Interaction of Sleep Apnea With Cardiovascular Disease

A 67-year-old man presents with a three-month history of pauses in breathing during sleep, witnessed by his wife. There is no history of snoring or difficulty falling asleep, although he has been waking up occasionally due to shortness of breath which resolves several minutes after sitting upright. He has recently been diagnosed with heart failure and his medications are aspirin, lisinopril, atorvastatin, and metoprolol. Vitals: temperature 36.6 °C (97.9 °F), left arm BP 128/78 mm Hg, pulse rate 88/min, respiration rate 16/min, body mass index 24 kg/m2. Cardiorespiratory examination demonstrates regular pulse, an S3 without any murmurs, JVP 6 cm, bibasilar crackles and trace bipedal edema. Overnight sleep oximetry reveals baseline saturations of 94% on room air with frequent desaturations (Figure 1). On polysomnography, there is characteristic Cheyne-Stokes ventilation.

Figure 1:  Overnight Sleep Oximetry at Presentation
Figure 1. Overnight Sleep Oximetry at Presentation

Which of the following is the next best therapeutic intervention for this patient?

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