Clinical impact of screening for sleep related breathing disorders in atrial fibrillation
Introduction
Approximately 1–5% of the adult population of western countries suffer from sleep related breathing disorders (SRBD) [1], [2]. In recent years several studies demonstrated a relationship between SRBD and AF in subjects with a variety of cardiovascular conditions, including patients with congestive heart failure and patients with a primary diagnosis of AF [3], [4]. Although known risk factors, such as age, arterial hypertension and obesity are common in patients with AF and SRBD, an independent association between both conditions is suspected.
Gami et al. first described a high prevalence of sleep apnea syndrome diagnosed by questionnaire in patients with a variety of cardiovascular conditions including heart failure [3]. Recurrence of AF after electrical cardioversion has been shown to be lower in subjects with appropriate treatment for SRBD compared to those without [5]. An association between SRBD and AF has also been described in subjects without evidence of structural heart disease and normal LVEF [4] whereas another study found sleep apnea to be common in subjects with lone AF but not more common compared to control subjects without AF [6].
Proposed pathophysiological mechanisms to explain the occurrence of AF in patients with SRBD include a reduction in oxygen saturation and hypercapnic phases due to repetitive hypopneic and apneic phases leading e.g. to chemoreceptor activation and arousals with consecutive increasing sympathetic neural activity [7]. In general, SRBD is suspected in the presence of combined night- and daytime symptoms, such as nightly gasping or excessive daytime sleepiness, especially in the presence of SRBD risk factors. However, cardiologists rarely refer their AF patients for SRBD screening. This study sought to investigate the prevalence of SRBD in patients with AF using an overnight screening analysis and to quantify daytime symptoms by questionnaire in those with and without SRBD.
Section snippets
Materials and methods
Patients with paroxysmal or persistent non-valvular AF admitted to two tertiary referral hospitals due to a variety of cardiac conditions were screened for the presence of SRBD with a validated device based on trans-nasal airflow measurement [8] (MicroMesam®, ResMed GmbH & Co. KG, Switzerland). The device allows overnight respiratory pressure measurements via a nasal cannula and automated analysis of apnea, hypopnea and snoring episodes. Apnea was defined as cessation of airflow > 10 s and
Results
One-hundred-and-two patients with persistent (73%) and paroxysmal (27%) AF were screened for the presence of SRBD. Eight patients were excluded due to device malfunction (n = 1), dislocation of nasal cannula (n = 6) and hyperthyroidism (n = 1). In the remaining 94 patients (age 69 ± 11 years), 43% (40/94) were diagnosed with SRBD. Baseline characteristics of the study population are presented in Table 1.
There were no significant differences between patients with and without SRBD with respect to
Discussion
In patients with a variety of cardiovascular diseases and concomitant persistent or paroxysmal non-valvular AF we determined a prevalence of 43% of SRBD using an overnight screening device based on trans-nasal airflow pressure measurement. This finding is consistent with previous studies, which used different methods to diagnose SRBD [3], [12]. The novel finding of our study is that daytime sleepiness was low in patients with SRBD, even in subjects with high AHI.
Daytime sleepiness has been
Conclusions
SRBD is frequent in patients with AF but typical symptoms of SRBD such as daytime sleepiness and obesity as a risk factor for OSA are rare. Although every effort had been made to convince patients with SRBD to undergo PSG, only 15% underwent PSG and in only 5% of patients CPAP ventilation was started on.
Acknowledgements
The authors of this manuscript have certified that they comply with the Principles of Ethical Publishing in the International Journal of Cardiology. We would like to thank Mirjam Schefer for her tireless efforts in patient recruitment and data collection [22].
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David R. Altmann and Hans Rickli contributed equally to the work.