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* From the Divisions of Pulmonary, Critical Care, Sleep Medicine (Drs. Stanchina and Millman, Ms. Tosi, and Ms. Carlisle) and Cardiology (Drs. Ellison, Anderson, Kirk, and Buxton), Rhode Island Hospital, Brown Medical School, Providence, RI; Sleep Medicine Division (Dr. Malhotra), Brigham and Women’s Hospital, Boston, MA; and Discovery Research Portfolio Management (Dr. Benser), Cardiac Rhythm Management Division, St. Jude Medical, Sylmar, CA.
Correspondence to: Michael Stanchina, MD, FCCP, Pulmonary, Critical Care, and Sleep Medicine Division, Rhode Island Hospital, 1285 South County Trail, East Greenwich, RI 02818; e-mail: mstanchina{at}lifespan.org
Abstract
Background: Cardiac resynchronization therapy (CRT) has been shown to improve cardiac function and reduce Cheyne-Stokes respiration but has not been evaluated in patients with obstructive sleep apnea (OSA). In this pilot study, we investigated the impact of both CRT and CRT plus increased rate pacing in heart failure (ie, congestive heart failure [CHF]) patients with OSA. We hypothesized that through increased cardiac output CRT/pacing would reduce obstructive events and daytime symptoms of sleepiness.
Methods: Full polysomnograms were performed on CHF patients who were scheduled for CRT, and those patients with an apnea-hypopnea index (AHI) of > 5 events per hour were approached about study enrollment. Patients had a pre-CRT implant baseline echocardiogram and an echocardiogram a mean (± SEM) duration of 6.6 ± 1.4 months post-CRT implant; polysomnography; and responded to the Minnesota Living with Heart Failure questionnaire, the Epworth sleepiness scale, and the Functional Outcomes of Sleep Questionnaire. An additional third polysomnography was performed combining CRT with a pacing rate of 15 beats/min above the baseline sleeping heart rate within 1 week of the second polysomnography. Assessments for the change in cardiac output during the polysomnography were performed using circulation time to pulse oximeter as a surrogate.
Results: Twenty-four patients were screened, and 13 patients (mean age, 68.6 years; body mass index, 28.7 kg/m2) had evidence of OSA. The mean AHI decreased from 40.9 ± 6.4 to 29.5 ± 5.9 events per hour with CRT (p = 0.04). The mean baseline ejection fraction was 22 ± 1.7% and increased post-CRT to 33.6 ± 2.0% (p < 0.05). The reduction in AHI with CRT closely correlated with a decrease in circulation time (r = 0.89; p < 0.001) with CRT. Increased rate pacing made no additional impact on the AHI or circulation time. CRT had a limited impact on sleep architecture or daytime symptom scores.
Conclusions: CRT improved cardiac function and reduced the AHI. Reduced circulatory delay likely stabilized ventilatory control systems and may represent a new therapeutic target in OSA.
Key Words: cardiac pacing • congestive heart failure • obstructive sleep apnea • resynchronization
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  T. Kara, M. Novak, J. Nykodym, K. A. Bybee, J. Meluzin, M. Orban, Z. Novakova, J. Lipoldova, D. L. Hayes, M. Soucek, et al. Short-term Effects of Cardiac Resynchronization Therapy on Sleep-Disordered Breathing in Patients With Systolic Heart Failure Chest, July 1, 2008; 134(1): 87 - 93. [Abstract] [Full Text] [PDF]
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