Central Sleep Apnea and Cardiovascular Disease State-of-the-Art.

Central sleep apnea (CSA), a rare polysomnographic finding in the general population, is prevalent in certain cardiovascular conditions including systolic and diastolic left ventricular dysfunction, atrial fibrillation, coronary artery disease, carotid artery stenosis, stroke and use of certain cardiac-related medications. Polysomnographic findings of CSA with adverse cardiovascular impacts include nocturnal hypoxemia and arousals, which can lead to increased sympathetic activity both at night and in the daytime. Among cardiovascular diseases, CSA is most prevalent in patients with left ventricular systolic dysfunction; a large study of more than 900 treated patients has shown a dose dependent relationship between nocturnal desaturation and mortality. Multiple small randomized controlled trials have shown mitigation of sympathetic activity when CSA is treated with nocturnal oxygen, continuous positive airway pressure and adaptive servoventilation. However, two early randomized controlled trials with positive airway pressure devices have shown either neutral effect on survival or excess premature mortality in the active treatment arm, compared to untreated CSA. In contrast, the results of the most recent trial using an advanced adaptive servoventilation device showed improved quality of life and no signal for mortality suggesting that treatment of CSA was at least safe. In addition to positive airway pressure devices, multiple medications have been shown to improve CSA, but no long-term trials of pharmacologic therapy have been published. Currently, phrenic nerve stimulation is approved for treatment of CSA, and the results of a randomized controlled trial showed significant improvement in sleep metrics and quality of life.
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