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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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slide1

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

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?

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

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
slide14

Left Ventricular Intracavitary Pressure = 100 mmHg

Pericardial Pressure = 0 mmHg

LV transmural pressure = 100 mmHg

slide15

Left Ventricular Intracavitary Pressure = 100 mmHg

Pericardial Pressure = 20 mmHg

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

slide16

Left Ventricular Intracavitary Pressure = 100 mmHg

Pericardial Pressure = +20 mmHg

LV transmural pressure = 100 - 20 = 80 mmHg

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

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.

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

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

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.

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