Title Should All Congestive Heart Failure Patients Have a Routine Sleep Apnea Screening ?

Sleep-disordered breathing (SDB) is one of the most common comorbidities in people with congestive heart failure (CHF). Although SDB has major cardiometabolic consequences, the attributable risk of SDB in asymptomatic CHF patients remains unclear. Whether early intervention using positive airway pressure would improve the prognosis in CHF patients is uncertain. As yet, there is insufficient evidence that routine polysomnography screening is cost-effective for asymptomatic CHF patients. Careful clinical risk evaluation and thoughtful use of limited-channel home sleep testing should be considered before the application of routine polysomnography in all CHF patients. Received for publication March 23, 2015. Accepted April 20, 2015. Corresponding author: Dr Atul Malhotra, 9300 Campus Point Drive #7381, La Jolla, California 92037-7381, USA. Tel. : þ1-858-657-6159; fax: þ1-858-657-7107. E-mail: amalhotra@ucsd.edu See page 942 for disclosure information. http://dx.doi. org/10.1016/j.cjca. 2015.04. 013 0828-282X/ 2015 Canadian Cardiovascular Society. Published by Elsevier Inc. A R ESUM E Les troubles respiratoires du sommeil (TRS) sont l’une des plus fr equentes comorbidit es chez les personnes atteintes d’insuffisance cardiaque congestive (ICC). Bien que les TRS aient des cons equences cardiom etaboliques majeures, le risque attribuable aux TRS chez les patients souffrant d’ICC qui sont asymptomatiques demeure obscur. L’on ignore si l’intervention pr ecoce par pression positive expiratoire continue am eliorerait le pronostic chez les patients souffrant d’ICC. Jusqu’à maintenant, il n’existe pas suffisamment de donn ees probantes montrant que le d epistage syst ematique au moyen de la polysomnographie est rentable chez les patients atteints d’ICC qui sont asymptomatiques. L’ evaluation clinique approfondie du risque et l’utilisation judicieuse du test de sommeil à canaux limit es à domicile devraient être consid er ees avant l’utilisation de la polysomnographie syst ematique chez tous les patients atteints d’ICC. The prevalence of sleep abnormalities is high in congestive heart failure (CHF) patients. Epidemiological studies have suggested 40%-70% of people with CHF will have evidence of obstructive sleep apnea (OSA) or central sleep apnea on polysomnography (PSG), and the prevalence of clinically important OSA is approximately 6%-13% in the general adult population. OSA is defined by ongoing respiratory efforts during the cessation/reduction in airflow leading to intermittent hypoxemia and recurrent arousals from sleep with associated catecholamine surges. Central sleep apnea (CSA) refers to stoppages/reductions in airflow without respiratory effort. CSA with Cheyne Stokes Breathing is a form of CSA with a waxing and waning pattern of breathing characterized by a crescendo-decrescendo pattern, also leading to intermittent hypoxemia and recurrent arousals from sleep associated with catecholamine surges. In many CHF patients, features of OSA and CSA are observed, leading some to refer to these collective abnormalities as sleepdisordered breathing (SDB) rather than making an arbitrary distinction between the 2 entities (OSA and CSA). In addition, patients might have insomnia, fatigue, periodic limb movements, and other sleep complaints which are potentially amenable to intervention. Data suggest abnormalities are highly prevalent in patients with CHF with preserved left ventricular ejection fraction (EF) and in those with reduced EF, although the bulk of the studies have been in those with systolic dysfunction. Patients with CHF rarely report excessive sleepiness, perhaps because of sympathoexcitation underlying the condition, even when sleep is very disturbed. As a result, the history and physical examination might be unreliable in defining sleep