Congestive heart failure and obstructive sleep apnea
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Sara Zand, M.D.[2] Edzel Lorraine Co, D.M.D., M.D. [3]
Overview
Obstructive sleep apnea is a sleep-related breathing disorder with effects on cardiovascular system by increasing the risk of hypertension, coronary artery disease, cardiac arrhythmias, sudden cardiac death, and heart failure. Obstructive sleep apnea contributes to the development and progression of HF. Hypoxia caused activation of inflammatory pathway leading to endothelial damage, atherogenesis, and heart failure. Activate profibrotic transforming growth factor-β during inflammatory process may cause increased deposition of extracellular matrix and consequent myocardial fibrosis and worsening LV diastolic function.
Sleep apnea in heart failure disease
- Sleep apnea is defined as partial or complete cessation of breathing during night-time sleep, resulting in repeated arousal from sleep, oxyhemoglobin desaturation, and daytime sleepiness.
- Apnea is as complete cessation of airflow for >10 s.
- Hypopnea, or partial cessation of airflow, is defined as a 50% to 90% reduction in airflow for >10 s, and >3% decrease in oxyhemoglobin saturation (SaO2) terminated by arousal.[1]
- The 3 types of apnea include central, obstructive, and mixed.
- Central sleep apnea (CSA) is characterized by a complete withdrawal of central respiratory drive to the inspiratory muscles, including the diaphragm, and results in the simultaneous absence of naso-oral airflow and thoracoabdominal excursions.
- In obstructive sleep apnea (OSA), the thoracic inspiratory muscles, including the diaphragm, are active, so thoracoabdominal excursions are seen.
- Absence of airflow results from upper-airway occlusion caused by lost pharyngeal dilator muscle tone, with consequent pharyngeal collapse.
- Obstructive sleep apnea is classified as mild (apnea-hypopnea index or AHI, 5–14), moderate (AHI, 15–30), or severe (AHI, >30)
- Mixed apnea has an initial central component followed by an obstructive component.
- Two types of hypopnea include obstructive or central.
Pathophysiology
- Obstructive sleep apnea is characterized by recurrent pharyngeal collapse during sleep.
- Hypopnea or apnea occurs in the presence of pharynx collapse upon normal withdrawal of pharyngeal dilator muscle tone during sleep.
- Obesity and fat deposition around the pharynx are responsible of pharyngeal narrowing.
- During sleeping period, edema of the peripharyngeal area due to leg fluid redistribution, may predispose the patients to OSA.[2]
- Obstructive sleep apnea causes a drop in intrathoracic pressure, hypoxia, and arousal.[3]
- The drop in intrathoracic pressure increases left ventricular (LV) transmural pressure, and afterload.
- This drop in pressure increases venous return, causing right ventricular distention and a leftward shift of the interventricular septum and consequent decreased LV filling.
- Decreased LV filling and increased afterload lead to reduced stroke volume.
- Obstructive sleep apnea leading to elevations in systemic blood pressure (BP) secondary to hypoxia, arousals from sleep, and increased sympathetic nervous system activity (SNA).
- The combination of increased LV afterload and increased heart rate secondary to augmented SNA leads to myocardial oxygen supply/demand mismatch, cardiac ischemia and arrhythmias, LV hypertrophy, LV enlargement, and HF.
- Rapid-eye-movement (REM) sleep constitutes 20% to 25% of sleep and is associated with short surges of sympathetic activity.
- Sleep generally is a period of increased vagal activity and slower heart rates and lower BP. However, arousals after disordered breathing events in OSA leading to increase sympathetic nerve activity and risk of HF disease.
- Hypoxemia caused systolic and diastolic dysfunction may also lessen oxygen delivery to the myocardium.[4]
- Increased free oxygen radicals and inflammation may cause myocardial ischemia, arrhythmias, and sudden cardiac death.[5]
- Plasma nitrite concentrations, and endothelial-mediated vasodilation decrease in patients with OSA.
- Reactive oxygen species selectively activate inflammatory pathways.
- Activation of NFκB leads to increased production of tumor necrosis factor-α, interleukin-6, interleukin-8, and C-reactive protein, as well as adhesion molecules such as intracellular and vascular cell adhesion molecules, E selecting, and CD15, CD32.
- Activate inflammatory pathways can lead to endothelial damage, atherogenesis, and heart failure.
- Activate profibrotic transforming growth factor-β during inflammatory process leads to increased deposition of extracellular matrix and consequent myocardial fibrosis, and to worsening LV diastolic function.[6]
- Common risk factors of OSA in patients with HFrEF include older age, male sex, higher BMI, and habitual snoring.[7]
- In patients with HFrEF and HFpEF, OSA is more prevalent than in the general population.
- Predictors of risk OSA and CSA in HFrEF are atrial fibrillation, ventricular arrhythmias, lower LV ejection fraction (LVEF, and higher levels of serum brain natriuretic peptide (BNP), endothelin-1, and urinary norepinephrine.[7][8][9][8]
Effect of CPAP in patients with HFrEF
- Use of nocturnal continuous positive airway pressure (CPAP) in OSA and HFrEF was associated with reduced central sympathetic vasoconstrictor outflow and improve vagal modulation of the heart by increasing high-frequency heart rate variability.[10][11]
- Other advantages of use of CPAP in HFrEF include reduction in apnea-hypopnea index, number of arousal per night, and daytime systolic blood pressure and heart rate combined with decrease in left ventricular end-systolic diameter and an 8.8% absolute increase in LVEF.[12][13]
- Use of CPAP was associated with improvement in quality of life.
Effect of CPAP in patients with HFpEF
- There are no clinical trials regarding the effects of chronic CPAP therapy in patients with OSA and HFpEF. However, CPAP therapy may have beneficial effects on diastolic function as follows:
- Decreased diastolic blood pressure
- Improved systolic and diastolic function (increased E/A ratio, decreased IVRT)[14]
- Regression of LV hypertrophy[14]
- Reduced LV wall thickness (interventricular septum and LV posterior wall)[15]
- Improved diastolic velocities
- Mortality rate was not decreased after use of CPAP in heart failure patients (HFpEF, HFrEF) with OSA.[16]
2022 AHA/ACC/HFSA Heart Failure Guideline (DO NOT EDIT) [17]
Management of Sleep Disorders
| Class IIa |
| "1. In patients with HF and suspicion of sleep-disordered breathing, a formal sleep assessment is reasonable to confirm the diagnosis and differentiate between obstructive and central sleep apnea. [18][19](Level of Evidence: C-LD) " |
| "2. In patients with HF and obstructive sleeep apnea, continuous positive airway pressure may be reasonable to improve sleep quality and decrease daytime sleepiness. [18][20][21][22](Level of Evidence: B-R) " |
| Class III (Harm) |
| "3. In patients with NYHA class II to IV HFrEF and central sleep apnea, adaptive servo-ventilation causes harm. [20][21] (Level of Evidence: B-R) " |
Source
- 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines[23]
References
- ↑ Chowdhury M, Adams S, Whellan DJ (February 2010). "Sleep-disordered breathing and heart failure: focus on obstructive sleep apnea and treatment with continuous positive airway pressure". J Card Fail. 16 (2): 164–74. doi:10.1016/j.cardfail.2009.08.006. PMID 20142029.
- ↑ Remmers JE, deGroot WJ, Sauerland EK, Anch AM (June 1978). "Pathogenesis of upper airway occlusion during sleep". J Appl Physiol Respir Environ Exerc Physiol. 44 (6): 931–8. doi:10.1152/jappl.1978.44.6.931. PMID 670014.
- ↑ Brinker JA, Weiss JL, Lappé DL, Rabson JL, Summer WR, Permutt S, Weisfeldt ML (March 1980). "Leftward septal displacement during right ventricular loading in man". Circulation. 61 (3): 626–33. doi:10.1161/01.cir.61.3.626. PMID 7353253.
- ↑ Yu AY, Shimoda LA, Iyer NV, Huso DL, Sun X, McWilliams R, Beaty T, Sham JS, Wiener CM, Sylvester JT, Semenza GL (March 1999). "Impaired physiological responses to chronic hypoxia in mice partially deficient for hypoxia-inducible factor 1alpha". J Clin Invest. 103 (5): 691–6. doi:10.1172/JCI5912. PMC 408131. PMID 10074486.
- ↑ Wyman RM, Farhi ER, Bing OH, Johnson RG, Weintraub RM, Grossman W (January 1989). "Comparative effects of hypoxia and ischemia in the isolated, blood-perfused dog heart: evaluation of left ventricular diastolic chamber distensibility and wall thickness". Circ Res. 64 (1): 121–8. doi:10.1161/01.res.64.1.121. PMID 2909295.
- ↑ Westermann D, Lindner D, Kasner M, Zietsch C, Savvatis K, Escher F, von Schlippenbach J, Skurk C, Steendijk P, Riad A, Poller W, Schultheiss HP, Tschöpe C (January 2011). "Cardiac inflammation contributes to changes in the extracellular matrix in patients with heart failure and normal ejection fraction". Circ Heart Fail. 4 (1): 44–52. doi:10.1161/CIRCHEARTFAILURE.109.931451. PMID 21075869.
- ↑ 7.0 7.1 Yumino D, Wang H, Floras JS, Newton GE, Mak S, Ruttanaumpawan P, Parker JD, Bradley TD (May 2009). "Prevalence and physiological predictors of sleep apnea in patients with heart failure and systolic dysfunction". J Card Fail. 15 (4): 279–85. doi:10.1016/j.cardfail.2008.11.015. PMID 19398074.
- ↑ 8.0 8.1 Vazir A, Hastings PC, Dayer M, McIntyre HF, Henein MY, Poole-Wilson PA, Cowie MR, Morrell MJ, Simonds AK (March 2007). "A high prevalence of sleep disordered breathing in men with mild symptomatic chronic heart failure due to left ventricular systolic dysfunction". Eur J Heart Fail. 9 (3): 243–50. doi:10.1016/j.ejheart.2006.08.001. PMID 17030014.
- ↑ Javaheri S (January 2006). "Sleep disorders in systolic heart failure: a prospective study of 100 male patients. The final report". Int J Cardiol. 106 (1): 21–8. doi:10.1016/j.ijcard.2004.12.068. PMID 16321661.
- ↑ Usui K, Bradley TD, Spaak J, Ryan CM, Kubo T, Kaneko Y, Floras JS (June 2005). "Inhibition of awake sympathetic nerve activity of heart failure patients with obstructive sleep apnea by nocturnal continuous positive airway pressure". J Am Coll Cardiol. 45 (12): 2008–11. doi:10.1016/j.jacc.2004.12.080. PMID 15963401.
- ↑ Gilman MP, Floras JS, Usui K, Kaneko Y, Leung RS, Bradley TD (February 2008). "Continuous positive airway pressure increases heart rate variability in heart failure patients with obstructive sleep apnoea". Clin Sci (Lond). 114 (3): 243–9. doi:10.1042/CS20070172. PMID 17824846.
- ↑ Kaneko Y, Floras JS, Usui K, Plante J, Tkacova R, Kubo T, Ando S, Bradley TD (March 2003). "Cardiovascular effects of continuous positive airway pressure in patients with heart failure and obstructive sleep apnea". N Engl J Med. 348 (13): 1233–41. doi:10.1056/NEJMoa022479. PMID 12660387.
- ↑ Mansfield DR, Gollogly NC, Kaye DM, Richardson M, Bergin P, Naughton MT (February 2004). "Controlled trial of continuous positive airway pressure in obstructive sleep apnea and heart failure". Am J Respir Crit Care Med. 169 (3): 361–6. doi:10.1164/rccm.200306-752OC. PMID 14597482.
- ↑ 14.0 14.1 Cloward TV, Walker JM, Farney RJ, Anderson JL (August 2003). "Left ventricular hypertrophy is a common echocardiographic abnormality in severe obstructive sleep apnea and reverses with nasal continuous positive airway pressure". Chest. 124 (2): 594–601. doi:10.1378/chest.124.2.594. PMID 12907548.
- ↑ Akar Bayram N, Ciftci B, Durmaz T, Keles T, Yeter E, Akcay M, Bozkurt E (May 2009). "Effects of continuous positive airway pressure therapy on left ventricular function assessed by tissue Doppler imaging in patients with obstructive sleep apnoea syndrome". Eur J Echocardiogr. 10 (3): 376–82. doi:10.1093/ejechocard/jen257. PMID 18845553.
- ↑ Jilek C, Krenn M, Sebah D, Obermeier R, Braune A, Kehl V, Schroll S, Montalvan S, Riegger GA, Pfeifer M, Arzt M (January 2011). "Prognostic impact of sleep disordered breathing and its treatment in heart failure: an observational study". Eur J Heart Fail. 13 (1): 68–75. doi:10.1093/eurjhf/hfq183. PMID 20961913.
- ↑ Heidenreich PA, Bozkurt B, Aguilar D, Allen LA, Byun JJ, Colvin MM; et al. (2022). "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines". Circulation. 145 (18): e876–e894. doi:10.1161/CIR.0000000000001062. PMID 35363500 Check
|pmid=value (help). - ↑ 18.0 18.1 Arzt M, Schroll S, Series F, Lewis K, Benjamin A, Escourrou P; et al. (2013). "Auto-servoventilation in heart failure with sleep apnoea: a randomised controlled trial". Eur Respir J. 42 (5): 1244–54. doi:10.1183/09031936.00083312. PMID 23222879.
- ↑ Arzt M, Floras JS, Logan AG, Kimoff RJ, Series F, Morrison D; et al. (2007). "Suppression of central sleep apnea by continuous positive airway pressure and transplant-free survival in heart failure: a post hoc analysis of the Canadian Continuous Positive Airway Pressure for Patients with Central Sleep Apnea and Heart Failure Trial (CANPAP)". Circulation. 115 (25): 3173–80. doi:10.1161/CIRCULATIONAHA.106.683482. PMID 17562959.
- ↑ 20.0 20.1 O'Connor CM, Whellan DJ, Fiuzat M, Punjabi NM, Tasissa G, Anstrom KJ; et al. (2017). "Cardiovascular Outcomes With Minute Ventilation-Targeted Adaptive Servo-Ventilation Therapy in Heart Failure: The CAT-HF Trial". J Am Coll Cardiol. 69 (12): 1577–1587. doi:10.1016/j.jacc.2017.01.041. PMID 28335841.
- ↑ 21.0 21.1 Cowie MR, Woehrle H, Wegscheider K, Angermann C, d'Ortho MP, Erdmann E; et al. (2015). "Adaptive Servo-Ventilation for Central Sleep Apnea in Systolic Heart Failure". N Engl J Med. 373 (12): 1095–105. doi:10.1056/NEJMoa1506459. PMC 4779593. PMID 26323938.
- ↑ Yamamoto S, Yamaga T, Nishie K, Nagata C, Mori R (2019). "Positive airway pressure therapy for the treatment of central sleep apnoea associated with heart failure". Cochrane Database Syst Rev. 12: CD012803. doi:10.1002/14651858.CD012803.pub2. PMC 6891032 Check
|pmc=value (help). PMID 31797360. - ↑ Heidenreich PA, Bozkurt B, Aguilar D, Allen LA, Byun JJ, Colvin MM, Deswal A, Drazner MH, Dunlay SM, Evers LR, Fang JC, Fedson SE, Fonarow GC, Hayek SS, Hernandez AF, Khazanie P, Kittleson MM, Lee CS, Link MS, Milano CA, Nnacheta LC, Sandhu AT, Stevenson LW, Vardeny O, Vest AR, Yancy CW (May 2022). "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines". Circulation. 145 (18): e895–e1032. doi:10.1161/CIR.0000000000001063. PMID 35363499 Check
|pmid=value (help).