SLEEP APNEA IN CONGESTIVE HEART FAILURE

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Sleep apnea and congestive heart failure (CHF) are both common disorders, occurring in approximately 2% to 4% and 1% of the general middle-aged population, respectively.4, 96 There appears to be considerable overlap between the two disorders. In two studies,51, 64 approximately 40% to 50% of stable symptomatic outpatients with CHF had either obstructive sleep apnea (OSA) or Cheyne-Stokes respiration with central sleep apnea (CSR-CSA). Evidence is also accumulating that sleep-related breathing disorders can contribute to progression of heart failure and affect its prognosis. Several studies, for example, have described higher mortality rates in CHF patients with, than in those without, CSR-CSA.2, 31, 42 Other studies56, 64, 85 have demonstrated that nightly treatment of either type of sleep apnea with continuous positive airway pressure (CPAP) is associated with marked improvements in cardiac function and symptoms of heart failure.

Despite recent advances in the pharmacologic therapy of CHF, its prognosis remains poor. In the largest and longest study to date, although the angiotensin-converting-enzyme inhibitor, enalapril, reduced mortality compared with placebo, after 3.5 years, mortality among the enalapril treated group was still 35%.86 That is a death rate that rivals that of many malignancies.4 If the clinical outcome of CHF is to improve, therefore, novel approaches to its treatment will have to be developed. This article reviews data suggesting that one promising approach to improving the prognosis of CHF may be the diagnosis and specific treatment of sleep-related breathing disorders in those patients.

Section snippets

Pathophysiology

OSA is a condition in which repetitive upper airway obstructions occur during sleep, giving rise to recurrent apneas. Three key pathological effects of obstructive apneas could have detrimental effects on the cardiovascular system—generation of large negative intrathoracic pressure swings against the occluded upper airway, hypoxemia, and arousals from sleep.

In healthy humans, the onset of nonrapid eye movement sleep (NREM) is associated with reductions in metabolic rate, sympathetic nervous

Pathophysiology

CSR-CSA is a breathing disorder characterized by recurrent episodes of central apneas, alternating with hyperpneas, during which there is a crescendo–decrescendo pattern of tidal volume.45 Unlike OSA, CSR-CSA likely is a consequence, rather than a cause, of CHF. The key pathophysiologic feature of CSR-CSA is a tendency to hyperventilate, causing arterial partial pressure of carbon dioxide (Pa co2) to fall below an apneic threshold, triggering recurrent central apneas (Table 2). Patients with

CONCLUSION

As this review indicates, sleep-related breathing disorders are commonly associated with CHF and may complicate its course. Unfortunately, breathing disorders are almost certainly being underdiagnosed in the CHF population. Because there is growing evidence that the specific diagnosis and treatment of those disorders can have beneficial short- and medium-term effects on cardiac function, more attention needs to be drawn toward their management in the setting of CHF. Effective treatment of OSA

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    Address reprint requests to T. Douglas Bradley, MD, FRCPC, Sleep Research Laboratory, Room 1220, Rehabilitation Institute of Toronto, 550 University Avenue, Toronto, Ontario, M5G 2A2, Canada

    This work was supported by operating grants MT-11607 and MA-12422 to T. D. Bradley from the Medical Research Council of Canada. T. D. Bradley is a Career Scientist of the Ontario Ministry of Health. M. T. Naughton is a recipient of an Australian Lung Foundation Career Development Award and a Viertal Clinical Investigatorship.

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    Copyright © 1998 W. B. Saunders Company. Published by Elsevier Inc. All rights reserved.