Skip to main content

Prognostic effect of sleep-disordered breathing on hospitalized patients following acute heart failure



Identifying patients at risk for poor clinical outcomes following acute heart failure (AHF) is essential. However, data regarding the prognostic effect of sleep-disordered breathing (SDB) and treatment with positive airway pressure (PAP) on clinical outcomes of hospitalized patients following AHF is lacking.


This study investigated the prognostic effect of SDB, PAP treatment, and compliance with PAP treatment on patient clinical outcomes. Polysomnography was performed in hospitalized patients whose left ventricular ejection fraction was < 50%. Patients were divided into groups based on whether SDB was defined as an apnea–hypopnea index ≥ 15 and if they had received PAP treatment. Furthermore, patients with SDB and PAP were subdivided into more and less compliant groups. We assessed the incidences of deaths and rehospitalizations due to heart failure.


Overall, 241 patients were enrolled; 73% had SDB and 29% were initiated on PAP treatment. At a median follow-up of 1.7 years, 74 clinical events (32 deaths, 42 rehospitalizations) occurred. In the multivariable analysis, compared with the non-SDB group, SDB without PAP treatment was associated with an increased risk of clinical outcomes (hazard ratio [HR] 1.79, P = 0.049), whereas SDB with PAP treatment was not (HR 0.78, P = 0.582). Among patients with PAP treatment, a more compliant group was also inversely associated with clinical events (HR 0.11, P = 0.012).


In hospitalized patients with AHF, untreated SDB was associated with worse clinical outcomes that might be reversible by PAP treatment. However, this potential may be suppressed in less compliant patients.

This is a preview of subscription content, access via your institution.

Fig. 1
Fig. 2


  1. Ponikowski P, Voors AA, Anker SD, Bueno H, Cleland JGF, Coats AJS et al (2016) 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC) Developed with the special contribution of the Heart Failure Association (HFA) of the ESC. Eur Heart J 37(27):2129–2200

    Article  Google Scholar 

  2. Mentz RJ, Kelly JP, von Lueder TG, Voors AA, Lam CS, Cowie MR et al (2014) Noncardiac comorbidities in heart failure with reduced versus preserved ejection fraction. J Am Coll Cardiol 64(21):2281–2293

    Article  Google Scholar 

  3. Suda S, Kasai T, Matsumoto H, Shiroshita N, Kato M, Kawana F et al (2018) Prevalence and clinical correlates of sleep-disordered breathing in patients hospitalized with acute decompensated heart failure. Can J Cardiol 34(6):784–790

    Article  Google Scholar 

  4. Peppard PE, Young T, Palta M, Skatrud J (2000) Prospective study of the association between sleep-disordered breathing and hypertension. N Engl J Med 342(19):1378–1384

    CAS  Article  Google Scholar 

  5. Gottlieb DJ, Yenokyan G, Newman AB, O’Connor GT, Punjabi NM, Quan SF et al (2010) Prospective study of obstructive sleep apnea and incident coronary heart disease and heart failure: the sleep heart health study. Circulation 122(4):352–360

    Article  Google Scholar 

  6. Shahar E, Whitney CW, Redline S, Lee ET, Newman AB, Nieto FJ et al (2001) Sleep-disordered breathing and cardiovascular disease: cross-sectional results of the Sleep Heart Health Study. Am J Respir Crit Care Med 163(1):19–25

    CAS  Article  Google Scholar 

  7. Schober OH, Meyer GJ, Bossaller C, Creutzig H, Lichtlen PR, Hundeshagen H (1985) Quantitative determination of regional extravascular lung water and regional blood volume in congestive heart failure. Eur J Nucl Med 10(1–2):17–24

    CAS  PubMed  Google Scholar 

  8. Khayat R, Abraham W, Patt B, Brinkman V, Wannemacher J, Porter K et al (2012) Central sleep apnea is a predictor of cardiac readmission in hospitalized patients with systolic heart failure. J Card Fail 18(7):534–540

    Article  Google Scholar 

  9. Khayat R, Jarjoura D, Porter K, Sow A, Wannemacher J, Dohar R et al (2015) Sleep disordered breathing and post-discharge mortality in patients with acute heart failure. Eur Heart J 36(23):1463–1469

    Article  Google Scholar 

  10. Kato T, Suda S, Kasai T (2014) Positive airway pressure therapy for heart failure. World J Cardiol 6(11):1175–1191

    Article  Google Scholar 

  11. Kasai T, Narui K, Dohi T, Yanagisawa N, Ishiwata S, Ohno M et al (2008) Prognosis of patients with heart failure and obstructive sleep apnea treated with continuous positive airway pressure. Chest 133(3):690–696

    Article  Google Scholar 

  12. McKee PA, Castelli WP, McNamara PM, Kannel WB (1971) The natural history of congestive heart failure: the Framingham study. N Engl J Med 285(26):1441–1446

    CAS  Article  Google Scholar 

  13. Sato N, Kajimoto K, Asai K, Mizuno M, Minami Y, Nagashima M et al (2010) Acute decompensated heart failure syndromes (ATTEND) registry. A prospective observational multicenter cohort study: rationale, design, and preliminary data. Am Heart J 159(6):949–955

    Article  Google Scholar 

  14. Berry RB, Gamaldo CE, Harding SM, et al (2015) The AASM Manual for the scoring of sleep and associated events rules, terminology and tech- nical specifications. Version 2.2. Darien, IL: American Academy of Sleep Medicine

  15. Matsuo S, Imai E, Horio M, Yasuda Y, Tomita K, Nitta K et al (2009) Revised equations for estimated GFR from serum creatinine in Japan. Am J Kidney Dis 53(6):982–992

    CAS  Article  Google Scholar 

  16. Javaheri S, Shukla R, Zeigler H, Wexler L (2007) Central sleep apnea, right ventricular dysfunction, and low diastolic blood pressure are predictors of mortality in systolic heart failure. J Am Coll Cardiol 49(20):2028–2034

    Article  Google Scholar 

  17. Wang H, Parker JD, Newton GE, Floras JS, Mak S, Chiu KL et al (2007) Influence of obstructive sleep apnea on mortality in patients with heart failure. J Am Coll Cardiol 49(15):1625–1631

    Article  Google Scholar 

  18. Javaheri S, Caref EB, Chen E, Tong KB, Abraham WT (2011) Sleep apnea testing and outcomes in a large cohort of Medicare beneficiaries with newly diagnosed heart failure. Am J Respir Crit Care Med 183(4):539–546

    Article  Google Scholar 

  19. Khayat RN, Javaheri S, Porter K, Sow A, Holt R, Randerath W et al (2020) In-hospital management of sleep apnea during heart failure hospitalization: a randomized controlled trial. J Card Fail 26(8):705–712

    Article  Google Scholar 

  20. Kapur VK, Auckley DH, Chowdhuri S, Kuhlmann DC, Mehra R, Ramar K et al (2017) Clinical practice guideline for diagnostic testing for adult obstructive sleep apnea: an american academy of sleep medicine clinical practice guideline. J Clin Sleep Med 13(3):479–504

    Article  Google Scholar 

  21. Kasai T, Bradley TD (2011) Obstructive sleep apnea and heart failure: pathophysiologic and therapeutic implications. J Am Coll Cardiol 57(2):119–127

    Article  Google Scholar 

  22. Matsumoto H, Kasai T (2018) Central sleep apnea in heart failure: pathogenesis and management. Curr Sleep Med Rep 4(3):210–220

    Article  Google Scholar 

  23. Murata A, Kasai T (2019) Treatment of central sleep apnea in patients with heart failure: Now and future. World J Respirol 9(1):1–7

    Article  Google Scholar 

  24. Bradley TD, Logan AG, Kimoff RJ, Series F, Morrison D, Ferguson K et al (2005) Continuous positive airway pressure for central sleep apnea and heart failure. N Engl J Med 353(19):2025–2033

    CAS  Article  Google Scholar 

  25. Cowie MR, Woehrle H, Wegscheider K, Angermann C, d’Ortho MP, Erdmann E et al (2015) Adaptive servo-ventilation for central sleep apnea in systolic heart failure. N Engl J Med 373(12):1095–1105

    CAS  Article  Google Scholar 

  26. Khayat RN, Abraham WT, Patt B, Pu M, Jarjoura D (2009) In-hospital treatment of obstructive sleep apnea during decompensation of heart failure. Chest 136(4):991–997

    Article  Google Scholar 

  27. O’Connor CM, Whellan DJ, Fiuzat M, Punjabi NM, Tasissa G, Anstrom KJ et al (2017) Cardiovascular outcomes with minute ventilation-targeted adaptive servo-ventilation therapy in heart failure: The CAT-HF trial. J Am Coll Cardiol 69(12):1577–1587

    Article  Google Scholar 

  28. Van Ryswyk E, Anderson CS, Antic NA, Barbe F, Bittencourt L, Freed R et al (2019) Predictors of long-term adherence to continuous positive airway pressure in patients with obstructive sleep apnea and cardiovascular disease. Sleep.

    Article  PubMed  Google Scholar 

Download references


We are indebted to Nanako Shiroshita, Mitsue Kato and Fusae Kawana for scientific advice.


This study is partly supported by a Grant-in-Aid for Scientific Research (Grant Number, 26507010); JSPS KAKENHI (Grant Number, JP17K09527); JSPS KAKENHI (Grant Number, JP18K15904); a grant to The Intractable Respiratory Diseases and Pulmonary Hypertension Research Group from the Ministry of Health, Labor and Welfare (20FC1027); a grant from the Ministry of Education, Culture, Sports, Science and Technology (MEXT) Program for the Strategic Research Foundation at Private Universities, 2014–2018, Japanese Center for Research on Women in Sport, Juntendo University, Project for Fostering, Survey Research for the Strategic Strengthening of Female Athletes 2017–2018 by the Japan Sports Agency. These funding sources did not play any other role in this study.

Author information

Authors and Affiliations



SI contributed to this manuscript. Study design: SI and TK. Data collection: authors. Data analysis and statistical analysis: SI and TK. Manuscript draft: SI and TK. Critical revision, editing, and approval of the final manuscript: all authors. SI, TK, HD, and TM are responsible for the overall content as guarantors.

Corresponding author

Correspondence to Takatoshi Kasai.

Ethics declarations

Conflict of interest

Dr. S. Ishiwata, Dr. T. Kasai, Dr. A. Sato, Dr. Y. Matsue, and Dr. R. Naito are affiliated with a department endowed by Philips, ResMed, and Fukuda Denshi. Dr. T. Kasai is affiliated with an endowed department by Paramount Bed. Dr. Y. Matsue received an honorarium from Otsuka Pharmaceutical Co. and Novartis Japan, and received research funds from Otsuka Pharmaceutical Co. and Pfizer Japan Inc. Dr. H. Daida reports research grants from CANON MEDICAL SYSTEMS CORPORATION, Philips Japan, Ltd., TOHO HOLDINGS CO., LTD., ASAHI KASEI CORPORATION, Inter Reha Co., Ltd., scholarship grants from Nippon Boehringer Ingelheim Co., Ltd., Otsuka Pharmaceutical Co., Ltd., Sanofi K.K., MSD K.K., Daiichi-Sankyo Company, Limited, Pfizer Co., Ltd., Mitsubishi Tanabe Pharma Corp., Astellas Pharma Inc., Takeda Pharmaceutical Co. Ltd., TEIJIN PHARMA LTD., Shionogi & Co. Ltd., Actelion Pharmaceuticals Ltd., Actelion Ltd., KOWA Pharmaceutical Company Ltd., Bayer Yakuhin, Ltd, lecture fees from Amgen Inc., Daiichi-Sankyo Company, Ltd., KOWA Pharmaceutical LTD., MSD K.K.

Ethics approval

The Institutional Review Board of the Juntendo University Hospital approved the study protocol (871).

Informed consent

The study complied with the Declaration of Helsinki. Informed consent was obtained from all patients.

Consent to publish

Consent to publish was obtained.

Consent to participate

All study participants provided informed consent.

Supplementary Information

Below is the link to the electronic supplementary material.

Supplementary file1 (DOCX 306 KB)

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Ishiwata, S., Kasai, T., Sato, A. et al. Prognostic effect of sleep-disordered breathing on hospitalized patients following acute heart failure. Clin Res Cardiol 111, 663–672 (2022).

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI:


  • Acute heart failure
  • Sleep-disordered breathing
  • Positive airway pressure