new ASV users

[palerider]

Has anybody had to get an echocardiogram before being prescribed an ASV in the last few years?

[BTS]

Not me ....

Edit: testing was done prior xPAP

[Pugsy]

Not me ....

Have you ever EVER had any sort of cardiac workup to check for heart function...echocardiagram is one such test, a Muga scan is another and there may be others but these are the 2 that I am aware of.
Anything that measures ejection rate or cardiac function/output?

[BTS]

Actually now thinking of it I think this may have been done prior to xPAP when figuring out what was up with me .. They did a lot of testing with electrodes on the chest and legs and then the sets of breathing tests, all within a month of each other I kinda lost track and didn't know the names of these tests .. But as far as moving up in machines they didn't do a special test moving to ASV yet they probably already had this info ...

I lose track so often with so many tests and exams from monitoring the brain tumor that I just can't remember all the names and such ...

[Pugsy]

It's possible that at some time in the not too distant past from the prescribing of an ASV machine that some sort of heart function test might have been done already and the doctor already knew the ejection rate hence no special test immediately prior to taking possession of the machine.
I am unsure as to just how long would be good enough in the past IF..big IF...anyone is even still watching ejection rates and ASV use.

It wouldn't be impossible for the echo to have been done as part of an extensive work up and the patient not remember it or even know it was being done. Now the Muga scan...that involves IV and is more definitive than the echo. I learned about it because of my mom and her chemo. She had to have one before she started chemo because the drug she takes has a known side effect of causing heart failure.
Plus she has to get a Muga scan every 3 months to watch it...and the ejection rate has dropped but still within acceptable limits at this time. She started out with disgustingly good function for an 85 year old fat woman who never gets any sort of exercise. We just did the last one last Thursday.
She's got a little room for it to drop without raising alarms. I think one more in 3 months from now and the last one at the end of chemo in late Oct.

[ShiftWorker]

I needed one before my ASV was prescribed. I do have a history of CHF so this was probably a wise move! I also have great insurance so I have been able to jump through the many obstacles placed in the ASV path.

[squid13]

My sleep doctor last year had my heart doctor run some test, I really can't remember what she was checking but everything was OK. They were checking for ventricular ejection fraction. https://aasm.org/special-safety-notice- ... t-failure/

[jnk...]

It is one factor in a multifactorial combination contraindication. So potential ASV patients do not need to be subjected to some sort of diagnostic prescreening to evaluate the possibility of the full contraindication. A contraindication in this context, as stated in the advisory, is something ALREADY known, not something that must be thoroughly investigated before a non-CHF patient should be considered a candidate for ASV.

Stated another way, I am not aware of any provision for getting an echo paid for in the simple interests of clearing ASV use for an asymtomatic non-CHF patient. If someone is already known as CHF, the latest known data may suffice for the doc's forming recommendations to the patient regarding ASV--in my opinion as a nobody, anyway.

I believe ResMed handled the study findings admirably well, but overreactions and underreactions are still inevitable no matter how well something is handled.

[timbalionguy]

Isn't ASV prescribed for patients with other problems than CHF? I'm on ASV because I experience odd patterns of central apneas, fractured sleep patterns, as well as OSA. It isn't so much the servo ventilation that I need as the machine's rapid response to breathing changes.

[palerider]

Isn't ASV prescribed for patients with other problems than CHF? I'm on ASV because I experience odd patterns of central apneas, fractured sleep patterns, as well as OSA. It isn't so much the servo ventilation that I need as the machine's rapid response to breathing changes.

Um, It's the servo ventilation that allows the rapid response to centrals.

And, yes, it's prescribed for central/complex apnea, not because of CHF.

[jnk...]

Isn't ASV prescribed for patients with other problems than CHF?

Yes. Which is a key point.

In particular, if you have a patient with symptomatic, chronic heart failure (NYHA 2-4) and with a reduced left ventricular ejection fraction (LVEF ≤ 45%), using ASV to treat their moderate to severe central sleep apnea syndrome may be harmful. . . . These results do not inform us about the effects of ASV on patients with other forms of central sleep apnea syndrome, such as that due to opiates, other medical problems, treatment emergent central sleep apnea, or primary central sleep apnea. What should you do? Only you and your patient can determine the best course of action. However, based upon the available information at this time, the following is recommended: Stop prescribing ASV to treat central sleep apnea in patients with symptomatic heart failure and LVEF<45%. Until more is known, this evidence suggests such treatment may be harmful for such patients. Before starting a patient on ASV, each patient should be assessed for the presence of heart failure. If heart failure symptoms are present, an objective assessment of LVEF is indicated to see if they are in the higher risk group. -- https://aasm.org/special-safety-notice- ... t-failure/

Color added by me.

My understanding of the above is that the contraindication involves four concurrent factors: (1) The patient is symptomatic with chronic heart failure; (2) the patient has a reduced left ventricular ejection fraction of a particular severity; (3) the patient has predominantly central sleep apnea; (4) that predominantly central sleep apnea is moderate to severe.

My further understanding of the above is that the assessment of the presence of heart failure is specifically, in this context, an assessment of symptoms and that only if symptoms are present would initiating a direct assessment of LVEF be warranted. At least, I assume that is how some docs might interpret the above, based on the wording--especially with the wiggle-room disclaimer in the above that "only you and your patient can determine the best course of action." That statement implies that some docs may feel that the circumstances of a particular case may override the specifics of the contraindication, even when all four factors are present, since it is only a suggested recommendation based on very limited early information.

What would that likely mean in actual practice? That if someone has no symptoms of heart failure, no echo would be needed. And if someone is symptomatic of heart failure, he likely would already have had an echo with available results for the prescribing doc. So requiring an echo directly in conjunction with ASV prescription would likely be a rare circumstance.

Even then, the fact is that although early findings of statistical associations without clear causation should always be taken into consideration, that information may not be enough to dictate treatment decisions to some doc/patient teams.

Then again, I've been wrong with my interpretations of doc-speak before. Sometimes often.

[palerider]

The study that kicked off the furor about LVEF < 45% was so badly done and full of so many holes, I can't find anything other than an extreme overabundance of caution as a justification for paying any attention to it at all...

http://www.sciencedirect.com/science/ar ... 9215003505

[jnk...]

The study that kicked off the furor about LVEF < 45% was so badly done and full of so many holes, I can't find anything other than an extreme overabundance of caution as a justification for paying any attention to it at all...

http://www.sciencedirect.com/science/ar ... 9215003505

I agree that nothing about the trial was originally meant to be used the way it ended up being used. I believe the question might have been whether sweeping the unexpected "results" under the rug would have been ethical, no matter how loose or limited the data. It seems to have been a lose/lose decision, and they opted for transparency, despite the limitations of what was attempted.

Some of how it all ended up may have been a bit of a backlash against the ones who were proclaiming ASV the savior of the world and overhawking it.

But from where I sit, if the AASM saw fit to take it somewhat seriously by endorsing the partial/suggested/maybe basis for a semi-contraindication, I can see why some heart docs might want to cover their own, uh, assets by at least considering the data, imperfect as it is, as worth considering.

My understanding is that ASV may be old from the perspective of the short history of PAP in sleep medicine but relatively new from the perspective of some heart docs. So it is what it is.

Another location for the same info: https://journal.chestnet.org/article/S0 ... 0350-5/pdf

[garlford]

Has anybody had to get an echocardiogram before being prescribed an ASV in the last few years?

My diagnosis and treatment was very much by the book. I'm on medicare and in Oct., 2017 during a routine primary care doctor visit, the Dr. observed that my throat was shaped in a way common to sleep apnea, so she referred me to the local sleep clinic. They had me do an in home sleep study where it was determined I had moderate sleep apnea with AHI=21. I was then scheduled for an in clinic night for titration. The sleep doctor contacted me a week later to inform me that they were unable to treat me with regular cpap because I had complex apnea with a large number of centrals. He wanted to try me on ASV but said I would need to have an echocardiogram done first because it would be dangerous to use ASV if I had CHF. I had the echocardigram done and findings were normal. Then I was scheduled for another in clinic night for titration on an ASV. They were happy with the results and sent a prescription to a local DME of my choosing. A week later I came home with a new Resmed Aircurve S10 ASV. Since then, my treated AHI is nightly less than 1, and many nights zero.

[jnk...]

. . . treatment was very much by the book. . . . said I would need to have an echocardiogram done first because it would be dangerous to use ASV if I had CHF . . .

Interesting. I wonder whose book, exactly, that was done by.