Mechanisms and Clinical Consequences of Untreated Central Sleep Apnea in Heart Failure

Abstract

Central sleep apnea (CSA) is a highly prevalent, though often unrecognized, comorbidity in patients with heart failure (HF). Data from HF population studies suggest that it may present in 30% to 50% of HF patients. CSA is recognized as an important contributor to the progression of HF and to HF-related morbidity and mortality. Over the past 2 decades, an expanding body of research has begun to shed light on the pathophysiologic mechanisms of CSA. Armed with this growing knowledge base, the sleep, respiratory, and cardiovascular research communities have been working to identify ways to treat CSA in HF with the ultimate goal of improving patient quality of life and clinical outcomes. In this paper, we examine the current state of knowledge about the mechanisms of CSA in HF and review emerging therapies for this disorder.

Impact of sacubitril–valsartan combination in patients with chronic heart failure and sleep apnoea syndrome: the ENTRESTO‐SAS study design

“…Patients with CSA have increased chemoresponsiveness that promotes hyperventilation and hypocapnia 10, 12, 13. A factor contributing to hyperventilation is pulmonary vagal irritant receptor stimulation by pulmonary venous congestion.…”

“…However, both OSA and CSA interfere with neurohumoral systems and thus may worsen CHF, for example, by increasing sympathetic and renin–angiotensin–aldosterone activity, both targets of CHF therapy. To date, there is a consensus to consider that the first step in the management plan for patients with SDB and CHF should be optimization of CHF treatment 12, 13, 14. Indeed, previous studies have reported that optimization of pharmacological therapy15, 16, 17, 18, 19, 20 and the use of non‐pharmacological methods21, 22 to treat CHF can lead to an improvement in SDB.…”

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

“…Current treatment options for CSA include medications, oxygen, positive airway pressure and neurostimulation of the phrenic nerve. [35] While a number of medications have been studied in small trials with acetazolamide and theophylline demonstrating some improvement in randomized trials, none are currently recommended due to lack of larger and longer term trials. [36] Oxygen has been used and improves symptoms in some studies, but no long term randomized trials have been completed.…”

Cardiac adrenergic neuronal activity, sleep apnea, and potential therapeutic role of nocturnal ventilatory assistance in patients with heart failure

“…Patients with congestive heart failure (CHF) and systolic dysfunction have a high prevalence of sleep disorder breathing. [1][2][3][4][5][6][7] This is mainly in the form of Cheyne Stokes breathing and central sleep apnea (CSA). CSA is characterized by a dysregulated and insufficient drive for breathing during sleep, resulting in repetitive episodes of insufficient ventilation and inadequate gas exchange.…”

“…1,3,4,11 In addition, several parameters of cardiac performance as well as neuroendocrine abnormalities associated with CHF have also shown an improvement with the use of these ventilatory devices. 2,4 This has resulted in an increasing use of these ventilator systems in patients with CHF and CSA.…”