Long-term Auto-Servoventilation or Constant Positive Pressure in Heart Failure and Coexisting Central With Obstructive Sleep Apnea

Institute of Pneumology at the University Witten/Herdecke, Clinic for Pneumology and Allergology, Center of Sleep Medicine and Respiratory Care, Bethanien Hospital, Solingen, Germany.
Chest (Impact Factor: 7.48). 01/2012; 142(2):440-7. DOI: 10.1378/chest.11-2089
Source: PubMed


The coexistence of obstructive sleep apnea (OSA) and central sleep apnea (CSA) and Cheyne-Stokes respiration (CSR) is common in patients with heart failure (HF). While CPAP improves CSA/CSR by about 50%, maximal suppression is crucial in improving clinical outcomes. Auto-servoventilation (ASV) effectively suppresses CSA/CSR in HF, but few trials have been performed in patients with coexisting OSA and CSA/CSR. Our objective was to evaluate a randomized, controlled trial to compare the efficacy of ASV and CPAP in reducing breathing disturbances and improving cardiac parameters in patients with HF and coexisting sleep-disordered breathing.
Both modes were delivered using the BiPAP autoSV (Philips Respironics) over a 12-month period. Seventy patients (63 men, 66.3 ± 9.1 y, BMI 31.3 ± 6.0 kg/m(2)) had coexisting OSA and CSA/CSR, arterial hypertension, coronary heart disease, or cardiomyopathy and clinical signs of heart failure New York Heart Association classes II-III. Polysomnography, brain natriuretic peptide (BNP), spiroergometry, and echocardiography were performed at baseline and after 3 and 12 months of treatment.
Both modes of therapy significantly improved respiratory disturbances, oxygen desaturations, and arousals over the study period. ASV reduced the central apnea hypopnea index (baseline CPAP, 21.8 ± 11.7; ASV, 23.1 ± 13.2; 12 months CPAP, 10.7 ± 8.7; ASV, 6.1 ± 7.8, P < .05) and BNP levels (baseline CPAP, 686.7 ± 978.7 ng/mL; ASV, 537.3 ± 891.8; 12 months CPAP, 847.3 ± 1848.1; ASV, 230.4 ± 297.4; P < .05) significantly more effectively as compared with CPAP. There were no relevant differences in exercise performance and echocardiographic parameters between the groups.
ASV improved CSA/CSR and BNP over a 12-month period more effectively than CPAP.

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    • "demonstrated a decrease of the AHI from 49 to 9/h [16], which was confirmed in a long-term RCT [17]. The overall compliance was >4 h/night in both the CPAP and ASV group with no significant differences between them (CPAP 4.3 ± 2.3 vs ASV 5.2 ± 2.0 h/night). "

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    ABSTRACT: Background: Adaptive servoventilation (ASV) has demonstrated efficacy in treating sleep-disordered breathing (SDB) in patients with heart failure (HF), but large randomized trials are lacking. We, therefore, sought to perform a systematic review and meta-analysis of existing data. Methods: A systematic search of the PubMed database was undertaken in March 2012. Publications were independently assessed by two investigators to identify studies of ≥ 1-week duration that compared ASV to a control condition (ie, subtherapeutic ASV, continuous or bilevel pressure ventilation, oxygen therapy, or no treatment) in adult patients with SDB and HF. Mean, variability,and sample size data were extracted independently for the following outcomes: apneahypopnea index (AHI), left ventricular ejection fraction (LVEF), quality of life (SF-36 Health Survey; Medical Outcomes Trust), 6-min walk distance, peak oxygen consumption ( VO 2 ) % predicted, and ventilatory equivalent ratio for CO 2 ( VE / Vco 2 ) slope measured during exercise. Random effects meta-analysis models were applied. Results: Fourteen studies were identified (N = 538). Comparing ASV to control conditions, the weighted mean difference in AHI ( -14.64 events/h; 95% CI, -21.03 to - 8.25) and LVEF (0.40;95% CI, 0.08-0.71) both significantly favored ASV. ASV also improved the 6-min walk distance,but not peak O 2 % predicted, VE / VCO 2 slope, or quality of life, compared with control conditions. Conclusions: In patients with HF and SDB, ASV was more effective than control conditions in reducing the AHI and improving cardiac function and exercise capacity. These data provide a compelling rationale for large-scale randomized controlled trials to assess the clinical impact of ASV on hard outcomes in these patients.
    Full-text · Article · Jun 2012 · Chest
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    ABSTRACT: We tested the hypotheses that in patients with congestive heart failure (CHF) and sleep-disordered breathing (SDB) auto-servo ventilation (ASV) improves cardiac function and quality of life.Between 3/2007 and 9/2009 patients with stable CHF (left ventricular ejection fraction, LVEF≤40%) and SDB (apnea-hypopnea index, AHI ≥20·h(-1)) were randomized to either ASV (BiPAP ASV, Philips Respironics, n=37) and optimal medical management or optimal medical management alone (n=35). Outcomes were assessed at baseline and 12 weeks.The AHI assessed with polysomnography scored in one core-lab was significantly more reduced in the ASV-group (-39±16 vs. -1±13/hour, p<0.001) with an average use of 4.5±3.0 hours/day. Both groups showed similar improvements of the primary endpoint LVEF (+3.4±5 vs. +3.5±6%, p=0.915) assessed with echocardiography. In the ASV-group reduction of N-terminal pro brain natriuretic peptide (NT-proBNP) was significantly greater (-360±569 versus +135±625 ng·mL(-1), p=0.010). No differences were observed between the groups in subjective quality of life.In patients with CHF and SDB ASV reduced NT-proBNP levels, but improvement of LVEF or quality of life was not greater than in the control group. Data support that such patients can be randomized in large scale long-term trials of PAP therapy versus control to determine effects on cardiovascular outcome.
    Full-text · Article · Dec 2012 · European Respiratory Journal
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