This clinical scenario involves patients with central sleep apnoea (CSA) and concurrent Cheyne-Stokes breathing (CSB) occurring in the setting of heart failure with preserved ejection fraction (HFpEF) — left ventricular ejection fraction above 45% — in whom optimisation of heart failure therapy has not achieved resolution of central sleep apnoea.
CSA with concurrent Cheyne-Stokes breathing — a form of periodic breathing with waxing and waning tidal volume — is a recognised feature of low cardiac output states. In heart failure with preserved ejection fraction (HFpEF), impaired cardiac filling and relaxation underlie this presentation. The LVEF in this population is above 45%.
The first-line approach of optimisation of heart failure therapy — encompassing pharmacological management targeting ventricular afterload, fluid balance, sympathetic activity, and, where applicable, cardiac rhythm or resynchronisation — did not achieve the required goal of resolution of central sleep apnoea. This protocol addresses the next treatment step.
In this population, a targeted positive airway pressure-based therapy is the established next line. The full protocol specifies the exact modality, delivery parameters, and any adjunct options applicable to this scenario — details are available via the link below.
Adequate control of central sleep apnoea, defined as an apnoea-hypopnoea index (AHI) below 15 events per hour.
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.
In patients who have had inadequate response to heart failure optimisation, the next line of therapy is continuous positive airway pressure (CPAP) therapy.
A subsequent post hoc analysis showed that among subjects of the Canadian Continuous Positive Airway Pressure for Patients with Central Sleep Apnea and Heart Failure Trial (CANPAP) with CSA syndrome that were adequately controlled with CPAP therapy (AHI <15 events per h), the transplant-free survival and LVEF were better than in non-suppressed and control subjects.
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