THE LINK BETWEEN OBSTRUCTIVE SLEEP APNEA AND ATRIAL

FIBRILLATION

Jennifer D. Butler MDPiedmont HenryPulmonary, CCM & Sleep Medicine

I HAVE NO DISCLOSURES

OUTLINE

• What is OSA?

• Describe the mechanisms that link OSA and AF.

• Clinical Outcomes And the Effect Of CPAP Therapy on Afib recurrence.

• Screening tools, diagnostic testing and treatment options

DEFINITION OF OSA

• Obstructive sleep apnea (OSA), characterized by recurrent partial or complete collapse of the upper airway during sleep.

• This leads to partial reductions (hypopneas) and complete pauses (apneas) in breathing that last at least 10 seconds during sleep and can lead to abrupt reductions in blood oxygen saturation.

• A common measurement of sleep apnea is the apnea-hypopnea index (AHI). This is an average that represents the combined number of apneas and hypopneas that occur per hour of sleep.

• Mild OSA: AHI of 5-15

Involuntary sleepiness during activities that require little attention, such as watching TV or reading

• Moderate OSA: AHI of 15-30

Involuntary sleepiness during activities that require some attention, such as meetings or presentations

• Severe OSA: AHI of more than 30

Involuntary sleepiness during activities that require more active attention, such as talking or driving

High risk

PREVALENCE OF SLEEP-DISORDERED BREATHING AMONG

U.S. ADULTS

OBESITY IS ON THE RISE

Sleep Med Clin. 2009 Mar 1; 4(1): 37–46.doi: 10.1016/j.jsmc.2008.11.003

LET’S TALK ABOUT MECHANISMS

ASSOCIATION BETWEEN AF AND SLEEP APNEA

By using low‐level transcutaneous electrical stimulation (LL‐TS) of the auricular branch of the vagus nerve at the tragus to modulate the function of the intrinsic and extrinsic CANS, is a potential noninvasive approach for treating OSA‐induced AF

ASSOCIATION BETWEEN AF AND SLEEP APNEA

EFFECT OF ACUTE OSA ON LA DIAMETER

Am J Respir Crit Care Med. 2006 Apr 15; 173(8): 910–916. Published online 2006 Jan 19. doi: 10.1164/rccm.200509-1442OC

CLINICAL OUTCOMES AND EFFECT OF CPAP TREATMENT

Untreated OSA

More catheter ablation procedural failures Associated with increased AF recurrence after electrical

cardioversion

Circulation. 2003 May 27;107(20):2589-94. Epub 2003 May 12.Obstructive sleep apnea and the recurrence of atrial fibrillation.Kanagala R1, Murali NS, Friedman PA, Ammash NM, Gersh BJ, Ballman KV, Shamsuzzaman AS, Somers VK

• Total of 39 patients

• 27 in the untreated OSA

• 12 in the treated OSA

• The recurrence rate of AF at 12 months in untreated subjects with OSA was 82%.

• 42% in the treated OSA group (P0.013)

• 53% in the control group without known OSA (P0.009)

• Untreated group had a lower BMI (P0.39), less history of hypertension

(P0.07), and better functional capacity as defined byNYHA class (P0.11) than treated OSA patients

• The incidence of OSA in patients undergoing PVAI in this series was higher than that found in the general population.

• OSA was independently associated with PVAI failure.

• All patients treated with CPAP had higher PVAI success rates than patients not on CPAP.

• Patients with OSA had more non-PV triggers.

• Non-PV triggers, coronary artery disease, and AF type were predictors of procedural failure.

• Patients not treated with CPAP and who had non-PV triggers were more likely to fail

the procedure

Treatment with CPAP reduced the rate of AF recurrence (79% versus 68%, p=0.003)

LET’S TALK ABOUT SCREENING

SCREENING ACCORDING THE AMERICAN ACADEMY OF SLEEP MEDICINE

Risk groups • People who are overweight (Body Mass Index of 25 to 29.9) and obese (Body Mass Index of 30

and above) • Men and women with large neck sizes: 17 inches or more for men, 16 inches or more for women • Middle-aged and older men, and post-menopausal women • Ethnic minorities • People with abnormalities of the bony and soft tissue structure of the head and neck • Adults and children with Down Syndrome • Children with large tonsils and adenoids • Anyone who has a family member with OSA • People with endocrine disorders such as Acromegaly and Hypothyroidism • Smokers • Those suffering from nocturnal nasal congestion due to abnormal morphology, rhinitis or both.

SCREENING TOOL: STOP-BANG

EPIC

EPWORTH

4-V TOOL

• 4-V is an equation consisting of four variables including gender, BMI, blood pressure, and self-reported snoring.

• The equation is as follows:OSA = (gender*4) + (BMI category value) + (BP category value) + (snoring*4)

DIAGNOSIS

• Overnight video polysomnography, typically conducted in a sleep laboratory.

• Home sleep studies have obtained FDA approval for diagnosis of sleep apnea.

• Some home sleep testing devices also have thoracic impedance bands to allow diagnosis of CSA.

IN-LAB PSG

WATCHPAT

• FDA-cleared wrist mounted device• Clinically validated against the polysomnography (PSG),

with a documented correlation of up to 90% to PSG • Most of the Piedmont sleep labs use Watchpat

• 1.2.1. PM is not appropriate for the diagnosis of OSA in patients with significant comorbid medical conditions that may degrade the accuracy of PM, including, but not limited to, moderate to severe pulmonary disease, neuromuscular disease, or congestive heart failure.

• 1.1. PM for the diagnosis of OSA should be performed only in conjunction with a comprehensive sleep evaluation. Clinical sleep evaluations using PM must be supervised by a practitioner with board certification in sleep medicine or an individual who fulfills the eligibility criteria for the sleep medicine certification examination. In the absence of a

h i l l ti th i i di ti f th

•LET’S TALK ABOUT TREATMENT

TREATMENT OPTIONS FOR OSA

• PAP Therapy (CPAP / Bi-level PAP etc.)*

• Oral appliances

• Hypoglossal nerve stimulator

• Surgery oUvulopalatopharyngoplasty (UPPP) o Adenotonsillectomy

INSPIRE

COMPLIANCE MATTERS

TYPE OF MASK MATTERS

SUMMARY

• Obstructive sleep apnea is a heterogeneous disorder with multiple endotypes and phenotypes.

• The prevalence of both OSA and AF is rising likely due to increases in cardiovascular disease and obesity.

• Untreated OSA can lead to catheter ablation failures & increased AF recurrence after electrical cardioversion.

• STOP BANG is the most sensitive screening tool (and its in EPIC).

• In-lab PSG for complicated patients & Home sleep study devices like WatchPATare the best ways to diagnose OSA.

• CPAP therapy is the gold standard but compliance matters.

REFERENCES

• Marulanda-Londoño E, Chaturvedi S. The Interplay between Obstructive Sleep Apnea and Atrial Fibrillation. Frontiers in Neurology. 2017;8:668. doi:10.3389/fneur.2017.00668.

• Mehra R, Benjamin EJ, Shahar E, et al. Association of Nocturnal Arrhythmias with Sleep-disordered Breathing: The Sleep Heart Health Study. American Journal of Respiratory and Critical Care Medicine. 2006;173(8):910-916. doi:10.1164/rccm.200509-1442OC.

• Tanigawa T, Yamagishi K, Sakurai S, et al. Arterial oxygen desaturation during sleep and atrial fibrillation. Heart. 2006;92(12):1854-1855. doi:10.1136/hrt.2005.081257.

• Kanagala R, Murali NS, Friedman PA, Ammash NM, Gersh BJ, Ballman KV, Shamsuzzaman AS, Somers VK. Obstructive sleep apnea and the recurrence of atrial fibrillation. Circulation 2003;107:2589-94

• Patel D, Mohanty P, Di Biase L, Shaheen M, Lewis WR, Quan K, et al. Safety and efficacy of pulmonary vein antral isolation in patients with obstructive sleep apnea: the impact of continuous positive airway pressure. Circ Arrhythm Electrophysiol.

• Chest. 2015 Oct;148(4):945-952. doi: 10.1378/chest.15-0229. Severity of OSA is an independent predictor of incident atrial fibrillation hospitalization in a large sleep-clinic cohort. Cadby G1, McArdle N2, Briffa T3, Hillman DR4, Simpson L5, Knuiman M3, Hung J6.

• De Andrade RGS, Piccin VS, Nascimento JA, Viana FML, Genta PR, Lorenzi-Filho G. Impact of the type of mask on the effectiveness of and adherence to continuous positive airway pressure treatment for obstructive sleep apnea . Jornal Brasileiro de Pneumologia. 2014;40(6):658-668. doi:10.1590/S1806-37132014000600010.