Apnea, Opioids a Dangerous Mix in Acute Heart Failure Patients

Author: Nikki Keen

Anesthesiology News

Many patients who are admitted to the hospital with acute heart failure (HF) have previously undiagnosed sleep-disordered breathing (SDB), according to a new study. And even when the breathing problems are detected during their hospital stay, the patients often are still given opioids, despite their potential for causing respiratory depression and other effects that can exacerbate SDB.

The study underscored the potential dangers of such opioid use. The investigators found that approximately 26% of high-risk patients with HF and SDB who received opioids required urgent transfer to an ICU due to breathing problems and other issues, versus only 4% of patients not given the medications.

In addition, these high-risk patients were more likely to be readmitted to the hospital after 30 days than patients not given opioids, reported lead investigator Sunil Sharma, MD, the director of the West Virginia University Medical ICU, in Morgantown (Ann Am Thorac Soc 2019;16[9]:1165-1170).

“Physicians admitting patients with [HF] should be aware of the high prevalence of SDB and screen these patients for the condition,” Dr. Sharma said. “Opioids should be avoided in these high-risk patients.”

To assess the prevalence of SDB and the effect of in-hospital opioid use on the breathing disorder, Dr. Sharma and his co-investigators studied patients admitted for acute HF and who received a portable sleep study (PSS) after screening for SDB using the STOP-BANG questionnaire. The researchers then conducted a retrospective chart review evaluating use of opioids, need for escalation of care (defined as transfer to the ICU), 30-day readmission and length of stay. “Participants were considered exposed to opioids if they received at least one dose during their stay in the hospital. Opioids were generally administered after the Pss, but the exact timing was not recorded,” the authors noted.

Most patients were given opioids to manage back pain, arthritis and gout, or as part of their home medication regimen, Dr. Sharma said in an interview. The types and doses of opioids varied and included oxycodone, oxycodone and acetaminophen, and morphine sulfate.

The study involved 301 patients with acute HF admitted to the hospital during November 2016 through October 2017. Of the patients, 125 (41.5%) received opioids in the hospital and 149 (49.5%) were at high risk for SDB (apnea-hypopnea index ≥10 per hour by PSS). Among participants with SDB, 54% had predominantly central apnea/Cheyne-Stokes breathing and 46% had predominantly obstructive sleep apnea. “In this high-risk group, 47 [32%] received opioids,” the authors wrote.

Among the high-risk patients, escalation of care occurred in 12 of the 47 patients (25.5%) who received opioids compared with four of the 102 patients (3.9%) who did not (P<0.001).

Similarly, hospital readmission within 30 days was more common among high-risk patients who received opioids, occurring in seven of the 47 patients who received opioids (14.9%) versus nine of the 102 patients who did not (8.8%), although the difference was not significant (P=0.14). Mean hospital length of stay did not differ between the two groups.

“This is the first study, to our knowledge, to assess the impact of opioid administration on escalation of care in patients with undiagnosed SDB admitted for acute [HF],” Dr. Sharma said. The incidence of opioid use in these high-risk hospitalized patients “was quite high,” he said, at nearly 42%, which highlights how difficult it remains to reduce inappropriate opioid use.

Screening Urged

Opioids, particularly morphine, have been used for the acute treatment of HF to reduce anxiety and dyspnea, and to produce vasodilation. However, the results of this study call into question this long-standing practice, especially in the presence of SDB, Dr. Sharma said. Clinicians also need to heed the various ways that SDB is diagnosed and characterized, he suggested. The American Thoracic Society describes SDB as an umbrella term for several chronic respiratory conditions, often manifesting as either obstructive sleep apnea or Cheyne-Stokes respiration—a type of central apnea seen in patients with HF, as confirmed in this study.

Atul Malhotra, MD, the Peter C. Farrell Presidential Chair in Respiratory Medicine at the University of California, San Diego, said these definitions can be hard to pin down. “There is some nuance regarding different forms of central apnea,” Dr. Malhotra explained. “Cheyne-Stokes patients are thought to have high respiratory drive, whereas opioids may serve to lower drive. But both can contribute to central apnea, although mechanisms are complex and incompletely studied.” What is clear, he added, is “the opioid epidemic has taught us that many people are prescribed opioids for many reasons—including to treat breathlessness, which can be a problem in high-risk patients.”

Evidence Is Clear

Dr. Sharma acknowledged that this study had some limitations. “It is possible that these findings are unique to the underserved population at our medical center, due to poor socioeconomic status and the increased probability of chronic therapeutic opioid use and abuse. Thus, replicating these findings at a dissimilar institution is warranted.”

The good news at his hospital is that all opioids were immediately stopped in patients with SDB and HF, and patients were intubated and mechanically ventilated until respiratory failure resolved, Dr. Sharma said.

He added that the evidence for the positive effects of such interventions is clear: Patients diagnosed with SDB who are provided positive airway pressure therapy have lower readmission rates over six months after discharge, according to results of a previous study he conducted (Am J Cardiol 2016;117[6]:940-945).