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Lancet Respir Med. 2016 Nov;4(11):873-881. doi: 10.1016/S2213-2600(16)30244-2. Epub 2016 Aug 31.

Mechanisms underlying increased mortality risk in patients with heart failure and reduced ejection fraction randomly assigned to adaptive servoventilation in the SERVE-HF study: results of a secondary multistate modelling analysis.

Author information

1
Department of Medical Biometry and Epidemiology, University Medical Center Eppendorf, Hamburg, Germany; Department for Epidemiology, University Medical Center Groningen, Groningen, Netherlands. Electronic address: c.h.zu.eulenburg@umcg.nl.
2
Department of Medical Biometry and Epidemiology, University Medical Center Eppendorf, Hamburg, Germany.
3
ResMed Science Center, ResMed Germany Inc, Martinsried, Germany; Sleep and Ventilation Center Blaubeuren, Respiratory Center Ulm, Ulm, Germany.
4
Department of Medicine I and Comprehensive Heart Failure Center, University Hospital and University of Würzburg, Würzburg, Germany.
5
University Paris Diderot, Sorbonne Paris Cité, Hôpital Bichat, Explorations Fonctionnelles, DHU FIRE, Assistance Publique Hôpitaux de Paris, Paris, France.
6
Heart Center, University of Cologne, Cologne, Germany.
7
Centre Hospitalier Universitaire de Grenoble, and Université Grenoble Alpes, HP2 laboratory to CHU, Grenoble, France.
8
NIHR Respiratory Biomedical Research Unit, Royal Brompton & Harefield NHS Foundation Trust, London, UK.
9
Mayo Clinic and Mayo Foundation, Rochester, MI, USA.
10
Inserm, Université de Lorraine, Centre Hospitalier Universitaire Nancy, Nancy, France.
11
Department of Pneumology, Ruhrlandklinik, West German Lung Center, University Hospital Essen, University Duisburg-Essen, Essen, Germany.
12
Imperial College London, London, UK.

Abstract

BACKGROUND:

A large randomised treatment trial (SERVE-HF) showed that treatment of central sleep apnoea with adaptive servoventilation in patients with heart failure and reduced ejection fraction (HFREF) increased mortality, although the analysis of the composite primary endpoint (time to first event of death from any cause, life-saving cardiovascular intervention, or unplanned hospital admission for worsening heart failure) was neutral. This secondary multistate modelling analysis of SERVE-HF data investigated associations between adaptive servoventilation and individual components of the primary endpoint to try to better understand the mechanisms underlying the observed increased mortality.

METHODS:

In SERVE-HF, participants were randomly assigned to receive either optimum medical treatment for heart failure alone (control group), or in combination with adaptive servoventilation. We analysed individual components of the primary SERVE-HF endpoint separately in a multistate model, with and without three covariates suggested for effect modification (implantable cardioverter defibrillator at baseline, left ventricular ejection fraction [LVEF], and proportion of Cheyne-Stokes Respiration [CSR]). The SERVE-HF study is registered with ClinicalTrials.gov, number NCT00733343.

FINDINGS:

Univariate analysis showed an increased risk of both cardiovascular death without previous hospital admission (hazard ratio [HR] 2·59, 95% CI 1·54-4·37, p<0·001) and cardiovascular death after a life-saving event (1·57, 1·01-2·44, p=0·045) in the group receiving adaptive servoventilation versus the control group. Adjusted analysis showed that the increased risk attributed to adaptive servoventilation of cardiovascular death without previous hospital admission for worsening heart failure varied with LVEF and that the risk attributed to adaptive servoventilation of hospital admission for worsening heart failure varied with LVEF and CSR. In patients with LVEF less than or equal to 30%, use of adaptive servoventilation markedly increased the risk of cardiovascular death without previous hospital admission (HR 5·21, 95% CI 2·11-12·89, p=0·026).

INTERPRETATION:

Adaptive servoventilation is associated with an increased risk of cardiovascular death in patients with heart failure and reduced ejection fraction (LVEF ≤45%) treated for predominant central sleep apnoea. This multistate modelling analysis shows that this risk is increased for cardiovascular death in patients not previously admitted to hospital, presumably due to sudden death, and in patients with poor left ventricular function.

FUNDING:

ResMed.

PMID:
27592224
DOI:
10.1016/S2213-2600(16)30244-2
[Indexed for MEDLINE]
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