Sleep Apnea Afib Presentation

Sleep Apnea & Atrial Fibrillation Turner Curry, Joel Hake, Joe Wrask

Introduction: Sleep Apnea ● ●

Sleep apnea occurs when someone has repeated stops and starts of breathing while sleeping. Signs/ Symptoms... ○ ○ ○ ○

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If experiencing these signs & symptoms, also check… ○ ○ ○

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Loud snoring Problems with staying asleep and daytime sleepiness Breathing stops during sleep as witnessed by someone else Fatigue/ Irritability Blood pressure (Usually high) Heart rate (Increased) Feeling SOB

Risk Factors… ○ ○ ○ ○ ○ ○ ○ ○

Obesity or excess weight Older age Narrowed airway (Tonsils) Family history Male Heart disorders Alcohol & smoking Coronary artery disease

Continued...

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Diagnosis… ○

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Nocturnal polysomnography ■ Monitors heart, lung, and brain activity ■ Breathing patterns ■ Arm/ leg movement ■ SpO2 ■ Apnea hypopnea index >5

Treatment ○ ○ ○ ○

CPAP (Most Common) BiPAP (More pressure when inhaling/ Less while exhaling) Surgery (Tissue removal, Tracheostomy, etc.) Lifestyle changes

Introduction: Atrial Fibrillation

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AF is episodes of irregular and rapid heart rate Signs/ Symptoms… ○ ○ ○ ○

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Palpitations SOB Weakness Chest pain

Risk Factors… ○ ○ ○ ○ ○ ○ ○ ○

Older age Obesity Heart diseases HTN Alcohol Sleep apnea Family history Diabetes, chronic kidney disease, lung disease, etc….

Continued…

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Diagnosis… ○ ○ ○ ○ ○

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Treatment… ○ ○ ○ ○ ○

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ECG (Primary) Holter Monitor (Portable) Echocardiogram Stress test X-Ray Cardioversion (Electrical/ Drug) Antiarrhythmics Digoxin (Heart rate control) Catheter ablation (Destroy “Hot Spots”) Anticoagulants (Closely monitor with doctor) ■ Warfarin ■ Eliquis (Newer) Lifestyle modifications

Complications ○

Clots, stroke, cardiomyopathy, heart failure

Sleep Apnea Facts

● More than 22 million people are currently dealing with sleep apnea ● Over 80% of sleep apnea cases are undiagnosed ● Truck drivers are 5x more likely to crash with undiagnosed sleep apnea ● Death rates are tripled for people suffering from sleep apnea

Atrial Fibrillation Facts

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2.7-6.1 million people currently living in United States with A. fib 5x more likely to have a stroke 750,000 hospitalizations per year 130,000 deaths per year Costs 6 billion dollars from United States yearly More common in people over 65 years old

Problem

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Sleep apnea and A. fib are often diagnosed together or come from one another. We want to see if having sleep apnea can cause A. fib. Since people can go for years with sleep apnea, being able to diagnose it sooner can help decrease the risk of developing A. fib.

Research Question

● Does sleep apnea cause or increase the risk of atrial fibrillation?

Relationship Between Sleep Apnea & Atrial Fibrillation ●

Sleep apnea can provoke AF and arrhythmias if prolonged ○ ○

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Sleep apnea increases the risk for AF by... ○ ○

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When untreated, repeated apneas throughout the nights put a lot of stress on the body and mostly the heart The heart will work harder to make up for the sleep apnea, thus causing more stress while it should be getting rest Prolonged stress on the heart can induce AF and can even arrest Intermittent night time hypoxemia and hypercapnia Increase blood pressure and volume blood pressure during apneic episodes leading to left atrial stretching Increased oxidative stress and inflammation leading to left atrial damage (Fein et al, 2013)

People already with A. fib and are undergoing treatment via cardioversion and catheter ablation are at a high risk for recurrence if the patients already suffer from sleep apnea (Erdogan et al, 2009).

Treatments

Sleep Apnea ●

CPAP ○ ○ ○

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Lifestyle Changes ○ ○ ○ ○

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Continuous Positive Airway Pressure Allow airflow without any disturbance throughout the night Many people use this for treatment and there are many different types to find a correct fit Exercise (30 min/ day) Healthy diet Reduce stress Quit smoking

Surgery ○ ○

Tissue removal Tracheostomy

Treatments Continued...

Atrial Fibrillation ● ● ●

Depends of severity of A. fib Focus on curing underlying cause Resetting heart rhythm ○ ○

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Pulmonary Vein Isolation ○

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Electrical Cardioversion Anti-arrhythmics drugs Catheter used to electrically destroy sensory tissue in the pulmonary veins which causes irregular impulses (AF)

Lifestyle modifications ○ ○ ○ ○

Diet Smoking Exercise BP and Cholesterol

Studies ●

Sleep study of an A fib group and a non-A fib group to test for prevalence of sleep apnea. ○ ○ ○

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Slight increase of occurence of sleep apnea in the a fib group. Neck circumference, a known factor for sleep apnea, on average was significantly higher in A-fib group Study suggests a relationship between sleep apnea and A fib (Porthan et al, 2004)

Study population involved 62 pulmonary vein isolation treatment patients with A fib, who also had sleep apnea. ○ ○ ○ ○

PVI is effective to treat A fib, but A fib often reoccurs. 32 used CPAP to treat their sleep apnea, 30 did not. Recurrence rate of A fib in patients who used CPAP was significantly lower Treatment of sleep apnea by CPAP decreased the chance of Afib re-occuring, which means CPAP could be a contributing cause of A fib (Fein et al, 2013)

Studies Cont...

● Post op coronary artery bypass graft (CABG) ○ ○ ○ ○

Patients who were having a CABG done were tested They were able to discover which patients had and did not have sleep apnea before the graft After the patients surgeries they discovere which patients had AFIB 4x more likely

Studies Cont...

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Monitored A. fib for patients with suspected sleep apnea ○ ○ ○

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13/201 patients had atrial fibrillation p=0.038 and needed to be <0.05 to be significant Limitations consisted of how ECG recordings were conducted (April 2012-November 2013) ■ At home, 30 sec. 2x/day, and whenever the patient felt an A. fib episode ■ Could miss an episode due to 30 sec. And patient might be too busy to record

Observed the prevalence of A. fib in sleep apnea patients ○ ○ ○

38/427 sleep apnea patients had A. fib Patients were investigated with a full night polysomnography Severity of sleep apnea did not significantly differ between patients with and without AF

Conclusion

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Evidence shows that a patient is more likely to develop A fib if they have sleep apnea and that treatment of sleep apnea can reduce the likelihood of developing A fib. Other risk factors for A. fib other than sleep apnea are obesity, diabetes mellitus, high blood pressure, hyperlipidemia, coronary artery disease, smoking, etc. If a person has some of these along with sleep apnea, it can put them at high risk for developing atrial fibrillation. It is important to treat sleep apnea to prevent a fib, and to treat atrial fibrillation in itself, to prevent stroke or sudden death.

References Erdogan, A., Parahuleva, M., Schaefer, S., Guettler, N., Neuhof, C., Akcay, B., Bilgin, M.,Mayer, K., Reichenberger, F., & Schulz, R. (2009). Prevalence of atrial fibrillation in obstructive sleep apnea. Somnologie, 13, 211-214. doi: 10.1007/s11818-009-0444-2

Fein, A.S., Shvilkin, A., Shah, D., Haffajee, C., & Das, S. (2013). Treatment of obstructive sleepapnea reduces the risk of atrial fibrillation recurrence after catheter ablation. Journal of the American College of Cardiology, 62, 300305.doi: 10.1016/j.jacc.2013.03.052 Hendrikx, T., Sundqvist, M., Sandstrom, H., Sahlin, C., Rohani, M., Al-Khalili, F., Hornsten, R.,Blomberg, A., Wester, P., Rosenqvist, M., & Franklin, K. (2017). Atrial fibrillation among patients under investigation for suspected obstructive sleep apnea. PLos ONE, 12, 1-9. doi: 10.1371/journal.pone.0171575 Mehra, R., Benjamin, E.J., Shahar, E., & Gottlieb, D.J. (2006). Association of nocturnalarrhythmias with sleep disordered breathing: the sleep heart health study. American Journal of Respiratory and Critical Care Medicine, 173, 910-916. doi: 10.1164/rccm.200509-1442OC

Porthan, K.M., Melin, J.H., Kupila, J.T., Venho, K.K.K., & Partinen, M.M. (2004). Prevalenceof sleep apnea syndrome in lone atrial fibrillation. American College of Chest Physicians, 125, 879-885. doi: 10.1016/j.rehab.2016.07.181 Zhao, L., Kofidis, T., Lim, T., Chan, S., & Thun, H. (2015). Sleep apnea is associated withnewonset atrial fibrillation after coronary artery bypass grafting. Journal of Critical Care, 30, 1418.e1-1418.e5. doi: http://dx.doi.org.proxy.ohiolink.edu:9099/10.1016/j.jcrc.2015.07.00