Research Priorities for Patients with Heart Failure and Central Sleep Apnea. An Official American Thoracic Society Research Statement

Abstract

Background: Central sleep apnea (CSA) is common among patients with heart failure and has been strongly linked to adverse outcomes. However, progress toward improving outcomes for such patients has been limited. The purpose of this official statement from the American Thoracic Society is to identify key areas to prioritize for future research regarding CSA in heart failure. Methods: An international multidisciplinary group with expertise in sleep medicine, pulmonary medicine, heart failure, clinical research, and health outcomes was convened. The group met at the American Thoracic Society 2019 International Conference to determine research priority areas. A statement summarizing the findings of the group was subsequently authored using input from all members. Results : The workgroup identified 11 specific research priorities in several key areas: 1 ) control of breathing and pathophysiology leading to CSA, 2 ) variability across individuals and over time, 3 ) techniques to examine CSA pathogenesis and outcomes, 4 ) impact of device and pharmacological treatment, and 5 ) implementing CSA treatment for all individuals Conclusions: Advancing care for patients with CSA in the context of heart failure will require progress in the arenas of translational (basic through clinical), epidemiological, and patient-centered outcome research. Given the increasing prevalence of heart failure and its associated substantial burden to individuals, society, and the healthcare system, targeted research to improve knowledge of CSA pathogenesis and treatment is a priority.

Endotyping Sleep Apnea One Breath at a Time: An Automated Approach for Separating Obstructive from Central Sleep-disordered Breathing

“…Developing validated tools to better characterize CSA, especially in patients with heart failure, is one of the research priorities of the American Thoracic Society (ATS). 2 A recent international taskforce report advised that the principal step in the approach to treating CSA is establishing the presence of an underlying CSA pathophysiology in an individual; establishing the presence of CSA is fundamental to its treatment. 6 As such, the primary step toward effective treatment of CSA is establishing presence of CSA, or absence thereof, which the proposed P obs achieves reliably within a matter of minutes from a routine clinical NPSG.…”

“…Effective treatment of sleep apnea requires characterization of the disorder by establishing the presence, type, and severity of the sleep apnea. 1,2 Currently, the presence of sleep apnea is documented through the observation of apneas and hypopneas on routine nocturnal polysomnography (NPSG). Severity is assessed by the frequency of apneas and hypopneas, constituting the apnea-hypopnea index (AHI), as well as the physiological consequences associated with respiratory events (e.g., oxygen desaturation).…”

Home sleep apnea testing for chronic heart failure: time to break the Cheyne?

“…A recent American Thoracic Society research statement for patients with CHF and SDB highlighted the importance of addressing health disparities, which may be due to sociodemographic factors and inequitable health care access. 21 In this regard, this study advances our understanding of how HSAT could be used to improve access to SDB diagnosis in this complex patient population in an era of constrained health care resources and high burden of unmet SDB care. This issue is particularly poignant during the global COVID-19 pandemic, as access to resources is even further limited and the backlog of patients requiring polysomnography continues to grow.…”

“…15,16 CSA and Cheyne-Stokes respiration are particularly common among patients with heart failure and portend a poor prognosis in this population 15,[17][18][19][20] due to direct adverse effects such as sleep disruption, oxygen desaturation, and sympathetic hyperactivity. 21 Identification of patients with SDB among patients with CHF also has therapeutic implications; positive airway pressure (PAP) therapy in patients with CHF and concomitant SDB has demonstrated reduction in the apnea-hypopnea index and may improve quality of life, cardiac function, and heart-transplant-free survival. [22][23][24] Consistent with guideline recommendations, diagnosis of SDB in individuals with CHF is typically made using polysomnography; however, the high cost and limited availability of laboratory-based testing may preclude timely diagnosis in many patients.…”

Novel Drug Targets for Central Apneas in Heart Failure: On the Road

“…In the official American Thoracic Research Statement, Orr and colleagues highlight the research priorities in the field of central apneas (CA) in heart failure (HF) ( 1 ). The authors underscore that the pathophysiological mechanisms of CA have only been partially addressed and that a deeper understanding of the neurobiology of respiration both during sleep and wakefulness in health and disease is needed.…”