Erik Skobel

Impact of sleep‐related breathing disorders on health‐related quality of life in patients with chronic heart failure

Quality of life in patients with chronic heart failure (HF) is often severely compromised. Sleep‐related breathing disorders (SRBD) like Cheyne–Stokes Respiration (CSR) or obstructive sleep apnea (OSAS) are often observed in patients with severe HF resulting in fragmentation of sleep, excessive daytime sleepiness and an increased mortality. While an apnea/hypopnea‐index (AHI) >30/h represents an independent predictor of poor prognosis, clinical relevance of even minor SRBD with an AHI <30/h remains unclear with respect to quality of life, exercise capacity or depression rate.

Cardioprotection by Carvedilol: Antiapoptosis is Independent of β-Adrenoceptor Blockage in the Rat Heart:

Background: Carvedilol, a β-blocking agent with α-blocking properties is now widely used for the treatment of congestive heart failure. In addition to its β-adrenergic receptor blockage, antiapoptotic effects have been demonstrated in experimental animals. Objective: The cardioprotective effects of carvedilol and its hydroxylated analogue BM-91.0228 were tested with regard to their infarct-limiting and antiapoptotic properties in an experimental infarct model in the rat heart. Methods: Anesthetized rats were subjected to either 30 (groups I to 3) or 60 minutes (groups. 4 to 6) of coronary artery occlusion followed by 30 minutes of reperfusion. Groups 1 and 4 served as the control; groups 2 and 5 received intravenous Carvedilol (1 mg/kg) and groups 3 and 6 received intravenous administration of BM-91.0228 (1 mg/kg), respectively, 5 minutes prior to coronary occlusion. Infarct sizes were measured by triphenyltetrazolium chloride staining. In situ visualization of apoptosis was measured by nick end labeling. Results: Carvedilol reduced infarct size after 30 minutes of coronary occlusion compared to controls (8.7% ± 2.7% versus 27.3% ± 3.4%, P < .001), while BM-91.0228 showed no significant infarct size reduction (23.7% ± 5.9%, NS). Neither Carvedilol (36.9% ± 3.9%) nor BM-91.0228 (42.4% ± 3.6%) reduced infarct size after 60 minutes of coronary occlusion compared to controls (47.7% ± 3.9%, NS). Carvedilol reduced apoptosis after 30 minutes (4.9% ± 1.3% versus 16.7% ± 3.2%, P < .01) and after 60 minutes (11.7% ± 1.8% versus 25.5% ± 0.5%, P < .001) of coronary occlusion compared to controls. BM-91.0228 reduced apoptosis after 30 minutes (7.3% ± 1.4% versus 16.7% ± 3.2%, P < .01) and after 60 minutes (13.4% ± 1.8% versus 25.5% ± 0.5%, P < .001) of coronary occlusion compared to controls. Conclusion: Carvedilol is cardioprotective by preventing ischemia-perfusion-induced necrosis and apoptosis of cardiomyocytes. The antiapoptotic effects of Carvedilol are independent of its β-adrenoceptor blocking effects, but its effects might be caused by antioxidant properties and by modulation of the signalling pathway.

Evaluation of a newly designed shirt-based ECG and breathing sensor for home-based training as part of cardiac rehabilitation for coronary artery disease

Background Participation in phase-III cardiac rehabilitation (CR) remains low but adherence could potentially be improved with supervised home-based CR. New technological approaches are needed to provide sufficient supervision with respect to safety and performance of individual exercise programmes. Design The newly designed closed-loop tool, HeartCycle’s guided exercise (GEX) system, will support professionals and patients during exercise-based CR. Patients wear a dedicated shirt with incorporated wireless sensors, and ECG, heart rate (HR), breathing frequency (BF), and activity are monitored during exercise. This information is streamed live to a mobile device (PDA) that processes these parameters. Methods A phase-I study was performed to evaluate feasibility, function, and reliability of this GEX device and compare it to conventional cardiac exercise testing (CPX, spiroergometry) in 50 patients (seven women, meanu2009±u2009SD age 69u2009±u20099 years, body mass index 26u2009±u20093u2009kg/m2, ejection fraction 58u2009±u200910%). ECG, HR, and BF were monitored using standard equipment and the GEX device simultaneously. Furthermore, HR recorded on the PDA was compared with CPX measurements. Results The fit of the shirt and the sensor was good. No technical problems were encountered. All occurring arrhythmia were reliably detected. There was an acceptable comparability between HR on the GEX device vs. CPX, a good comparability between HR on the PDA vs. CPX, and a moderate comparability between BF on the GEX device vs. CPX. Conclusions Comparability between CPX and the GEX device was acceptable for HR measurement and moderate for BF; arrhythmias were reliably detected. HR processing and display on the PDA was even better comparable. The whole system seems suitable for monitoring home-based CR. Further studies are now needed to implement training prescription to facilitate individual exercise.

Risk factors for, and prevalence of, sleep apnoea in cardiac rehabilitation facilities in Germany: The Reha-Sleep registry:

Aim To determine the prevalence of, and the risk factors for, sleep apnoea in cardiac rehabilitation (CR) facilities in Germany. Methods 1152 patients presenting for CR were screened for sleep-disordered breathing with 2-channel polygraphy (ApneaLink™; ResMed). Parameters recorded included the apnoea–hypopnoea index (AHI), number of desaturations per hour of recording (ODI), mean and minimum nocturnal oxygen saturation and number of snoring episodes. Patients rated subjective sleep quality on a scale from 1 (poor) to 10 (best) and completed the Epworth Sleepiness Scale (ESS). Results Clinically significant sleep apnoea (AHI ≥15/h) was documented in 33% of patients. Mean AHI was 14u2009±u200916/h (range 0–106/h). Sleep apnoea was defined as being of moderate severity in 18% of patients (AHI ≥15–29/h) and severe in 15% (AHI ≥30/h). There were small, but statistically significant, differences in ESS score and subjective sleep quality between patients with and without sleep apnoea. Logistic regression model analysis identified the following as risk factors for sleep apnoea in CR patients: age (per 10 years) (odds ratio (OR) 1.51; pu2009<u20090.001), body mass index (per 5 units) (OR 1.31; pu2009=u20090.001), male gender (OR 2.19; pu2009<u20090.001), type 2 diabetes mellitus (OR 1.45; pu2009=u20090.040), haemoglobin level (OR 0.91; pu2009=u20090.012) and witnessed apnoeas (OR 1.99; pu2009<u20090.001). Conclusions The findings of this study indicate that more than one-third of patients undergoing cardiac rehabilitation in Germany have sleep apnoea, with one-third having moderate-to-severe SDB that requires further evaluation or intervention. Inclusion of sleep apnoea screening as part of cardiac rehabilitation appears to be appropriate.

Sistieren nächtlicher pathologischer Atmungsmuster nach orthotoper Herztransplantation Ein Fallbericht sowie eine Übersicht über den aktuellen Stand der Therapie

BACKGROUNDnCheyne-Stokes respiration is characterized by recurrent phases of central apneas during sleep alternating with a crescendo-decrescendo hyperventilation. This abnormal respiratory pattern is often observed in patients with severe congestive heart failure and associated with fragmentation of sleep, excessive daytime sleepiness, and a relatively high mortality. Increased peripheral and central chemosensitivity, prolonged circulation time, and reduced blood gas buffering capacity are the major factors contributing to the pathology. However, the exact pathophysiologic mechanisms are not clear yet. Respiratory stimulants, oxygen and continuous or bilevel positive airway pressure (CPAP or BiPAP) might reduce the severity of Cheyne-Stokes respiration but have little effect on daytime sleepiness and cardiac function. There is only limited data supporting the assumption that intensive heart failure therapy has an effect on Cheyne-Stokes respiration.nnnCASE REPORTnA 55-year-old male patient with dilative cardiomyopathy (NYHA IV) suffered excessive daytime sleepiness (Epworth Sleepiness Scale: 24 points). The patient was a heavy snorer with a normal body mass index. Treatment was initiated including ACE-inhibitors, beta-receptor blockers, diuretics and digoxin. The patient underwent sleep analysis with a Somno-Check system which demonstrated Cheyne-Stokes breathing (Respiratory Disturbance Index RDI: 40/h, lowest desaturation 76%) and body position dependent snoring. Oxygen therapy (21/min) had no effect on daytime sleepiness. Due to the cardiac condition, the patient was accepted for heart transplantation. Three weeks after transplantation sleep analysis was repeated and demonstrated a lack of evidence for periodic breathing (RDI 1/h, no desaturations below 90%), while snoring remained unchanged. Daytime sleepiness improved significantly (Epworth Sleepiness Scale: 6 points). Three weeks after normalizing left ventricular function a complete recovery from severe Cheyne-Stokes respiration was observed.nnnCONCLUSIONnAdequate therapy of the underlying cause of Cheyne-Stokes breathing such as end-stage congestive heart failure might sufficiently abolish any breathing abnormalities.ZusammenfassungHintergrund: Bei Patienten mit primär oder sekundär deutlich eingeschränkter linksventrikulärer Funktion (zum Beispiel bei dilatativer Kardiomyopathie, ischämischer Kardiomyopathie) kommt es während des Schlafes in 40% der Fälle (und bei besonders schweren Formen auch am Tage) zu periodischen Atmungsmustern in Form einer Cheyne-Stokes-Atmung. Das Vorliegen dieser Atmungsform bei Herzinsuffizienz korreliert mit einer erhöhten Mortalität und stellt einen unabhängigen Prognoseparameter dar. Der genaue Mechanismus der Entstehung dieser Atmungsform ist nicht bekannt.nn Fallbericht: Bei einem 55-jährigen, leicht adipösen Patienten mit einer dilatativen Kardiomyopathie (Ejektionsfraktion 12%) zeigte sich eine ausgeprägte Tagesmüdigkeit mit Einschlafneigung beim Sitzen und Zeitunglesen (Epworth-Sleepiness-Scale: 24 Punkte). Bei der schlafmedizinischen Untersuchung zeigten sich durchgehend zentrale Atemaussetzer im Sinne einer Cheyne-Stokes-Atmung mit arteriellen Sauerstoffentsättigungen bis 76% mit einem Respiratory-Disturbance-Index (Apnoeereignisse/Stunde) von 40/Stunde sowie ausgeprägtes Schnarchen. Eine neurologische Ursache fand sich nicht, sodass von einer kardialen Ursache der pathologischen nächtlichen Atmungsform ausgegangen werden musste. Aufgrund der kardialen Grunderkrankung wurde eine orthotope Herztransplantation komplikationslos durchgeführt. Zwei Wochen nach der Herztransplantation zeigte sich echokardiographisch eine gute linksventrikuläre Funktion mit einer Ejektionsfraktion von 60%. Die ausgeprägte Tagesmüdigkeit des Patienten war komplett verschwunden (Epworth-Sleepiness-Scale: 6 Punkte). Bei der schlafmedizinischen Kontrolluntersuchung war keine Cheyne-Stokes-Atmung mehr nachweisbar; es kam nicht mehr zu Sauerstoffentsättigungen, und es zeigte sich lediglich phasenweise Schnarchen.nn Schlußfolgerung: Nach Normalisierung der linksventrikulären Funktion durch Herztransplantation kam es bei einem Patienten mit dilatativer Kardiomyopathie innerhalb kürzester Zeit zu einem vollständigen Sistieren einer vorbestehenden Cheyne-Stokes-Atmung. Dieser Fall zeigt, dass die Ursache der Cheyne-Stokes-Atmung auch in der Herzinsuffizienz liegen kann und entsprechend durch eine optimale kausale Therapie erfolgreich behandelt werden kann.AbstractBackground: Cheyne-Stokes respiration is characterized by recurrent phases of central apneas during sleep alternating with a crescendo-decrescendo hyperventilation. This abnormal respiratory pattern is often observed in patients with severe congestive heart failure and associated with fragmentation of sleep, excessive daytime sleepiness, and a relatively high mortality. Increased peripheral and central chemosensitivity, prolonged circulation time, and reduced blood gas buffering capacity are the major factors contributing to the pathology. However, the exact pathophysiologic mechanisms are not clear yet. Respiratory stimulants, oxygen and continuous or bilevel positive airway pressure (CPAP or BiPAP) might reduce the severity of Cheyne-Stokes respiration but have little effect on daytime sleepiness and cardiac function. There is only limited data supporting the assumption that intensive heart failure therapy has an effect on Cheyne-Stokes respiration.nn Case Report: A 55-year-old male patient with dilative cardiomyopathy (NYHA IV) suffered excessive daytime sleepiness (Epworth Sleepiness Scale: 24 points). The patient was a heavy snorer with a normal body mass index. Treatment was initiated including ACE-inhibitors, beta-receptor blockers, diuretics and digoxin. The patient underwent sleep analysis with a Somno-Check system which demonstrated Cheyne-Stokes breathing (Respiratory Disturbance Index RDI: 40/h, lowest desaturation 76%) and body position dependent snoring. Oxygen therapy (2l/min) had no effect on daytime sleepiness. Due to the cardiac condition, the patient was accepted for heart transplantation. Three weeks after transplantation sleep analysis was repeated and demonstrated a lack of evidence for periodic breathing (RDI 1/h, no desaturations below 90%), while snoring remained unchanged. Daytime sleepiness improved significantly (Epworth Sleepiness Scale: 6 points). Three weeks after normalizing left ventricular function a complete recovery from severe Cheyne-Stokes respiration was observed.nn Conclusion: Adeguate therapy of the underlying cause of Cheyne-Stokes breathing such as end-stage congestive heart failure might sufficiently abolish any breathing abnormalities.

Internet-based training of coronary artery patients: the Heart Cycle Trial

Low adherence to cardiac rehabilitation (CR) might be improved by remote monitoring systems that can be used to motivate and supervise patients and tailor CR safely and effectively to their needs. The main objective of this study was to evaluate the feasibility of a smartphone-guided training system (GEX) and whether it could improve exercise capacity compared to CR delivered by conventional methods for patients with coronary artery disease (CAD). A prospective, randomized, international, multi-center study comparing CR delivered by conventional means (CG) or by remote monitoring (IG) using a new training steering/feedback tool (GEx System). This consisted of a sensor monitoring breathing rate and the electrocardiogram that transmitted information on training intensity, arrhythmias and adherence to training prescriptions, wirelessly via the internet, to a medical team that provided feedback and adjusted training prescriptions. Exercise capacity was evaluated prior to and 6xa0months after intervention. 118 patients (58xa0±xa010xa0years, 105 men) with CAD referred for CR were randomized (IG: nxa0=xa055, CG: nxa0=xa063). However, 15 patients (27xa0%) in the IG and 18 (29xa0%) in the CG withdrew participation and technical problems prevented a further 21 patients (38xa0%) in the IG from participating. No training-related complications occurred. For those who completed the study, peak VO2 improved more (pxa0=xa00.005) in the IG (1.76xa0±xa04.1xa0ml/min/kg) compared to CG (−0.4xa0±xa02.7xa0ml/min/kg). A newly designed system for home-based CR appears feasible, safe and improves exercise capacity compared to national CR. Technical problems reflected the complexity of applying remote monitoring solutions at an international level.

An m-Health system for education and motivation in cardiac rehabilitation: the experience of HeartCycle guided exercise:

Introduction Home-based programmes for cardiac rehabilitation play a key role in the recovery of patients with coronary artery disease. However, their necessary educational and motivational components have been rarely implemented with the help of modern mobile technologies. We developed a mobile health system designed for motivating patients to adhere to their rehabilitation programme by providing exercise monitoring, guidance, motivational feedback, and educational content. Methods Our multi-disciplinary approach is based on mapping “desired behaviours” into specific system’s specifications, borrowing concepts from Fogg’s Persuasive Systems Design principles. A randomised controlled trial was conducted to compare mobile-based rehabilitation (55 patients) versus standard care (63 patients). Results Some technical issues related to connectivity, usability and exercise sessions interrupted by safety algorithms affected the trial. For those who completed the rehabilitation (19 of 55), results show high levels of both user acceptance and perceived usefulness. Adherence in terms of started exercise sessions was high, but not in terms of total time of performed exercise or drop-outs. Educational level about heart-related health improved more in the intervention group than the control. Exercise habits at 6 months follow-up also improved, although without statistical significance. Discussion Results indicate that the adopted design methodology is promising for creating applications that help improve education and foster better exercise habits, but further studies would be needed to confirm these indications.

SERVE-HF: What does it mean for cardiac rehabilitation?

This editorial describes the impact of the results of the SERVE-HF study for cardiac rehabilitation as heart failure and sleep apnoea in cardiac rehabilitation patients is very common. Sleep apnoea is an independent risk factor for cardiovascular diseases. The most prevalent type of sleep apnoea is obstructive sleep apnoea (OSA), contributing to 38,000 cardiovascular deaths every year. Myocardial damage is thought to occur secondary to increased sympathetic activity, heart rate variability, endothelial dysfunction, systemic inflammation, oxidative stress, platelet activation and/or metabolic abnormalities. OSA represents a significant, but modifiable, risk factor for cardiovascular disease. However, OSA appears to be under-diagnosed in patients with coronary artery disease. Data from the Reha-Sleep registry suggest that the prevalence of sleep apnoea in patients attending cardiac rehabilitation facilities could be as high as 33%, and that there are few differences between patients with and without sleep apnoea with respect to sleep quality and daytime sleepiness. The prevalence of heart failure in western countries is about 1–2% of the adult population, with significant increases with age. Recent guidelines differentiate between heart failure due to reduced systolic left ventricular ejection fraction (HF-REF) and heart failure with preserved ejection fraction (HF-PEF) and impaired diastolic function. HF-REF is the most widely investigated and best understood type of heart failure, with a high prevalence in men with ischaemic heart disease. In contrast, HF-PEF is more prevalent in women and often has a non-ischaemic aetiology. Epidemiological data suggest that HF-REF and HF-PEF have a similar prognostic impact. A number of comorbidities have been linked to the development and progression of heart failure. One that is gaining increasing recognition is sleep-disordered breathing (SDB) with predominant OSA or central sleep apnoea (CSA) with or without Cheyne–Stokes respiration (CSR). CSR occurs when arterial carbon dioxide partial pressures fall below the apnoeic threshold. The cycle length of alternating periods of hypocapnia induces apnoea and reflex hyperventilation. CSR is inversely proportional to cardiac output and thus directly related to the severity of heart failure. A reduced left ventricular function delays the circulation time between the lungs and the chemoreceptors and increases the sensitivity of chemoreceptors, especially to carbon dioxide. The degree of carbon dioxide hypersensitivity is a major determinant of CSR. Small studies published to date have reported that the prevalence of SDB was almost 70–80% in patients with HF-PEF and up to 76% in those with HF-REF based on a cut-off of an apnoea–hypopnoea index (apnoeas and hypopnoeas per hour; AHI) 5/hour while moderate to severe sleep apnoea with an AHI 15/hour was prevalent in about half of the patients. SDB in general, as well as OSA and, in particular, CSA have been shown to be independently associated with worse prognosis in patients with HF-REF. The Sleep Heart Health Study identified OSA as an independent risk factor for the development of heart failure, with more impact in men than in women. Patients with CSA have been shown to have a reduced quality of life and to be at increased risk of developing cardiac arrhythmias. In addition, the prevalence of CSA–CSR appears to increase as the severity of heart failure increases and cardiac function decreases. Management of HF-REF starts with an accurate diagnosis and requires a rational combination of drug therapy and non-pharmacological management (education, fluid control, weight monitoring and physical exercise training). The use of beta-blockers or cardiac resynchronisation therapy results in a reduction of CSR. However, even in these patients with optimal

Trauma and syncope-evidence for further sleep study? A case report

We report on an 83-year-old male with traumatic brain injury after syncope with a fall in the morning. He had a history of seizures, coronary artery disease and paroxysmal atrial fibrillation (AF). No medical cause for seizures and syncope was determined. During rehabilitation, the patient still complained of seizures, and also reported sleepiness and snoring. Sleep apnea diagnostics revealed obstructive sleep apnea (SA) with an apnea-hypopnoea index of 35/h, and sudden onset of tachycardia with variations of heart rate based on paroxysmal atrial fibrillation. Additional tests showed nocturnal AF which spontaneously converted to sinus rhythm mid-morning with an arrest of 5 s (sick sinus syndrome) and seizures. A DDD-pacer was implanted and no further seizures occurred. SA therapy with nasal continuous positive airway pressure was refused by the patient. Our findings suggests that screening for SA may offer the possibility to reveal causes of syncope and may introduce additional therapeutic options as arrhythmia and SA often occur together which in turn might be responsible for trauma due to syncope episodes.