Prevalence, risk factors, and type of sleep apnea in patients with paroxysmal atrial fibrillation

G M Traaen; B Øverland; L Aakerøy; T E Hunt; C Bendz; L Sande; S Aakhus; H Zaré; S Steinshamn; O G Anfinsen; J P Loennechen; L Gullestad; H Akre

doi:10.1016/j.ijcha.2019.100447

Prevalence, risk factors, and type of sleep apnea in patients with paroxysmal atrial fibrillation

Int J Cardiol Heart Vasc. 2019 Dec 19:26:100447. doi: 10.1016/j.ijcha.2019.100447. eCollection 2020 Feb.

Authors

G M Traaen^{1

2

3}, B Øverland⁴, L Aakerøy^{5

6}, T E Hunt^{1

2

7}, C Bendz¹, L Sande⁸, S Aakhus^{9

10}, H Zaré¹¹, S Steinshamn^{5

6}, O G Anfinsen^{1

7}, J P Loennechen^{6

10}, L Gullestad^{1

2

3}, H Akre^{2

12}

Affiliations

¹ Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway.
² Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway.
³ KG Jebsen Center for Cardiac Research, University of Oslo, Norway and Center for Heart Failure Research, Oslo University Hospital, Norway.
⁴ Department of Otorhinolaryngology, Head & Neck Surgery, Sleep Unit, Lovisenberg Diakonale Hospital, Oslo, Norway.
⁵ Department of Thoracic Medicine, St. Olavs University Hospital, Trondheim, Norway.
⁶ Department of Circulation and Medical Imaging, Faculty of Medicine and Health Science, Norwegian University of Science and Technology, Trondheim, Norway.
⁷ Department of Cardiology and Center for Cardiological Innovation, Oslo University Hospital, Rikshospitalet, Oslo, Norway.
⁸ Moloklinikken, Fornebu, Norway.
⁹ Department of Circulation and Imaging, Faculty of Medicine and Health Science, NTNU, Norwegian University of Science and Technology, Trondheim, Norway.
¹⁰ Department of Cardiology, St. Olavs University Hospital, Trondheim, Norway.
¹¹ Clinical Trial Unit, Department of Pharmacology, Oslo University Hospital, Rikshospitalet, Oslo, Norway.
¹² Department of Otorhinolaryngology, Head & Neck Surgery, Oslo University Hospital, Rikshospitalet, Oslo, Norway.

Abstract

Background: Recent studies have suggested an association between sleep apnea (SA) and atrial fibrillation (AF). We aimed to study the prevalence, characteristics, risk factors and type of sleep apnea (SA) in ablation candidates with paroxysmal AF.

Methods/results: We prospectively studied 579 patients with paroxysmal AF, including 157 women (27.1%) and 422 men (72.9%). Mean age was 59.9 ± 9.6 years and mean body mass index (BMI) 28.5 ± 4.5 kg/m². SA was diagnosed using polygraphy for two nights at home. The Epworth Sleepiness Scale (ESS), STOP-Bang Questionnaire, and Berlin Questionnaire (BQ) assessed the degree of SA symptoms. A total of 479 (82.7%) patients had an apnea-hypopnea index (AHI) ≥ 5, whereas moderate-severe SA (AHI ≥ 15) was diagnosed in 244 patients (42.1%). The type of SA was predominantly obstructive, with a median AHI of 12.1 (6.7-20.6) (range 0.4-85.8). The median central apnea index was 0.3 (0.1-0.7). AHI increased with age, BMI, waist and neck circumference, body and visceral fat. Using the Atrial Fibrillation Severity Scale and the SF-36, patients with more severe SA had a higher AF burden, severity and symptom score and a lower Physical-Component Summary score. Age, male gender, BMI, duration of AF, and habitual snoring were independent risk factors in multivariate analysis (AHI ≥ 15). We found no association between ESS and AHI (R² = 0.003, p = 0.367).

Conclusions: In our AF population, SA was highly prevalent and predominantly obstructive. The high prevalence of SA detected in this study may indicate that SA is under-recognized in patients with AF. None of the screening questionnaires predicted SA reliably.

Keywords: AASM, American Academy of Sleep Medicine; ACE-I, Aangiotensin converting enzyme inhibitor; AF, Atrial fibrillation; AFSS, Atrial Fibrillation Severity Scale; AHI, Apnea-hypopnea index; ARB, Angiotensin receptor blocker; AUC, Area under the curve; Atrial fibrillation; BMI, Body mass index; BQ, Berlin Questionnaire; CI, Confidence interval; COPD, Chronic obstructive pulmonary disease; CPAP; CPAP, Continuous positive airway pressure; CSA, Central sleep apnea; DC, Direct current; ESS, Epworth Sleepiness Scale; FEV1, Forced expiratory volume in 1 s; GERD, Gastroesophageal reflux disease; IQR, Interquartile range; NOAC, Novel oral anticoagulant; ODI, Oxygen desaturation index; OR, Odds ratio; OSA, Obstructive sleep apnea; PAF, Paroxysmal atrial fibrillation; PVI, Pulmonary vein isolation; Prevalence; SA, Sleep apnea; SD, Standard deviation; SF-36, Short form-36; Sleep apnea; TIA, Transient ischaemic attack; cAHI, Central apnea-hypopnea index.