An overview of central sleep apnea with heart failure

INTRODUCTION: Central sleep apnea (CSA) affects up to one-third of patients with heart failure (HF) and is linked to sympathetic activation, arrhythmias, impaired quality of life, and worse prognosis. Understanding epidemiology, mechanisms, and evolving therapies is essential as management recommendations are rapidly changing. AREAS COVERED: This review synthesizes data retrieved from a PubMed database search on CSA prevalence across HF phenotypes, delineates pathophysiology, and appraises therapies. We performed a structured search for randomized trials, large observational studies, meta-analyses, and recent guidance, with focused appraisal of the latest statements from the American Academy of Sleep Medicine (AASM) and the European Respiratory Society (ERS). EXPERT OPINION: The field is shifting from one size fits all apnea-hyponea index (AHI) suppression to phenotype-guided care, prioritizing patient centered and cardiac outcomes. Integrating endotyping, remote monitoring, and HF co-management is key. Major gaps include optimal patient selection, long-term cardiovascular endpoints, and harmonization of guideline recommendations. If optimization of HF therapy and a continuous positive airway pressure (CPAP) trial fail to improve symptoms, adaptive servoventilation (ASV) becomes the preferred therapeutical option.