What device is recommended for treating central sleep apnea in a patient, considering potential underlying conditions such as heart failure?

Device Recommendations for Central Sleep Apnea

Adaptive servo-ventilation (ASV) is absolutely contraindicated and causes harm in patients with heart failure with reduced ejection fraction (HFrEF, LVEF ≤45%) and central sleep apnea, but may be considered for central sleep apnea in patients without heart failure or with preserved ejection fraction (>45%) after failing standard therapies. 1

Critical First Step: Determine Cardiac Function

Before selecting any device therapy for central sleep apnea, you must obtain a left ventricular ejection fraction (LVEF) measurement. 2, 3, 4 This single value determines whether ASV is safe or lethal for your patient.

Treatment Algorithm Based on Ejection Fraction

For Patients WITH Heart Failure (LVEF ≤45%)

Do NOT use ASV—it increases all-cause mortality and cardiovascular death. 1, 5 The 2017 ACC/AHA/HFSA guidelines assign a Class III: Harm recommendation based on the SERVE-HF trial, which demonstrated increased mortality rates when ASV was added to guideline-directed medical therapy in patients with NYHA class II-IV heart failure and reduced ejection fraction. 1

Recommended devices for HFrEF patients:

• CPAP (continuous positive airway pressure) as first-line therapy 3
• Supplemental oxygen as an alternative if PAP therapies fail 3, 6
• BPAP with backup rate if CPAP inadequate 2, 4

For Patients WITHOUT Heart Failure or WITH Preserved EF (LVEF >45%)

Use a stepwise approach: 2, 4

1. Start with standard CPAP as first-line therapy 2, 4
2. Progress to BPAP with backup rate (BPAP-ST) if CPAP fails to control central events (AHI remains >10-15/hour) 2, 4
3. Consider ASV only if BPAP proves inadequate and LVEF confirmed >45% 2, 3, 4

Evidence Supporting ASV in Non-Heart Failure Patients

When used appropriately in patients without reduced ejection fraction, ASV effectively treats central sleep apnea:

• ASV significantly reduces the apnea-hypopnea index (AHI) from baseline levels of 48-55 events/hour to 4-11 events/hour 7, 8
• Quality of life improves substantially in symptomatic patients, with median FOSQ score increases of +1.69 points at 12 months 9
• Daytime sleepiness decreases significantly, with Epworth Sleepiness Scale scores dropping from 12.8 to 7.8 7, 9
• ASV is superior to CPAP for controlling central sleep apnea specifically 8

Critical Safety Considerations and Common Pitfalls

The most dangerous error is using ASV in heart failure patients with reduced ejection fraction. 1 Multiple trials demonstrated harm, including the landmark SERVE-HF trial showing hazard ratios of 1.28 for all-cause mortality and 1.34 for cardiovascular death. 5 A third trial was aborted due to ethical concerns. 1

Always obtain and document ejection fraction before prescribing ASV. 2, 3, 4 This is not optional—it is the critical safety determinant that separates appropriate therapy from potentially lethal intervention.

Do not skip the stepwise approach. 2, 4 Even in patients with preserved ejection fraction, start with CPAP, then BPAP with backup rate, before advancing to ASV. This allows assessment of response to less complex (and less expensive) therapies first.

Distinguish central sleep apnea from obstructive sleep apnea. 1 The treatment algorithms differ completely. For obstructive sleep apnea, CPAP remains appropriate even in heart failure patients (Class IIb recommendation). 1

Monitoring Requirements

Patients on ASV require close monitoring and follow-up. 3 Adherence averages 4.2 hours per night, and effectiveness should be reassessed with objective measures. 7 The greatest improvements in quality of life occur in symptomatic patients (those with baseline FOSQ <17.9 or ESS >10). 9