscription to the journal or buy individual articles.

Learn more about membership or Purchase a Full Subscription.

INSTITUTIONAL ACCESS

Institutional access is now available through ScienceDirect and can be purchased at myelsevier.com.

Sign In to Access Full Content

MEMBER & INDIVIDUAL SUBSCRIBER

Want Access?

NEW TO CHEST?

Become a CHEST member and receive a FREE subscription as a benefit of membership.

Individuals can purchase this article on ScienceDirect.

Individuals can purchase a subscription to the journal.

Individuals can purchase a subscription to the journal or buy individual articles.

Learn more about membership or Purchase a Full Subscription.

INSTITUTIONAL ACCESS

Institutional access is now available through ScienceDirect and can be purchased at myelsevier.com.

Figures

Tables

References

NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).

Some tools below are only available to our subscribers or users with an online account.

Sign In to Access Full Content

MEMBER & INDIVIDUAL SUBSCRIBER

Want Access?

NEW TO CHEST?

Become a CHEST member and receive a FREE subscription as a benefit of membership.

Individuals can purchase this article on ScienceDirect.

Individuals can purchase a subscription to the journal.

Individuals can purchase a subscription to the journal or buy individual articles.

Learn more about membership or Purchase a Full Subscription.

INSTITUTIONAL ACCESS

Institutional access is now available through ScienceDirect and can be purchased at myelsevier.com.

Related Content

Customize your page view by dragging & repositioning the boxes below.

Find Similar Articles
CHEST Journal Articles
PubMed Articles
  • CHEST Journal
    Print ISSN: 0012-3692
    Online ISSN: 1931-3543