Obstructive sleep apnoea in patients with dilated cardiomyopathy: effects of continuous positive airway pressure

doi:10.1016/0140-6736(91)92299-H

The Lancet

Volume 338, Issue 8781, 14 December 1991, Pages 1480-1484

https://doi.org/10.1016/0140-6736(91)92299-H Get rights and content

Abstract

The combined effects of negative intrathoracic pressure swings during obstructive sleep apnoeas (OSAs) and increased sympathetic nervous system tone associated with hypoxia and sleep arousal may lead to pulmonary oedema or left-ventricular hypertrophy. Therefore, we have done a study of patients with congestive heart failure secondary to idiopathic dilated cardiomyopathy to see whether OSA could contribute to impaired left-ventricular function and to assess nasal continuous positive airway pressure (NCPAP) for treatment. Eight men (aged 29-69 years) took part in the study; all were obese. Left-ventricular ejection fraction (LVEF) was measured while on stable medication and then 4 weeks after the start of nocturnal NCPAP. NCPAP was associated with abolition of OSA (mean [SE] number of apnoeas and hypopnoeas per hour of sleep 54·1 [7·2] and 1·0 [0·4] for pretreatment and NCPAP nights, respectively, p<0·0001). Mean (SE) LVEF increased from 37 (4)% pretreatment to 49 (5)% after four weeks' NCPAP therapy (p<0·0001). Withdrawal of NCPAP for 1 week in four patients was associated with a reduction in LVEF from 53 (6)% to 45 (5)% (p<0·001). OSA may contribute to impaired left-ventricular function in some patients with dilated cardiomyopathy of otherwise unknown origin, and reversal of OSA by NCPAP can lead to significant improvement in LVEF.

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Heart failure (HF) affects many patients worldwide every year. It represents a leading cause of hospitalization and still, today, mortality remains high, albeit the progress in treatment strategies. Several factors contribute to the development and progression of HF. Among these, sleep apnea syndrome represents a common but still underestimated factor because its prevalence is substantially higher in patients with HF than in the general population and is related to a worse prognosis. This review summarizes the current knowledge about sleep apnea syndrome coexisting with HF in terms of morbidity and mortality to provide actual and future perspectives about the diagnosis, evaluation, and treatment of this association.
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Citation Excerpt :
The study did show a lower risk of stroke with good CPAP adherence as well as improved snoring, daytime sleepiness, and quality of life.40 Despite these results, several other studies have shown significant benefit in CPAP for other cardiovascular outcomes, particularly in patients with HF.16,23,24 In HF patients with CSA, research has shown benefit with CPAP therapy.
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Untreated obstructive sleep apnoea (OSA) is associated with increased risk of coronary artery disease (CAD) and heart failure. High-sensitivity cardiac troponin (hs Trop-T) and B-type natriuretic peptide (NT-pro-BNP) are sensitive biomarkers for myocardial injury and heart failure respectively. No randomised controlled trials have examined the treatment effect of continuous positive airway pressure (CPAP) in patients with OSA on these biomarkers.
Patients >21 years old with apnoea-hypopnoea index (AHI) ≥25/h by overnight polysomnography were recruited. Main exclusion criteria were previous CPAP use and any significant comorbidities including CAD and heart failure. Eligible subjects were randomised to receive CPAP or sham CPAP for eight weeks each in a crossover design with a wash out period of one month between the treatments. Blood samples were collected at 8pm, 3am, and 8am during sleep studies conducted at the end of each eight-week treatment period.
Of the 37 patients who were randomised, 28 patients had stored frozen samples available for analysis. In comparison to sham treatment, CPAP significantly lowered the NT-pro-BNP level by 0.91 pmol/L (p = 0.0002). The reduction of 0.235 ng/L in hs Trop-T on CPAP therapy was not statistically significant (p = 0.052). There were no overnight changes, across the three time points, in either biomarker with either treatment.
Our study confirms CPAP therapy in patients with moderate-severe OSA reduces NT-pro-BNP, but we did not confirm a significant effect on hs Trop-T. Future larger studies of longer duration incorporating biomarkers and cardiac functional measures are needed to better establish the benefit of OSA treatment.

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ORIGINAL ARTICLESObstructive sleep apnoea in patients with dilated cardiomyopathy: effects of continuous positive airway pressure

Abstract

Lancet

Lancet

Chest

Lancet

Clin Chest Med

Controlled Clin Trials

Int J Cardiol

Snoring as a risk factor for hypetension and angina pectoris

Lancet

Snoring as a risk factor for ischaemic heart disease and stroke in men

Br Med J

Role of daytime hypoxemia in the pathogenesis of right heart failure in obstructive sleep apnea syndrome

Am Rev Respir Dis

Pulmonary edema as a presenting factor of sleep apnea syndrome

Chest

Left ventricular hypertrophy independent of hypertension in patients with obstructive sleep apnoea

J Hypertens

Is high and fluctuating sympathetic activity in the sleep apnea syndrome of pathogenetic importance for the development of hypertension?

J Hypertens

The effects of negative intrathoracic pressure on left ventricular function in patients with coronary artery disease

Circulation

ORIGINAL ARTICLES
Obstructive sleep apnoea in patients with dilated cardiomyopathy: effects of continuous positive airway pressure