Obstructive sleep apnoea and atrial fibrillation: a key omission in guidelines
Dear Sirs,
The National Institute for Health and Care Excellence (NICE) guidelines for atrial fibrillation (AF) and obstructive sleep apnoea (OSA) lack recommendations for the subset of patients with both conditions. There is growing evidence of a bidirectional association between AF and OSA, which we believe is not highlighted in current NICE guidelines. The ORBIT-AF (Outcomes Registry for Better Informed Treatment of Atrial Fibrillation) cohort study highlighted that about one in five patients with AF also had OSA.1 For this group of patients, screening, diagnosis and treatment are crucial.
AF is the most common cardiac arrhythmia in clinical practice,2 while OSA had an estimated UK prevalence of 1.5 million adults in 2014.3 With the obesity epidemic and demographic changes with an ageing population, the prevalence of both conditions is likely to increase with OSA and AF sharing common independent risk factors, such as age, obesity, smoking status and alcohol intake.4-7
Although the pathophysiological processes for the associated interplay between AF and OSA are complex, and continue to be debated by the scientific community, studies have demonstrated increased prevalence of AF in OSA patients and vice versa.8,9 The Sleep Heart study, comprising of participants with sleep-disordered breathing, found that those with severe OSA had a four-fold risk of AF when compared with those without OSA (adjusted odds ratio [OR] 4.02, 95% confidence interval [CI] 1.03 to 15.74).8 The British Lung Foundation notes that OSA is underdiagnosed,3 and, thus, clinicians could be missing the opportunity for diagnosis by not screening for OSA in AF patients and vice versa.
Patients diagnosed with concurrent AF and OSA without appropriate continuous positive airway pressure (CPAP) therapy may also respond poorly to pharmacological and non-pharmacological treatment of AF.10‑13 The risk of recurrence of AF after cardioversion or ablation was found to be higher in patients with untreated OSA,10 while, in those who had treatment, the risk was similar to patients without OSA.11,12
OSA is an important, yet overlooked, risk factor in AF. At present, there is no reference to the association between OSA and AF in the NICE guidelines for AF and the only reference to this subset is within the OSA guidelines, whereby NICE suggests clinicians assess “any associated conditions”. In contrast, the American Heart Association, American College of Cardiology and Heart Rhythm Society guidelines highlight OSA as a risk factor in AF and recommends a sleep study for AF patients with suspected OSA.14 We would recommend that clinicians screen and test for OSA in AF patients and request that guidelines reconsider including OSA screening as a part of standard practice in AF patients.
Conflicts of interest
GYHL: Consultant and speaker for BMS/Pfizer, Boehringer Ingelheim and Daiichi-Sankyo. No fees are received personally. NS, AM and SI: None declared.
Funding
None.
Natalia Shafiqa
Foundation Year Two Doctor
Aintree University Hospital, Lower Lane, Fazakerley, Liverpool, L9 7AL
Ari Manuel
Respiratory Consultant and Senior Clinical Lecturer
Gregory Y H Lip
Professor of Cardiovascular Medicine
Liverpool Centre for Cardiovascular Science, University of Liverpool, Brownlow Hill, Liverpool, L69 7TX
Sriram Iyer
Respiratory Consultant and Sleep Physician, and Sleep and Ventilation Lead
Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield Teaching Hospital, Herries Road, Sheffield, S5 7AU
References
1. Holmqvist F, Guan N, Zhu Z, et al. Impact of obstructive sleep apnea and continuous positive airway pressure therapy on outcomes in patients with atrial fibrillation – results from the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation (ORBIT-AF). Am Heart J 2015;169:647.e2–654.e2. https://doi.org/10.1016/j.ahj.2014.12.024
2. Adderley NJ, Ryan R, Nirantharakumar K et al. Prevalence and treatment of atrial fibrillation in UK general practice from 2000 to 2016. Heart 2019;105:27–33. https://doi.org/10.1136/heartjnl-2018-312977
3. British Lung Foundation. Obstructive sleep apnoea. Toolkit for commissioning and planning local NHS services in the UK 2015. London: British Lung Foundation, 2015. Available from: www.blf.org.uk/sites/default/files/OSA_Toolkit_2015_BLF_0.pdf [accessed 11 September 2021].
4. Young T, Skatrud J, Peppard PE. Risk factors for obstructive sleep apnoea in adults. JAMA 2004;291:2013–16. https://doi.org/10.1001/jama.291.16.2013
5. Zhang L, Hou Y, Po SS. Obstructive sleep apnoea and atrial fibrillation. Arrhythm Electrophysiol Rev 2015;4:14–18. https://doi.org/10.15420/aer.2015.4.1.14
6. Marulanda-Londoño E, Chaturvedi S. The interplay between obstructive sleep apnea and atrial fibrillation. Front Neurol 2017;8:668. https://doi.org/10.3389/fneur.2017.00668
7. Shantha G, Pelosi F, Morady F. Relationship between obstructive sleep apnoea and AF. Arrhythm Electrophysiol Rev 2019;8:180–3. https://doi.org/10.15420/aer.2019.35.2
8. Mehra R, Benjamin EJ, Shahar E et al. Association of nocturnal arrhythmias with sleep-disordered breathing: the Sleep Heart Health study. Am J Resp Crit Care Med 2006;173:910–16. https://doi.org/10.1164/rccm.200509-1442OC
9. Gami AS, Hodge DO, Herges RM et al. Obstructive sleep apnea, obesity, and the risk of incident atrial fibrillation. J Am Coll Cardiol 2007;49:565–71. https://doi.org/10.1016/j.jacc.2006.08.060
10. Kanagala R, Murali NS, Friedman PA et al. Obstructive sleep apnea and the recurrence of atrial fibrillation. Circulation 2003;107:2589–94. https://doi.org/10.1161/01.CIR.0000068337.25994.21
11. Naruse Y, Tada H, Satoh M et al. Concomitant obstructive sleep apnea increases the recurrence of atrial fibrillation following radiofrequency catheter ablation of atrial fibrillation: clinical impact of continuous positive airway pressure therapy. Heart Rhythm 2013;10:331–7. https://doi.org/10.1016/j.hrthm.2012.11.015
12. Fein AS, Shvilkin A, Shah D et al. Treatment of obstructive sleep apnea reduces the risk of atrial fibrillation recurrence after catheter ablation. J Am Coll Cardiol 2013;62:300–05. https://doi.org/10.1016/j.jacc.2013.03.052
13. Monahan K, Brewster J, Wang L et al. Relation of the severity of obstructive sleep apnoea in response to anti-arrhythmic drugs in patients with atrial fibrillation or atrial flutter. Am J Cardiol 2012;110:369–72. https://doi.org/10.1016/j.amjcard.2012.03.037
14. January CT, Wann LS, Calkins H et al. 2019 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society in collaboration with the Society of Thoracic Surgeons. Circulation 2019;140:125–51. https://doi.org/10.1161/CIR.0000000000000665
