A new scientific statement from the American Heart Association (AHA) provides guidance about sleep-disordered breathing and its association with the development of cardiac arrhythmia.
Published in Circulation, the analysis was authored by a panel led by Reena Mehra and Mina Chung (both Cleveland Clinic, Cleveland, USA) as chair and vice chair. The statement provides data showing the potential value of how sleep-disordered breathing treatment affects cardiac arrhythmias beneficially and thereby can improve patient outcomes.
Studies have shown that the physiological stress of sleep-disordered breathing has sustained biological effects, which alter the structure of the heart and increase risk for heart arrhythmias. In uncontrolled studies, treatment of sleep-disordered breathing has been shown to reduce recurrence of arrhythmia after interventions such as catheter ablation and cardioversion for atrial fibrillation (AF).
“Strong evidence indicates that sleep-disordered breathing can lead to severe health consequences, which can directly affect cardiac function,” says Mehra. “Our panel’s data synthesis is designed to increase knowledge and awareness of the existing science in this area.”
“The association of sleep apnoea and obesity with atrial fibrillation has made identification and treatment of sleep-disordered breathing and weight loss an important part of lifestyle and risk factor reduction in the treatment of atrial fibrillation,” adds Chung.
The evidence for the scientific statement came from data reviews conducted by the author panel from large retrospective and prospective trials. The statement was peer reviewed by outside experts in epidemiology and clinical, translational and experimental research focused on sleep-disordered breathing or cardiac arrhythmias. The panel’s findings are not formal clinical recommendations but rather considerations and suggestions for best clinical practice.
The panel’s key conclusions include the following:
- Day-night patterning and circadian biology of sleep-disordered breathing-induced consequences jointly influence the structural and electrophysiological structure of the heart, creating an ideal setting for cardiac arrhythmias to occur
- Cohort studies support strong associations between sleep-disordered breathing and cardiac arrhythmia, providing evidence that discrete episodes of stopping breathing trigger atrial and ventricular arrhythmia events.
- Observational evidence suggests that treating sleep-disordered breathing lessens AF recurrence after rhythm control interventions (such as ablation and cardioversion), but there are currently no high-level evidence from randomised trials supporting a role for sleep-disordered breathing intervention in rhythm control.
- Opportunities exist to optimise sleep-disordered breathing screening, characterise sleep-disordered breathing predictive metrics and underlying pathophysiology, elucidate sex- and race/ethnicity-specific influences in sleep-disordered breathing, assess the role of mobile health innovations, and prioritise conduct of rigorous and sufficiently powered clinical trials.
Sleep-disordered breathing subtypes relevant to the AHA document include obstructive sleep apnoea (OSA), central sleep apnoea (CSA), and CSA–Cheyne-Stokes breathing (CSB).
While noting that many observational studies suggest that treatment of sleep-disordered breathing improves atrial fibrillation outcomes, the panel identifies confirmation of this association in randomised controlled trials as a research priority. “Currently there are only small or limited randomised studies that have addressed sleep-disordered breathing and atrial fibrillation, and they have shown conflicting results,” Chung says.
“We definitely need adequately powered, rigorously designed randomised controlled trials to ascertain whether intervening in patients with sleep-disordered breathing actually improves arrhythmia outcomes,” Mehra adds. “The bulk of the data we have are for atrial fibrillation, and research is needed on other arrhythmias and on the impact of other factors, such as health disparities.”