ASV and LVEF<45%

[DeepBreathing]

I just came across a Resmed press release relating to ASV treatment of people with preserved ejection fraction - preliminary results indicate positive outcomes. I don't know if there have been any follow-up studies or papers.

https://www.resmed.com/au/en/hospital/ne...comes.html

[zzzZorro]

I just came across a Resmed press release relating to ASV treatment of people with preserved ejection fraction - preliminary results indicate positive outcomes. I don't know if there have been any follow-up studies or papers.

https://www.resmed.com/au/en/hospital/ne...comes.html

Preserved EF (HFpEF) is >50%.  I read that but if you are (HFrEF) <45% you are not inclusive.

WIKI: Approximately half of people with heart failure have HFpEF, while the remainder display a reduction in ejection fraction, or heart failure with reduced ejection fraction (HFrEF).[/url]

HFpEF is characterized by abnormal diastolic function, which manifests as an increase in the stiffness of the heart's left ventricle and a decrease in left ventricular relaxation when filling with blood before the next beat. There is an increased risk for atrial fibrillation and pulmonary hypertension. Risk factors for HFpEF include hypertension, hyperlipidemia, diabetes, smoking, and obstructive sleep apnea. There is a query about the relationship between diastolic heart failure and HFpEF.

Signs and symptoms:

Clinical manifestations of HFpEF are similar to those observed in HFrEF and include shortness of breath including exercise induced dyspnea, paroxysmal nocturnal dyspnea and orthopnea, exercise intolerance, fatigue, elevated jugular venous pressure, and edema.[4]

Patients with HFpEF poorly tolerate stress, particularly hemodynamic alterations of ventricular loading or increased diastolic pressures. Often there is a more dramatic elevation in systolic blood pressure in HFpEF than is typical of HFrEF.[5]

[url=https://en.wikipedia.org/wiki/Heart_failure_with_preserved_ejection_fraction#cite_note-5]Which leads a lay person such as I to conclude HFpEF ain't good either, so funny it is OK and HFrEF isn't



Thanks

[Sleeprider]

The ST simply stands for a bilevel that has both spontaneous and timed modes. It is fixed bilevel pressure, but will change from EPAP to IPAP if it does not detect a spontaneous breath within the timing of the BPM setting. People with central and complex apnea may be induced to breathe during IPAP if pressure support is sufficient to inflate the lungs, however that much pressure support causes those people to have much higher rates of CA, so they are nearly 100% dependent on the machine to breath as CO2 washes out and the spontaneous respiratory drive is eliminated. It's rather machanical and uncomfortable. In addition, the machine has not ability meter pressure for other needs like hypopnea or flow limitation, it's the same PS all the time. This is great if you suffer from COPD or hypoventilation, in combination with OSwhich is what the machine is intended to treat.

ASV is much smarter. The Resmed uses Pacewave to track your respiratory rate and volume, then try to maintain that using pressure support on a breath by breath basis. It provides the minimum PS when there are no events, but adds a little bit as volumes drop below the Pacewave median for the last 30 minutes. That prevents hypopnea, flow limits and periodic or Cheyne-Stokes respiration. The ASV should be setup with enough PS to cause you to take a breath, but the rate is determined by your recent respiration (or a manual setting if you choose). In addition, the ASV can determine when the EPAP needs to be raised to stabilize the airway. So the current generation of Auto/Advanced ASV not only provides pressure support, it also provides variable EPAP pressure...something the SERVE-HF study did not consider.

Read Resmed's intended use for each machine and see which one applies to you.
ASV: he AirCurve 10 ASV offers truly personalized therapy for obstructive sleep apnea (OSA), central and/or mixed apneas, or periodic breathing. By treating central breathing disorders with auto-adjusting pressure support – and upper airway obstruction with auto-adjusting EPAP – the device works to rapidly stabilize respiration.

ST-A: The AirCurve™ 10 ST-A provides effective non-invasive ventilation for patients with respiratory insufficiency such as neuromuscular disease, restrictive lung disorders, severe COPD and hypoventilation syndromes. It features iVAPS (intelligent Volume-Assured Pressure Support), ResMed’s proprietary mode that automatically adapts to each patient’s changing needs, and an intelligent Backup Rate (iBR)* that maximizes their opportunity to breathe spontaneously. The AirCurve 10 ST-A includes both fixed and adjustable alarms for added safety and built-in cellular connectivity to AirView™ for remote monitoring and the ultimate in patient care.

[zzzZorro]

I just came across a Resmed press release relating to ASV treatment of people with preserved ejection fraction - preliminary results indicate positive outcomes. I don't know if there have been any follow-up studies or papers.

https://www.resmed.com/au/en/hospital/ne...comes.html

Preserved LV EF (HFpEF) is >50%.  I read that but if you are (HFrEF) <45% you are not inclusive
________________________________________________________________________________________________________________

Excellent Sleeprider.  That is bascially what I told the Primary Care Doc today, along with that IF I had to I would spring for an ASV out of my pocket, to which he said, You shouldn't have to do that- let me work on it'

Please delete the last post I made as I was in a hurry and did not have a chance to clean it up.  Will repost it here the way it was supposed to be; was to hard to read.
Thanks

________________________________________________________________________________________________________________
WIKI: Approximately half of people with heart failure have HFpEF, while the remainder display a reduction in ejection fraction, or heart failure with reduced ejection fraction (HFrEF).
 
 HFpEF is characterized by abnormal diastolic function, which manifests as an increase in the stiffness of the heart's left ventricle and a decrease in left ventricular relaxation when filling with blood before the next beat. There is an increased risk for atrial fibrillation and pulmonary hypertension. Risk factors for HFpEF include hypertension, hyperlipidemia, diabetes, smoking, and obstructive sleep apnea. There is a query about the relationship between diastolic heart failure and HFpEF.

Signs and symptoms:

Clinical manifestations of HFpEF (>50%) are similar to those observed in HFrEF (<45%) and include shortness of breath including exercise induced dyspnea, paroxysmal nocturnal dyspnea and orthopena, exercise intolerance, fatigue, elevated jugular venous pressure and edema.
Patients with HFpEF (>50%) poorly tolerate stress, particularly hemodynamic alterations of ventricular loading or increased diastolic pressures. Often there is a more dramatic elevation in systolic blood pressure in HFpEF (>50%) than is typical of HFrEF (<45%).

Which leads a lay person such as me to wonder..  ‘As ASV is OK with HFpEF why is ASV not OK with HFrEF (<45%)?? 

Thanks

[zzzZorro]

High pressure is going to be the worst for your events.  You seem to tolerate the EPR, but again, I would limit the top pressure to perhaps 16 and see how that goes.   Since my memory is not particularly good, can you review for me what we have tried so far?

You are not just SPY CAR's "Master", You are to many of us here. I also appreciate the mentorship you provide.  The short time since I have been reading this forum has given me information I seriously doubt the medical profession would ever have provided.  Facing the fact that I am an OldTimer, I can say from experience that what the medical profession has achieved through technology it has lost through personal professionalism.  Sad prophesy for the youngsters following behind.
[That said] While waiting on a legitimate determination from said medical profession, I decided to continue 'poking around' with the APAP I have.  The nocturnia that happens typically 5-6 times a night is reduced to 2-3 times no matter how lousy the AHI readings.  Believe me, that factor alone helps getting a meaningful night's sleep.  Last night I tried CPAP at a set 11 (hoping to reduce CA's) and had the feeling after a short time I was suffocating.  Shut it off for several hours then tried it again at 13.4 till morning.  Still felt like I was not getting enough 0-2 although I'm sure I was.  Even though the graph shows 13.4 it was set on 11 prior to midnight.  I'll put it here for kicks as it is laced with Apneas. https://imgur.com/a/qAfzc

If I fail to get the prescription for the ASV (...waiting...) and decide to go 'rogue', Can I titrate myself with the ASV to obtain optimal results?  Even if I can get the 'blessing' I dread a third night in the hell-hole which is probably a given!

Thanks Kindly for all the guidance

[ajack]

If you have a heart issue <45 and can't use the ASV because of cheyne stokes, etc. These seem actually protective to a heart failure patient. I would speak to a specialist, because you can possibly still use a ST or possibly VAPS

[Sleeprider]

High pressure is going to be the worst for your events.  You seem to tolerate the EPR, but again, I would limit the top pressure to perhaps 16 and see how that goes.   Since my memory is not particularly good, can you review for me what we have tried so far?

You are not just SPY CAR's "Master", You are to many of us here. I also appreciate the mentorship you provide.  The short time since I have been reading this forum has given me information I seriously doubt the medical profession would ever have provided.  Facing the fact that I am an OldTimer, I can say from experience that what the medical profession has achieved through technology it has lost through personal professionalism.  Sad prophesy for the youngsters following behind.
[That said] While waiting on a legitimate determination from said medical profession, I decided to continue 'poking around' with the APAP I have.  The nocturnia that happens typically 5-6 times a night is reduced to 2-3 times no matter how lousy the AHI readings.  Believe me, that factor alone helps getting a meaningful night's sleep.  Last night I tried CPAP at a set 11 (hoping to reduce CA's) and had the feeling after a short time I was suffocating.  Shut it off for several hours then tried it again at 13.4 till morning.  Still felt like I was not getting enough 0-2 although I'm sure I was.  Even though the graph shows 13.4 it was set on 11 prior to midnight.  I'll put it here for kicks as it is laced with Apneas. https://imgur.com/a/qAfzc

If I fail to get the prescription for the ASV (...waiting...) and decide to go 'rogue', Can I titrate myself with the ASV to obtain optimal results?  Even if I can get the 'blessing' I dread a third night in the hell-hole which is probably a given!

Thanks Kindly for all the guidance

Of course you know the "Master" came from a passing reference to a Kung Fu thing by Spy Car, and we are old guys that saw the Carradine show.  I am aware of what should work based on what I have researched, and the results we've seen here on the forum.  I am also aware of the "art" of adapting this to individual needs, and the fact that we are in the end, practitioners of trial and error.  Having followed your story, I'm sure you are on the right track for you, in spite of the comment by ajack. I know that ASV will work better than ST and CPAP which were not evaluated as alternative risks in HF-SERVE. I don't know that it is without increased or equal risk.

[ajack]

It's questionable suggesting to someone with <45% to use an ASV. The death rate risk is astronomical. It is the reason it has been a discontinued treatment and a safety notice issued. I most certainly would seek proper medical advice from a specialist. There are other machines that can be used.

[DeepBreathing]

As I read the above thread, the OP is not within the identified at-risk group. Nevertheless, qualified medical advice should always be sought as applicable.

I don't think it's fair to describe ASV as a discontinued treatment - it's certainly not. It is still the gold standard for the treatment of central and complex apnea, except for patients within the at-risk group.  I think it's over-reach to describe the risk as "astronomical". From Resmed's FAQ:

Results showed no significant difference between patients randomized to ASV and those in the control
group for the primary endpoint of time to all-cause mortality or unplanned hospitalization for worsening
heart failure (based on a hazard ratio HR=1.13 , 95 percent confidence interval [95% CI] =(0.97, 1.31)),
p-value= 0.10). However, there is a statistically significant 2.6% absolute increased annual risk of
cardiovascular mortality for those randomized to ASV therapy compared to the control group.  In the
study, 10.2% of the ASV group experienced a cardiovascular death each year compared to 7.6% of the
control group, representing a 34% relative increased risk of cardiovascular mortality (HR=1.34,
95%CI=(1.09, 1.65), p-value=0.006).*

So a larg(ish) increase from a low base. I wouldn't call that astronomical.

[zzzZorro]

It's questionable suggesting to someone with <45% to use an ASV. The death rate risk is astronomical. It is the reason it has been a discontinued treatment and a safety notice issued. I most certainly would seek proper medical advice from a specialist. There are other machines that can be used.

Thanks all!  This is what I hoped to see as "It is my butt on the line" and I want to hear 'facts'".  'Just the facts Ma-am'

ajack; I would be most interested to read the information that led you to this conclusion.  I have read the SERVE-HF (Sept-2015) study and it does not put other PAP versions into the equation for comparison with the ASV.  So the ASV is 'bad' according to SERVE-HF with the 'group' to which we refer.. comparing a control 'group' that is still expiring.. none of which were hooked-up to other PAP versions to see if they still would have punched out?  Ain't none of us going to make it out of here alive  anyway, so if it means forfeiting a few days as a trade off for a quality life it should be the patients decision not some bureaucratic boob.  At this point I at least consider the SERVE-HF to be bogus and performed for a self-serving conclusion.  If that is an improper thought please set me back on the right track with facts.

After reading ASV in CHF Recommendations too restrictive (Sept-2016)there appears to be a huge hole in the SERVE-HF 'study' (that I vented on earlier).

Please do not take affront with my questioning as it is my mission to come up with a viable conclusion for/against ASV use as in the end it is to my best interests. I doubt that a prescription will order a ASV for me as said study probably has the medical profession scared of litigation (no matter what they personally believe), so if I decide that it is the logical solution to my apnea issues it will have to be off the grid and $$ out of my pocket.