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Oxygen desaturation and heart rate variability due to Cheyne-Stokes respiration in congestive heart failure patients
Biomed Pharmacother 56 (2002) 345s–348s www.elsevier.com/locate/biopha
Original paper
Oxygen desaturation and heart rate variability due to Cheyne-Stokes respiration in congestive heart failure patients Osamu Tateishi a,*, Seibu Mochizuki b, Katsuhiko Machida a a
Department of Laboratory Medicine, Jikei University School of Medicine, Chiba, Japan b Department of Cardiology, Jikei University School of Medicine, Chiba, Japan
Abstract Cheyne-Stokes respiration is common in congestive heart failure patients and causes cyclical fluctuation of the RR interval. We studied the characteristics of apnea-related heart rate variability (apnea HRV) and the relation between apnea HRV and oxygen desaturation was examined. Ambulatory electrocardiograms and data on respiration (oronasal flow, tracheal sounds, abdominal wall movement and oxygen saturation) were simultaneously recorded by a multi-channel digital recorder for 16 congestive heart failure patients (10 men and 6 women; mean age, 68±13 years). HRV occurred as a result of cyclical apnea attacks between 0.005 and 0.03 Hz (apnea band). Apnea HRV was obtained as the power ratio of apnea HRV normalized by the very low frequency band (0.003-0.04 Hz). Apnea HRV increased with the number of apnea episodes and the oxygen desaturation index, but no relation between apnea HRV and either mean oxygen density or oxygen desaturation time was observed. We concluded that apnea HRV is a predictor of the number of apnea attacks or oxygen desaturation, but does not reflect the degree of oxygen desaturation in Cheyne-Stokes respiration. © 2002 Éditions scientifiques et médicales Elsevier SAS. All rights reserved. Keywords: Heart rate variability; Sleep apnea; Congestive heart failure
1. Introduction Cheyne-Stokes respiration is a common breathing disorder in congestive heart failure patients [3]. It causes hemodynamic changes, such as desaturation of the blood oxygen or blood pressure fluctuation following cyclical apnea attacks [8]. These cause the increase of sympathetic nervous activity and aggravate the prognosis of congestive heart failure patients with Cheyne-Stokes respiration. Recently, we reported the clinical utility of the apnea-related heart rate variability (Apnea HRV) as a screening method for detecting Cheyne-Stokes respiration in congestive heart failure patients [7]. However, we presented no data on the relationship between the desaturation of blood oxygen and apnea HRV. In the present study, we simultaneously recorded electrocardiograms and blood oxygen saturation for congestive heart failure patients and studied the relationship
* Corresponding author. E-mail address: [email protected] (O. Tateishi). © 2002 Éditions scientifiques et médicales Elsevier SAS. All rights reserved. PII: S 0 7 5 3 - 3 3 2 2 ( 0 2 ) 0 0 3 1 4 - 1
between the degree of reduction of blood oxygen density and apnea HRV.
2. Subjects and methods 2.1. Ambulatory monitoring of polysphygmogram We made twenty-four-hour ambulatory recordings for 16 congestive heart failure patients (10 men and 6 women; 10 patients with dilated cardiomyopathy, 4 with ischemic heart disease, 2 with valvular heart disease; mean age 68±13 years) with an ejection fraction of 40% or less using a commercially available multifunctional digital recorder (Fukuda FM-500, Japan). Two electrocardiograms (NASA and CC5) and the following respiratory data were simultaneously recorded: (a) oronasal flow (using a thermocouple); (b) tracheal sounds (with a microphone); (c) abdominal wall movement (capacitance manometer); (d) position; (e) oxygen saturation (pulse oximeter: SpO2). An electroencephalography was not performed. Cheyne-Stokes respiration was
346s
O. Tateishi et al. / Biomed Pharmacother 56 (2002) 345s–348s
defined according to the guideline of the American Academy of Sleep Medicine Task Force as: 5 or more reductions (>50%) per hour in the amplitude of oronasal flow during sleep, relative to the baseline (11 pm–5 am) (apneahypopnea index, AHI, ≥5). Each subject was informed of the purpose of the study and gave consent for the recordings. 2.2. Measurement of heart rate variability HRV was analyzed by the maximum entropy method (MemCalc/CHIRAM, Suwa Trust, Japan). The apnea band was defined, as in previous studies of Cheyne-Stokes respiration, as 0.005–0.03 Hz [2,4,6]. Apnea HRV was calculated from the power ratio of the apnea band normalized by the power from the very low frequency band (0.003–0.04 Hz).
Fig. 1. Polysphygmogram of a case of Cheyne-Stokes respiration. Heart rate and blood oxygen density fluctuated cyclically with apnea attacks. SpO2: blood oxygen saturation by pulse oximeter; HR: heart rate; Oronasal: oronasal flow; Abdominal: abdominal wall movement.
2.3. Reduction of blood oxygen density and apnea HRV by Cheyne-Stokes respiration The oxygen desaturation index and time were measured by ambulatory monitoring of SpO2 during sleep. The oxygen desaturation index was defined as the number of events of SpO2 desaturation per hour during apneahypopnea attacks and oxygen desaturation time was defined as the total time that the blood oxygen saturation level is under 90%. With these data, the relationship between the apnea HRV and the desaturation of blood oxygen was studied.
analyses. All data are presented as the mean ± standard deviation of mean.
2.4. Statistical analysis
Fig. 1 shows an example of an ambulatory recording of a Cheyne-Stokes respiration patient. After the oronasal flow and the abdominal wall movement had ceased, a cyclical crescendo-decrescendo variation in breathing amplitude
A simple correlation coefficient was used to assess data, and p<0.05 was regarded as statistically significant for all
3. Results 3.1. Incidence of Cheyne-Stokes respiration in congestive heart failure patients
Table 1 Results of the polysphygmogram Case 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 .
AHI (/hr) 17.8 13 10 8.5 8 4.8 4.5 4.5 4.3 4.3 3.3 1.8 1.3 0.3 0 0
Type CSR CSR CSR CSR CSR
Mean SpO2(%) 95.2 96.5 96.7 – 94.6 95 95.4 95.1 96.8 94.4 95.8 96.6 97.3 95.1 98.5 97.2
ODI ^3(/hr) 19.7 13.3 10.8 – 7.5 6.7 4.5 4.5 4.8 5.3 8.7 2 2.2 2 0 0
ODI ^4(/hr) 16.3 11.3 9.7 – 6.2 5 3.5 3.2 4 4.2 6.7 1.5 1.3 1.7 0 0
ODT 16.6 2.8 1.4 – 1.8 0.2 0 0 0.1 0.3 6.3 1.5 0 1.4 0 0.02
(min)
Apnea HRV (%) 90 89 82 74 86 77 74 74 82 68 64 – 72 71 56 72
AHI = apnea-hypopnea index; ODI = oxygen desaturation index; ODT = oxygen desaturation time; CSR = Cheyne-Stokes respiration.
O. Tateishi et al. / Biomed Pharmacother 56 (2002) 345s–348s
347s
Fig. 2. Heart rate variability of the VLF band in a Cheyne-Stokes respiration patient. The spectral peaks observed during sleep appear on the left.
was observed. Oxygen desaturation and bradycardia appeared along with apnea attacks. Table 1 shows the results of AHI, oxygen desaturation index, mean SpO2 and apnea HRV in our study. The HRV could not be analyzed in case 12, because of the noise of bodily movements, and the SpO2 could not be recorded in case 4, because the sensor installed in the patient became detached during the examination. Cheyne-Stokes respiration was found in 5 out of 16 patients (31%). 3.2. Blood oxygen and heart rate variability in congestive heart failure patients Fig. 2 shows an example of the power spectrum of HRV in Cheyne-Stokes respiration patients (Case 1). The spectrum peak was observed in the apnea band, and the apnea HRV was 90%. Fig. 3 shows the relationship between apnea HRV and both the AHI and oxygen desaturation index. The apnea HRV was significantly higher in Cheyne-Stokes respiration patients. The value of apnea HRV rose with AHI or the oxygen desaturation index, and Cheyne-Stokes respiration was very likely in the cases of apnea HRV > 80%. Fig. 4 shows the relationship between apnea HRV and both mean SpO2 and oxygen desaturation time. There was no significant relationship between them.
Fig. 3. Relationship between the apnea-related heart rate variability and AHI or ODI. Heart rate variability increased with the number of apnea or desaturation episodes. AHI: apnea-hypopnea index; ODI: oxygen desaturation index; HRV: heart rate variability.
4. Discussion Recently, a number of enthusiastic proposals have been made, for the continuous positive airway pressure method for the improvement of cases of congestive heart failure complicated by Cheyne-Stokes respiration, [1,5]. The detection of Cheyne-Stokes respiration cases among congestive heart failure patients has thus become important. Our previous study revealed that the more frequent the apnea attacks, the higher the values of apnea HRV [7]. The present study further clarifies the relationship between desaturation of blood oxygen and heart rate variability. The apnea HRV showed a good correlation with the oxygen desaturation index, but was not correlated to the oxygen desaturation
348s
O. Tateishi et al. / Biomed Pharmacother 56 (2002) 345s–348s
This study, however, covered only a small number of subjects and did not include severe Cheyne-Stokes respiration patients. Furthermore, the cross-spectrum between oxygen density and heart rate was not analyzed. These are questions for future examination.
References
Fig. 4. Relationship between the apnea-related heart rate variability and mean SpO2 or ODT. There was no significant relationship between heart rate variability and mean oxygen density or oxygen desaturation time. ODT: oxygen desaturation time; HBV: heart rate variability.
time nor to the mean SpO2. This indicated that apnea HRV can be regarded as a predictor of oxygen desaturation, but does not reflect its degree.
[1]
Bradley TD, Logan AG, Floras JS. Rationale and design of the Canadian continuous positive airway pressure trial for congestive heart failure patients with central sleep apnea-CANPAP. Can J Cardiol 2001;17:677.
[2]
Goldberger AL, Findley LJ, Blackburn MR, Mandell AJ. Nonlinear dynamics in heart failure: Implications of long-wavelength cardiopulmonary oscillations. Am Heart J 1984;107:612.
[3]
Javaheri S, Parker TJ, Liming JD, Corbett WS, Nishiyama H, Wexler L, Roselle GA. Sleep apnea in 81 ambulatory male patients with stable heart failure. Circulation 1998;97:2154.
[4]
Saul JP, Arai Y, Berger RD, Lilly LS, Colucci WS, Cohen RJ. Assessment of autonomic regulation in chronic congestive heart failure by heart rate spectral analysis. Am J Cardiol 1988;61:1292.
[5]
Sin DD, Logan AG, Fitzgerald FS, Liu PP, Bradley TD. Effects of continuous positive airway pressure on cardiovascular outcomes in heart failure patients with and without Cheyne-Stokes respiration. Circulation 2000;102:61.
[6]
Tateishi O, Shouda T, Azuma Y, Chin K, Nogimura T, Gotou Y, et al. Heart rate variability in congestive heart failure. Clin Exp Hypertens 2002;24(1&2):75.
[7]
Tateishi O, Shouda T, Honda Y, Sakai T, Mochizuki S, Machida K. Study of sleep-related heart rate variability and its clinical utility in congestive heart failure patients. Ann Non-invasive Electrocardiol 00 (in press).
[8]
Yamashiro Y, Kryger MH. Sleep in heart failure. Sleep 1993;16:513.
Original paper
Oxygen desaturation and heart rate variability due to Cheyne-Stokes respiration in congestive heart failure patients Osamu Tateishi a,*, Seibu Mochizuki b, Katsuhiko Machida a a
Department of Laboratory Medicine, Jikei University School of Medicine, Chiba, Japan b Department of Cardiology, Jikei University School of Medicine, Chiba, Japan
Abstract Cheyne-Stokes respiration is common in congestive heart failure patients and causes cyclical fluctuation of the RR interval. We studied the characteristics of apnea-related heart rate variability (apnea HRV) and the relation between apnea HRV and oxygen desaturation was examined. Ambulatory electrocardiograms and data on respiration (oronasal flow, tracheal sounds, abdominal wall movement and oxygen saturation) were simultaneously recorded by a multi-channel digital recorder for 16 congestive heart failure patients (10 men and 6 women; mean age, 68±13 years). HRV occurred as a result of cyclical apnea attacks between 0.005 and 0.03 Hz (apnea band). Apnea HRV was obtained as the power ratio of apnea HRV normalized by the very low frequency band (0.003-0.04 Hz). Apnea HRV increased with the number of apnea episodes and the oxygen desaturation index, but no relation between apnea HRV and either mean oxygen density or oxygen desaturation time was observed. We concluded that apnea HRV is a predictor of the number of apnea attacks or oxygen desaturation, but does not reflect the degree of oxygen desaturation in Cheyne-Stokes respiration. © 2002 Éditions scientifiques et médicales Elsevier SAS. All rights reserved. Keywords: Heart rate variability; Sleep apnea; Congestive heart failure
1. Introduction Cheyne-Stokes respiration is a common breathing disorder in congestive heart failure patients [3]. It causes hemodynamic changes, such as desaturation of the blood oxygen or blood pressure fluctuation following cyclical apnea attacks [8]. These cause the increase of sympathetic nervous activity and aggravate the prognosis of congestive heart failure patients with Cheyne-Stokes respiration. Recently, we reported the clinical utility of the apnea-related heart rate variability (Apnea HRV) as a screening method for detecting Cheyne-Stokes respiration in congestive heart failure patients [7]. However, we presented no data on the relationship between the desaturation of blood oxygen and apnea HRV. In the present study, we simultaneously recorded electrocardiograms and blood oxygen saturation for congestive heart failure patients and studied the relationship
* Corresponding author. E-mail address: [email protected] (O. Tateishi). © 2002 Éditions scientifiques et médicales Elsevier SAS. All rights reserved. PII: S 0 7 5 3 - 3 3 2 2 ( 0 2 ) 0 0 3 1 4 - 1
between the degree of reduction of blood oxygen density and apnea HRV.
2. Subjects and methods 2.1. Ambulatory monitoring of polysphygmogram We made twenty-four-hour ambulatory recordings for 16 congestive heart failure patients (10 men and 6 women; 10 patients with dilated cardiomyopathy, 4 with ischemic heart disease, 2 with valvular heart disease; mean age 68±13 years) with an ejection fraction of 40% or less using a commercially available multifunctional digital recorder (Fukuda FM-500, Japan). Two electrocardiograms (NASA and CC5) and the following respiratory data were simultaneously recorded: (a) oronasal flow (using a thermocouple); (b) tracheal sounds (with a microphone); (c) abdominal wall movement (capacitance manometer); (d) position; (e) oxygen saturation (pulse oximeter: SpO2). An electroencephalography was not performed. Cheyne-Stokes respiration was
346s
O. Tateishi et al. / Biomed Pharmacother 56 (2002) 345s–348s
defined according to the guideline of the American Academy of Sleep Medicine Task Force as: 5 or more reductions (>50%) per hour in the amplitude of oronasal flow during sleep, relative to the baseline (11 pm–5 am) (apneahypopnea index, AHI, ≥5). Each subject was informed of the purpose of the study and gave consent for the recordings. 2.2. Measurement of heart rate variability HRV was analyzed by the maximum entropy method (MemCalc/CHIRAM, Suwa Trust, Japan). The apnea band was defined, as in previous studies of Cheyne-Stokes respiration, as 0.005–0.03 Hz [2,4,6]. Apnea HRV was calculated from the power ratio of the apnea band normalized by the power from the very low frequency band (0.003–0.04 Hz).
Fig. 1. Polysphygmogram of a case of Cheyne-Stokes respiration. Heart rate and blood oxygen density fluctuated cyclically with apnea attacks. SpO2: blood oxygen saturation by pulse oximeter; HR: heart rate; Oronasal: oronasal flow; Abdominal: abdominal wall movement.
2.3. Reduction of blood oxygen density and apnea HRV by Cheyne-Stokes respiration The oxygen desaturation index and time were measured by ambulatory monitoring of SpO2 during sleep. The oxygen desaturation index was defined as the number of events of SpO2 desaturation per hour during apneahypopnea attacks and oxygen desaturation time was defined as the total time that the blood oxygen saturation level is under 90%. With these data, the relationship between the apnea HRV and the desaturation of blood oxygen was studied.
analyses. All data are presented as the mean ± standard deviation of mean.
2.4. Statistical analysis
Fig. 1 shows an example of an ambulatory recording of a Cheyne-Stokes respiration patient. After the oronasal flow and the abdominal wall movement had ceased, a cyclical crescendo-decrescendo variation in breathing amplitude
A simple correlation coefficient was used to assess data, and p<0.05 was regarded as statistically significant for all
3. Results 3.1. Incidence of Cheyne-Stokes respiration in congestive heart failure patients
Table 1 Results of the polysphygmogram Case 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 .
AHI (/hr) 17.8 13 10 8.5 8 4.8 4.5 4.5 4.3 4.3 3.3 1.8 1.3 0.3 0 0
Type CSR CSR CSR CSR CSR
Mean SpO2(%) 95.2 96.5 96.7 – 94.6 95 95.4 95.1 96.8 94.4 95.8 96.6 97.3 95.1 98.5 97.2
ODI ^3(/hr) 19.7 13.3 10.8 – 7.5 6.7 4.5 4.5 4.8 5.3 8.7 2 2.2 2 0 0
ODI ^4(/hr) 16.3 11.3 9.7 – 6.2 5 3.5 3.2 4 4.2 6.7 1.5 1.3 1.7 0 0
ODT 16.6 2.8 1.4 – 1.8 0.2 0 0 0.1 0.3 6.3 1.5 0 1.4 0 0.02
(min)
Apnea HRV (%) 90 89 82 74 86 77 74 74 82 68 64 – 72 71 56 72
AHI = apnea-hypopnea index; ODI = oxygen desaturation index; ODT = oxygen desaturation time; CSR = Cheyne-Stokes respiration.
O. Tateishi et al. / Biomed Pharmacother 56 (2002) 345s–348s
347s
Fig. 2. Heart rate variability of the VLF band in a Cheyne-Stokes respiration patient. The spectral peaks observed during sleep appear on the left.
was observed. Oxygen desaturation and bradycardia appeared along with apnea attacks. Table 1 shows the results of AHI, oxygen desaturation index, mean SpO2 and apnea HRV in our study. The HRV could not be analyzed in case 12, because of the noise of bodily movements, and the SpO2 could not be recorded in case 4, because the sensor installed in the patient became detached during the examination. Cheyne-Stokes respiration was found in 5 out of 16 patients (31%). 3.2. Blood oxygen and heart rate variability in congestive heart failure patients Fig. 2 shows an example of the power spectrum of HRV in Cheyne-Stokes respiration patients (Case 1). The spectrum peak was observed in the apnea band, and the apnea HRV was 90%. Fig. 3 shows the relationship between apnea HRV and both the AHI and oxygen desaturation index. The apnea HRV was significantly higher in Cheyne-Stokes respiration patients. The value of apnea HRV rose with AHI or the oxygen desaturation index, and Cheyne-Stokes respiration was very likely in the cases of apnea HRV > 80%. Fig. 4 shows the relationship between apnea HRV and both mean SpO2 and oxygen desaturation time. There was no significant relationship between them.
Fig. 3. Relationship between the apnea-related heart rate variability and AHI or ODI. Heart rate variability increased with the number of apnea or desaturation episodes. AHI: apnea-hypopnea index; ODI: oxygen desaturation index; HRV: heart rate variability.
4. Discussion Recently, a number of enthusiastic proposals have been made, for the continuous positive airway pressure method for the improvement of cases of congestive heart failure complicated by Cheyne-Stokes respiration, [1,5]. The detection of Cheyne-Stokes respiration cases among congestive heart failure patients has thus become important. Our previous study revealed that the more frequent the apnea attacks, the higher the values of apnea HRV [7]. The present study further clarifies the relationship between desaturation of blood oxygen and heart rate variability. The apnea HRV showed a good correlation with the oxygen desaturation index, but was not correlated to the oxygen desaturation
348s
O. Tateishi et al. / Biomed Pharmacother 56 (2002) 345s–348s
This study, however, covered only a small number of subjects and did not include severe Cheyne-Stokes respiration patients. Furthermore, the cross-spectrum between oxygen density and heart rate was not analyzed. These are questions for future examination.
References
Fig. 4. Relationship between the apnea-related heart rate variability and mean SpO2 or ODT. There was no significant relationship between heart rate variability and mean oxygen density or oxygen desaturation time. ODT: oxygen desaturation time; HBV: heart rate variability.
time nor to the mean SpO2. This indicated that apnea HRV can be regarded as a predictor of oxygen desaturation, but does not reflect its degree.
[1]
Bradley TD, Logan AG, Floras JS. Rationale and design of the Canadian continuous positive airway pressure trial for congestive heart failure patients with central sleep apnea-CANPAP. Can J Cardiol 2001;17:677.
[2]
Goldberger AL, Findley LJ, Blackburn MR, Mandell AJ. Nonlinear dynamics in heart failure: Implications of long-wavelength cardiopulmonary oscillations. Am Heart J 1984;107:612.
[3]
Javaheri S, Parker TJ, Liming JD, Corbett WS, Nishiyama H, Wexler L, Roselle GA. Sleep apnea in 81 ambulatory male patients with stable heart failure. Circulation 1998;97:2154.
[4]
Saul JP, Arai Y, Berger RD, Lilly LS, Colucci WS, Cohen RJ. Assessment of autonomic regulation in chronic congestive heart failure by heart rate spectral analysis. Am J Cardiol 1988;61:1292.
[5]
Sin DD, Logan AG, Fitzgerald FS, Liu PP, Bradley TD. Effects of continuous positive airway pressure on cardiovascular outcomes in heart failure patients with and without Cheyne-Stokes respiration. Circulation 2000;102:61.
[6]
Tateishi O, Shouda T, Azuma Y, Chin K, Nogimura T, Gotou Y, et al. Heart rate variability in congestive heart failure. Clin Exp Hypertens 2002;24(1&2):75.
[7]
Tateishi O, Shouda T, Honda Y, Sakai T, Mochizuki S, Machida K. Study of sleep-related heart rate variability and its clinical utility in congestive heart failure patients. Ann Non-invasive Electrocardiol 00 (in press).
[8]
Yamashiro Y, Kryger MH. Sleep in heart failure. Sleep 1993;16:513.