Nonpharmacologic Management and Health Care Maintenance in Patients With Chronic Heart Failure
Other Therapies
Recommendation
Continuous positive airway pressure to improve daily functional capacity and quality of life is recommended in patients with HF and obstructive sleep apnea documented by approved methods of polysomnography. (Strength of Evidence = B)
Background
Sleep-disordered breathing is highly prevalent in HF patients.33-35 Formal sleep evaluation is therefore recommended for patients who remain symptomatic despite optimal HF therapy. Testing should be considered for patients with a positive screening questionnaire or whose sleep partner reports signs suggesting apnea or periodic breathing. Whether clinical outcome is favorably affected by treatment of sleep-disordered breathing is unclear, but patient quality of life and functional capacity is increased by treatment when the respiratory disturbance index is at least moderately elevated, and individual studies have shown that use of continuous positive airway pressure (CPAP) reduces edema, daytime muscle sympathetic nerve activity, systolic blood pressure, frequency of ventricular premature beats during sleep, and improves LV function.36-40 Concomitant treatment for restless leg syndrome may be reduced when the patient is treated for associated sleep-disordered breathing.
The other component of sleep-disordered breathing, central sleep apnea, was studied in a large-scale trial that tested the hypothesis that CPAP would improve the survival rate without transplantation for patients with central sleep apnea and HF. The Canadian Continuous Positive Airway Pressure for Patients with Central Sleep Apnea and Heart Failure trial (CANPAP) of 258 patients found that those patients randomized to CPAP had attenuated central sleep apnea, improved nocturnal oxygenation, increased LVEF, and improved 6-minute walk distances, but did not survive longer.41
Recommendation
Supplemental oxygen, either at night or during exertion, is not recommended for patients with HF in the absence of an indication of underlying pulmonary disease. Patients with resting hypoxemia or oxygen desaturation during exercise should be evaluated for residual fluid overload or concomitant pulmonary disease. (Strength of Evidence = B)
Background
Pulmonary vascular congestion creating resting or exertional hypoxemia requires aggressive diuretic therapy, rather than supplemental oxygen. Oxygen supplementation is a useful therapeutic adjunct in hospitalized patients during acute decompensation or with coronary ischemia. Patients with residual resting hypoxemia or exertional arterial oxygen desaturation after optimization of intravascular volume should be evaluated for concomitant pulmonary disease, pleural effusion, pulmonary emboli, pulmonary hypertension, silent myocardial ischemia, obesity-hypoventilation syndrome, and sleep-disordered breathing.
Pulmonary vascular congestion creating resting or exertional hypoxemia requires aggressive diuretic therapy, rather than supplemental oxygen. Oxygen supplementation is a useful therapeutic adjunct in hospitalized patients during acute decompensation or with coronary ischemia. Patients with residual resting hypoxemia or exertional arterial oxygen desaturation after optimization of intravascular volume should be evaluated for concomitant pulmonary disease, pleural effusion, pulmonary emboli, pulmonary hypertension, silent myocardial ischemia, obesity-hypoventilation syndrome, and sleep-disordered breathing.
Recommendation
The identification of treatable conditions, such as sleep-disordered breathing, urologic abnormalities, restless leg syndrome, and depression should be considered in patients with HF and chronic insomnia. Pharmacologic aids to sleep induction may be necessary. Agents that do not risk physical dependence are preferred. (Strength of Evidence = C)
Background
Chronic insomnia is associated with a risk of psychological instability and impaired cognitive function. After metabolic, physiologic, pharmacologic, and dietary causes are excluded, screening should be considered for urologic abnormality, sleep-disordered breathing, restless leg syndrome, depression, and anxiety disorders. Nocturnal anxiety may be a manifestation of paroxysmal nocturnal dyspnea. Sedatives can worsen apnea and should be initially eliminated. Paradoxical agitation from the use of antihistamine products or benzodiazepine preparations is not uncommon. For these reasons, the use of medication to aid sleep induction should be undertaken only when necessary, and then with caution and careful monitoring.