Ventilatory Support, Including Adaptive Servo-Ventilation, in Patients With Sleep Apnea and Heart Failure: Impact on Mortality and Clinical Outcomes. A systematic review..

Abstract

ABSTRACT Background: Sleep-disordered breathing (SBD) frequently coexists with heart failure (HF), compounding morbidity and mortality risks. Various ventilatory support strategies are employed to treat SDB in heart failure patients. Yet, the evidence on their comparative effectiveness remains inconsistent. Objective: To evaluate the impact of different ventilatory support modalities (CPAP, BiPAP, ASV) and home oxygen therapy (HOT) on mortality and clinical outcomes in adults with concurrent heart failure and sleep apnea. Methods: A systematic review was conducted in accordance with PRISMA guidelines. Six databases were searched, yielding 2,639 records. After screening and eligibility assessment, 13 randomised controlled trials (RCTs) were included. Data extraction covered population characteristics, interventions, and various clinical outcomes. Continuous outcomes were summarised using mean differences (MD), and dichotomous outcomes were assessed using odds ratios (OR) with 95% confidence intervals (CI). Risk of bias was evaluated using the Cochrane RoB 2 tool. Results: 13 RCTs were included with a total of 3,366 participants. 6 studies included patients with HfrEF and predominant CSA, 3 included those with HfrEF and predominant OSA, 3 included those with HfrEF and unspecified/mixed SBD, and 1 included patients with HfpEF and unspecified SBD. Ventilatory support demonstrated variable effectiveness across clinical outcomes. For quality of life (QoL), changes were modest and favoured ASV or CPAP, though not uniformly. Hospitalisation rates and heart transplantation events were unaffected. Importantly, ASV was associated with increased odds of both all-cause (OR: 1.29,95% CI: 1.02-1.63) and cardiovascular mortality (OR: 1.35, 95% CI: 1.06-1.72), as reported in the largest trial. Adaptive servo-ventilation (ASV) and Home Oxygen Therapy (HOT) showed modest improvements in left ventricular ejection fraction (LVEF), with corrected MDs ranging from +5.47% to +7.10% in favour of intervention. Apnea-hypopnea index (AHI) consistently decreased across modalities, particularly with ASV, CPAP, and APAP, yielding MDs from -9.50 to -37.00 events/hour. Risks of bias were low in one study, high in two, and unclear in the remainder due primarily to poor reporting of blinding procedures. Conclusions: While ventilatory support improves surrogate outcomes like AHI and LVEF, its effect on hard outcomes such as mortality and hospitalisation is inconsistent and may vary by modality. Notably, ASV may increase mortality in selected populations, underscoring the need for individualised treatment decisions. Further high-quality RCTs are warranted to delineate the long-term benefits and harms of ventilatory intervention in this high-risk group.