Multiple reports show that obstructive sleep apnea reduces the efficacy of catheter ablation treatment for atrial fibrillation.1-5 Indeed, severe obstructive sleep apnea is an independent risk factor for ablation failure.6 Moreover, continuous positive airway pressure (CPAP) treatment of patients with obstructive sleep apnea improves outcomes after catheter ablation to levels similar to patients without obstructive sleep apnea.7 While consensus statements recommend screening for obstructive sleep apnea prior to embarking on a rhythm control strategy,8 not all thought leaders agree.9 New work strongly supports the use of at-home sleep apnea screening in all patients with atrial fibrillation prior to pulmonary vein catheter ablation.10
Laboratory polysomnography is the key barrier to optimal care
Those who advise against screening for obstructive sleep apnea prior to ablation do so mainly because of the expense and logistical barriers to polysomnography.9 Admittedly, this is a concern. In-laboratory polysomnography does require a substantial commitment from patients. Each patient must stay overnight in a sleep lab and, if found to have sleep apnea, return for a second night for treatment titration. If we required laboratory polysomnography testing prior to catheter ablation, many patients would avoid catheter ablation altogether.
Sleepiness screening ineffective in AFib
Some experts advocate using daytime sleepiness screening as a more convenient, more cost-effective approach first step to sleep apnea screening. Utilizing methods such as the Epworth Sleepiness Scale, cardiologists could pre-screen patients for OSA then proceed with a full polysomnography study. One problem with this approach is that at least half of all patients with severe sleep apnea do not report symptoms of daytime sleepiness or restless sleep—a rate that may be even higher in patients with cardiovascular disease.10,11 Thus, using the Epworth Sleepiness Scale or other instruments to determine who should be sent for a sleep study misses more than 50% of the relevant population.
Home sleep apnea testing is accurate and convenient
One obvious way to overcome this barrier is to use an alternative to laboratory polysomnography that is both accurate and convenient. Indeed, at-home sleep apnea testing has progressed to the point that it is now a feasible diagnostic tool for obstructive, central, and mixed apneas.10,12-14 One successful approach has been to use a sensor package worn on the wrist and index finger that measures peripheral arterial tonometry, oxygen saturation, heart rate, wrist actigraphy, snoring, and body position (WatchPAT system). A proprietary algorithm provides highly accurate information on more than a dozen metrics, including the presence of obstructive sleep apnea and its severity.10,14,15 In short, at-home sleep apnea testing is accurate and clinically useful.
Nearly 100% of patients could perform home sleep apnea testing
Recent results by Tanaka and coauthors show almost all patients could set up and record data with the WatchPAT home sleep apnea testing system.10 As part of their study, researchers mailed the WatchPAT device to study participants with only the standard instructions found within the packaging. Remarkably, 774 out of 776 patients (99.7%) successfully generated data that could be used for analysis and diagnostic purposes. Not only did patients avoid a night in the sleep lab, but they were also able to generate accurate and usable sleep study data without direct medical observation in the home.
Patients scheduled for catheter ablation should undergo home sleep apnea testing
The Tanaka study answered several critical questions for cardiologists considering if and how to diagnose obstructive sleep apnea in their atrial fibrillation patients. First, the study adds to the long list of papers showing the insensitivity of daytime sleepiness screening for moderate or severe obstructive sleep apnea. Second, home sleep apnea testing—testing as efficacious as polysomnography—is convenient and easy to use for patients. Combined, these results strongly support the assertions of thought leaders16,17 that patients with atrial fibrillation receive obstructive sleep apnea testing prior to a pulmonary vein catheter ablation procedure.
1. Kawakami H, Nagai T, Fujii A, et al. Apnea-hypopnea index as a predictor of atrial fibrillation recurrence following initial pulmonary vein isolation: usefulness of type-3 portable monitor for sleep-disordered breathing. J Interv Card Electrophysiol. 2016;47(2):237-244. 10.1007/s10840-016-0148-z
2. Neilan TG, Farhad H, Dodson JA, et al. Effect of sleep apnea and continuous positive airway pressure on cardiac structure and recurrence of atrial fibrillation. J Am Heart Assoc. 2013;2(6):e000421. 10.1161/JAHA.113.000421
3. Ng CY, Liu T, Shehata M, Stevens S, Chugh SS, Wang X. Meta-analysis of obstructive sleep apnea as predictor of atrial fibrillation recurrence after catheter ablation. Am J Cardiol. 2011;108(1):47-51. 10.1016/j.amjcard.2011.02.343
4. Sauer WH, McKernan ML, Lin D, Gerstenfeld EP, Callans DJ, Marchlinski FE. Clinical predictors and outcomes associated with acute return of pulmonary vein conduction during pulmonary vein isolation for treatment of atrial fibrillation. Heart Rhythm. 2006;3(9):1024-1028. 10.1016/j.hrthm.2006.05.007
5. Szymanski FM, Filipiak KJ, Platek AE, et al. Presence and severity of obstructive sleep apnea and remote outcomes of atrial fibrillation ablations – a long-term prospective, cross-sectional cohort study. Sleep Breath. 2015;19(3):849-856. 10.1007/s11325-014-1102-x
6. Matiello M, Nadal M, Tamborero D, et al. Low efficacy of atrial fibrillation ablation in severe obstructive sleep apnoea patients. Europace. 2010;12(8):1084-1089. 10.1093/europace/euq128
7. Li L, Wang ZW, Li J, et al. Efficacy of catheter ablation of atrial fibrillation in patients with obstructive sleep apnoea with and without continuous positive airway pressure treatment: a meta-analysis of observational studies. Europace. 2014;16(9):1309-1314. 10.1093/europace/euu066
8. Calkins H, Hindricks G, Cappato R, et al. 2017 HRS/EHRA/ECAS/APHRS/SOLAECE expert consensus statement on catheter and surgical ablation of atrial fibrillation. Heart Rhythm. 2017;14(10):e275-e444. 10.1016/j.hrthm.2017.05.012
9. Mansukhani MP, Somers VK, Caples SM. COUNTERPOINT: Should All Patients With Atrial Fibrillation Who Are About to Undergo Pulmonary Vein Ablation Be Evaluated for OSA? No. Chest. 2018;154(5):1010-1012. 10.1016/j.chest.2018.06.041
10. Tanaka N, Tanaka K, Hirao Y, et al. Home Sleep Apnea Test to Screen Patients With Atrial Fibrillation for Sleep Apnea Prior to Catheter Ablation. Circ J. 2021;85(3):252-260. 10.1253/circj.CJ-20-0782
11. Somers VK, White DP, Amin R, et al. Sleep apnea and cardiovascular disease: an American Heart Association/American College of Cardiology Foundation Scientific Statement from the American Heart Association Council for High Blood Pressure Research Professional Education Committee, Council on Clinical Cardiology, Stroke Council, and Council on Cardiovascular Nursing. J Am Coll Cardiol. 2008;52(8):686-717. 10.1016/j.jacc.2008.05.002
12. Zancanella E, do Prado LF, de Carvalho LB, Machado Junior AJ, Crespo AN, do Prado GF. Home sleep apnea testing: an accuracy study. Sleep Breath. 2021. 10.1007/s11325-021-02372-6
13. Defaye P, de la Cruz I, Marti-Almor J, et al. A pacemaker transthoracic impedance sensor with an advanced algorithm to identify severe sleep apnea: the DREAM European study. Heart Rhythm. 2014;11(5):842-848. 10.1016/j.hrthm.2014.02.011
14. Epstein M, Musa T, Chiu S, et al. Use of the WatchPAT to detect occult residual sleep-disordered breathing in patients on CPAP for obstructive sleep apnea. J Clin Sleep Med. 2020;16(7):1073-1080. 10.5664/jcsm.8406
15. Pillar G, Berall M, Berry R, et al. Detecting central sleep apnea in adult patients using WatchPAT-a multicenter validation study. Sleep Breath. 2020;24(1):387-398. 10.1007/s11325-019-01904-5
16. Mehra R, Wazni O. POINT: Should All Patients With Atrial Fibrillation Who Are About to Undergo Pulmonary Vein Ablation Be Evaluated for OSA? Yes. Chest. 2018;154(5):1008-1010. 10.1016/j.chest.2018.06.042
17. January CT, Wann LS, Alpert JS, et al. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines and the Heart Rhythm Society. Circulation. 2014;130(23):2071-2104. 10.1161/CIR.0000000000000040