Sleep Disordered Breathing and Cardiovascular Disease Sleep Disordered
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
Sleep and Cardiovascular Disease Confidential Dr. David White, International Group HHS, 09. 10. 2009 2
Baseline Confidential Dr. David White, International Group HHS, 09. 10. 2009
Prevalence of SDB in Heart Failure Percent n=81 n=450 n=20 n=38 Chan et al, 1997, Javaheri et al, 1998, Sin et al, 1999, Abraham et al, 2002 Confidential Dr. David White, International Group HHS, 09. 10. 2009
What are the Consequences of Cheyne-Stokes Respiration? • Why do we specifically want to treat this disorder? Confidential Dr. David White, International Group HHS, 09. 10. 2009
Baseline Confidential Dr. David White, International Group HHS, 09. 10. 2009
Consequences of Sleep Disorders Breathing in Congestive Heart Failure • Sleep fragmentation little daytime sleepiness. • Hypoxia plus arousals recurrent sympathetic nervous system activation. • Attributable mortality (? ). • Progression of heart failure (? ). Confidential Dr. David White, International Group HHS, 09. 10. 2009
nmol//L Nmol/mmol Creatinine Cheyne-Stokes Respiration Recurrent Sympathetic Nervous System Activation NOREPINEPHRINE N PLASMA URINE Naughton et al. Am J Respir Crit Care Med, 1995 Confidential Dr. David White, International Group HHS, 09. 10. 2009
Sin et al Circulation, 2000 Confidential Dr. David White, International Group HHS, 09. 10. 2009
Cheyne-Stokes Respiration • Will therapy specifically aimed at Cheyne-Stokes Respiration improve both quality of life and survival in patients with this disorder? Confidential Dr. David White, International Group HHS, 09. 10. 2009
Cheyne-Stokes Respiration What can be done to correct this? First always maximize cardiac medications. • • • Confidential Theophylline (respiratory stimulant) Acetazolamide Oxygen administration CO 2 inhalation CPAP [continuous positive airway pressure] Dr. David White, International Group HHS, 09. 10. 2009
Confidential Dr. David White, International Group HHS, 09. 10. 2009
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 Confidential Dr. David White, International Group HHS, 09. 10. 2009
Left Ventricular Intracavitary Pressure = 100 mm. Hg Pericardial Pressure = 0 mm. Hg LV transmural pressure = 100 mm. Hg Confidential Dr. David White, International Group HHS, 09. 10. 2009
Left Ventricular Intracavitary Pressure = 100 mm. Hg Pericardial Pressure = 20 mm. Hg LV transmural pressure = 100 – (-20) = 120 mm. Hg Confidential Dr. David White, International Group HHS, 09. 10. 2009
Left Ventricular Intracavitary Pressure = 100 mm. Hg Pericardial Pressure = +20 mm. Hg LV transmural pressure = 100 - 20 = 80 mm. Hg Confidential Dr. David White, International Group HHS, 09. 10. 2009
Naughton et al. Am J Respir Crit Care Med, 1995 LVEF (%) BL Confidential 1 M Dr. David White, International Group HHS, 09. 10. 2009 3 M
nmol//L Nmol/mmol Creatinine Naughton et al. AJRCCM 1995 CONTROL NCPAP CONTROL NOREPINEPHRINE NCPAP EPINEPHRINE CONTROL NOREPINEPHRINE URINE Confidential NCPAP CONTROL EPINEPHRINE PLASMA Dr. David White, International Group HHS, 09. 10. 2009 NCPAP
Naughton et al. AJRCCM, 1994 Baseline NCPAP EEG EMG RIBCAGE ABDOMEN VT (L) 1. 0 100 Sa. O 2 (%) 75 1 minute V 1 = 8. 9 L/min Confidential Dr. David White, International Group HHS, 09. 10. 2009 V 1 = 4. 8 L/min
Sin et al - Circulation 2000, 102: 61 -66 Confidential Dr. David White, International Group HHS, 09. 10. 2009
2005 Confidential Dr. David White, International Group HHS, 09. 10. 2009
Bradley et al, New Engl J Med - 2005 Confidential Dr. David White, International Group HHS, 09. 10. 2009
Bradley et al, New Engl J Med - 2005 Confidential Dr. David White, International Group HHS, 09. 10. 2009
Circulation 2007 Confidential Dr. David White, International Group HHS, 09. 10. 2009
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. Confidential Dr. David White, International Group HHS, 09. 10. 2009
Arzt et al, Circulation 2007 Confidential Dr. David White, International Group HHS, 09. 10. 2009
CPAP - 7 cm H 20 Confidential Dr. David White, International Group HHS, 09. 10. 2009
Computer-Assisted Positive Airway Pressure Confidential Dr. David White, International Group HHS, 09. 10. 2009
CANPAP 2 PI: 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+ Auto SV 3. Confidential Dr. David White, International Group HHS, 09. 10. 2009
CANPAP 2 PI: Doug Bradley, MD • Outcomes: - Transplant free survival - Cardiac function - Exercise capacity - QOL - RDI Confidential Dr. David White, International Group HHS, 09. 10. 2009
Confidential Dr. David White, International Group HHS, 09. 10. 2009
Prevalence of SDB in Heart Failure Percent n=81 n=450 n=20 n=38 Chan et al, 1997, Javaheri et al, 1998, Sin et al, 1999, Abraham et al, 2002 Confidential Dr. David White, International Group HHS, 09. 10. 2009
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. Confidential Dr. David White, International Group HHS, 09. 10. 2009
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, Ph. D, Kuo-Liang Chiu, MD, MSc, Pimon Ruttanaumpawan, MD, George Tomlinson, Ph. D and T. Douglas Bradley, MD Toronto, Ontario, Canada Confidential Dr. David White, International Group HHS, 09. 10. 2009
Wang et al, JACC 2007 Confidential Dr. David White, International Group HHS, 09. 10. 2009
Wang et al, JACC 2007 Confidential Dr. David White, International Group HHS, 09. 10. 2009
2003 Confidential Dr. David White, International Group HHS, 09. 10. 2009
Kaneko et al, NEJM 2003 Confidential Dr. David White, International Group HHS, 09. 10. 2009
Kaneko et al, NEJM 2003 Confidential Dr. David White, International Group HHS, 09. 10. 2009
Am J Resp Crit Care Med 2004 Confidential Dr. David White, International Group HHS, 09. 10. 2009
Mansfield et al, AJRCCM 2004 Confidential Dr. David White, International Group HHS, 09. 10. 2009
Mansfield et al, AJRCCM 2004 P<0. 001 LVEF (%) P=NS Baseline 3 Months Baseline Control Group CPAP Group P=0. 04 Confidential 3 Months Dr. David White, International Group HHS, 09. 10. 2009
CHEST 2008 Confidential Dr. David White, International Group HHS, 09. 10. 2009
Kasai et al, CHEST 2008 Confidential Dr. David White, International Group HHS, 09. 10. 2009
Kasai et al, CHEST 2008 Confidential Dr. David White, International Group HHS, 09. 10. 2009
CANPAP 2 PI: 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+ Auto SV 3. Confidential Dr. David White, International Group HHS, 09. 10. 2009
Sleep and Cardiovascular Disease Confidential Dr. David White, International Group HHS, 09. 10. 2009 47
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