Treatment Of Sleep-disordered Breathing In Patients Research Articles

Sleep-Disordered Breathing-a Real Therapeutic Target for Hypertension, Pulmonary Hypertension, Ischemic Heart Disease, and Chronic Heart Failure?

Sleep-disordered breathing (SDB) is a risk factor for cardiovascular disease including acute coronary syndrome and acute myocardial infarction, and treating SDB prevents their development and recurrence and improves a patient's prognosis. Therefore, SDB is considered a therapeutic target for cardiovascular disease. In 2010, the Japanese Circulation Society published guidelines for the diagnosis and treatment of SDB in patients with cardiovascular disease. However, therapeutic intervention for patients with SDB was recently reported not to suppress the development or deterioration of cardiovascular disease in three middle- to large-sized randomized clinical trials: the SERVE-HF trial, which examined the effects of adaptive servo-ventilation (ASV) on patients with chronic heart failure (CHF) and central sleep apnea; the CAT-HF trial, which examined the effects of ASV therapy on patients with CHF after acute deterioration; and the SAVE study, which examined the secondary preventive effect of continuous positive airway pressure (CPAP) on patients with ischemic heart disease who had mild to moderate obstructive sleep apnea. These studies caused hesitation among clinicians to proactively treat SDB by ASV or CPAP therapy. The present review is focused on hypertension, pulmonary hypertension, ischemic heart disease, and CHF to newly summarize the studies available to date from the viewpoints of epidemiology, pathogenesis, and treatment. I expect this review be informative and useful for physicians who treat patients with SDB by CPAP or ASV therapy in the clinical setting.

Interrelationship Between Sleep-Disordered Breathing and Sarcoidosis

Sleep-disordered breathing (SDB) has a high prevalence in sarcoidosis. This high prevalence may be the result of increased upper airways resistance from sarcoidosis of the upper respiratory tract, corticosteroid-induced obesity, or parenchymal lung involvement from sarcoidosis. OSA is a form of SDB that is particularly common in patients with sarcoidosis. Sarcoidosis and SDB share many similar symptoms and clinical findings, including fatigue, gas exchange abnormalities, and pulmonary hypertension (PH). Sarcoidosis-associated fatigue is a common entity for which stimulants may be beneficial. Sarcoidosis-associated fatigue is a diagnosis of exclusion that requires an evaluation for the possibility of OSA. Hypercapnia is unusual in a patient with sarcoidosis without severe pulmonary dysfunction and, in this situation, should prompt evaluation for alternative causes of hypercapnia, such as SDB. PH is usually mild when associated with OSA, whereas the severity of sarcoidosis-associated PH is related to the severity of sarcoidosis. PH caused by OSA usually responds to CPAP, whereas sarcoidosis-associated PH commonly requires the use of vasodilators. Management of OSA in sarcoidosis is problematic because corticosteroid treatment of sarcoidosis may worsen OSA. Aggressive efforts should be made to place the patient on the lowest effective dose of corticosteroids, which involves early consideration of corticosteroid-sparing agents. Because of the significant morbidity associated with SDB, early recognition and treatment of SDB in patients with sarcoidosis may improve their overall quality of life.

Sleep-disordered breathing and cardiac disease

The prevalence of sleep-disordered breathing (SDB) is ca. 30 % in patients with coronary heart disease, ca. 30 % in patients with Hypertonus, ca. 50 % in patients with congestive heart failure and ca. 60 % in patients with atrial fibrillation. In patients with resistent hypertension, prevalence of SDB is about 80 %. However, patients with SDB and associated cardiac disease like atrial fibrillation or congestive heart failure do not report daytime symptoms like excessive daytime sleepiness. Ambulatory cardiorespiratory polygraphy is used to screen for SDB in patients with cardiac disease. An effective treatment of SDB can reduced blood pressure and can avoid arrhythmias. The effect of treatment of SDB in patients with congestive heart failure is currently investigated in clinical randomized trials.

Recognition and Management of Sleep-Disordered Breathing in Chronic Heart Failure

It is increasingly recognized that sleep-disordered breathing (SDB) is a common modifiable risk factor for cardiovascular disease with significant impact on morbidity and potentially mortality. SDB is highly prevalent in patients with systolic or diastolic heart failure. A high index of suspicion is necessary to diagnose SDB in patients with heart failure because the vast majority of affected patients do not report daytime symptoms. Recent clinical trials have demonstrated improvement in heart function, exercise tolerance, and quality of life after treatment of SDB in patients with heart failure. Accumulating evidence suggests that treatment of SDB should complement the established pharmacologic therapy for chronic heart failure. However, mortality benefit has yet to be demonstrated.

Sleep disordered breathing in chronic heart failure

Heart failure is a growing problem, placing an increasing burden on public health resources and continuing to exert a high toll in mortality and morbidity. Sleep disordered breathing (SDB) is also a major public health problem and is associated with an increased risk of fatal and non-fatal cardiovascular events. Current evidence suggests SDB, particularly central SDB, is more prevalent in patients with chronic heart failure (CHF) than in the general population, but is under-diagnosed as SDB symptoms are less prevalent in CHF. This is further hampered by the absence of a simple and accurate screening tool and limited access to sleep facilities to diagnose SDB in the large numbers of patients with CHF. The presence of SDB in patients with CHF imposes increased haemodynamic burdens and results in autonomic abnormalities. Central SDB is an independent marker of worse prognosis, and evidence is increasing that obstructive SDB is also associated with higher mortality in patients with CHF. Optimal treatment of central SDB in these patients remains uncertain. While evidence of efficacy of positive pressure ventilation is stronger in obstructive SDB, improvement in survival for patients with both CHF and SDB awaits definitive trials. This paper summarizes our current understanding of the pathophysiology of SDB in CHF, and the cardiovascular consequences, and reviews the evidence for the beneficial effects of treatment of SDB in patients with CHF.