Sleep disordered breathing:
prevalence and pathophysiology
Martin R Cowie
Professor of Cardiology
National Heart & Lung In...
Declaration of Interests
• Received research funding and consultancy/speaking 
fees from ResMed, Servier, St Jude Medical,...
Daytime sleepiness no longer!
Johns MR. A new method of measuring daytime sleepiness:
The Epworth Sleepiness Scale. Sleep 14(6):540-545, 1991.
2
2
3
0
3...
OSA
CSR
CSA
60 seconds
100
%
70
100
%
70
100
%
70
Flow
Thorax
Abdomen
SaO2
Flow
Thorax
Abdomen
SaO2
Flow
Thorax
Abdomen
Sa...
Mechanical Effects of OSA on Heart Function
Kasai et al. J Am Coll Cardiol 2011;57:119–27
Inspiration effort with
occluded...
Clinical observation
• ‘The only peculiarity in the last period of his illness, which 
lasted only 8 or 9 days, was in the...
OSA
CSR
CSA
60 seconds
100
%
70
100
%
70
100
%
70
Flow
Thorax
Abdomen
SaO2
Flow
Thorax
Abdomen
SaO2
Flow
Thorax
Abdomen
Sa...
HF and mechanism of CSA
Prolonged circulation time 
(Circulatory Delay)
SM Caples et al J Appl Physiol 2005; 99: 2433-2439...
Quantifying SDB
• Apnoea Hypopnoea Index (AHI)
o Number of apneas and hypopneas per hour
o Apnoea = cessation of flow for ...
Is SDB common in HF?
• Vazir et al. 2007
• 55 men with CHF
• EF < 45%
• NYHA II
• Stable
• 53% SDB (AHI ≥ 15):
– 38% CSA
–...
SDB Prevalence by Gender and Age
n=190
* Woehrle H et al. BMC CV Disord 2014; 14: 46
Bitter et al. Eur J Heart Fail 2009
SDB prevalence in HFpEF
*
Prevalence of AHI
≥ 5 similar (70-
80%) to HFrEF
©ResMed 2014 I
Prevalence of SDB in Acute HF
Average LVEF on admission 30%
80% had SDB (AHI>15) of whom 75% had CSA
Tremel...
But so what?
SDB in HF – French registry data
Damy T et al. Eur J Heart Failure 2012; 24: 1009 - 19
SDB in HF – French registry data
Damy T et al. Eur J Heart Failure 2012; 24: 1009 - 19
*Outcome: death or transplant or VAD
SDB in HF – German single-centre  registry data
SDB in HF – risk of malignant ventricular arrhythmias
Cut off AHI ≥ 15/h
Bitter T P et al. Eur Heart J 2011; 32: 61-74
Cut off AHI ≥ 15/h
SDB in HF – risk of malignant ventricular arrhythmias
Bitter T P et al. Eur Heart J 2011; 32: 61-74
SDB in HF – risk of malignant ventricular arrhythmias
Bitter T P et al. J Cardiovasc Electrophysiol 2013; 24: 1132 – 40
SDB in HF – risk of malignant ventricular arrhythmias
Bitter T P et al. J Cardiovasc Electrophysiol 2013; 24: 1132 – 40
SERVE-HF StudySERVE-HF Study
Treatment of sleep-disordered breathing with
predominant central sleep apnoea by adaptive
ser...
• 1325 patients with HFrEF 
and predominantly central 
sleep apnoea randomised
• 651+ events (All cause 
mortality + HF ad...
Safety note issued 13 May 2015
• “The preliminary primary results show no significant difference between 
patients treated...
CSR: Risk factor, risk marker or compensatory 
mechanism??
Prevalence and pathophysiology
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Prevalence and pathophysiology

Prevalence and pathophysiology
Published on: Mar 4, 2016
Published in: Healthcare      
Source: www.slideshare.net


Transcripts - Prevalence and pathophysiology

  • 1. Sleep disordered breathing: prevalence and pathophysiology Martin R Cowie Professor of Cardiology National Heart & Lung Institute Imperial College London (Royal Brompton Hospital Campus) m.cowie@imperial.ac.uk
  • 2. Declaration of Interests • Received research funding and consultancy/speaking  fees from ResMed, Servier, St Jude Medical,  Medtronic, Boston Scientific, Novartis, Pfizer, Alere,  Roche Diagnostics, Bayer • Co-Principal Investigator for SERVE-HF
  • 3. Daytime sleepiness no longer!
  • 4. Johns MR. A new method of measuring daytime sleepiness: The Epworth Sleepiness Scale. Sleep 14(6):540-545, 1991. 2 2 3 0 3 0 2 0 12/24
  • 5. OSA CSR CSA 60 seconds 100 % 70 100 % 70 100 % 70 Flow Thorax Abdomen SaO2 Flow Thorax Abdomen SaO2 Flow Thorax Abdomen SaO2
  • 6. Mechanical Effects of OSA on Heart Function Kasai et al. J Am Coll Cardiol 2011;57:119–27 Inspiration effort with occluded upper airway Negative Intrathoracic Pressure Increased: LV transmural pressure LV afterload RV pre-load RV distension Leftward septum movement during diastole Impaired LV filling Reduced LV pre-load Reduced stroke volume UA = Upper Airway
  • 7. Clinical observation • ‘The only peculiarity in the last period of his illness, which  lasted only 8 or 9 days, was in the state of his respiration. For  several days his breathing was irregular; it would entirely cease  for a quarter of a minute, then it would become perceptible,  though very low, then by degrees it became heaving and quick,  and then it would gradually cease again. This revolution in the  state of his breathing occupied about a minute, during which  there were about thirty acts of respiration.’ William Stokes (1804-1878) Treatise on the Diseases and Treatment of Diseases of the Chest (1837).
  • 8. OSA CSR CSA 60 seconds 100 % 70 100 % 70 100 % 70 Flow Thorax Abdomen SaO2 Flow Thorax Abdomen SaO2 Flow Thorax Abdomen SaO2
  • 9. HF and mechanism of CSA Prolonged circulation time  (Circulatory Delay) SM Caples et al J Appl Physiol 2005; 99: 2433-2439 Increased CO2 sensitivity
  • 10. Quantifying SDB • Apnoea Hypopnoea Index (AHI) o Number of apneas and hypopneas per hour o Apnoea = cessation of flow for at least 10 sec o Hypopnoea = 30% reduction of flow for at least 10 sec with a  4% O2 desaturation o AHI < 5 (normal), AHI 5-14 (mild), AHI ≥ 15 (moderate/severe) • Oxygen Desaturation Index (ODI) o Number of O2 desaturations (of at least 4%) per hour
  • 11. Is SDB common in HF? • Vazir et al. 2007 • 55 men with CHF • EF < 45% • NYHA II • Stable • 53% SDB (AHI ≥ 15): – 38% CSA – 15% OSA • Oldenburg et al. 2007 • 700 pts with CHF • EF ≤ 40% • NYHA II, III or IV • Stable • 51% SDB (AHI ≥ 15): – 32% CSA – 19% OSA Oldenburg O et al. Eur J Heart Fail 2007; 9: 251-7Vazir A et al. Eur J Heart Fail 2007; 9: 243-50
  • 12. SDB Prevalence by Gender and Age n=190 * Woehrle H et al. BMC CV Disord 2014; 14: 46
  • 13. Bitter et al. Eur J Heart Fail 2009 SDB prevalence in HFpEF * Prevalence of AHI ≥ 5 similar (70- 80%) to HFrEF
  • 14. ©ResMed 2014 I Prevalence of SDB in Acute HF Average LVEF on admission 30% 80% had SDB (AHI>15) of whom 75% had CSA Tremel et al., Eur Heart J 1999 *
  • 15. But so what?
  • 16. SDB in HF – French registry data Damy T et al. Eur J Heart Failure 2012; 24: 1009 - 19
  • 17. SDB in HF – French registry data Damy T et al. Eur J Heart Failure 2012; 24: 1009 - 19 *Outcome: death or transplant or VAD
  • 18. SDB in HF – German single-centre  registry data
  • 19. SDB in HF – risk of malignant ventricular arrhythmias Cut off AHI ≥ 15/h Bitter T P et al. Eur Heart J 2011; 32: 61-74
  • 20. Cut off AHI ≥ 15/h SDB in HF – risk of malignant ventricular arrhythmias Bitter T P et al. Eur Heart J 2011; 32: 61-74
  • 21. SDB in HF – risk of malignant ventricular arrhythmias Bitter T P et al. J Cardiovasc Electrophysiol 2013; 24: 1132 – 40
  • 22. SDB in HF – risk of malignant ventricular arrhythmias Bitter T P et al. J Cardiovasc Electrophysiol 2013; 24: 1132 – 40
  • 23. SERVE-HF StudySERVE-HF Study Treatment of sleep-disordered breathing with predominant central sleep apnoea by adaptive servo ventilation in patients with heart failure NCT 00733343
  • 24. • 1325 patients with HFrEF  and predominantly central  sleep apnoea randomised • 651+ events (All cause  mortality + HF admissions) • Results under consideration  with NEJM Eur J Heart Failure 2013; 15: 937 – 43 STOP press
  • 25. Safety note issued 13 May 2015 • “The preliminary primary results show no significant difference between  patients treated with ASV and those in the control group for the primary  endpoint: – time to all-cause mortality or unplanned hospitalization for worsening heart  failure (HR =1.136 [0.974 - 1.325], p=0.104).  • However, there was a 2.5% absolute increased annual risk of cardiovascular  mortality for those randomized to ASV therapy compared to the control  group: – 10% of the ASV group experienced a CV death each year compared to 7.5% of the  control group, (HR=1.335 [1.070-1.666), p=0.010).  • The increased risk appears to be greater in those with more severe  ventricular dysfunction • The majority of excess mortality is due to death occurring out of hospital  (likely sudden cardiac death). The risk does not diminish with time on therapy  and is independent of perceived symptomatic benefit from therapy.”
  • 26. CSR: Risk factor, risk marker or compensatory  mechanism??

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