Pressure-dependent hemodynamic effect of continuous positive airway pressure in severe chronic heart failure: A case series

Abstract

Two third of stable severe Chronic Heart Failure (CHF) patients are affected by central or obstructive sleep disordered breathing (SDB). Although Continuous Positive Airway Pressure (CPAP) is a validated treatment for obstructive sleep apnea (OSA) in CHF [ [1] Kaneko Y. Floras J.S. Usui P.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 Crossref PubMed Scopus (902) Google Scholar ], its interest in central sleep apnea (CSA) associated with CHF remains still controversial. The CANPAP randomized controlled trial showed an increase in event rates and mortality occurring during the first months of CPAP initiation [ [2] Bradley T.D. Logan A.G. Kimoff R.J. et al. Continuous airway pressure for central sleep apnea and heart failure. N Engl J Med. 2005; 353: 2025-2033 Crossref PubMed Scopus (947) Google Scholar ]. It suggests that CPAP may have an early adverse effect in some CHF patients suffering from CSA. Using CPAP in CHF patients, when filling pressures are high, the cardiac output seems to increase, and when pressures are low, it seems to decrease. Potentially, upward titration of CPAP reduced cardiac output in some patients and may then be deleterious [ [2] Bradley T.D. Logan A.G. Kimoff R.J. et al. Continuous airway pressure for central sleep apnea and heart failure. N Engl J Med. 2005; 353: 2025-2033 Crossref PubMed Scopus (947) Google Scholar ]. As recently highlighted by a Task Force report [ [3] Aurora R.N. Chowdhuri S. Ramar K. et al. The treatment of central sleep apnea syndromes: practice parameters with an evidence-based literature review and meta-analyses. Sleep. 2012; 35: 17-40 PubMed Google Scholar ], a clear limitation of most of the studies in the field is that CPAP therapy was not titrated. In clinical practice, CPAP titration in CHF is mainly addressing the correction of SDB but its impact on hemodynamic should probably be included in the titration process in CHF patients [ [4] Jaffuel D. Combes N. Jaber S. Heterogeneity of response to constant positive pressure in patients with heart failure and co-existing central and obstructive sleep apnea: why?. Chest. 2013; 143: 11833 Crossref Scopus (3) Google Scholar ]. A more careful CPAP titration might avoid some adverse events.