Quality of Life and Mental Health in Patients with Exacerbated Heart Failure: The Role of Obstructive and Central Sleep Apnea Phenotypes

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

I have received a review article entitled “Quality of Life and Mental Health in Patients with Exacerbated 2 Heart Failure: The Role of Obstructive and Central Sleep Apnea 3 Phenotypes” which is being processed by the journal Journal of Mind and Medical Sciences.

The topic of the manuscript is an interesting one and draws attention to the association between central sleep apnea syndrome and secondary cardiac decompensation. The quality of life of patients with HF is an essential element of their management because of its prognostic role in the long term.

The abstract is well structured, presents a pertinent summary of the manuscript, emphasizing the results obtained

 

Introduction – presents the main elements of the topic known in the literature. The aim of the study is mentioned in a separated section and I suggest the authors to include it at the end of the first section.

 

Materials and method - Section 3.1 - in order to facilitate the reading of the manuscript, it would be useful to make a flow chart of the study group. The ethics committee's acceptance should also be included.

Results - Table 2 - evaluated comorbidities should be presented in the section of materials and method (including criteria for definition based on clinical best practice guidelines).

Discussion - presents a comparative analysis of the data obtained with similar data from the literature, but needs expansion.

Conclusions - summarize the main issues highlighted.

In conclusion, the proposed manuscript brings to attention an extremely interesting topic, presenting scientific information with therapeutic and prognostic value.

Author Response

comment 3 - The aim of the study has now been integrated into the final paragraph of the Introduction to ensure logical continuity and better flow. The previously separated section has been removed, in line with your recommendation.

comment 4 - We have created and included a flow chart (Figure 1) to visually represent the patient screening and classification process. Additionally, we have now included a statement in the “Materials and Methods” section confirming that the study protocol was approved by the institutional ethics committee.

comment 5 - In response to your suggestion, we have added a detailed paragraph in the “Materials and Methods” section outlining the definitions of comorbidities evaluated in the study. These definitions are based on the most recent guidelines of the European Society of Cardiology (ESC) and the American Diabetes Association (ADA), and are now clearly referenced.

 comment 6 - We have significantly revised and expanded the Discussion section. Additional comparative references were added to provide broader context, and we have addressed mechanisms, prognostic implications, and recent literature on personalized approaches in the management of SA in heart failure. These changes are intended to enhance the depth and clinical relevance of the discussion.

comment 7 - The conclusion has been rewritten to better synthesize the key findings of the study, highlight the clinical relevance of the SA phenotype in heart failure, and emphasize the need for personalized, phenotype-based care. The revised version is more aligned with the expanded discussion.

Author Response File: Author Response.docx

Reviewer 2 Report

Comments and Suggestions for Authors

Dear Editor and Authors,

It was my pleasure to review this manuscript titled "Quality of Life and Mental Health in Patients with Exacerbated Heart Failure: The Role of Obstructive and Central Sleep Apnea Phenotypes" by Dr. Kalaydzhiev and colleagues from Sofia, Bulgaria.

In this single center, prospective cohort study over 3 years, the authors investigate the effect of the combination of acute cardiac failure (ACF) and obstructive sleep apnea in the quality of life and mental health of these patients. A total of 150 patients admitted with ACF a total of 81 were found to also present with obstructive (OSA) and central sleep apnea (CSA) and were evaluated. The authors found OSA patients exhibited better quality of life and mental health compared to the CSA patients.

This study is well conducted with robust inclusion and exclusion criteria, solid methodologically and relatively well written and presented. I have the following comments to make:

1. Why wasn't a power study - sample size calculation conducted considering this was a prospective study to determine the optimal number of enrolled patients? Is the number of patients now presented adequate to provide statistically meaningful results between the 2 study groups (OSA vs CSA)?
2. How do the authors explain the differences in LVH and IHD between the two groups?
3. The discussion needs a bit more discussion of the findings and the relevant history.

Kindest regards.

Comments on the Quality of English Language

Language needs some minor editing.

Author Response

Comment 1: We thank the reviewer for this valuable observation. As a single-center prospective study conducted over three years, the sample size was determined pragmatically, reflecting real-world admissions and strict inclusion criteria. While no formal power calculation was conducted in advance, statistically significant differences were observed in key outcomes (e.g., KCCQ and BDI, both p < 0.001), indicating the sample was sufficient to detect meaningful differences.

We fully acknowledge the limited group size as a study limitation—this is explicitly stated in the “Limitations” section. Given the clinical characteristics of this population, recruiting a substantially larger cohort at a single center is challenging. Nevertheless, our findings identify important trends that warrant confirmation in future multicenter studies with larger sample sizes.

Comment 2: Thank you for raising this important point. The observed differences in the prevalence of left ventricular hypertrophy (LVH) and ischemic heart disease (IHD) between the two groups are addressed in paragraph five of the Discussion section. We explain that the higher rate of LVH in OSA patients is likely related to elevated body mass index, increased prevalence of metabolic syndrome, and higher blood pressure. Conversely, the higher IHD prevalence in CSA patients aligns with lower LVEF, elevated NT-proBNP levels, and a more advanced heart failure phenotype. These interpretations are supported by current literature and reflect known pathophysiological mechanisms.

Comment 3: We thank the reviewer for this suggestion. In response, we have substantially expanded the discussion to better contextualize our findings within the existing literature, including aspects of epidemiology, pathophysiology, and mental health across SA phenotypes. We also emphasized correlations with key biomarkers and clinical indicators. All major additions have been highlighted in yellow for easier review.

Author Response File: Author Response.docx

Reviewer 3 Report

Comments and Suggestions for Authors

The authors have submitted a research article regarding an impact of obstructive and central sleep apnea (OSA and CSA, respectively) phenotypes on mental health such as depressive state in patients with acute heart failure, illustrating a reliable hypothesis that personalized medicine offers promising strategies to enhance care and outcomes since, although CSA patients exhibited more severe depression as compared with OCA patients, the OCA patients showed higher QOL as compared the CSA patients. This issue is of interest, and impact of their results is strong. My overall concern with the article describing the current available data regarding beneficial availability of the relationship between phenotypes of sleep apnea and the severity of depression offer something substantial that helps advance our understanding of effective personalized management which draws novel class of effective treatment available in clinic.

To strengthen authors’ perspectives, the authors are strongly recommended to add a “clinical trial” discussion in detail regarding known anti-depressant on better improvement in QOL, for instance. The opposite, mal-effects of expected outcomes, if known, may influence largely the authors’ perspective.

Author Response

Comment 1 - We sincerely thank the reviewer for their positive and encouraging evaluation. We appreciate the recognition of our work's relevance to clinical practice and personalized care in heart failure patients with sleep apnea.

Comment 2- Thank you for this valuable comment. In response, we have added a concise discussion on pharmacological strategies for depression in heart failure, highlighting the clinical relevance of antidepressant use and its possible impact on QoL. Although not the primary focus of our study, we recognize its importance and have addressed it in the revised manuscript. The new paragraph has been highlighted in yellow.

Author Response File: Author Response.docx

Round 2

Reviewer 3 Report

Comments and Suggestions for Authors

The authors have revised the manuscript according to the referees comments.

I have no more comments.