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Volume 13 No. 11
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Accepted Papers

Scientific Investigations

Distinct Patterns of Hyperpnea During Cheyne-Stokes Respiration: Implication for Cardiac Function in Patients With Heart Failure

Elisa Perger, MD1,2; Toru Inami, MD1,2; Owen D. Lyons, MD1,2; Hisham Alshaer, MD, PhD1; Stephanie Smith, BSc1; John S. Floras, MD, DPhil1; Alexander G. Logan, MD1; Michael Arzt, MD3; Joaquin Duran Cantolla, MD4; Diego Delgado, MD1; Michael Fitzpatrick, MD5; John Fleetham, MD6; Takatoshi Kasai, MD, PhD7; R. John Kimoff, MD8; Richard S.T. Leung, MD, PhD9; Geraldo Lorenzi Filho, MD, PhD10; Pierre Mayer, MD11; Lisa Mielniczuk, MD12; Debra L. Morrison, MD13; Gianfranco Parati, MD14; Sairam Parthasarathy, MD15; Stefania Redolfi, MD, PhD16; Clodagh M. Ryan, MD1,2; Frederic Series, MD17; George A. Tomlinson, PhD1; Anna Woo, MD1; T. Douglas Bradley, MD1,2
1University Health Network/Mount Sinai Hospital, Toronto, Ontario, Canada; 2Centre for Sleep Medicine and Circadian Biology of the University of Toronto, Toronto, Ontario, Canada; 3Universitätsklinikum Regensburg, Regensburg, Germany; 4Hospital Universitario Txagorritxu, Vitoria, Spain; 5Queen's University, Kingston, Ontario, Canada; 6Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada; 7Juntendo University Hospital, Tokyo, Japan; 8McGill University Health Centre, Montreal, Quebec, Canada; 9St Michael's Hospital, Toronto, Ontario, Canada; 10Instituto do Coração do Hospital das Clínicas da FMUSP, Sao Paulo, Brazil; 11Hôpital Hôtel-Dieu du CHUM, Université de Montréal, Montreal, Quebec, Canada; 12University of Ottawa Heart Institute, Ottawa, Ontario, Canada; 13Capital District Health Authority, Halifax, Nova Scotia, Canada; 14Ospedale San Luca, Milan, Italy; 15University of Arizona College of Medicine, Tucson, Arizona; 16Groupe Hospitalier Pitie-Salpetriere Charles Fox, Paris, France; 17Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec City, Quebec, Canada

Study Objectives:

In heart failure (HF), we observed two patterns of hyperpnea during Cheyne-Stokes respiration with central sleep apnea (CSR-CSA): a positive pattern where end-expiratory lung volume remains at or above functional residual capacity, and a negative pattern where it falls below functional residual capacity. We hypothesized the negative pattern is associated with worse HF.


Patients with HF underwent polysomnography. During CSR-CSA, hyperpnea, apnea-hyperpnea cycle, and lung to finger circulation times (LFCT) were measured. Plasma N-terminal prohormone of brain natriuretic peptide (NT-proBNP) concentration and left ventricular ejection fraction (LVEF) were assessed.


Of 33 patients with CSR-CSA (31 men, mean age 68 years), 9 had a negative hyperpnea pattern. There was no difference in age, body mass index, and apnea-hypopnea index between groups. Patients with a negative pattern had longer hyperpnea time (39.5 ± 6.4 versus 25.8 ± 5.9 seconds, P < .01), longer cycle time (67.8 ± 15.9 versus 51.7 ± 9.9 seconds, P < .01), higher NT-proBNP concentrations (2740 [6769] versus 570 [864] pg/ml, P = .01), and worse New York Heart Association class (P = .02) than those with a positive pattern. LFCT and LVEF did not differ between groups.


Patients with HF and a negative CSR-CSA pattern have evidence of worse cardiac function than those with a positive pattern. Greater positive expiratory pressure during hyperpnea is likely generated during the negative pattern and might support stroke volume in patients with worse cardiac function.


A commentary on this article appears in this issue on page 1227.

Clinical Trial Registration:

The trial is registered with Current Controlled Trials (; ISRCTN67500535) and Clinical Trials (; NCT01128816).


Perger E, Inami T, Lyons OD, Alshaer H, Smith S, Floras JS, Logan AG, Arzt M, Duran Cantolla J, Delgado D, Fitzpatrick M, Fleetham J, Kasai T, Kimoff RJ, Leung RS, Lorenzi Filho G, Mayer P, Mielniczuk L, Morrison DL, Parati G, Parthasarathy S, Redolfi S, Ryan CM, Series F, Tomlinson GA, Woo A, Bradley TD. Distinct patterns of hyperpnea during Cheyne-Stokes respiration: implication for cardiac function in patients with heart failure. J Clin Sleep Med. 2017;13(11):1235–1241.

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