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Sleep-disordered breathing in heart failure

Authors: Atul Malhotra, MD, James C Fang, MD

Section Editor: M Safwan Badr, MD
Deputy Editor: April F Eichler, MD, MPH

All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Jun 2018. | This topic last updated: Jul 10, 2018.

INTRODUCTION — Sleep-disordered breathing (SDB) is common and under-diagnosed in patients

with heart failure across a range of ejection fractions and New York Heart Association (NYHA)
classes. The most common forms of SDB in heart failure patients are obstructive sleep apnea and
central sleep apnea with Cheyne-Stokes breathing. SDB is important to recognize because it is
associated with adverse cardiovascular outcomes and mortality, and because accumulating evidence
suggests that treatment of SDB can improve heart failure-related outcomes and quality of life.

In this review, the prevalence, risk factors, pathogenesis, clinical manifestations, diagnosis, and
treatment of SDB in patients with heart failure are discussed. In addition, the impact of treatment on
heart failure-related outcomes is reviewed. The treatment of SDB in more general populations is
discussed separately. (See "Management of obstructive sleep apnea in adults" and "Central sleep
apnea: Treatment".)

OBSTRUCTIVE VERSUS CENTRAL SLEEP APNEA — Two types of sleep-disordered breathing

(SDB) are common among patients with heart failure: obstructive sleep apnea (OSA) and central
sleep apnea with Cheyne-Stokes breathing (CSA-CSB):

● OSA is characterized by reductions or cessations of airflow during sleep, despite ongoing

respiratory effort. It is due to upper airway obstruction. (See "Clinical presentation and diagnosis
of obstructive sleep apnea in adults", section on 'Diagnosis'.)

● CSB is characterized by cyclic crescendo-decrescendo respiratory effort and airflow during

wakefulness or sleep, without upper airway obstruction. When the decrescendo effort is
accompanied by apnea during sleep, it is considered a type of central sleep apnea syndrome.
(See "Polysomnography in the evaluation of sleep-disordered breathing in adults", section on
'Cheyne-Stokes respiration' and "Central sleep apnea: Risk factors, clinical presentation, and
diagnosis", section on 'Diagnostic criteria'.)

We refer to OSA and CSA-CSB collectively as sleep-disordered breathing (SDB) in this review. They
frequently coexist and can be clinically difficult to distinguish from one another because there is

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overlap in pathophysiology and clinical manifestations.

PATHOGENESIS — The pathogenesis of obstructive sleep apnea (OSA) and central sleep apnea
with Cheyne-Stokes breathing (CSA-CSB) are best conceptualized as distinct processes, although
they share common pathophysiologic principles.

The pathogenesis of OSA involves abnormalities in pharyngeal anatomy, pharyngeal function, and
ventilatory control. In patients with heart failure, edema of the upper airway is an additional factor that
may contribute to pharyngeal airway narrowing [1]. The pathogenesis of OSA is discussed in detail
separately. (See "Pathophysiology of obstructive sleep apnea in adults".)

The pathogenesis of CSA-CSB is uncertain, but the favored hypothesis is based on the observation
that patients who have heart failure and CSA-CSB tend to have lower arterial carbon dioxide tensions
(PaCO2) than patients who have heart failure without CSA-CSB [2,3]. It is best conceptualized as a
sequence of events:

● In an effort to correct the hypocapnia, a hypersensitive respiratory control center initiates an

apnea. This occurs when the PaCO2 is below the "apneic threshold." The PaCO2 then begins to
rise.

● The duration from the beginning of the apnea until the respiratory control center detects the
increasing PaCO2 is prolonged due to the increased circulatory time caused by the heart failure.
Although some circulatory delay is required for CSA-CSB to occur, its importance as a contributor
to CSA-CSB is debated [4].

● Hypercapnia exists by the time the respiratory control center terminates the apnea.

● The hypercapnia then stimulates robust hyperpnea, which yields marked hypocapnia and allows
the cycle of events to repeat.

The net effect is oscillation of ventilation between apnea and hyperpnea. Elimination of the
hypocapnia with inhaled CO2, continuous positive airway pressure (CPAP), or oxygen can markedly
attenuate CSA-CSB [5-8].

Both OSA and CSA-CSB can impair systolic and diastolic cardiac function by a variety of
mechanisms. First, intermittent hypoxemia and arousals induce adrenergic surges that may lead to
heart disease progression. Second, the extremely negative intrapleural pressures increase ventricular
transmural wall stress and afterload [9].

The second mechanism can be described in detail as follows. Transmural pressure of the left ventricle
is the pressure inside the left ventricle minus the pressure outside the left ventricle (ie, approximately
the intrathoracic or pleural pressure). During spontaneous inspiration, the intrathoracic pressure
becomes more negative, which increases the transmural pressure. The increase in transmural
pressure contributes to left ventricular wall stress during left ventricular ejection (ie, afterload). This
effect is greater in patients with heart failure who must generate more negative intrathoracic pressures
to overcome low lung compliance caused by pulmonary congestion [10].

PREVALENCE AND RISK FACTORS — While obstructive sleep apnea (OSA) is more common than
central sleep apnea with Cheyne-Stokes breathing (CSA-CSB) in the general population, CSA-CSB

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may be more common than OSA in patients with heart failure [11,12].

Single-center observational studies estimate that the prevalence of SDB may be as high as 50 percent
among all patients with heart failure and as high as 70 percent among patients with heart failure who
are referred to a sleep laboratory [11-14]. The prevalence may be even higher among patients with
acute decompensated heart failure [15], as suggested by a study that detected an apnea-hypopnea
index ≥10 events per hour of sleep in 22 out of 29 such patients (76 percent) [16].

Such prevalence estimates are limited by referral bias, variable definitions of SDB, variable severities
of heart failure, and variable optimization of the medical management of the heart failure.

SDB appears to be common even among patients whose heart failure is optimally managed. A
prospective cohort study followed 108 patients who visited a heart failure clinic with stable heart
failure, which was defined as clinical stability without hospitalizations or medication changes within the
past 30 days [17]. SDB was detected in 61 percent of patients and was independently associated with
the presence of atrial fibrillation and a worse New York Heart Association (NYHA) functional class.

Risk factors for SDB in patients with heart failure vary according to the type of SDB. Risk factors for
OSA include advanced age and an increasing body mass index (BMI). Risk factors for CSA-CSB in
patients with heart failure include male gender, advanced age, atrial fibrillation, and hypocapnia (ie,
transcutaneous carbon dioxide ≤38 mmHg) [14].

PROGNOSTIC IMPLICATIONS — Sleep-disordered breathing (SDB) in patients with heart failure is

under-recognized but important because it may independently predict mortality due to heart failure
and may contribute to disease progression.

Multiple observational studies have found that heart failure accompanied by SDB is associated with a
worse prognosis than heart failure in the absence of SDB [18]. This is illustrated by the following
observations:

● With respect to obstructive sleep apnea (OSA), a prospective cohort study followed 164 patients
who had heart failure and a left ventricular ejection fraction of 45 percent or less [19]. At a mean
of three years, patients who had OSA (defined as an apnea-hypopnea index (AHI) of at least 15
events per hour) had a higher cardiac mortality than patients who did not have OSA (8.7 versus
4.2 deaths per 100 patient-years).

● With respect to central sleep apnea with Cheyne-Stokes breathing (CSA-CSB), a prospective
cohort study followed 62 patients with NYHA class II to III heart failure [20]. At a mean of 28
months, cardiac mortality was associated with an AHI greater than 30 events per hour. The AHI
was a better predictor of cardiac mortality than demographic variables, Holter monitoring,
exercise studies, echocardiography, or autonomic testing. CSB was found to predict mortality in
numerous other studies of patients with heart failure [12,21-24].

These studies do not definitively indicate the mechanism by which SDB is associated with increased
cardiac mortality. SDB could be a marker of more severe heart failure, a precipitant of worsening heart
failure, or both. SDB may also carry prognostic implications for hospitalized patients [25].

CLINICAL FEATURES — Sleep-disordered breathing (SDB) can be asymptomatic or symptomatic in

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patients who have heart failure [26]. A sleep history should be sought from both the patient and the
bed partner because, in many cases, it is only the bed partner who is aware of the abnormal
ventilatory pattern.

● When obstructive sleep apnea (OSA) is the predominant type of SDB, poor sleep quality and
snoring are common. As a result, sleep disruption and easy fatigability often exist and may be out
of proportion to the severity of the heart failure. However, sleepiness is relatively uncommon in
patients with heart failure for reasons that remain unclear [27].

While not specific to OSA, additional signs and symptoms may include awakening with a
sensation of gasping or choking, morning headaches, and poor concentration or memory
impairment (table 1). (See "Clinical presentation and diagnosis of obstructive sleep apnea in
adults", section on 'Clinical features'.)

● When central sleep apnea with Cheyne-Stokes breathing (CSA-CSB) is the predominant type of
SDB, symptoms due to CSA-CSB may be indistinguishable from those due to the heart failure
[11]. Symptoms of poor sleep quality (eg, excessive daytime sleepiness) are subtle and generally
unreliable. Occasionally, patients with CSA-CSB report paroxysmal nocturnal dyspnea (due to the
hyperpnea that follows an apnea) [28]. A bed partner may report episodic hyperpnea, hypopnea,
and apneic periods. (See "Central sleep apnea: Risk factors, clinical presentation, and diagnosis",
section on 'Clinical findings'.)

SDB may contribute to nocturnal angina in patients with heart failure, presumably due to hypoxemia
and catecholamine release [28].

In addition, recurrent arrhythmias, such as atrial fibrillation or ventricular tachycardia, may be triggered
or perpetuated by SDB [14,29-32]. SDB has also been identified as a risk factor for appropriate
cardioverter-defibrillator therapies in heart failure patients with ICDs. (See "Ventricular arrhythmias in
heart failure and cardiomyopathy".)

These arrhythmias often occur in the absence of any symptoms or signs of SDB. Thus, a high index of
suspicion should be maintained and evaluation for SDB should be considered in heart failure patients
with recurrent arrhythmias.

WHO SHOULD BE TESTED? — Patients with heart failure who report snoring, excessive daytime
somnolence, and poor sleep quality should have their sleep patterns assessed formally by
polysomnography in a sleep laboratory or out-of-center sleep testing. We also consider diagnostic
testing for sleep-disordered breathing (SDB) in heart failure patients with the following symptoms and
signs, since they have been associated with SDB in observational studies:

● Nocturnal angina

● Recurrent arrhythmias

● Refractory heart failure symptoms

● Witnessed abnormal respiratory pattern or apneas

● Repetitive oxygen desaturations during sleep [15]

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The American College of Cardiology/American Heart Association (ACC/AHA) guidelines on the

diagnosis and treatment of chronic heart failure indicate that clinical judgment should be used to
screen for SDB in selected patients (eg, those with risk factors) [33].

It is not known whether screening questionnaires developed in the general OSA population (eg,
STOP-Bang, sleep apnea clinical score [SACS], Berlin questionnaire) have any validity in heart failure
patients to help identify which patients to refer for a diagnostic sleep study. In addition, with a pretest
probability of 50 percent or greater in heart failure patients, it is unclear whether a screening
questionnaire would add any additional benefit [34]. In a prospective study that included over 1500
patients with heart failure, a 7-item questionnaire assessing snoring, nocturnal sweating, nocturia,
witnessed apneas, chronic fatigue, and frequent napping had low sensitivity and specificity for the
diagnosis of SDB [35].

The use of screening questionnaires in the general population is reviewed in detail separately. (See
"Clinical presentation and diagnosis of obstructive sleep apnea in adults", section on 'Screening
questionnaires'.)

DIAGNOSIS — The diagnostic evaluation of suspected sleep-disordered breathing (SDB) is the same
for patients with or without heart failure. An in-laboratory overnight polysomnogram is the gold
standard diagnostic test.

Out-of-center sleep testing is also available and is now sometimes mandated by insurers for
uncomplicated OSA. Although it has not been as well studied in patients with heart failure, who are at
risk for more complicated SDB, emerging data suggest that unattended diagnostic sleep studies may
be feasible and accurate in patients hospitalized with heart failure and allow for expedited diagnosis
and treatment [36-38].

These tests are described separately, as are the diagnostic criteria for obstructive sleep apnea (OSA)
and central sleep apnea syndromes. (See "Home sleep apnea testing for obstructive sleep apnea in
adults" and "Clinical presentation and diagnosis of obstructive sleep apnea in adults" and "Central
sleep apnea: Risk factors, clinical presentation, and diagnosis" and "Polysomnography in the
evaluation of sleep-disordered breathing in adults".)

MANAGEMENT — Management of sleep-disordered breathing (SDB) in patients with heart failure

should focus both on optimizing heart failure and treating the abnormal breathing pattern.

Heart failure therapy — Case series and observational studies suggest that the following
interventions are associated with improved SDB in patients with heart failure:

● Medical management (eg, ACE inhibitors, beta blockers, and diuretics) [1,19,39,40]

● Cardiac transplantation [41-43]

● Cardiac resynchronization (ie, biventricular pacing) [44-46]

● Left ventricular assist device (LVAD) implantation [47]

For the most part, such interventions do not lead to complete resolution of the abnormal breathing
pattern and should be considered complementary to positive airway pressure therapy.

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Treatment of heart failure is discussed in detail separately. (See "Overview of the therapy of heart
failure with reduced ejection fraction" and "Treatment and prognosis of heart failure with preserved
ejection fraction" and "Management of refractory heart failure with reduced ejection fraction" and
"Short-term mechanical circulatory assist devices".)

Positive airway pressure therapy — For patients who have heart failure complicated by obstructive
sleep apnea (OSA) or central sleep apnea with Cheyne-Stokes breathing (CSA-CSB), continuous
positive airway pressure (CPAP) therapy may improve cardiac function, blood pressure, exercise
capacity, and quality of life [7,22,48-55]. Limited data also suggest that treatment can reduce the
burden of arrhythmias. (See "Obstructive sleep apnea and cardiovascular disease in adults".)

A major limitation with this body of evidence is that most studies evaluated the impact of SDB therapy
on surrogate outcomes (eg, blood pressure, catecholamine levels, cardiac function) and did not
measure clinically important outcomes (eg, quality of life, hospitalizations, mortality, functional class).

Taken together, the evidence suggests that CPAP may improve heart failure-related outcomes in
patients who have persistent SDB despite optimization of their heart failure. The 2013 American
College of Cardiology Foundation/American Heart Association (ACCF/AHA) guidelines for the
management of heart failure endorse treatment of SDB in patients with heart failure for the purposes
of increasing left ventricular ejection fraction and improving functional status [33].

Alternatives to positive airway pressure therapy for patients with OSA, such as oral appliances,
surgery, and hypoglossal nerve stimulation, have not been adequately studied in patients with heart
failure.

For patients with predominantly central sleep apnea who fail or do not tolerate CPAP, increased
caution is warranted when considering alternative modes of positive airway pressure therapy, such as
adaptive servo-ventilation (ASV) or bilevel positive airway pressure (BPAP) with a backup rate. In
these patients, options include optimization of heart failure therapy and nocturnal oxygen.

The treatment of SDB, including indications and the choice of therapy, are discussed separately. (See
"Management of obstructive sleep apnea in adults" and "Central sleep apnea: Treatment".)

Heart failure outcomes

Continuous positive pressure — With respect to patients whose heart failure is complicated
by OSA, two small randomized trials (n = 55, n = 24) found that CPAP improved left ventricular
ejection fraction compared to untreated controls [49,50], although this finding has not been universal
[51]. A meta-analysis that included six randomized trials found that CPAP was associated with a 5
percent improvement in ejection fraction in patients with heart failure and OSA [56]. A randomized trial
that directly compared CPAP to bilevel positive airway pressure (BPAP) found greater improvement in
cardiac function among patients receiving BPAP [52].

With respect to patients whose heart failure is complicated by CSA-CSB, CPAP appears to improve
exercise capacity, cardiac function, and nocturnal oxygenation, while decreasing catecholamine levels
[7,22,48,54].

The most robust data come from the Canadian Positive Airway Pressure (CANPAP) trial, in which 258

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patients who had heart failure and central sleep apnea syndrome were randomly assigned to receive
CPAP or no CPAP for two years [48]. The CPAP group had a greater reduction in the apnea-hypopnea
index (AHI), as well as greater improvements in mean nocturnal arterial oxyhemoglobin saturation, left
ventricular ejection fraction, and the six-minute walk distance than the control group. However, there
were no differences in the number of hospitalizations, quality of life, or transplant-free survival. There
was an early mortality hazard associated with CPAP use, which may have been related to decreases
in cardiac output among patients who were particularly preload dependent (eg, hypovolemic patients,
patients with atrial fibrillation). A major limitation of the study is that the CPAP level was not titrated to
effect.

In a post hoc subgroup analysis from the CANPAP trial, patients whose AHI was reduced to less than
15 events per hour by CPAP therapy had significant improvement in ejection fraction and transplant-
free survival compared to controls, although the latter barely reached statistical significance (figure 1)
[54]. There are two potential interpretations of this result. First, therapies that effectively and
consistently lower the AHI may improve outcomes. Alternatively, improvement of AHI may not be a
result of the CPAP per se, but simply a marker of a good prognosis that is unrelated to CPAP therapy.

Adaptive servoventilation — Adaptive servo-ventilation (ASV), a modified method of delivering

positive airway pressure, has also been studied as a treatment for CSA-CSB in patients with heart
failure. In patients with stable heart failure, a meta-analysis of 14 randomized studies (n = 538)
comparing ASV to a control condition (subtherapeutic ASV, CPAP, supplemental oxygen or no
treatment) found that ASV significantly improved AHI, left ventricular ejection fraction, and exercise
capacity [57].

However, results of a large randomized trial (SERVE-HF) of ASV in patients with symptomatic heart
failure (New York Heart Association [NYHA] class II to IV) and a low ejection fraction (EF ≤45 percent)
have raised concern that ASV may be harmful in this population [58]. With a median follow-up of 31
months, patients treated with ASV had an increased risk of both cardiovascular mortality (30 versus
24 percent; HR 1.34, 95% CI 1.09-1.65) and all-cause mortality (35 versus 29 percent; hazard ratio
[HR] 1.28, 95% CI 1.06-1.55) compared with the control arm. Based on these results, ASV should not
be initiated in patients with CSA-CSB due to symptomatic heart failure and a low EF [59]. Decisions
about continuing or stopping therapy in patients already being treated with ASV should be
individualized after disclosure of the available data from the SERVE-HF study and re-evaluation of the
balance of risks and benefits [60,61]. (See "Central sleep apnea: Treatment", section on 'Patients with
ejection fraction ≤45 percent'.)

The use of ASV to treat CSA in hospitalized patients with heart failure has also been attempted. A trial
of 126 hospitalized patients (CAT-HF) with heart failure and moderate-to-severe sleep apnea (AHI
>15, predominantly CSA) failed to show a difference in a combined endpoint of death, cardiovascular
hospitalizations, and timed walk distance in patients randomly assigned to ASV plus optimized
medical therapy compared with optimized medical therapy alone (HR 1.06, 95% CI 0.75-1.51) [62].
The trial was stopped early, in part due to the SERVE-HF trial results, which limits the interpretation of
these results. A subgroup analysis found that patients with preserved ejection fraction derived benefit
from ASV, but small numbers limit confidence in the finding, and further study is required in these
patients.

Arrhythmias — Limited data suggest that treatment of SDB might reduce ventricular arrhythmia

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burden in heart failure patients with implantable cardioverter-defibrillators (ICDs). In an observational

study that included 182 heart failure patients with an ICD and evidence of moderate to severe SDB on
sleep polygraphy (AHI >15 events per hour), there was a significant prolongation in the time to first
cardioverter-defibrillator therapy in patients who were treated with ASV compared with those who
were not (35 versus 26 months) [63]. This effect remained significant in an adjusted analysis, although
since therapy was non-randomized, results remain susceptible to confounding by unmeasured
variables.

Overall survival — It is unknown whether positive airway pressure therapy improves heart failure-
related mortality in patients with sleep apnea. As discussed above, published randomized trials of
CPAP in patients with heart failure, such as the CANPAP trial, have failed to show a difference in
overall survival [48].

In the subset of patients with CSA-CSB due to symptomatic heart failure and a low ejection fraction,
there is now concern that one form of positive airway pressure, ASV, may actually increase the risk of
cardiovascular mortality [58]. (See "Central sleep apnea: Treatment", section on 'Patients with ejection
fraction ≤45 percent'.)

Weight loss and exercise — Obesity is the most important risk factor for OSA in the general adult
population as well as those with heart failure. While weight loss alone rarely leads to complete
remission of OSA, it has been shown to decrease the apnea-hypopnea index (AHI), improve quality of
life, and probably decrease daytime sleepiness in unselected patients with OSA. Exercise can
promote weight loss and may also be of benefit independent of weight loss. (See "Management of
obstructive sleep apnea in adults", section on 'Weight loss and exercise'.)

In heart failure patients specifically, exercise programs have shown mixed results in small studies. In
one study, a six-month aerobic exercise program reduced the number of central but not obstructive
apneas [64]. In another study, a four-month exercise training program improved the AHI, minimum
oxyhemoglobin saturation, and sleep quality in patients with OSA but not central sleep apnea [65].

Other therapies — Positive airway pressure therapy is the mainstay of treatment for SDB in patients
with and without heart failure. Limited data also suggest that nocturnal oxygen is beneficial in heart
failure patients with CSB who have hypoxemia during sleep. Theophylline has also been explored in
patients with heart failure, but more data are needed before it can be suggested for use in this setting.

Nocturnal oxygen — Supplemental oxygen during sleep, typically used along with positive airway
pressure, is suggested for patients with CSA-CSB who have hypoxemia during sleep [66]. It is also
suggested in patients who do not tolerate positive airway pressure therapy. (See "Central sleep
apnea: Treatment", section on 'Supplemental oxygen during sleep'.)

This practice is supported by several small randomized trials demonstrating that low flow nocturnal
oxygen (2 to 3 L/min) reduces CSB and improves left ventricular function, heart failure functional
class, sleep quality, and cognitive function [8,40,67-73]. However, this evidence is limited by small
sample sizes and use of short-term and surrogate outcomes. In various studies, the relative reduction
in AHI achieved by nocturnal oxygen ranged from 30 to 80 percent of baseline [67]; in the largest
study (n = 36), the mean AHI decreased from 49 to 29 events per hour [74]. In two small studies that
compared nocturnal oxygen with CPAP (19 total patients), both therapies were effective compared

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with baseline and the magnitude of the reduction in AHI was similar between groups [75,76].

Although data on clinically important outcomes remain limited, no harm has been demonstrated in
these studies. Theoretical risks of hyperoxia have not been observed to date in small studies using
oxygen supplementation to relieve hypoxemia.

Theophylline — The possible role of theophylline in patients with heart failure complicated by SDB
was evaluated in a double-blind cross-over trial of 15 such patients who received either theophylline or
placebo twice daily for five days [77]. Theophylline reduced the number of apneas plus hypopneas, as
well as the percentage of sleep time during which the arterial oxyhemoglobin saturation was less than
90 percent. Clinical outcome data are required before routine use of theophylline can be
recommended in this setting.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from

selected countries and regions around the world are provided separately. (See "Society guideline
links: Heart failure in adults" and "Society guideline links: Sleep-related breathing disorders in adults".)

SUMMARY AND RECOMMENDATIONS

● Two types of sleep-disordered breathing are common among patients with heart failure:
obstructive sleep apnea (OSA) and central sleep apnea with Cheyne-Stokes breathing (CSA-
CSB). They are referred to collectively as sleep-disordered breathing (SDB). (See 'Obstructive
versus central sleep apnea' above.)

● Patients who have heart failure and SDB can be asymptomatic or symptomatic. Symptoms
typically include snoring and/or consequences of disrupted sleep (eg, excessive daytime
sleepiness, fatigue). Nocturnal angina, paroxysmal nocturnal dyspnea, and recurrent refractory
arrhythmias may occur with either type of SDB. (See 'Clinical features' above.)

● The routine evaluation of patients with heart failure should include questions about potential SDB
symptoms. Formal sleep testing via polysomnography in a sleep laboratory or out-of-center sleep
testing is suggested in patients with heart failure who report snoring, excessive daytime
somnolence, or poor sleep quality. Diagnostic sleep testing should also be considered in patients
with nocturnal angina, recurrent arrhythmias, refractory heart failure symptoms, or repetitive
oxygen desaturations during sleep. (See 'Who should be tested?' above and 'Diagnosis' above.)

● Heart failure accompanied by SDB is associated with a worse prognosis than heart failure in the
absence of SDB. (See 'Prognostic implications' above.)

● Primary therapy for patients whose heart failure is complicated by SDB is optimization of the
medical management of heart failure because it improves both heart failure-related and SDB-
related outcomes. For patients who have persistent SDB despite the optimization of heart failure
therapy, continuous positive airway pressure (CPAP) may also improve both heart failure-related
and SDB-related outcomes. (See 'Management' above.)

● Adaptive servo-ventilation (ASV), a modified method of positive airway pressure ventilation,

appears to increase cardiovascular mortality in patients with CSA due to symptomatic heart
failure and a reduced ejection fraction, based on results of the SERVE-HF trial. In these patients,

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we recommend not initiating ASV to treat CSA-CSB (Grade 1B).

Decisions about continuing or stopping therapy in heart failure patients already being treated with
ASV must be individualized after disclosure of the available data from the SERVE-HF study and
re-evaluation of the balance of risks and benefits. (See 'Heart failure outcomes' above.)

● For heart failure patients with CSA-CSB and hypoxemia during sleep, we suggest supplemental
oxygen during sleep (Grade 2C). (See 'Nocturnal oxygen' above.)

● Treatment of SDB, including indications and the choice of therapy, is discussed separately. (See
"Management of obstructive sleep apnea in adults" and "Central sleep apnea: Treatment".)

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Topic 7682 Version 36.0

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GRAPHICS

Clinical features of obstructive sleep apnea (OSA)

Examination findings

Narrow or "crowded" airway

Obesity

Large neck circumference

Retrognathia

Symptoms

Daytime sleepiness

Nonrestorative sleep

Loud snoring

Witnessed apneas by bed partner

Awakening with choking

Nocturnal restlessness

Insomnia with frequent awakenings

Lack of concentration

Cognitive deficits

Changes in mood

Morning headaches

Vivid, strange, or threatening dreams

Nocturia

Associated conditions

Systemic hypertension

Obesity hypoventilation syndrome

Cardiovascular disease

Cerebrovascular disease

Cardiac dysrhythmias

Pulmonary hypertension

Cor pulmonale

Gastroesophageal reflux

Polycythemia

Floppy eyelid syndrome

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For further information refer to UpToDate content on clinical evaluation of obstructive sleep apnea.

Graphic 55633 Version 10.0

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Effect of CPAP therapy on heart transplant-free survival in patients

who have central sleep apnea associated with heart failure

Kaplan-Meier survival plots demonstrating that compared with the control group, the CPAP-
CSA-suppressed group had significantly improved heart transplant-free survival (* unadjusted
p = 0.043), whereas the CPAP-CSA-unsuppressed group did not (unadjusted p = 0.260).

Reproduced with permission from: Arzt M, Floras JS, Logan AG, et al. Suppression of central sleep
apnea by continuous positive airway pressure and transplant-free survival in heart failure: A post
hoc analysis of the Canadian Continuous Positive Airway Pressure for Patients with Central Sleep
Apnea and Heart Failure trial (CANPAP). Circulation 2007; 115:3173. Copyright © 2007 Lippincott
Williams & Wilkins.

Graphic 83625 Version 4.0

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Contributor Disclosures
Atul Malhotra, MD Consultant/Advisory Boards: Alfred Mann Foundation. Other Financial Interest:
ResMed [philanthropic donation to UCSD]. James C Fang, MD Nothing to disclose M Safwan Badr,
MD Nothing to disclose April F Eichler, MD, MPH Nothing to disclose

Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these
are addressed by vetting through a multi-level review process, and through requirements for
references to be provided to support the content. Appropriately referenced content is required of all
authors and must conform to UpToDate standards of evidence.

Conflict of interest policy

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