Advertisement

Central Sleep Apnea is a Predictor of Cardiac Readmission in Hospitalized Patients With Systolic Heart Failure

      Abstract

      Background

      Hospitalized heart failure patients have a high readmission rate. We sought to determine the independent risk due to central sleep apnea (CSA) of readmission in patients with systolic heart failure (SHF).

      Methods and Results

      This was a prospective observational cohort study of hospitalized patients with SHF. Patients underwent sleep studies during their hospitalization and were followed for 6 months to determine their rate of cardiac readmissions; 784 consecutive patients were included; 165 patients had CSA and 139 had no sleep-disordered breathing (SDB); the remainder had obstructive sleep apnea (OSA). The rate ratio for 6 months' cardiac readmissions was 1.53 (95% confidence interval 1.1–2.2; P = .03) in CSA patients compared with no SDB. This rate ratio was adjusted for systolic function, type of cardiomyopathy, age, weight, sex, diabetes, coronary disease, length of stay, admission sodium, creatinine, hemoglobin, blood pressure, and discharge medications. Severe OSA was also an independent predictor of readmissions with an adjusted rate ratio of 1.49 (P = .04).

      Conclusion

      In this first evaluation of the impact of SDB on cardiac readmissions in heart failure, CSA was an independent risk factor for 6 months' cardiac readmissions. The effect size of CSA exceeded that of all known predictors of heart failure readmissions.

      Key Words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Journal of Cardiac Failure
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • From A.M.
        • Leibson C.L.
        • Bursi F.
        • Redfield M.M.
        • Weston S.A.
        • Jacobsen S.J.
        • et al.
        Diabetes in heart failure: prevalence and impact on outcome in the population.
        Am J Med. 2006; 119: 591-599
        • Barker W.H.
        • Mullooly J.P.
        • Getchell W.
        Changing incidence and survival for heart failure in a well-defined older population, 1970–1974 and 1990–1994.
        Circulation. 2006; 113: 799-805
        • Lloyd-Jones D.
        • Adams R.J.
        • Brown T.M.
        • Carnethon M.
        • Dai S.
        • de Simone G.
        • et al.
        Heart disease and stroke statistics—2010 update: a report from the American Heart Association.
        Circulation. 2010; 121: e46-e215
        • Jencks S.F.
        • Williams M.V.
        • Coleman E.A.
        Rehospitalizations among patients in the Medicare fee-for-service program.
        N Engl J Med. 2009; 360: 1418-1428
        • Muzzarelli S.
        • Leibundgut G.
        • Maeder M.T.
        • Rickli H.
        • Handschin R.
        • Gutmann M.
        • et al.
        Predictors of early readmission or death in elderly patients with heart failure.
        Am Heart J. 2010; 160: 308-314
        • Hernandez A.F.
        • Greiner M.A.
        • Fonarow G.C.
        • Hammill B.G.
        • Heidenreich P.A.
        • Yancy C.W.
        • et al.
        Relationship between early physician follow-up and 30-day readmission among Medicare beneficiaries hospitalized for heart failure.
        JAMA. 2010; 303: 1716-1722
        • Fonarow G.C.
        • Abraham W.T.
        • Albert N.M.
        • Stough W.G.
        • Gheorghiade M.
        • Greenberg B.H.
        • et al.
        Factors identified as precipitating hospital admissions for heart failure and clinical outcomes: findings from OPTIMIZE-HF.
        Arch Intern Med. 2008; 168: 847-854
        • Fonarow G.C.
        The relationship between body mass index and mortality in patients hospitalized with acute decompensated heart failure.
        Am Heart J. 2007; 154: e21
        • Fonarow G.C.
        • Abraham W.T.
        • Albert N.M.
        • Gattis Stough W.
        • Gheorghiade M.
        • Greenberg B.H.
        • et al.
        Influence of a performance-improvement initiative on quality of care for patients hospitalized with heart failure: results of the Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure (OPTIMIZE-HF).
        Arch Intern Med. 2007; 167: 1493-1502
        • Fonarow G.C.
        • Abraham W.T.
        • Albert N.M.
        • Stough W.G.
        • Gheorghiade M.
        • Greenberg B.H.
        • et al.
        Carvedilol use at discharge in patients hospitalized for heart failure is associated with improved survival: an analysis from Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure (OPTIMIZE-HF).
        Am Heart J. 2007; 153: 82.e1-82.e11
        • Fonarow G.C.
        • Abraham W.T.
        • Albert N.M.
        • Stough W.G.
        • Gheorghiade M.
        • Greenberg B.H.
        • et al.
        Association between performance measures and clinical outcomes for patients hospitalized with heart failure.
        JAMA. 2007; 297: 61-70
        • Khayat R.
        • Jarjoura D.
        • Patt B.
        • Yamokoski T.
        • Abraham W.T.
        In-hospital testing for sleep-disordered breathing in hospitalized patients with decompensated heart failure: report of prevalence and patient characteristics.
        J Card Fail. 2009; 15: 739-746
        • Paulino A.
        • Damy T.
        • Margarit L.
        • Stoica M.
        • Deswarte G.
        • Khouri L.
        • et al.
        Prevalence of sleep-disordered breathing in a 316-patient French cohort of stable congestive heart failure.
        Arch Cardiovasc Dis. 2009; 102: 169-175
        • Sin D.D.
        • Fitzgerald F.
        • Parker J.D.
        • Newton G.
        • Floras J.S.
        • Bradley T.D.
        Risk factors for central and obstructive sleep apnea in 450 men and women with congestive heart failure.
        Am J Respir Crit Care Med. 1999; 160: 1101-1106
        • Javaheri S.
        • Shukla R.
        • Zeigler H.
        • Wexler L.
        Central sleep apnea, right ventricular dysfunction, and low diastolic blood pressure are predictors of mortality in systolic heart failure.
        J Am Coll Cardiol. 2007; 49: 2028-2034
        • Teschler H.
        • Dohring J.
        • Wang Y.M.
        • Berthon-Jones M.
        Adaptive pressure support servo-ventilation: a novel treatment for Cheyne-Stokes respiration in heart failure.
        Am J Respir Crit Care Med. 2001; 164: 614-619
        • American Academy of Sleep Medicine
        The AASM manual for the scoring of sleep and associated events: rules, terminology and technical specifications.
        1st ed. American Academy of Sleep Medicine, Westchester, IL2007
        • Santos-Silva R.
        • Sartori D.E.
        • Truksinas V.
        • Truksinas E.
        • Alonso F.F.
        • Tufik S.
        • Bittencourt L.R.
        Validation of a portable monitoring system for the diagnosis of obstructive sleep apnea syndrome.
        Sleep. 2009; 32: 629-636
        • Collop N.A.
        • Anderson W.M.
        • Boehlecke B.
        • Claman D.
        • Goldberg R.
        • Gottlieb D.J.
        • et al.
        Portable Monitoring Task Force of the American Academy of Sleep Medicine. Clinical guidelines for the use of unattended portable monitors in the diagnosis of obstructive sleep apnea in adult patients.
        J Clin Sleep Med. 2007; 3: 737-747
        • O'Connor C.M.
        • Abraham W.T.
        • Albert N.M.
        • Clare R.
        • Gattis Stough W.
        • Gheorghiade M.
        • et al.
        Predictors of mortality after discharge in patients hospitalized with heart failure: an analysis from the Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure (OPTIMIZE-HF).
        Am Heart J. 2008; 156: 662-673
        • Abraham W.T.
        • Fonarow G.C.
        • Albert N.M.
        • Stough W.G.
        • Gheorghiade M.
        • Greenberg B.H.
        • et al.
        Predictors of in-hospital mortality in patients hospitalized for heart failure: insights from the Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure (OPTIMIZE-HF).
        J Am Coll Cardiol. 2008; 52: 347-356
        • Lawless J.E.
        Negative binomial and mixed poisson regression.
        Can J Stat. 1987; 15: 209-225
        • Glynn R.J.
        • Buring J.E.
        Ways of measuring rates of recurrent events.
        BMJ. 1996; 312: 364-367
        • Little R.J.
        • Rubin D.B.
        Statistical analysis with missing data.
        2nd ed. John Wiley & Sons, New York2002
        • Solin P.
        • Bergin P.
        • Richardson M.
        • Kaye D.M.
        • Walters E.H.
        • Naughton M.T.
        Influence of pulmonary capillary wedge pressure on central apnea in heart failure.
        Circulation. 1999; 99: 1574-1579
        • Yumino D.
        • Redolfi S.
        • Ruttanaumpawan P.
        • Su M.C.
        • Smith S.
        • Newton G.E.
        • et al.
        Nocturnal rostral fluid shift: a unifying concept for the pathogenesis of obstructive and central sleep apnea in men with heart failure.
        Circulation. 2010; 121: 1598-1605
        • Xie A.
        • Skatrud J.B.
        • Khayat R.
        • Dempsey J.A.
        • Morgan B.
        • Russell D.
        Cerebrovascular response to carbon dioxide in patients with congestive heart failure.
        Am J Respir Crit Care Med. 2005; 172: 371-378
        • Javaheri S.
        • Parker T.J.
        • Liming J.D.
        • Corbett W.S.
        • Nishiyama H.
        • Wexler L.
        • Roselle G.A.
        Sleep apnea in 81 ambulatory male patients with stable heart failure. Types and their prevalences, consequences, and presentations.
        Circulation. 1998; 97: 2154-2159
        • Pepperell J.C.
        • Maskell N.A.
        • Jones D.R.
        • Langford-Wiley B.A.
        • Crosthwaite N.
        • Stradling J.R.
        • Davies R.J.
        A randomized controlled trial of adaptive ventilation for Cheyne-Stokes breathing in heart failure.
        Am J Respir Crit Care Med. 2003; 168: 1109-1114
        • Katragadda S.
        • Xie A.
        • Puleo D.
        • Skatrud J.B.
        • Morgan B.J.
        Neural mechanism of the pressor response to obstructive and nonobstructive apnea.
        J Appl Physiol. 1997; 83: 2048-2054
        • Fletcher E.C.
        Effect of episodic hypoxia on sympathetic activity and blood pressure.
        Respir Physiol. 2000; 119: 189-197
        • MacCarthy P.A.
        • Shah A.M.
        Impaired endothelium-dependent regulation of ventricular relaxation in pressure-overload cardiac hypertrophy.
        Circulation. 2000; 101: 1854-1860
        • Naughton M.T.
        • Benard D.C.
        • Liu P.P.
        • Rutherford R.
        • Rankin F.
        • Bradley T.D.
        Effects of nasal CPAP on sympathetic activity in patients with heart failure and central sleep apnea.
        Am J Respir Crit Care Med. 1995; 152: 473-479
        • Bradley T.D.
        • Logan A.G.
        • Kimoff R.J.
        • Series F.
        • Morrison D.
        • Ferguson K.
        • et al.
        Continuous positive airway pressure for central sleep apnea and heart failure.
        N Engl J Med. 2005; 353: 2025-2033
        • Leung R.S.
        • Diep T.M.
        • Bowman M.E.
        • Lorenzi-Filho G.
        • Bradley T.D.
        Provocation of ventricular ectopy by cheyne-stokes respiration in patients with heart failure.
        Sleep. 2004; 27: 1337-1343
        • Javaheri S.
        Effects of continuous positive airway pressure on sleep apnea and ventricular irritability in patients with heart failure.
        Circulation. 2000; 101: 392-397
        • Arzt M.
        • Harth M.
        • Luchner A.
        • Muders F.
        • Holmer S.R.
        • Blumberg F.C.
        • et al.
        Enhanced ventilatory response to exercise in patients with chronic heart failure and central sleep apnea.
        Circulation. 2003; 107: 1998-2003
        • Arzt M.
        • Schulz M.
        • Wensel R.
        • Montalvan S.
        • Blumberg F.C.
        • Riegger G.A.
        • Pfeifer M.
        Nocturnal continuous positive airway pressure improves ventilatory efficiency during exercise in patients with chronic heart failure.
        Chest. 2005; 127: 794-802
        • Oldenburg O.
        • Schmidt A.
        • Lamp B.
        • Bitter T.
        • Muntean B.G.
        • Langer C.
        • Horstkotte D.
        Adaptive servoventilation improves cardiac function in patients with chronic heart failure and Cheyne-Stokes respiration.
        Eur J Heart Fail. 2008; 10: 581-586
        • Khayat R.N.
        • Abraham W.T.
        • Patt B.
        • Pu M.
        • Jarjoura D.
        In-hospital treatment of obstructive sleep apnea during decompensation of heart failure.
        Chest. 2009; 136: 991-997
        • Yoshihisa A.
        • Shimizu T.
        • Owada T.
        • Nakamura Y.
        • Iwaya S.
        • Yamauchi H.
        • et al.
        Adaptive servo ventilation improves cardiac dysfunction and prognosis in chronic heart failure patients with Cheyne-Stokes respiration.
        Int Heart J. 2011; 52: 218-223
        • Javaheri S.
        • Caref E.B.
        • Chen E.
        • Tong K.B.
        • Abraham W.T.
        Sleep apnea testing and outcomes in a large cohort of medicare beneficiaries with newly diagnosed heart failure.
        Am J Respir Crit Care Med. 2011; 183: 539-546
        • O'Connor C.M.
        • Hasselblad V.
        • Mehta R.H.
        • Tasissa G.
        • Califf R.M.
        • Fiuzat M.
        • et al.
        Triage after hospitalization with advanced heart failure: the ESCAPE (Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness) risk model and discharge score.
        J Am Coll Cardiol. 2010; 55: 872-878