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3. بسم الله الرحمن الرحيم

4. Study Of Sleep Disordered Breathing, Respiratory Muscle Strength And Respiratory Neural Drive In Patients With Compensated Heart Failure By Maha Yousif Aly El-Hefnawy

8. Introduction

11. Aim of the work

13. Patients and Methods

14. ( EF ≤ 45%) Internal medicine clinic Cardiology clinic 50 Internal medicine clinic Internal medicine clinic Internal medicine clinic

15. EF ≤ 45% Stable Treatment An echocardiographic left ventricular EF ≤ 45% Stable clinical condition with no episodes of acute heart failure within 4 weeks prior to the study. Optimized heart failure therapy with no change in medications over 4 weeks prior to study. Inclusion criteria

16. Exclusion Criteria Decompensated HF, unstable angina, acute pulmonary edema, valvular and congenital heart disease Known patients with intrinsic pulmonary disease e.g moderate to severe obstructive lung disease and interstitial lung diseases Clinical signs CNS impairment e.g sensory or motor impairment, history of stroke, cocaine, alcohol abuse Daily use of theophylline, benzodiazepines, or morphine derivatives The patient's refusal NO

17. Exclusion Criteria Severe obesity ( body mass index (BMI) > 30 kg/m2). Untreated hypothyroidism; and kyphoscoliosis . Patients who can't tolerate the PFT maneuvers e.g. those with aneurysm, uncontrolled hypertension, urinary incontinence. Known patients with renal or liver cell failure.

18. 1. History & Examination 3. ESS score 2. NYHA class 6. Polysomnography 5. Pulmonary function tests SVC & FVC MIP/MEP P0.1 4. Routine investigations CBC, kidney & liver function test, Chest X-ray and CT (if needed).

20. The whole PFT device

21. The MIP/MEP valve

24. The P0.1 valve

27. The EEG electrodes

29. Snoring sensor (white), ECG cables (red) and limb movement cables (black)

30. The bed side unit (left) and Embla S 4000 (right)

31. The sleep lab room

32. EMG Tibialis S PO2 Abdominal movement Thoracic movement Body position ECG EOG EEG EMG Submentalis Flow Snoring The patient`s hookup

34. Results

35. 70% 76% 24% Prevalence of SDB in patients with compensated LVHF OSA n = 16 (32%) Non-SDB n = 12 (24%) CSA n = 22 (44%)

36. Non- SDB SDB Total Males Females 56% Non-SDB SDB Total 25% 75% 34% 54% 65% 66% Sex distribution among the studied patients.

37. Total n=50 Non SDB SDB n=38 P- value Baseline patient characteristics. = 0.012 * ≤ 0.001 ** ≤ 0.001** ≤ 0.001** 2.7 ± 0.5 2.0 ± 0.0 2.5 ± 0.5 NYHA class 35.1 ± 6.4 42.0 ± 1.8 36.7 ± 6.4 EF% 13.3 ± 4 7.8 ± 1.9 11.9 ± 4.3 ESS 25.5 ± 3.2 23.1 ± 1.9 24.9 ± 3.1 BMI

38. Total n=50 Non SDB SDB n=38 P- value Polysomnographic characteristics of the studied patients. ≤ 0.001 ** ≤ 0.001 ** ≤ 0.001** ≤ 0.001** 26.7 ± 10 6.3 ± 2 21.8 ± 12.5 DI 29.1 ± 11 6.7 ± 2 23.7 ± 13 AHI 27.9 ± 8.8 14.9 ± 6.5 24.8 ± 10 AI 66.4 ±7.3 79 ± 6 69 ± 9 SE

39. Total n=50 Non SDB SDB n=38 P- value Pulmonary function characteristics of the studied patients. 0.021* = 0.005* ≤ 0.001** ≤ 0.001** 0.1 ± 0.04 0.07 ± 0.02 0.1 ± 0.03 P0.1/MIP 6.1 ± 1.3 4 ± 1.2 5.6 ± 1.6 P0.1 100.8± 18.7 118.7 ± 16 105 ±19.6 MEP 53.8 ±13 58.7 ± 9.2 56.1 ± 12 MIP

40. Baseline characteristics of patients with SDB CSA OSA 25 ± 3 13 ± 4 3 ± 0.4 14 ± 4 40 ± 4 BMI ESS EF% 27 ± 3 31 ± 5 2.4 ± 0.5 NYHA class P ≤ 0.05 P - value for Mann-Whitney rank sum test between CSA and OSA groups

41. Pulmonary function characteristics of patients with SDB CSA OSA 48 ± 11 94 ± 17 0.14 ± 1 109 ± 17 5.4 ± 1 MIP MEP P0.1 61 ± 12 6.6 ± 1 0.08 ± 1 P0.1/MIP P ≤ 0.05 P - value for Mann-Whitney rank sum test between CSA and OSA groups

42. Correlations between patient characteristics and sleep parameters 0.000** 0.000** 0.000** 0.0057* 0.709 P-value -0.459 0.675 0.668 0.387 0.0539 r-value DI 0.000** 0.000** 0.080 0.0153* 0.594 P-value -0.458 0.666 0.682 0.342 0.0769 r-value AHI 0.002** 0.000** 0.000** 0.241 0.432 P-value -0.436 0.461 0.553 0.168 0.113 r-value AI 0.0177* 0.000** 0.000** 0.007* 0.977 P-value 0.335 -0.577 -0.570 -0.377 0.00421 r-value SE EF% NYHA ESS BMI Age

43. Correlations between patient characteristics and pulmonary function tests. 0.473 0.182 -0.057 0.0960 r-value P0.1/MIP 0.000** 0.205 0.694 0.506 P-value 0.000** 0.083 0.902 0.298 P-value 0.422 0.436 0.208 0.187 r-value P0.1 0.002* 0.002* 0.147 0.193 P-value -0.620 -0.25 0.0177 -0.150 r-value MEP 0.0455* 0.501 0.238 0.431 P-value -0.284 0.097 0.169 -0.114 r-value MIP NYHA ESS BMI Age

44. Correlations between patient characteristics and pulmonary function tests. 0.001** -0.732 0.0017* -0.435 0.001** 0.698 0.001** 0.752 EF% 0.473 0.182 -0.057 0.0960 r-value P0.1/MIP 0.001** 0.205 0.694 0.506 P-value 0.001** 0.083 0.902 0.298 P-value 0.422 0.436 0.208 0.187 r-value P0.1 0.002* 0.002* 0.147 0.193 P-value -0.620 -0.25 0.0177 -0.150 r-value MEP 0.0455* 0.501 0.238 0.431 P-value -0.284 0.097 0.169 -0.114 r-value MIP NYHA ESS BMI Age

45. Correlations between sleep parameters and pulmonary function tests. 0.402 0.419 0.497 -0.335 r-value P0.1/MIP 0.004* 0.003* 0.000** 0.018* P-value 0.083 0.094 0.0867 0.160 P-value 0.555 0.581 0.532 -0.466 r-value P0.1 0.0001** 0.0002** 0.0004** 0.0007** P-value -0.416 -0.406 -0.245 0.201 r-value MEP 0.441 0.425 0.294 0.916 P-value -0.111 -0.115 -0.151 -0.0152 r-value MIP DI AHI AI SE

49. Conclusions

50. Click to edit title style The occurrence and severity of SDB is linked to the severity of decline in LVEF In compensated LVHF The severity of SDB is not related to the severity of daytime sleepiness Patients with compensated LVHF may have decreased respiratory muscle strength A B C D E SDB especially CSA is highly prevalent in patients with compensated LVHF The respiratory drive can be increased in patients with compensated LVHF

51. Recommendations

52. Screening for SDB in patients with depressed LVEF Interdisciplinary approach involving cardiologists, and pulmonologists for management of SDB in HF Evidence based diagnostic thresholds and management algorithms need to be established Further studies should focus on the effect of sleep apnea on the long term progression of HF Further studies on MIP, MEP and P0.1 as prognostic markers of HF and its treatment

53. Maha Yousif