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Running head: EFFECT OF SERVO-VENTILATION THERAPY ON HEART FAILURE Effect of Servo-Ventilation Therapy on Heart Failure Austin Maier University of Mary 1 EFFECT OF SERVO-VENTILATION THERAPY ON HEART FAILURE 2 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 EFFECT OF SERVO-VENTILATION THERAPY ON HEART FAILURE 3 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 EFFECT OF SERVO-VENTILATION THERAPY ON HEART FAILURE 4 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. EFFECT OF SERVO-VENTILATION THERAPY ON HEART FAILURE 5 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.