J Interv Card Electrophysiol (2015) 43:279–286 DOI 10.1007/s10840-015-0014-4
Occult obstructive sleep apnea and clinical outcomes of radiofrequency catheter ablation in patients with atrial fibrillation Peter M. Farrehi 1 & Louise M. O’Brien 2,3 & Hatice Duygu Bas 1 & Kazim Baser 1 & Krit Jongnarangsin 1 & Rakesh Latchamsetty 1 & Hamid Ghanbari 1 & Thomas Crawford 1 & Frank Bogun 1 & Eric Good 1 & Frank Pelosi 1 & Aman Chugh 1 & Fred Morady 1 & Hakan Oral 1
Received: 14 February 2015 / Accepted: 30 April 2015 / Published online: 3 June 2015 # Springer Science+Business Media New York 2015
Abstract Background Recurrent atrial fibrillation (AF) after successful cardioversion can be predicted by obstructive sleep apnea (OSA) diagnosed by polysomnography. However, it is not known whether the validated STOP-BANG questionnaire can predict AF recurrence after radiofrequency ablation (RFA). Our objective is to determine the prevalence of unrecognized OSA in patients with AF and its relation to freedom from AF after RFA. Methods Validated surveys were administered to 247 consecutive AF patients following radiofrequency ablation from January to October 2011. OSA status was assessed at baseline RFA. Clinical follow up occurred at 3-6 month intervals. Results OSA had been previously diagnosed in 94/247 (38%). Among 153 patients without prior diagnosis of OSA, 121 (79%) had high risk STOP-BANG scores for OSA. Probability of maintaining sinus rhythm after RFA was similar among patients with known OSA (66/94, 70%) and high risk OSA scores (95/124, 77%) and higher than among patients with low risk OSA scores (29/32, 91%, P=0.03). Among patients without prior OSA, a high
* Peter M. Farrehi [email protected] 1
Division of Cardiovascular Medicine, Cardiovascular Center, University of Michigan Health System, Room 2722, 1500 E. Medical Center Drive, Ann Arbor, MI 48109-5853, USA
2
Department of Neurology, University of Michigan Health System, Ann Arbor, MI, USA
3
Department of Oral and Maxillofacial Surgery, University of Michigan Health System, Ann Arbor, MI, USA
risk STOP-BANG score did predict recurrent AF (OR=3.7, 95 % CI 1.4–11.4, P=0.0005). Multivariate analysis showed a higher risk of atrial arrhythmia recurrence for non-paroxysmal AF patients (OR=3.1, ± 95 % CI 1.4–7.1, P=0.005). Conclusions The majority of AF patients undergoing RFA have high risk OSA scores, suggesting that OSA is vastly underdiagnosed in this population. STOP-BANG independently predicted recurrent AF in patients without a prior diagnosis of OSA. Keywords Atrial fibrillation . Catheter ablation . Obstructive sleep apnea . Survey There is a well-established association between obstructive sleep apnea (OSA) and atrial fibrillation (AF) [1, 2]. Not all patients with OSA have major risk factors such as obesity, male gender, habitual snoring, and excessive daytime sleepiness [3]. The accepted method for diagnosing OSA, polysomnography, can be time-consuming and expensive to perform in all AF patients. A previously validated STOPBANG survey (Snoring, Tiredness, Observed apnea and blood Pressure-Body mass index, Age, Neck circumference and Gender) has been widely adopted as a screening tool for OSA patients [4]. Although untreated OSA diagnosed by polysomnography is associated with recurrent AF after cardioversion to sinus rhythm, it is not known whether the simpler STOP-BANG survey can predict AF recurrence after radiofrequency ablation (RFA) [5, 6]. The goal of this study is to determine the prevalence of occult OSA in patients with AF undergoing RFA and to determine the effect of OSA on the outcomes of RFA based on the STOP-BANG survey.
280
1 Methods 1.1 Study subjects We enrolled 258 consecutive patients returning for their first office visit after RFA between January and October 2011. Of these, 247 (97 %) met the inclusion criteria for analysis. Eleven (4 %) patients were excluded due to incomplete responses to the survey (seven), incomplete data (three), and refusal to consent (one).
J Interv Card Electrophysiol (2015) 43:279–286
riding in a car, talking, resting in the afternoon, sitting after lunch or driving a car. A summed value ≥10 (out of a maximum score of 24), indicates excessive daytime sleepiness. Hypertension was defined as a clinical systolic blood pressure ≥140 mmHg or diastolic blood pressure ≥90 mmHg. Successful outcome of RFA was defined as freedom from atrial arrhythmias (>30 s) in the absence of antiarrhythmic drug therapy after a 3-month blanking period. 1.3 Radiofrequency catheter ablation
1.2 Study protocol All participants provided written informed consent approved by the University of Michigan Institutional Review Board. Investigators collected demographic data through patient interviews, verified such from the medical record, and measured neck circumference at the level of the cricothyroid membrane and blood pressure during the clinic visit. Sleep assessment All patients were asked if they had a history of OSA. Subjects who reported OSA were asked about their use of continuous positive airway pressure (CPAP) therapy. CPAP use was recorded as Bnever^, B1– 4 h per night^ or Bgreater than 4 h per night^. Since there were no polysomnogram data available, the severity of OSA could not be determined. To determine the level of OSA risk and excessive daytime sleepiness, all subjects self-reported their responses to questions regarding sleep habits and level of daytime sleepiness, which are part of two standard, validated screening tools, as described in the following paragraphs. STOP-BANG questionnaire Patients at high risk for OSA are identified by asking four yes/no questions related to snoring, tiredness, observed apnea, and blood pressure. One point is given for each Byes^ response. The screen also incorporates one additional point for body mass index >35 kg/m2, age >50, neck circumference >40 cm, and male gender. The maximum score is 8, and a score of ≥3 is considered a high risk OSA score. The STOP-BANG has been validated against polysomnography and has a sensitivity of 84 % and specificity of 56 % for identifying an apnea–hypopnea index of five events per hour, which is the most commonly used threshold for OSA in clinical practice [4]. Epworth Sleepiness Scale Excessive daytime sleepiness is one of the most common symptoms in patients with OSA. The Epworth Sleepiness Scale is a validated eight-item questionnaire which evaluates the likelihood of dozing off to sleep during common daily activities [7]. Subjects rank on a scale of 0–3 the likelihood of becoming sleepy while reading, watching television, sitting in a meeting,
All subjects underwent a first (n=142) or repeat RFA (n=105) for AF within 6 months prior to the clinic visit. RFA techniques have been previously described [8]. Briefly, antral pulmonary vein isolation was performed with an open-irrigated-tip ablation catheter guided by a threedimensional electroanatomical mapping system [9]. All patients were observed during an overnight hospital stay and anticoagulated for at least 3 months after RFA.
1.4 Clinical follow-up All patients were seen in an outpatient clinic 3–6 months after the RFA and received an auto-triggered event monitor for 3 weeks to determine arrhythmia burden. Patients contacted a dedicated nurse if they experienced arrhythmia symptoms. Sleep assessment and surveys were performed during the first ambulatory clinic visit between 3 and 6 months after ablation. Survey results and recommendations for follow-up care were provided to the patients. In patients who remained in sinus rhythm, antiarrhythmic drug therapy was discontinued. All patients were then evaluated in the clinic approximately at 6month intervals or as needed based on clinical status. In patients who remained in sinus rhythm, antiarrhythmic drug therapy was discontinued after the blanking period.
1.5 Statistical analysis Categorical variables were summarized using counts and percentages and compared using Fisher’s exact test. Continuous variables were shown as mean±SD and compared using independent samples T-tests. A multivariate logistic regression model for AF recurrence was created using the variables that were significant at the 0.1 level in univariate analyses. The survival curves and P-values were calculated using the Turnbull estimator and the logrank test with Sun's scores for interval-censored data. All analyses were conducted using R version 2.15.2 and the Interval package. A P-value
Occult obstructive sleep apnea and clinical outcomes of radiofrequency catheter ablation in patients with atrial fibrillation Peter M. Farrehi 1 & Louise M. O’Brien 2,3 & Hatice Duygu Bas 1 & Kazim Baser 1 & Krit Jongnarangsin 1 & Rakesh Latchamsetty 1 & Hamid Ghanbari 1 & Thomas Crawford 1 & Frank Bogun 1 & Eric Good 1 & Frank Pelosi 1 & Aman Chugh 1 & Fred Morady 1 & Hakan Oral 1
Received: 14 February 2015 / Accepted: 30 April 2015 / Published online: 3 June 2015 # Springer Science+Business Media New York 2015
Abstract Background Recurrent atrial fibrillation (AF) after successful cardioversion can be predicted by obstructive sleep apnea (OSA) diagnosed by polysomnography. However, it is not known whether the validated STOP-BANG questionnaire can predict AF recurrence after radiofrequency ablation (RFA). Our objective is to determine the prevalence of unrecognized OSA in patients with AF and its relation to freedom from AF after RFA. Methods Validated surveys were administered to 247 consecutive AF patients following radiofrequency ablation from January to October 2011. OSA status was assessed at baseline RFA. Clinical follow up occurred at 3-6 month intervals. Results OSA had been previously diagnosed in 94/247 (38%). Among 153 patients without prior diagnosis of OSA, 121 (79%) had high risk STOP-BANG scores for OSA. Probability of maintaining sinus rhythm after RFA was similar among patients with known OSA (66/94, 70%) and high risk OSA scores (95/124, 77%) and higher than among patients with low risk OSA scores (29/32, 91%, P=0.03). Among patients without prior OSA, a high
* Peter M. Farrehi [email protected] 1
Division of Cardiovascular Medicine, Cardiovascular Center, University of Michigan Health System, Room 2722, 1500 E. Medical Center Drive, Ann Arbor, MI 48109-5853, USA
2
Department of Neurology, University of Michigan Health System, Ann Arbor, MI, USA
3
Department of Oral and Maxillofacial Surgery, University of Michigan Health System, Ann Arbor, MI, USA
risk STOP-BANG score did predict recurrent AF (OR=3.7, 95 % CI 1.4–11.4, P=0.0005). Multivariate analysis showed a higher risk of atrial arrhythmia recurrence for non-paroxysmal AF patients (OR=3.1, ± 95 % CI 1.4–7.1, P=0.005). Conclusions The majority of AF patients undergoing RFA have high risk OSA scores, suggesting that OSA is vastly underdiagnosed in this population. STOP-BANG independently predicted recurrent AF in patients without a prior diagnosis of OSA. Keywords Atrial fibrillation . Catheter ablation . Obstructive sleep apnea . Survey There is a well-established association between obstructive sleep apnea (OSA) and atrial fibrillation (AF) [1, 2]. Not all patients with OSA have major risk factors such as obesity, male gender, habitual snoring, and excessive daytime sleepiness [3]. The accepted method for diagnosing OSA, polysomnography, can be time-consuming and expensive to perform in all AF patients. A previously validated STOPBANG survey (Snoring, Tiredness, Observed apnea and blood Pressure-Body mass index, Age, Neck circumference and Gender) has been widely adopted as a screening tool for OSA patients [4]. Although untreated OSA diagnosed by polysomnography is associated with recurrent AF after cardioversion to sinus rhythm, it is not known whether the simpler STOP-BANG survey can predict AF recurrence after radiofrequency ablation (RFA) [5, 6]. The goal of this study is to determine the prevalence of occult OSA in patients with AF undergoing RFA and to determine the effect of OSA on the outcomes of RFA based on the STOP-BANG survey.
280
1 Methods 1.1 Study subjects We enrolled 258 consecutive patients returning for their first office visit after RFA between January and October 2011. Of these, 247 (97 %) met the inclusion criteria for analysis. Eleven (4 %) patients were excluded due to incomplete responses to the survey (seven), incomplete data (three), and refusal to consent (one).
J Interv Card Electrophysiol (2015) 43:279–286
riding in a car, talking, resting in the afternoon, sitting after lunch or driving a car. A summed value ≥10 (out of a maximum score of 24), indicates excessive daytime sleepiness. Hypertension was defined as a clinical systolic blood pressure ≥140 mmHg or diastolic blood pressure ≥90 mmHg. Successful outcome of RFA was defined as freedom from atrial arrhythmias (>30 s) in the absence of antiarrhythmic drug therapy after a 3-month blanking period. 1.3 Radiofrequency catheter ablation
1.2 Study protocol All participants provided written informed consent approved by the University of Michigan Institutional Review Board. Investigators collected demographic data through patient interviews, verified such from the medical record, and measured neck circumference at the level of the cricothyroid membrane and blood pressure during the clinic visit. Sleep assessment All patients were asked if they had a history of OSA. Subjects who reported OSA were asked about their use of continuous positive airway pressure (CPAP) therapy. CPAP use was recorded as Bnever^, B1– 4 h per night^ or Bgreater than 4 h per night^. Since there were no polysomnogram data available, the severity of OSA could not be determined. To determine the level of OSA risk and excessive daytime sleepiness, all subjects self-reported their responses to questions regarding sleep habits and level of daytime sleepiness, which are part of two standard, validated screening tools, as described in the following paragraphs. STOP-BANG questionnaire Patients at high risk for OSA are identified by asking four yes/no questions related to snoring, tiredness, observed apnea, and blood pressure. One point is given for each Byes^ response. The screen also incorporates one additional point for body mass index >35 kg/m2, age >50, neck circumference >40 cm, and male gender. The maximum score is 8, and a score of ≥3 is considered a high risk OSA score. The STOP-BANG has been validated against polysomnography and has a sensitivity of 84 % and specificity of 56 % for identifying an apnea–hypopnea index of five events per hour, which is the most commonly used threshold for OSA in clinical practice [4]. Epworth Sleepiness Scale Excessive daytime sleepiness is one of the most common symptoms in patients with OSA. The Epworth Sleepiness Scale is a validated eight-item questionnaire which evaluates the likelihood of dozing off to sleep during common daily activities [7]. Subjects rank on a scale of 0–3 the likelihood of becoming sleepy while reading, watching television, sitting in a meeting,
All subjects underwent a first (n=142) or repeat RFA (n=105) for AF within 6 months prior to the clinic visit. RFA techniques have been previously described [8]. Briefly, antral pulmonary vein isolation was performed with an open-irrigated-tip ablation catheter guided by a threedimensional electroanatomical mapping system [9]. All patients were observed during an overnight hospital stay and anticoagulated for at least 3 months after RFA.
1.4 Clinical follow-up All patients were seen in an outpatient clinic 3–6 months after the RFA and received an auto-triggered event monitor for 3 weeks to determine arrhythmia burden. Patients contacted a dedicated nurse if they experienced arrhythmia symptoms. Sleep assessment and surveys were performed during the first ambulatory clinic visit between 3 and 6 months after ablation. Survey results and recommendations for follow-up care were provided to the patients. In patients who remained in sinus rhythm, antiarrhythmic drug therapy was discontinued. All patients were then evaluated in the clinic approximately at 6month intervals or as needed based on clinical status. In patients who remained in sinus rhythm, antiarrhythmic drug therapy was discontinued after the blanking period.
1.5 Statistical analysis Categorical variables were summarized using counts and percentages and compared using Fisher’s exact test. Continuous variables were shown as mean±SD and compared using independent samples T-tests. A multivariate logistic regression model for AF recurrence was created using the variables that were significant at the 0.1 level in univariate analyses. The survival curves and P-values were calculated using the Turnbull estimator and the logrank test with Sun's scores for interval-censored data. All analyses were conducted using R version 2.15.2 and the Interval package. A P-value
