What treatment approach is recommended for a patient with low ejection fraction (EF) and central apnea?

Treatment for Patients with Low Ejection Fraction and Central Sleep Apnea

Adaptive servo-ventilation (ASV) should NOT be used for patients with low ejection fraction (≤45%) and central sleep apnea due to increased mortality risk.1

Evidence-Based Approach

First-Line Management

• Optimize guideline-directed medical therapy (GDMT) for heart failure with reduced ejection fraction (HFrEF)
  • Focus on medications that improve mortality and morbidity:
    • ACE inhibitors/ARBs/ARNI
    • Beta-blockers
    • Mineralocorticoid receptor antagonists (MRAs)
    • SGLT2 inhibitors

Central Sleep Apnea Treatment Options

For patients with EF ≤45%:

• Avoid adaptive servo-ventilation (ASV)
  • Strong contraindication (Class III: Harm, Level B-R) 1
  • ASV increases all-cause and cardiovascular mortality in patients with EF ≤45% and central sleep apnea 1, 2
  • The SERVE-HF trial demonstrated a 34% increase in cardiovascular mortality with ASV in these patients 2

For patients with EF >45%:

• ASV may be considered (Option level recommendation) 1
  • Only for patients with mild CHF-related central sleep apnea
  • Benefits include improved apnea-hypopnea index (AHI) and potentially improved cardiac function 1, 3

Alternative treatments for central sleep apnea in HFrEF:

1. Continuous positive airway pressure (CPAP)

   • May be considered in selected patients
   • Less effective than ASV for central sleep apnea but safer in HFrEF 4
   • Caution: CPAP has not shown mortality benefit in large trials 1

2. Transvenous phrenic nerve stimulation (TPNS)

   • May reduce AHI and improve daytime sleepiness 4
   • Limited long-term data on cardiovascular outcomes

3. Bi-level PAP with back-up rate (BPAP-BUR)

   • Less effective than ASV but safer alternative 4
   • Limited evidence for mortality benefit

Treatment Algorithm

1. Assess ejection fraction

   • If EF ≤45%: ASV is contraindicated
   • If EF >45%: ASV may be considered as an option

2. For patients with EF ≤45% and central sleep apnea:

   • Optimize GDMT for heart failure
   • Consider CPAP if obstructive component is present
   • Consider TPNS or BPAP-BUR as alternative options
   • Monitor for improvement in sleep parameters and heart failure symptoms

Important Considerations

• Central sleep apnea in HFrEF may be a compensatory mechanism rather than a primary pathology requiring aggressive suppression 1
• The presence of central sleep apnea often reflects the severity of underlying heart failure
• Treatment should focus on improving the underlying heart failure condition first
• Regular reassessment of sleep parameters and cardiac function is essential

Common Pitfalls to Avoid

• Using ASV in patients with EF ≤45% and central sleep apnea (increases mortality)
• Focusing on treating sleep apnea without optimizing heart failure management
• Failing to distinguish between central and obstructive sleep apnea (different treatment approaches)
• Overlooking the potential for treatment-emergent central sleep apnea in patients initially treated for obstructive sleep apnea

Remember that the recent ADVENT-HF trial 5 showed that while ASV effectively eliminated sleep-disordered breathing, it had no effect on the primary composite outcome or mortality in HFrEF patients, supporting the current recommendation to avoid ASV in patients with EF ≤45%.