In patients with heart failure, enhanced ventilatory response to exercise is associated with severe obstructive sleep apnea

Abstract

Study objectives: Patients with congestive heart failure (CHF) frequently exhibit an elevated ratio of minute ventilation over CO₂ output (VE/VCO₂ slope) while undergoing exercise tests. One of the factors contributing to this elevated slope is an increased chemosensitivity to CO₂ in that this slope significantly correlates with the slope of the ventilatory response to CO₂ rebreathing at rest. A previous study in patients with CHF and central sleep apnea showed that the highest VE/VCO₂ slope during exercise was associated with the most severe central sleep apnea. In the current study, we tested the hypothesis that in patients with CHF and obstructive sleep apnea (OSA), the highest VE/VCO₂ slope is also associated with the most severe OSA. If the hypothesis is correct, then it implies that in CHF, augmented instability in the negative feedback system controlling breathing predisposes to both OSA and central sleep apnea.

Methods: This preliminary study involved 70 patients with stable CHF and a spectrum of OSA severity who underwent full-night polysomnography, echocardiography, and cardiopulmonary exercise testing. Peak oxygen consumption and the VE/VCO₂ slope were calculated.

Results: There was significant positive correlation between the apnea-hypopnea index and the VE/VCO₂ slope (r = .359; P = .002). In the regression model, involving the relevant variables of age, body mass index, sex, VE/VCO₂ slope, peak oxygen consumption, and left ventricular ejection fraction, the apnea-hypopnea index retained significance with VE/VCO₂.

Conclusions: In patients with CHF, the VE/VCO₂ slope obtained during exercise correlates significantly to the severity of OSA, suggesting that an elevated CO₂ response should increase suspicion for the presence of severe OSA, a treatable disorder that is potentially associated with excess mortality.

Clinical trial registration: Registry: ClinicalTrials.gov; Name: Comparison Between Exercise Training and CPAP Treatment for Patients With Heart Failure and Sleep Apnea; URL: https://clinicaltrials.gov/ct2/show/record/NCT01538069; Identifier: NCT01538069.

Citation: Bittencourt L, Javaheri S, Servantes DM, Pelissari Kravchychyn AC, Almeida DR, Tufik S. In patients with heart failure, enhanced ventilatory response to exercise is associated with severe obstructive sleep apnea. J Clin Sleep Med. 2021;17(X):1875-1880.

Keywords: enhanced ventilatory response; exercise; heart failure; obstructive sleep apnea.