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The Impact of Cardiac Resynchronization Therapy on Obstructive Sleep Apnea in Heart Failure Patients: A Pilot Study

¹Pulmonary, Critical Care, Sleep Medicine and Cardiology Divisions, Rhode Island Hospital, Brown Medical School, Providence, RI ²Sleep Medicine Division, Brigham and Women's Hospital, Boston, MA ³Senior Staff Scientist, Discovery Research Portfolio Management, St Jude Medical CRMD, Sylmar, CA

mstanchina{at}lifespan.org

Abstract

BackgroundCardiac resynchronization (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 (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 (PSG) were performed on CHF patients scheduled for CRT and those patients with an apnea hypopnea index (AHI) > 5 events/hr were approached about study enrollment. Patients had pre-CRT implant baseline and (mean ± SEM) 6.6 ± 1.4 month post-CRT echocardiograms, PSG, Minnesota Heart Failure, Epworth, and Functional Outcomes of Sleep questionnaires. An additional third PSG was performed combining CRT with the pacing rate15 beats per minute above the baseline sleeping heart rate within 1 week of the second PSG. Assessments for the change in cardiac output during the PSG were performed using circulation time to pulse oximeter as a surrogate. Results: 24 patients were screened and 13 (mean age 68.6 yrs, BMI 28.7 kg/m²) had evidence of OSA. AHI decreased from 40.9 ± 6.4 to 29.5 ± 5.9 events/hr with CRT, p = 0.04. 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 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 • Resynchronization • Obstructive Sleep Apnea • Congestive Heart Failure

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