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From the author

Respiratory Medicine, University Hospital Umeå, Umeå, Sweden.

I am grateful for the interest and the comments by O. Oldenburg and co-workers regarding my editorial 1.

There is no question that treatment of sleep apnoea among patients with congestive heart failure is of great interest, because sleep apnoea is common among such patients, especially in the form of central apnoea and Cheyne–Stokes respiration 2. My major concern relates to large-scale screening programmes for sleep apnoea in patients with heart failure before solid evidence of treatment effect on central sleep apnoea regarding patient-related outcomes is obtained, i.e. survival, symptoms or quality of life.

O. Oldenburg and co-workers argue that the apnoea/hypopnoea index could be used as a surrogate end-point, since a diagnosis of central sleep apnoea is associated with an impaired prognosis 3–5. Oxygen, continuous positive airway pressure and ventilators all reduce the frequency of central apnoeas, i.e. the central apnoea/hypopnoea index. However, other authors have not observed any increased mortality among patients with central sleep apnoea 6, 7. Surrogate end-points also infer a risk of false interpretation. One such example was anti-arrhythmic treatment studies on patients suffering acute myocardial infarction with arrhythmia as the outcome. Reduction of the number of ventricular arrhythmia was later shown to be associated with an increased mortality rate 8.

I am certainly in agreement with O. Oldenburg and co-workers that we need high-quality treatment studies in patients with congestive heart failure and sleep apnoea. My concern is that we should wait for the results of these studies before starting large-scale screening programmes.

REFERENCES

1. Franklin KA. Sleep apnoea screening in heart failure? Not until benefit is proven!. Eur Respir J 2007;29:1073–1074.[Free Full Text]
2. Javaheri S, Parker TJ, Liming JD, et al. Sleep apnea in 81 ambulatory male patients with stable heart failure. Types and their prevalences, consequences, and presentations. Circulation 1998;97:2154–2159.[Abstract/Free Full Text]
3. Hanly PJ, Zuberi-Khokhar NS. Increased mortality associated with Cheyne–Stokes respiration in patients with congestive heart failure. Am J Respir Crit Care Med 1996;153:272–276.[Abstract]
4. Lanfranchi PA, Braghiroli A, Bosimini E, et al. Prognostic value of nocturnal Cheyne–Stokes respiration in chronic heart failure. Circulation 1999;99:1435–1440.[Abstract/Free Full Text]
5. Javaheri S, Shukla R, Zeigler H, Wexler L. Central sleep apnea, right ventricular dysfunction, and low diastolic blood pressure are predictors of mortality in systolic heart failure. J Am Coll Cardiol 2007;49:2028–2034.[Abstract/Free Full Text]
6. Andreas S, Hagenah G, Moller C, Werner GS, Kreuzer H. Cheyne–Stokes respiration and prognosis in congestive heart failure. Am J Cardiol 1996;78:1260–1264.[CrossRef][Web of Science][Medline] [Order article via Infotrieve]
7. Roebuck T, Solin P, Kaye DM, Bergin P, Bailey M, Naughton MT. Increased long-term mortality in heart failure due to sleep apnoea is not yet proven. Eur Respir J 2004;23:735–740.[Abstract/Free Full Text]
8. Epstein AE, Hallstrom AP, Rogers WJ, et al. Mortality following ventricular arrhythmia suppression by encainide, flecainide, and moricizine after myocardial infarction. The original design concept of the Cardiac Arrhythmia Suppression Trial (CAST). JAMA 1993;270:2451–2455.[Abstract/Free Full Text]

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