title: Apnea-hypopnea and desaturations in heart failure with reduced ejection fraction: Are we aiming at the right target?
abstract: BACKGROUND
  Sleep disordered breathing (SDB) is common in patients with heart failure with reduced ejection fraction (HFrEF). An increased apnea-hypopnea index (AHI) is associated with poor outcomes. We examined whether an analysis of nocturnal desaturations (NDs) can improve the risk stratification.
  
  
  METHODS
  Three-hundred seventy-six consecutive patients with stable chronic HFrEF and LVEF ≤ 45% were prospectively screened using polygraphy. Sleep apnea (SA) was defined as an AHI ≥ 15. The mean age was 59 ± 13 years, the mean LVEF was 30 ± 6%, and the median AHI was 18 [IQR: 9.33). The composite end-point of death, heart transplantation or LV assistance occurred in 98 patients (26%) within 3 years. Minimal oxygen saturation (MOS) during sleep, the number of desaturations <90%/h and the time spent with oxygen saturation <90% were significantly associated with adverse events (adjusted HR 1.25 [1.03-1.52], 1.25 [1.03-1.53], and 1.28 [1.04-1.59]), whereas the AHI was not (1.10 [0.86-1.39]). The best MOS cut-off value for poor outcomes was ≤ 88%. The patients with an MOS ≤ 88% had a significantly higher event rate (31.9%) than those with an MOS >88% (15.6%; p<0.01). The risk assessment using an MOS of ≤ 88% in addition to established prognostic markers yielded a net reclassification index (NRI) of nearly 6% and was particularly useful in the subgroup of patients with events (NRI: 8.4%).
  
  
  CONCLUSIONS
  In HFrEF patients, ND ≤ 88% appears to be predictive of adverse events, independent of the presence of SA. This suggests that the risk assessment in HFrEF should also include ND in top of AHI.
authors.affiliation: Cardiology Department, APHP, Henri-Mondor Hospital, F-94010 Créteil, France; Mondor Institute Biomedical Research (IMRB), INSERM U955, F-94010 Créteil, France; Cardiology Department, Poitiers University Hospital, F-86021 Poitiers, France. Electronic address: barnabas.gellen@hmn.aphp.fr.
authors.forename: Barnabas
authors.initials: B
authors.lastname: Gellen
authors.affiliation: Public Health Department and Clinical Research Unit (URC-Mondor), APHP, Henri-Mondor Hospital, F-94010 Créteil, France; CEpiA (Clinical Epidemiology and Ageing) EA4393, Medical School, UPEC, F-94010 Créteil, France.
authors.forename: Florence
authors.initials: F
authors.lastname: Canouï-Poitrine
authors.affiliation: Mondor Institute Biomedical Research (IMRB), INSERM U955, F-94010 Créteil, France; Physiology Department, APHP, Henri-Mondor Hospital, F-94010 Créteil, France.
authors.forename: Laurent
authors.initials: L
authors.lastname: Boyer
authors.affiliation: Physiology Department, APHP, Henri-Mondor Hospital, F-94010 Créteil, France; Physiology Department, Poitiers University Hospital, F-86021 Poitiers, France.
authors.forename: Xavier
authors.initials: X
authors.lastname: Drouot
authors.affiliation: Public Health Department and Clinical Research Unit (URC-Mondor), APHP, Henri-Mondor Hospital, F-94010 Créteil, France; CEpiA (Clinical Epidemiology and Ageing) EA4393, Medical School, UPEC, F-94010 Créteil, France.
authors.forename: Aurélie
authors.initials: A
authors.lastname: Le Thuaut
authors.affiliation: Cardiology Department, APHP, Henri-Mondor Hospital, F-94010 Créteil, France.
authors.forename: Diane
authors.initials: D
authors.lastname: Bodez
authors.affiliation: Physiology Department, APHP, Henri-Mondor Hospital, F-94010 Créteil, France.
authors.forename: Ala
authors.initials: A
authors.lastname: Covali-Noroc
authors.affiliation: Physiology Department, APHP, Bichat Hospital, F-75018 Paris, France.
authors.forename: Marie Pia
authors.initials: MP
authors.lastname: D'ortho
authors.affiliation: Cardiology Department, APHP, Henri-Mondor Hospital, F-94010 Créteil, France.
authors.forename: Soulef
authors.initials: S
authors.lastname: Guendouz
authors.affiliation: Cardiology Department, APHP, Henri-Mondor Hospital, F-94010 Créteil, France.
authors.forename: Stéphane
authors.initials: S
authors.lastname: Rappeneau
authors.affiliation: Cardiology Department, APHP, Henri-Mondor Hospital, F-94010 Créteil, France.
authors.forename: Mounira
authors.initials: M
authors.lastname: Kharoubi
authors.affiliation: Cardiology Department, APHP, Henri-Mondor Hospital, F-94010 Créteil, France; Mondor Institute Biomedical Research (IMRB), INSERM U955, F-94010 Créteil, France; CEpiA (Clinical Epidemiology and Ageing) EA4393, Medical School, UPEC, F-94010 Créteil, France.
authors.forename: Jean-Luc
authors.initials: JL
authors.lastname: Dubois-Rande
authors.affiliation: Cardiology Department, APHP, Henri-Mondor Hospital, F-94010 Créteil, France; Mondor Institute Biomedical Research (IMRB), INSERM U955, F-94010 Créteil, France; CEpiA (Clinical Epidemiology and Ageing) EA4393, Medical School, UPEC, F-94010 Créteil, France.
authors.forename: Luc
authors.initials: L
authors.lastname: Hittinger
authors.affiliation: Mondor Institute Biomedical Research (IMRB), INSERM U955, F-94010 Créteil, France; Physiology Department, APHP, Henri-Mondor Hospital, F-94010 Créteil, France.
authors.forename: Serge
authors.initials: S
authors.lastname: Adnot
authors.affiliation: Public Health Department and Clinical Research Unit (URC-Mondor), APHP, Henri-Mondor Hospital, F-94010 Créteil, France; CEpiA (Clinical Epidemiology and Ageing) EA4393, Medical School, UPEC, F-94010 Créteil, France.
authors.forename: Sylvie
authors.initials: S
authors.lastname: Bastuji-Garin
authors.affiliation: Cardiology Department, APHP, Henri-Mondor Hospital, F-94010 Créteil, France; Mondor Institute Biomedical Research (IMRB), INSERM U955, F-94010 Créteil, France.
authors.forename: Thibaud
authors.initials: T
authors.lastname: Damy
mesh_terms: D016757:Death, Sudden, Cardiac; D005260:Female; D006333:Heart Failure / Q000097:blood / Q000378:metabolism* / Q000503:physiopathology; D016027:Heart Transplantation; D006801:Humans; D008297:Male; D008875:Middle Aged; D010100:Oxygen / Q000097:blood*; D017286:Polysomnography / Q000379:methods; D011237:Predictive Value of Tests; D011379:Prognosis; D011446:Prospective Studies; D012891:Sleep Apnea Syndromes / Q000097:blood / Q000378:metabolism* / Q000503:physiopathology; D020181:Sleep Apnea, Obstructive / Q000097:blood / Q000378:metabolism* / Q000503:physiopathology; D013318:Stroke Volume / Q000502:physiology
chemical_list: D010100:Oxygen
keywords: Apnea–hypopnea index; Desaturation; Heart failure; Prognosis; Sleep disordered breathing