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Treatment of Central Sleep Apnea and Cheyne Stokes

There are a variety of potential treatments for central sleep apnea with Cheyne-Stokes respiration (CSA/CSR) including CPAP, adaptive servoventilation (ASV), and nocturnal oxygen therapy. The benefits of these therapies in CSA/CSR patients with comorbid heart failure (HF) has remained questionable. One large trial, SERVE-HF, even demonstrated increased mortality with ASV in those with reduced left ventricular ejection fraction (LVEF). To better understand the effect of CPAP, ASV, and nocturnal oxygen therapy on LVEF in patients with CSA/CSR and comorbid HF, Schwarz et al performed a network-meta-analysis published in the Journal of Clinical Sleep Medicine on December 15, 2019.

Included in the analysis were 16 randomized controlled trials of 951 adults with HF and predominantly CSA/CSR allocated to treatment arms including CPAP, ASV, nocturnal oxygen therapy or control groups using either sham-devices or standard of care. Their primary outcome was the comparative effectiveness of these therapies on LVEF from baseline to study follow-up. Statistically significant improvements in LVEF were found among those treated with CPAP and ASV versus controls (4.4% and 3.8% respectively). There was no significant effect of nocturnal oxygen as compared to controls. There was also no significant difference in the effect on LVEF between CPAP and ASV. Among patients with an LVEF <45%, those with lower LVEF experienced greater benefit with either CPAP or ASV versus controls.

Current guidelines recommend against the use of ASV in patients with HF with reduced LVEF given the signal of significant harm. However, the mechanism for this increase in mortality is still unclear. Nonetheless, this network meta-analysis by Schwarz et al demonstrates that an improvement in LVEF can be achieved with CPAP, and that this effect is not seen with nocturnal oxygen therapy alone.

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(Post by: Oren Cohen)