Sleep Breath DOI 10.1007/s11325-014-0997-6
SHORT COMMUNICATION
Utility of extended cardiac monitoring to detect atrial fibrillation in patients with severe obstructive sleep apnea Arijit Chanda & Armand Wolff & Craig McPherson & Jeff Kwon
Received: 27 February 2014 / Revised: 29 April 2014 / Accepted: 30 April 2014 # Springer-Verlag Berlin Heidelberg 2014
Abstract Background The relationship between obstructive sleep apnea (OSA) and increased risk for atrial fibrillation (AF) has been well established in previous studies. The relationship between OSA and silent AF is unknown. We hypothesized that patients with OSA but no known history of AF are at an increased risk for the arrhythmia and may be detectable by prolonged electrocardiogram (ECG) monitoring. In this study, we examined whether 7 days of extended cardiac monitoring with an ECG event recorder is an effective screening tool to detect intermittent, silent AF in patients with severe OSA. Methods The study was a prospective observational study. Randomly chosen patients with newly diagnosed severe OSA, apnea-hypopnea index (AHI)≥30, were included. Demographic, medical history, and sleep data were collected. Patients with a history of AF or symptoms of palpitations were excluded from participating. Seven consecutive days of ambulatory ECG event recording (with Model ER920W,
eCardio, Houston, TX) were performed prior to the initiation of CPAP treatment. Results A total of 20 subjects, with a BMI of 38.8±12.2, successfully completed the study. The mean age group was 52.6±12.6 years and mean AHI 63.5±29.2. The majority of subjects (70 %) had no abnormal cardiac rhythms detected. AF lasting for 7 s was seen in one subject, and paroxysmal atrial tachycardia lasting for 3.6 s was seen in another. Clinically relevant AF was not detected in any of the subjects. Conclusion In patients with severe OSA without a known history of AF, 7 days of extended cardiac monitoring with an ECG event recorder did not detect clinically meaningful, silent AF. Keywords Obstructive sleep apnea . Atrial fibrillation . Extended cardiac monitoring
Introduction A. Chanda : A. Wolff : C. McPherson : J. Kwon Bridgeport Hospital, Yale New Haven Health, Bridgeport, CT, USA A. Chanda e-mail: [email protected] A. Wolff e-mail: [email protected] C. McPherson e-mail: [email protected] C. McPherson Yale School of Medicine, New Haven, CT, USA A. Chanda Yale New Haven Hospital, New Haven, CT, USA J. Kwon (*) Section of Pulmonary, Critical Care, and Sleep Medicine, 267 Grant St., Bridgeport, CT 06610, USA e-mail: [email protected]
Several studies have demonstrated an increased prevalence and incidence of atrial fibrillation (AF) in patients with obstructive sleep apnea (OSA) [1, 2]. OSA is also known to have detrimental effects on rhythm control of AF, including ablation failure [3]. It has been suggested that the acute physiologic effects of pharyngeal collapse resulting in obstructive apneas may promote AF through the effects of intermittent hypoxemia, acidosis, increased vagal tone, and arousals that engender increased sympathetic activity [4, 5]. Although the link between OSA and clinically apparent AF is well recognized, the relationship between OSA and subclinical AF is not known. It is reasonable to speculate that some patients with severe OSA may experience “clinically silent” AF that may go undetected, especially if AF is intermittent. Given the association between AF and stroke, the diagnosis of silent AF may be clinically meaningful. We
Sleep Breath
hypothesized that extended cardiac monitoring in OSA patients may have utility in the early diagnosis of silent AF. We conducted the present pilot study to test the hypothesis that extended cardiac monitoring would be a useful screening tool in detecting silent AF in patients with severe OSA but no previously documented cardiac arrhythmias.
Materials and methods Subjects were enrolled over a period of 12 months at the Bridgeport Hospital Center for Sleep Medicine. Bridgeport Hospital is a large community-based teaching hospital of the Yale New Haven Health System. The center is accredited by The American Academy of Sleep Medicine. All patients referred for sleep evaluation were interviewed and examined by a board-certified sleep medicine physician (JK, AW). Patients suspected of having OSA were invited to undergo an overnight, attended polysomnography. All sleep studies are conducted with real time monitoring by certified sleep technicians. Data obtained during each study included oxygen saturation by pulse oximeter, nasal and oral airflow, thoraco-abdominal excursions, electroencephalogram (EEG), electro-oculogram (EOG), electromyogram (EMG), and single-lead electrocardiogram (ECG). Each study was scored according to international consensus guidelines and confirmed by the sleep physicians. Hypopneas were defined as periods lasting at least 10 s in which nasal airflow decreased at least 50 %, thoraco-abdominal effort persisted and oxygen saturation reduction ≥4 %. Apneas were defined as at least 90 % reduction in nasal airflow persisting for at least 10 s. Obstructive apneas were scored if there was ongoing thoracoabdominal effort, whereas central apneas were scored when respiratory effort was absent. The apnea-hypopnea index (AHI) was reported as the average number of apneic and hypopneic episodes per hour. Among individuals with AHI≥30 without a significant number of central events (
SHORT COMMUNICATION
Utility of extended cardiac monitoring to detect atrial fibrillation in patients with severe obstructive sleep apnea Arijit Chanda & Armand Wolff & Craig McPherson & Jeff Kwon
Received: 27 February 2014 / Revised: 29 April 2014 / Accepted: 30 April 2014 # Springer-Verlag Berlin Heidelberg 2014
Abstract Background The relationship between obstructive sleep apnea (OSA) and increased risk for atrial fibrillation (AF) has been well established in previous studies. The relationship between OSA and silent AF is unknown. We hypothesized that patients with OSA but no known history of AF are at an increased risk for the arrhythmia and may be detectable by prolonged electrocardiogram (ECG) monitoring. In this study, we examined whether 7 days of extended cardiac monitoring with an ECG event recorder is an effective screening tool to detect intermittent, silent AF in patients with severe OSA. Methods The study was a prospective observational study. Randomly chosen patients with newly diagnosed severe OSA, apnea-hypopnea index (AHI)≥30, were included. Demographic, medical history, and sleep data were collected. Patients with a history of AF or symptoms of palpitations were excluded from participating. Seven consecutive days of ambulatory ECG event recording (with Model ER920W,
eCardio, Houston, TX) were performed prior to the initiation of CPAP treatment. Results A total of 20 subjects, with a BMI of 38.8±12.2, successfully completed the study. The mean age group was 52.6±12.6 years and mean AHI 63.5±29.2. The majority of subjects (70 %) had no abnormal cardiac rhythms detected. AF lasting for 7 s was seen in one subject, and paroxysmal atrial tachycardia lasting for 3.6 s was seen in another. Clinically relevant AF was not detected in any of the subjects. Conclusion In patients with severe OSA without a known history of AF, 7 days of extended cardiac monitoring with an ECG event recorder did not detect clinically meaningful, silent AF. Keywords Obstructive sleep apnea . Atrial fibrillation . Extended cardiac monitoring
Introduction A. Chanda : A. Wolff : C. McPherson : J. Kwon Bridgeport Hospital, Yale New Haven Health, Bridgeport, CT, USA A. Chanda e-mail: [email protected] A. Wolff e-mail: [email protected] C. McPherson e-mail: [email protected] C. McPherson Yale School of Medicine, New Haven, CT, USA A. Chanda Yale New Haven Hospital, New Haven, CT, USA J. Kwon (*) Section of Pulmonary, Critical Care, and Sleep Medicine, 267 Grant St., Bridgeport, CT 06610, USA e-mail: [email protected]
Several studies have demonstrated an increased prevalence and incidence of atrial fibrillation (AF) in patients with obstructive sleep apnea (OSA) [1, 2]. OSA is also known to have detrimental effects on rhythm control of AF, including ablation failure [3]. It has been suggested that the acute physiologic effects of pharyngeal collapse resulting in obstructive apneas may promote AF through the effects of intermittent hypoxemia, acidosis, increased vagal tone, and arousals that engender increased sympathetic activity [4, 5]. Although the link between OSA and clinically apparent AF is well recognized, the relationship between OSA and subclinical AF is not known. It is reasonable to speculate that some patients with severe OSA may experience “clinically silent” AF that may go undetected, especially if AF is intermittent. Given the association between AF and stroke, the diagnosis of silent AF may be clinically meaningful. We
Sleep Breath
hypothesized that extended cardiac monitoring in OSA patients may have utility in the early diagnosis of silent AF. We conducted the present pilot study to test the hypothesis that extended cardiac monitoring would be a useful screening tool in detecting silent AF in patients with severe OSA but no previously documented cardiac arrhythmias.
Materials and methods Subjects were enrolled over a period of 12 months at the Bridgeport Hospital Center for Sleep Medicine. Bridgeport Hospital is a large community-based teaching hospital of the Yale New Haven Health System. The center is accredited by The American Academy of Sleep Medicine. All patients referred for sleep evaluation were interviewed and examined by a board-certified sleep medicine physician (JK, AW). Patients suspected of having OSA were invited to undergo an overnight, attended polysomnography. All sleep studies are conducted with real time monitoring by certified sleep technicians. Data obtained during each study included oxygen saturation by pulse oximeter, nasal and oral airflow, thoraco-abdominal excursions, electroencephalogram (EEG), electro-oculogram (EOG), electromyogram (EMG), and single-lead electrocardiogram (ECG). Each study was scored according to international consensus guidelines and confirmed by the sleep physicians. Hypopneas were defined as periods lasting at least 10 s in which nasal airflow decreased at least 50 %, thoraco-abdominal effort persisted and oxygen saturation reduction ≥4 %. Apneas were defined as at least 90 % reduction in nasal airflow persisting for at least 10 s. Obstructive apneas were scored if there was ongoing thoracoabdominal effort, whereas central apneas were scored when respiratory effort was absent. The apnea-hypopnea index (AHI) was reported as the average number of apneic and hypopneic episodes per hour. Among individuals with AHI≥30 without a significant number of central events (
