Atrial fibrillation may be reduced in sleep apnoea patients using airway pressure therapy and ablation

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Continuous positive airway pressure may help to reduce atrial fibrillation recurrence in patients with obstructive sleep apnoea undergoing pulmonary vein isolation, a study published ahead of print in the Journal of the American College of Cardiology (JACC) has found.

“Obstructive sleep apnoea is increasingly recognised as a potential risk factor for the development of atrial fibrillation,” Adam S Fein (Harvard Thorndike Electrophysiology Institute, Cardiovascular Division, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA) and others wrote. “While continuous positive airway pressure has been shown to decrease atrial fibrillation recurrence following cardioversion, its effect on arrhythmia control in patients undergoing atrial fibrillation ablation procedures is unknown.” Therefore, the researchers set out to examine the effect of this therapy on atrial fibrillation recurrence in patients with obstructive sleep apnoea undergoing pulmonary vein isolation.


The study included 426 patients with symptomatic atrial fibrillation who were referred to the Beth Israel Deaconess Medical Center from July 2007 to January 2010. Fein
et al found that 62 patients had a polysomnography-confirmed diagnosis of obstructive sleep apnoea, 32 of those were using continuous positive airway pressure; the remaining 30 were non-users. The researchers analysed both groups individually and against two control groups a group of 30 patients without obstructive sleep apnoea undergoing pulmonary vein isolation, and a group of 22 obstructive sleep apnoea patients managed medically.


According to the authors, the majority of patients were hypertensive and male, they were borderline obese. There was an equal split between persistent and paroxysmal atrial fibrillation patients, and they were treated with an average of 1.4 antiarrhythmic drugs.


The primary endpoint of the study was freedom from atrial fibrillation and/or organised atrial tachyarrhythmias at one year after the first ablation procedure. The secondary endpoint was freedom from atrial fibrillation and/or organised atrial tachyarrhythmias at one year off antiarrhythmic drugs or redo ablation procedures, Fein et al noted.


Results


A higher atrial fibrillation free survival rate (71.9%) was perceived in patients using continuous airway pressure therapy compared to non-users (36.7%) and atrial fibrillation free survival off anti-arrhythmic medications or repeat ablation following pulmonary vein isolation was also higher compared to non-users (65.6% vs. 33.3%).


Atrial fibrillation recurrence rate of patients treated with continuous positive airway pressure was similar to the group of patients without obstructive sleep apnoea.


Atrial fibrillation recurrence following pulmonary vein isolation in non-users of continuous positive airway pressure was significantly higher and similar to that of obstructive sleep apnoea patients under medication without ablation.

“Our analysis shows that continuous positive airway pressure therapy is associated with better procedurial outcome in the obstructive sleep apnoea patient population undergoing pulmonary vein isolation,” Fein et al wrote. “We demonstrated continuous positive airway pressure to be so efficacious that obstructive sleep apnoea treated patients had an arrhythmia recurrence rate that matched that of patients without the diagnosis of obstructive sleep apnoea.”


The authors also highlighted that “pulmonary vein isolation offered minimal benefits to obstructive sleep apnoea patients that were not compliant with continuous positive airway pressure, with rates of atrial fibrillation recurrence no different than obstructive sleep apnoea patients managed medically.”


“These findings suggest that unless a patient is ‘optimised’ from the standpoint of obstructive sleep apnoea, there may be little value in pursuing invasive treatment procedures,” the authors concluded.


Bernard Belhassen (Department of Cardiology, Tel-Aviv Sourasky Medical Center, Tel-Aviv and Sackler School of Medicine, Tel-Aviv University, Israel) wrote in an accompanying editorial: “Treatment of obstructive sleep apnoea before ablation can help reduce atrial fibrillation recurrence, allowing for more efficient treatment of atrial fibrillation. It is thus important for physicians to monitor atrial fibrillation patients for obstructive sleep apnoea and monitor those with obstructive sleep apnoea for atrial fibrillation.”


Belhassen also recomended physicians to undertake randomised controlled trials to confirm these initial results.


Elad Anter, Cardiac Electrophysiology Beth Israel Deaconess Medical Center, Harvard Medical School, senior author of the study told Cardiac Rhythm News: “Obstructive sleep apnoea is common in patients with atrial fibrillation and is probably under recognised. Detection and treatment of sleep apnoea in these patients is important and allows for more effective therapies.”