From the Guidelines
Low ejection fraction (EF) patients should not be treated with adaptive servo-ventilation (ASV) therapy due to the increased risk of mortality associated with its use in patients with heart failure with reduced ejection fraction (HFrEF). This recommendation is based on the findings of the SERVE-HF trial, which demonstrated a significant increase in cardiovascular mortality in HFrEF patients using ASV compared to those receiving standard care 1. The American Academy of Sleep Medicine (AASM) has also updated its guidelines to reflect this evidence, stating that ASV should not be used for the treatment of central sleep apnea syndrome (CSAS) related to congestive heart failure (CHF) in adults with an ejection fraction ≤ 45% and moderate or severe CSA predominant, sleep-disordered breathing 1.
The mechanism behind this adverse effect involves ASV's suppression of normal respiratory patterns, which may interfere with the compensatory mechanisms that heart failure patients develop. ASV works by dynamically adjusting pressure support to maintain a target ventilation, but this can potentially increase cardiac workload and reduce venous return in patients with already compromised cardiac function. Key points to consider when evaluating the use of ASV in patients with low EF include:
- The increased risk of cardiovascular mortality associated with ASV use in HFrEF patients
- The potential for ASV to interfere with compensatory mechanisms developed by heart failure patients
- The importance of alternative treatments, such as CPAP, oxygen therapy, or positional therapy, for patients with low EF and sleep-disordered breathing
- The need for a thorough cardiovascular assessment, including echocardiography to determine ejection fraction, before initiating any positive airway pressure therapy in heart failure patients.
In clinical practice, it is essential to prioritize the safety and well-being of patients with low EF, and to consider alternative treatments that do not carry the same risks as ASV therapy. By doing so, healthcare providers can help to minimize the risk of adverse outcomes and improve the quality of life for patients with heart failure and sleep-disordered breathing.
From the Research
Low EF and ASV Therapy
- Low ejection fraction (EF) patients may not be suitable for adaptive servo-ventilation (ASV) therapy due to potential increased mortality risks 2, 3.
- Studies have shown that ASV therapy can have negative effects on patients with chronic systolic heart failure (CHF) and central sleep apnea (CSA), particularly those with low EF 2.
- In contrast, automatic continuous positive airway pressure (CPAP) has been shown to favorably alter sympatho-vagal balance in patients with CSA without CHF, but not in those with CHF 2.
Mortality Risks and ASV Therapy
- A meta-analysis found that ASV therapy had no effect on all-cause mortality in patients with heart failure with reduced ejection fraction (HFrEF) and CSA, but short-term treatment with ASV may be beneficial 3.
- Another study found that periodic short-term positive-pressure ventilation can significantly improve cardiac function and survival in patients with HFrEF and CSA, but prolonged treatment may have negative effects 3.
Alternative Therapies for Low EF Patients
- Other studies have explored alternative therapies for patients with low EF, such as transvenous lead extraction with left ventricular assist devices, which can provide intraoperative hemodynamic support and facilitate lifesaving interventions 4.
- Adaptive servo-ventilation devices have also been shown to be effective in treating central sleep apnea in patients with congestive heart failure, but larger randomized controlled trials are needed to demonstrate their ultimate role in such patients 5.