Il paziente
cardiologico
&
DISTURBI
RESPIRATORI
DURANTE
SONNO
Vincenzo Patruno
SOC Pneumologia Riabilitativa
I.M.F.R. - Udine
due punti di vista..................
Paziente con apnee durante sonno  quali malattie cardiache ?
Paziente con malattie cardiache  quali apnee durante sonno?
Epidemiology: discovered the association
Hypertension
OSA
Cardiac
Arrhythmia
Coronary
Ischemic
disease
Heart Failure
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
2007
EUROPEAN SOCIETY OF CARDIOLOGY – EUROPEAN
SOCIETY OF HYPERTENSION
GUIDELINES
….FIRST ACKNOWLEDGE OSA AS ONE
OF THE FACTORS RESPONSIBLE FOR
RESISTANT HYPERTENSION
The Journal of Clinical Hypertension
Volume 9, Issue Supplement s1, pages 2–6,
January 2007
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.
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.
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)
Gami AS
Obstructive sleep apnea, obesity, and the risk of incident atrial fibrillation.
J Am Coll Cardiol 2007;49:565–71.
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 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.
(Am J Respir Crit Care Med. 163, 19-25 2001)
Coronary Heart Disease
OR 1.22
Obstructive Sleep Apnea & Chronic Heart Failure
10% of CHF patients have obstructive apneas
Javaheri 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 apneas
Lanfranchi P., Somers VK et al. Circulation 2003 107/5 727-732
matic Positive Airway Pressure
(APAP)
Pressione critica
=
concetto dinamico
Pcrit = Dynamic
OSA
Pressione efficace
Best PAP
= = Dynamic
variabile
CVDs
 FE 37%  49% in una settimana di trattamento CPAP
Malone et al. Lancet 1991;338:1480-4
Cuore e Respiro: Due punti di vista
Paziente con apnee  quali malattie cardiache ?
Paziente con malattia cardiaca quali apnee ?
Central Sleep Apnea & Chronic Heart Failure
40% of CHF patients have CSA-CSR
Javaheri 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-CSR
Lanfranchi P. Circulation 2003 feb 11 107/5) 727-732
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
*
+
=
+
*Intellectual property of A. Braghiroli
OSCILLAZIONI PERIODICHE INTORNO ALLA SOGLIA APNEICA CO2
Elevata risposta ventilatoria
Ridotto C.O.
Ridotta forza muscolare
Ridotte riserve O2
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
QUALE E’ IL SIGNIFICATO DEL CSR ?
FENOMENO CHE RISPECCHIA UN DANNO D’ORGANO……..
QUALE E’ IL SIGNIFICATO DEL CSR ?
1) Meccanismo in se capace di danneggiare il cuore…..?
2) Meccanismo “di compenso” più benefico che dannoso…..?
258 CHF + CSA/CRS
(mean Age 63, FE% 24, AHI 40)
CPAP Group 130
Control 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 underpowered for meaningful conclusions
–Early increased mortality with
CPAP, but without regard to
usage 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...
.......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...
http://dx.doi.org/10.1016/j.ijcard.2013.04.107
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.