The Management of Co-Morbidities in Patients with Heart Failure – Central Sleep Apnoea

Andrew JS Coats, Louise G Shewan, William T Abraham


Despite many therapeutic advances, heart failure (HF) remains challenging to treat and continues to be associated with high rates of morbidity and mortality. There is an ongoing need to identify co-morbidities that either contribute to the progression of heart failure or limit the therapeutic response to treatment. One area under active investigation is the treatment of central sleep apnoea (CSA). CSA has consistently been shown to be associated with a worse prognosis in HF patients. Thus, understanding how to diagnose and treat CSA is of paramount importance to the HF clinician. Without treatment, HF patients continue to be at risk for the devastating consequences of CSA. Prognosis is very poor with studies consistently demonstrating poor outcomes among HF patients with CSA. Over the course of the night, each discrete event contributes to increased nor- epinephrine levels and hypoxia which are associated with progressive heart failure and arrhythmias. Initial therapeutic options utilized therapies which were developed for obstructive sleep apnoea with limited success or even harm. ASV is now contraindicated in HF patients with an EF < 45% leaving only 2 potential treatment options: CPAP and transvenous phrenic nerve stimulation. Data from the recently presented (post ESC guidelines) trial on transvenous phrenic nerve stimulation demonstrated efficacy without the need for patient compliance or any safety concerns. It is expected that additional studies in CSA will continue to demonstrate the full impact of treating this important co-morbidity on patients with HF.


Cardiology; Heart failure; Sleep Apnoea; Guidelines

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Lanfranchi PA, Braghiroli A, Bosimini E, et al: Prognostic value of nocturnal Cheyne-Stokes respiration in chronic heart failure. Circulation. 99:1435-40, 1999

Hanly PJ, Zuberi-Khokhar NS: Increased mortality associated with Cheyne-Stokes respiration in patients with congestive heart failure. Am J Resp Crit Care Med. 153:272-6, 1996.

Javaheri S, Shukla R, Zeigler H, Wexler L: Central sleep apnea, right ventricular dysfunction and low diastolic blood pressure are predictors of mortality in systolic heart failure. J Am Coll Cardiol. 49:2028-34, 2007.

Jilek C, Krenn M, Sebah D, et al: Prognostic impact of sleep disordered breathing and its treatment in heart failure: an observational study. Eur J Heart Fail. 13:68-75, 2011.

Khayat R, Abraham W, Patt B, et al: Central sleep apnea is a predictor of cardiac readmission in hospitalized patients with systolic heart failure. J Cardiac Fail. 18:534-40, 2012.

Khayat R, Jarjoura D, Porter K, et al: Sleep disordered breathing and post-discharge mortality in patients with acute heart failure. Eur Heart J. 36:1463-69, 2015.

American Academy of Sleep Medicine. International classification of sleep disorders: diagnostic and coding manual. 2nd ed. Westchester, IL, 2005.

Oldenburg O, Lamp B, Faber L, et al: Sleep disordered breathing in patients with symptomatic heart failure: a contemporary study of prevalence in and characteristics of 700 patients. Eur J Heart Fail. 9:251-7, 2007.

Javaheri S: Sleep disorders in systolic heart failure: a prospective study of 100 male patients. The final report. Int J Cardiol. 106:21-8, 2006.

Sin DD, Fitzgerald F, Parker JD, et al: Risk factors for central and obstructive sleep apnea in 450 men and women with congestive heart failure. Am J Respir Crit Care Med. 160:1101-6, 1999.

MacDonald M, Fang J, Pittman SD, et al: The current prevalence of sleep disordered breathing in congestive heart failure patients treated with beta-blockers. J Clin Sleep Med. 4:38-42, 2008.

Chan J, Sanderson J, Chan W, et al: Prevalence of sleep-disordered breathing in diastolic heart failure. Chest. 111:1488-93, 1999.

Herrscher TE, Akre H, Øverland B, et al: High prevalence of sleep apnea in heart failure outpatients: even in patients with preserved systolic function. J Card Fail. 17:420-5, 2011.

Bitter T, Faber L, Hering D, et al: Sleep-disordered breathing in heart failure with normal left ventricular ejection fraction. Eur J Heart Fail. 11:602-8, 2009.

Ward M: Periodic respiration. A short historical note. Ann R Coll Surg Engl. 52:330-4, 1973.

Allen R, Truk JL, Muricy R: The Case Books of John Hunter, FRS. New York, Parthenon 1993.

Cheyne J: A case of apoplexy, in which the fleshy part of the heart was converted into fat. Dublin Hospital Reports and Communications. 2:216-23, 1818.

Stokes W: Observations on some cases of permanently slow pulse. Dublin Quarterly Journal of Medical Sciences 2:73-85, 1846.

Naughton M, Benard D, Tam A, et al: Role of hyperventilation in the pathogenesis of central sleep apneas in patients with congestive heart failure. Am Rev Respir Dis. 148:330-8, 1993.

Hanly P, Zuberi N, Gray R: Pathogenesis of Cheyne-Stokes respiration in patients with congestive heart failure: relationship to arterial PCO2. Chest 104:1079-84, 1993.

Dempsey JA: Crossing the apnoeic threshold: causes and consequences. Exp Physiol 90:13-24, 2005.

Yu J, Zhang JF, Fletcher EC: Stimulation of breathing by activation of pulmonary peripheral afferents in rabbits. J Appl Physiol. 85:1485-92, 1998.

Solin P, Bergin P, Richardson M: Influence of pulmonary capillary wedge pressure on central apnea in heart failure. Circulation. 99:1574-9, 1999.

Lorenzi-Filho G, Azevedo ER, Parker JD, et al: Relationship of carbon dioxide tension in arterial blood to pulmonary wedge pressure in heart failure. Eur Respir J. 19:37-40, 2002.

Javaheri S: A mechanism of central sleep apnea in patients with heart failure. N Engl J Med. 341:949-54, 1999.

Solin P, Roebuck T, Johns DP, et al: Peripheral and central ventilatory responses in central sleep apnea with and without congestive heart failure. Am J Respir Crit Care Med. 162:2194-200, 2000.

Khoo MC, Kronauer RE, Strohl KP, et al: Factors inducing periodic breathing in humans: a general model. J Appl Physiol. 53:644-59, 1982.

Hall MJ, Xie A, Rutherford R, et al: Cycle length of periodic breathing in patients with and without heart failure. Am J Respir Crit Care Med. 154:376-81, 1996.

Javaheri S, Dempsey JA: Central sleep apnea. Compr Physiol. 3:141–63, 2013.

Naughton MT, Benard DC, Liu PP, et al: Effects of nasal CPAP on sympathetic activity in patients with heart failure and central sleep apnea. Am J Respir Crit Care Med. 152:473–9, 1995.

Bitter T, Westerheide N, Prinz C, et al: Cheyne-Stokes respiration and obstructive sleep apnoea are independent risk factors for malignant ventricular arrhythmias requiring appropriate cardioverter-defibrillator therapies in patients with congestive heart failure. Eur Heart J. 32: 61–74, 2011.

Somers VK, White DP, Amin R, et al: Sleep apnea and cardiovascular disease: an American Heart Association/American College of Cardiology Foundation scientific statement from the American Heart Association Council for High Blood Pressure Research Professional Education Committee, Council on Clinical Cardiology, Stroke Council, and Council on Cardiovascular Nursing. Circulation. 118:1080-1111, 2008.

Sleep-related breathing disorders in adults: recommendations for syndrome definition and measurement techniques in clinical research. The report of an American Academy of Sleep Medicine Task Force. Sleep. 22:667-89, 1999.

El Shayeb M, Topfer LA, Stafinski T, et al: Diagnostic accuracy of level 3 portable sleep tests versus level 1 polysomnography for sleep-disordered breathing: a systematic review and meta-analysis. CMAJ. 186:E25-E51, 2014.

Costanzo MR, Khayat R, Ponikowski P et al. Mechanisms and clinical consequences of untreated central sleep apnea in heart failure. J Am Coll Cardiol 2015;65:72-84.

Aurora RN; Chowdhuri S; Ramar K; Bista SR; Casey KR; Lamm CI; Kristo DA; Mallea JM; Rowley JA; Zak RS; Tracy SL. The treatment of central sleep apnea syndromes in adults: practice parameters with an evidence-based literature review and meta-analyses. SLEEP 2012;35(1):17-40.

Khayat RN; Abraham WT. Current treatment approaches and trials in central sleep apnea. Int J Cardiol 2016;206:S22-S27.

Bradley TD, Logan AG, Kimoff RJ et al. Continuous positive airway pressure for central sleep apnea and heart failure. N Engl J Med 2005;353:2025-33

Cowie MR, Wegscheider K, Teschler H. Adaptive Servo-Ventilation for Central Sleep Apnea in Heart Failure. N Engl J Med 2016;374:690-1.

Abraham WT, Jagielski D, Oldenburg O, Augostini R, Krueger S, Kolodziej A, Gutleben KJ, Khayat R, Merliss A, Harsch MR, Holcomb RG, Javaheri S, Ponikowski P on behalf of the remedē® Pilot Study Investigators. Phrenic Nerve Stimulation for the Treatment of Central Sleep Apnea. JCHF 2015;5:360-369.

Costanzo MR, Ponikowski P, Javaheri S, Augostini R, Goldberg L, Holcomb R, Kao A, Khayat RN, Oldenburg O, Stellbrink C, Abraham WT; remedé System Pivotal Trial Study Group. Transvenous neurostimulation for central sleep apnoea: a randomised controlled trial. Lancet. 2016 Sep 3;388(10048):974-82. doi: 10.1016/S0140-6736(16)30961-8.

Shewan L.G., Coats A.J.S., Henein M. Requirements for Ethical Publishing in Biomedical Journals. International Cardiovascular Forum Journal. 2015;2:2.


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