COLUMBUS, Ohio – As if the shortness of breath, fatigue and swelling associated with congestive heart failure (CHF) weren’t distressing enough, an estimated half of all sufferers also experience a sleep disorder that puts further strain on the heart, exacerbating their symptoms and causing exhaustion that interferes with their daily routines.
A new clinic at The Ohio State University Medical Center has pioneered an outpatient treatment approach in the United States by having sleep specialists and cardiologists see patients together in an integrated program that is improving patients’ quality of life and promoting research to better understand links between the combined conditions.
A study led by OSU medical researchers and recently published in the journal Congestive Heart Failure showed that more than 40 percent of CHF patients had frequent abnormal respiratory events during sleep, a sign of sleep apnea. Additional research suggests the prevalence of sleep apnea among heart failure patients is more likely to exceed 50 percent, said Dr. William Abraham, director of cardiovascular medicine at OSU Medical Center.
The link has been identified so recently that screening for sleep apnea among heart failure patients has not become routine, he said. “Given the current lack of awareness regarding the link between sleep apnea and heart failure, one of the goals of the integrated program at OSU is setting the standard of care in this very important arena,” Abraham said. “It’s a big problem nationally. Fifty percent of heart failure patients have sleep apnea, but fewer than 5 percent are being tested for it.”
The integrated program operates in the outpatient heart failure clinic based in the Richard M. Ross Heart Hospital at Ohio State. “The combined approach allows us to provide better care and gives us more information to make the clinical diagnosis,” Abraham said.
The trouble for these patients: Having sleep apnea means that many times each night, either their airway narrows or collapses or they briefly stop breathing, preventing oxygen from getting to the lungs. When they try to breathe, they are aroused or awakened, resulting in a fragmented night of sleep. These episodes, which can occur as frequently as once per minute, cause a drop in oxygen levels, constricted blood vessels, adrenalin surges and swings in blood pressure – all damaging effects that elevate the risk for stroke, blood clots or an irregular heartbeat in patients with already weakened hearts.
“By the end of the night, the heart is exhausted, the patient is exhausted, blood pressure is elevated, the patient is sleepy, and the patient’s ability to work or exercise is compromised,” said Dr. Rami Khayat, a pulmonologist and sleep medicine specialist at OSU Medical Center. “In many ways, this is one of the worst things that can happen to patients with heart failure.”
A sleep study is required to diagnose sleep apnea and determine its severity. Sleep studies are typically performed in sleep labs; OSU Medical Center recently built a new state-of-the-art Sleep Disorders Center at its University Hospital East location.
The most effective treatment for sleep apnea – patients with heart failure included – is the use of CPAP, a device that delivers continuous positive airway pressure during sleep. The device encompasses a mask worn over the nose, tubing and a fan that delivers enough air pressure to keep the throat open, preventing obstruction of the airway, and reversing the negative consequences of sleep apnea on the heart.
Since launching the integrated program in the spring, physicians have seen, on average, a 10 percent to 30 percent improvement in heart function among many patients with CHF using the CPAP machines, Khayat said.
“This has been particularly helpful to heart failure patients who have been on effective medication, but have still been tired,” Abraham said. “They have had a sleep study and started the CPAP, and they literally come back for their next appointment and say they haven’t felt so well in months or even years.”
And OSU physicians are studying whether the sleep apnea treatment actually prolongs the life of heart failure patients, as well. Early data suggest that eliminating the effects of sleep apnea has resulted in improvements in the size and strength of some patients’ hearts – a process called reverse remodeling.
“The research suggests this can reverse the process of heart failure. While it doesn’t cure heart failure, it certainly improves patients’ condition,” Abraham said.
Patients also benefit from the sheer convenience of the integrated program, which reduces the need for multiple physician appointments and accelerates access to the sleep lab for patients considered at highest risk for sleep apnea. This is significant, Khayat said, given the national shortage of specialized sleep labs, which limits access for patients who are in critical need of sleep evaluation.
“On a practical level, patients have a lot to gain from this approach because sleep and heart specialists decide on the ideal treatment approach for an individual patient, and they’re able to integrate this approach with the overall heart failure treatment program of the individual patient. This is presented to the patients first in the heart failure clinic, which is familiar territory for them,” Khayat said.# # #
Medical Center Communications