Treatment of Central Sleep Apnea with Cheyne-Stokes Breathing in Heart Failure with Preserved Ejection Fraction

Clinical Scenario

This protocol applies to central sleep apnoea (CSA) occurring alongside Cheyne-Stokes breathing (CSB) — a form of periodic breathing characterised by cyclical waxing and waning of tidal volume — in the setting of heart failure with preserved ejection fraction (HFpEF), defined by a left ventricular ejection fraction greater than 45%.

CSA–CSB in this context arises as a consequence of the low cardiac output state associated with HFpEF, driven by impaired cardiac filling and relaxation.

Treatment Approach

Management centres on optimisation of the underlying heart failure therapy — with pharmacological approaches addressing sympathetic nervous activity, cardiac loading, and fluid congestion — alongside device-based interventions for selected patients. The complete regimen and full therapeutic sequence are available in the structured protocol below.

Treatment Goal

Target outcome

Resolution of central sleep apnoea.

Instant Access to Structured Evidence-Based Regimens

References

DOI: 10.1183/20734735.0235-2023

CSA, often with concurrent CSB (a form of periodic breathing with waxing and waning amplitude of flow/tidal volume), can be observed in low cardiac output states including heart failure with reduced ejection fraction (HFrEF), heart failure with preserved ejection fraction (HFpEF; impaired cardiac filling/relaxation) and cardiac arrhythmia.

Optimisation of heart failure therapy should be incorporated in all patients with cardiac dysfunction as it has been shown to improve CSA among other clinical outcomes, such as cardiac function, cardiovascular-related mortality and overall quality of life.

This includes β-blockers to reduce sympathetic nervous activity, angiotensin-converting enzyme-inhibitor to reduce ventricular afterload and blockade of the renin–angiotensin system, diuretics to reduce pulmonary venous congestion and appropriate rate/rhythm control of atrial fibrillation.

Heart failure patients with ventricular conduction delay can also benefit from cardiac resynchronisation therapy, which has improved cardiac function and reduced CSA–CSB severity.

In some cases, this may resolve their CSA without further intervention.

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