Skip to main content

Cardiac effects of CPAP treatment in patients with obstructive sleep apnea and atrial fibrillation

Abstract

Purpose

Obstructive sleep apnea (OSA) has been recognized as an independent risk factor for the development and progression of atrial fibrillation (AF). We aimed to investigate the changes in heart rate and atrial and ventricular ectopy after continuous positive airway pressure (CPAP) treatment in patients with OSA and AF.

Methods

Consecutive patients with AF underwent ambulatory sleep monitoring, and OSA was defined as an Apnea-Hypopnea-Index (AHI) ≥ 5/h. Treated patients completed in-laboratory CPAP titration study. A 24-h ECG Holter was performed at baseline and at 3 and 6 months after CPAP treatment.

Results

One hundred patients (70% males) with AF were included in the final analysis. OSA was diagnosed in 85% of patients. There were no significant changes in mean 24-h heart rate in patients with paroxysmal or permanent AF at 3 and 6 months of treatment compared to baseline. In patients with paroxysmal AF (n = 29), atrial and ventricular ectopy counts/24 h significantly decreased at 3 months compared to baseline (median (IQR) 351 (2049) to 57 (182), P = 0.002; 68 (105) to 16 (133), P = 0.01 respectively). At 6 months follow-up, the atrial ectopy count/24 h significantly decreased in patients with paroxysmal AF compared to baseline (median (IQR) 351 (2049) to 31 (113), P = 0.016, n = 14). In patients with permanent AF (n = 15), there was a significant reduction in ventricular ectopy count/24 h at 3 months compared to baseline (median (IQR) 100 (1116) to 33 (418), P = 0.02).

Conclusions

There is a significant decrease in atrial and ventricular ectopy count/24 h in patients with AF and OSA at 3 and 6 months of CPAP treatment compared to baseline.

This is a preview of subscription content, access via your institution.

Fig. 1
Fig. 2

Abbreviations

AF:

Atrial fibrillation

AHI:

Apnea-Hypopnea-Index

CPAP:

Continuous positive airway pressure

ECG:

Electrocardiogram

OSA:

Obstructive sleep apnea

PSG:

Polysomnography

TST:

Total sleep time

References

  1. Voight J, Akkaya M, Somasundaram P, Karim R, Valliani S, Kwon Y, et al. Risk of new-onset atrial fibrillation and stroke after radiofrequency ablation of isolated, typical atrial flutter. Heart Rhythm. 2014;11(11):1884–9. https://doi.org/10.1016/j.hrthm.2014.06.038.

    Article  PubMed  Google Scholar 

  2. 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.

    Article  CAS  PubMed  Google Scholar 

  3. Abumuamar AM, Mollayeva T, Sandor P, Newman D, Nanthakumar K, Shapiro CM. Efficacy of continuous positive airway pressure treatment in patients with cardiac arrhythmia and obstructive sleep apnea: what is the evidence? Clinical Medicine Insights: Therapeutics. 2017;9(Supplementary Material_734227):1179559X17734227. https://doi.org/10.1177/1179559X17734227.

    Article  Google Scholar 

  4. Dimitri H, Ng M, Brooks AG, Kuklik P, Stiles MK, Lau DH, et al. Atrial remodeling in obstructive sleep apnea: implications for atrial fibrillation. Heart Rhythm. 2012;9(3):321–7. https://doi.org/10.1016/j.hrthm.2011.10.017.

    Article  PubMed  Google Scholar 

  5. Chen C-Y, Ho C-H, Chen C-L, Yu C-C. Nocturnal desaturation is associated with atrial fibrillation in patients with ischemic stroke and obstructive sleep apnea. JCSM. 2017;13(5):729–35. https://doi.org/10.5664/jcsm.6594.

    Article  PubMed  Google Scholar 

  6. Jeong E-M, Liu M, Sturdy M, Gao G, Varghese ST, Sovari AA, et al. Metabolic stress, reactive oxygen species, and arrhythmia. J Mol Cell Cardiol. 2012;52(2):454–63. https://doi.org/10.1016/j.yjmcc.2011.09.018.

    Article  CAS  PubMed  Google Scholar 

  7. Chan KH, Wilcox I. Obstructive sleep apnea: novel trigger and potential therapeutic target for cardiac arrhythmias. Expert Rev Cardiovasc Ther. 2010;8(7):981–94. https://doi.org/10.1586/erc.10.80.

    Article  PubMed  Google Scholar 

  8. Camen G, Clarenbach CF, Stöwhas A-C, Rossi VA, Sievi NA, Stradling JR, et al. The effects of simulated obstructive apnea and hypopnea on arrhythmic potential in healthy subjects. Eur J Appl Physiol. 2013;113(2):489–96. https://doi.org/10.1007/s00421-012-2457-y.

    Article  PubMed  Google Scholar 

  9. Clarenbach CF, Camen G, Sievi NA, Wyss C, Stradling JR, Kohler M. Effect of simulated obstructive hypopnea and apnea on thoracic aortic wall transmural pressures. J Appl Physiol. 2013;115(5):613–7. https://doi.org/10.1152/japplphysiol.00439.2013.

    Article  PubMed  PubMed Central  Google Scholar 

  10. Orban M, Bruce CJ, Pressman GS, Leinveber P, Romero-Corral A, Korinek J, et al. Dynamic changes of left ventricular performance and left atrial volume induced by the mueller maneuver in healthy young adults and implications for obstructive sleep apnea, atrial fibrillation, and heart failure. Am J Cardiol. 2008;102(11):1557–61. https://doi.org/10.1016/j.amjcard.2008.07.050.

    Article  PubMed  PubMed Central  Google Scholar 

  11. 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. https://doi.org/10.1093/europace/eup107.

    Article  PubMed  Google Scholar 

  12. Narkiewicz K, Kato M, Phillips BG, Pesek CA, Davison DE, Somers VK. Nocturnal continuous positive airway pressure decreases daytime sympathetic traffic in obstructive sleep apnea. Circulation. 1999;100(23):2332–5.

    Article  CAS  PubMed  Google Scholar 

  13. Mills PJ, Kennedy BP, Loredo JS, Dimsdale JE, Ziegler MG. Effects of nasal continuous positive airway pressure and oxygen supplementation on norepinephrine kinetics and cardiovascular responses in obstructive sleep apnea. Europace. 2006;100(1):343–8. https://doi.org/10.1152/japplphysiol.00494.2005.

    CAS  Article  Google Scholar 

  14. Karamanlı H, Özol D, Ugur KS, Yıldırım Z, Armutçu F, Bozkurt B, et al. Influence of CPAP treatment on airway and systemic inflammation in OSAS patients. Sleep & Breathing. 2014;18(2):251–6. https://doi.org/10.1007/s11325-012-0761-8.

    Article  Google Scholar 

  15. Bayir PT, Demirkan B, Bayir O, Duyuler S, Firat H, Güray U, et al. Impact of continuous positive airway pressure therapy on atrial electromechanical delay and P-wave dispersion in patients with obstructive sleep apnea. Ann Noninvasive Electrocardiol. 2014;19(3):226–33. https://doi.org/10.1111/anec.12106.

    Article  PubMed  Google Scholar 

  16. Linz D, McEvoy RD, Cowie MR, Somers VK, Nattel S, Lévy P, et al. Associations of obstructive sleep apnea with atrial fibrillation and continuous positive airway pressure treatment: a review. JAMA Cardiol. 2018;3(6):532–40. https://doi.org/10.1001/jamacardio.2018.0095.

    Article  PubMed  Google Scholar 

  17. A comparison of two nights of ambulatory sleep testing in arrhythmia patients. - PubMed - NCBI. (n.d.). Retrieved August 1, 2018, from https://www.ncbi.nlm.nih.gov/pubmed/29973998

  18. Abumuamar AM, Dorian P, Newman D, Shapiro CM. The STOP-BANG questionnaire shows an insufficient specificity for detecting obstructive sleep apnea in patients with atrial fibrillation. J Sleep Res. 2018;0(0):e12702. https://doi.org/10.1111/jsr.12702.

    Article  Google Scholar 

  19. Holmqvist F, Guan N, Zhu Z, Kowey PR, Allen LA, Fonarow GC, 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(5):647–654.e2. https://doi.org/10.1016/j.ahj.2014.12.024.

    Article  PubMed  Google Scholar 

  20. Kanagala R, Murali NS, Friedman PA, Ammash NM, Gersh BJ, Ballman KV, et al. Obstructive sleep apnea and the recurrence of atrial fibrillation. Circulation. 2003;107(20):2589–94. https://doi.org/10.1161/01.CIR.0000068337.25994.21.

    Article  PubMed  Google Scholar 

  21. Dediu GN, Dumitrache-Rujinski S, Lungu R, Frunză S, Diaconu C, Bartoş D, et al. Positive pressure therapy in patients with cardiac arrhythmias and obstructive sleep apnea. Pneumologia. 2015;64(1):18–22.

    PubMed  Google Scholar 

  22. Harbison J, O’Reilly P, McNicholas WT. Cardiac rhythm disturbances in the obstructive sleep apnea syndrome: effects of nasal continuous positive airway pressure therapy. Chest. 2000;118(3):591–5.

    Article  CAS  PubMed  Google Scholar 

  23. Ryan CM, Usui K, Floras JS, Bradley TD. Effect of continuous positive airway pressure on ventricular ectopy in heart failure patients with obstructive sleep apnoea. Thorax. 2005;60(9):781–5. https://doi.org/10.1136/thx.2005.040972.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  24. Acharya T, Tringali S, Bhullar M, Nalbandyan M, Ilineni VK, Carbajal E, et al. Frequent atrial premature complexes and their association with risk of atrial fibrillation. Am J Cardiol. 2015;116(12):1852–7. https://doi.org/10.1016/j.amjcard.2015.09.025.

    Article  PubMed  Google Scholar 

  25. Linz D, Hohl M, Ukena C, Mahfoud F, Wirth K, Neuberger H-R, et al. Obstructive respiratory events and premature atrial contractions after cardioversion. Eur Respir J. 2015;45(5):1332–40. https://doi.org/10.1183/09031936.00175714.

    Article  PubMed  Google Scholar 

  26. 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. https://doi.org/10.1093/europace/euv122.

    Article  PubMed  Google Scholar 

  27. Namtvedt SK, Randby A, Einvik G, Hrubos-Strøm H, Somers VK, Røsjø H, et al. Cardiac arrhythmias in obstructive sleep apnea (from the Akershus Sleep Apnea Project). Am J Cardiol. 2011;108(8):1141–6. https://doi.org/10.1016/j.amjcard.2011.06.016.

    Article  PubMed  Google Scholar 

  28. Serizawa N, Yumino D, Kajimoto K, Tagawa Y, Takagi A, Shoda M, et al. Impact of sleep-disordered breathing on life-threatening ventricular arrhythmia in heart failure patients with implantable cardioverter-defibrillator. Am J Cardiol. 2008;102(8):1064–8. https://doi.org/10.1016/j.amjcard.2008.05.057.

    Article  PubMed  Google Scholar 

  29. Kwon Y, Koene RJ, Kwon O, Kealhofer JV, Adabag S, Duval S. Effect of sleep-disordered breathing on appropriate implantable cardioverter-defibrillator therapy in patients with heart failure: a systematic review and meta-analysis. Circ Arrhythm Electrophysiol. 2017;10(2):–e004609. https://doi.org/10.1161/CIRCEP.116.004609.

  30. Weaver TE, Grunstein RR. Adherence to continuous positive airway pressure therapy: the challenge to effective treatment. Proc Am Thorac Soc. 2008;5(2):173–8. https://doi.org/10.1513/pats.200708-119MG.

    Article  PubMed  PubMed Central  Google Scholar 

  31. Abumuamar AM, Dorian P, Newman D, Shapiro CM. The prevalence of obstructive sleep apnea in patients with atrial fibrillation. Clin Cardiol. 2018;41(5):601–7. https://doi.org/10.1002/clc.22933.

    Article  PubMed  PubMed Central  Google Scholar 

Download references

Acknowledgments

We appreciate the collaboration and administrative support of the staff at the Sleep and Alertness Clinic, the Cardiomatters Diagnostics, and the Atrial Fibrillation Clinic at St. Michael’s Hospital in Toronto, ON, Canada. We acknowledge the support of the Neurozone MSH Inc. Canada and the CPAP Direct Ltd.

Funding

The Neurozone MSH Inc. Canada provided the equipment of home sleep testing for participants in the study. CPAP devices and supplies were provided by the CPAP Direct Ltd.

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Asmaa M. Abumuamar.

Ethics declarations

Ethical approval was obtained from University Health Network and St. Michael’s Hospital Research Ethics Boards.

Conflict of interest

CS has shares in the Neurozone MSH Inc. Canada which provided the equipment for the ambulatory sleep testing and the analysis of the sleep reports testing system. AA, DN, and PD have no conflicts of interest to disclose.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Abumuamar, A.M., Newman, D., Dorian, P. et al. Cardiac effects of CPAP treatment in patients with obstructive sleep apnea and atrial fibrillation. J Interv Card Electrophysiol 54, 289–297 (2019). https://doi.org/10.1007/s10840-018-0482-4

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10840-018-0482-4

Keywords

  • Obstructive sleep apnea
  • Atrial fibrillation
  • Continuous positive airway pressure
  • Atrial ectopy
  • Ventricular ectopy
  • CPAP compliance
  • Arrhythmia
  • Ambulatory sleep monitoring