Heart failure and central sleep apnea in the era of implantable recorders

Sleep-disordered breathing (SDB) is a complex syndrome with a high prevalence and a significant impact on the general well-being of the overall population. Heart failure (HF) is a major health issue with an increasing incidence, a high rate of hospitalizations, and high mortality in developing countries. Focusing on early recognition and management of HF comorbidities may have an important role in reducing the economic burden and public health impact of HF. The close interconnection between HF, heart rhythm disturbances, and sleep apnea is supported by the mutual risk factors such as age, smoking, obesity, and male sex. Central sleep apnea (CSA) may be considered a marker of advanced HF, often being associated with elevated pulmonary capillary wedge pressure, brain natriuretic peptide (BNP), and noradrenaline levels and with low left ventricular ejection fraction. In the same way, there is an important correlation between CSA and different types of arrhythmias. The large intraindividual rhythm variability reported in patients with SDB who underwent continuous monitoring by implantable loop recorder (ILR) demonstrated the incapacity of 24-hour and 48-hour Holter monitoring to accurately determine the incidence of cardiac arrhythmias. In patients with HF and CSA, the extended cardiac monitoring by ILR becomes compulsory because in-time interventions could be life saving, but with the absolute lack of solid evidence in this field, there is an acute need for extensive randomized trials to further highlight the potential beneficial effect of ILR monitoring in patients with CSA and HF.