Hemodynamic Effects of Simulated Obstructive Apneas in Humans With and Without Heart Failure

doi:10.1378/chest.119.6.1827

Chest

Volume 119, Issue 6, June 2001, Pages 1827-1835

https://doi.org/10.1378/chest.119.6.1827 Get rights and content

Study objectives

To determine whether generation of negative intrathoracic pressure during apnea would cause morepronounced and sustained reductions in cardiac output in patients withcongestive heart failure (CHF) than in healthy subjects.

Design

Physiologic intervention study.

Setting

Cardiorespiratory physiology laboratory.

Participants

Nine patients with CHF and nine healthycontrol subjects matched for age and sex.

Interventions

Patients with CHF and healthy subjectsgenerated − 30 cm H₂O of intrathoracic pressure during15-s Mueller maneuvers (MMs) to simulate the acute hemodynamiceffects and aftereffects of obstructive apneas.

Results

In both groups, MMs caused an immediate rise inleft ventricular transmural pressure during systole (LVPtmsys)[p < 0.05], but in CHF patients, this immediate increase wasfollowed by a significant drop in LVPtmsys (p < 0.05), associated with significantly greater reductions in systolic BP and cardiac index than in healthy subjects (− 25 ± 3 mm Hg vs − 11 ± 2 mm Hg[p < 0.05] and − 0.53 ± 0.11 L/min/m² vs− 0.15 ± 0.11 L/min/m² [p < 0.05], respectively). Healthy subjects recovered promptly, but in CHF patients, these adverse hemodynamic effects were sustained following release of the MM.

Conclusions

CHF patients experience more pronounced and sustained reductions in BP and cardiac output both during and followingthe MM than do healthy subjects. These findings suggest the potentialfor adverse hemodynamic effects and aftereffects of negativeintrathoracic pressure generation during obstructive sleep apnea inpatients with CHF.

Section snippets

Subjects

We studied nine men with the following: (1) CHF of at least 6-months duration secondary to ischemic (n = 3) or idiopathic dilated cardiomyopathy (n = 6); (2) a resting LV ejection fraction of ≤ 45% as measured by ⁹⁹Tc equilibrium radionuclide angiography; (3) chronic exertional dyspnea despite medical therapy; and (4) sinus rhythm. Patients suffering from angina or a myocardial infarction within 3 months of the study and patients with primary valvular heart disease were excluded. Nine healthy

Characteristics of the Subjects

Mean age, body mass index, and values of physiologic variables were similar in the two groups (Table 1) . The CHF patients had severe LV systolic dysfunction as indicated by a mean LV ejection fraction of 19 ± 5%. Five CHF patients were in New York Heart Association class II, and four patients were in class III. All patients with CHF were receiving appropriate medical therapy for CHF, which included diuretics in nine patients, digoxin and angiotensin-converting enzyme inhibitors in eight

Discussion

Since generation of negative intrathoracic pressure against the occluded airway is a unique feature of OSA that could have adverse effects on cardiac function, we designed these experiments to focus specifically on this particular pathophysiologic aspect of OSA independent of potential confounding hemodynamic influences of hypoxia²⁴ or arousals from sleep.²² To do so necessitated studying subjects while awake so that we could assess and compare responses to a stimulus of constant length and

ACKNOWLEDGMENT

The authors wish to acknowledge Beverly Senn, RN, and Fabia Fitzgerald, RN, for their technical assistance in performing experiments and analyzing data.

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: Supported by operating grant MOP-11607 from the Medical Research Council of Canada.

^†: Dr. Hall (deceased) was a recipient of a Medical Research Council of Canada/Canadian Lung Association Fellowship. Dr. Ando was a recipient of a Canadian Hypertension Society/Merck Frosst Canada Fellowship and of support from the George R. Gardiner Foundation (Toronto, Canada). Dr. Floras is a Career Scientist of the Heart and Stroke Foundation of Ontario, and Dr. Bradley holds a Senior Scientist Award from the Canadian Institutes of Health Research

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Chest

Clinical InvestigationsSleep and BreathingHemodynamic Effects of Simulated Obstructive Apneas in Humans With and Without Heart Failure

Study objectives

Design

Setting

Participants

Interventions

Results

Conclusions

Section snippets

Subjects

Characteristics of the Subjects

Discussion

ACKNOWLEDGMENT

J Card Fail

Chest

Prog Cardiovasc Dis

Lancet

J Auton Nerv Syst

Am J Cardiol

Lancet

Chest

Obstructive sleep apnoea in patients with dilated cardiomyopathy: effects of continuous positive airway pressure

Lancet

Tracheostomy and hemodynamic changes in sleep-induced apnea

Ann Intern Med

Reduced stroke volume related to pleural pressure in obstructive sleep apnea

J Appl Physiol

The acute and chronic effects of airway obstruction on left ventricular performance in a canine model of obstructive sleep apnea

Am J Respir Crit Care Med

Effect of intrathoracic pressure on left ventricular performance

N Engl J Med

Impairment of cerebral perfusion during obstructive sleep apneas

Am J Respir Crit Care Med

Neurocirculatory consequences of negative intrathoracic pressure versus asphyxia during voluntary apnea

J Appl Physiol

Cardiovascular effects of periodic occlusions of the upper airways in dogs

Am Rev Respir Dis

Sympathetic neural mechanisms in obstructive sleep apnea

J Clin Invest

Cardiovascular changes associated with obstructive sleep apnea syndrome

J Appl Physiol

Leftward septal displacement during right ventricular loading in man

Circulation

Magnitude and time course of hemodynamic responses to Mueller maneuvers in patients with congestive heart failure

J Appl Physiol

Sleep apnea in 81 ambulatory male patients with stable heart failure

Circulation

Clinical Investigations
Sleep and Breathing
Hemodynamic Effects of Simulated Obstructive Apneas in Humans With and Without Heart Failure