A New Device for Central Sleep Apnea in HF Patients?

Summary and Comment |
September 1, 2015

A New Device for Central Sleep Apnea in HF Patients?

  1. Frederick A. Masoudi, MD, MSPH, FACC, FAHA

Adaptive servo-ventilation in these heart failure patients was associated with a higher death rate.

  1. Frederick A. Masoudi, MD, MSPH, FACC, FAHA

Sleep-disordered breathing (central or obstructive) is common in patients with heart failure (HF) and is associated with adverse consequences. A study of ventilatory support with continuous positive airway pressure (CPAP) in patients with central apnea and HF was inconclusive but had suggestive post-hoc subgroup findings of possible benefits when the apnea-hypopnea index (AHI) was greatly reduced. In a manufacturer-sponsored, randomized, controlled trial, investigators have now assessed servo-controlled inspiratory pressure combined with expiratory positive pressure support.

The 1325 participants had chronic symptomatic systolic HF, predominantly class III symptoms, an AHI of ≥15 events per hour, and ≥10 central events per hour (mean age, 69; mean left ventricular ejection fraction [LVEF], 32%). All patients received guideline-based HF therapy. Intervention recipients were asked to use the device ≥5 hours nightly.

Treatment was effective at reducing AHI (mean: baseline, 31.2 events/hour; 12 months, 6.6 events/hour). However, at a mean follow-up of 31 months, the groups showed no differences in time to the primary composite endpoint of death, lifesaving cardiovascular intervention, or unplanned HF hospitalization (intervention, 54.1%; control, 50.8%). Deaths from any cause were significantly more common with the intervention (34.8% vs. 29.3%), reflecting its higher rate of cardiovascular deaths. In both groups, 6-minute walk test distances declined, but to a greater extent with the intervention.

Comment

Servo-ventilation for central sleep apnea in patients with systolic HF does not improve outcomes. The additional, although secondary, finding of higher death rates with the treatment is reasonable evidence that it should be avoided in patients who fit this study's enrollment criteria; still, we await results from studies of other adaptive servo-ventilation devices (e.g., ADVENT-HF). In assessing patients with HF and sleep-disordered breathing, clinicians should clearly distinguish those with a predominantly central mechanism.

More robust studies of therapy for obstructive sleep apnea in HF would also be welcome. American College of Cardiology/American Heart Association guidelines have a class IIa recommendation for CPAP to increase LVEF and functional status, but it is based on relatively limited data.

Editor Disclosures at Time of Publication

  • Disclosures for Frederick A. Masoudi, MD, MSPH, FACC, FAHA at time of publication Grant / Research support National Heart, Lung, and Blood Institute; American College of Cardiology; Patient-Centered Outcomes Research Institute; John. A. Hartford Foundation Editorial boards Circulation: Cardiovascular Quality and Outcomes Leadership positions in professional societies American College of Cardiology (Senior Medical Officer, National Cardiovascular Data Registries; Member, Board of Trustees); American Heart Association (Chair, Council on Quality of Care and Outcomes Research)

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