Chapter 4 68 Sleep-disordered breathing (SDB), of which obstructive sleep apnea is the most common subtype, has been shown to be highly prevalent in patients with atrial fibrillation (AF) (1). The arrhythmogenic mechanisms of SDB facilitating AF include nocturnal high-frequency desaturation and reoxygenation, intrathoracic pressure changes and sympathovagal activation (2). This provokes progressive structural atrial remodelling in long-term SDB, creating a complex and dynamic substrate for AF. Therefore, concomitant SDB and AF is associated with lower success rates of anti-arrhythmic therapy with increased risk of AF recurrence (3). Sleep apnea in patients scheduled for AF ablation is highly underdiagnosed. The OSA-AF study, published in the current edition of the IJC Heart & Vasculature, focused on the association of undiagnosed SDB on the outcome of AF catheter ablation in 164 patients (4). After exclusion of patients with previously diagnosed SDB (n = 30), 104 of 134 eligible patients were enrolled and underwent SDB screening. The median AHI was 11.5 (interquartile range 6.8–21.9) and 39 patients (38%) had SDB which was undiagnosed during the first year after ablation. AF recurrence in the first year after catheter ablation occurred in 40 patients (38%). The risk of AF recurrence was higher in the group with undiagnosed SDB in comparison to those without SDB (51% versus 31%, P = 0.04). Interestingly, the prevalence of AF recurrence was similar between patients with previously diagnosed and undiagnosed SDB (51% versus 50%, P = 0.92). This study shows that a significant proportion of patients undergoing catheter ablation of AF have undiagnosed SDB which is associated with a twofold higher risk of AF recurrence. Given the high prevalence and negative prognostic factor on AF outcomes, undiagnosed SDB is an underutilized modifiable AF risk factor and component of antiarrhythmic management. However, identifying SDB is difficult as most patients with AF do not report typical SDB-related symptoms as daytime sleepiness (5). Self-reported questionnaires on SDB-related symptoms, even if combined with basic clinical characteristics, seem insufficient in detecting SDB in AF patients (5). Additionally, a joint survey by the European Heart Rhythm Association (EHRA) and the Association of Cardiovascular Nurses and Allied Professions (ACNAP) recently identified a number of challenges occur in SDB management in patients with AF. A majority of health care professionals reported a missing collaboration between cardiology and sleep clinic as well as lack of financial and personnel related resources as major barriers in a systematical SDB screening (6). Further, access to polysomnography (PSG) based SDB screening, the current gold-standard, is limited due to various reasons. Polygraphy based home sleep testing may be a solution, as recent studies showed a high to fair sensitivity in detecting SDB when compared to PSG (7). Remote home SDB testing can herein provide accessible and reliable results with lower costs compared with conventional polysomnography (8). This can promote early detection and treatment of SDB in patients with AF. The relative cost of this approach could be justified by the benefits of improved treatment efficacy, which reduces medical and economic burden (see Fig. 1). The clinical challenge that remains is, however, identifying which patients need to be selected for SDB-screening. Current international AF management guidelines recommend identification and treatment of OSA in confirmed cases to help
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