Barnabas Gellen1, Florence Canouï-Poitrine2, Laurent Boyer3, Xavier Drouot4, Aurélie Le Thuaut2, Diane Bodez5, Ala Covali-Noroc6, Marie Pia D'ortho7, Soulef Guendouz5, Stéphane Rappeneau5, Mounira Kharoubi5, Jean-Luc Dubois-Rande8, Luc Hittinger8, Serge Adnot3, Sylvie Bastuji-Garin2, Thibaud Damy9. 1. Cardiology Department, APHP, Henri-Mondor Hospital, F-94010 Créteil, France; Mondor Institute Biomedical Research (IMRB), INSERM U955, F-94010 Créteil, France; Cardiology Department, Poitiers University Hospital, F-86021 Poitiers, France. Electronic address: barnabas.gellen@hmn.aphp.fr. 2. Public Health Department and Clinical Research Unit (URC-Mondor), APHP, Henri-Mondor Hospital, F-94010 Créteil, France; CEpiA (Clinical Epidemiology and Ageing) EA4393, Medical School, UPEC, F-94010 Créteil, France. 3. Mondor Institute Biomedical Research (IMRB), INSERM U955, F-94010 Créteil, France; Physiology Department, APHP, Henri-Mondor Hospital, F-94010 Créteil, France. 4. Physiology Department, APHP, Henri-Mondor Hospital, F-94010 Créteil, France; Physiology Department, Poitiers University Hospital, F-86021 Poitiers, France. 5. Cardiology Department, APHP, Henri-Mondor Hospital, F-94010 Créteil, France. 6. Physiology Department, APHP, Henri-Mondor Hospital, F-94010 Créteil, France. 7. Physiology Department, APHP, Bichat Hospital, F-75018 Paris, France. 8. Cardiology Department, APHP, Henri-Mondor Hospital, F-94010 Créteil, France; Mondor Institute Biomedical Research (IMRB), INSERM U955, F-94010 Créteil, France; CEpiA (Clinical Epidemiology and Ageing) EA4393, Medical School, UPEC, F-94010 Créteil, France. 9. Cardiology Department, APHP, Henri-Mondor Hospital, F-94010 Créteil, France; Mondor Institute Biomedical Research (IMRB), INSERM U955, F-94010 Créteil, France.
Abstract
BACKGROUND: Sleep disordered breathing (SDB) is common in patients with heart failure with reduced ejection fraction (HFrEF). An increased apnea-hypopnea index (AHI) is associated with poor outcomes. We examined whether an analysis of nocturnal desaturations (NDs) can improve the risk stratification. METHODS: Three-hundred seventy-six consecutive patients with stable chronic HFrEF and LVEF ≤ 45% were prospectively screened using polygraphy. Sleep apnea (SA) was defined as an AHI ≥ 15. The mean age was 59 ± 13 years, the mean LVEF was 30 ± 6%, and the median AHI was 18 [IQR: 9.33). The composite end-point of death, heart transplantation or LV assistance occurred in 98 patients (26%) within 3 years. Minimal oxygen saturation (MOS) during sleep, the number of desaturations <90%/h and the time spent with oxygen saturation <90% were significantly associated with adverse events (adjusted HR 1.25 [1.03-1.52], 1.25 [1.03-1.53], and 1.28 [1.04-1.59]), whereas the AHI was not (1.10 [0.86-1.39]). The best MOS cut-off value for poor outcomes was ≤ 88%. The patients with an MOS ≤ 88% had a significantly higher event rate (31.9%) than those with an MOS >88% (15.6%; p<0.01). The risk assessment using an MOS of ≤ 88% in addition to established prognostic markers yielded a net reclassification index (NRI) of nearly 6% and was particularly useful in the subgroup of patients with events (NRI: 8.4%). CONCLUSIONS: In HFrEF patients, ND ≤ 88% appears to be predictive of adverse events, independent of the presence of SA. This suggests that the risk assessment in HFrEF should also include ND in top of AHI.
BACKGROUND:Sleep disordered breathing (SDB) is common in patients with heart failure with reduced ejection fraction (HFrEF). An increased apnea-hypopnea index (AHI) is associated with poor outcomes. We examined whether an analysis of nocturnal desaturations (NDs) can improve the risk stratification. METHODS: Three-hundred seventy-six consecutive patients with stable chronic HFrEF and LVEF ≤ 45% were prospectively screened using polygraphy. Sleep apnea (SA) was defined as an AHI ≥ 15. The mean age was 59 ± 13 years, the mean LVEF was 30 ± 6%, and the median AHI was 18 [IQR: 9.33). The composite end-point of death, heart transplantation or LV assistance occurred in 98 patients (26%) within 3 years. Minimal oxygen saturation (MOS) during sleep, the number of desaturations <90%/h and the time spent with oxygen saturation <90% were significantly associated with adverse events (adjusted HR 1.25 [1.03-1.52], 1.25 [1.03-1.53], and 1.28 [1.04-1.59]), whereas the AHI was not (1.10 [0.86-1.39]). The best MOS cut-off value for poor outcomes was ≤ 88%. The patients with an MOS ≤ 88% had a significantly higher event rate (31.9%) than those with an MOS >88% (15.6%; p<0.01). The risk assessment using an MOS of ≤ 88% in addition to established prognostic markers yielded a net reclassification index (NRI) of nearly 6% and was particularly useful in the subgroup of patients with events (NRI: 8.4%). CONCLUSIONS: In HFrEF patients, ND ≤ 88% appears to be predictive of adverse events, independent of the presence of SA. This suggests that the risk assessment in HFrEF should also include ND in top of AHI.
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