Editorial 69 maintain sinus rhythm. However, specific recommendations concerning when and how to test for SDB, remain uncertain. A systematic testing by home sleep test or respiratory polygraphy as well as structured SDB management pathways are often not established (6). The high prevalence and the negative prognostic effect of undiagnosed SDB on treatment efficacy in AF patients indicates a potentially high number of patients for SDB screening. Even with more cost effective and accessible SDB screening solutions, as for example home sleep tests, a pre-selection might therefore be necessary. We propose the assessment of pre-test probability of SDB based on SDB- related and clinical characteristics to further guide patient selection for SDB screening (2). However, evidence is needed for which patient characteristics or reported symptoms SDB screening is indicated in patients with AF. SDB screening can be reasonable in every patient who is experiencing SDB related symptoms. However, patients with difficult to treat hypertension or high AF symptom burden/AF recurrence can also benefit from SDB screening, as these conditions can be symptoms or consequences of SDB (9). Within AF patients, these might more often be patients who are scheduled for AF ablation or other rhythm control strategies, as investigated by the authors of the OSA-AF study, published in the current issue (4). However, the authors did not investigate consecutive AF patients and no prospective data was collected yet. Also, recent studies have demonstrated that OSA-severity exhibits considerable night-to-night variability, particularly in patients with cardiovascular disease, which cannot be detected by one overnight sleep assessment (10). The implementation of SDB screening and management in AF clinics requires a close interdisciplinary collaboration between the cardiologist and sleep specialists, ideally within an integrated care approach. Examples of integrated, multidisciplinary pathways for detection and treatment of SDB in patients with AF are slowly emerging. Previously, a virtual remote management pathway incorporating an mobile-health based overnight home sleep test was introduced in two AF outpatient clinics in the Netherlands (8). Integrated care pathways in this case can enable an interactive structured follow-up to assess AF burden, disease progression, and treatment efficacy. Simultaneously, the interactive feedback between patient and clinician may induce treatment success by empowering patient self-management through education. The majority of patients is not aware of the negative prognostic effects of SDB on AF (8). Educating and engaging patients supports informed decision making and adherence to treatment. Lifestyle intervention programs, such as sleep hygiene, alcohol abstinence and weight loss, could also be implemented as a component of the structured follow-up. Collectively, AF-SDB digital and remote monitoring tools may allow patient-tailored management decisions. Although the required technologies are available, implementation of SDB screening in AF clinics is complicated by lack of infrastructure and inflexible reimbursement models. SDB can probably be considered the most expensive cardiovascular risk factor in terms of its assessment. Management trials justifying SDB-screening and consecutive management are required to firmly establish the role of SDB treatment in AF management guidelines and thereby promote implementation in AF clinics. A systematical SDB screening approach can be considered relevant for patients with E5
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