Download Effects of Sero-Ventilation Therapy on Heart Failure

Running head: EFFECT OF SERVO-VENTILATION THERAPY ON HEART FAILURE
Effect of Servo-Ventilation Therapy on Heart Failure
Austin Maier
University of Mary
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EFFECT OF SERVO-VENTILATION THERAPY ON HEART FAILURE
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Effect of Servo-Ventilation Therapy on Heart Failure
Appraised by: Austin Maier RN BSN (Doctorate of Family Nurse Practitioner program,
University of Mary Bismarck, ND)
Case Scenario
Mr. Johnson is a 74-year-old male who has a history of systolic heart failure and a sleepbreathing disorder called central sleep apnea who presents in the clinic for a follow-up
appointment for his central sleep apnea. He was started on a continuous positive airway pressure
(CPAP) device five years ago. However, the patient did not tolerate it well as he avoided
therapy. The patient was changed to a new type of therapy called servo-ventilation therapy three
months ago. The patient has a normal weight and no history of smoking. He is compliant with
new therapy and reports using it every night. The patient’s heart failure has been controlled with
only one acute exacerbation last year which required three days of hospitalization. Currently, the
blood pressure is slightly elevated at 139/80 and pulse 70 bpm. Patient denies dyspnea,
insomnia, anxiety, weight gain, chest pain, or peripheral edema.
PICO Question
In patients with both central sleep apnea and heart failure, will the use of adaptive servoventilation therapy improve patients’ cardiac function?
Synthesis of Evidence for Sharma et al. (2012)
There has been a recent interest in the literature on the use of adaptive servo-ventilation
(ASV) over continuous positive airway pressure (CPAP) device for treatment of central sleep
apnea. Smaller population control trials have demonstrated efficacy in treating sleep-disordered
breathing (SDB) in patients with heart failure, but currently, there are no large-scale randomized
trials. There is a close relation of patients with systolic heart failure developing SDB. The need
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to effectively treat SDB in patients who have lower left ventricular ejection fracture systolic
heart failure is heavily debated. A level evidence of I, Sharma et al. (2012), performed a
systematic review and meta-analysis of the existing clinical data on March 2012. A total of 14
studies were identified for a total population of 5,538. According to Sharma et al. (2012), the
systematic review and meta-analysis showed that ASV was more effective than control
conditions and CPAP treatment in treating patients with SDB and heart failure. Although, some
of the clinical data suggested poorer outcomes for heart failure patients and other trials suggested
no major impact with ASV therapy. This data provides a compelling rationale for large-scale,
randomized, controlled trials to assess the clinical importance of ASV on mortality rate and
cardiac function in patients with SDB and heart failure (Sharma et al., 2012). Potential bias
consists of the pooling of disparate studies may not accurately summarize the overall effect of
ASV therapy which may limit the generalizability of the results (Sharma et al., 2012). The
number of studies was reasonably small and did not investigate heterogeneity such as age and
sex. Another bias relates to the clinical data used as it did not record the impact of ASV on
myocardial infarction, sudden cardiac death, and hospitalizations. However, this systematic
review and meta-analysis provided a compelling rationale for further research on the use of ASV
for SBD on heart failure patients.
Synthesis of Evidence for Cowie et al. (2015)
Sleep breathing disorders like central sleep apnea are associated with poor prognosis and
mortality in patients with heart failure (Cowie et al., 2015). ASV is a type of treatment for
central sleep apnea which uses a noninvasive ventilator to deliver servo-controlled inspiratory
pressure support on top of expiratory positive airway pressure. Cowie et al. (2015) investigated
the effects of ASV therapy in patients who had heart failure with reduced ejection fraction and
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central sleep apnea. A randomized study was conducted with selecting 1,325 randomly patients
who have left ejection fracture less than 45% and apnea-hypopnea index (AHI) of 15 or more
events per hour. According to Cowie et al. (2015), “We found that in patients who had heart
failure with a reduced ejection fraction and predominantly central sleep apnea, the addition of
adaptive servo-ventilation to guideline-based medical treatment did not improve the outcome”.
Clinical Bottom Line
According to the two articles above, ASV therapy was shown to be more effective
treatment than CPAP for central sleep apnea in heart failure patients from a systematic review
and meta-analysis from Sharma et al. (2012). However, the most recent evidenced-based data
from SERVE-HF trial conducted by Cowie et al. (2015), presented opposite clinical implication
of the use of ASV therapy. There was no significant effect of improving cardiac function. In
fact, the risk of cardiovascular death showed an increase by 34% with the use of ASV therapy in
heart failure patients. These results were seen despite effective control of central sleep apnea
during ASV therapy (Cowie et al., 2015). Further research is needed from randomized clinical
trials to display the effect on cardiac function when using adaptive servo-ventilation for sleepdisordered breathing in heart failure patients.
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References
Cowie, M. R., Woehrle, H., Wegscheider, K., Angermann, C., D’Ortho, M. P., Erdmann, E., ...
& Teschler, H. (2015). Adaptive servo-ventilation for central sleep apnea in systolic heart
failure. New England Journal of Medicine, 373(12), 1095-1105.
Sharma, B. K., Bakker, J. P., McSharry, D. G., Desai, A. S., Javaheri, S., & Malhotra, A. (2012).
Adaptive servo-ventilation for treatment of sleep-disordered breathing in heart failure: a
systematic review and meta-analysis. Chest Journal, 142(5), 1211-1221.