Chapter 4 58 SDB is considered a modifiable risk factor for AF (1). The combination of LA remodelling and deranged neurohumoral and autonomic nervous activity seems to be responsible for the increased vulnerability for AF in SDB patients. Adequate treatment of SDB may reduce the development of AF and reduce AF burden. Randomized controlled trials have shown that aggressive treatment of modifiable risk factors for AF, including SDB, successfully reverses early onset AF (20–22). As SDB shares the same modifiable risk factors as AF, being hypertension, smoking, diabetes, hyperlipidaemia, alcohol, obesity, and physical inactivity (20), aggressive risk factor management may have a positive influence on both entities. In the clinical context of catheter ablation, the presence of SDB may also be important. Previous studies have shown a negative impact of SDB on the efficacy of catheter ablation of AF, with a 25% increased risk of AF recurrence (2–6). Interestingly, a meta-analysis demonstrated that SDB diagnosed by polysomnography (PSG) was a strong predictor of AF recurrence after catheter ablation, but not when SDB was diagnosed by the Berlin questionnaire (6). This suggests that the method of SDB screening is relevant to predict AF recurrence. Furthermore, treatment of appropriately diagnosed SDB with CPAP improves arrhythmia-free survival after catheter ablation in observational studies (8–10). The challenge is that screening for SDB is suboptimal in clinical practice. A large majority of patients with SDB remain undiagnosed as demonstrated by our study and others (13–15). Screening for SDB can be done with questionnaires (e.g., Berlin, STOP-BANG, ESS) but the accuracy of these questionnaires is limited, especially in patients with cardiovascular disease (13,23–24). Kadhim et al. previously demonstrated that excessive daytime sleepiness (ESS ≥ 11) was present in only 22 of 149 ambulatory patients (15%) with AF and moderate-to-severe SDB (AHI ≥ 15, assessed by PSG) (13). This low prevalence of excessive daytime sleepiness is also seen in our population and thus daytime sleepiness should not be used in clinical practice to select patients for SDB screening. Even more dedicated questionnaires such as STOP-BANG do not accurately predict SDB although patients with SDB did more often had an abnormal STOP-BANG score (24). Further research is needed before deciding on the most optimal screening method and the role of questionnaires. Currently, it is not clear whether it is cost-effective to perform SBD testing in every patient who is eligible for catheter ablation. Maybe it is more cost-
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