Adaptive Servo-Ventilation for Central Sleep Apnea in Systolic Heart Failure.
Adaptive Servo-Ventilation for Central Sleep Apnea in Systolic Heart Failure.
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DOI：
10.1056/nejmoa1506459
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发表时间：
2015-09-17
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影响因子：
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通讯作者：
Teschler H
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作者：
Cowie MR;Woehrle H;Wegscheider K;Angermann C;d'Ortho MP;Erdmann E;Levy P;Simonds AK;Somers VK;Zannad F;Teschler H
中枢性睡眠呼吸暂停与心力衰竭患者的预后不良和死亡相关。自适应伺服通气是一种使用无创呼吸机治疗中枢性睡眠呼吸暂停的治疗方法，通过在呼气正压通气的基础上提供伺服控制的吸气压力支持。我们研究了适应性伺服通气对心力衰竭伴射血分数降低和中枢性睡眠呼吸暂停患者的影响。我们将1325例左心室射血分数≤ 45%、呼吸暂停低通气指数（AHI）≥ 15起事件（呼吸暂停或呼吸不足）/小时、中枢事件占优势的患者随机分为接受基于指南的药物治疗和自适应伺服通气或仅接受基于指南的药物治疗（对照）。至事件发生时间分析的主要终点是首起全因死亡事件、挽救生命的心血管干预（心脏移植、心室辅助装置植入、心脏骤停后复苏或适当的挽救生命的休克）或因心力衰竭恶化而计划外住院。在适应性伺服通气组中，12个月时的平均AHI为每小时6.6起事件。主要终点的发生率在自适应伺服通气组和对照组之间没有显著差异（分别为54.1%和50.8%;风险比，1.13; 95%置信区间[CI]，0.97至1.31; P = 0.10）。自适应伺服通气组的全因死亡率和心血管死亡率显著高于对照组（全因死亡的风险比为1.28; 95%CI为1.06 ~ 1.55; P = 0.01;心血管死亡的风险比为1.34; 95%CI为1.09 ~ 1.65; P = 0.006）。自适应伺服通气对射血分数降低的心力衰竭患者和主要为中枢性睡眠呼吸暂停的患者的主要终点没有显著影响，但这种治疗的全因死亡率和心血管死亡率均增加。
Central sleep apnea is associated with poor prognosis and death in patients with heart failure. Adaptive servo-ventilation is a therapy that uses a noninvasive ventilator to treat central sleep apnea by delivering servo-controlled inspiratory pressure support on top of expiratory positive airway pressure. We investigated the effects of adaptive servo-ventilation in patients who had heart failure with reduced ejection fraction and predominantly central sleep apnea. We randomly assigned 1325 patients with a left ventricular ejection fraction of 45% or less, an apnea–hypopnea index (AHI) of 15 or more events (occurrences of apnea or hypopnea) per hour, and a predominance of central events to receive guideline-based medical treatment with adaptive servo-ventilation or guideline-based medical treatment alone (control). The primary end point in the time-to-event analysis was the first event of death from any cause, lifesaving cardiovascular intervention (cardiac transplantation, implantation of a ventricular assist device, resuscitation after sudden cardiac arrest, or appropriate lifesaving shock), or unplanned hospitalization for worsening heart failure. In the adaptive servo-ventilation group, the mean AHI at 12 months was 6.6 events per hour. The incidence of the primary end point did not differ significantly between the adaptive servo-ventilation group and the control group (54.1% and 50.8%, respectively; hazard ratio, 1.13; 95% confidence interval [CI], 0.97 to 1.31; P = 0.10). All-cause mortality and cardiovascular mortality were significantly higher in the adaptive servo-ventilation group than in the control group (hazard ratio for death from any cause, 1.28; 95% CI, 1.06 to 1.55; P = 0.01; and hazard ratio for cardiovascular death, 1.34; 95% CI, 1.09 to 1.65; P = 0.006). Adaptive servo-ventilation had no significant effect on the primary end point in patients who had heart failure with reduced ejection fraction and predominantly central sleep apnea, but all-cause and cardiovascular mortality were both increased with this therapy.