Ventricular arrhythmia in heart failure patients with reduced ejection fraction and central sleep apnoea

Abstract

Cheyne-Stokes respiration (CSR) may trigger ventricular arrhythmia in patients with heart failure with reduced ejection fraction (HFrEF) and central sleep apnoea (CSA). This study determined the prevalence and predictors of a high nocturnal ventricular arrhythmia burden in patients with HFrEF and CSA (with and without CSR) and to evaluate the temporal association between CSR and the ventricular arrhythmia burden.This cross-sectional ancillary analysis included 239 participants from the SERVE-HF major sub-study who had HFrEF and CSA, and nocturnal ECG from polysomnography. CSR was stratified in ≥20% and <20% of total recording time (TRT). High burden of ventricular arrhythmia was defined as >30 premature ventricular complexes (PVCs) per hour of TRT. A sub-analysis was performed to evaluate the temporal association between CSR and ventricular arrhythmias in sleep stage N2.High ventricular arrhythmia burden was observed in 44% of patients. In multivariate logistic regression analysis, male sex, lower systolic blood pressure, non-use of antiarrhythmic medication and CSR ≥20% were significantly associated with PVC >30/h (odds ratio [95% confidence interval]: 5.49 [1.51–19.91], p=0.010; 0.98 [0.97–1.00], p=0.017; 5.02 [1.51–19.91], p=0.001; and 2.22 [1.22–4.05]; p=0.009; respectively). PVCs occurred more frequently during sleep phases with versus without CSR (median [interquartile range]: 64.6 [24.8–145.7] versus 34.6 [4.8–75.2]/h N2 sleep; p=0.006).Further mechanistic studies and arrhythmia analysis of major randomised trials evaluating the effect treating CSR on ventricular arrhythmia burden and arrhythmia-related outcomes are warranted to understand how these data match with the results of the parent SERVE-HF study.

Methodology for the nocturnal cardiac arrhythmia ancillary study of the ADVENT-HF trial in patients with heart failure with reduced ejection fraction and sleep-disordered breathing

“…Therefore we implemented stringent training of the investigators for ECG analysis according to standardized guidelines [18] . Such training of investigators has not been reported in previous studies using single-lead ECGs during PSGs in subjects with HFrEF [23] , [35] , [36] , [37] , [38] .…”

“…Employing quality assurance methods is essential in a population with HFrEF, in whom wide QRS complexes and both atrial and ventricular pacing are common [23] , [32] , in order to achieve similar inter-observer agreement on electrocardiographic variables using a single-lead ECG recorded during PSG compared to studies in which participants did not have overt heart disease [33] , [34] . Therefore we implemented stringent training of the investigators for ECG analysis according to standardized guidelines [18] .…”

“…Furthermore, in the present study standardized technical specifications and quality criteria for the detection of QRS complexes by the Holter ECG software ( Table S1 , online supplement) as well as standardized criteria for exclusion of artifacts and dropped out signals are outlined. In only one other study using a single-lead ECG derived from PSG did the authors describe their quality criteria for the analysed ECGs, but did not address technical and scoring aspects of the ECG separately since they did not use dedicated ECG-Holter software [23] . Furthermore, none of the previous studies reported explicit reasons for ECG exclusion (e.g.…”

“…To control for inter-observer variability, the investigators applied standardized quality criteria to identify difficult-to-interpret ECGs ( Table 1 ) adapted from a recently published study [23] . If no consensus was achieved by these investigators, the ECG was submitted to the arrhythmia adjudication committee (see online supplement), including an experienced electrophysiologist (STS), for final arrhythmic event determination.…”

“…Atrial rhythm was classified as sinus, atrial flutter or atrial fibrillation (AF) or not classifiable (e.g., in case of paced ventricular rhythm). Paced rhythms were classified as either atrial, ventricular or atrio-ventricular sequential [23] .…”