Trattamento delle bradi-tachi aritmie nei disturbi del ritmo del sonno

Giovanna Giubilato, MDGiovanna Giubilato, MDEP Lab Osp. S. Eugenio, RomaEP Lab Osp. S. Eugenio, RomaCentro Cuore Mater Dei, RomaCentro Cuore Mater Dei, Roma

“La sindrome delle apnee notturne: una sfida diagnostico terapeutica”

Roma 15 Novembre 2012

1012

2000 2010 2030

Sleep apnea syndrome prevalence: 100 million people WW1

1. World Health Organization 2007 - Global surveillance, prevention and control of chronic respiratory diseases: a comprehensive approach / Jean Bousquet and Nikolai Khaltaev editors2 Grimm et al., PACE 2009 3. Garrigue et al., CIRCULATION 2008 4. Bitter T et al. Eur Heart J. 2011 ; 32 : 61-74 – estimation

60% prevalence of sleep apnea (un-diagnosed) in arrhythmic

patients2-4

9% of middle-aged women and 25% of middle-aged men suffer

from OSA

9%25%

Young, N Engl J Med 1993; 328:1230-1235

Role of pacing in Sleep Apnea Syndrome

Atrial overdrive pacing significantly reduces the number of episodes of obstructive and central sleep apnea and increases arterial oxyhemoglobin saturation without altering total sleep time.

Sleep Apnea and cardiac rhythm abnormalities

• Severe Sleep Apnea is associated with an increased prevalence of arrhythmias

Association of Nocturnal Arrhythmias with Sleep-disordered Breathing The Sleep Heart Health Study. Mehra R et al. Am J Respir Crit Care Med 2006 ; 173 : 910–916,

Sleep Disordered Breathing patients

Non Sleep Disordered Breathing patients

OSA

Obstructive Sleep Apnea associated with increased risk of nocturnal sudden death

Death certificates of 112 Minnesota residents who had undergome polysomnography and had died suddenly

Day-night pattern of sudden death in obstructive sleep apnea. Gami AS et al. N Engl J Med 2005 ; 352 : 1206-14

OSA

• Sleep Apnea in HF constitutes a significantly increased risk of death• In HF patients with Sleep Apnea, use of PAP therapy is associated with

decreased mortality rate• Population: 296 HF patients, FU 7 years

CSA

OSA

CSA

Jilek, European Journal of Heart Failure (2011) 13, 68–75

Sleep Apnea in HF population and PAP effects

Sleep Apnea associated with increased life threatening arrhythmias in HF

Bitter T et al. Eur Heart J. 2011 ; 32 : 61-74.

• In patients with HF, CSA and OSA are independently associated with an increased risk for ventricular arrhythmias and appropriate cardioverter-defibrillator therapies

• Increased appropriate therapies (AHI ≥15):

• CSA: by 3.4-fold

• OSA: by 2.1-fold

POPULATION: 255 CRTD pts

FU: 4 years

Primary Endpoint: event-free survival time period to first appropriate cardioverter-defibrillator therapy

PROTOCOL excluded patient undergoing CPAP

OSACSA

Sleep Apnea and cardiac rhythm abnormalities

• Sleep Apnea is associated with increased risk of incident atrial fibrillation

AS Gami et al. J Am Coll Cardiol 2007; 49: 565-71

3542 subjects (Olmsted County)

OSA

Sleep Apnea and cardiac rhythm abnormalities

• Sleep Apnea increase the risk of AF recurrences following Catheter Ablation

K Jognarangsin et al. J Cardiovasc Electrophysiol 2008

OSA

CRT effectiveness on OSA/CSA: meta analysis

Lamba, Europace (2011) 13, 1174–1179

• CRT significantly reduces AHI in CSA but not OSA

CRT

OSA

CSA

Sudden DeathSleep Apnea increases risk for VT/VF & appropriate ICD therapies by 2-3 fold1,2

Sleep Apnea increases risk of nocturnal SCD compared to normals (RR: 2.57 vs 0.77)3

Atrial FibrillationSleep Apnea is an independent predictor of new onset AF4, and may be a causative factor in the development of AF5

Sleep Apnea increases likelihood for AF recurrence post cardioversion (from 42% to 82%)6

Recurrence decreases after CPAP therapy7

1. Bitter, EHJ. 20112. Tomaello, Clin Cardiol. 20103. Gami, NEJM 20054. Gami, JACC 20075. Mehra, AJRCCM 2997 6. Gami, Circ 20047. Kanagala, Circulation 2003

Cardiovascular consequences of Sleep Apnea

ConclusionsSleep Apnea is:highly prevalent in implanted populationan undiagnosed major pathologyassociated wiht increased risk for AF, SCD in ICD and CRT populationassociated with increased mortality and morbidity in HF

Sleep Apnea consequences can be reversed by appropriate therapy (i.e. positive air pressure therapies, optimization of pharamcological therapy)

Usual strategies for screening of Sleep Apnea are less effective in HF population

1. Shalaby, PACE 2006