Sleep and Breathing

, Volume 15, Issue 4, pp 701–709 | Cite as

The impact of positive airway pressure on cardiac status and clinical outcomes in patients with advanced heart failure and sleep-disordered breathing: a preliminary report

  • Apostolos Karavidas
  • Fotis Kapsimalis
  • George Lazaros
  • Evaggelos Markozanes
  • Sophia Arapi
  • Kiriaki Cholidou
  • Vassiliki Matzaraki
  • Konstantina Kyrkou
  • Dimitris Tsiachris
  • Evaggelos Matsakas
  • Vlassios Pyrgakis
  • Manos Alchanatis
Original Article



Heart failure (HF) is a major public health problem associated with high rates of morbidity and mortality. Patients with HF exhibit a high prevalence of sleep-disordered breathing (SDB). We have investigated the long-term impact of positive airway pressure (PAP) therapy on heart function and clinical outcomes in patients with advanced HF and concomitant SDB.

Materials and methods

We assessed 18 patients with advanced HF (New York Heart Association (NYHA) functional classification III–IV) and concomitant SDB (diagnosed with polysomnography) either of obstructive or central type. Eleven patients who received PAP therapy (auto-titrating PAP or adaptive servo-ventilation) for 12 months were compared with seven patients who refused this therapy. All participants were assessed at both baseline and end of follow-up for NYHA functional status, left and right ventricular function, neurohormonal activation, and exercise tolerance. The rates of hospitalization, deaths, and the combination of both were also recorded.


Patients treated with PAP achieved better functional status, higher left ventricular ejection fraction, improved longitudinal right ventricular contractile function, lower levels of b-type natriuretic peptide, and greater exercise performance compared to those who remained untreated. PAP-treated group had a significantly lower incidence of the prespecified combined end-point (i.e., hospital admissions and death) than the control group (87.5 vs. 18.2%, p = 0.013). Interestingly, the mortality rate was 28% (two out of seven patients) in the control group, while no deaths were recorded in the PAP-treated group.


In this preliminary study, we found that treatment of SDB, irrespective of type, in stable patients with advanced HF receiving optimal medical therapy was associated with improvement in cardiac functional status, ventricular contraction, physical performance, and neurohormonal status, leading to better clinical outcomes.


Heart failure Sleep-disordered breathing Positive airway pressure therapy Cardiac status Clinical outcome 


  1. 1.
    Braunwald E, Bristow M (2000) Congestive heart failure: 50 years of progress. Circulation 102:(20 Suppl 4):IV14–23Google Scholar
  2. 2.
    Sans S, Kesteloot H, Kromhout D (1997) The burden of cardiovascular diseases mortality in Europe. Task force of the European society of cardiology on cardiovascular mortality and morbidity statistics in Europe. Eur Heart J 18:1231–1248Google Scholar
  3. 3.
    The SOLVD Investigators (1991) Effect of enalapril on survival in patients with reduced left ventricular ejection fractions and congestive heart failure. N Eng J Med 325:293–302CrossRefGoogle Scholar
  4. 4.
    Shahar E, Whitney CW, Redline S, Lee ET, Newman AB, Javier Nieto F, O’Connor GT, Boland LL, Schwartz JE, Samet JM (2001) Sleep disordered breathing and cardiovascular disease: cross-sectional results of the sleep heart health study. Am J Respir Crit Care Med 163:19–25PubMedGoogle Scholar
  5. 5.
    Sin D, Fitzgerald F, Parker JD, Newton G, Floras JS, Bradley TD (1999) Risk factors for central and obstructive apnoea in 450 men and women with congestive heart failure. Am J Respir Crit Care Med 160:1101–1106PubMedGoogle Scholar
  6. 6.
    Javaheri S, Parker TJ, Liming JD, Corbett WS, Nishiyama H, Wexler L, Roselle GA (1998) Sleep apnea in 81 ambulatory male patients with stable heart failure. Circulation 97:2154–2159PubMedGoogle Scholar
  7. 7.
    Javaheri S, Parker TJ, Wexler L, Michaels SE, Stanberry E, Nishyama H, Roselle GA (1995) Occult sleep disordered breathing in stable congestive heart failure. Ann Intern Med 122:487–492PubMedGoogle Scholar
  8. 8.
    Bradley TD, Floras JS (2003) Sleep apnea and heart failure: Part I: obstructive sleep apnea. Circulation 107:1671–1678PubMedCrossRefGoogle Scholar
  9. 9.
    Bradley TD, Floras JS (2003) Sleep apnea and heart failure: Part II: central sleep apnea. Circulation 107:1822–1826PubMedCrossRefGoogle Scholar
  10. 10.
    Butt M, Dwivedi G, Khair O, Lip GY (2010) Obstructive sleep apnea and cardiovascular disease. Int J Cardiol 139:7–16PubMedCrossRefGoogle Scholar
  11. 11.
    Arzt M, Bradley TD (2006) Treatment of sleep apnea in heart failure. Am J Respir Crit Care Med 173:1300–1308PubMedCrossRefGoogle Scholar
  12. 12.
    De Backer W, Javaheri S (2007) Treatment of sleep apnea in heart failure. Sleep Med Clin 2:631–638CrossRefGoogle Scholar
  13. 13.
    Teschler H, Dohring J, Wang YM, Berthon-Jones M (2001) Adaptive pressure support servo-ventilation. A novel treatment for Cheyne–Stokes respiration in heart failure. Am J Respir Crit Care Med 164:614–619PubMedGoogle Scholar
  14. 14.
    Masa JF, Jimenez A, Duran J, Capote F, Monasterio C, Mayos M, Teran J, Hermandez L, Barbe F, Maimo A, Rubio M, Montserrat JM (2004) Alternative methods of titrtating continous positive airway pressure: a large multicenter study. Am J Respir Crit Care Med 170:1218–1224PubMedCrossRefGoogle Scholar
  15. 15.
    Massie CA, McArdle N, Hart RW, Schmidt-Nowara WW, Lankford A, Hudgel DW, Gordon N, Douglas NJ (2003) Comparison between automatic and fixed positive airway pressure therapy at home. Am J Respir Crit Care Med 167:20–23PubMedCrossRefGoogle Scholar
  16. 16.
    Smith LA, Vennelle M, Gardner RS, McDonagh TA, Denvir MA, Douglas NJ, Newby DE (2007) Auto-titrating continuous positive pressure therapy in continuous positive airway pressure in patients with chronic heart failure and obstructive sleep apnea: a randomized placebo-controlled trial. Eur Heart J 28:1221–1227PubMedCrossRefGoogle Scholar
  17. 17.
    Caples SM, Somers V (2007) CPAP treatment for obstructive sleep apnea in heart failure: expectations unmet. Eur Heart J 28:1184–1186PubMedCrossRefGoogle Scholar
  18. 18.
    Heart Failure Society of America (2006) Executive summary: HFSA 2006 comprehensive heart failure practice guideline. J Card Fail 12:10–38CrossRefGoogle Scholar
  19. 19.
    Iber C, Ancoli-Israel S, Chesson A, Quan SF, editors. 1st ed. Westchester, IL: American Academy of Sleep Medicine; 2007. The AASM manual for the scoring of sleep and associated events: rules, terminology, and technical specificationGoogle Scholar
  20. 20.
    Kushida CA, Littner MR, Morgenthaler T, Alessi CA, Bailey D, Coleman J Jr, Friedman L, Hirshkowitz M, Kapen S, Kramer M, Lee-Chiong T, Loube DL, Owens J, Pancer JP, Wise M (2005) Practice parameters for the indications for polysomnography and related procedures: an update for 2005. Sleep 28:499–521PubMedGoogle Scholar
  21. 21.
    Quiñones MA, Douglas PS, Foster E, Gorcsan J 3rd, Lewis JF, Pearlman AS, Rychik J, Salcedo EE, Seward JB, Stevenson JG, Thys DM, Weitz HH, Zoghbi WA (2003) ACC/AHA clinical competence statement on echocardiography: a report of the American College of Cardiology/American Heart Association/American College of Physicians-American Society of Internal Medicine Task Force on Clinical Competence. J Am Coll Cardiol 41:687–708PubMedCrossRefGoogle Scholar
  22. 22.
    Lang RM, Bierig M, Devereux RB, Flachskampf FA, Foster E, Pellikka PA, Picard MH, Roman MJ, Seward J, Shanewise J, Solomon S, Spencer KT, St John Sutton M, Stewart W (2006) American Society of Echocardiography’s Nomenclature and Standards Committee; Task force on chamber quantification; American College of Cardiology Echocardiography Committee; American Heart Association; European Association of Echocardiography, European Society of Cardiology. Recommendations for chamber quantification. Eur J Echocardiogr 7:79–108PubMedCrossRefGoogle Scholar
  23. 23.
    Donovan CL, Armstrong WF, Bach DS (1995) Quantitative Doppler tissue imaging of the left ventricular myocardium: validation in normal subjects. Am Heart J 130:100–104PubMedCrossRefGoogle Scholar
  24. 24.
    Karavidas A, Lazaros G, Matsakas E, Farmakis D, Parissis J, Paraskevaidis IA, Michailidis C, Avramidis D, Zacharoulis A, Arapi S, Kaoukis A, Zacharoulis A (2008) Clinical value of B-type natriuretic peptide for the assessment of left ventricular filling pressures in patients with systolic heart failure and inconclusive tissue Doppler indexes. Heart Vessels 23:181–186PubMedCrossRefGoogle Scholar
  25. 25.
    Opasich C, Pinna GD, Mazza A, Febo O, Riccardi R, Riccardi PG, Capomolla S, Forni G, Cobelli F, Tavazzi L (2001) Six-minute walking performance in patients with moderate to severe heart failure; is it a useful indicator in clinical practice? Eur Heart J 22:488–496PubMedCrossRefGoogle Scholar
  26. 26.
    Javaheri S (2006) Sleep disorders in systolic heart function: a prospective study in 100 male patients. The final report. Int J Cardiol 106:21–28PubMedCrossRefGoogle Scholar
  27. 27.
    Ferrier K, Campell A, Yee B, Richards M, O’Meeghan T, Weatherall M, Neill A (2005) Sleep-disordered breathing occurs frequently in stable outpatients with congestive heart failure. Chest 128:2116–2122PubMedCrossRefGoogle Scholar
  28. 28.
    Wang H, Parker JD, Newton GE, Floras JS, Mak S, Chiu KL, Ruttanaumpawan P, Tomlinson G, Bradley TD (2007) Influence of obstructive sleep apnea on mortality in patients with heart failure. J Am Coll Cardiol 49:1625–1631PubMedCrossRefGoogle Scholar
  29. 29.
    Kasai T, Narui K, Dohi T, Yanagisawa N, Ishiwata S, Ohno M, Yamaguchi T, Momomura S (2008) Prognosis of patients with heart failure and obstructive sleep apnea treated with continuous positive airway pressure. Chest 133:690–696PubMedCrossRefGoogle Scholar
  30. 30.
    Yumino D, Wang H, Floras JS, Newton GE, Mak S, Ruttanaumpawan P, Parker JD, Bradley TD (2009) Relationship between sleep apnoea and mortality in patients with ischemic heart failure. Heart 95:819–824PubMedCrossRefGoogle Scholar
  31. 31.
    Roebuck T, Solin P, Kaye DM, Bergin P, Bailey M, Naughton MT (2004) Increased long-term mortality in heart failure due to sleep apnea is not yet proven. Eur Respir J 23:735–740PubMedCrossRefGoogle Scholar
  32. 32.
    Andreas S, Hagenah G, Moller C, Werner GS, Kreuzer H (1996) Cheyne-Stokes respiration and prognosis in congestive heart failure. Am J Cardiol 78:1260–1264PubMedCrossRefGoogle Scholar
  33. 33.
    Finley LJ, Zwillich CW, Ancoli-Israel S, Kripke D, Tisi G, Moser KM (1985) Cheyne-Stokes breathing during sleep in patients with left ventricular heart failure. S Med J 78:11–15CrossRefGoogle Scholar
  34. 34.
    Lanfranchi PA, Braghiroli A, Bosimini E, Mazzuero G, Colombo R, Donner CF, Giannuzzi P (1999) Prognostic value of nocturnal Cheyne stokes respiration in chronic heart failure. Circulation 99:1435–1440PubMedGoogle Scholar
  35. 35.
    Sin DD, Logan AG, Fitzerald FS, Liu PP, Bradley TD (2000) Effects of continuous positive airway pressure on cardiovascular outcomes in heart failure in patients with and without Cheyne-Stokes respiration. Circulation 102:61–66PubMedGoogle Scholar
  36. 36.
    Hanly PJ, Zuberi-Khokhar NS (1996) Increased mortality associated with Cheyne-Stokes respiration in patients with congestive heart failure. Am J Respir Crit Care Med 153:272–276PubMedGoogle Scholar
  37. 37.
    Johnson CB, Beanlands RS, Yoshinaga K, Haddad H, Leech J, de Kemp R, Burwash IG (2008) Acute and chronic effects of continuous positive airway pressure therapy on left ventricular systolic and diastolic function in patients with obstructive sleep apnea and congestive heart failure. Can J Cardiol 24:697–704PubMedCrossRefGoogle Scholar
  38. 38.
    Malone S, Liu PP, Holloway R, Rutherford R, Xie A, Bradley TD (1991) Obstructive sleep apnea in patient with dilated cardiomyopathy; effects of continuous positive airway pressure. Lancet 338:1480–1484PubMedCrossRefGoogle Scholar
  39. 39.
    Kaneko Y, Floras JS, Usui K, Plante J, Tkacova R, Kubo T, Ando S, Bradley TD (2003) Cardiovascular effects of continuous positive airway pressure in patients with heart failure and obstructive sleep apnea. N Eng J Med 348:1233–1241CrossRefGoogle Scholar
  40. 40.
    Mansfield DR, Gollogly NC, Kaye DM, Richardson M, Bergin P, Naughton MT (2004) Controlled trial of continuous positive airway pressure therapy in obstructive sleep apnea and heart failure. Am J Respir Crit Care Med 169:361–366PubMedCrossRefGoogle Scholar
  41. 41.
    Bradley TD, Logan AG, Kimoff RJ, Sériès F, Morrison D, Ferguson K, Belenkie I, Pfeifer M, Fleetham J, Hanly P, Smilovitch M, Tomlinson G, Floras JS (2005) CANPAP Investigators. Continuous positive airway pressure for central sleep apnea and heart failure. N Eng J Med 353:2025–2033CrossRefGoogle Scholar
  42. 42.
    Arzt M, Wensel R, Montalvan S, Schichtl T, Schroll S, Budweiser S, Blumberg FC, Riegger GA, Pfeifer M (2008) Effects of dynamic bi-level airway pressure support on central sleep apnea in men with heart failure. Chest 134:61–66PubMedCrossRefGoogle Scholar
  43. 43.
    Naughton MT, Liu PP, Bernard DC, Goldstein RS, Bradley TD (1995) Treatment of congestive heart failure and Cheyne stokes during sleep by continuous positive airway pressure. Am J Respir Crit Care Med 151:92–97PubMedGoogle Scholar
  44. 44.
    Naughton MT, Benard DC, Liu PP, Rutherford R, Rankin F, Bradley TD (1995) Effects of nasal CPAP on sympathetic activity in patients with heart failure and central sleep apnea. Am J Respir Crit Care Med 152:473–479PubMedGoogle Scholar
  45. 45.
    Javaheri S (2000) Effects of continuous positive airway pressure on sleep apnea and ventricular irritability in patients with HF. Circulation 101:392–397PubMedGoogle Scholar
  46. 46.
    Buckle P, Millar T, Kryger M (1992) The effects of short term nasal CPAP on Cheyne-Stokes respiration in congestive heart failure. Chest 102:31–35PubMedCrossRefGoogle Scholar
  47. 47.
    Javaheri S (2006) CPAP should not be used for central sleep apnea in congestive sleep apnea. J Clin Sleep Med 2:399–402PubMedGoogle Scholar
  48. 48.
    Philippe C, Stoïca-Herman M, Drouot X, Raffestin B, Escourrou P, Hittinger L, Michel PL, Rouault S, d’Ortho MP (2005) Compliance with and efficacy of adaptive servo-ventilation (ASV) versus continuous positive airway pressure (CPAP) in the treatment of Cheyne-Stokes respiration in heart failure over a 6 month period. Heart 92:337–342PubMedCrossRefGoogle Scholar
  49. 49.
    Oldenburg O, Schmidt A, Lamp B, Bitter T, Muntean BG, Langer C (2008) Adaptive servo ventilation improves cardiac function in patients with chronic heart failure and Cheyne-Stokes respiration. Eur J Heart Fail 10:581–586PubMedCrossRefGoogle Scholar
  50. 50.
    Kasai T, Usui Y, Yoshioka T, Yanagisawa N, Takata Y, Narui K, Yamaguchi T, Yamashina A, Momomura SI (2010) JASV Investigators. Effect of flow-triggered adaptive servo-ventilation compared with continuous positive airway pressure in patients with chronic heart failure with coexisting obstructive sleep apnea and Cheyne-Stokes respiration. Circ Heart Fail 3:140–148PubMedCrossRefGoogle Scholar
  51. 51.
    Hastings PC, Vazir A, Meadows GE, Dayer M, Poole-Wilson PA, McIntyre HF, Morrell MJ, Cowie MR, Simonds AK (2010) Adaptive servo-ventilation in heart failure patients with sleep apnea: a real world study. Int J Cardiol 139:17–24PubMedCrossRefGoogle Scholar
  52. 52.
    Nagueh SF, Middleton KJ, Kopelen HA, Zoghbi WA, Quinones MA (1997) Doppler tissue imaging: a noninvasive technique for evaluation of left ventricular relaxation and estimation of filling pressures. J Am Coll Cardiol 30:1527–1533PubMedCrossRefGoogle Scholar
  53. 53.
    Ommen SR, Nishimura RA, Appleton CP, Miller FA, Oh JK, Redfield MM, Tajik AJ (2000) Clinical utility of Doppler echocardiography and tissue Doppler imaging in the estimation of left ventricular filling pressures: a comparative simultaneous Doppler-catheterization study. Circulation 102:1788–1794PubMedGoogle Scholar
  54. 54.
    Eskafi M, Cline C, Nilner M, Israelsson B (2006) Treatment of sleep apnea in congestive heart failure with a dental device: the effect on brain natriuretic peptide and quality of life. Sleep Breath 10:90–97PubMedCrossRefGoogle Scholar
  55. 55.
    Nahmias J, Lao R, Karetzky M (1996) Right ventricular dysfunction in obstructive sleep apnoea: reversal with nasal continuous positive airway pressure. Eur Respir J 9:945–951PubMedCrossRefGoogle Scholar
  56. 56.
    Arias MA, García-Río F, Alonso-Fernández A, Martínez I, Villamor J (2006) Pulmonary hypertension in obstructive sleep apnoea: effects of continuous positive airway pressure: a randomized, controlled cross-over study. Eur Heart J 27:1106–1113PubMedCrossRefGoogle Scholar
  57. 57.
    Olsson LG, Swedberg K, Clark AL, Witte KK, Cleland JG (2005) Six minute corridor test as an outcome measure for the assessment of treatment in randomized, blinded, intervention trials of chronic heart failure: a systematic review. Eur Heart J 26:778–793PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag 2010

Authors and Affiliations

  • Apostolos Karavidas
    • 1
  • Fotis Kapsimalis
    • 2
  • George Lazaros
    • 1
  • Evaggelos Markozanes
    • 2
  • Sophia Arapi
    • 1
  • Kiriaki Cholidou
    • 2
  • Vassiliki Matzaraki
    • 1
  • Konstantina Kyrkou
    • 2
  • Dimitris Tsiachris
    • 1
  • Evaggelos Matsakas
    • 1
  • Vlassios Pyrgakis
    • 1
  • Manos Alchanatis
    • 2
  1. 1.Department of CardiologyAthens General HospitalAthensGreece
  2. 2.Sleep Laboratory, 1st Department of Respiratory MedicineUniversity of Athens, Sotiria Hospital for Chest DiseasesAthensGreece

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