American Thoracic Society patient education

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American Thoracic Society patient education

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American Thoracic Society







What is Sleep Disordered Breathing (SDB)?

SDB is a general term used to describe various different 

abnormalities in breathing pattern which occur during sleep, 

including obstructive and central sleep apnea. Obstructive 

sleep apnea (OSA) is a common disorder which affects rough-

ly 10% of the US population and approximately 1/3 of people 

with congestive heart failure. OSA patients have reductions 

or stoppages in airflow despite ongoing respiratory efforts. In 

contrast, central sleep apnea (CSA) patients have reductions 

or stoppages in airflow without respiratory effort. Cheyne 

Stokes respirations (CSR) is a special form of CSA which is 

seen in roughly 1/3 people with congestive heart failure. OSA 

and CSA sometime occur in the same individuals either at dif-

ferent times of the night or from one night to the next. Thus, 

the term SDB is used to refer to both OSA and CSA together 

since the distinction is sometimes hard to make.

Is SDB bad for my health?

Most, but not all, studies suggest that heart failure patients 

with SDB have worse prognosis than matched heart fail-

ure patients without SDB. This means they can have more 

symptoms and poorer health and disease control. Patients 

with either OSA or CSA are thought to be at risk of increased 

mortality and risk of hospitalizations. There have been some 

theories suggesting that CSR may be beneficial for certain pa-

tients, but this view has not been widely accepted by experts.

What is the new medical research study called 

SERVE-HF all about?

Results of a new medical research study were reported at 

the recent American Thoracic Society medical conference 

in May 2015 in Denver CO. The study involved over 1300 pa-

tients with CHF and CSA along with a specific type of heart 

problem (impaired left ventricular systolic function, ejection 

fraction ≤45%). The results led to a field safety notice which 

had some concerning findings. The study was a randomized 

trial which was sponsored by the company ResMed com-

paring adaptive servo-ventilation (ASV) with usual medical 

therapy. The primary outcome was a composite measure of 

either mortality or unplanned hospitalization which showed 

no difference between groups. Of note, sudden cardiac death 

was more common in the ASV group as compared to the 

medical therapy group (10% vs. 7.5%, p<0.05); this difference 

was considered to be not likely due to chance alone. Experts 

are currently not clear why this risk occurred. Based on this 

finding, patients who are using ASV are advised to talk with 

their health care provider about stopping it. 

Should I stop my ASV?

It depends, talk to your health care provider. Many patients 

have received ASV for other reasons that were not studied 

in the SERVE-HF study. For example, ASV has been used for 

complex sleep apnea (treatment emergent central apnea), 

narcotic induced central apnea, SDB in people with CHF with 

preserved ejection fraction. There is no good reason at this 

time to stop using ASV for these conditions. For patients 

who have a new diagnosis of CSA with impaired left ventricu-

lar systolic function, we would not recommend starting ASV 

at this time. For patients with CSA and CHF with reduced 

ejection fraction, we believe the decision needs to be 

individualized in communication with your specialist. Some 

patients feel much better on ASV and are willing to take a 

small potential risk of sudden cardiovascular death because 

of their improved quality of life from ASV. Some patients 

who are struggling with ASV may be very willing to give it up

since they may not be using it very much in the first place. 

For patients who are on ASV with CHF, a careful medical 

evaluation would be worthwhile. Optimization of medical 

therapy would be beneficial since withdrawing ASV abruptly 

may also have risks, particularly in patients whose condition 

is not controlled optimally. In some cases, transitioning pa-

tients from ASV to standard CPAP could also be considered. 

For example, patients who have never been on CPAP who 

have OSA may not need ASV and in such cases transition-

ing to CPAP would seem reasonable. In patients who have 

previously failed CPAP, ASV withdrawal could be considered, 

Use of Adaptive Servo-ventilation (ASV) for People 

With Heart Failure and Trouble Sleeping

People with heart failure often have trouble breathing 

while asleep. Studies have shown that roughly 2 out of 

every 3 patients with heart failure will have some sort 

of breathing problem while asleep (known as sleep 

disordered breathing).

Am J Respir Crit Care Med Vol. 192, P1-P2, 2015

ATS Patient Education Series © 2015 American Thoracic Society

American Thoracic Society



Am J Respir Crit Care Med Vol. 192, P1-P2, 2015

ATS Patient Education Series © 2015 American Thoracic Society

although the optimal management of these patients remains 

unclear. Treatment options such as oxygen and medicines 

that help the body clear extra fluids, such as acetazolamide, 

could be alternatives you can discuss with your health care 

provider. Careful monitoring of electrolytes, such as potassi-

um and magnesium levels, would also seem reasonable. Talk 

to your specialist before you decide what to do.

Why is ASV a problem?

The findings of this new study were unexpected and thus 

experts have been discussing why this finding might have 


1.  The possibility exists that the findings were by chance 

(bad luck) and that more studies will be needed before 

we can believe that ASV is really harmful. Sometimes 

imbalances occur at randomization such that one group 

is sicker than the other by chance and thus the poor out-

comes may relate to patient characteristics rather than a 

real effect of the ASV therapy. 

2.  There may be direct effects of ASV which could affect 

breathing pattern or heart function, although standard 

CPAP has similar effects and is not thought to carry the 

same risks. The ASV settings can sometimes lead to 

hyperventilation (breathing too much) which can lead to 

respiratory alkalosis (low carbon dioxide, high pH in the 

body) and could have associated electrolyte abnormali-

ties (such as potassium level). These metabolic changes, 

if present, could trigger arrhythmias which can lead to 

sudden cardiac death. 

3.  Another possibility is indirect effects of ASV. For example, 

changes in medications or health behaviors can occur 

in any un-blinded study which can be important. For 

example, if patients stop taking their medications, or start 

excessive daily activities abruptly, or the doctor changes 

their medications, these effects could be problematic at 

least for some patients.

Because the details are unclear, we do not know exactly 

why cardiac sudden death occurred in some patients on ASV 

therapy. We have speculated here, but await further data.

What if I have a different brand of ASV machine?

Several companies make ASV machines including ResMed, 

Philips Respironics etc. The SERVE-HF study involved the 

ResMed ASV machine (adaptive servo-ventilation). Philips 

Respironics released a statement suggesting their device 

(auto servo-ventilation) is likely to have similar effects to 

that of ResMed given that the algorithms are similar. Thus, 

the type of device probably does not make a major differ-

ence from the standpoint of what is recommended. 

I have heart failure and don’t feel great—should I see 

a sleep or lung specialist at this point?

Yes, the new findings suggest we need to be cautious about 

treating CSR, but there are still many contributors to sleepiness 

and fatigue that are common in heart failure which your health 

care provider can address. For example, insomnia, leg move-

ments, obstructive sleep apnea, and other factors may contrib-

ute to feeling poorly and should still be identified and treated. 

I am on PAP (CPAP or APAP) but don’t have heart 

failure, am I OK?

The new findings relate only to patients with congestive 

heart failure with impaired left ventricular function. Obstruc-

tive sleep apnea remains an important disease with import-

ant effects on health. You should continue CPAP therapy as 

it should make you feel better and may protect your heart. 

APAP (auto-titration PAP) is not related to ASV and thus 

there is no cause for concern based on the new findings.


  Atul Malhotra, MD. 


 Marianna Sockrider MD, DrPH

Acknowledgment: We appreciate Dr. Kevin Wilson’s contri-

bution to the Glossary of Terms

This information is a public service of the American Thoracic Society.  

The content is for educational purposes only. It should not be used as a substitute 

for the medical advice of one’s health care provider.

Additional Resources:

American Thoracic Society

American Heart Association

American Academy of Sleep Medicine

Glossary of Terms

Congestive Heart Failure—a build-up of fluid in the body 

due to the heart not working well

Respiratory effort—taking a breath; breathing

Ejection fraction—measure of how well the heart pumps 


Randomized trial—type of research study in which pa-

tients are randomly assigned to one treatment or another

Un-blinded study—type of research study in which both 

the patients and researchers know which treatment they 

are receiving

Field safety notice—medical care notice sent out to health 

care providers and institutions about a safety issue

Primary outcome—the main outcome of a research study

Composite measure—an outcome of a research study that 

combines two or more measurements

Optimized medical therapy—using the best available 

medicine(s) or other treatment to help a person manage 

a health problem/disease

Arrhythmias—abnormal heart rhythm

Sudden cardiac death—unexpected death due to heart 


  • What is Sleep Disordered Breathing (SDB)
  • Is SDB bad for my health
  • What is the new medical research study called SERVE-HF all about
  • What if I have a different brand of ASV machine
  • I have heart failure and don’t feel great—should I see a sleep or lung specialist at this point
  • I am on PAP (CPAP or APAP) but don’t have heart failure, am I OK
  • Author
  • American Thoracic Society

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