Cardio Sleep Review

Dedicated to the Nexus of Cardiology and Sleep Apnea Management

Issue 1,

Comorbid Sleep Apnea and Atrial Fibrillation: Evidence Mounts, Awareness Slowly Follows

by Sree Roy
Chief Editor


Research linking AFib to sleep apnea has been steadily increasing. But the awareness that sleep apnea is a risk factor for AFib so far remains low. A recent survey of 1,013 Americans found that while nearly half are aware that the risk of developing AFib is increased by family history (48%) and hypertension (43%), only 16% knew that sleep apnea is a risk factor.1 Meanwhile, studies have found that treating obstructive sleep apnea can improve AFib outcomes. A meta-analysis published in 2015 linked CPAP use with a 42% relative risk reduction in AFib recurrence in patients with OSA post-ablation.”2 Active screening for obstructive sleep apnea in all patients who undergo treatment for atrial fibrillation is imperative as the use of CPAP will influence the outcome of therapy and likely reduce some of the cardiovascular morbidity associated with atrial fibrillation,” said study author and electrophysiologist Larry A. Chinitz. Cardiologist Ronald H. Wharton published a study that supports systematic sleep apnea screening for all patients in cardiology clinics.3 It found that body mass index (BMI) did not correlate to cardiology patients’ likelihood of sleep apnea or to OSA’s severity (as measured by AHI) The study concludes that wide screening should be done. Wharton says, “The cardiologist’s office is the natural place to look for sleep apnea; the patient population is naturally selected for you.” 

Wharton’s findings are in line with the European Society of Cardiology’s (ESC) AFib clinical practice guidelines issued in 2016, which state, “Interrogation for clinical signs of obstructive sleep apnea should be considered in all AF [atrial fibrillation] patients.”4


Though screening is relatively easy to implement (a sleep questionnaire can be administered at the initiation of the office visit), obstacles can arise during the referral and diagnosis process with sleep specialists.

“Interrogation for clinical signs of obstructive sleep apnea should be considered in all [AFib] patients.”

Sree Roy

Home sleep testing company Itamar® Medical began educating clinicians about the links between OSA and AFib in 2013 when CEO Gilad Glick joined. “I spent my first 20 years working for Biosense Webster (Johnson & Johnson). Still, to date, 1-year outcomes, measured in AFib recurrence rate, are a mixed bag with 50% to 60% success rate and a poor chance to predict which patients will do well,” Glick says in a phone interview. “Then came the ‘aha moment’: I was shown data that explained it all by Dr. Elad Anter, director of the electrophysiology lab at Beth Israel Deaconess Medical Center in Boston. This seemingly 50% outcome was made up of 2 groups: those with OSA who had a much lower result of <40%, and those without OSA or on an effective CPAP therapy with results of >70%. I realized it is probably sleep apnea causing such a big part of those failed ablations.”5


For patients who have been diagnosed with OSA and undergo ablation, Glick notes that sleep therapy is especially crucial in the time immediately following the AFib procedure. “It needs to be ensured that OSA is managed successfully…in what is called the ‘remodeling period,’ a period in which the electrical circuits in the heart are reforming around those ablation RF lines,” he says. Glick emphasizes that a simple, though not necessarily easy, solution is a “true seamless integration of sleep medicine into the AFib patient care pathway every step of the way,” He continues, “From systematic screening with a questionnaire when the patient shows up with the first symptoms of AFib in the cardiology office through a thorough explanation of the link between the two diseases by the electrophysiologists through an easy to do initial home sleep test (and if needed, a deeper polysomnography study) all the way to feeding back the CPAP compliance information right into the patient’s medical record so the electrophysiologist can know if the recurrence may be associated with lack of compliance or ineffectiveness of CPAP therapy.”

For full article go to: 


  1. iRhythm. September is national atrial fibrillation awareness month: survey shows Americans lack awareness about “afib,” its risk factors and symptoms. 22 Sept 2014.!74676
  2. Shukla A, Aizer A, Holmes D, et al. Effect of obstructive sleep apnea treatment on atrial fibrillation recurrence: a meta-analysis. JACC Clinical Electrophysiology. 2015;1(1-2):41-51.
  3. Zaremski L, Wharton R. Wide screening of obstructive sleep apnea in a cardiology clinic. Cardiovasc Investig. 2017;1:1.
  4. Kirchhof P, Benussi S, Kotecha D, et al. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J. 2016;37(38):2893–962.
  5. Fein AS, Shvilkin A, Shah D, et al. Treatment of obstructive sleep apnea reduces the risk of atrial fibrillation recurrence after catheter ablation. J Am Coll Cardiol.2013;62(4):300-5.

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Cardio Sleep Review
Publisher: Itamar Medical
Editor: Melih Alvo

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