Chest
Volume 113, Issue 1, January 1998, Pages 104-110
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Clinical Investigations
Effects of Cardiac Dysfunction on Non-Hypercapnic Central Sleep Apnea

https://doi.org/10.1378/chest.113.1.104Get rights and content

Introduction

Non-hypercapnic central sleep apnea (CSA) commonly occurs during nonrapid eye movement (non-REM) sleep in adults with congestive heart failure (CHF) and in some subjects without signs or symptoms of CHF. Hyperventilation, reduced lung volume, and circulatory delay are known to contribute to CSA, but to differing degrees depending on presence or absence of CHF.

Aim

To determine whether the pattern of ventilation during sleep could be used to determine the presence of CHF.

Methods

Full polysomnographs demonstrating CSA were examined in 10 consecutive subjects with CHF and in 10 without CHF. Ventilatory, apnea, and cycle lengths, and circulation time (from the onset of ventilatory effort to the nadir of oximeter trace) were measured from cyclic apneas during non-REM sleep.

Results

The non-CHF group had a greater left ventricular ejection fraction (LVEF) (59.7±1.9% vs 19.2±2.2%). Circulation time (11.8±0.5 s vs 24.9±1.7 s; p<0.001) and cycle length (35.1±2.8 s vs 69.5±4.5 s; p<0.001) were significantly greater in the CHF group compared with the non-CHF group, but not apnea length (21.3±1.8 s vs 26.8±2.0 s; p=0.06). Ventilatory length to apnea length ratio (VL:AL) was uniformly >1.0 in the CHF group (mean, 1.65; range, 1.02 to 2.33), and in the non-CHF group <1.0 (mean, 0.66; range, 0.54 to 0.89). LVEF correlated negatively with both circulation time (r=–0.86; p<0.001) and cycle length (r=–0.79; p<0.001).

Conclusion

The VL:AL ratio >1.0, as well as both circulation time >15 s and cycle length >45 s, can be used to recognize the presence of CHF in subjects with CSA.

Section snippets

Subjects

Subjects aged 18 to 75 years were selected on the basis of (1) at least two of following clinical features: snoring, witnessed apnea, excessive daytime sleepiness, restless sleep, or nocturnal dyspnea; (2) CSA during non-REM sleep (>10 apneas per hour); and (3) mean overnight transcutaneous Pco2 ≤45 mm Hg.

Consecutive subjects with and without a history of CHF were recruited. A history of CHF constituted ≥6 months of dyspnea, a documented hospital admission for CHF associated with radiologic

Characteristics of Subjects

Twenty male subjects were studied, 10 in each group. The non-CHF group was slightly younger (50.3±2.8 years vs 57.8±2.1 years; p=0.046) and had a greater mean body mass index (30.6±1.1 kg/m2 vs 25.6±0.8 kg/m2; p=0.002) than the CHF group (Table 1). Arterial blood gases awake were in the normal range and were comparable except for the pH which was statistically higher in the CHF group (7.41 ±0.01 vs 7.44±0.01; p<0.01). Spirometry was measured in all but one patient from each group and was

Discussion

The major finding in this study of subjects with non-hypercapnic CSA was that stable CHF could be predicted on polysomnography by means of either a VL:AL ratio >1.0, or prolonged circulation time >15 s with CL >45 s, but not by differences in AL. Moreover, LVEF correlated negatively with circulation time and CL.

In clinical practice, CHF is a major health problem in terms of mortality and morbidity.12 One cardinal feature of CHF is nocturnal dyspnea, which may precipitate referral to a sleep

Acknowledgments

We express our gratitude to Dr. Michael Kelly for the measurement and analysis of left ventricular ejection fractions, to Dr. Malcolm Wilkinson for discussions regarding theoretical measures of respiratory loop gain, to the Department of Cardiology, and to the staff of the Sleep Disorders Centre at the Alfred Hospital for technical support.

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