Author + information
- Ian Wilcox, PhD∗ (, )
- Kim Hoe Chan, MB and
- Hany Dimitri, PhD
- ↵∗Department of Medicine, Sydney Medical School, University of Sydney, Sydney, NSW 2006, Australia
Fein et al. (1) report that obstructive sleep apnea (OSA) adversely affects the results of ablation for paroxysmal or persistent atrial fibrillation (AF) except in those who reported using continuous positive airway pressure. Clearly, the study advances our understanding of the role that OSA may play in AF and its management.
The indications for testing for OSA in the study cohort were not reported, but what is likely, given that patients were predominantly middle-aged men, is that OSA was underdiagnosed, as the authors indicated. A key conclusion from this study is that testing patients with AF for OSA should be undertaken more systematically.
The current definition of obstructive sleep apnea syndrome requires not only ≥5 apneas/hypopneas per hour but also daytime sleepiness. This is despite data showing that <25% of patients with repetitive obstructive apneas are sleepy (2) and that there is no relationship between daytime sleepiness and the cardiovascular consequences of OSA (3) in most studies.
In addition, definitions of OSA severity based on the average number of apneas per hour of sleep may be also overly simplistic. In sleeping humans with obstructive apneas and in pig models of obstructed breathing, a single apnea can trigger AF. Factors that lead to the persistence of AF are not entirely understood (4), but clearly electroanatomic atrial remodeling plays a role in those with a high burden of AF (5).
We have previously advocated the concept that although OSA presents with respiratory symptoms, the most important adverse health effects are cardiovascular (6). In the case of AF, OSA is such a potent trigger that a case can be made for regarding it as a symptom of sleep apnea whether or not the patient happens to have daytime sleepiness. Therefore, if we are to test patients with heart disease for sleep apnea, we should not restrict our testing to sleepy patients, as is currently recommended.
Please note: Dr. Wilcox is a consultant to ResMed Inc. Drs. Chan and Dimitri have reported that they have no relationships relevant to the contents of this paper to disclose.
- American College of Cardiology Foundation
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