Sleep Outcomes From AWAKE-HF: A Randomized Clinical Trial of Sacubitril/Valsartan Versus Enalapril in Patients With Heart Failure With Reduced Ejection Fraction.

Abstract

IMPORTANCE\nHeart failure and sleep disordered breathing have been increasingly recognized as co-occurring conditions. Their bidirectional relationship warrants investigation into whether heart failure therapy improves sleep and sleep disordered breathing.\n\n\nOBJECTIVE\nTo explore the effect of treatment with sacubitril/valsartan on sleep-related endpoints from the AWAKE-HF study.\n\n\nDESIGN, SETTING, PARTICIPANTS, AND EXPOSURES\nAWAKE-HF was a randomized, double-blind study conducted in 23 centers in the United States. Study participants with heart failure with reduced rejection fraction and New York Heart Association class II or III symptoms were randomly assigned to receive treatment with either sacubitril/valsartan or enalapril. All endpoints were assessed at baseline and after 8 weeks of treatment.\n\n\nMAIN OUTCOMES AND MEASURES\nPortable sleep monitoring equipment was used to measure the apnea hypopnea index, including obstructive and central events. Total sleep time, wake after sleep onset, and sleep efficiency were exploratory measures assessed using wrist actigraphy.\n\n\nRESULTS\nOne hundred and forty patients received treatment in the double-blind phase (sacubitril/valsartan, n\u202f=\u202f70; enalapril, n\u202f=\u202f70). At baseline, 39% and 40% of patients randomly assigned to receive sacubitril/valsartan and enalapril, respectively, presented with undiagnosed, untreated, moderate-to-severe sleep-disordered breathing (≥15 events/h), with nearly all having obstructive sleep apnea. After 8 weeks of treatment, the mean 4% apnea hypopnea index changed minimally from 16.3/h to 15.2/h in the sacubitril/valsartan group and from 16.8/h to 17.6/h in the enalapril group. Mean total sleep time was long at baseline and decreased only slightly in both treatment groups at week 8 (-14 and -11 minutes for sacubitril/valsartan and enalapril, respectively), with small changes in wake after sleep onset and sleep efficiency in both groups.\n\n\nCONCLUSIONS AND RELEVANCE\nIn a cohort of patients with heart failure with reduced rejection fraction who met prescribing guidelines for sacubitril/valsartan, one-third had undiagnosed moderate-to-severe obstructive sleep apnea. Addition of sacubitril/valsartan therapy did not significantly improve sleep-disordered breathing or sleep duration or efficiency. Patients who meet indications for treatment with sacubitril/valsartan should be evaluated for sleep-disordered breathing.\n\n\nTRIAL REGISTRATION\nAWAKE-HF NCT02970669.