Sleep Apnea Treatment and AF Ablation Outcomes
Several studies have observed associations between AF and OSA. Epidemiological data suggest AF prevalence and progression are linked with OSA severity,313,314 whereas observational data have linked OSA with a more severely remodeled atrial substrate.311 Treatment of OSA with CPAP, however, appears to favorably impact AF management, regardless of the rhythm control strategy adopted.315,316
Several studies have examined the impact of CPAP intervention on arrhythmia-free survival following catheter ablation of AF.283,289,290,291,316,317,318,319 Although OSA has been associated with poorer outcomes, CPAP appears to attenuate the deleterious impact of OSA. Pooled analysis suggests that although OSA increases the risk of AF recurrence following ablation (RR 1.31; 95% CI 1.16–1.48; P <.001), CPAP therapy improves ablation success to rates comparable with non-OSA populations (RR 1.25; 95% CI 0.77–2.03; P = .37).320 Nonuse of CPAP increases the risk of recurrent AF after ablation by 57% (RR 1.57; 95% CI 1.36–1.81; P <.001).320 One study demonstrated an increased prevalence of non-PV triggers in patients with OSA.290
The observational nature of the literature that evaluates CPAP use in OSA, however, limits its generalizability and precision. In most studies, formal sleep studies were not used to systematically screen all patients for sleep apnea. Clinical history or diagnostic questionnaires (e.g., Berlin questionnaire) formed the basis of OSA diagnosis in some, whereas the diagnosis was rarely excluded by sleep study in non-OSA groups.283,289,290,291,316 Similarly, treatment efficacy was assessed by self-reported CPAP use.289,290,291,316 These study deficiencies lead to a poorly defined treatment effect of CPAP on AF recurrence after ablation.
A survey of the writing group shows that 80% of the writing group members screen for signs and symptoms of sleep apnea when evaluating patients for an AF ablation procedure. This survey also revealed that 94% refer patients being evaluated for an AF ablation procedure, in whom signs and symptoms of sleep apnea are detected, to a sleep center for evaluation and management of sleep apnea. Eighty-six percent of the writing group members currently have ready access to a sleep program at their center.