FA et

Apnée du Sommeil

La RéunionOctobre 2017

Pascal DefayeCHU Grenoble-Alpes

Richard L. Verrier, and Mark E. Josephson Circ Arrhythm Electrophysiol. 2009;2:450-459

HR 2,18

Obstructive Sleep Apnea and AFIncidence of atrial fibrillation (AF), based on presence or absence of OSA.

Cumulative frequency curves for incident AF for subjects

Gami AS et al.Circulation 2004;110:364-67

49%

32%

Association between AF and OSA(uni and multivariate analysis)

OSA screening in a general cardiology population(554 patients)

Prevalence and incidence

Prevalence and incidence

First data in 1983 : 400 patients with severe SAS :

AF prevalence : 2,5%,

Mean FU : 3 yearsGuilleminault et al. Am J Cardiol 52(5):490-494

Sleep Heart Health Study : AF prevalence

4,8 % in case of SAS < > 0,9% withoutMehra R et coll. Am J respir Crit Care Med 2006;173:906-916

Circulation 2007; 115: 1703-9

This population was not known to have SAS

Epidemiology of SAS : patients with pacemaker

44 pts

708y, 32 M

BMI 26.24.2

LVEF 4321%

Epworth 6.14.1 (15% > 10)

Garrigue, Pepin, Defaye, Circulation 2007; 115: 1703-9

There is no significant correlation between the AHI and the Epworth score

Kreuz J et al. Am J Cardiol 2013;111:1319-23

133 patients, 82 (62%) had SDB

Arrhythmia & Electrophysiology Review 2015;4(1):14–8

Pathophysiological mechanisms contributing to AF in OSA

Somers V J Clin Invest 1995;96:1897-1904

VasoconstrictionAcute BP elevationsAcute tachycardia

Mechanisms of arrhythmias in OSA

Goyal SK World J Cardiol 2013;5:157-163

Mechanisms of atrial fibrillation in OSA

obstructive

mixed

central

Increased respiratory efforts with large variations in intrathoracic pressures

Conduction impairment relatedto increased vagal tone owingto persistent breathing efforts against UA collapse

Acute diastolic dysfunction

Left atrial enlargment

Goyal SK World J Cardiol 2013;5:157-163

Mechanisms of atrial fibrillation in OSA

Dimitri H Heart Rhythm. 2012 ;9:321-7

Atrial remodelingin obstructive sleep apnea

Electroanatomic voltage maps Atrial enlargement,

Reduction in voltage,

site specific and widespreadconduction abnormalities,

and longer sinus node recovery

AF ablation : 20 patients with SAS/ 20 reference patients

Circulation 2017;136:583–596Electroanatomical maps and electrophysiological parameters in different AF substrate

J Am Coll Cardiol 2014;64:2013–23

Drager LF, JACC 2013:62:569-76

Sleep apnea is a multimorbid disease. Obstructive Sleep Apnea: A CardioMetabolic Risk in Obesity and Metabolic Syndrome

Chamberlain AM, et al. Metabolic syndrome and incidence of atrial fibrillation among blacks and whites in the Atherosclerosis Risk in Communities (ARIC) Study. Am Heart J. 2010;159:850–856.

Association of risk factors with AF development.

Stevenson I . Eur Heart J 2008;29:1662-69

Atrial fibrillation burden increases with sleep apnea severity

Atrial Fibrillation during OSA

Monahan K Am J Cardiol 2012, 110:369-72

The rate of non-response to pharmacologic treatmentincreases with the increase in OSA severity

Kanagala et al.Circulation 2003;107:2589-2594

Direct current cardioversionR

ecur

renc

e of

atr

ial f

ibri

llatio

n (%

)

01020304050607080

Controls CPAP OSA

Johnson KG et al. J Clin Sleep Med 2010; 6:131-7

OSA prevalence in stroke patients

Redline S et al. AJRCCM 2010;182:269-77

5422 participants followed median 8.7 years 193 incident ischemic strokes observed

In the mild to moderate range (OAHI 5 to 25), one unit increase in OAHI in men was estimated to increase stroke risk by 6%

Incident stroke and sleep apnea

Sleep Med 2013;14:243–246

Patients with OSA who had a stroke had higher rates of AF even after accounting for potential confounders

Olmsted county

Modify CHA2DS2 Vasc score by adding one extra “S” at the end (CHA2DS3 Vasc )? Barone DA Curr Atheroscler Rep. 2013;15:334

Hazard ratio of each variable of the CHA2DS2 Vasc score to predict stroke issimilar or lower to the hazard ratio of OSA (with the exception of prior stroke)

Am J Cardiol 2015;116:1781-1788

Am J Cardiol 2015;116:1781-1788

Circulation 2017;136:583–596Major AF mechanisms related to risk factors.

J Am Coll Cardiol 2015;66:2899–906

Cardiometabolic risk factors contribute to the development and consequences of AF and can be modified by weight loss, exercise, and management of comorbidcardiac risk factors

Components of risk factor modificationin ARREST-AF and LEGACY studies

Kaplan-Meier curves of various lifestyle modifications

Lau DH. Circulation. 2017;136:583–596.

Europace 2010; 12: 1084-89

Patel D et al. Circ Arrhythm Electrophysiol2010;3:445-51

3000 AF ablationWith SAS screening

HR

Ablation resultimprovement if

treatment of SAS withCPAP

Recurrence factor after ablation failure

Naruse Y et al. Heart Rhythm 2013;10:331–337

Patients with untreated OSA have a higher recurrence of AF after ablationN=153, prospective study

Concomitant obstructive sleep apnea increases the recurrence of atrial fibrillation following RF catheter ablation

Patients with OSA hada 31% greater risk of AF recurrence aftercatheter ablationthan did patients

without OSA

Europace 2014 ; 16 :1309–1314

OSA and risk of recurrence of AF

Am J Cardiol 2015;116:1767-1773

Relationship of CPAP with recurrence riskof atrial fibrillation

Heart Rhythm, October 2017

Conclusion SAS has an significant impact on the occurrence of AF For AF therapy (drugs, electrical CV & AF ablation) OSAS is an independent

predictive factor of failureThe association between OSA and stroke may, in part, be due

to the increased incidence of atrial fibrillation Treatment with CPAP has the potential to : reduce or eliminate AF be a complement to AAR drugs or ablation to improve the result of the treatment

Implantable devices (ICD++, PM) may be useful in the diagnostic and follow-up of SAS and AF prevalence in patients with pacing/ICD indication

Cardiologist should care about sleep apnea in case of AF and particularly failure of AF ablation

SASFourth pillar of

AF care.

FA �et� Apnée du SommeilObstructive Sleep Apnea and AFPrevalence and incidencePrevalence and incidenceEpidemiology of SAS : patients with pacemakerDiapositive numéro 6Diapositive numéro 7Pathophysiological mechanisms contributing to AF in OSAMechanisms of arrhythmias in OSAMechanisms of atrial fibrillation in OSAIncreased respiratory efforts with large variations in intrathoracic pressuresMechanisms of atrial fibrillation in OSAAtrial remodeling� in obstructive sleep apneaDiapositive numéro 14Diapositive numéro 15Sleep apnea is a multimorbid disease. Obstructive Sleep Apnea: A CardioMetabolic Risk in Obesity and Metabolic SyndromeDiapositive numéro 17Atrial Fibrillation during OSAThe rate of non-response to pharmacologic treatment increases with the increase in OSA severityDirect current cardioversionOSA prevalence in stroke patientsIncident stroke and sleep apneaDiapositive numéro 23Hazard ratio of each variable of the CHA2DS2 Vasc score to predict stroke is similar or lower to the hazard ratio of OSA (with the exception of prior stroke)Diapositive numéro 25Diapositive numéro 26Diapositive numéro 27Diapositive numéro 28Diapositive numéro 29Diapositive numéro 30Recurrence factor after ablation failureConcomitant obstructive sleep apnea increases the recurrence of atrial fibrillation following RF catheter ablation OSA and risk of recurrence of AFDiapositive numéro 35Diapositive numéro 36Diapositive numéro 37Diapositive numéro 38ConclusionDiapositive numéro 40