What are the recommendations for using Adaptive Servo-Ventilation (ASV) in patients with heart failure, considering the findings of the SERVE-HF trial versus the ADVENT-HF trial?

Adaptive Servo-Ventilation in Heart Failure: ADVENT-HF vs SERVE-HF Recommendations

Adaptive servo-ventilation (ASV) should NOT be used in heart failure patients with reduced ejection fraction (LVEF ≤45%) and predominant central sleep apnea due to increased risk of cardiovascular mortality. 1

Current Guidelines on ASV Use in Heart Failure

The recommendations for ASV use in heart failure patients differ based on ejection fraction and type of sleep apnea:

For Heart Failure with Reduced Ejection Fraction (HFrEF)

• LVEF ≤45% with predominant central sleep apnea (CSA):

  • ASV is contraindicated (Standard Against) 1
  • European Society of Cardiology (ESC) guidelines give this a Class III, Level B recommendation (treatment that causes harm) 1
  • This recommendation is based on the SERVE-HF trial which showed increased cardiovascular mortality with ASV use in this population 2

• LVEF >45% or mild CHF-related CSA:

  • ASV may be considered (Option) 1
  • Evidence quality is lower for this recommendation

For Obstructive Sleep Apnea (OSA) in Heart Failure

• The ADVENT-HF trial showed ASV safely eliminated sleep-disordered breathing in HFrEF patients but did not improve cardiovascular outcomes 3
• No mortality increase was observed in OSA patients using ASV in the ADVENT-HF trial (HR 1.00) 3

Key Trial Findings

SERVE-HF Trial (2015)

• Population: 1,325 patients with HFrEF (LVEF ≤45%) and predominantly central sleep apnea
• Primary finding: Increased all-cause mortality (HR 1.28) and cardiovascular mortality (HR 1.34) in the ASV group 2
• Mechanism: On-treatment analysis confirmed the increased cardiovascular death risk was related to ASV usage 4

ADVENT-HF Trial (2024)

• Population: 731 patients with HFrEF (LVEF ≤45%) and sleep-disordered breathing (both OSA and CSA)
• Primary finding: No effect on composite outcome (HR 0.95) or all-cause mortality (HR 0.89) 3
• Subgroup analysis:
  • For OSA: HR for mortality was 1.00
  • For CSA: HR for mortality was 0.74 (trending toward benefit but not statistically significant) 3

Clinical Decision Algorithm

1. For all heart failure patients:

   • Screen for sleep-disordered breathing
   • Distinguish between OSA and CSA through proper sleep evaluation

2. If LVEF ≤45% with predominant CSA:

   • DO NOT use ASV due to increased mortality risk
   • Consider alternative treatments for CSA

3. If LVEF >45% with CSA:

   • ASV may be considered (lower level of evidence)
   • Monitor cardiac function closely

4. If OSA is predominant:

   • Consider CPAP as first-line therapy
   • ASV did not show mortality benefit but was safe in the ADVENT-HF trial

Important Caveats and Pitfalls

• Device differences: The SERVE-HF trial used volume-triggered ASV while ADVENT-HF used peak-flow triggered ASV, which may partially explain outcome differences 3
• Patient selection: Careful assessment of sleep apnea type (central vs. obstructive) is critical before considering ASV
• Ejection fraction threshold: The 45% LVEF cutoff is a critical decision point for ASV contraindication
• Monitoring: If ASV is used in appropriate patients, regular monitoring of cardiac function is essential

Despite some promising physiological effects on sleep quality and apnea-hypopnea index, the mortality risk in HFrEF patients with CSA outweighs potential benefits of ASV therapy 5. The most recent evidence from ADVENT-HF suggests ASV is safe but does not improve outcomes even in carefully selected patients 3.