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Sleep Disorders and Atrial Fibrillation: Current Situation and Future Directions

Alireza Sepehri Shamloo, Arash Arya, Nikolas Dagres, Gerhard Hindricks
Atrial fibrillation (AF) is a growing health problem worldwide. In recent years, there has been a rising interest in the relationship between sleep disorders and AF. Several studies have reported higher prevalence and incidence rates of AF in patients with obstructive sleep apnea-hypopnea syndrome (OSAHS). However, some believe that OSAHS is not a risk factor for AF; but AF, by itself, is regarded as one of the possible triggers for OSAHS. In this study, the related literature investigating the association between OSAHS and AF was reviewed, and then the possible mechanisms of this interplay were discussed. To conclude, recommendations for further research in this field were presented to researchers and some points were highlighted for physicians.[GMJ.2018;7:e1416]
Atrial Fibrillation; Sleep Apnea, Obstructive; Primary Prevention; Aging; Obesity; Arrhythmias, Cardiac

Kirchhof P, Breithardt G, Bax J, Benninger G, Blomstrom-Lundqvist C, Boriani G et al. A roadmap to improve the quality of atrial fibrillation management: proceedings from the fifth Atrial Fibrillation Network/European Heart Rhythm Association consensus conference. Europace. 2016;18(1):37-50.


Gardarsdottir M, Sigurdsson S, Aspelund T, Rokita H, Launer LJ, Gudnason V et al. Atrial fibrillation is associated with decreased total cerebral blood flow and brain perfusion. Europace. 2017.


Fumagalli S, Potpara TS, Bjerregaard Larsen T, Haugaa KH, Dobreanu D, Proclemer A et al. Frailty syndrome: an emerging clinical problem in the everyday management of clinical arrhythmias. The results of the European Heart Rhythm Association survey. Europace. 2017;19(11):1896-902.


Guerra F, Brambatti M, Nieuwlaat R, Marcucci M, Dudink E, Crijns H et al. Symptomatic atrial fibrillation and risk of cardiovascular events: data from the Euro Heart Survey. Europace. 2017;19(12):1922-9.


Berge T, Brynildsen J, Larssen HKN, Onarheim S, Jenssen GR, Ihle-Hansen H et al. Systematic screening for atrial fibrillation in a 65-year-old population with risk factors for stroke: data from the Akershus Cardiac Examination 1950 study. Europace. 2017(00):1-7.

Sidhu K, Tang A. Modifiable Risk Factors in Atrial Fibrillation: The Role of Alcohol, Obesity, and Sleep Apnea. Can J Cardiol. 2017;33(7):947-9.


Voskoboinik A, Prabhu S, Ling LH, Kalman JM, Kistler PM. Alcohol and Atrial Fibrillation: A Sobering Review. J Am Coll Cardiol. 2016;68(23):2567-76.


Hobbelt AH, Siland JE, Geelhoed B, Van Der Harst P, Hillege HL, Van Gelder IC et al. Clinical, biomarker, and genetic predictors of specific types of atrial fibrillation in a community-based cohort: data of the PREVEND study. Europace. 2017;19(2):226-32.


Lip GYH, Coca A, Kahan T, Boriani G, Manolis AS, Olsen MH et al. Hypertension and cardiac arrhythmias: a consensus document from the European Heart Rhythm Association (EHRA) and ESC Council on Hypertension, endorsed by the Heart Rhythm Society (HRS), Asia-Pacific Heart Rhythm Society (APHRS) and Sociedad Latinoamericana de Estimulación Cardíaca y Electrofisiología (SOLEACE). Europace. 2017;19(6):891-911.


Bekfani T, Abraham WT. Current and future developments in the field of central sleep apnoea. Europace. 2016;18(8):1123-34.


Youssef I, Kamran H, Yacoub M, Patel N, Goulbourne C, Kumar S et al. Obstructive Sleep Apnea as a Risk Factor for Atrial Fibrillation: A Meta-Analysis. J Sleep Disord Ther. 2018;7(1).


Deng F, Raza A, Guo J. Treating obstructive sleep apnea with continuous positive airway pressure reduces risk of recurrent atrial fibrillation after catheter ablation: a meta-analysis. Sleep Med. 2018;46:5-11.


Zhao E, Chen S, Du Y, Zhang Y. Association between Sleep Apnea Hypopnea Syndrome and the Risk of Atrial Fibrillation: A Meta-Analysis of Cohort Study. Biomed Res Int. 2018;2018:5215868.

Mehra R, Benjamin EJ, Shahar E, Gottlieb DJ, Nawabit R, Kirchner HL et al. Association of nocturnal arrhythmias with sleep-disordered breathing: The Sleep Heart Health Study. Am J Respir Crit Care Med. 2006;173(8):910-6.

PMid:16424443 PMCid:PMC2662909

Tanigawa T, Yamagishi K, Sakurai S, Muraki I, Noda H, Shimamoto T et al. Arterial oxygen desaturation during sleep and atrial fibrillation. Heart. 2006;92(12):1854-5.

PMid:17105888 PMCid:PMC1861267

Jiang P, Wu J, Guo S, He Y, OuYang F. Atrial fibrillation and sleep apnea: A chicken and egg situation. Int J Cardiol. 2018;271:120.


Mazza A, Bendini MG, De Cristofaro R, Lovecchio M, Valsecchi S, Boriani G. Pacemaker-detected severe sleep apnea predicts new-onset atrial fibrillation. Europace. 2017;19(12):1937-43.


Desteghe L, Hendriks JML, McEvoy RD, Chai-Coetzer CL, Dendale P, Sanders P et al. The why, when and how to test for obstructive sleep apnea in patients with atrial fibrillation. Clin Res Cardiol. 2018;107(8):617-31.


Drager LF, McEvoy RD, Barbe F, Lorenzi-Filho G, Redline S. Sleep Apnea and Cardiovascular Disease: Lessons From Recent Trials and Need for Team Science. Circulation. 2017;136(19):1840-50.

PMid:29109195 PMCid:PMC5689452

Cadby G, McArdle N, Briffa T, Hillman DR, Simpson L, Knuiman M et al. Severity of OSA is an independent predictor of incident atrial fibrillation hospitalization in a large sleep-clinic cohort. Chest. 2015;148(4):945-52.


Lin GM, Colangelo LA, Lloyd-Jones DM, Redline S, Yeboah J, Heckbert SR et al. Association of Sleep Apnea and Snoring With Incident Atrial Fibrillation in the Multi-Ethnic Study of Atherosclerosis. Am J Epidemiol. 2015;182(1):49-57.

PMid:25977516 PMCid:PMC4479113

May AM, Blackwell T, Stone PH, Stone KL, Cawthon PM, Sauer WH et al. Central Sleep-disordered Breathing Predicts Incident Atrial Fibrillation in Older Men. Am J Respir Crit Care Med. 2016;193(7):783-91.

PMid:26595380 PMCid:PMC4824932

Tung P, Anter E. Atrial Fibrillation And Sleep Apnea: Considerations For A Dual Epidemic. J Atr Fibrillation. 2016;8(6):1283.

PMid:27909488 PMCid:PMC5089463

Gami AS, Hodge DO, Herges RM, Olson EJ, Nykodym J, Kara T et al. Obstructive sleep apnea, obesity, and the risk of incident atrial fibrillation. J Am Coll Cardiol. 2007;49(5):565-71.


Khawaja O, Sarwar A, Albert CM, Gaziano JM, Djousse L. Sleep duration and risk of atrial fibrillation (from the Physicians' Health Study). Am J Cardiol. 2013;111(4):547-51.

PMid:23218998 PMCid:PMC3563866

Chao TF, Liu CJ, Chen SJ, Wang KL, Lin YJ, Chang SL et al. Incidence and risk of atrial fibrillation in sleep-disordered breathing without coexistent systemic disease. Circ J. 2014;78(9):2182-7.


Kwon Y, Gharib SA, Biggs ML, Jacobs DR, Jr., Alonso A, Duprez D et al. Association of sleep characteristics with atrial fibrillation: the Multi-Ethnic Study of Atherosclerosis. Thorax. 2015;70(9):873-9.

PMid:25986436 PMCid:PMC5495463

Zhao LP, Kofidis T, Lim TW, Chan SP, Ong TH, Tan HC et al. Sleep apnea is associated with new-onset atrial fibrillation after coronary artery bypass grafting. J Crit Care. 2015;30(6):1418.e1-5.


Selim BJ, Koo BB, Qin L, Jeon S, Won C, Redeker NS et al. The Association between Nocturnal Cardiac Arrhythmias and Sleep-Disordered Breathing: The DREAM Study. J Clin Sleep Med. 2016;12(6):829-37.

PMid:26951420 PMCid:PMC4877315

Mehra R, Stone KL, Varosy PD, Hoffman AR, Marcus GM, Blackwell T et al. Nocturnal Arrhythmias across a spectrum of obstructive and central sleep-disordered breathing in older men: outcomes of sleep disorders in older men (MrOS sleep) study. Arch Intern Med. 2009;169(12):1147-55.

PMid:19546416 PMCid:PMC2802061

Porthan KM, Melin JH, Kupila JT, Venho KK, Partinen MM. Prevalence of sleep apnea syndrome in lone atrial fibrillation: a case-control study. Chest. 2004;125(3):879-85.


Wong JK, Maxwell BG, Kushida CA, Sainani KL, Lobato RL, Woo YJ et al. Obstructive Sleep Apnea Is an Independent Predictor of Postoperative Atrial Fibrillation in Cardiac Surgery. J Cardiothorac Vasc Anesth. 2015;29(5):1140-7.


Mooe T, Gullsby S, Rabben T, Eriksson P. Sleep-disordered breathing: a novel predictor of atrial fibrillation after coronary artery bypass surgery. Coron Artery Dis. 1996;7(6):475-8.


Christensen MA, Dixit S, Dewland TA, Whitman IR, Nah G, Vittinghoff E et al. Sleep characteristics that predict atrial fibrillation. Heart Rhythm. 2018;15(9):1289-95.


Ghazi L, Bennett A, Petrov ME, Howard VJ, Safford MM, Soliman EZ et al. Race, Sex, Age, and Regional Differences in the Association of Obstructive Sleep Apnea With Atrial Fibrillation: Reasons for Geographic and Racial Differences in Stroke Study. J Clin Sleep Med. 2018;14(9):1485-93.

PMid:30176963 PMCid:PMC6134254

Anselmino M, Matta M, Castagno D, Giustetto C, Gaita F. Catheter ablation of atrial fibrillation in chronic heart failure: state-of-the-art and future perspectives. Europace. 2016;18(5):638-47.


Kirchhof P, Benussi S, Kotecha D, Ahlsson A, Atar D, Casadei B et al. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Europace. 2016;18(11):1609-78.


Liu Y, Zhan X, Xue Y, Deng H, Fang X, Liao H et al. Incidence and outcomes of cerebrovascular events complicating catheter ablation for atrial fibrillation. Europace. 2016;18(9):1357-65.


Mazza A, Bendini MG, Cristofori M, Nardi S, Leggio M, De Cristofaro R et al. Baseline apnoea/hypopnoea index and high-sensitivity C-reactive protein for the risk of recurrence of atrial fibrillation after successful electrical cardioversion: a predictive model based upon the multiple effects of significant variables. Europace. 2009;11(7):902-9.


Ng CY, Liu T, Shehata M, Stevens S, Chugh SS, Wang X. Meta-analysis of obstructive sleep apnea as predictor of atrial fibrillation recurrence after catheter ablation. Am J Cardiol. 2011;108(1):47-51.


Patel N, Donahue C, Shenoy A, Patel A, El-Sherif N. Obstructive sleep apnea and arrhythmia: A systemic review. Int J Cardiol. 2017;228:967-70.


Lau DH, Nattel S, Kalman JM, Sanders P. Modifiable Risk Factors and Atrial Fibrillation. Circulation. 2017;136(6):583-96.


Gao M, Zhang L, Scherlag BJ, Huang B, Stavrakis S, Hou YM et al. Low-level vagosympathetic trunk stimulation inhibits atrial fibrillation in a rabbit model of obstructive sleep apnea. Heart Rhythm. 2015;12(4):818-24.


Kwon Y, Misialek JR, Duprez D, Alonso A, Jacobs DR, Jr., Heckbert SR et al. Association between sleep disordered breathing and electrocardiographic markers of atrial abnormalities: the MESA study. Europace. 2017;19(11):1759-66.


Linz D. Apnoea-associated intrathoracic pressure swings create a dynamic arrhythmogenic atrial substrate during sleep. Europace. 2016;18(3):469.


Schlatzer C, Schwarz EI, Sievi NA, Clarenbach CF, Gaisl T, Haegeli LM et al. Intrathoracic pressure swings induced by simulated obstructive sleep apnoea promote arrhythmias in paroxysmal atrial fibrillation. Europace. 2016;18(1):64-70.


Goudis CA, Ketikoglou DG. Obstructive sleep and atrial fibrillation: Pathophysiological mechanisms and therapeutic implications. Int J Cardiol. 2017;230:293-300.


Staerk L, Sherer JA, Ko D, Benjamin EJ, Helm RH. Atrial Fibrillation: Epidemiology, Pathophysiology, and Clinical Outcomes. Circ Res. 2017;120(9):1501-17.

PMid:28450367 PMCid:PMC5500874

Friedman DJ, Liu P, Barnett AS, Campbell KB, Jackson KP, Bahnson TD et al. Obstructive sleep apnea is associated with increased rotor burden in patients undergoing focal impulse and rotor modification guided atrial fibrillation ablation. Europace. 2017.

Schlatzer C, Kohler M. Apnoea-associated intrathoracic pressure swings create a dynamic arrhythmogenic atrial substrate during sleep: author's reply. Europace. 2016;18(3):469-70.


Odening KE, Deiss S, Dilling-Boer D, Didenko M, Eriksson U, Nedios S et al. Mechanisms of sex differences in atrial fibrillation: role of hormones and differences in electrophysiology, structure, function, and remodelling. Europace. 2018.

Jones DG, Markides V, Chow AWC, Schilling RJ, Kanagaratnam P, Wong T et al. Characterization and consistency of interactions of triggers and substrate at the onset of paroxysmal atrial fibrillation. Europace. 2017;19(9):1454-62.


Zhao J, Xu W, Yun F, Zhao H, Li W, Gong Y et al. Chronic obstructive sleep apnea causes atrial remodeling in canines: mechanisms and implications. Basic Res Cardiol. 2014;109(5):427.


Yu L, Li X, Huang B, Zhou X, Wang M, Zhou L et al. Atrial Fibrillation in Acute Obstructive Sleep Apnea: Autonomic Nervous Mechanism and Modulation. J Am Heart Assoc. 2017;6(9).

Matassini MV, Brambatti M, Guerra F, Scappini L, Capucci A. Sleep-disordered breathing and atrial fibrillation: review of the evidence. Cardiol Rev. 2015;23(2):79-86.


Jani BD, Nicholl BI, McQueenie R, Connelly DT, Hanlon P, Gallacher KI et al. Multimorbidity and co-morbidity in atrial fibrillation and effects on survival: findings from UK Biobank cohort. Europace. 2017.

Gillott RG, Willan K, Kain K, Sivananthan UM, Tayebjee MH. South Asian ethnicity is associated with a lower prevalence of atrial fibrillation despite greater prevalence of established risk factors: a population-based study in Bradford Metropolitan District. Europace. 2017;19(3):356-63.


Hong KL, Glover BM. The impact of lifestyle intervention on atrial fibrillation. Curr Opin Cardiol. 2018;33(1):14-9.


Otto ME, Belohlavek M, Romero-Corral A, Gami AS, Gilman G, Svatikova A et al. Comparison of cardiac structural and functional changes in obese otherwise healthy adults with versus without obstructive sleep apnea. Am J Cardiol. 2007;99(9):1298-302.


Patel D, Mohanty P, Di Biase L, Shaheen M, Lewis WR, Quan K et al. Safety and efficacy of pulmonary vein antral isolation in patients with obstructive sleep apnea: the impact of continuous positive airway pressure. Circ Arrhythm Electrophysiol. 2010;3(5):445-51.


Fein AS, Shvilkin A, Shah D, Haffajee CI, Das S, Kumar K et al. Treatment of obstructive sleep apnea reduces the risk of atrial fibrillation recurrence after catheter ablation. J Am Coll Cardiol. 2013;62(4):300-5.


Naruse Y, Tada H, Satoh M, Yanagihara M, Tsuneoka H, Hirata Y 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(3):331-7.



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