Cowie Martin R
National Heart and Lung Institute, Imperial College London (Royal Brompton Hospital), Dovehouse Street, London, SW3 6LY, UK.
Curr Heart Fail Rep. 2016 Oct;13(5):255-265. doi: 10.1007/s11897-016-0304-x.
The majority of patients with heart failure have sleep-disordered breathing (SDB)-with central (rather than obstructive) sleep apnoea becoming the predominant form in those with more severe disease. Cyclical apnoeas and hypopnoeas are associated with sleep disturbance, hypoxaemia, haemodynamic changes, and sympathetic activation. Such patients have a worse prognosis than those without SDB. Mask-based therapies of positive airway pressure targeted at SDB can improve measures of sleep quality and partially normalise the sleep and respiratory physiology, but recent randomised trials of cardiovascular outcomes in central sleep apnoea have been neutral or suggested the possibility of harm, likely from increased sudden death. Further randomised outcome studies (with cardiovascular mortality and hospitalisation endpoints) are required to determine whether mask-based treatment for SDB is appropriate for patients with chronic systolic heart failure and obstructive sleep apnoea, for those with heart failure with preserved ejection fraction, and for those with decompensated heart failure. New therapies for sleep apnoea-such as implantable phrenic nerve stimulators-also require robust assessment. No longer can the surrogate endpoints of improvement in respiratory and sleep metrics be taken as adequate therapeutic outcome measures in patients with heart failure and sleep apnoea.
大多数心力衰竭患者存在睡眠呼吸障碍（SDB），其中中枢性（而非阻塞性）睡眠呼吸暂停在病情较重的患者中成为主要形式。周期性呼吸暂停和呼吸浅慢与睡眠障碍、低氧血症、血流动力学变化及交感神经激活有关。此类患者的预后比无SDB的患者更差。针对SDB的基于面罩的气道正压治疗可改善睡眠质量指标，并使睡眠和呼吸生理部分恢复正常，但近期关于中枢性睡眠呼吸暂停心血管结局的随机试验结果呈中性，或提示存在危害可能性，可能源于猝死增加。需要进一步的随机结局研究（以心血管死亡率和住院为终点）来确定针对SDB的基于面罩的治疗是否适用于慢性收缩性心力衰竭合并阻塞性睡眠呼吸暂停的患者、射血分数保留的心力衰竭患者以及失代偿性心力衰竭患者。睡眠呼吸暂停的新疗法，如植入式膈神经刺激器，也需要进行有力评估。在心力衰竭和睡眠呼吸暂停患者中，不再能将呼吸和睡眠指标改善的替代终点视为充分的治疗结局指标。
