The full content of Annals is available to subscribers

Subscribe/Learn More  >
Articles |

Occult Sleep-Disordered Breathing in Stable Congestive Heart Failure

Shahrokh Javaheri, MD; Thomas J. Parker, MD; Laura Wexler, MD; Scott E. Michaels, PhD; Elizabeth Stanberry, PhD; Hiroshi Nishyama, MD; and Gary A. Roselle, MD
[+] Article, Author, and Disclosure Information

From the Department of Veterans Affairs Medical Center and the University of Cincinnati College of Medicine, Cincinnati, Ohio. Requests for Reprints: Shahrokh Javaheri, MD, Sleep Disorders Laboratory, Pulmonary Section (111F), Veterans Affairs Medical Center, 3200 Vine Street, Cincinnati, OH 45220. Grant Support: By Merit Review Grants from the Department of Veterans Affairs.

Copyright ©2004 by the American College of Physicians

Ann Intern Med. 1995;122(7):487-492. doi:10.7326/0003-4819-122-7-199504010-00002
Text Size: A A A

Objective: To determine the prevalence and effect of sleep-disordered breathing in ambulatory patients with stable, optimally treated congestive heart failure.

Design: A prospective, longitudinal study.

Setting: Referral sleep laboratory of a Department of Veterans Affairs medical center.

Patients: 42 of the 48 eligible patients with stable congestive heart failure and left ventricular systolic dysfunction (left ventricular ejection fraction ≤ 45%).

Measurements: After an adaptation night, polysomnography and Holter monitoring were done in the sleep laboratory. Arterial blood gases and pH were measured, and cardiac radionuclide ventriculography and pulmonary, renal, and thyroid function tests were done.

Results: Patients were divided into two groups. Group I (n = 23) had an hourly rate of apnea and hypopnea (apnea–hypopnea index) of 20 episodes per hour or less; group II (n = 19 [45%; CI, 30% to 60%]) had an index of more than 20 episodes per hour. In group II, the index varied from 26.5 to 82.2 episodes per hour (mean ±SD, 44 ±13 episodes per hour; CI, 38 to 51 episodes per hour). Group II had significantly more arousals (24 ±12 compared with 3 ±3 in group I) that were directly attributable to episodes of apnea and hypopnea, longer periods of time with an arterial oxyhemoglobin saturation of less than 90% (23% ±24% of total sleep time compared with 2% ±4%), lower arterial oxyhemoglobin saturation during sleep (74% ±13% compared with 87% ±4%), lower left ventricular ejection fraction (22% ±9% compared with 30% ±10%), and a significantly increased number of episodes of nocturnal ventricular arrhythmias. Multiple regression analyses showed that left ventricular systolic dysfunction was an independent risk factor for sleep apnea in patients with congestive heart failure.

Conclusions: The prevalence of severe occult sleep-disordered breathing is high in ambulatory patients with stable, optimally treated chronic congestive heart failure. The breathing episodes are associated with severe nocturnal arterial blood oxyhemoglobin desaturation and excessive arousals. Severe untreated sleep-disordered breathing may adversely affect left ventricular function, resulting in a vicious cycle that could contribute to death in patients with congestive heart failure. Prospective, longitudinal studies on survival are needed.


Grahic Jump Location
Figure 1.
Frequency distribution of the apnea–hypopnea index in 10-unit intervals in 42 patients with stable, optimally treated congestive heart failure.
Grahic Jump Location
Grahic Jump Location
Figure 2.
Sleep-disordered breathing episodes and arterial oxyhemoglobin saturation in the two groups.

AH I = apnea–hypopnea index; CA I = central apnea index; OAH I = obstructive apnea–hypopnea index; Ar I DB = arousal index associated with disordered breathing; BASE SAT = baseline arterial oxyhemoglobin saturation in supine position before sleep onset; LOW SAT = lowest arterial oxyhemoglobin saturation during sleep; SAT < 90%, min = time in sleep (in minutes) when arterial oxyhemoblobin saturation was less than 90%; SAT < 90%, TST = percentage of total sleep time when arterial oxyhemoglobin saturation was less than 90%. Values are expressed as mean ±SD.

Grahic Jump Location




Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).


Submit a Comment/Letter
Submit a Comment/Letter

Summary for Patients

Clinical Slide Sets

Terms of Use

The In the Clinic® slide sets are owned and copyrighted by the American College of Physicians (ACP). All text, graphics, trademarks, and other intellectual property incorporated into the slide sets remain the sole and exclusive property of the ACP. The slide sets may be used only by the person who downloads or purchases them and only for the purpose of presenting them during not-for-profit educational activities. Users may incorporate the entire slide set or selected individual slides into their own teaching presentations but may not alter the content of the slides in any way or remove the ACP copyright notice. Users may make print copies for use as hand-outs for the audience the user is personally addressing but may not otherwise reproduce or distribute the slides by any means or media, including but not limited to sending them as e-mail attachments, posting them on Internet or Intranet sites, publishing them in meeting proceedings, or making them available for sale or distribution in any unauthorized form, without the express written permission of the ACP. Unauthorized use of the In the Clinic slide sets will constitute copyright infringement.


Buy Now for $32.00

to gain full access to the content and tools.

Want to Subscribe?

Learn more about subscription options

Related Articles
Topic Collections
PubMed Articles
Forgot your password?
Enter your username and email address. We'll send you a reminder to the email address on record.