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Sleep Apnea Afib Paper-3
Sleep Apnea Afib Paper-3
04/25/2018
Abstract
The purpose of this research was to find whether there is a significant relationship between sleep
apnea and atrial fibrillation. Given the six articles of research that was gathered, it was concluded
that there was in fact a significant relationship between sleep apnea and atrial fibrillation. It was
also found that elderly people (around 60 years or older) had a higher risk of having atrial
fibrillation. Other risk factors for AF that went along with sleep apnea included diabetes mellitus,
cardiovascular diseases, and metabolic diseases. Many people in these studies who already had
atrial fibrillation and sleep apnea could only manage their AF with digitalis, antiarrhythmic drugs
and warfarin. Others opted for treatment of AF with catheter ablation. Overall, it was found that
sleep apnea can increase the risk of getting atrial fibrillation in certain cases.
SLEEP APNEA & ATRIAL FIBRILLATION 2
A good night sleep is something that everyone should get. While someone is sleeping, it
gives the body time to relax and essentially get a reboost for the next day. Sometimes, things can
happen during sleep that someone might not be aware of. This is called sleep apnea. Basically,
sleep apnea is when there is a blockage of air going to the lungs. While this happens, you are
essentially not breathing for ten seconds or more. During this time, the body tries to adapt,
putting more work load on the heart - rather than it being relaxed. Too much of this stress can
lead to more problems - one of which is atrial fibrillation. To prevent this from happening, the
person at risk should be aware of the signs and symptoms and see their doctor if any of these
occur. Sleep apnea occurs in many people and it can easily go unnoticed. A person might feel
tired throughout the day or even fall asleep at their desk. A sleep study will be given to a patient
suspected for sleep apnea and will be referred to a sleep facility. With one night sleep during the
study, the sleep technicians will be able to diagnose whether the patient has sleep apnea or not.
Heart anomalies and sleep apnea often “run together”. However, there hasn’t been much research
on whether or not sleep apnea causes atrial fibrillation. That leads us to the question: Does sleep
Literature Review
Introduction
and ProQuest. Six articles were chosen to extract information from. Information found included:
SLEEP APNEA & ATRIAL FIBRILLATION 3
the relationship between sleep apnea and atrial fibrillation, ways to diagnose sleep apnea, and
Sleep Apnea
Sleep apnea is a very common disorder among adults and it usually can go undiagnosed.
Risk factors include: obesity, age, male, family history, heart disorders, diabetes, smoking,
alcohol, etc. According to Erdogan et al. (2009), cardiovascular disease and sleep apnea are
closely associated with each other and can cause arrythmias and other anomalies - one of which
is atrial fibrillation (Erdogan et al., 2009, p. 211). Prevention is key to stopping the onset of sleep
apnea. Factors as simple as diet and exercise can be ways to help prevent sleep apnea.
Atrial Fibrillation
Atrial fibrillation occurs when there is a “quiver” and the atria is not in sync with the
ventricles. According to Hendrikx et al. (2017), people with severe sleep apnea reported having
atrial fibrillation - which is 4 times more than someone without sleep apnea. Atrial fibrillation
also occurs more often in older people. “Atrial fibrillation occurs in about 4% of subjects in the
population aged 60–69 years and in about 10% of subjects aged 70– 79 years” (Hendrikx et al.
2017, p. 2). In a study done by Erdogan et al. (2009), the authors found that there was relatively
no difference between the severity of sleep apnea and the occurrence of atrial fibrillation
(Erdogan et al. 2009, p. 213). This suggest that even the slightest occurrence of sleep apnea, over
a prolonged period of time, can provoke atrial fibrillation. Risk factors for AF are very similar to
sleep apnea risk factors, if not the same. This is why atrial fibrillation and sleep apnea are so
closely correlated.
SLEEP APNEA & ATRIAL FIBRILLATION 4
Treatment
atrial fibrillation. Some of these treatments consist of: lifestyle changes - like losing weight -
exercise, diet, and cessation of tobacco usage. CPAP, or continuous positive airway pressure, is
the main treatment for sleep apnea in which a fitted mask with a hose allows airflow without
disturbance throughout the night. Atrial fibrillation can also be life-threatening if not treated.
Electrical cardioversion and anti-arrhythmic drugs are common treatments, along with a
procedure called pulmonary vein isolation. In pulmonary vein isolation, a catheter is used to
electrically destroy sensory tissue causing irregular impulses, and forming scar tissue around
them.
A study by Fein et al.(2013), focuses of CPAP and pulmonary vein isolation. The study
included 62 patients with atrial fibrillation and sleep apnea. All 62 patients underwent pulmonary
vein isolation to treat their atrial fibrillation. Even though PVI is an effective treatment, it often
results in a recurrence of atrial fibrillation. Of the 62 patients, 32 of them also used CPAP to treat
their sleep apnea, while 30 did not. The recurrence rate of atrial fibrillation in patients who used
CPAP to treat their sleep apnea was significantly lower (Fein et al. 2013). This study shows how
treating sleep apnea can prevent atrial fibrillation from developing because sleep apnea is a
which sleep apnea causes atrial fibrillation include: periodic nighttime hypoxemia and
hypercapnia, increased blood pressure and volume during apneic episodes leading to left atrial
SLEEP APNEA & ATRIAL FIBRILLATION 5
stretching, and increased oxidative stress and inflammation leading to left atrial damage (Porthan
et al, 2004). Atrial Fibrillation is also brought on by a number of other causes. As stated
previously, coronary artery disease is a complication that does in fact lead to atrial fibrillation.
As Zhoa et al. (2009) stated, atrial fibrillation becomes a large problem on a postoperative
patient that has received an coronary artery bypass graft. Zhoa et al. (2009) adds that having
atrial fibrillation after this bypass graft can even lead to complications such as stroke and heart
failure. With such horrific complications, it seems necessary to find a correlation between atrial
fibrillation resulting from the coronary artery bypass graft. Knowing which patients are at a
higher risk for atrial fibrillation after the graft would be a huge advantage in preventive care. In
fact, a few studies show that sleep apnea relates to the occurrence of atrial fibrillation (Zhoa et al,
2009). With all of these moving parts, Zhoa et al. (2009) concluded that a study must be
performed to determine whether or not sleep apnea affects the results of atrial fibrillation
occuring in a postoperative CABG patient. The patients that were scheduled for the graft
received a preoperative sleep study using a portable wrist device monitoring their sleep patterns
(Zhoa et al, 2009). This helped to establish the number of patients who fell under the sleep apnea
category. Of the 160 patients in the study, 80% of the patients ended up having an
apnea-hypopnea index ≥5, which classified them for falling in the sleep apnea category (Zhoa et
al, 2009).
post-CABG AF was higher in the sleep apnea group than the non–sleep apnea group
Although the number of patients participating in the study was a small group, the results were
accurate on what Zhoa et al. (2009) had said about sleep apnea increasing the risk for atrial
fibrillation. With sleep apnea affecting the heart and leading to a higher risk for atrial fibrillation,
the category of sleep disordered breathing (SDB) sparked an interest with Mehra et al. (2006), as
they believed that SDB would cause cardiac arrhythmias due to intermittent hypoxia. The results
found were that the people with SDB and atrial fibrillation were 5.3% vs the people that did not
have SDB but did have cardiac arrhythmias at 1.2% (Mehra et al, 2006). Using tools like an
EKG and sleep monitor help to assure accuracy of the study. However, the amount of sleep
disordered breathing in one night makes it hard to get an accurate result in any study.
Throughout the study, Mehra et al. (2006) adds that the SDB patients already had more risk
factors of cardiac disease than the non SDB groups such as a high BMI, diabetes, and high
cholesterol that needed to be taken into fact. Sleep apnea and atrial fibrillation continue to be a
major problem in the health care and more precautions must be taken to help decrease the rate of
people with these diseases. Risk factors include: obesity, age, male, family history, heart
disorders, diabetes, smoking, alcohol, etc. (Erdogan et al, 2009). Working on the modifiable risk
factors like obesity, smoking, and alcohol can all attribute to lowering the chances of developing
sleep apnea or atrial fibrillation. Although sleep apnea is prevalent in today's medical care,
Americans currently (Zhoa et al, 2009). Looking into both of the studies, there is a definite
correlation between sleep apnea and atrial fibrillation and that sleep apnea does in fact increase
Conclusion
SLEEP APNEA & ATRIAL FIBRILLATION 7
When analyzing a variety of scholarly studies for a relationship between sleep apnea and atrial
fibrillation, it was determined that sleep apnea is indeed a contributing cause of atrial fibrillation.
Patients are more likely to develop atrial fibrillation if they have sleep apnea, and especially if
they do not treat their sleep apnea. Other risk factors for atrial fibrillation include: obesity,
diabetes mellitus, high blood pressure, hyperlipidemia, coronary artery disease, and smoking. If a
person has some of these factors along with sleep apnea, it can put them at high risk for
developing atrial fibrillation. It is important to treat sleep apnea to prevent atrial fibrillation and
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
Fein, A.S., Shvilkin, A., Shah, D., Haffajee, C., & Das, S. (2013). Treatment of obstructive sleep
apnea reduces the risk of atrial fibrillation recurrence after catheter ablation. Journal of
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,
Mehra, R., Benjamin, E.J., Shahar, E., & Gottlieb, D.J. (2006). Association of nocturnal
arrhythmias with sleep disordered breathing: the sleep heart health study. American
10.1164/rccm.200509-1442OC
Porthan, K.M., Melin, J.H., Kupila, J.T., Venho, K.K.K., & Partinen, M.M. (2004). Prevalence
of sleep apnea syndrome in lone atrial fibrillation. American College of Chest Physicians,
Zhao, L., Kofidis, T., Lim, T., Chan, S., & Thun, H. (2015). Sleep apnea is associated with
newonset atrial fibrillation after coronary artery bypass grafting. Journal of Critical Care,
http://dx.doi.org.proxy.ohiolink.edu:9099/10.1016/j.jcrc.2015.07.00
SLEEP APNEA & ATRIAL FIBRILLATION 9