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David P. White, MD, Chief Medical Officer, Philips Respironics

Sleep Disordered Breathing and Cardiovascular Disease Sleep Disordered Breathing in Patients with Congestive Heart Failure:CSR and OSA. David P. White, MD, Chief Medical Officer, Philips Respironics. Professor of Medicine Harvard Medical School. September 10, 2009.

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David P. White, MD, Chief Medical Officer, Philips Respironics

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  1. Sleep Disordered Breathing and Cardiovascular DiseaseSleep Disordered Breathing in Patients with Congestive Heart Failure:CSR and OSA David P. White, MD, Chief Medical Officer, Philips Respironics Professor of Medicine Harvard Medical School September 10, 2009

  2. Sleep and Cardiovascular Disease

  3. Baseline

  4. Prevalence of SDB in Heart Failure n=81 n=450 n=20 Percent n=38 Chan et al, 1997, Javaheri et al, 1998, Sin et al, 1999, Abraham et al, 2002

  5. What are the Consequences of Cheyne-Stokes Respiration? Why do we specifically want to treat this disorder?

  6. Baseline

  7. Consequences of Sleep Disorders Breathing inCongestive Heart Failure Sleep fragmentation little daytime sleepiness. Hypoxia plus arousals recurrent sympathetic nervous system activation. Attributable mortality (?). Progression of heart failure (?).

  8. Cheyne-Stokes RespirationRecurrent Sympathetic Nervous System Activation nmol//L Nmol/mmol Creatinine NOREPINEPHRINE EPINEPHRINE NOREPINEPHRINE EPINEPHRINE N PLASMA URINE Naughtonet al. Am J RespirCrit Care Med, 1995

  9. Sin et alCirculation, 2000

  10. Cheyne-Stokes Respiration Will therapy specifically aimed at Cheyne-Stokes Respiration improve both quality of life and survival in patients with this disorder?

  11. Cheyne-Stokes Respiration What can be done to correct this? First always maximize cardiac medications. • Theophylline (respiratory stimulant) • Acetazolamide • Oxygen administration • CO2 inhalation • CPAP [continuous positive airway pressure]

  12. How does CPAP work in CHF with Cheyne-Stokes Ventilation • OSA eliminated if present Alleviated exaggerated negative intrathoracic pressure. • Decreased transmural pressure • Increased cardiac output. • Reduced LV afterload (wall tension). • Decreased venous return Decreased preload Decreased venous congestion. Jellinek JAP 2000, 88:926-932

  13. Left Ventricular Intracavitary Pressure = 100 mmHg Pericardial Pressure = 0 mmHg LV transmural pressure = 100 mmHg

  14. Left Ventricular Intracavitary Pressure = 100 mmHg Pericardial Pressure = 20 mmHg LV transmural pressure = 100 – (-20) = 120 mmHg

  15. Left Ventricular Intracavitary Pressure = 100 mmHg Pericardial Pressure = +20 mmHg LV transmural pressure = 100 - 20 = 80 mmHg

  16. Naughton et al. Am J Respir Crit Care Med, 1995 LVEF (%) BL 1M 3M

  17. Naughton et al. AJRCCM 1995 Nmol/mmol Creatinine nmol//L CONTROL NCPAP CONTROL NCPAP CONTROL NCPAP CONTROL NCPAP NOREPINEPHRINE EPINEPHRINE NOREPINEPHRINE EPINEPHRINE URINE PLASMA

  18. Naughton et al. AJRCCM, 1994 Baseline NCPAP EEG EMG RIBCAGE ABDOMEN VT (L) 1.0 100 SaO2 (%) 75 1 minute V1 = 8.9 L/min V1 = 4.8 L/min

  19. Sin et al - Circulation 2000, 102:61-66

  20. 2005

  21. Bradley et al, New Engl J Med - 2005

  22. Bradley et al, New Engl J Med - 2005

  23. Circulation 2007

  24. Arzt et al, Circulation 2007 Figure 1. Flow diagram indicating progress of eligible subjects through the study.Bold boxes represent subjects who were included in the analysis of the present report of the CANPAP trial.PSG indicates polysomnography.

  25. Arzt et al, Circulation 2007

  26. CPAP - 7 cm H20

  27. Computer-Assisted Positive Airway Pressure

  28. CANPAP 2PI: Doug Bradley, MD • 880 patients with CHF and either OSA, CSR, or both. • >25 sites (Canada, US, Australia, Eur) • Randomized to: - Maximal management of CHF - Maximal management of CHF+ Auto SV 3.

  29. CANPAP 2PI: Doug Bradley, MD • Outcomes: - Transplant free survival - Cardiac function - Exercise capacity - QOL - RDI

  30. Prevalence of SDB in Heart Failure n=81 n=450 n=20 Percent n=38 Chan et al, 1997, Javaheri et al, 1998, Sin et al, 1999, Abraham et al, 2002

  31. OSA in Patients with CHF One reasonable study comparing outcomes (survival) in patients with CHF who have with those who do not have OSA. There are 2 studies accessing the effect of CPAP on cardiac function in patients with OSA and CHF. One study comparing survival in patients with OSA and CHF either treated or not treated with CPAP.

  32. JACC 2007 Influence of Obstructive Sleep Apnea on Mortality in Patients With Heart Failure Hanqiao Wang, MD, John D. Parker, MD, FACC, Gary E. Newton, MD, FACC, John S. Floras, MD, DPhil, FACC,, Susanna Mak, MD, PhD, Kuo-Liang Chiu, MD, MSc, Pimon Ruttanaumpawan, MD, George Tomlinson, PhD and T. Douglas Bradley, MD Toronto, Ontario, Canada

  33. Wang et al, JACC 2007

  34. Wang et al, JACC 2007

  35. 2003

  36. Kaneko et al, NEJM 2003

  37. Kaneko et al, NEJM 2003

  38. Am J Resp Crit Care Med 2004

  39. Mansfield et al, AJRCCM 2004

  40. Mansfield et al, AJRCCM 2004 P=NS P<0.001 LVEF (%) Baseline 3 Months Baseline 3 Months Control Group CPAP Group P=0.04

  41. CHEST 2008

  42. Kasai et al, CHEST 2008

  43. Kasai et al, CHEST 2008

  44. CANPAP 2PI: Doug Bradley, MD • 880 patients with CHF and either OSA, CSR, or both. • >25 sites (Canada, US, Australia, Eur) • Randomized to: - Maximal management of CHF - Maximal management of CHF+ Auto SV 3.

  45. Sleep and Cardiovascular Disease

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