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Canadian Journal of Cardiology

Overnight Effects of Obstructive Sleep Apnea and Its Treatment on Stroke Volume in Patients With Heart Failure

  • Takatoshi Kasai
    Affiliations
    Sleep Research Laboratory of the University Health Network Toronto Rehabilitation Institute, Toronto, Ontario, Canada

    Centre for Sleep Medicine and Circadian Biology, University of Toronto, Toronto, Ontario, Canada
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  • Dai Yumino
    Affiliations
    Sleep Research Laboratory of the University Health Network Toronto Rehabilitation Institute, Toronto, Ontario, Canada

    Centre for Sleep Medicine and Circadian Biology, University of Toronto, Toronto, Ontario, Canada
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  • Stefania Redolfi
    Affiliations
    Sleep Research Laboratory of the University Health Network Toronto Rehabilitation Institute, Toronto, Ontario, Canada

    Centre for Sleep Medicine and Circadian Biology, University of Toronto, Toronto, Ontario, Canada
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  • Mao-chang Su
    Affiliations
    Sleep Research Laboratory of the University Health Network Toronto Rehabilitation Institute, Toronto, Ontario, Canada

    Centre for Sleep Medicine and Circadian Biology, University of Toronto, Toronto, Ontario, Canada
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  • Pimon Ruttanaumpawan
    Affiliations
    Sleep Research Laboratory of the University Health Network Toronto Rehabilitation Institute, Toronto, Ontario, Canada

    Centre for Sleep Medicine and Circadian Biology, University of Toronto, Toronto, Ontario, Canada
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  • Susanna Mak
    Affiliations
    Mount Sinai Hospital, Toronto, Ontario, Canada
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  • Gary E. Newton
    Affiliations
    Mount Sinai Hospital, Toronto, Ontario, Canada
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  • John S. Floras
    Affiliations
    Mount Sinai Hospital, Toronto, Ontario, Canada

    Departments of Medicine of the University Health Network Toronto General Hospital, Toronto, Ontario, Canada
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  • T. Douglas Bradley
    Correspondence
    Corresponding author: Dr T. Douglas Bradley, University Health Network Toronto General Hospital, 9N-943, 200 Elizabeth St, Toronto, Ontario M5G 2C4, Canada. Tel.: +1-416-340-4719; fax: +1-416-340-4197.
    Affiliations
    Sleep Research Laboratory of the University Health Network Toronto Rehabilitation Institute, Toronto, Ontario, Canada

    Centre for Sleep Medicine and Circadian Biology, University of Toronto, Toronto, Ontario, Canada

    Departments of Medicine of the University Health Network Toronto General Hospital, Toronto, Ontario, Canada
    Search for articles by this author
Published:January 14, 2015DOI:https://doi.org/10.1016/j.cjca.2015.01.001

      Abstract

      Background

      We previously showed in heart failure (HF) patients that obstructive respiratory events during sleep and generation of negative intrathoracic pressure during Mueller manoeuvres, mimicking obstructive apneas, acutely reduced stroke volume (SV). We also showed that treating obstructive sleep apnea (OSA) with continuous positive airway pressure (CPAP) increased left ventricular ejection fraction over a 1-month period. We therefore hypothesized that, in HF patients, those with OSA would have greater overnight declines in SV and cardiac output (CO) than in those without sleep apnea, and that therapy of OSA using CPAP would prevent these declines.

      Methods

      We examined overnight percent change in SV and CO in 32 HF patients with and 28 without OSA using digital photoplethysmography. Among patients with OSA, we also examined changes in SV and CO during a CPAP titration study.

      Results

      During the baseline polysomnogram SV and CO decreased more overnight in those with OSA than in those without sleep apnea (−12.6 ± 7.7% vs −3.2 ± 6.8%; P < 0.001 and −16.2 ± 9.9% vs −3.7 ± 8.3%; P < 0.001, respectively). Overnight changes in SV and CO correlated inversely with total apnea-hypopnea index (r = −0.551; P < 0.001 and r = −0.522; P < 0.001, respectively). In 21 patients with OSA, CPAP reduced the total apnea-hypopnea index from 37.7 ± 21.4 to 15.0 ± 16.0 (P < 0.001) in association with attenuation of the overnight reduction of SV (from −14.0 ± 7.9% to −3.4 ± 9.8%; P = 0.002) and CO (from −17.2 ± 9.0% to −9.7 ± 10.7%; P = 0.042).

      Conclusions

      In patients with HF, coexisting OSA causes overnight declines in SV and CO that are prevented through reversal of OSA by CPAP.

      Résumé

      Introduction

      Nous avons précédemment montré chez les patients atteints d’insuffisance cardiaque (IC) que les événements respiratoires obstructifs survenant durant le sommeil et que la génération de pression intrathoracique négative durant la manœuvre de Mueller, qui imite les apnées obstructives, réduisaient à court terme le volume d'éjection (VE). Nous avons également montré que le traitement de l’apnée obstructive du sommeil (AOS) à l’aide de la ventilation spontanée en pression positive expiratoire continue (CPAP : continuous positive airway pressure) augmentait la fraction d’éjection ventriculaire gauche sur une période de 1 mois. Par conséquent, nous avons posé l’hypothèse que les patients atteints d’IC qui ont des AOS pourraient avoir des baisses plus importantes du VE et du débit cardiaque (DC) au cours de la nuit que ceux n’ayant pas d’apnée du sommeil et que le traitement de l’AOS par CPAP pourrait empêcher ces baisses.

      Méthodes

      Nous avons examiné la variation en pourcentage du VE et du DC au cours de la nuit chez 32 patients souffrant d’IC et 28 patients n’ayant pas d’AOS à l’aide de la photopléthysmographie numérique. Parmi les patients ayant des AOS, nous avons également examiné les changements du VE et du DC au cours d’une étude de titrage de la CPAP.

      Résultats

      Le polysomnogramme initial a montré que le VE et le DC diminuaient plus durant la nuit chez ceux ayant des AOS que chez ceux n’ayant pas d’apnée du sommeil (−12,6 ± 7,7 % vs −3,2 ± 6,8 %; P < 0,001 et −16,2 ± 9,9 % vs −3,7 ± 8,3 %; P < 0,001, respectivement). Les variations du VE et du DC au cours de la nuit ont corrélé de manière inverse avec l’index d’apnées-hypopnées totales (r = −0,551; P < 0,001 et r = −0,522; P < 0,001, respectivement). Chez 21 patients ayant des AOS, la CPAP a réduit l’index d’apnées-hypopnées totales de 37,7 ± 21,4 à 15,0 ± 16,0 (P < 0,001) tout en modérant la réduction du VE (de −14,0 ± 7,9 % à −3,4 ± 9,8 %; P = 0,002) et du DC (de −17,2 ± 9,0 % à −9,7 ± 10,7 %; P = 0,042) au cours de la nuit.

      Conclusions

      Chez les patients atteints d’IC, la coexistence d’AOS cause des baisses du VE et du DC au cours de la nuit qui sont évitables en diminuant le nombre d’AOS à l’aide de la CPAP.
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      References

        • Yumino D.
        • Wang H.
        • Floras J.S.
        • et al.
        Prevalence and physiological predictors of sleep apnea in patients with heart failure and systolic dysfunction.
        J Card Fail. 2009; 15: 279-285
        • Wang H.
        • Parker J.D.
        • Newton G.E.
        • et al.
        Influence of obstructive sleep apnea on mortality in patients with heart failure.
        J Am Coll Cardiol. 2007; 49: 1625-1631
        • Kasai T.
        • Bradley T.D.
        Obstructive sleep apnea and heart failure: pathophysiologic and therapeutic implications.
        J Am Coll Cardiol. 2011; 57: 119-127
        • Yumino D.
        • Kasai T.
        • Kimmerly D.
        • et al.
        Differing effects of obstructive and central sleep apneas on stroke volume in patients with heart failure.
        Am J Respir Crit Care Med. 2013; 187: 433-438
        • Tkacova R.
        • Rankin F.
        • Fitzgerald F.S.
        • Floras J.S.
        • Bradley T.D.
        Effects of continuous positive airway pressure on obstructive sleep apnea and left ventricular afterload in patients with heart failure.
        Circulation. 1998; 98: 2269-2275
      1. EEG arousals: scoring rules and examples: a preliminary report from the Sleep Disorders Atlas Task Force of the American Sleep Disorders Association.
        Sleep. 1992; 15: 173-184
        • Rechtschaffen A.
        • Kales A.
        A Manual of Standardized Terminology, Techniques and Scoring for Sleep Stages of Human Subjects.
        UCLA Brain Information Service/Brain Research Institute, Los Angeles1968
        • Pitt M.S.
        • Marshall P.
        • Diesch J.P.
        • Hainsworth R.
        Cardiac output by Portapres.
        Clin Sci (Lond). 2004; 106: 407-412
        • Jellema W.T.
        • Wesseling K.H.
        • Groeneveld A.B.
        • et al.
        Continuous cardiac output in septic shock by simulating a model of the aortic input impedance: a comparison with bolus injection thermodilution.
        Anesthesiology. 1999; 90: 1317-1328
        • Shahar E.
        • Whitney C.W.
        • Redline S.
        • et al.
        Sleep-disordered breathing and cardiovascular disease: cross-sectional results of the Sleep Heart Health Study.
        Am J Respir Crit Care Med. 2001; 163: 19-25
        • Gottlieb D.J.
        • Yenokyan G.
        • Newman A.B.
        • et al.
        Prospective study of obstructive sleep apnea and incident coronary heart disease and heart failure: the Sleep Heart Health study.
        Circulation. 2010; 122: 352-360
        • Peters J.
        • Fraser C.
        • Stuart R.S.
        • Baumgartner W.
        • Robotham J.L.
        Negative intrathoracic pressure decreases independently left ventricular filling and emptying.
        Am J Physiol. 1989; 257: H120-H131
        • Bradley T.D.
        • Hall M.J.
        • Ando S.
        • Floras J.S.
        Hemodynamic effects of simulated obstructive apneas in humans with and without heart failure.
        Chest. 2001; 119: 1827-1835
        • Ross Jr., J.
        Afterload mismatch and preload reserve: a conceptual framework for the analysis of ventricular function.
        Prog Cardiovasc Dis. 1976; 18: 255-264
        • Haruki N.
        • Takeuchi M.
        • Nakai H.
        • et al.
        Overnight sleeping induced daily repetitive left ventricular systolic and diastolic dysfunction in obstructive sleep apnoea: quantitative assessment using tissue Doppler imaging.
        Eur J Echocardiogr. 2009; 10: 769-775
        • Fletcher E.C.
        • Proctor M.
        • Yu J.
        • et al.
        Pulmonary edema develops after recurrent obstructive apneas.
        Am J Respir Crit Care Med. 1999; 160: 1688-1696
        • Chan H.S.
        • Chiu H.F.
        • Tse L.K.
        • Woo K.S.
        Obstructive sleep apnea presenting with nocturnal angina, heart failure, and near-miss sudden death.
        Chest. 1991; 99: 1023-1025
        • Yoshinaga K.
        • Burwash I.G.
        • Leech J.A.
        • et al.
        The effects of continuous positive airway pressure on myocardial energetics in patients with heart failure and obstructive sleep apnea.
        J Am Coll Cardiol. 2007; 49: 450-458
        • Mansfield D.R.
        • Gollogly N.C.
        • Kaye D.M.
        • et al.
        Controlled trial of continuous positive airway pressure in obstructive sleep apnea and heart failure.
        Am J Respir Crit Care Med. 2004; 169: 361-366
        • Usui K.
        • Bradley T.D.
        • Spaak J.
        • et al.
        Inhibition of awake sympathetic nerve activity of heart failure patients with obstructive sleep apnea by nocturnal continuous positive airway pressure.
        J Am Coll Cardiol. 2005; 45: 2008-2011
        • Kaneko Y.
        • Floras J.S.
        • Usui K.
        • et al.
        Cardiovascular effects of continuous positive airway pressure in patients with heart failure and obstructive sleep apnea.
        N Engl J Med. 2003; 348: 1233-1241
        • Duran-Cantolla J.
        • Aizpuru F.
        • Montserrat J.M.
        • et al.
        Continuous positive airway pressure as treatment for systemic hypertension in people with obstructive sleep apnoea: randomised controlled trial.
        BMJ. 2010; 341: c5991
        • Campos-Rodriguez F.
        • Grilo-Reina A.
        • Perez-Ronchel J.
        • et al.
        Effect of continuous positive airway pressure on ambulatory BP in patients with sleep apnea and hypertension: a placebo-controlled trial.
        Chest. 2006; 129: 1459-1467
        • Drager L.F.
        • Ueno L.M.
        • Lessa P.S.
        • et al.
        Sleep-related changes in hemodynamic and autonomic regulation in human hypertension.
        J Hypertens. 2009; 27: 1655-1663
        • Khatri I.M.
        • Freis E.D.
        Hemodynamic changes during sleep.
        J Appl Physiol. 1967; 22: 867-873
        • Kasai T.
        • Narui K.
        • Dohi T.
        • et al.
        Prognosis of patients with heart failure and obstructive sleep apnea treated with continuous positive airway pressure.
        Chest. 2008; 133: 690-696