Congestive heart failure and obstructive sleep apnea

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Congestive Heart Failure Microchapters
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Specific Groups: Special Populations Patients who have concomitant disorders Obstructive Sleep Apnea in the Patient with CHF NSTEMI with Heart Failure and Cardiogenic Shock
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

Obstructive sleep apnea is a sleep-related breathing disorder that affects on cardiovascular function. Common complications association obstructive sleep apnea include hypertension, coronary artery disease, cardiac arrhythmias, sudden cardiac death, and heart failure.

Sleep apnea in heart failure disease

• Sleep apnea is defined as partial or complete cessation of breathing during night-time sleep, resulting in repeated arousal from sleep, oxyhemoglobin desaturation, and daytime sleepiness.
• Apnea is as complete cessation of airflow for >10 s.
• Hypopnea, or partial cessation of airflow, is defined as a 50% to 90% reduction in airflow for >10 s, and >3% decrease in oxyhemoglobin saturation (SaO2) terminated by arousal.
• The 3 types of apnea include central, obstructive, and mixed.
• Central sleep apnea (CSA) is characterized by a complete withdrawal of central respiratory drive to the inspiratory muscles, including the diaphragm, and results in the simultaneous absence of naso-oral airflow and thoracoabdominal excursions.
• In obstructive sleep apnea (OSA), the thoracic inspiratory muscles, including the diaphragm, are active, so thoracoabdominal excursions are seen.
• Absence of airflow results from upper-airway occlusion caused by lost pharyngeal dilator muscle tone, with consequent pharyngeal collapse.
• Mixed apnea has an initial central component followed by an obstructive component.
• Two types of hypopnea include obstructive or central.

• Obstructive sleep apnea is characterized by recurrent pharyngeal collapse during sleep.
• Hypopnea or apnea occurs in the presence of pharynx collapse upon normal withdrawal of pharyngeal dilator muscle tone during sleep.
• Obesity and fat deposition around the pharynx are responsible of pharyngeal narrowing.
• Edema of the peripharyngeal when lying asleep due to leg fluid displacement during the day predisposing the individual to OSA.
• Obstructive sleep apnea causes a drop in intrathoracic pressure, hypoxia, and arousal.
• The drop in intrathoracic pressure increases left ventricular (LV) transmural pressure, and afterload.
• This drop in pressure increases venous return, causing right ventricular distention and a leftward shift of the interventricular septum and consequent decreased LV filling.
• Decreased LV filling and increased afterload lead to reduced stroke volume.
• Obstructive sleep apnea leading to elevations in systemic blood pressure (BP) secondary to hypoxia, arousals from sleep, and increased sympathetic nervous system activity (SNA).
• The combination of increased LV afterload and increased heart rate secondary to augmented SNA leads to myocardial oxygen supply/demand mismatch, cardiac ischemia and arrhythmias, LV hypertrophy, LV enlargement, and HF.