Sleep-disordered breathing (SDB) is critically associated with cardiovascular mortality and morbidity, especially in patients with heart failure (HF). However, the majority of SDB patients remain undiagnosed. In contrast, abnormality in heart rate variability has been reported in patients with SDB. To explore an efficient electrocardiogram (ECG)-based screening tool for SDB, we examined the usefulness of cyclic variation in heart rate score (CVHRS) by Holter ECG in subjects with HF.
METHODS:
In this study, 102 subjects with HF were enrolled. We simultaneously performed Holter ECG with overnight portable sleep monitoring, and we measured the respiratory disturbance index (RDI) and CVHRS. We determined the temporal position of the individual dips comprising the CVHRS using time-domain methods. CVHRS was measured as cyclic and autocorrelated dips in smoothed interbeat interval time series.
RESULTS:
There were 25 subjects with severe SDB (RDI ≥ 30 events/h) and 77 subjects with none-to-moderate SDB (0 ≤ RDI < 30 events/h). There was a significant positive correlation between CVHRS and RDI (r = 0.60, P < .001). In receiver operating characteristic analysis, CVHRS (cutoff of 30 events/h) identified severe SDB with a sensitivity of 82%, a specificity of 77%, and an area under the curve of 0.83.
CONCLUSIONS:
CVHRS determined by Holter ECG is a useful screening index for severe SDB in subjects with HF.
Writing Committee Members, YancyCW, JessupM, BozkurtB, ButlerJ, CaseyDEJr, et al. 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. Circulation, 2013; 128(16):e240–e327.
2.
BitterT, WesterheideN, PrinzC, HossainMS, VogtJ, LangerC, et al. Cheyne-Stokes respiration and obstructive sleep apnoea are independent risk factors for malignant ventricular arrhythmias requiring appropriate cardioverter-defibrillator therapies in patients with congestive heart failure. Eur Heart J, 2011; 32(1):61–74.
3.
YamadaS, SuzukiH, KamiokaM, SuzukiS, KamiyamaY, YoshihisaA, et al. Sleep-disordered breathing increases risk for fatal ventricular arrhythmias in patients with chronic heart failure. Circ J, 2013; 77(6):1466–1473.
4.
JavaheriS, ShuklaR, ZeiglerH, WexlerL. 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(20):2028–2034.
5.
WangH, ParkerJD, NewtonGE, FlorasJS, MakS, ChiuKL, et al. Influence of obstructive sleep apnea on mortality in patients with heart failure. J Am Coll Cardiol, 2007; 49(15):1625–1631.
6.
KoyamaT, WatanabeH, IgarashiG, TeradaS, MakabeS, ItoH. Short-term prognosis of adaptive servo-ventilation therapy in patients with heart failure. Circ J, 2011; 75(3):710–712.
7.
MiyataM, YoshihisaA, SuzukiS, YamadaS, KamiokaM, KamiyamaY, et al. Adaptive servo ventilation improves Cheyne-Stokes respiration, cardiac function, and prognosis in chronic heart failure patients with cardiac resynchronization therapy. J Cardiol, 2012; 60(3):222–227.
8.
OwadaT, YoshihisaA, YamauchiH, IwayaS, SuzukiS, YamakiT, et al. Adaptive servoventilation improves cardiorenal function and prognosis in heart failure patients with chronic kidney disease and sleep-disordered breathing. J Card Fail, 2013; 19(4):225–232.
9.
YoshihisaA, SuzukiS, YamakiT, SugimotoK, KuniiH, NakazatoK, et al. Impact of adaptive servo-ventilation on cardiovascular function and prognosis in heart failure patients with preserved left ventricular ejection fraction and sleep-disordered breathing. Eur J Heart Fail, 2013; 15(5):543–550.
10.
JavaheriS, CarefEB, ChenE, TongKB, AbrahamWT. Sleep apnea testing and outcomes in a large cohort of Medicare beneficiaries with newly diagnosed heart failure. Am J Respir Crit Care Med, 2011; 183(4):539–546.
11.
Heart rate variability. Standards of measurement, physiological interpretation, and clinical use. Task Force of the European Society of Cardiology and the North American Society of Pacing and Electrophysiology. Eur Heart J, 1996; 17(3):354–381.
12.
SzollosiI, KrumH, KayeD, NaughtonMT. Sleep apnea in heart failure increases heart rate variability and sympathetic dominance. Sleep, 2007; 30(11):1509–1514.
13.
AbdullahH, MaddageNC, CosicI, CvetkovicD. Cross-correlation of EEG frequency bands and heart rate variability for sleep apnoea classification. Med Biol Eng Comput, 2010; 48(12):1261–1269.
14.
GuilleminaultC, ConnollyS, WinkleR, MelvinK, TilkianA. Cyclical variation of the heart rate in sleep apnoea syndrome. Mechanisms, and usefulness of 24 h electrocardiography as a screening technique. Lancet, 1984; 1(8369):126–131.
15.
LeungRS, FlorasJS, Lorenzi-FilhoG, RankinF, PictonP, BradleyTD. Influence of Cheyne-Stokes respiration on cardiovascular oscillations in heart failure. Am J Respir Crit Care Med, 2003; 167(11):1534–1539.
16.
SpicuzzaL, BernardiL, CalciatiA, Di MariaGU. Autonomic modulation of heart rate during obstructive versus central apneas in patients with sleep-disordered breathing. Am J Respir Crit Care Med, 2003; 167(6):902–910.
17.
PenzelT, McNamesJ, MurrayA, de ChazalP, MoodyG, RaymondB. Systematic comparison of different algorithms for apnoea detection based on electrocardiogram recordings. Med Biol Eng Comput, 2002; 40(4):402–407.
18.
KhandokerAH, PalaniswamiM, KarmakarCK. Support vector machines for automated recognition of obstructive sleep apnea syndrome from ECG recordings. IEEE Trans Inf Technol Biomed, 2009; 13(1):37–48.
19.
MendezMO, CorthoutJ, Van HuffelS, MatteucciM, PenzelT, CeruttiS, BianchiAM. Automatic screening of obstructive sleep apnea from the ECG based on empirical mode decomposition and wavelet analysis. Physiol Meas, 2010; 31(3):273–289.
20.
BabaeizadehS, WhiteDP, PittmanSD, ZhouSH. Automatic detection and quantification of sleep apnea using heart rate variability. J Electrocardiol, 2010; 43(6):535–541.
21.
SomersVK, WhiteDP, AminR, AbrahamWT, CostaF, CulebrasA, et al. Sleep apnea and cardiovascular disease. An American Heart Association/American College of Cardiology Foundation Scientific Statement from the American Heart Association Council for High Blood Pressure Research Professional Education Committee, Council on Clinical Cardiology, Stroke Council, and Council on Cardiovascular Nursing in collaboration with the National Heart, Lung, and Blood Institute National Center on Sleep Disorders Research (National Institutes of Health). Circulation, 2008; 118(10):1080–1111.
22.
MiletinMS, HanlyPJ. Measurement properties of the Epworth sleepiness scale. Sleep Med, 2003; 4(3):195–199.
23.
SilberMH, Ancoli-IsraelS, BonnetMH, ChokrovertyS, Grigg-DambergerMM, HirshkowitzM, et al. The visual scoring of sleep in adults. J Clin Sleep Med, 2007; 3(2):121–131.
24.
BerryRB, BudhirajaR, GottliebDJ, GozalD, IberC, KapurVK, et al. Rules for scoring respiratory events in sleep: update of the 2007 AASM Manual for the Scoring of Sleep and Associated Events. Deliberations of the Sleep Apnea Definitions Task Force of the American Academy of Sleep Medicine. J Clin Sleep Med, 2012; 8(5):597–619.
25.
BianchiAM, MainardiL, PetrucciE, SignoriniMG, MainardiM, CeruttiS. Time-variant power spectrum analysis for the detection of transient episodes in HRV signal. IEEE Trans Biomed Eng, 1993; 40(2):136–144.
26.
LeveyAS, CoreshJ, GreeneT, StevensLA, ZhangYL, HendriksenS, et al. Using standardized serum creatinine values in the modification of diet in renal disease study equation for estimating glomerular filtration rate. Ann Intern Med, 2006; 145(4):247–254.
27.
RudskiLG, LaiWW, AfilaloJ, HuaL, HandschumacherMD, ChandrasekaranK, et al. Guidelines for the echocardiographic assessment of the right heart in adults: a report from the American Society of Echocardiography endorsed by the European Association of Echocardiography, a registered branch of the European Society of Cardiology, and the Canadian Society of Echocardiography. J Am Soc Echocardiogr, 2010; 23(7):685–713.
28.
YuminoD, KasaiT, KimmerlyD, AmirthalingamV, FlorasJS, BradleyTD. Differing effects of obstructive and central sleep apneas on stroke volume in patients with heart failure. Am J Respir Crit Care Med, 2013; 187(4):433–438.
29.
FranklinKA, SandströmE, JohanssonG, BâlforsEM. Hemodynamics, cerebral circulation, and oxygen saturation in Cheyne-Stokes respiration. J Appl Physiol, 1997; 83(4):1184–1191.
30.
ThomasRJ, MietusJE, PengCK, GilmartinG, DalyRW, GoldbergerAL, GottliebDJ. Differentiating obstructive from central and complex sleep apnea using an automated electrocardiogram-based method. Sleep, 2007; 30(12):1756–1769.
31.
Yagishita-TagawaY, YuminoD, TakagiA, SerizawaN, HagiwaraN. Association between sleep apnea and overnight hemodynamic changes in hospitalized heart failure patients with and without paroxysmal nocturnal dyspnea. J Cardiol, 2013; 61(5):348–353.
32.
BadrMS. Central sleep apnea. Prim Care, 2005; 32(2):361–374.
33.
RocheF, CelleS, PichotV, BarthélémyJC, SforzaE. Analysis of the interbeat interval increment to detect obstructive sleep apnoea/hypopnoea. Eur Respir J, 2007; 29(6):1206–1211.
34.
HayanoJ, WatanabeE, SaitoY, SasakiF, FujimotoK, NomiyamaT, et al. Screening for obstructive sleep apnea by cyclic variation of heart rate. Circ Arrhythm Electrophysiol, 2011; 4(1):64–72.
35.
FauchierL, BabutyD, CosnayP, AutretML, FauchierJP. Heart rate variability in idiopathic dilated cardiomyopathy: characteristics and prognostic value. J Am Coll Cardiol, 1997; 30(4):1009–1014.
36.
van de BorneP, MontanoN, PaganiM, OrenR, SomersVK. Absence of low-frequency variability of sympathetic nerve activity in severe heart failure. Circulation, 1997; 95(6):1449–1454.
37.
HirschAT, DzauVJ, CreagerMA. Baroreceptor function in congestive heart failure: effect on neurohumoral activation and regional vascular resistance. Circulation, 1987; 75(5 Pt 2):IV36–IV48.
38.
UenoLM, DragerLF, RodriguesAC, RondonMU, MathiasWJr, KriegerEM, et al. Day-night pattern of autonomic nervous system modulation in patients with heart failure with and without sleep apnea. Int J Cardiol, 2011; 148(1):53–58.
39.
TamuraA, KawanoY, NaonoS, KotokuM, KadotaJ. Relationship between beta-blocker treatment and the severity of central sleep apnea in chronic heart failure. Chest, 2007; 131(1):130–135.
40.
SasaiT, MatsuuraM, InoueY. Change in heart rate variability precedes the occurrence of periodic leg movements during sleep: an observational study. BMC Neurol, 2013; 13(1):139.
