Congestive Heart Failures
Association between hemodynamic impairment and cheyne-stokes respiration and periodic breathing in chronic stable congestive heart failure secondary to ischemic or idiopathic dilated cardiomyopathy

https://doi.org/10.1016/S0002-9149(99)00462-2Get rights and content

Abstract

Irregular breathing occurs frequently in patients with congestive heart failure (CHF) both during daytime and nighttime. Many factors are involved in the genesis of these breathing abnormalities, but the role of the hemodynamic impairment remains controversial. This study investigated the relation between worsening ventricular function and the frequency of respiratory disorders in patients with mild to severe CHF. One hundred fifty patients with CHF (mean age 53 ± 8 years, left ventricular (LV) ejection fraction 26 ± 7, in New York Heart Association [NYHA] classes II to IV, and who underwent stable therapy for ≥2 weeks) were studied. Analysis of instantaneous lung volume signal and arterial oxygen saturation during awake daytime revealed a normal respiratory pattern in 63 patients, whereas 87 had a persistent alteration of breathing, with a typical Cheyne-Stokes respiration (CSR) in 42 and periodic breathing (PB [oscillation of tidal volumes without apnea]) in 45 patients. Patients with PB and CSR showed a more pronounced hemodynamic impairment with a significantly reduced cardiac index, an increased pulmonary arterial wedge pressure, and a longer lung-to-ear circulation time (LECT) compared with patients with normal respiratory patterns. In a logistic regression model that included all of the variables significantly associated with breathing disorders, cardiac index and LECT emerged as the major determinants of CSR. In those patients with LECT ≥30 seconds (upper quartile) and cardiac index ≤1.9 L/min/m2 (lower quartiles), the incidence of CSR was significantly higher (69%) than in patients with lower LECT and higher cardiac index (14%, p <0.001). In conclusion, abnormalities of breathing activity during daytime are significantly associated with a prolonged circulation time and a more severe impairment of systolic and diastolic LV indexes.

Section snippets

Patient group

One hundred fifty consecutive in-patients with stable CHF (mean age 53 ± 8 years, women 13%, body mass index 25.9 ± 3.5 kg/m2) were enrolled in the study. All patients were admitted to our hospital for consideration of possible heart transplantation. They had to have a LV ejection fraction of <40% and ≥1 episode of severe cardiac decompensation in the preceding 6 months. At entry to our study all the patients were in a stable condition (no changes in signs and symptoms in the preceding 2 weeks)

Results

PB and CSR were detected respectively in 30% and 28% of the patients studied, whereas in the remaining 42% the respiratory pattern was normal. Clinical and hemodynamic characteristics of the overall population and of the 3 groups of subjects are reported in Table I. A close and linear relation exists between breathing disorders and hemodynamic impairment, particularly when considering patients with CSR (Figure 1) ; in contrast, a weak nonsignificant association seems to be present when only

Discussion

This study shows that these gross abnormalities of breathing are frequently observed during the day and are largely related to the level of hemodynamic dysfunction as expressed both by prolongation of the circulation time and by reduced cardiac index and increased pulmonary arterial wedge pressure. Other parameters that only weakly and indirectly reflect hemodynamic impairment, such as LV ejection fraction or maximal work capacity, were not significantly related to an altered pattern of

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