Running  Head:  SLEEP  APNEA  &  ATRIAL  FIBRILLATION  

 

Relationship Between Sleep Apnea & Atrial Fibrillation

Turner Curry, Joel Hake, Joe Wrask

04/25/2018

NURS 3947: Nursing Research

Dr. Patricia Hoyson & Dr. Mary Shortreed

 
  
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Abstract

The purpose of this research was to find whether there is a significant relationship between sleep

apnea and atrial fibrillation. Given the six articles of research that was gathered, it was concluded

that there was in fact a significant relationship between sleep apnea and atrial fibrillation. It was

also found that elderly people (around 60 years or older) had a higher risk of having atrial

fibrillation. Other risk factors for AF that went along with sleep apnea included diabetes mellitus,

cardiovascular diseases, and metabolic diseases. Many people in these studies who already had

atrial fibrillation and sleep apnea could only manage their AF with digitalis, antiarrhythmic drugs

and warfarin. Others opted for treatment of AF with catheter ablation. Overall, it was found that

sleep apnea can increase the risk of getting atrial fibrillation in certain cases.
  
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Relationship Between Sleep Apnea & Atrial Fibrillation

A good night sleep is something that everyone should get. While someone is sleeping, it

gives the body time to relax and essentially get a reboost for the next day. Sometimes, things can

happen during sleep that someone might not be aware of. This is called sleep apnea. Basically,

sleep apnea is when there is a blockage of air going to the lungs. While this happens, you are

essentially not breathing for ten seconds or more. During this time, the body tries to adapt,

putting more work load on the heart - rather than it being relaxed. Too much of this stress can

lead to more problems - one of which is atrial fibrillation. To prevent this from happening, the

person at risk should be aware of the signs and symptoms and see their doctor if any of these

occur. Sleep apnea occurs in many people and it can easily go unnoticed. A person might feel

tired throughout the day or even fall asleep at their desk. A sleep study will be given to a patient

suspected for sleep apnea and will be referred to a sleep facility. With one night sleep during the

study, the sleep technicians will be able to diagnose whether the patient has sleep apnea or not.

Heart anomalies and sleep apnea often “run together”. However, there hasn’t been much research

on whether or not sleep apnea causes atrial fibrillation. That leads us to the question: Does sleep

apnea cause or increase the risk of atrial fibrillation?

Literature Review

Introduction

Information was gathered from various databases including: OhioLINK, EBSCOhost,

and ProQuest. Six articles were chosen to extract information from. Information found included:

the relationship between sleep apnea and atrial fibrillation, ways to diagnose sleep apnea, and

treatment methods. These will be discussed in this research report.

  
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Sleep Apnea

Sleep apnea is a very common disorder among adults and it usually can go undiagnosed.

Risk factors include: obesity, age, male, family history, heart disorders, diabetes, smoking,

alcohol, etc. According to Erdogan et al. (2009), cardiovascular disease and sleep apnea are

closely associated with each other and can cause arrythmias and other anomalies - one of which

is atrial fibrillation (Erdogan et al., 2009, p. 211). Prevention is key to stopping the onset of sleep

apnea. Factors as simple as diet and exercise can be ways to help prevent sleep apnea.

Atrial Fibrillation

Atrial fibrillation occurs when there is a “quiver” and the atria is not in sync with the

ventricles. According to Hendrikx et al. (2017), people with severe sleep apnea reported having

atrial fibrillation - which is 4 times more than someone without sleep apnea. Atrial fibrillation

also occurs more often in older people. “Atrial fibrillation occurs in about 4% of subjects in the

population aged 60–69 years and in about 10% of subjects aged 70– 79 years” (Hendrikx et al.

2017, p. 2). In a study done by Erdogan et al. (2009), the authors found that there was relatively

no difference between the severity of sleep apnea and the occurrence of atrial fibrillation

(Erdogan et al. 2009, p. 213). This suggest that even the slightest occurrence of sleep apnea, over

a prolonged period of time, can provoke atrial fibrillation. Risk factors for AF are very similar to

sleep apnea risk factors, if not the same. This is why atrial fibrillation and sleep apnea are so

closely correlated.

Treatment

Treatment of sleep apnea is crucial in preventing further health complications, especially

atrial fibrillation. Some of these treatments consist of: lifestyle changes - like losing weight -
  
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exercise, diet, and cessation of tobacco usage. CPAP, or continuous positive airway pressure, is

the main treatment for sleep apnea in which a fitted mask with a hose allows airflow without

disturbance throughout the night. Atrial fibrillation can also be life-threatening if not treated.

Electrical cardioversion and anti-arrhythmic drugs are common treatments, along with a

procedure called pulmonary vein isolation. In pulmonary vein isolation, a catheter is used to

electrically destroy sensory tissue causing irregular impulses, and forming scar tissue around

them.

A study by Fein et al.(2013), focuses of CPAP and pulmonary vein isolation. The study

included 62 patients with atrial fibrillation and sleep apnea. All 62 patients underwent pulmonary

vein isolation to treat their atrial fibrillation. Even though PVI is an effective treatment, it often

results in a recurrence of atrial fibrillation. Of the 62 patients, 32 of them also used CPAP to treat

their sleep apnea, while 30 did not. The recurrence rate of atrial fibrillation in patients who used

CPAP to treat their sleep apnea was significantly lower (Fein et al. 2013). This study shows how

treating sleep apnea can prevent atrial fibrillation from developing because sleep apnea is a

contributing cause of atrial fibrillation.

Correlation between Sleep Apnea and Atrial Fibrillation

Sleep apnea is thought to be a contributing cause of atrial

fibrillation. A few ways in which sleep apnea causes atrial

fibrillation include: periodic nighttime hypoxemia and hypercapnia,

increased blood pressure and volume during apneic episodes leading

to left atrial stretching, and increased oxidative stress and

inflammation leading to left atrial damage (Porthan et al, 2004).

Atrial Fibrillation is also brought on by a number of other causes. As

  
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stated previously, coronary artery disease is a complication that

does in fact lead to atrial fibrillation. As Zhoa et al. (2009) stated,

atrial fibrillation becomes a large problem on a postoperative

patient that has received an coronary artery bypass graft. Zhoa et

al. (2009) adds that having atrial fibrillation after this bypass graft

can even lead to complications such as stroke and heart failure. With

such horrific complications, it seems necessary to find a correlation

between atrial fibrillation resulting from the coronary artery

bypass graft. Knowing which patients are at a higher risk for atrial

fibrillation after the graft would be a huge advantage in preventive

care. In fact, a few studies show that sleep apnea relates to the

occurrence of atrial fibrillation (Zhoa et al, 2009). With all of these

moving parts, Zhoa et al. (2009) concluded that a study must be

performed to determine whether or not sleep apnea affects the

results of atrial fibrillation occuring in a postoperative CABG

patient. The patients that were scheduled for the graft received a

preoperative sleep study using a portable wrist device monitoring

their sleep patterns (Zhoa et al, 2009). This helped to establish the

number of patients who fell under the sleep apnea category. Of the

160 patients in the study, 80% of the patients ended up having an

  
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apnea-hypopnea index ≥5, which classified them for falling in the

sleep apnea category (Zhoa et al, 2009).

Post-CABG AF developed in 36 patients, giving an incidence of 22.5%. The incidence of

post-CABG AF was higher in the sleep apnea group than the non–sleep apnea group

(24.8% vs 9.7%; P = .07) (Zhoa et al, 2009, p. 3).

Although the number of patients participating in the study was a small group, the results were

accurate on what Zhoa et al. (2009) had said about sleep apnea increasing the risk for atrial

fibrillation. With sleep apnea affecting the heart and leading to a higher risk for atrial fibrillation,

the category of sleep disordered breathing (SDB) sparked an interest with Mehra et al. (2006), as

they believed that SDB would cause cardiac arrhythmias due to intermittent hypoxia. The results

found were that the people with SDB and atrial fibrillation were 5.3% vs the people that did not

have SDB but did have cardiac arrhythmias at 1.2% (Mehra et al, 2006). Using tools like an

EKG and sleep monitor help to assure accuracy of the study. However, the amount of sleep

disordered breathing in one night makes it hard to get an accurate result in any study.

Throughout the study, Mehra et al. (2006) adds that the SDB patients already had more risk

factors of cardiac disease than the non SDB groups such as a high BMI, diabetes, and high

cholesterol that needed to be taken into fact. Sleep apnea and atrial fibrillation continue to be a

major problem in the health care and more precautions must be taken to help decrease the rate of

people with these diseases. Risk factors include: obesity, age, male, family history, heart

disorders, diabetes, smoking, alcohol, etc. (Erdogan et al, 2009). Working on the modifiable risk

factors like obesity, smoking, and alcohol can all attribute to lowering the chances of developing

sleep apnea or atrial fibrillation. Although sleep apnea is prevalent in today's medical care,

unfortunately, the obstructive and hypoxic condition goes undiagnosed in 12 to 18 million

  
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Americans currently (Zhoa et al, 2009). Looking into both of the studies, there is a definite

correlation between sleep apnea and atrial fibrillation and that sleep apnea does in fact increase

the risk for a person to develop atrial fibrillation.

Conclusion

When analyzing a variety of scholarly studies for a relationship between sleep apnea and atrial

fibrillation, it was determined that sleep apnea is indeed a contributing cause of atrial fibrillation.

Patients are more likely to develop atrial fibrillation if they have sleep apnea, and especially if

they do not treat their sleep apnea. Other risk factors for atrial fibrillation include: obesity,

diabetes mellitus, high blood pressure, hyperlipidemia, coronary artery disease, and smoking. If a

person has some of these factors along with sleep apnea, it can put them at high risk for

developing atrial fibrillation. It is important to treat sleep apnea to prevent atrial fibrillation and

to treat atrial fibrillation in itself, to prevent stroke or sudden death.

  
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References

Erdogan, A., Parahuleva, M., Schaefer, S., Guettler, N., Neuhof, C., Akcay, B., Bilgin, M.,

Mayer, K., Reichenberger, F., & Schulz, R. (2009). Prevalence of atrial fibrillation in

obstructive sleep apnea. Somnologie, 13, 211-214. doi: 10.1007/s11818-009-0444-2

Fein, A.S., Shvilkin, A., Shah, D., Haffajee, C., & Das, S. (2013). Treatment of obstructive sleep

apnea reduces the risk of atrial fibrillation recurrence after catheter ablation. Journal of

the American College of Cardiology, 62, 300-305.doi: 10.1016/j.jacc.2013.03.052

Hendrikx, T., Sundqvist, M., Sandstrom, H., Sahlin, C., Rohani, M., Al-Khalili, F., Hornsten, R.,

Blomberg, A., Wester, P., Rosenqvist, M., & Franklin, K. (2017). Atrial fibrillation

among patients under investigation for suspected obstructive sleep apnea. PLos ONE, 12,

1-9. doi: 10.1371/journal.pone.0171575

Mehra, R., Benjamin, E.J., Shahar, E., & Gottlieb, D.J. (2006). Association of nocturnal
  
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arrhythmias with sleep disordered breathing: the sleep heart health study. American

Journal of Respiratory and Critical Care Medicine, 173, 910-916. doi:

10.1164/rccm.200509-1442OC

Porthan, K.M., Melin, J.H., Kupila, J.T., Venho, K.K.K., & Partinen, M.M. (2004). Prevalence

of sleep apnea syndrome in lone atrial fibrillation. American College of Chest Physicians,

125, 879-885. doi: 10.1016/j.rehab.2016.07.181

Zhao, L., Kofidis, T., Lim, T., Chan, S., & Thun, H. (2015). Sleep apnea is associated with

newonset atrial fibrillation after coronary artery bypass grafting. Journal of Critical Care,

30, 1418.e1-1418.e5. Doi:

http://dx.doi.org.proxy.ohiolink.edu:9099/10.1016/j.jcrc.2015.07.00