Sleep-Disordered Breathing and Cardiac Arrhythmias

doi:10.1016/j.cjca.2015.04.022

Canadian Journal of Cardiology

Volume 31, Issue 7, July 2015, Pages 928-934

https://doi.org/10.1016/j.cjca.2015.04.022 Get rights and content

Abstract

Over the past few years sleep-disordered breathing has been identified as an important factor in arrhythmogenesis and a potential target of therapy to prevent cardiac arrhythmias in selected patients. In this review we highlight the role of obstructive sleep apnea and Cheyne-Stokes respiration in the pathophysiology of arrhythmias, address their clinical effect in supraventricular and ventricular tachyarrhythmias, and in conduction disturbances, and address the role of current treatment options for sleep-disordered breathing in the primary and secondary prevention of arrhythmic events.

Résumé

Au cours des dernières années, il a été reconnu que les troubles respiratoires du sommeil sont un facteur important de l’arythmogenèse et une cible potentielle de traitement pour prévenir les arythmies cardiaques chez certains patients. Dans cette revue, nous soulignons le rôle de l’apnée obstructive du sommeil et de la respiration de Cheyne-Stokes dans la physiopathologie des arythmies, abordons leurs conséquences cliniques dans les tachyarythmies supraventriculaires et ventriculaires, et dans les troubles de conduction, puis abordons le rôle des options actuelles de traitements contre les troubles respiratoires du sommeil dans la prévention primaire et secondaire des événements arythmiques.

Section snippets

Pathophysiological Effects of Sleep-Disordered Breathing

Adults spend 75%-85% of their total sleep time in nonrapid eye movement sleep, which is generally considered a time of parasympathetic tone predominance and cardiovascular quiescence with reduced sympathetic nerve system activity and altered cardiac repolarization that prevents patients from cardiac dysrhythmias.7, 8, 9, 10 Underlying mechanisms to understand the pathophysiological effects of sleep-disordered breathing (SDB) on arrhythmia evolution are currently under intensive investigation.

Clinical Effect of SDB

The clinical association between SDB and cardiac arrhythmias has been studied for 3 decades. Several population-based studies have shown an association between OSA and rhythm disorders.39, 40 Recently, a Brazilian study involving 767 volunteers demonstrated rhythm disturbances in 53.3% of the sample without SDB, and 92.3% of patients with severe OSA showed cardiac arrhythmias.⁴¹

Most of those arrhythmic events do not have prognostic relevance and thus need no specific treatment.¹ In this review

Summary

SDB seems to play an important role in the myocardial remodelling process and in triggering arrhythmic events. Recent clinical research has identified SDB as a significant risk factor that can be targeted in primary or secondary prevention of cardiac arrhythmias. Nocturnal ventilation treatment of SDB seems to prevent the occurrence and reoccurrence of arrhythmic events. However, one should keep in mind that although SDB therapy is helpful, it is not sufficient for preventing malignant

Disclosures

Thomas Bitter has received honoraria for lectures from ResMed Ltd. Olaf Oldenburg has received honoraria for lectures from ResMed Ltd and Philips Respironics. Henrik Fox, SaiPrassad Gaddam, and Dieter Horstkotte have no conflicts of interest to disclose.

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Cited by (27)

Sleep apnea and sudden death in the non-cardiac population: A systematic review
2024, Revista Portuguesa de Cardiologia
Obstructive sleep apnea (OSA) is one of the main risk factors for cardiovascular diseases and is associated with both morbidity and mortality. OSA has also been linked to arrhythmias and sudden death.
To assess whether OSA increases the risk of sudden death in the non-cardiac population.
This is a systematic review of the literature. The descriptors “sudden death” and “sleep apnea” and “tachyarrhythmias” and “sleep apnea” were searched in the PubMed/Medline and SciELO databases.
Thirteen articles that addressed the relationship between OSA and the development of tachyarrhythmias and/or sudden death with prevalence data, electrocardiographic findings, and a relationship with other comorbidities were selected. The airway obstruction observed in OSA triggers several systemic repercussions, e.g., changes in intrathoracic pressure, intermittent hypoxia, activation of the sympathetic nervous system and chemoreceptors, and release of catecholamines. These mechanisms would be implicated in the appearance of arrhythmogenic factors, which could result in sudden death.
There was a cause–effect relationship between OSA and cardiac arrhythmias. In view of the pathophysiology of OSA and its arrhythmogenic role, studies have shown a higher risk of sudden death in individuals who previously had heart disease. On the other hand, there is little evidence about the occurrence of sudden death in individuals with OSA and no heart disease, and OSA is not a risk factor for sudden death in this population.
A apneia obstrutiva do sono (AOS) é um dos principais fatores de risco para doenças cardiovasculares e está associada a relevante morbimortalidade. A AOS também tem sido relacionada com o desenvolvimento de arritmias e morte súbita.
Relacionar a AOS com o aumento do risco de morte súbita na população não cardiopata.
Trata-se de revisão sistemática da literatura. Foi realizada a pesquisa dos descritores “sudden death” and “sleep apnea” e “tachyarrhythmias” and “sleep apnea” nas plataformas Pubmed/Medline e SciELO.
Foram selecionados 13 estudos que abordavam a relação entre AOS e o desenvolvimento de taquiarritmias e/ou morte súbita com dados de prevalência, achados eletrocardiográficos e relação com outras comorbidades. A obstrução das vias aéreas observada na AOS desencadeia diversas repercussões sistémicas, como, por exemplo, alterações da pressão intratorácica, hipóxia intermitente, ativação do sistema nervoso simpático, ativação de quimiorreceptores e liberação de catecolaminas. Esses mecanismos estariam implicados no surgimento de fatores arritmogênicos, que poderiam implicar a ocorrência de morte súbita.
Verificou-se existência de relação causa-efeito entre AOS e arritmias cardíacas. Diante da fisiopatologia da AOS, no que tange ao seu papel arritmogênico, estudos demonstram maior risco de morte súbita em indivíduos previamente cardiopatas. Em contrapartida, existem poucas evidências sobre a ocorrência de morte súbita em indivíduos com AOS não cardiopatas, não se configurando a AOS por si um fator de risco para morte súbita nesta população.
2017 HRS/EHRA/ECAS/APHRS/SOLAECE expert consensus statement on catheter and surgical ablation of atrial fibrillation: Executive summary
2017, Journal of Arrhythmia
2017 HRS/EHRA/ECAS/APHRS/SOLAECE expert consensus statement on catheter and surgical ablation of atrial fibrillation
2017, Heart Rhythm
2017 HRS/EHRA/ECAS/APHRS/SOLAECE expert consensus statement on catheter and surgical ablation of atrial fibrillation: Executive summary
2017, Heart Rhythm
Sleep-Disordered Breathing and Arrhythmia in Heart Failure Patients
2017, Sleep Medicine Clinics
Citation Excerpt :
Explanations assumed to this circumstance, include that AF per se is associated with poor sleep quality, which makes identification of the additional comorbidity of SDB difficult.58 Apneas and hypopneas of SDB are often associated with excessive negative intrathoracic pressure changes that alter transmural pressures and cardiac and vessel volume relations30,59 (Fig. 2). SDB is believed to promote cardiac and, in particular, atrial remodeling.
Recurrent paroxysmal atrial fibrillation induced by marked hypoxia during sleep-disordered breathing
2016, Journal of Cardiology Cases
Sleep-disordered breathing (SDB) has a big impact on autonomic nervous activity and thus induces or deteriorates various cardiovascular diseases. We here describe a typical but rarely documented case which clearly indicates a strong link between SDB and cardiovascular disease. A 68-year-old woman complaining of frequent palpitations was referred to our institute. An electrocardiogram (ECG) at a previous clinic had shown atrial fibrillation, although it had already returned to sinus rhythm on arrival at our institute. Her body mass index was 32.5 kg/m² and she had a history of loud snoring. Simultaneous examinations of Holter ECG monitoring and ambulatory polysomnography (PSG) showed onset of paroxysmal atrial fibrillation following marked oxygen desaturation at midnight. In-hospital PSG revealed severe obstructive sleep apnea. A new device with desaturation triggered ambulatory blood pressure monitoring system performed 1 week later again showed a midnight onset of paroxysmal atrial fibrillation coincided with surge of blood pressure with marked desaturation. Her recurrence of palpitations had obviously decreased by continuous positive airway pressure therapy thereafter.
<Learning objective: A clinician should suspect sleep-disordered breathing (SDB) behind cardiac arrhythmia, especially if it is nocturnal. Nocturnal hypertension especially in obese patients may indicate SDB. Successful therapy for SDB by such as continuous positive airway pressure therapy attenuates sympatho-excitation and would improve the result of treatment of the arrhythmia.>

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ReviewSleep-Disordered Breathing and Cardiac Arrhythmias

Abstract

Résumé

Section snippets

Pathophysiological Effects of Sleep-Disordered Breathing

Clinical Effect of SDB

Summary

Disclosures

J Am Coll Cardiol

Am J Cardiol

Chest

Heart Rhythm

J Am Coll Cardiol

Heart Rhythm

Heart Rhythm

J Am Soc Echocardiogr

J Am Coll Cardiol

Chest

Am J Hypertens

Heart Rhythm

Chest

Chest

Lancet

Am J Cardiol

Chest

J Am Coll Cardiol

Chest

J Psychosom Res

Am J Cardiol

Heart Rhythm

J Am Coll Cardiol

Am J Cardiol

Am J Cardiol

J Am Coll Cardiol

Am J Cardiol

Chest

Am J Cardiol

Int J Cardiol

Am J Cardiol

Am J Med

Am J Cardiol

Mortality and morbidity in patients receiving ecainide, flecainide, or placebo. The Cardiac Arrhythia Suppression Trial

N Engl J Med

Reduction in inappropriate therapy and mortality through ICD programming

N Engl J Med

2013 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy: the Task Force on cardiac pacing and resynchronization therapy of the European Society of Cardiology (ESC). Developed in collaboration with the European Heart Rhythm Association

Eur Heart J

Epidemiologic assessment of chronic atrial fibrillation and the risk of stroke: the Framingham study

Neurology

Sleep and ventricular premature beats

Circulation

Autonomic activity during human sleep as a function of time and sleep stage

J Sleep Res

Circadian variation of beat-to-beat QT interval variability in patients with prior myocardial infarction and the effect of β-blocker therapy

Pacing Clin Electrophysiol

Circadian rhythms govern cardiac repolarization and arrhythmogenesis

Nature

Effect of renal denervation on neurohumoral activation triggering atrial fibrillation in obstructive sleep apnea

Hypertension

Changes in left and right ventricular mechanics during the Mueller maneuver in healthy adults

Circ Cardiovasc Imaging

Renal sympathetic denervation suppresses postapneic blood pressure rises and atrial fibrillation in a model for sleep apnea

Hypertension

Effect of hypoxia on sympathetic activity and blood pressure

Respir Physiol

Increased vasoconstrictor sensitivity in obstructive sleep apnea

J Appl Physiol

Review
Sleep-Disordered Breathing and Cardiac Arrhythmias