Breathe Better and Preserve Heart.

HomeJournal of the American Heart AssociationAhead of PrintBreathe Better and Preserve Heart Open AccessEditorialPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citations ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toOpen AccessEditorialPDF/EPUBBreathe Better and Preserve Heart William J. Healy, Rami Khayat and Younghoon Kwon William J. HealyWilliam J. Healy https://orcid.org/0000-0003-4515-5041 , Division of Pulmonary, Critical Care, and Sleep Medicine, , Medical College of Georgia at Augusta University, , Augusta, , GA, , USA, Search for more papers by this author , Rami KhayatRami Khayat https://orcid.org/0000-0003-4240-5754 , The University of California‐Irvine Sleep Disorders Center and the Division of Pulmonary and Critical Care, , University of California‐Irvine, , Irvine, , CA, , USA, Search for more papers by this author and Younghoon KwonYounghoon Kwon *Correspondence to: Younghoon Kwon, MD, MS, Harborview Medical Center, 325 9th Ave, Box 359748, Seattle, WA 98104‐2499. Email: E-mail Address: [email protected] https://orcid.org/0000-0002-8152-9170 , Division of Cardiology, , University of Washington, , Seattle, , WA, , USA, Search for more papers by this author Originally published8 Jul 2023https://doi.org/10.1161/JAHA.123.030806Journal of the American Heart Association. 2023;0:e030806Heart failure (HF) affects >32 million people worldwide and >3 million people in the United States, with 15% annual mortality.1 It is estimated that there are >1 million admissions for HF annually.2 In a recent review of readmission data, 18.2% of patients with HF were readmitted within 30 days and 31.2% were readmitted within 90 days.3 A review of HF readmissions from 2010 to 2014 in the US Nationwide Readmission Database showed the mean±SD total cost of hospitalization for patients with a 30‐day readmission was $15 618±$25 264; and the mean±SD total cost was $11 845±$22 710 for patients without a readmission.4 HF with preserved ejection fraction (HFpEF) is a clinical syndrome in patients with symptoms of HF with a left ventricular ejection fraction ≥50% and evidence of cardiac dysfunction as the cause of symptoms.5 The pathophysiological features of HFpEF are closely linked to aging and other cardiovascular risk factors, such as obesity, hypertension, and diabetes. Not surprisingly, HFpEF is increasingly diagnosed and constitutes a significant portion of new HF diagnosis and hospital admission.6 Previous studies demonstrated the association of sleep‐disordered breathing with HF readmissions.7, 8, 9 A recent analysis of a registry of patients with HF, including patients with both HFpEF and HF with reduced ejection fraction, showed higher mortality, readmissions, and associated hospitalization costs in those with either obstructive sleep apnea (OSA) or central sleep apnea compared with those without sleep apnea.10 Conversely, observational studies have suggested a relationship between adherence to continuous positive airway pressure (CPAP) and improved outcomes in HF.11, 12 However, up until now, studies focusing on the population with HFpEF have largely been lacking in this regard. On this background, the study by Cistulli et al in this issue of the Journal of the American Heart Association (JAHA) provides new insights by describing the impact of treatment adherence to CPAP on health care use in patients with HFpEF.13 To our knowledge, this is the largest evaluation of the effect of CPAP therapy on HFpEF readmission and economic analysis yet to date. In this research, the authors use innovative investigational methods to existing administrative data sets along with rigorous statistical design to deliver relevant insights in this population of critical clinical importance.This study, funded by a major manufacturer of CPAP, creatively linked an administrative insurance claims database containing detailed clinical information on individuals with HF and OSA with treatment data from the device‐monitoring servers. With recent practice patterns and regulatory requirements, the device manufacturer's databases increasingly contain comprehensive treatment adherence patterns and efficacy information that are critically needed to understand the impact of treatment of OSA. The study applies appropriate inclusion criteria to identify records from patient with HFpEF in the insurance claims database by requiring billing codes specific to HFpEF on at least 2 separate encounter claims or 1 hospitalization for HFpEF or diastolic HF in the year before the study. The investigators addressed the precision of the OSA diagnosis by requiring a sleep test and an appropriate diagnostic code before entering their observation period. Pharmacy claims data were used to identify adherence to HF medications, particularly β‐blockers, to serve as a proxy for healthy user behavior and reduce the “health user effect.”14 The investigators successfully identified 4237 patients with OSA and HFpEF in the both databases. The records were then divided by CPAP use data from the sponsor's servers into “adherent” group, accounting for 40% of all records; nonadherent group, accounting for 30% of the records; and “intermediate adherence” group, accounting for the remaining 30% of the records. The investigators identified a comprehensive list of relevant covariates from the administrative data set and used them appropriately in the propensity score matching–based analysis to select 2 tightly matched comparison cohorts of adherents and nonadherents. The comparison showed that the adherent group had fewer emergency department visits and fewer all‐cause and cardiovascular hospitalizations. This propensity score–based matching for the 2 cohorts delivered the main finding of the study (namely, an association between adherence to CPAP and decreased health care resource use [HCRU]). Patients who were adherent to CPAP had fewer HCRU visits than nonadherent patients. Compared with the year preceding CPAP initiation, adherent patients had a 26% decrease in emergency department visits and a 57% decrease in hospitalizations. Total health care costs were lower in the adherent patients compared with those who were nonadherent, which corroborates more general studies on the effects of CPAP on cardiovascular disease–related health care expenditures.15, 16 The benefit of CPAP on HCRU was recently also shown in patients with OSA and chronic obstructive pulmonary disease (overlap syndrome) by the same group.17 OSA with CPAP therapy in other studies has been shown to reduce HCRU, although the multifactorial, cardiopulmonary, physiological mechanisms by which this process occurs are the subject of much debate.18 It may be that the benefits observed from CPAP therapy were mainly from sleep improvement rather than directly from cardiovascular optimization. Insufficient sleep has been linked to higher rates of HCRU.19 OSA is a major cause of poor quality of sleep, and this can be reversed or reduced with CPAP.There was no dose‐response demonstrated in this analysis as HCRU was similar between the intermediate CPAP user and nonadherent group, except for all‐cause hospitalization. The study does not provide treatment efficacy information (ie, residual apnea‐hypopnea index). One way to view the HCRU data across the 3 groups may be that those with better health outcome have more opportunity to adhere to treatment (ie, opposite direction). In this regard, adherent behavior to medications cannot rule out that adherence to CPAP may require better state of health or different access to resources than is the case with medications. In fact, the lack of difference in adherence to medications across the 3 groups supports this notion. It would have been informative if another analysis of these data was done splitting the cohort into deciles of adherence instead of the 3 subgroups of adherence in a subsequent study focused on revising Centers for Medicare & Medicaid Services adherence criteria. One such effort may search for a minimally effective adherence threshold to see the observed effects. The current Centers for Medicare & Medicaid Services definition of appropriate CPAP adherence most likely originates from a small study from 1993 and, later, a small, longitudinal study to assess the effect of CPAP on sleepiness.20, 21 There have been recent motions to revise it, particularly as it may adversely affect access to durable medical equipment for those with health disparities.22 Nevertheless, the limitations of the data source and the observational nature of the study preclude it from addressing this possibility, and more controlled or at least prospectively designed studies would be needed to address this question. This concern, typical for all retrospective studies, must not detract from the rigor of the propensity score matching of the 2 cohorts in this study and the relative robustness of the comparison.The analysis also provides relatively novel predictors of adherence to CPAP in this population. Of particular interest is the Medicare and Medicaid payor, age, and sex. Beyond the potential economic implication for the payor variable, it is difficult to speculate about the causes of female sex as a negative predictor and older age as a positive predictor of adherence. Acceptance of these predictors must await further research, especially prospective cohort studies. As the authors point out, the study by its nature of evaluating claims data cannot separate the cohort based on symptoms, such as sleepiness or the severity of OSA. It is unknown whether these factors modify benefits suggested in this study.This study offers an important insight given the limited data on the effect of CPAP therapy on HFpEF HRCU before this analysis. Studies evaluating actual patients with consideration of different levels of adherence to CPAP are needed to confirm this observation. The importance of these confirmatory studies cannot be overstated given the recent history of negative randomized controlled trials evaluating treatment effect that were based on even more robust observational studies in patients with OSA and cardiovascular disease and patients with HF with reduced ejection fraction and central sleep apnea.23, 24 Future studies should consider delineation of clinically relevant thresholds of CPAP use. More important, the community will have a particular interest in how the observed effects of CPAP on readmissions and costs vary according to racial and socioeconomic groups as well as the degrees of baseline sleepiness. Perhaps there are even greater effects observed in these groups who have limited access to medical care and testing. This work by Cistulli et al is an important step in further clarifying the benefit of CPAP therapy in reducing readmissions and health care costs in patients with HFpEF.DisclosuresNone.Footnotes*Correspondence to: Younghoon Kwon, MD, MS, Harborview Medical Center, 325 9th Ave, Box 359748, Seattle, WA 98104‐2499. Email: [email protected]eduSee Editorial by Cistulli et al.For Disclosures, see page 3.This article was sent to Sula Mazimba, MD, MPH, Associate Editor, for editorial decision and final disposition.References1 Redfield MM, Borlaug BA. Heart failure with preserved ejection fraction: a review. JAMA. 2023; 329:827–838. doi: 10.1001/jama.2023.2020CrossrefMedlineGoogle Scholar2 Mozaffarian D, Benjamin EJ, Go AS, Arnett DK, Blaha MJ, Cushman M, Das SR, de Ferranti S, Després J‐P, Fullerton HJ, et al. Heart disease and stroke statistics‐2016 update: a report from the American Heart Association. 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N Engl J Med. 2015; 373:1095–1105. doi: 10.1056/NEJMoa1506459CrossrefMedlineGoogle Scholar eLetters(0)eLetters should relate to an article recently published in the journal and are not a forum for providing unpublished data. Comments are reviewed for appropriate use of tone and language. Comments are not peer-reviewed. Acceptable comments are posted to the journal website only. Comments are not published in an issue and are not indexed in PubMed. Comments should be no longer than 500 words and will only be posted online. References are limited to 10. Authors of the article cited in the comment will be invited to reply, as appropriate.Comments and feedback on AHA/ASA Scientific Statements and Guidelines should be directed to the AHA/ASA Manuscript Oversight Committee via its Correspondence page.Sign In to Submit a Response to This Article Previous Back to top Next FiguresReferencesRelatedDetails Article InformationMetrics Copyright © 2023 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley BlackwellThis is an open access article under the terms of the Creative Commons Attribution‐NonCommercial‐NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non‐commercial and no modifications or adaptations are made.https://doi.org/10.1161/JAHA.123.030806PMID: 37421298 Manuscript receivedJune 2, 2023Manuscript acceptedJune 6, 2023Originally publishedJuly 8, 2023 KeywordsEditorialsheart failureobstructive sleep apneahealth care resource useheart failure with preserved ejection fractionPDF download SubjectsHeart FailureQuality and Outcomes