The Breathless Heart: Apneas in Heart Failure

288 Pages·2017·7.301 MB·English

by  Michele Emdin, Alberto Giannoni, Claudio Passino

Michele Emdin
Alberto Giannoni
Claudio Passino Editors
The
Breathless Heart
Apneas in Heart Failure
123
The Breathless Heart
Michele Emdin (cid:129) Alberto Giannoni
Claudio Passino
Editors
The Breathless Heart
Apneas in Heart Failure
Editors
Michele Emdin Claudio Passino
Institute of Life Sciences Institute of Life Sciences
Scuola Superiore Sant’Anna and Scuola Superiore Sant’Anna and
Fondazione Toscana Gabriele Monasterio Fondazione Toscana Gabriele Monasterio
Pisa Pisa
Italy Italy
Alberto Giannoni
Fondazione Toscana Gabrielle Monasterio
Pisa
Italy
ISBN 978-3-319-26352-6 ISBN 978-3-319-26354-0 (eBook)
DOI 10.1007/978-3-319-26354-0
Library of Congress Control Number: 2016959210
© Springer International Publishing Switzerland 2017
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Pref ace

H eart failure is a major cause of hospitalization and mortality, despite recent
advancements in diagnosis and treatment. The search for hidden pathophysiological
triggers of disease evolution and potential targets of therapy has rediscovered an
old, forgotten feature of the heart failure syndrome: apnea. Apneas may present
themselves either as a sign or a symptom in the individual patient, but are often
overlooked by clinicians, though they are both a marker of severity and a mediator
of risk. Apneas are invariably associated with cyclic hyperpneas both in the asleep
and in the awake subject with heart failure, possibly as an initial compensatory
response.
A pnea/hyperpnea phenomena oblige the clinician to reevaluate the physiology of
respiration and cardiovascular function. However, is there still place for physiology
in the decision-making for patients with cardiovascular diseases in the era of imag-
ing, genetics, and molecular biology?
T he answer is in the affi rmative, as demonstrated by the clinical value of periodic
breathing/Cheyne-Stokes respiration (PB/CSR) [1, 2] in patients with heart failure
(Fig. 1 ) . This abnormal breathing pattern has been known for centuries, but it is only
during the last decades that its pathophysiology and its clinical meaning have been
adequately investigated.
In particular, the underlying derangement of neural control of respiratory cen-
ters, its impact on prognosis, and the relevance of the phenomenon as a therapeutic
target have been the object of an increase of interest and literature during the last
decades, yet with diverse experimental fi ndings and contradictory opinions.
The recent failure of two large trials testing the effectiveness of noninvasive
mechanical ventilation (CANPAP and SERVE-HF) [3, 4] in improving the outcome
of heart failure patients has confi rmed the need to summarize the current knowledge
on this topic. For this purpose, this book has been thought for all researchers and
clinicians interested in the fi eld. An international faculty has collaborated in fur-
nishing a complete overview touching all aspects of the apnea phenomenon in heart
failure patients.
The historical background of pathophysiological alterations determining the
occurrence of central apneas in different disorders will be presented. A thorough
description of the visceral feedbacks and in particular of the chemorefl ex system,
whose deregulation plays a key role in central apnea origin and maintenance, and
the mathematical models proposed to describe PB/CSR will be presented. The role
v
vi Preface
Fig. 1 “Record showing
Cheyne-Stokes respiration
(from a case of aortic and
mitral insuffi ciency with
atherosclerosis). The time
record gives second.”
Original legend in Ref. [5]
and feasibility of different diagnostic approaches, including the modern recording
of apneas by the implanted device, will be the object of analysis.
Finally, the authors will try to defi ne the signifi cance of apneas during sleep and
during wakefulness, the different pathophysiology of obstructive and central apneas,
and the most advanced tools for the treatment of central apneas, including the novel
technique of phrenic nerve stimulation, presented by a principal investigator of the
clinical trial addressing its effi cacy.
The whole matter, two thousand years after the Hippocrates’ description and two
centuries after the brilliant description by the Irish physician Cheyne, is still largely
debated: this book can be considered a companion for all interested in increasing their
knowledge on its signifi cance, in order to improve clinical care of heart failure patients.
Michele Emdin
Alberto Giannoni
Pisa , Italy Claudio Passino
Refer ences
1. Cheyne J. Dublin hospital reports. 1818;2:216.
2. Stokes W. The diseases of the heart and the aorta. Dublin: Hodges and Smith;
1854. p. 323–6.
3 . B radley TD, Logan AG, Kimoff RJ, Sériès F, Morrison D, Ferguson K, Belenkie I,
Pfeifer M, Fleetham J, Hanly P, Smilovitch M, Tomlinson G, Floras JS; CANPAP
Investigators. Continuous positive airway pressure for central sleep apnea and
heart failure. N Engl J Med. 2005;353:2025–33.
4. Cowie MR, Woehrle H, Wegscheider K, Angermann C, d’Ortho MP, Erdmann E,
Levy P, Simonds AK, Somers VK, Zannad F, Teschler H. Adaptive servo-
ventilation for central sleep apnea in systolic heart failure. N Engl J Med. 2015;
373:1095–105.
5. Howell WH. Infl uence of various conditions on respiration. Modifi ed respiratory
movements. In: A text book of physiology for medical students and physicians.
Philadelphia/London: WB Saunders Cop; 1919. p. 717.
Contents
1 Historical Background and Glossary of the
Apnea Phenomenon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Michele Emdin and Alberto Aimo
2 Mechanics and Chemistry of Respiration in Health . . . . . . . . . . . . . . 11
Claudio Passino , Elisabetta Cacace , Daniele Caratozzolo ,
Federico Rossari , and Luigi Francesco Saccaro
3 Hypopneas and Apneas as Physiological and Pathological
Phenomena Throughout the Life Span . . . . . . . . . . . . . . . . . . . . . . . . . 35
Alberto Giannoni , Chiara Borrelli , and Valentina Raglianti
4 Pathophysiology of Central Apneas in Heart Failure . . . . . . . . . . . . . 91
Alberto Giannoni, Maria Sole Morelli, and Darrel Francis
5 The Importance of Visceral Feedbacks: Focus
on Chemoreceptors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125
Alberto Giannoni , Alberto Aimo , Francesca Bramanti ,
and Massimo F. Piepoli
6 The Apneas Before and After Heart Failure . . . . . . . . . . . . . . . . . . . . . 147
Jens Spießhöfer and Olaf Oldenburg
7 Not Only Sleep Apnea: The “Awake” Apneas of the
Failing Heart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169
Maria Teresa La Rovere , Roberto Maestri ,
and Gian Domenico Pinna
8 Exertional Oscillatory Ventilation and Central Sleep
Apnea in Heart Failure: Siblings, Cousins, or What Else? . . . . . . . . . 183
Piergiuseppe Agostoni , Anna Apostolo , and Ugo Corrà
9 To Breathe, or Not to Breathe: That Is the Question . . . . . . . . . . . . . . 203
Gianluca Mirizzi , Alberto Giannoni , Claudio Passino ,
and Michele Emdin
vii
viii Contents
10 Diagnostic Tools: The Easier, the Better . . . . . . . . . . . . . . . . . . . . . . . . 219
Roberta Poletti , Alberto Aimo , Vincenzo Castiglione ,
Alessandro Di Gangi , Giovanni Iudice , Mauro Micalizzi ,
Claudio Passino , and Michele Emdin
11 Diagnostic Tools: Messages from Implanted Devices
(Pacemakers as Diagnostic Tools) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 235
Margherita Padeletti , Fabrizio Bandini , Edoardo Gronda ,
and Luigi Padeletti
12 Targeting and Treating Apneas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 247
Claudio Passino , Alberto Giannoni , Alberto Aimo ,
Gianluca Mirizzi , and Michele Emdin
13 Novel Tools for Treating Central Apneas . . . . . . . . . . . . . . . . . . . . . . . 271
Maria Rosa Costanzo
14 Breathless Heart: Final Remarks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 285
Michele Emdin , Alberto Giannoni , and Claudio Passino
1
Historical Background and Glossary
of the Apnea Phenomenon
Apneas and Heart Disease
Michele Emdin and Alberto Aimo
Abbreviations
AHI Apnea-hypopnea index
CSR Cheyne-Stokes respiration
EEG E lectroencephalogram/electroencephalography
HF Heart failure
OSAS Obstructive sleep apnea syndrome
PB Periodic breathing
PSG Polysomnography
RDI Respiratory disturbance index
1.1 Introduction
“ A remarkable abnormal rhythm of respiration, fi rst observed by Cheyne but after-
wards more fully studied by Stokes and hence called by their combined names,
occurs in certain pathological cases. The respiratory movements gradually decrease
both in extent and rapidity until they cease altogether, and a condition of apnoea,
lasting it may be for several seconds, ensues. This is followed by a feeble
M. Emdin (*)
Institute of Life Sciences, Scuola Superiore Sant’Anna , Pisa , Italy
Division of Cardiology and Cardiovascular Medicine , Fondazione Toscana Gabriele
Monasterio, Pisa , Italy
e-mail: [email protected]
A. Aimo
Institute of Life Sciences, Scuola Superiore Sant’Anna , Pisa , Italy
e-mail: [email protected]
© Springer International Publishing Switzerland 2017 1
M. Emdin et al. (eds.), The Breathless Heart,
DOI 10.1007/978-3-319-26354-0_1
2 M. Emdin and A. Aimo

Fig. 1.1 Typical example of Cheyne-Stokes respiration (Source: Hartridge H, 1940 [6 ])
respiration, succeeded in turn by a somewhat stronger one, and thus the respiration
returns gradually to the normal, or may even rise to hyperpnoea or slight dyspnea
after which it again declines in a similar manner (Fig. 1 .1) . The cause of the phe-
nomena is not thoroughly understood. Stokes connected it with a fatty condition of
the heart, but it has been met with in various maladies. Schiff observed it as the
result of compression of the medulla oblongata; and closely similar phenomena
have been observed during sleep, under perfectly normal conditions” [ 1 ].
This report summarizes the state of the art about Cheyne-Stokes respiration
(CSR) in 1879. The oscillatory respiratory pattern named CSR or periodic breathing
(PB) (according to the presence or absence of apneas, respectively) has stimulated
the curiosity of physicians for centuries.
1.2 From Hippocrates to Hunter, Cheyne and Stokes:
Watching the Ill Breathing
Interestingly, the condition now known as obstructive sleep apnea syndrome
(OSAS) was described only in 1889, while PB/CSR was noted long before, being
easily recognizable and most of all occurring also during wakefulness. The very
same father of medicine Hippocrates (460–379 BC) is thought to have provided the
fi rst account of PB/CSR: “His respiration was rare and large, l ike a person who
forgot for a time the need of breathing and then suddenly remembered ” [2 ].
We must wait until 1781 to fi nd another account of PB/CSR. Describing the
case history of a Mr. Boyed, who apparently suffered from atrial fi brillation and
congestive heart failure, the British surgeon John Hunter wrote: “The pulse was
irregular, as usual, and quick; but his breathing was very particular: he would
cease breathing for twenty or thirty seconds, and then begin to breathe softly,
which increased until he breathed extremely strong, or rather with violent strength,
which gradually died away till we could not observe that he breathed at all. He
could not lie down without running the risk of being suffocated, therefore he was
obliged to sit up in his chair” [ 3 ].