Should targeted sleep assessment be a routine component of atrial fibrillation care?

Take Home Messages
  • Obstructive sleep apnoea (OSA) directly predisposes to the development and progression of atrial fibrillation (AF) via multiple mechanisms.
  • Circa 50% of patients with AF have clinically relevant OSA.
  • The presence of AF should be considered a possible direct consequence of OSA.
  • AF patients with OSA do not report characteristic symptoms – typical questionnaire-based screening is ineffective and OSA should be screened for in the presence of risk factors.
  • Systematic sleep evaluation should be undertaken for all patients eligible for rhythm control or with cardiovascular comorbidity such as hypertension.
  • Currently, 10.8% of cardiology departments have a structured OSA pathway.
  • Treatment with CPAP significantly reduces major adverse cardiovascular events, stroke, hypertension, AF recurrence and progression.

Atrial fibrillation (AF) is the most common sustained arrhythmia, with an estimated 1 in 3 lifetime risk and a 2.3 fold rise in prevalence is predicted(1). AF is independently associated with a 1.5-2 fold increase in all-cause mortality(2), a 5-fold increased risk of stroke, with 15-20% of all strokes being attributed to the arrhythmia(3), risk of cognitive impairment (RR 1.4)(4), and impaired quality of life(5). AF accounts for circa 1% of the NHS budget and is predicted to increase to 1.35 – 4.27% of NHS expenditure over the next twenty years(6).

The symptomatic benefits of early rhythm control are well established(7)(8)(9). Recently, important data from the EAST AF trial demonstrated improved outcomes – HR 0.79 for major adverse cardiovascular events (95% CI 0.66-0.94) in patients managed with an early rhythm control strategy(10). Whilst rhythm control using drugs and catheter ablation have been extensively investigated, they remain individual elements of a wider integrated, holistic approach to AF.

Comorbidity contributes to AF incidence and progression. Most commonly, hypertension, diabetes mellitus, heart failure, coronary artery disease, chronic kidney disease, obesity, obstructive sleep apnoea and chronic inflammation(11). This is reflected in the holistic, three pillar approach recommended by the ESC – The ‘ABC Pathway’ – A: Anticoagulation, B: Better symptom management, C: Cardiovascular and comorbidity optimisation(12). The AFFIRM trial has demonstrated a significantly lower risk of all-cause mortality (HR 0.35), first hospitalisation (HR 0.65) and stroke/major bleeding/cardiovascular death (HR 0.35) for patients managed within ABC guidelines(13).