Revised AF Screening Recommendations for Patients With OSA: European Society of Cardiology (2020) Guidelines

Cardio May Blog1 Afib
Cardio May Blog1 Afib

Optimal management of OSA may be considered to reduce AF incidence, progression, recurrences, and symptoms.

Screening for AF should be considered in patients with OSA.

The newly revised European Society of Cardiology (ESC) guidelines for the diagnosis and management of atrial fibrillation (AF) recommend that screening for AF should be considered in patients with obstructive sleep apnea (OSA).

Furthermore, screening for OSA and OSA treatment for patients with symptomatic AF prior to the start of rhythm control therapy is recommended because treatment for OSA may reduce the need for rhythm control therapy as well as the recurrence, progression, and symptoms of AF. 

The revised guidelines emphasize that addressing the combination of cardiovascular risk factors as well as a range of comorbidities is found to reduce the lifetime risk of developing AF. 

The specific comorbidities include hypertension, heart failure, coronary artery disease, diabetes mellitus, and sleep apnea, as these may contribute to atrial remodeling, cardiomyopathy, and development of AF. 

OSA is the most common form of sleep-disordered breathing. OSA is highly prevalent in patients with AF, heart failure, and hypertension and is associated with increased risk of mortality and major cardiovascular events.

The revised recommendations regarding OSA screening are based upon the following:  

  • A high prevalence of OSA found among patients with AF
  • A well-defined mechanism by which OSA contributes to AF development
  • OSA, when present, can reduce the success of the treatment of AF
  • Availability of effective and reliable in-home methods for OSA screening and treatment  

High Prevalence of OSA in AF Patients

The basis of  the ESC clinical recommendations for screening for OSA in patients with AF is due to the high prevalence. One prospective study examined  consecutive patients undergoing electrocardioversion for AF (n=151) with  patients without past or current AF who were referred to a general cardiology practice (n=312).2 Patients in both groups were similar in age, gender, body mass index, diabetes rates, hypertension, and congestive heart failure. The results show a significantly higher  proportion of OSA in the AF group (49% [95% CI, .41%-57%] versus the general cardiology group (32% [95% CI, 27%-37%]; P<0.0004.)2 Additionally, the Sleep Heart Study demonstrated a risk of AF 4 times greater in patients with sleep-disordered breathing (both OSA and central sleep apnea) compared with patients with no sleep-disordered breathing.3

Well-Defined Pathophysiological Mechanism 

The pathophysiological mechanisms by which OSA promotes AF include repeated intermittent episodes of nocturnal hypoxia and hypercapnia, triggering a chemoreflex and enhancement of sympathetic nerve activity. The chemoreflex and sympathetic nerve activity can lead to tachycardia and elevated blood pressure which increase myocardial oxygen demand under hypoxic conditions, resulting in repeated myocardial and atrial ischemia during sleep, leading to AF.

OSA Screening and Treatment May Ameliorate AF Recurrence

The presence of OSA is shown to reduce success rates of antiarrhythmic drugs, electrical cardioversion, and catheter ablation in AF.4 Individuals with untreated OSA have a higher recurrence of AF after cardioversion than individuals without OSA. However, appropriate treatment of OSA with continuous positive airway pressure (CPAP) therapy is associated with lower recurrence of AF, and recent studies show that CPAP treatment for OSA reverses atrial remodeling in OSA.

Several methods of screening for OSA are available, including an in-home device for use during sleep to detect periods of apnea. The gold standard for OSA therapy is CPAP. The positive pressure keeps the pharyngeal area from collapsing and thus helps alleviate the airway obstruction.4 Data show that the treatment of OSA with CPAP may ameliorate OSA effects on the recurrence of AF and may improve rhythm control in patients with AF.5 

In conclusion, based upon the revised 2020 ESC guidelines, optimal management of OSA (see also: home sleep apnea testing) may be considered to reduce AF incidence, progression, recurrence, and symptoms. Consequently,  screening for AF should be considered in patients with OSA.1


  1. Hindricks G, Potpara T, Nikolaos D, et al; ESC Scientific Document Group. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J. 2020;42(5):373-498. doi: 10.1093/eurheartj/ehaa612
  2. Gami AS, Pressman G, Caples SM, et al. Association of atrial fibrillation and obstructive sleep apnea. Circulation. 2004;110(4):364-367. doi: 10.1161/01.CIR.0000136587.68725.8E
  3. Mehra R, Benjamin EJ, Shahar E, et al. Association of nocturnal arrhythmias with sleep-disordered breathing: the sleep heart health study. Am J Respir Crit Care Med. 2006;173(8):  910-916. doi: 10.1164/rccm.200509-1442OC
  4. Goudis CA, Ketikoglou DG. Obstructive sleep and atrial fibrillation: pathophysiological mechanisms and therapeutic implications. Int J Cardiol. 2017;230:293-300. doi: 10.1016/j.ijcard.2016.12.120 
  5. Linz D, McEvoy RD, Cowie MR, et al. Associations of obstructive sleep apnea with atrial fibrillation and continuous positive airway pressure treatment: a review. JAMA Cardiol. 2018;3(6):532-540. doi: 10.1001/jamacardio.2018.0095
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