Case history
Case history
A 65-year-old man presents with insomnia and frequent awakenings at night. Two years ago he was diagnosed with coronary artery disease and had ischaemic cardiomyopathy. He has had three hospitalisations for decompensated congestive heart failure (CHF) in the past year and he is now in atrial fibrillation. He reports intermittent orthopnoea and occasional paroxysmal nocturnal dyspnoea. On further questioning he states that he frequently falls asleep during the day if he is not active. After his nocturnal awakenings, he has difficulties getting back to sleep. He had a near-miss car accident 2 weeks ago because he fell asleep while driving. His wife reports that his breathing at night has changed. She notes some periods when he stops breathing and others when his breathing is rapid and deep, and at times accompanied by snoring.
Other presentations
Even though CHF patients may exhibit obstructive sleep apnoea (OSA) alone or combined with CSA (known as mixed central apnoea), CHF is the most commonly recognised cause of CSA with Cheyne-Stokes breathing (CSB) in clinical practice. Classic CHF signs and symptoms, such as paroxysmal nocturnal dyspnoea and orthopnoea in those with heart failure, might be explained in many instances by CSA-CSB. Although patients with heart failure and sleep-disordered breathing do not commonly report sleep-related complaints such as excessive daytime sleepiness, clinical characteristics of patients with CSA-CSB may be otherwise indistinguishable from those with OSA. For example, snoring, witnessed apnoeas, excessive daytime sleepiness, male sex, and advanced age are common to both CSA and the much more prevalent OSA syndrome. Although there are no reliable pathognomonic physical and history findings, up to 16% of patients with CSA-CSB may display periodic breathing during wakefulness, and this is uncommon in OSA syndrome.[4][5] Patients with CSA-CSB are more likely to have atrial fibrillation and poorer New York Heart Association (NYHA) class, supporting the notion that CSB is a consequence of progressive heart failure and possible indicator of higher morbidity and mortality.[6] In patients classified as NYHA class II to IV, with heart failure and suspicion of sleep-disordered breathing or excessive daytime sleepiness, a formal sleep assessment is needed to distinguish OSA from CSA.[7] Though found more frequently in CHF, CSB is not pathognomonic as it can also be observed in stroke and in chronic renal failure.
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