Cycle length identifies obstructive sleep apnea and central sleep apnea in heart failure with reduced ejection fraction

  • Thomas Bitter
  • Burak Özdemir
  • Henrik Fox
  • Dieter Horstkotte
  • Olaf Oldenburg
Sleep Breathing Physiology and Disorders • Original Article



To clarify whether unmasking of central sleep apnea during continuous positive airway pressure (CPAP) initiation can be identified from initial diagnostic polysomnography (PSG) in patients with heart failure with reduced ejection fraction (HFREF) and obstructive sleep apnea (OSA)

Materials and methods

Forty-three consecutive patients with obstructive sleep apnea and central sleep apnea (OSA/CSA) in HFREF were matched with 43 HFREF patients with OSA and successful CPAP initiation. Obstructive apneas during diagnostic PSG were then analyzed for cycle length (CL), ventilation length (VL), apnea length (AL), time to peak ventilation (TTPV), and circulatory delay (CD). We calculated duty ratio (DR) as the ratio of VL/CL and mathematic loop gain (LG).


While AL was similar, CL, VL, TTPV, CD, and DR was significantly longer in patients with OSA/CSA compared to those with OSA, and LG was significantly higher. Receiver operator curves identified optimal cutoff values of 50.2 s for CL (area under the curve (AUC) 0.85, 29.2 s for VL (AUC 0.92), 11.5 s for TTPV (AUC 0.82), 26.4 s for CD (AUC 0.79), and 3.96 (AUC 0.78)) respectively for LG to identify OSA/CSA.


OSA/CSA in HFREF can be identified by longer CL, VL, TTPV, and CD from obstructive events in initial diagnostic PSG. The underlying mechanisms seem to be the presence of an increased LG.


Sleep apnea Heart failure Treatment-emergent central sleep apnea Cycle length Complex sleep apnea 


Compliance with ethical standards

The study was approved by the Ethical Review Board of the Ruhr University, Bochum, and has therefore been performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments.

Conflict of interest

Olaf Oldenburg reports personal fees from ResMed, personal fees from LivaNova, personal fees from Novartis, and personal fees from Bayer, outside the submitted work. The other authors declare that they have no conflicts of interest.


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Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  • Thomas Bitter
    • 1
  • Burak Özdemir
    • 1
  • Henrik Fox
    • 1
  • Dieter Horstkotte
    • 1
  • Olaf Oldenburg
    • 1
  1. 1.Clinic for Cardiology, Herz- und Diabeteszentrum NRWRuhr-Universität BochumBad OeynhausenGermany

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