The Effect of Positive Airway Pressure Treatment of Obstructive and Central Sleep Apnea on the Recurrence of Atrial Fibrillation/Flutter Postintervention

Abstract

Study Objectives: A strong association between sleep-disordered breathing (SDB) and atrial fibrillation and/or atrial flutter (AF) has consistently been observed in epidemiologic and interventional studies. The effect of positive airway pressure (PAP) on AF recurrence is inconclusive. This study sought to evaluate the effectiveness of PAP therapy for SDB on AF recurrence. Methods: This was a single-center, retrospective study conducted at a tertiary referral center. All adult patients who had SDB on polysomnography and underwent AF intervention (ablation or cardioversion) following polysomnography from January 1992-December 2014 were analyzed. Primary outcome was time to first-documented recurrence of AF after AF intervention by Kaplan-Meier estimates. Results: Among 30,188 patients with obstructive and central SDB, 429 had this diagnosis before AF intervention; 269 were "PAP-adherent users," the remaining 160 were "PAP-nonusers." Patients in both groups had similar age, sex, body mass index (BMI), ejection fraction, left atrial volume index (LAVI), antiarrhythmic medications, diabetes mellitus, systemic hypertension, and heart failure diagnoses. Time to recurrence of AF postintervention was no different in PAP-adherent users and nonusers (4.8 and 4.1 months respectively, P =.7). Cardioversion (compared to catheter ablation) was the strongest independent predictor of recurrent AF (hazard ratio [HR] 2.02, 95% confidence interval [CI] 1.39-2.94, P < .001). BMI and LAVI were also significant predictors of recurrence in adjusted analyses (HR 1.01, 95% CI 1.003-1.023, P = .10 and HR 1.01, 95% CI 1.001-1.019, P = .024 respectively). Conclusions: Our study found no effect of PAP treatment of SDB on time to recurrence of AF post-AF intervention. Increased risk of recurrent AF was associated with high BMI and LAVI. These findings may affect the clinical management of AF.

International Consensus Statement on Obstructive Sleep Apnea

“…These studies have generally found that patients with OSA who are not treated with CPAP are significantly more likely to have recurrent AF than CPAP‐treated patients, with two‐ to six‐fold higher adjusted risk of recurrence 708,729,730,1215,1216 . No significant difference in rate of recurrence was seen, however, in two very small studies 712,728 and one large, retrospective cohort study 1217 . A single randomized clinical trial has been published comparing CPAP to usual care for prevention of recurrence following electrical cardioversion of AF.…”

Sleep Disordered Breathing, Obesity and Atrial Fibrillation: A Mendelian Randomisation Study

“…The results of this study did not support a causal pathway between SDB, in general, and AF, after accounting for BMI. There is a growing body of observational [ 8 , 9 , 10 , 11 ] and clinical trial evidence [ 12 , 13 ] suggesting a possible lack of direct causal association between OSA, the most common form of SDB, and AF. A recent, small RCT failed to show a benefit of CPAP against AF recurrence after cardioversion in patients with persistent AF [ 12 ], though the results should be interpreted with caution as recruitment targets were not met.…”

“…Some large observational studies have failed to demonstrate an association between OSA and AF that is independent of other cardiovascular risk factors [ 8 , 9 ]. Furthermore, the presence of OSA, and its treatment with CPAP, have recently been shown not to impact arrhythmia outcomes following ablation [ 10 , 11 ] or cardioversion [ 10 ]. Early and small RCTs have shown no impact of CPAP on time to AF recurrence post-cardioversion [ 12 ] or differences in AF burden or quality of life [ 13 ].…”

Obesity as a risk factor for cardiac arrhythmias

“…62 Finally, a large retrospective study of 30 188 patients with sleep-disordered breathing (obstructive sleep apnoea or central sleep apnoea) showed that time to recurrent AF after cardioversion or ablation was not influenced by continuous positive airway pressure treatment (hazard ratio 1.01 (95% confidence interval 1.00 to 1.02)). 63 The conflicting evidence for the effects of obstructive sleep apnoea on AF risk might be partly explained by the confounding effects of concurrent obesity. For instance, although obstructive sleep apnoea is twice as prevalent in patients who are obese compared with people of healthy weight; 64 this association might be bidirectional and obstructive sleep apnoea can increase susceptibility to weight gain by inducing leptin resistance.…”