Vincenzo PatrunoSOC Pneumologia Riabilitativa

I.M.F.R. - Udine

Il paziente cardiologico

&

DISTURBI RESPIRATORI

DURANTE SONNO

Paziente con apnee durante sonno quali malattie cardiache ?

Paziente con malattie cardiache quali apnee durante sonno?

due punti di vista..................

Hypertension

CardiacArrhythmia

Coronary Ischemic disease

Heart Failure

OSA

Epidemiology: discovered the association

Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of Hight Blood Pressure

“OSA as first of identifiable causes of hypertension”

Chobanian AV. JAMA 2003, 289:2560

The Journal of Clinical HypertensionVolume 9, Issue Supplement s1, pages 2–6, January 2007

….FIRST ACKNOWLEDGE OSA AS ONE OF THE FACTORS RESPONSIBLE FOR RESISTANT HYPERTENSION

2007 EUROPEAN SOCIETY OF CARDIOLOGY – EUROPEAN SOCIETY OF HYPERTENSION GUIDELINES

Atrial Fibrillation

In a substudy of the Sleep Heart Health Study, individuals with severe sleep apnea had four times the odds of having AF (OR 4.02, 95% CI 1.03–15.74) compared with individuals without OSA, even after adjusting for possible confounding factors.

Another cohort study of 3542 patients showed that OSA is an independent risk factors for AF (HR 3.29, 95% CI 1.35–8.04, P . 0.009)

Mehra R,Association of nocturnal arrhythmias with sleep-disordered breathing. The Sleep Heart Health Study. Am J Respir Crit Care Med 2006;173: 910–6.

Gami ASObstructive sleep apnea, obesity, and the risk of incident atrial fibrillation.J Am Coll Cardiol 2007;49:565–71.

Am J Cardiol. 2011 Jul 1;108(1):47-51. Epub 2011 Apr 29.

Meta-analysis of obstructive sleep apnea as predictor of atrial fibrillation recurrence after catheter ablation.

Ng CY, Liu T, Shehata M, Stevens S, Chugh SS, Wang X.

AF recurrence…..

…patients with OSA have a 25% greater risk of AF recurrence after catheter ablation than those without OSA (risk ratio 1.25, 95% confidence interval 1.08 to 1.45)….

(Am J Respir Crit Care Med. 163, 19-25 2001)

Coronary Heart Disease

OR 1.22

10% of CHF patients have obstructive apneasJavaheri S. Circulation 1998, 97:2154–2159 -.

11% of CHF patients have obstructive apneas

DON D. SIN.AM J RESPIR CRIT CARE MED 1999;160:1101–1106.

9% of CHF patients have obstructive apneasLanfranchi P., Somers VK et al. Circulation 2003 107/5 727-732

Obstructive Sleep Apnea & Chronic Heart Failure

OSA CVDs

FE 37% 49% in una settimana di trattamento CPAP

Malone et al. Lancet 1991;338:1480-4

Paziente con apnee quali malattie cardiache ?

Paziente con malattia cardiaca quali apnee ?

Cuore e Respiro: Due punti di vista

40% of CHF patients have CSA-CSRJavaheri S. Circulation 1998, 97:2154–2159 -.

27% of CHF patients have CSA-CSR

DON D. SIN.AM J RESPIR CRIT CARE MED 1999;160:1101–1106.

69% of CHF patients have CSA-CSRLanfranchi P. Circulation 2003 feb 11 107/5) 727-732

Central Sleep Apnea & Chronic Heart Failure

Mechanisms of CSR in CHF (I):Wedge pressure and carbon dioxide levels in heart failure

Solin P, et al. Influence of pulmonary capillary wedge pressure on central apnea in heart failure. Circulation. 1999;99:1574-1579

Mechanisms of CSR in CHF (II): Ventilatory Response to CO2

A MECHANISM OF CENTRAL SLEEP APNEA IN PATIENTS WITH HEART FAILURE

JAVAHERI, N Engl J Med 1999;341:949-54

Mechanisms of CSR in CHF (III): Circulatory delay and Cycle Lenght

OB= OSA, CN= CSR

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+

*Intellectual property of A. Braghiroli

*

=

OSCILLAZIONI PERIODICHE INTORNO ALLA SOGLIA APNEICA CO2

Ridotte riserve O2

Ridotto C.O.

Elevata risposta ventilatoria

Ridotta forza muscolare

Clinically, CSA–CSR was associated to higher mortality in CHF

In a large community based study CSA-CSR was not found to be associated with increased mortality

FENOMENO CHE RISPECCHIA UN DANNO D’ORGANO……..

QUALE E’ IL SIGNIFICATO DEL CSR ?

2) Meccanismo “di compenso” più benefico che dannoso…..?

QUALE E’ IL SIGNIFICATO DEL CSR ?

1) Meccanismo in se capace di danneggiare il cuore…..?

258 CHF + CSA/CRS(mean Age 63, FE% 24, AHI 40)

CPAP Group 130Control Group 128

2 years follow-up

CANPAP Commentary

–CANPAP study very selective patient set – strongly CSR / CSA (low OSA prevalence)–Beta Blockers not used in all subjects –Low over-all event rate (deaths) leave study under-powered for meaningful conclusions–Early increased mortality with CPAP, but without regard tousage or efficacy

Conclusioni

• Nello scompenso cardiaco cronico associato ad apnee ostruttive il trattamento con CPAP migliora la funzione cardiaca

• Nello scompenso cardiaco cronico associato ad apnee centrali non sono ancora disponibili evidenze definitive che la correzione efficace del disturbo respiratorio porti a un miglioramento della sopravvivenza...

one last question.......

http://dx.doi.org/10.1016/j.ijcard.2013.04.107

.......agire con il ventilatore per correggere il CSR o agire per migliorare l’emodinamica (che poi il CSR si corregge da solo)? Questo è il problema...

The unloading effect of CPAP therapy decreases both preload and stroke volumes (SV) in patients with low pulmonary capillary wedge pressure (PCWP). In contrast, PAP therapy increases SV in a state of high PCWP in patients with either exacerbated or stable CHF.

This intriguing phenomenon can be explained by diastolic ventricular interaction.

Unloading the RV by lower body negative pressure in patients with severe CHF reduces the external constraint on LV filling, resulting in the paradoxical dilation of the LV with a rightward shift of the interventricular septum.

Under these circumstances, the Frank-Starling law predicts an increase in SV.

……grazie per la vostra attenzione….