Paroxysmal atrial fibrillation

Dear Editor

We were delighted to see Obstructive Sleep Apnoea (OSA) flagged as a common risk factor for development of atrial fibrillation, with severe OSA increasing risk by 3.31 (95%CI 2.53-4.35). Patients with AF may not complain of OSA symptoms, so routine referral for sleep studies should be considered, potentially using STOP-BANG questionnaire for OSA assessment (1).

Effective treatment of OSA with CPAP (continuous positive airway pressure) has been shown in non-randomised studies to help maintain sinus rhythm after electrical cardioversion and catheter ablation in patients with AF and prevent progression to more permanent forms of AF (2,3). Robust randomised clinical trials are needed to confirm this and to establish whether early CPAP could even be sufficient as a therapy for AF and PAF. NICE OSA Guidelines advise prioritisation of OSA assessment and treatment in patients with unstable cardiovascular disease and poorly controlled arrhythmia (4). We suggest this should be considered prior to electrical cardioversion and catheter ablation in patients with AF, alongside the assessment of other risk factors.

1. Chung F, Abdullah HR, Liao P. STOP-Bang Questionnaire: A Practical Approach to Screen for Obstructive Sleep Apnea. Chest. 2016 Mar;149(3):631-8.
2. WT Qureshi et al. Meta-Analysis of Continuous Positive Airway Pressure as a Therapy of Atrial Fibrillation in Obstructive Sleep Apnea. Am J Cardiol. 2015 Dec 1;116(11):1767-73
3. F Holmqvist et al. Impact of obstructive sleep apnea and continuous positive airway pressure therapy on outcomes in patients with atrial fibrillation-Results from the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation (ORBIT-AF). Am Heart J. 2015 May;169(5):647-654.e2.
4. Obstructive sleep apnoea/hypopnoea syndrome and obesity hypoventilation syndrome in over 16s. NICE guideline [NG202] Published: 20 August 2021