The Relationship Between Obstructive Sleep Apnea and Atrial Fibrillation: Guidance for Clinicians

Christopher J. Lettieri, MD


December 19, 2012

In This Article

Impact of OSA on Cardioversion

Not only does OSA lead to AF, but it has been shown that OSA both decreases the likelihood of successful cardioversion and increases the risk for recurrence. Untreated OSA has been identified as a risk factor for failure of rhythm control strategies using antiarrhythmic therapy. Furthermore, the recurrence rate after cardioversion is higher in patients with untreated OSA than in those using continuous positive airway pressure (CPAP) therapy.

Monahan and colleagues[12] explored the impact of OSA severity on antiarrhythmic therapy among patients with symptomatic AF.Among the cohort, OSA was nearly universally present, with 40% having severe OSA. Both the AHI and the frequency of severe OSA were significantly higher in patients who did not respond to antiarrhythmic therapy. Nonresponders were more likely to have severe OSA than milder disease (52% vs 23%; P < .05). Similarly, those with severe OSA were less likely than those with nonsevere OSA to respond to antiarrhythmic therapy (39% vs 70%; P = .02). Fewer than one third of patients with severe OSA responded to antiarrhythmic therapy; in contrast, therapy was successful twice as often among patients without severe OSA (61% vs 30%; P = .02).

OSA seems to diminish the efficacy of electrical cardioversion. Among patients with OSA who underwent electrical cardioversion for AF, the recurrence rate at 1 year was more than doubled among those with untreated OSA compared with those using CPAP.[3] Similarly, Kanagala and colleagues[13] found that recurrence rates after cardioversion were 82% in patients with untreated OSA, 53% in those without sleep-disordered breathing, and 42% in those with treated OSA.

It seems that OSA also affects the efficacy of catheter ablation. Jongnarangsin and coworkers[14] observed that AF recurred after catheter ablation in 37% of patients without OSA compared with 59% of those with OSA.

In a similar study, Naruse and colleagues[15] showed that individuals with OSA have a higher risk for AF recurrence after radiofrequency catheter ablation.In this study, OSA was an independent predictor of AF. Among 153 patients in whom pharmacotherapy had failed (drug-refractory AF), 116 (75.8%) were found to have OSA by polysomnography. Concomitant OSA was associated with a greater than 2-fold increased risk for AF recurrence after ablation compared with patients without sleep-disordered breathing. Treatment with CPAP reduced this excess risk. OSA increased the risk for recurrence by 261%, whereas the use of CPAP reduced the risk for recurrence 59% (P < .05 and P < .01, respectively).

A recent meta-analysis investigated the role of OSA on AF recurrence.[16] Six studies with a total of 3995 patients were included.[16] Patients with OSA diagnosed by polysomnography had a 40% greater risk for AF recurrence after catheter ablation (risk ratio, 1.40; 95% confidence interval, 1.16 to 1.68; P=.0004).