false
Catalog
EP on EP Episode 62 - Obstructive Sleep Apnea and ...
EP on EP Episode 62_ Obstructive Sleep Apnea and A ...
EP on EP Episode 62_ Obstructive Sleep Apnea and AFib (1)
Back to course
[Please upgrade your browser to play this video content]
Video Transcription
Hi, this is Eric Prostowski. Welcome to another episode of EP on EP. Today, I'm delighted to have as my guest, Dr. Sunit Mittal, who is the Director of Electrophysiology at Valley Hospital in Ridgewood, New Jersey. So, great to have you here and we're going to talk about obstructive sleep apnea. So, thanks for coming. I really appreciate it. So, let me pose the question to you in a really kind of dummy sort of way. Do I really need to worry about obstructive sleep apnea? And I don't mean as a general medical issue, but about AFib. What are the data and what are your thoughts on that? Well, I wish I could tell you the answer and I'm going to say that I don't know. But let's talk a little bit about how we got here in the first place. So, of course, AFib is the reason we've been interested recently in our patients with obstructive sleep apnea. Why? Because we've learned in the last couple of years that risk factor modification may be an important component of therapy in patients with atrial fibrillation. So, we've started to recognize the importance of exercise, maybe keeping them off of alcohol. And sleep apnea has become very important because when you think about it, obesity is what's driving everything. So, obesity leads to issues with weight gain, maybe also important with issues of sleep apnea. So, all electrophysiologists now, we've started to recognize, hey, we better figure out whether our patients have sleep apnea or not. Now, when you think about it fundamental in that is the fact or the assumption that if we could figure that out, whether they had sleep apnea or not, treat that, that potentially we could help improve their atrial fibrillation as well as their overall well-being. And that's where the question really is still unanswered. Are we ready to say that that's really the case? Diagnosis, treatment is actually leading to better outcomes with respect to atrial fibrillation and more importantly maybe other hard endpoints in cardiovascular outcomes. So, that's what people have proposed because if you read, for example, I know you do atrial fibrillation and there are a whole bunch of papers out there that say if you have obstructive sleep apnea, your outcomes aren't as good. I never quite understood that. Actually, we published a paper not that long ago. We looked and we didn't find any difference in at least our study, but that's just one study. So, that got a lot of people thinking, right? That, well, maybe if I treat the sleep apnea, my outcomes will be better. But are there any outcome studies in the AFib space, not general medicine, that have said, yes, you'll do better arrhythmia-wise if you treat sleep apnea? Yeah, and this is where it's difficult because we rely a lot on observational studies. So, there's no question that there are certain labs that have looked at large cohorts of their own patients who have been ablated and have found that patients who had sleep apnea did worse with ablation and they did particularly bad if they had sleep apnea that was untreated. But I think we have to step back and recognize that those studies have limitations. One, patients are diagnosed with sleep apnea in a wide variety of ways, sometimes relying on just history taking, sometimes relying on questionnaires with various sensitivities and specificities, sometimes on various types of home sleep studies, and rarely using in-lab sleep studies, which is considered the gold standard. Afterwards, of course, you know, when you do an ablation, the ablation is not standardized. Different patients undergo different levels of ablation. And then the therapy is often not standardized. Some people get dental appliances. Some people get CPAP. More recently, some people get implantable devices. And we're not very good at tracking adherence to these systems. So, one observational study may not match, as was the case in your experience. I should add that although we tend to focus a lot on the studies that show a benefit, we sometimes don't focus a lot on the studies that don't show benefit. Just like you found, there have been other studies that have not found a benefit. Recently, there have been two that I've been intrigued by. One, a Mayo Clinic study, looking at patients who had AFib, had confirmed sleep apnea, underwent cardioversion. They were randomized to CPAP or no CPAP. Surprisingly, no difference in outcomes as reflected by likelihood of recurrent AFib. Small study, but really provocative. Another study from the Penn Group, they saw what is the value of a nurse-led risk factor modification clinic. So, they randomized patients into those who were nurse-led risk factor modification and usual care. Now, interestingly, when you had a nurse-led risk factor modification clinic, these patients lost weight. They were significantly more likely to be adherent with CPAP therapy. But, you know, when they saw what happened to their patients a year later, no difference in the likelihood whether they had AFib or not. So, I think the jury's out. So, I think it's really interesting. Did they go backwards and forget the risk factors, or did they keep the risk factor modification and it still didn't have an effect? That's the thing. So, in this group, the patients lost weight. They were diagnosed with sleep apnea. They were treated for sleep apnea. But, at the end of a year, they made no difference in the outcomes whether they were medically treated or underwent catheter ablation. And so, I think this speaks to the fact that what we really need is a randomized clinical trial in this space to demonstrate whether, certainly if you're using AFib as an endpoint, whether it makes a difference or not. And those trials have to have some standard definition of what sleep apnea is, what is an abnormal sleep test, and what the ablation protocol may look like in those patients. So, I think this is fascinating because over the years, I have seen, I thought if I treated the sleep apnea early on, when we all got involved in this, that I would be doing some really good. And I was disappointed to see that as I monitored the patients and didn't do anything else, they still had AFib. So, I've come to a more practical view, and I would be curious to get your input. I think it's good to treat sleep apnea for other reasons, right? Just how people feel. You don't like to see that large right ventricle on the echo. I can't imagine that being good for the patient. So, I'm still a proponent of having it treated, but I always tell the patient, don't think this is going to make a major difference. So, it sounds like that's what you're saying. Yeah, and I think even there we have some challenges because if you look at symptoms, and I'm going to focus on the things that are more readily available to us. Are they fatigued? Do they have daytime sleepiness or not? It turns out only about a third of the patients have these symptoms. So, even when you treat for symptoms, you have to recognize at least in the AFib population, maybe two-thirds of the patients won't even have symptoms that they can define. Of course, you and I, I'm sure, have had patients where they say, listen, before you made me go through all of this, I was sleeping great. I felt nothing. Now, I'm on CPAP. I can't sleep at night. I feel terrible. So, it's a two-edged sword. Now, we also, of course, want to focus on other non-AF related cardiovascular outcomes, but even there, you know, there have been large randomized clinical trials that haven't been able to show conclusive evidence in cardiovascular outcomes irrespective of severity of sleep apnea, how often they were using the CPAP machine, and so it does give you pause for caution about extrapolating too much about existing observational studies. So, if I had to summarize what I think I'm hearing from you is that at the moment, we can't really tell a patient we're going to make you better AFib-wise by treating your sleep apnea. If they're symptomatic, though, it seems like a rational thing to do as long as the patient will adhere to whatever therapy is, and beyond that, we need more data. Does that make sense? I think so, and I certainly think for the symptomatic ones or the ones that are snoring heavily, their spouses certainly will be happy that they're being treated. That is definitely true. But I think to argue that this is going to treat their AFib, we certainly need randomized clinical trials. I'm on the same page with you. Suneet, thank you for coming. Thank you for having me. I really appreciate it. Thank you so much. Thank you.
Video Summary
In this episode of EP on EP, Eric Prostowski interviews Dr. Sunit Mittal about the relationship between obstructive sleep apnea (OSA) and atrial fibrillation (AFib). They discuss the importance of risk factor modification in AFib patients and how OSA, often caused by obesity, is a significant risk factor. However, the impact of treating OSA on AFib outcomes is still unclear. Observational studies have shown mixed results, with some suggesting a benefit while others have not found a difference. Randomized clinical trials are needed to determine if treating OSA improves AFib outcomes. In the meantime, treating OSA for symptom relief and overall well-being is reasonable.
Keywords
EP on EP
interview
obstructive sleep apnea
atrial fibrillation
risk factor modification
Heart Rhythm Society
1325 G Street NW, Suite 500
Washington, DC 20005
P: 202-464-3400 F: 202-464-3401
E: questions@heartrhythm365.org
© Heart Rhythm Society
Privacy Policy
|
Cookie Declaration
|
Linking Policy
|
Patient Education Disclaimer
|
State Nonprofit Disclosures
|
FAQ
×
Please select your language
1
English