Can Treating Depression and Sleep Apnea Impact HF Outcomes?

For years, it has been suggested that there is a connection between depression and heart failure (HF). But now, some investigators are wondering whether diagnosing “the blues” can aid in the treatment of HF.

During a session Tuesday at the HFSA 14th Annual Scientific Sessions, entitled “Cormorbidities in Heart Failure,” presenter Mark D. Sullivan, MD, University of Washington School of Medicine, reviewed data from clinical trials in hopes of shedding the light on the question.

“Depression and heart failure can look very much the same,” said Sullivan, adding that the two conditions exist “in a mutually enforcing relationship.” For example, depression can increase the risk of developing systolic heart failure or cardiovascular disease in older adults, while HF has been shown to raise the risk of developing depression in this population

He estimated the prevalence of depression in HF patients at around 20%, which increases as HF becomes more sever. On a physiologic level, depression’s impact on HF may stem from its association with high sympathetic tone, platelet activation, elevated cortisol, or inflammation, said Sullivan. Or, the reason may stem from the fact that depressed patients are three times more likely than non-depressed patients to adhere to medications and lifestyle recommendations, and follow up with physicians, which “may account for the mortality affect.”

Among hospitalized chronic heart failure (CHF) patients with depression, the risk or mortality or rehospitalization is doubled, and patients with depressive symptoms exhibit a higher risk of death or functional decline over the next months. Some studies, according to Sullivan, question the potential role of antidepressants in increasing the risk of adverse events, but more research is needed to determine whether any such link exists.

Sullivan does, however believe that depression is critical in the management of heart failure, and because epidemiologic data has shown that depression can predict outcomes in HF patients, it is essential that the medical community further explore this relationship.

In another presentation, Stephen S. Gottlieb, MD, University of Maryland School of Medicine, discussed the prevalence, interventions, and interactions of sleep apnea and HF.

“It’s more common that you think, especially in heart failure patients,” said Gottlieb of sleep apnea, a disorder that impacts more than 12 million patients in the US. Although it’s difficult to determine the prevalence of the two types of sleep apnea—obstructive and central—in HF patients, one study of patients with a mean BMI of 30 estimated that around 26% had obstructive sleep apnea and 21% had central sleep apnea.

Research published in the New England Journal of Medicine suggested that patients who were administered CPAP was shown to reduce episodes of sleep apnea while increasing the rate of ejection fraction, meaning that it can have “beneficial effects” in HF treatment, according to Sullivan.

He also explained that the interaction between HF and sleep apnea is bi-directional; patients with heart failure are predisposed to periodic breathing, and sleep apnea exacerbates HF. But at the same time, treating sleep apnea can improve outcomes in heart failure.

Therefore, he urged clinicians to talk to their patients—as well as their partners and spouses—about how they are sleeping, and consider whether sleep apnea may be present. If there is sleep apnea, he recommended that clinicians investigate other treatments such as oxygen therapy.