Recommendations for Treatment of Sleep Disorders

CORLOERecommendationsComment/Rationale
IIaC-LDIn patients with NYHA class II–IV HF and suspicion of sleep-disordered breathing or excessive daytime sleepiness, a formal sleep assessment is reasonable (200,201).NEW: Recommendation reflects clinical necessity to distinguish obstructive versus central sleep apnea.
See Online Data Supplement G.
Sleep disorders are common in patients with HF. A study of adults with chronic HF treated with evidence-based therapies found that 61% had either central or obstructive sleep apnea (202). It is clinically important to distinguish obstructive sleep apnea from central sleep apnea, given the different responses to treatment. Adaptive servo-ventilation for central sleep apnea is associated with harm (203). Continuous positive airway pressure (CPAP) for obstructive sleep apnea improves sleep quality, reduces the apnea-hypopnea index, and improves nocturnal oxygenation (200,201).
IIbB-RIn patients with cardiovascular disease and obstructive sleep apnea, CPAP may be reasonable to improve sleep quality and daytime sleepiness (204).NEW: New data demonstrate the limited scope of benefit expected from CPAP for obstructive sleep apnea.
See Online Data Supplement G.
In patients with sleep apnea, a trial evaluated the impact of CPAP with usual therapy versus usual therapy alone on subsequent cardiovascular events, including HF (204). In this RCT of >2,700 patients, there was no evidence of benefit on cardiovascular events at a mean follow-up of 3.7 years for CPAP plus usual care compared with usual care alone. Improvements in sleep quality were noteworthy and represented the primary indication for initiating CPAP treatment (204). However, in patients with atrial fibrillation (AF) (a frequent comorbidity noted with HF), the use of CPAP for obstructive sleep apnea was helpful. In a trial of 10,132 patients with AF and obstructive sleep apnea, patients on CPAP treatment were less likely to progress to more permanent forms of AF than were patients without CPAP (205).
III: HarmB-RIn patients with NYHA class II–IV HFrEF and central sleep apnea, adaptive servo-ventilation causes harm (203).NEW: New data demonstrate a signal of harm when adaptive servo-ventilation is used for central sleep apnea.
See Online Data Supplement G.
Mortality rate (all cause and cardiovascular) was higher with adaptive servo-ventilation plus GDMT than with GDMT alone in a single RCT to test the addition of adaptive servo-ventilation (≥5 hours/night, 7 days/week) to GDMT in patients with HFrEF and central sleep apnea (203). A similar risk has been seen in another trial, and a third trial of adaptive servo-ventilation in central sleep apnea and HF was aborted because of ethical concerns. The weight of evidence does not support the use of adaptive servo-ventilation for central sleep apnea in HFrEF.