Recommendation 127: We suggest that patients with HFrEF and central sleep apnea (CSA) not be treated with adaptive servo-ventilator treatment (Weak Recommendation, Moderate Quality Evidence).

Recommendation 128: We suggest that physicians treating patients with HF encourage greater involvement in their programs of experienced sleep physicians and sleep laboratories with demonstrated capacity to discriminate between obstructive sleep apnea (OSA) and CSA using contemporary diagnostic standards (Weak Recommendation, Moderate Quality Evidence).

Recommendation 129: We recommend continuous positive airway pressure (CPAP) for symptom relief for patients with HF with OSA either who are limited by daytime hypersomnolence (Strong Recommendation, Moderate Quality Evidence) or whose OSA initiates arrhythmias including atrial fibrillation (Weak Recommendation, Moderate Quality Evidence).

Values and preferences: SDB treatment is complex and ongoing trials, including the ADVENT-HF trial will improve the knowledge of how best to treat patients with HF. This recommendation takes into account the value of treating OSA and the cost of diagnosis and treatment for OSA and/or CSA.

• Because the prevalence of coexisting OSA and CSA in patients managed by HF programs remains > 50% despite contemporary medical and device therapy and because most patients with HF with sleep apnea do not complain of daytime sleepiness, their evaluation should include inquiry from sleep partners into witnessed apneas, airway obstruction, and oscillating breathing patterns during sleep.
• Consider OSA in patients with HF presenting with paroxysmal or recurrent atrial fibrillation, hypertension refractory to optimal HF therapy, high body mass index (BMI), and unanticipated pulmonary hypertension or right ventricular (RV) dysfunction.
• Consider the coexistence of sleep-related breathing disorders in patients with HF when malignant ventricular arrhythmias are detected, particularly at night.