Sleep Disordered Breathing and Cardiovascular Disease
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Sleep Disordered Breathing and Cardiovascular Disease Sleep Disordered Breathing in Patients with Congestive Heart Failure:CSR and OSA. David P. White, MD, Chief Medical Officer, Philips Respironics. Professor of Medicine Harvard Medical School. September 10, 2009.

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David p white md chief medical officer philips respironics

Sleep Disordered Breathing and Cardiovascular DiseaseSleep Disordered Breathing in Patients with Congestive Heart Failure:CSR and OSA

David P. White, MD, Chief Medical Officer, Philips Respironics

Professor of Medicine Harvard Medical School

September 10, 2009


Sleep and cardiovascular disease

Sleep and Cardiovascular Disease


Baseline

Baseline


Prevalence of sdb in heart failure

Prevalence of SDB in Heart Failure

n=81

n=450

n=20

Percent

n=38

Chan et al, 1997, Javaheri et al, 1998, Sin et al, 1999, Abraham et al, 2002


What are the consequences of cheyne stokes respiration

What are the Consequences of Cheyne-Stokes Respiration?

Why do we specifically want to treat this disorder?


Baseline1

Baseline


Consequences of sleep disorders breathing in congestive heart failure

Consequences of Sleep Disorders Breathing inCongestive Heart Failure

Sleep fragmentation little daytime sleepiness.

Hypoxia plus arousals recurrent sympathetic nervous system activation.

Attributable mortality (?).

Progression of heart failure (?).


Cheyne stokes respiration recurrent sympathetic nervous system activation

Cheyne-Stokes RespirationRecurrent Sympathetic Nervous System Activation

nmol//L

Nmol/mmol Creatinine

NOREPINEPHRINE

EPINEPHRINE

NOREPINEPHRINE

EPINEPHRINE

N

PLASMA

URINE

Naughtonet al. Am J RespirCrit Care Med, 1995


Sin et al circulation 2000

Sin et alCirculation, 2000


Cheyne stokes respiration

Cheyne-Stokes Respiration

Will therapy specifically aimed at Cheyne-Stokes Respiration improve both quality of life and survival in patients with this disorder?


Cheyne stokes respiration1

Cheyne-Stokes Respiration

What can be done to correct this?

First always maximize cardiac medications.

  • Theophylline (respiratory stimulant)

  • Acetazolamide

  • Oxygen administration

  • CO2 inhalation

  • CPAP [continuous positive airway pressure]


How does cpap work in chf with cheyne stokes ventilation

How does CPAP work in CHF with Cheyne-Stokes Ventilation

  • OSA eliminated if present Alleviated exaggerated negative intrathoracic pressure.

  • Decreased transmural pressure

    • Increased cardiac output.

    • Reduced LV afterload (wall tension).

  • Decreased venous return Decreased preload Decreased venous congestion.Jellinek JAP 2000, 88:926-932


David p white md chief medical officer philips respironics

Left Ventricular Intracavitary Pressure = 100 mmHg

Pericardial Pressure = 0 mmHg

LV transmural pressure = 100 mmHg


David p white md chief medical officer philips respironics

Left Ventricular Intracavitary Pressure = 100 mmHg

Pericardial Pressure = 20 mmHg

LV transmural pressure = 100 – (-20) = 120 mmHg


David p white md chief medical officer philips respironics

Left Ventricular Intracavitary Pressure = 100 mmHg

Pericardial Pressure = +20 mmHg

LV transmural pressure = 100 - 20 = 80 mmHg


Naughton et al am j respir crit care med 1995

Naughton et al. Am J Respir Crit Care Med, 1995

LVEF

(%)

BL

1M

3M


Naughton et al ajrccm 1995

Naughton et al. AJRCCM 1995

Nmol/mmol Creatinine

nmol//L

CONTROL

NCPAP

CONTROL

NCPAP

CONTROL

NCPAP

CONTROL

NCPAP

NOREPINEPHRINE

EPINEPHRINE

NOREPINEPHRINE

EPINEPHRINE

URINE

PLASMA


Naughton et al ajrccm 1994

Naughton et al. AJRCCM, 1994

Baseline

NCPAP

EEG

EMG

RIBCAGE

ABDOMEN

VT (L)

1.0

100

SaO2 (%)

75

1 minute

V1 = 8.9 L/min

V1 = 4.8 L/min


Sin et al circulation 2000 102 61 66

Sin et al - Circulation 2000, 102:61-66


David p white md chief medical officer philips respironics

2005


Bradley et al new engl j med 2005

Bradley et al, New Engl J Med - 2005


Bradley et al new engl j med 20051

Bradley et al, New Engl J Med - 2005


Circulation 2007

Circulation 2007


Arzt et al circulation 2007

Arzt et al, Circulation 2007

Figure 1.

Flow diagram indicating progress of eligible subjects through the study.Bold boxes represent subjects who were included in the analysis of the present report of the CANPAP trial.PSG indicates polysomnography.


Arzt et al circulation 20071

Arzt et al, Circulation 2007


Cpap 7 cm h 2 0

CPAP - 7 cm H20


Computer assisted positive airway pressure

Computer-Assisted Positive Airway Pressure


Canpap 2 pi doug bradley md

CANPAP 2PI: Doug Bradley, MD

  • 880 patients with CHF and either OSA, CSR, or both.

  • >25 sites (Canada, US, Australia, Eur)

  • Randomized to:

    - Maximal management of CHF

    - Maximal management of CHF+ Auto SV 3.


Canpap 2 pi doug bradley md1

CANPAP 2PI: Doug Bradley, MD

  • Outcomes:

    - Transplant free survival

    - Cardiac function

    - Exercise capacity

    - QOL

    - RDI


Prevalence of sdb in heart failure1

Prevalence of SDB in Heart Failure

n=81

n=450

n=20

Percent

n=38

Chan et al, 1997, Javaheri et al, 1998, Sin et al, 1999, Abraham et al, 2002


Osa in patients with chf

OSA in Patients with CHF

One reasonable study comparing outcomes (survival) in patients with CHF who have with those who do not have OSA.

There are 2 studies accessing the effect of CPAP on cardiac function in patients with OSA and CHF.

One study comparing survival in patients with OSA and CHF either treated or not treated with CPAP.


Jacc 2007

JACC 2007

Influence of Obstructive Sleep Apnea on Mortality in Patients With Heart Failure

Hanqiao Wang, MD, John D. Parker, MD, FACC, Gary E. Newton, MD, FACC, John S. Floras, MD, DPhil, FACC,, Susanna Mak, MD, PhD, Kuo-Liang Chiu, MD, MSc, Pimon Ruttanaumpawan, MD, George Tomlinson, PhD and T. Douglas Bradley, MD

Toronto, Ontario, Canada


Wang et al jacc 2007

Wang et al, JACC 2007


Wang et al jacc 20071

Wang et al, JACC 2007


David p white md chief medical officer philips respironics

2003


Kaneko et al nejm 2003

Kaneko et al, NEJM 2003


Kaneko et al nejm 20031

Kaneko et al, NEJM 2003


Am j resp crit care med 2004

Am J Resp Crit Care Med 2004


Mansfield et al ajrccm 2004

Mansfield et al, AJRCCM 2004


Mansfield et al ajrccm 20041

Mansfield et al, AJRCCM 2004

P=NS

P<0.001

LVEF (%)

Baseline

3 Months

Baseline

3 Months

Control Group

CPAP Group

P=0.04


Chest 2008

CHEST 2008


Kasai et al chest 2008

Kasai et al, CHEST 2008


Kasai et al chest 20081

Kasai et al, CHEST 2008


Canpap 2 pi doug bradley md2

CANPAP 2PI: Doug Bradley, MD

  • 880 patients with CHF and either OSA, CSR, or both.

  • >25 sites (Canada, US, Australia, Eur)

  • Randomized to:

    - Maximal management of CHF

    - Maximal management of CHF+ Auto SV 3.


Sleep and cardiovascular disease1

Sleep and Cardiovascular Disease


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