Adaptive servo ventilation for sleep apnoea in heart failure: the FACE study 3-month data

Abstract

Rationale: Adaptive servo ventilation (ASV) is contraindicated in patients with systolic heart failure (HF) who have a left ventricular ejection fraction (LVEF) below 45% and predominant central sleep apnoea (CSA). However, the effects of ASV in other HF subgroups have not been clearly defined.

Objective: The European, multicentre, prospective, observational cohort trial, FACE, evaluated the effects of ASV therapy on morbidity and mortality in patients with HF with sleep-disordered breathing (SDB); 3-month outcomes in patient subgroups defined using latent class analysis (LCA) are presented.

Methods: Consecutive patients with HF with predominant CSA (±obstructive sleep apnoea) indicated for ASV were included from 2009 to 2018; the non-ASV group included patients who refused/were noncompliant with ASV. The primary endpoint was time to composite first event (all-cause death, lifesaving cardiovascular intervention or unplanned hospitalisation for worsening of chronic HF).

Measurements and main results: Baseline assessments were performed in 503 patients, and 482 underwent 3-month follow-up. LCA identified six discrete patient clusters characterised by variations in LVEF, SDB type, age, comorbidities and ASV acceptance. The 3- month rate of primary outcome events was significantly higher in cluster 1 patients (predominantly men, low LVEF, severe HF, CSA; 13.9% vs 1.5%-5% in other clusters, p<0.01).

Conclusion: For the first time, our data identified homogeneous patient clusters representing clinically relevant subgroups relating to SDB management in patients with HF with different ASV usage, each with a different prognosis. This may improve patient phenotyping in clinical practice and allow individualisation of therapy.

Keywords: sleep apnoea.

Figure 1

Patient flow chart.

Figure 2

Illustration of each cluster, by patient clinical characteristics and comorbidities. AHI, apnoea hypopnoea index; ASV, assisted servo ventilation device; BMI, body mass index; CSA, proportion of patients with central sleep apnoea; HFrEF, HFmrEF and HFpEF, heart failure with reduced, mid-range and preserved ejection fraction, respectively; ICD, implanted cardiac device (PM pacemaker, defibrillator, cardiac re-synchronisation); LVEF, left ventricular ejection fraction; NYHA, New York Heart Association class; OSA, proportion of patients with obstructive sleep apnoea T<90%, time spent with oxygen saturation below 90%; TIA, transient ischaemic attack.

Figure 3

Features of each cluster, by patient characteristics, cardiovascular risk factors, heart failure characteristics, therapeutics and medication, hypoxic burden and ASV acceptance. Variables are expressed as percentages, with quantitative variables (*) dichotomised based on the median value (ie, BMI, age and T90) on the basis of median (see tables 2–4 for absolute values) and shown here as percentages on the radial axis (from 0% to 100%). ARA, angiotensin receptor antagonist; ASV, acceptance of assisted servo ventilation device; BMI, body mass index; CSA, proportion of patient with central sleep apnoea; ICD, implanted cardiac device (pacemaker, defibrillator, cardiac re-synchronisation); NYHA, New York Heart Association class; T<90%, time spent with oxygen saturation below 90%; TIA, transient ischaemic attack.

Figure 4

Three-month Kaplan-Meier survival curves for the primary (A), all-cause death, life-saving cardiovascular intervention or hospitalisation for worsening heart failure) and secondary (B), all-cause death, or all-cause hospitalisation) outcome by cluster.