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

描述（由申请人提供）：睡眠呼吸障碍（SDB）在稳定型心力衰竭患者中的患病率超过50%，并且通常未被识别和治疗。阻塞性睡眠呼吸暂停（OSA）与肥胖、衰老、高血压和糖尿病有很强的病因关系，这些都是导致慢性心力衰竭的原因。在一项大型人群研究中，阻塞性睡眠呼吸暂停是发生心力衰竭的独立危险因素。肥胖和衰老，在普通人群中都呈上升趋势，是阻塞性睡眠呼吸暂停和心力衰竭的危险因素。因此，OSA可能在心血管疾病、肥胖或衰老患者心功能障碍的进展中起着重要作用。OSA是高血压的已知病因，可导致高血压、冠状动脉疾病（CAD）、房性和室性心律失常的不良结局，所有这些都是急性失代偿性心力衰竭（ADHF）的原因。因此，OSA可能与心力衰竭的急性失代偿有关，而心力衰竭通常由心房颤动、CAD或高血压引发。我们的初步数据证实，62%的ADHF住院患者存在未被识别的OSA；稳定型心力衰竭患者的患病率甚至高于目前的估计。阻塞性呼吸暂停发作会产生间歇性缺氧、交感神经活动增加和较大的胸内负压波动，所有这些对心功能恶化的患者都是毁灭性的扰动，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）治疗OSA可减少致死性和非致死性心血管事件。此外，在OSA和潜在心力衰竭患者中，CPAP可改善射血分数、交感神经活动和功能状态。尽管有这些发现，在ADHF住院患者甚至稳定型心力衰竭患者中识别和治疗新的OSA病例的系统方法并不是当前管理指南的一部分。迄今为止，尚未对ADHF住院患者的OSA进行系统诊断和治疗策略的评估。本研究将通过一项随机试验，评估一种快速住院识别和治疗OSA的方法对院内和出院后3个月心脏和功能结局的影响。ADHF患者将接受一项住院睡眠研究。在新诊断为OSA的ADHF患者中，一组（n=85）将在住院期间立即接受OSA治疗，另一组（n=85）将接受目前的标准治疗，包括门诊诊断实验室睡眠研究和门诊启动CPAP。该方法对患者CPAP依从性的影响也将被评估。公共卫生相关性：本研究将通过一项随机试验，评估急性失代偿性心力衰竭患者OSA住院识别和治疗的系统方法对院内和出院后3个月心脏和功能结局的影响。

DESCRIPTION (provided by applicant): 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. PUBLIC HEALTH RELEVANCE: 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.