European Journal of Heart Failure (2009) 11, 602–608

doi:10.1093/eurjhf/hfp057

Sleep-disordered breathing in heart failure with

normal left ventricular ejection fraction
Thomas Bitter*, Lothar Faber, Detlef Hering, Christoph Langer, Dieter Horstkotte,
and Olaf Oldenburg
Department of Cardiology, Heart and Diabetes Center North Rhine-Westphalia, Ruhr University Bochum, Georgstasse 11, D – 32545 Bad Oeynhausen, Germany

Received 1 September 2008; revised 25 February 2009; accepted 6 March 2009

Aims In patients with systolic heart failure (SHF) a high prevalence of sleep-disordered breathing (SDB) has been documen-
ted. The purpose of this study was to investigate the prevalence and type of SDB in patients with heart failure with
normal left ventricular ejection fraction (HFNEF).
.....................................................................................................................................................................................
Methods Two hundred and forty-four consecutive patients (87 women, aged 65.3 + 1.4 years) with HFNEF underwent capil-
and results lary blood gas analysis, measurement of NT-proBNP concentrations, echocardiography, cardiopulmonary exercise
testing (CPX), cardiorespiratory polygraphy, and simultaneous right and left heart catheterization. Sleep-disordered
breathing was defined as an apnoea–hypopnoea-index (AHI) 5/h. Sleep-disordered breathing was documented in
69.3% of all patients, 97 patients (39.8%) presented with OSA and 72 patients (29.5%) with CSA. With an increasing
impairment of diastolic function the proportion of SDB, and CSA in particular, increased. Patients with SDB per-
formed worse on CPX and six-minute walk test. Partial pressure of CO2 was lower in CSA, whereas AHI, left
atrial diameter, NT-proBNP, LVEDP, PAP, and PCWP were higher.
.....................................................................................................................................................................................
Conclusion There is a high prevalence of SDB in HFNEF. In parallel to SHF, CSA patients in particular are characterized by a more
impaired cardiopulmonary function. Whether SDB is of prognostic relevance in HFNEF needs to be determined.
-----------------------------------------------------------------------------------------------------------------------------------------------------------
Keywords Heart failure with normal left ventricular ejection fraction † HFNEF † Diastolic heart failure † Sleep disordered
breathing † Prevalence

The association between sleep-disordered breathing (SDB) and

Introduction
Congestive heart failure (CHF) is a major public health
problem in many countries.1 Patients who meet the criteria
for clinical diagnosis of heart failure are heterogeneous, with
an increasing proportion of heart failure with normal left ven-
tricular ejection fraction (HFNEF).2 By the seventh decade of
life the prevalence of HFNEF approaches, and by the eighth
decade of life it exceeds that of systolic heart failure (SHF).3
Several authors and guidelines have presented a definition for
HFNEF, all propose a classification scheme including the fol-
lowing criteria: clinical evidence of CHF, normal or mildly
abnormal LV systolic function expressed as ejection fraction
(EF), and evidence of abnormal LV relaxation, filling, or dias-
tolic stiffness.4 – 6 Survival of patients with HFNEF is similar to
that of patients with SHF.7
SHF is well known. In large-scale studies including up to 700
patients, a high prevalence of SDB among patients with SHF had
been documented.8 – 11 Obstructive sleep apnoea (OSA) is con-
sidered an independent risk factor for hypertension, CHF, and pul-
monary hypertension.12 – 14 Hypertensive patients with heart
failure often present with preserved left ventricular systolic func-
tion but compromised diastolic function and comprise a substantial
proportion of the patients with HFNEF. On the other hand,
Cheyne –Stokes-Respiration (CSR) and central sleep apnoea
(CSA) are highly prevalent in patients with pulmonary hyperten-
sion,15 one possible consequence of diastolic dysfunction.
The purpose of this study was to investigate the prevalence and
type of SDB in 244 patients with HFNEF and to evaluate subjective
and objective clinical, echocardiographic, and haemodynamic par-
ameters in these patients.

* Corresponding author. Tel: þ49 5731 97 1258, Fax: þ49 5731 97 2194, Email: akohlstaedt@hdz-nrw.de
Published on behalf of the European Society of Cardiology. All rights reserved. & The Author 2009. For permissions please email: journals.permissions@oxfordjournals.org.
SDB in patients with HFNEF
Methods
Patients
Between January 2006 and March 2008, a total of 878 patients with
symptoms of heart failure, admitted to our cardiology facility were
screened for presence and type of SDB. Of these, 244 patients with
HFNEF, defined according to the guidelines mentioned previously,4 – 6
were eligible according to the inclusion and exclusion criteria, and
were enrolled into the study. In summary, patients had to be in a
stable clinical condition, in NYHA class II – IV, with normal systolic func-
tion according to echocardiographic and invasive criteria (LVEF .55%)
with an end-diastolic volume index (LVEDVI) ,97 mL/m2.2 Diagnostic
evidence of diastolic dysfunction was obtained invasively [LV end-
diastolic pressure (LVEDP) .16 mmHg or mean pulmonary wedge
pressure (PCWP) .12 mmHg]. In addition patients had to be on
stable medication for at least 4 weeks. The majority of the remaining
634 patients were excluded from the trial due to compromised LV sys-
tolic function (n ¼ 511). Other reasons for exclusion were significant
valvular heart disease (any valve insufficiency or stenosis .first
degree), a history of SDB or ongoing treatment of SDB, evidence of pul-
monary disease, hypercapnia (pCO2 .45 mmHg) in capillary blood gas
samples, pregnancy, acute coronary syndrome, or acute cardiac decom-
pensation. This was a prospective observational study that used cardior-
espiratory polygraphy as an approved diagnostic procedure. The study
flow-chart is summarized in Figure 1. Sleep studies as well as all other
investigations were performed during the patients’ primary admission
to the cardiology department of our hospital.
All patients gave written informed consent to the clinical pro-
cedures. The study was retrospectively approved by the Ethical
Review Board of the University of Ruhr, Bochum.
Figure 1 Flow chart of patients’ inclusion.
603
Cardiorespiratory polygraphy
Sleep studies were performed by in-hospital unattended cardiorespira-
tory polygraphy (Embletta, Embla, The Netherlands). Nasal air flow,
chest and abdominal effort, pulse oximetry, and body position were
recorded continuously. The temporary loss of not more than one
channel, except for nasal air flow, was allowed. Analyses were per-
formed using Somnologica for EmblettaTM software (Medcare,
Embla, The Netherlands) and reviewed by two independent SDB
specialists not involved in the patients’ treatment. Hypopnoea was
defined as a 30% reduction in airflow in combination with an
oxygen desaturation of at least 3%. Apnoea was defined as a cessation
of airflow for 10 s, and in case of CSA without any thoracic or
abdominal breathing effort.
If the apnoea– hypopnoea-index (AHI) was ,5/h patients were con-
sidered to have no SDB (noSDB, AHI ,5), patients with an AHI 5/h,
were classified as central (CSA) or OSA according to the majority of
events. An AHI 5 – 14/h was considered to indicate mild, an AHI 15 –
29/h moderate, and an AHI 30/h severe, SDB.
Echocardiography
Diameters and dimensions of the left atrium (LA) and left ventricle
were measured by M-Mode and corrected by 2D echocardiography
following American Society of Echocardiography guidelines.16 Left ven-
tricular ejection fraction was measured according to the modified
Simpsońs method using apical four and two chamber views. Blood
flow Doppler as well as tissue Doppler were used to assess diastolic
function. Peak early (E) and peak atrial (A) Doppler mitral valve flow
velocity, ratio of peak early and peak atrial Doppler mitral valve flow
velocity (E/A), and deceleration time (DT) of early Doppler mitral
valve flow velocity were documented. Left ventricular filling patterns
were classified as normal, impaired relaxation, pseudonormal, or
restrictive, taking into account early diastolic (E0 ) lengthening velocities
and the ratio of early mitral valve flow velocity and early diastolic
lengthening velocities (E/E0 ). Normal pattern was defined by an E/A
ratio .1, a DT between 150, and 220 ms and E/E0 ,10. Impaired
relaxation was determined by E/A ,1, DT .220 ms, and E/E0 .10.
Pseudonormal pattern was identified by E/A between 1 and 2, DT
between 150 and 220 ms, and E/E0 .10. Finally, restrictive pattern
was defined by E/A .2, DT ,150 ms, and E/E0 .10.
Left and right heart catheterization
Left heart angiography was performed with a 5 –7F pigtail catheter
(Cordis, Langenfeld, Germany), which was introduced retrogradely
into the LV and connected to a cardiac functional laboratory for acqui-
sition of left ventricular end-diastolic pressure (LVEDP). Pulmonary
artery pressure (PAP) and pulmonary capillary wedge pressure
(PCWP) were recorded using a balloon-tipped flotation thermodilu-
tion catheter (7F Arrow, Arrow International) via the right femoral
vein.
Six-minute walk test
A six-minute walk test was performed according to guidelines issued
by the American Thoracic Society.17
Capillary blood gas analysis
Partial pressure of carbon dioxide (pCO2), partial pressure of oxygen
(pO2), and capillary oxygen saturation were measured using ABL 330
(Radiometer, Copenhagen, Denmark).
604 T. Bitter et al.

N-terminal pro-brain natriuretic peptide Results

N-terminal pro-brain natriuretic peptide (NT-proBNP) was used as
an additional marker of the severity of HFNEF. Analyses were
performed using the Elecsys 2010 analyzer (Roche, Basel,
Switzerland).
Cardiopulmonary exercise testing
In order to evaluate exercise tolerance, peak oxygen consumption
(VO2-peak), oxygen consumption at the individual
aerobic-anaerobic threshold (VO2-AT), and relationship of minute
ventilation and carbon dioxide production (VE/VCO2), a symptom-
limited bicycle exercise test was performed. Starting at 10 W,
workload was increased by 10 W every minute. Maximum work-
load and total exercise time were recorded; predicted VO2-peak
was calculated automatically taking patients gender and age into
account.
Statistics
Statistical analyses were performed using SPSS (version 10.2.6) soft-
ware (SPSS Inc. Chicago, IL, USA). Differences between groups were
compared by ANOVA test. Correlation analysis was performed
using Spearman rank correlation. A value of P , 0.05 was considered
significant for all comparisons.
Patients
A total of 244 patients with HFNEF were enrolled into the study, of
these 96 patients presented with an impaired left ventricular relax-
ation filling pattern, 104 with a pseudonormal left ventricular filling
pattern, and 44 patients with a restrictive left ventricular filling
pattern. The cause of heart failure was hypertensive heart
disease in 108 patients (44%), coronary artery disease in 80
patients (33%), and cardiomyopathies (hypertrophic, restrictive)
in 56 patients (23%). Baseline demographic and clinical data are
summarized in Table 1. The proportion of male patients was
highest in patients with CSA, and lowest in patients with noSDB.
Patients with SDB were significantly older, presented with a
higher NYHA-class and were more obese than patients with
noSDB. A history of hypertension was also more frequent in
these two subgroups. The percentage of patients with diabetes
was significantly higher in patients with OSA than in those with
CSA or noSDB. Compared with patients without SDB, more
patients with central sleep apnoea had atrial fibrillation.
Sleep-disordered breathing
Among the 244 patients with HFNEF, SDB was documented in 169
patients (69.3%), of these 97 patients (39.8%) presented with OSA

Table 1 Baseline demographic and clinical data for the study population

Variable CSA OSA noSDB

...............................................................................................................................................................................
n (%) 72 (29.5) 97 (39.8) 75 (30.7)
Ð
Male, n (%) 60 (83.3)‡ 61 (63.0)† 36 (48.0)
Age, years 66.9 + 2.4‡ 66.8+1.9† 61.6 + 3.3
Ð
Height, cm 174.9 + 1.9‡ 170.1 + 2 171.3 + 2.4
Ð
Weight, kg 89.8 + 3.4‡ 84.9 + 3.2† 77.9 + 3.7
‡
BMI 29.3 + 0.9 29.3+1.1† 26.42 + 1
NYHA class 2.5 + 0.2‡ 2.4 + 0.24† 2.2 + 0.33
Hypertension, n (%) 67 (87.0)‡ 88 (88.0)† 60 (80.0)
Ð
Diabetes, n (%) 22 (28.6) 45 (45.0) † 11 (14.7)
Atrial fibrillation, n (%) 17 (23.6)‡ 19 (19.6) 13 (17.3)
Cerebrovascular disease, n (%) 9 (12.5) 14 (14.4) 10 (13.3)
Medication, n (%)
Beta-blockers 64 (83.1) 78 (78.0) 64 (85.3)†
ACE/AT1-inhibitors 66 (85.7) 76 (76.0) 56 (74.6)
Calcium-channel blockers 30 (39.0) 46 (46.0) 29 (38.7)
Nitrates 16 (20.8) 24 (24.0) 12 (16.0)
Digitalis glycosides 9 (11.7) 9 (9.0) 3 (4.0)
Diuretics 53 (68.8) 57(57.0) 41 (54.7)
Other 76 (98.7)‡ 97(97.0)† 67 (89.3)
Capillary blood gas analysis
Ð
pCO2 (mmHg) 34.9 + 0.8‡ 39.4 + 0.7† 37.2 + 0.8
pO2 (mmHg) 76.0 + 2.1 80.6 + 15.4 79.9 + 2.5

†
P , 0.05 OSA vs. noSDB.
‡
ÐP , 0.05 CSA vs. noSDB.
P , 0.05 OSA vs. CSA.
SDB in patients with HFNEF
and 72 patients (29.5%) with CSA. Only 75 patients (30.7%) had no
relevant SDB. Severity of SDB was mild in 21 patients with CSA
(8.3%) and in 40 patients with OSA (40%), moderate in 15 patients
with CSA (6.0%) and 36 patients with OSA (36%), and severe in 41
patients with CSA (16.3%) and 24 patients with OSA (24%). In the
group with an impaired left ventricular relaxation filling pattern, 24
patients (25%) presented with CSA, 33 patients (34.4%) with OSA,
Figure 2 Relative proportions of different types of sleep-
disordered breathing in patients in different stages of heart
failure with normal left ventricular ejection fraction.
Table 2 Cardiorespiratory polygraphy results
Variable
...............................................................................................................................................................................
n (%)
AHI, h21
Mean oxygen saturation, %
Maximum oxygen desaturation, %
Average oxygen desaturation, %
Longest apnoea duration, s
Longest hypopnoea duration, s
†
P , 0.05 pseudonormal vs. impaired relaxation.
‡
P , 0.05 restrictive vs. impaired relaxation.
605
and 39 patients (40.6%) with noSDB. Of the patients with a pseu-
donormal left ventricular filling pattern, 30 had a CSA (29.1%), 48
an OSA (46.6%), and 25 patients (24.3%) had noSDB. Of the
patients with a restrictive left ventricular filling pattern, 18 had
CSA (40.9%), 16 had OSA (36.4%), and 10 had noSDB in 10
(22.7%) (Figure 2). Additional findings are presented in Table 2.
The AHI in the restrictive and pseudonormal left ventricular
filling pattern group was higher than in the impaired relaxation
left ventricular filling pattern group. In addition, patients with a
pseudonormal left ventricular filling pattern had longer apnoea
and hypopnoea periods compared with the other subgroups.
Echocardiographic parameters
Echocardiographic findings are presented in Table 3. Left atrial
enlargement was more pronounced in the CSA group than in
the OSA and noSDB groups (P , 0.05). Patients with OSA had a
larger left atrial diameter compared with patients with noSDB
(P , 0.05). E wave was higher in the CSA group than in the
noSDB group (P , 0.05), E/A ratio was higher in the CSA group
compared with OSA (P , 0.05) and DT was higher in the
noSDB group than in the OSA group (P , 0.05).
N-terminal pro-brain natriuretic peptide
A significantly higher level of NT-proBNP was observed in patients
with CSA (1237 + 544 pg/mL) compared with those with OSA
(643 + 378 pg/mL) and those with noSDB (376 + 192 pg/mL).
Blood gas analysis
pCO2 was lower in patients with CSA than in those with noSDB
and those with OSA (P , 0.05). The noSDB group presented
with a lower pCO2 compared with the OSA group (P , 0.05,
Table 1). There was no significant difference in pO2 among the
three groups.
Six-minute walk test
The mean walk distance was 296 + 68 m in CSA patients, 334 +
59 m in OSA patients, and 423 + 63 m in noSDB patients (P ,
0.05 noSDB vs. CSA; P , 0.05 noSDB vs. OSA, P , 0.05 OSA
vs. CSA).
Impaired relaxation Pseudonormal Restrictive
96 (39.3) 104 (42.6) 44 (18.0)
15.0 + 3.6 20.0 + 3.3† 23.4 + 6.2‡
92.6 + 0.6 92.9 + 0.6 92.6 + 0.9
84.6 + 1.0 83.6 + 1.2 83.5 + 1.8
4.5 + 0.4 5.2 + 0.6 5.0 + 0.7
22.3 + 4.0 30.1 + 4.0† 25.4 + 7.5
32.1 + 3.0 39.1 + 3.7† 37.8 + 6.3
606 T. Bitter et al.

Table 3 Results from echocardiography, cardiopulmonary exercise testing, and invasive haemodynamic measurements

Variable CSA OSA noSDB

...............................................................................................................................................................................
Echocardiographic results
E wave (m/s) 0.91 + 0.11‡ 0.86 + 0.06 0.78 + 0.06
A wave (m/s) 0.71 + 0.08 0.77 + 0.05 0.75 + 0.06
Ð
E/A ratio 1.57 + 0.28 1.26 + 0.15 1.27 + 0.22
DT (ms) 216 + 23 199 + 15† 236 + 23
Ð
LA (mm) 49.6 + 1.6 ‡ 46.1 + 1.5† 43 + 1.7
Cardiopulmonary exercise testing
VO2 AT (mL/min/kg) 13.7 + 1.2‡ 14.1 + 1.2 19.5 + 6.5
VO2 peak (mL/min/kg) 15.9 + 1.4‡ 16.3 + 1.3† 19.8 + 1.5
Pred. VO2 peak (%) 73.5 + 7.3‡ 74.8 + 5.3† 85.9 + 5.8
Workload (W) 89.9 + 12.6 91.1 + 10.7† 108.2 + 13.6
VE/VCO2 slope 31.6 + 2.1‡ 29.6 + 1.6 28.2 + 1.5
Invasive haemodynamics
Ð
PAP (mmHg) 31 + 2.4‡ 27.8 + 1.8 26.4 + 2.3
Ð
PCWP (mmHg) 21 + 1.3‡ 19 + 1.2 18.7 + 1.9
Ð
LVEDP (mmHg) 23.4 + 1.8‡ 21.1 + 1.2 21.0 + 1.3

†
P , 0.05 OSA vs. no SDB.
‡
ÐP , 0.05 CSA vs. noSDB.
P , 0.05 OSA vs. CSA.

Cardiopulmonary exercise test
Results from cardiopulmonary exercise testing are presented in
Table 3. VO2 at the aerobic/anaerobic threshold in the CSA group
was lower than in the noSDB group, whereas patients with CSA
and patients with OSA showed a more severely reduced VO2
peak in comparison to patients with noSDB. While the OSA
group presented with a lower maximum workload compared with
patients with noSDB, the CSA group had a higher VE/VCO2-slope
in comparison to patients with OSA or noSDB (P , 0.05).
Invasive haemodynamic measurements
Haemodynamic parameters are summarized in Table 3. Patients
with CSA had higher LVDEP, a higher PAP, and a higher PCWP
compared with patients with OSA and noSDB (P , 0.05).
Discussion
This is the first large-scale-study to show a high prevalence of SDB
in patients with HFNEF, with the proportion rising in parallel to an
increased impairment of diastolic function measured by echocar-
diography. Patients with SDB and especially central sleep apnoea
presented with more advanced symptoms and more impaired car-
diovascular function.
In patients with CHF and reduced LV-function, a high prevalence
of SDB is well documented. In a study of 700 patients with SHF,
SDB was documented in 76% of patients, of whom 40% had
central sleep apnoea and 36% OSA, using an apnoea–
hypopnoea-index cut-off of 5/h.8 Using an AHI cut-off of 15/h,
several studies have documented moderate-to-severe SDB in
about 50% of heart failure patients with reduced ejection frac-
tion.8 – 11
In contrast, data on patients with HFNEF are rare. In a small
cohort of 20 patients, Chan et al.18 reported that 55% had signifi-
cant SDB, mainly OSA, which is mostly consistent with our results.
Furthermore, they demonstrated that E-wave deceleration time of
mitral inflow, an index of diastolic relaxation, was more prolonged
in the group with SDB. We could not show analogous results,
mainly because our study population included a higher proportion
of patients with pseudonormal or restrictive left ventricular filling
pattern which produces a faster E-wave deceleration time.
However, our finding that with greater impairment of diastolic
function the proportion of patients with SDB, and CSA in particu-
lar, increases is supported by similar findings for SHF, where a
greater impairment of systolic function is linked to a larger inci-
dence of SDB and CSA as well.8
Whether SDB occurs as a consequence of HFNEF or SDB
induces diastolic dysfunction has not yet been clarified.
On the one hand, Fung et al.19 investigated 68 OSA patients for
parameters of diastolic dysfunction and stated that more severe
SDB was associated with a higher degree of diastolic dysfunction.
These results were supported by Otto et al.,20 who compared
23 otherwise healthy patients with OSA to 18 patients without
OSA and found an increased left atrial volume index as well as
abnormal diastolic filling parameters in the OSA group. Besides
an increased left atrial volume index, Romero-Corral et al. 21
reported an association between SDB and an impaired myocardial
performance index. Correspondingly Sidana et al.22 found a higher
prevalence of diastolic dysfunction in moderate-to-severe OSA
than in those with mild or no OSA. The main reason for this
could be repeated nocturnal hypoxaemias leading to sympathetic
SDB in patients with HFNEF
nerve activation with a consequent increase in hormonal activation
and arterial blood pressure,14 thus predisposing to wall thickening
and compromised diastolic function.
On the other hand, a mechanism of central sleep apnoea is said
to be based upon pulmonary congestion induced stimulation of
pulmonary vagal irritant receptors and enhanced central and per-
ipheral chemosensitivity leading to hyperventilation and respiratory
instability.23 – 27 In HFNEF, pulmonary congestion may arise from a
compromised left ventricular filling pattern which supports the
theory that SDB, and CSA in particular, could be a consequence
of HFNEF. Our findings of a correlation between PCWP and
AHI in the entire cohort and in the CSA-group specifically,
support this idea as do the findings of Bucca et al.28 that diuretic
treatment of HFNEF produces a significant decrease in AHI, poss-
ibly due to a reduction in pulmonary congestion.
Finally, the impaired clinical, haemodynamic, and echocardio-
graphic parameters detected in this study suggest that SDB, and
central sleep apnoea in particular, may serve as a marker of the
severity of HFNEF, a model that has been proposed for heart
failure with reduced ejection fraction as well,29 possibly suggesting
a worsened prognosis. Therefore event-driven studies are needed
to confirm the clinical implications of the data presented here.
There are some limitations to our study that should be men-
tioned. First, the study population was selected from patients
attending a tertiary academic cardiac referral unit, thus it includes
patients with a number of different cardiomyopathies who met the
inclusion criteria. This might not be representative of patients in
outpatient facilities and community hospitals. On the other hand,
this study setting allowed deep insights into diastolic heart failure
by investigating the whole range from early-stage impaired relax-
ation to end-stage restrictive filling patterns of the left ventricle.
Unlike previous studies18 – 22 that mainly concentrated on early-
stage patients, this study aimed to give an overview of HFNEF, a
goal which is difficult to achieve by just investigating patients
with coronary artery disease or hypertensive heart disease. Sec-
ondly, we evaluated SDB by cardiorespiratory polygraphy rather
than polysomnography (PSG) which still represents the gold stan-
dard. In a previous study, EmblettaTM -based cardiorespiratory
polygraphy results were compared with PSG. Even though theor-
etically AHI in unattended cardiorespiratory polygraphy could be
underestimated due to shorter actual sleeping time compared
with recording time, an extremely close correlation between the
results obtained by PSG and EmblettaTM screening (r ¼ 0.98,
P , 0.001), was reported.30 Thirdly, we founded our classification
on a one-night-investigation which may not be representative of
other nights. However, a recent study in 50 patients with SHF
showed that a single night of cardiorespiratory monitoring gave
representative results on severity and type of SDB.31
Finally we classified patients as having either CSA or OSA
according to the majority of events. Even though 10% of
events were obstructive events in 13% of our CSA-cohort and
10% of events were central events in 7% of our OSA-cohort,
the vast majority of patients presented with either CSA or OSA.
In addition, there was not a single case with equal proportions
of obstructive apnoea/hypopnoea events and central apnoeas/ per-
iodic breathing, which is supported by our daily clinical experience
and previous studies.8
607
In conclusion, we found a high prevalence of SDB in patients
with HFNEF, with a correlation between impairment of diastolic
function assessed by echocardiography and frequency of SDB.
Patients with SDB presented with more advanced symptoms
and greater impairment of cardiovascular function. Controlled
studies are now required to investigate the prognostic impact of
SDB in HFNEF and to evaluate whether treatment of obstructive
and central sleep apnoea in patients with heart failure with
preserved left ventricular ejection fraction can ameliorate symp-
toms of heart failure and improve cardiopulmonary exercise
tolerance.
Conflict of interest: none declared.
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