The Role of Obstructive Sleep Apnea in the Acutely Decompensated Heart Failure

摘要 睡眠呼吸障碍（SDB）在稳定性心力衰竭患者中的患病率超过50%， 通常得不到承认和治疗。阻塞性睡眠呼吸暂停（OSA）有很强的病因 与肥胖、衰老、高血压和糖尿病的关系，所有这些都是慢性心力衰竭的原因。在 一项基于大规模人群的研究表明，OSA是发生心力衰竭的独立危险因素。肥胖， 和老龄化，两者在普通人群中都在上升，是OSA和心力衰竭的危险因素。因此，我们认为， OSA可能在患有以下疾病的患者的心功能障碍的进展中起重要作用： 心血管疾病、肥胖或衰老。阻塞性睡眠呼吸暂停综合征是高血压的一个既定原因， 高血压、冠状动脉疾病（CAD）、房性和室性心律失常的结局，所有这些 急性失代偿性心力衰竭（ADHF）的病因。因此，OSA可能特别涉及 心力衰竭的急性失代偿，通常由心房颤动、CAD或高血压引发。 我们的初步数据证实，62%的ADHF住院患者患有未被识别的OSA; 在稳定性心力衰竭患者中的患病率甚至高于目前的估计。 阻塞性呼吸暂停的发作产生间歇性缺氧，交感神经活动增加， 负胸内压波动，所有这些都是恶化患者的破坏性扰动， 心脏功能，并可能导致失代偿性心力衰竭。有强有力的证据表明， 持续气道正压通气（CPAP）可减少致命和非致命性心血管事件。 此外，在患有OSA和潜在心力衰竭的患者中，CPAP改善了射血分数、交感神经功能和心功能。 活动和功能状态。尽管有这些发现，系统的方法来识别和治疗 在因ADHF住院的患者或甚至稳定性心力衰竭患者中， 不是现行管理方针的一部分。系统诊断和治疗的评价 目前还没有对ADHF住院患者的OSA采取治疗策略。 这项拟议的研究将评估一种快速住院患者识别方法的影响， OSA的治疗在院内和出院后3个月的心脏和功能结果，通过 随机试验ADHF患者将接受院内睡眠研究。在ADHF患者中， 新诊断为OSA，一组（n = 85）将在其治疗期间接受OSA的立即治疗。 住院，而另一个随机分组（n = 85）将接受当前标准治疗，包括 门诊诊断与实验室睡眠研究和门诊CPAP启动。这种方法对 还将评估患者对CPAP的依从性。这项拟议的研究将评估住院病人识别的系统方法的影响， 急性失代偿性心力衰竭患者在院内和术后3个月的OSA治疗 通过随机试验排出心脏和功能结果。

ABSTRACT The prevalence of Sleep Disordered Breathing (SDB) in patients with stable heart failure exceeds 50%, and usually goes unrecognized and untreated. Obstructive Sleep Apnea (OSA) has strong etiological relationships with obesity, aging, hypertension and diabetes, all of which are causes of chronic heart failure. In a large population based study, OSA was an independent risk factor for developing heart failure. Obesity, and aging, both on the rise in the general population, are risk factors for both OSA and heart failure. Therefore, it is likely that OSA is playing a significant role in the progression of cardiac dysfunction in patients with cardiovascular disease, obesity, or aging. OSA, an established cause of hypertension, promotes poor outcomes of hypertension, Coronary Artery Disease (CAD), and atrial and ventricular arrhythmia, all of which are causes of Acutely Decompensated Heart Failure (ADHF). Therefore, OSA may particularly be implicated in the acute decompensation of heart failure, a condition often triggered by atrial fibrillation, CAD or hypertension. Our preliminary data confirm that 62% of patients hospitalized with ADHF have unrecognized OSA; an even higher prevalence than the current estimates in patients with stable heart failure. Episodes of obstructive apnea produce intermittent hypoxia, increased sympathetic activity, and large negative intra-thoracic pressure swings, all of which are devastating perturbations in patients with deteriorating cardiac function and may lead to decompensated heart failure. There is strong evidence that treatment of OSA with Continuous Positive Airway pressure (CPAP) reduces fatal and non-fatal cardiovascular events. Additionally, in patients with OSA and underlying heart failure, CPAP improves ejection fraction, sympathetic activity, and functional status. Despite these findings, systematic approaches to identifying and treating new cases of OSA among patients hospitalized for ADHF or even patients with stable heart failure are not part of current management guidelines. An evaluation of a systematic diagnostic and therapeutic strategy for OSA in patients hospitalized with ADHF has not been undertaken to date. This proposed research will evaluate the impact of an approach of expedited inpatient identification and treatment of OSA on within hospital and 3 month post-discharge cardiac and functional outcomes, through a randomized trial. Patients with ADHF will undergo an in-hospital sleep study. Among patients with ADHF who are newly diagnosed with OSA, one group (n=85) will receive immediate treatment for OSA during their hospitalization while the other randomized group (n=85) will receive the current standard of care including outpatient diagnosis with in-lab sleep study and outpatient initiation of CPAP. The effect of this approach on patients' adherence to CPAP will also be evaluated. This proposed research will evaluate the impact of a systematic approach of inpatient identification and treatment of OSA in patients with Acutely Decompensated Heart Failure on within hospital and 3 month post- discharge cardiac and functional outcomes, through a randomized trial.