Sleep apnea in heart failure S. Javaheri, M.D Professor Emeritus of Medicine University of Cincinnati, College of Medicine Medical Director Sleepcare Diagnostics

Sleep apnea in heart failure

S. Javaheri , M.DProfessor Emeritus of Medicine

University of Cincinnati, College of MedicineMedical Director Sleepcare Diagnostics

Cincinnati, Ohio

Breathe Conference, Kings IslandOctober 21st, 2011

[email protected]

Prevalence ofHeart Failure in U.S.

• 2% of population (6 million)• 6–10% of population >65 y old

• Leading cause of hospitalization in people > 65 y

The crystal ball

Poor survival in heart failure in the era of beta blockers

“Despite our many successes in the treatment of heart failure, our current drug regimens probably prolong survival only about 9 to 18 months relative to where we were in 1985”

GS Francis, JACC, 2006Current estimates of 5 y survival: 30 to 35%

Sleep apnea and heart failure

Identification and effective treatment of co-morbidities which contribute to the

progression of heart failure is of utmost importance.

Sleep Medicine Physician Board Review

OSA in heart failure occurs in subjects with compromised airway


1 00 1 40 1 00

1 00 1 40 1 00

Pp l Pp l Pp l

0 .0 0 .0 -4 0

1 0 0 - ( 0 .0 ) = 1 0 0 1 4 0 - ( 0 .0 ) = 1 4 0 1 0 0 - (- 4 0 ) = 1 4 0

N orm al H ype rte ns ion U A O

PrLVT m

SLEEP APNEA INCREASES LV TRANSMURAL PRESSURE


Prevalence of sleep apnea in Systolic Heart Failure

100 out of 114 consecutive patients

68% with AHI ≥ 5/h 49% with AHI ≥ 15/h

Javaheri et al: Ann Intern Med 1995 Circulation 1998 Int J Cardiol 2006

Prevalence of sleep apnea in recent prospective studies of SHF

Country(year) n % AHI≥10/hr % AHI≥15/hr %

CSA%

OSA

* USA (06) 100 49 37 12

USA (08) 108 61 31 30

*Canada (07) 287 47 21 26

*UK (07) 55 53 38 15

Germany (07) 700 52 33 19

*Germany (09) 50 64 44 20

*Germany (10) 273 64 50 14

*Portugal (10) 103 46 n/a n/a

China (07) 126 71 46 25

Germany (07) 203 71 28 43

Germany (07) 102 54 37 17

France (09) 316 81 25 56


54% (897/1676)

34% (541/1573)

20% (308/1573)

Prevalence of sleep apnea inHeart Failure with PEF

• n = 244 consecutive patients (87 women)• Mean age 65• Echocardiogram, Polygraphy, and R and L heart catheterization• Cause of DHF:

- HTN (44%)- CAD (33%)- Hypertrophic/Restrictive (23%)

Bitter T, 2009 EJHF

Prevalence of Sleep Apnea in Heart Failure with PEF

How frequently patients with HF are tested for SA?

A retrospective cohort study used the 2004-2005 Medicare Standard Analytical Files (SAFs).

SAFs contain a 5 % sample of randomly selected Medicare beneficiaries.

The study population included newly diagnosed HF patients in the first quarter of 2004 without prior

diagnosis of SA.


Study CohortN=30,719

SA tested N=572 (2%)

Not SA testedN=30,147 (98%)

SA Dx: N=553 (97%) No SA Dx N=19 (3%)

tested, diagnosed, not treated

N=295

tested, diagnosed, treated N=258

Under-diagnosis of sleep apnea in patients with heart failure

Javaheri et al. Am J Respir Crit Care Med 2011 Sleep Medicine Physician Board Review

The mystery of the lack of subjective EDS in patients with SHF

Most studies show no difference in subjective EDS in patients with systolic heart

failure with or without sleep apnea.However, when tested objectively, by

MSLT or Osler test, heart failure patients with sleep apnea are sleeper than those without

sleep apnea.

No difference in subjective EDS among the 3 groups(n=100)

No SA

CSAOSA

Patients (n)

90

80

70

60

50

40

30

20

10

0

p=0.8

EDS (%)*vs. Group I†vs. Group II

Javaheri et al: 1998, 2006

Clinical impact of lack of subjective EDS in SHF

1.Under diagnosis of sleep apnea in systolic heart failure

2. Inadequate long-term CPAP adherence could diminish its effectiveness in maximizing LVEF

and survival both for OSA and CSA


Sleep Apnea in Heart Failure:

Then what should the primary care physicians and the cardiologists look for to suspect presence of sleep apnea in their patients with systolic heart failure?

The phenotype depends differs in OSA and CSA

Hallmarks of OSA in SHF

p=0.1

Group I

Group II

Group III

Patients(n)

90

80

70

60

50

40

30

20

10

0

p=0.1

p<0.001

p=0.02

p=0.8

p=0.1

Age(y)

Ht(in)

BMI(kg/m2)

Snoring(%)

EDS(%)

Apnea(%)

*†

*†

*vs. Group I†vs. Group II


Hallmarks of CSA in SHF


Treatment of OSA in CHF

• Promote sleep hygiene• Avoid ETOH, benzodiazepines, opioids, and Viagra• Weight loss• Positive airway pressure devices: CPAP, bilevel,

Provent• Mandibular advancement devices• Upper airway procedures• Hypoglossal N stimulation• Nocturnal use of supplemental oxygen


Provent

Effects of PAP therapy on LVEF in RCT OSA/SHF

KanekoOpen

MansfieldOpen

EgeaDB

SmithDB

KhayatOpen

KhayatOpen

n 12 19 20 23 11 13

AHI, n/h 40 25 44 36 30 34

LVEF, % 25 35 29 30 29 26

Change in LVEF, % 9* 5* 2.2* 0.0 0.5 8.5*

Duration 4w 3m 3m 6w 3m 3mPAP

titrationCPAP yes

CPAP yes

CPAP yes

Auto no

CPAP yes

Bilevel yes

Compliance

hr 6.2 5.6 NR 3.5 3.6 4.5

OSA as Cause of Mortality in SHF

Wang et al; JAAC, 2007

• 218 patients with LVEF<45%• 45 with CSA (21%)

• 113 control group, AHI < 15, mean = 7/h• 41 untreated OSA, AHI ≥15/hr, mean = 33/h

Wang H et al. J Am Coll Cardiol. 2007; 49: 1632

Worsening Survival of Patients With Heart Failure and OSA

Wang H et al. J Am Coll Cardiol. 2007; 49: 1632

70

75

80

85

90

95

100

0 20 40 60 80

Time (months)

Su

rviv

al

(%)

AHI ≥ 15/hr, mean = 33/h(n=41; 9 deaths)

AHI<15, mean = 7/h(n=113;14 deaths)

M-NSA=mild to no sleep apneaOSA=obstructive sleep apnea

H.R. = 2.81

p = 0.029†

† After adjusting for left ventricular ejection fraction,NYHA functional class, age

Study CohortN=30,719

SA tested N=572 (2%)

Not SA testedN=30,147 (98%)

SA Dx: N=553 (97%) No SA Dx N=19 (3%)

tested, diagnosed, not treated

N=295

tested, diagnosed, treated N=258

Under-diagnosis of sleep apnea in patients with heart failure

Javaheri et al. Am J Respir Crit Care Med 2011


Kaplan-Meier Survival Curves, Adjusted by Age, Gender, and Charlson Comorbidity Index, 2004-2005

60%

70%

80%

90%

100%

Baseline 1 2 3 4 5 6 7 8

Quarters after HF Onset

Hazard ratio = .33 (95% CI = .21-.51), P <.0001

Percent of Cohort Alive

Tested, Diagnosed, Treated, N=258

Not Tested, Not Treated, N=30,065



0

20

40

60

80

100Cu

mul

ative

Eve

nt F

ree

Surv

ival

(%)

0 12 24 36 48 60Months

Treated

Untreated

Cumulative event-free survival in CPAP-treated and untreated patients

HR 2.03 (1.07-3.68) P=0.03

N=65

N=23

Kasai T, et al. Chest, 2008

AHI: 38 /hrLVEF: 35 %



0

20

40

60

80

100Cu

mul

ative

Eve

nt F

ree

Surv

ival

(%)

0 12 24 36 48 60Months

(6.0 hr/night)

(3.5 hr/night)

HR 4.02 (1.33-12.2) P=0.014

N=33

N=32

Kasai T, et al. Chest, 2008

Cumulative event-free survival by compliance status




Gami et al, NEJM, 2006

OSA Patients Die During Sleep


If I can choose……

Dr, are you telling me that if I use my CPAP I will die during daytime while awake!

I know you mean good, but I prefer to die during sleep


CSA is an independentpredictor of mortality in SHF

• N = 114 eligible• N = 100 Enrolled• N = 12 with OSA Excluded• N = 88 32 with AHI <5/hr ( mean = 2 ) 56 with AHI ≥5/hr ( mean = 34 ; CAI = 23)

• Median F/U : 51 months Javaheri et al , J Am Coll Cardiol (May, 2007)


CSA is a Predictor of Mortality in SHF

Months

AHI < 5/h (n=32)

AHI ≥5/h (n=56)

Surv

ival

%

Hazard ratio=2.14

P=0.02

100

90

80

70

60

50

20

40

10

0

30

100908070605020 40100 30 110 120 150130 140 160 170

Javaheri S et al. J Am Coll Cardiol 2007 Sleep Medicine Physician Board Review

The predictors of poor survival in SHF Three variables, AHI , RVEF and DBP

independently correlated with poor survival :

AHI (HR=2.14, P=0.02) RVEF (HR=0.97, P=0.003) DBP (HR=0.96, P=0.02) Javaheri, JACC, 2007


Bradley TD et al., N Engl J Med 2005

Heart-Transplantation-Free SurvivalTr

ansp

lant

ation

-fre

e Su

rviv

al (%

)

Time from Enrollment (mo)

Control group

CPAP group

P=0.54

100

80

60

40

20

00 12 24 36 48 60


Treatment of sleep apnea with CPAP in SHF

In regard to therapy with CPAP,

how does CSA differ from OSA?


CSA in SHFPrevalence of CPAP-responders and non-

responders

Patients n Responders Non-responders

21 43% 57%

AHI(36 to 4/h) AHI(62 to 62)

Javaheri, Circulation, 2000


Baseline Polysomnogram: HCSB

CPAP

Reasons why CPAP increased mortality

1. CPAP- nonresponders (43 % up to 57%)2. Adverse hemodynamic consequences of

CPAP:CPAP increases intrathoracic P and decreases venous return to R ventricle

Javaheri , JCSM, 2006


The predictors of poor survival in SHF

Three variables, AHI , RVEF and DBP

independently correlated with poor survival :

AHI HR=2.14, P=0.02 RVEF HR=0.97, P=0.003 DBP HR=0.96, P=0.02

Javaheri, JACC, 2007Sleep Medicine Physician Board Review


1. CPAP- nonresponders 2. Adverse hemodynamic consequences of

CPAP:CPAP increases intrathoracic P and decreases venous return to R ventricle

Javaheri , JCSM, 2006



If my statements are correct, then:1. CPAP responders should have a better

survival than the control group, and2. CPAP non-responders should have a

poorer survival than the control group


Bradley TD et al., N Engl J Med 2005

Heart-Transplantation-Free SurvivalTr

ansp

lant

ation

-fre

e Su

rviv

al (%

)

Time from Enrollment (mo)

Control group

CPAP group, n=128

P=0.54

100

80

60

40

20

0 0 12 24 36 48 60


Transplant-free survival in SHF patients according to effect of CPAP on CSA (Artz, Circ, 2007)

CPAP responders*(AHI at 3 months < 15/hr, n = 57)

CPAP non-respondersCPAP non-responders(AHI at 3 months (AHI at 3 months 15/hr, n = 43) 15/hr, n = 43)

00 66 1212 1818 2424 3030 3636 4242 4848 5454 6060

Time from enrollment (months)Time from enrollment (months)

ControlControl

00

2020

4040

6060

8080

100100T

ran

spla

nt-

free

su

rviv

al (

%)

Tra

nsp

lan

t-fr

ee s

urv

ival

(%

)

* * vs. control: HR=0.36, vs. control: HR=0.36, p=0.040p=0.040


Transplant-free survival according to effect of CPAP on CSA

CPAP responders*(AHI at 3 months < 15/hr, n = 57)

CPAP non-responders(AHI at 3 months 15/hr, n = 43)

0 6 12 18 24 30 36 42 48 54 60

Time from enrollment (months)

Control

0

20

40

60

80

100

Tra

ns

pla

nt-

free

su

rviv

al (

%)

*versus control: HR=0.36, p=0.040

Control


CSA in SHFPrevalence of CPAP-responders and non-responders

Potential Therapeutic Role of PSSV Devices

Patients n Responders Non-responders

Javaheri (1st night) 21 43% 57%(Circulation,2000) AHI (36 to 4/h) AHI (62 to 62) (lowPCO2)

Artz (at 3 m)(Circulation,2007) 100 57% 43%

AHI (34 to 6.5) AHI (47 to 35)


Regarding CPAP in CSA/SHF

2 important concerns:1. CPAP non-responders2. Poor adherence with CPAP in

responders


ASV devices

• VPAP Adapt ASV Enhanced

• BiPAP AutoSV Advanced


Hypopnea Hyperpnea

Patients Airflow

Inspiratory support decreasing during hyperpnea and increasing during hypopneaDeviceInspiratorypressuresupport

Expiratory pressure

General operation of ASV devices

Operation of BiPap auto SV Advanced EP increased from 4 to7 cm H2O

during obstructive disordered breathing events

Javaheri et al, Sleep 2011, In PressAHI comparative data across various nights (N=37)

6.1

10.4

34.5

53.1

0

10

20

30

40

50

60

70

80

90

100

Dx_PSG CPAP autoSV autoSV Advanced

vs. Dx_PSG ----- <0.001 <0.001 <0.001

vs. autoSV Advanced

<0.001 <0.001 0.0354 -----

Effects of PAP treatment on survival in patients with SHF and severe sleep apnea

Jilek et al. EJHF, 2011

months100806040200

Surv

ival

, %

100

80

60

40

20

PAP treated; AHI=49/h

16 events, 18%

untreated ; AHI=42

44 events, 52%

adjusted HR 0.3 (95%CI: 0.2 – 0.6, p=0.001)


Thanks for your attention

Ref: S. Javaheri, Heart Failure in: Principles and Practice of Sleep Medicine, 2010

A patient with HCSB on VPAP Adapt Enhanced


• Cardiovascular changes in NREM & REM sleep– NREM Sleep:– Sympathetic and Parasympathetic Activity – HR & BP – Ventilation

– Phasic REM sleep HR and BP

• NREM sleep is peaceful for CV system• Phasic REM sleep is not peaceful for CV system

Differences of ESS Score between HF patients (University of Toronto) and the GP (Madison Sleep Cohort) according to the

AHI

AHI < 5 AHI 5-15 AHI 15

Subj

ectiv

e Sl

eepi

ness

(ESS

Sco

re)

†

†

† GP

HF

†

4

5

6

7

8

9

10

11

(† p<0.05, †† p<0.01)

†

Arzt M et al. Arch Int Med 2006


Long-term CPAP adherence in OSA

one year use of CPAP in nonsleepy OSA patients in the Spanish trial

Adherence: 4.7 ± 2 hrsBarbe et al, Am J Respir Crit Care, 2010


Kaplan-Meier Survival Curves, Adjusted by Age, Gender, and Charlson Comorbidity Index, 2004-2005

80%

90%

100%

Baseline 1 2 3 4 5 6 7 8Quarters after HF

Tested, Diagnosed and TreatedN=258

Tested, Diagnosed and Not treatedN=295

Hazard ratio =.49 (95% CI= .29-.84), P=0.009

Percent of Cohort Alive



Future direction

2 RCT, one with VPAP Adapt Enhanced one with BiPap AutoSV Advanced are in progress in systolic heart failure


100 out of 114 consecutive patients10% on beta blockers

Javaheri et al :

Ann Intern Med 1995 Circulation 1998 Int J Cardiol 2006

AHI ≥ 15/h 49%

Prevalence of sleep apnea in Systolic Heart Failure


Prevalence of sleep apnea in 6 recent prospective PSG studies of SHF

0

10

20

30

40

50

60

70

USA(06)

Canada(07)

UK(07)

Germany(09)

Germany(10)

%AHI≥15/hr

%CSA

%OSA


Country(year) n AHI≥15/hr CSA OSA

USA (06) 100 49 37 12

Canada (07) 287 135 60 75

UK (07) 55 29 21 8

Germany (09) 50 32 22 10

Germany (10) 273 175 137 38

Portugal (10) 103 46 n/a n/a

Total 868 466 277 143

Prevalence of sleep apnea in 6 recent prospective studies of SHF

Prevalence of sleep apnea in 12 recent prospective studies of 2,423 consecutive patients with SHF

Country (year)

n AHI≥10/hr (n)

AHI≥15/hr (n)

CSA (n)

OSA (n)

*USA (06) 100 49 37 12

USA (08) 108 66 33 32

*Canada (07) 287 135 60 75

China (07) 126 89 58 32

*UK (07) 55 29 21 8

Germany (07) 700 364 231 133

Germany (07) 203 144 57 87

Germany (07) 102 55 38 17

France (09) 316 256 79 177

*Germany (09) 50 32 22 10

*Germany (10) 273 175 137 38

*Portugal (10) 103 46 n/a n/a

Total 2,423 544 896 773 621


Country(year) n %

AHI≥10/hr%

CSA%

OSA%

β blockers

China (07) 126 71 46 25 80

Germany (07) 203 71 28 43 90

Germany (07) 102 54 37 17 80

France (09) 316 81 25 56 82

Total 747 73 31 42 84


Country(year) n %

AHI≥15/hr%

CSA%

OSA%

β blockers

* USA (06) 100 49 37 12 10

USA (08) 108 61 31 30 82

*Canada (07) 287 47 21 26 80

*UK (07) 55 53 38 15 78

Germany (07) 700 52 33 19 85

*Germany (09) 50 64 44 20 100

*Germany (10) 273 64 50 14 88

*Portugal (10) 103 46 n/a n/a 90

Total 1676 54 34 20 81

Prevalence of sleep apnea in SHF (blue=EEG/red=no EEG)

Prevalence of sleep apnea in 2 recent polygraphy studies of SHF (n=808)

AHI≥15/hr CSA OSA

Prevalence of Sleep Apnea inRecent Prospective Studies of SHF

Canada (07)

China (07)

Germany (07)

US (06) US(08)

n

%AHI≥ 10/hr

% β blockers

%AHI≥ 15/hr

80

1082

80

71

47

4961

52 85

287

100 108

126

700

Country (y)

90203

54 80102

Germany (07)

Germany (07)

71

UK (07) 7855 53

85

Prevalence of Sleep Apnea in SHFThe World Series

n = 431n = 1250

AHI ≥10 AHI ≥15

Prevalence of CSA in Systolic Heart Failure


49% with AHI ≥ 15/h 37% CSA


Prevalence of Sleep Apnea inRecent Prospective Studies of SHF

Canada (07)

China (07)

Germany (07)

US (06) US(08)

n

%AHI≥ 10/hr

% β blockers

%AHI≥ 15/hr

80

1082

80

%CSA

21

3731

46

71

47

4961

52 85

287

100 108

126

700

Country (y)

9028203

54 8037102

Germany (07)

Germany (07)

71

UK (07) 783855 53

33 85

0

5

10

15

20

25

30

35

40

%

n = 431 n = 1250

AHI ≥10 AHI ≥15

35% 31%

Prevalence of CSA in SHF The World Series

Prevalence of CSA in Systolic Heart Failure


49% with AHI ≥ 15/h 12% OSA


Prevalence of OSA in SHF Recent Studies

Canada (07)

China (07)

Germany (07)

US (06)

n

%AHI≥ 10/hr

% β blockers

%AHI≥ 15/hr

8010

%

OSA

71

47

49

26

12

25

52

287

100

126

700

Country (y)

9043203

54 8017102

Germany (07)

Germany (07)

71

UK (07) 781555 53

19 85

80

Prevalence of OSA in SHFThe World Series

0

5

10

15

20

25

30

35

%

AHI ≥ 10 AHI ≥ 15

32

20

n = 431

n = 1250

World wide prevalence of sleep apnea in systolic heart failure

Author,Country (y)

n AHI > 15/hr%

B blockers%

Javaheri,USA (06)

100 49 10

MacDonald,USA (08)

108 61 82

Wang,Canada (07)

287 47 80

Vazir,UK (07)

55 53 78

Oldenburg,Germany (07)

700 52 85

Worldwide prevalence of sleep apnea in 1250 consecutive patients with SHF

0

10

20

30

40

50

60 52

31

21%

AHI ≥15 CSA OSASleep Medicine Physician Board Review

Prevalence of Sleep Apnea in Heart Failure with PEF(n=244)

AHI≥15/hr


54% (467/868)

36% (277/765)

19% (143/765)

Prevalence of Sleep Apnea in Heart Failure with PEF

• Patients with SA performed worse on exercise test and 6 minute walk

• With increasing impairment of diastolic dysfunction the prevalence of SA, and CSA in particular increased

• Patients with CSA had lower PCO₂, higher NT-proBNP, LVEDP, PCWP, and PAP



Among a population of 30,719 newly diagnosed HF patients, only 1,263 (4%) were clinically

suspected to have SA. Of these, 553 (only 2% of the total cohort) were

tested for SA.

Javaheri et al, AJRCCM, 2011



A retrospective cohort study used the 2004-2005 Medicare Standard Analytical Files (SAFs).

SAFs contain a 5 % sample of randomly selected Medicare beneficiaries.

The study population included newly diagnosed HF patients in the first quarter of 2004 without prior

diagnosis of SA. Javaheri et al. Am J Respir Crit Care Med 2011.


Phenotype of heart failure patients with and without sleep apnea

p=0.1

NO SA CSAOSA

Patients(n)

90

80

70

60

50

40

30

20

10

0

p=0.1

p<0.001

p=0.02

p=0.8

Age(y)

Ht(in)

BMI(kg/m2)

Snoring(%)

EDS(%)

*†

*†

*vs. Group I†vs. Group II Sleep Medicine Physician Board Review

PAP devices decreases LV afterload

100 140 100 100

100 140 100 100

Pp l Pp l Pp l Pp l

0.0 0.0 -40 +10

100 - (0 .0) = 100 140 - (0 .0) = 140 100 - (- 40) = 140 100 - (+10) = 90

Norm al Hypertension CPAPUAO

PrLVTm

OSA , HF and CPAP

1.CPAP titration in OSA with heart failure is the same as OSA without HF

2. Generally, OSA is eliminated with overnight

CPAP titration

3.Occasionally central apneas may occur

during titration with CPAP

4.In most patients, OSA is controlled with low pressure

What is critical is long-term adherence


CPAP adherence in OSA

What is a major determinant of long-term adherence to CPAP in OSA patients ?


Optimize Therapy of Heart Failure

ACEI; ß-Blockers; Diuretics; Digoxin; CRT

SRBD Eliminated

Persistent SRBD

Follow-up Clinically

Consider Treatment

Cardiac Transplantation

Medications

TheophyllineNocturnal Nasal Oxygen

Acetazolamide CPAP ASVBilevel

Positive Airway Pressure Devices

Phrenic Nerve Stimulation

Ap

nea

-Hyp

op

nea

In

dex

(n

/hr)

0

10

20

30

40

50

60

70

80 Changes in AHI with low flow nasal O2 in CSA patientswith heart failure and systolic dysfunction

Room Air

Oxygen

N=9 N=7 N=11 N=7 N=22 N=29Hanly FranklinStaniforthWalsh Andreas Javaheri

p<0.0001

p<0.01

p<0.001

p=0.02

p=0.01

p<0.05

MeansSD

RCT : Theophylline Improves CSA

Placebo

15 15/0

66 175

88 ND

Theo

15 15/0

66 175 88 11 Javaheri et al., NEJM, 1996

Values are means; ND=not detectable

Baseline

15 15/0 66 175 89

ND

Variable

NGender,

M/FAge, yHt, cmWt, kgTheo, ug/ml

RCT:Theophylline improves CSA in HF

Placebo

37 26 2 2

17

Theo

18* 6* 2 1 8* Javaheri et al., NEJM, 1996, 335, 562-7

Values are means; * p < 0.05

Baseline

47 26 2 2

24

Variable

AHI, n/hCAI, n/hOAI, n/hMAI, n/hDBArI, n/h

VariableAHI, n/hCAI, n/hOAI, n/hDBArI, n/h

Placebo 57 49 1 20

Actz 34*†

23*†

2 13

RCT: Disordered breathing events of 12 SHF patients with CSA treated with single dose of

acetazolamide before bedtime

Baseline 55 44 1 25

p 0.002 0.004 0.6 0.06

p < 0.05 versus baseline † = p < 0.05 versus placebo

Javaheri, Am J Respir Crit Care Med, 2006

Long-term CPAP adherence in SHFis inadequate (Arzt, Circulation, 2007)

CPAP-CSA suppressed

n=57

CPAP-CSAunsuppresse

dn=43

AHI (n/hr) 6 35P (cm H2O) 9 9CPAP use at 3 m (hr)

4.6 4.2

CPAP use at 12 m

(hr)

3.6 3.6

Bi-level

0

Fixed expiratory pressure

15

5

10

20 Fixed inspiratory pressure

Fixed inspiratory support = IPAP - EPAP

Pressurecm/H₂O

VPAP Adapt SV Enhanced

0

Fixed expiratory pressure(Manually adjusted)

18

4

7

25

Variable inspiratory pressure support

Default min pressure support 3

Default max pressure support 5

Max inspiratory P = 25

Pressurecm/H₂O

BiPAP Auto SV AdvancedPressurecm/H₂O

0

18

4

11

25

Variable inspiratory pressure support Min inspiratory support = 0 Max pressure support = 25 – instantaneous EPAP

Min expiratory P = 4 with automatic adjustment

Max inspiratory P = 25

Features of ASV devices

– EP to eliminate obstructive events.– Back up rate to abort any impending

apnea– Variable inspiratory support which

with hypopneas and with hyperpneas


Documents

Sleep apnea in heart failure S. Javaheri, M.D Professor Emeritus of Medicine University of Cincinnati, College of Medicine Medical Director Sleepcare Diagnostics