Clinical Briefing: Continuous Positive Airway Pressure Therapy for Patients with Obstructive Sleep Apnea and Atrial Fibrillation
March/April 2009
The Penn Sleep Centers are currently using continuous
positive airway pressure (CPAP) to treat patients with
obstructive sleep apnea (OSA) who have atrial fibrillation.
The primary therapy for OSA, CPAP has known antihypertensive and
antisympathetic effects, and has been demonstrated to reduce the risk
of recurrent atrial fibrillation.
Obstructive sleep apnea is characterized by repetitive pharyngeal
collapse during sleep resulting in blockage of the airway,
hypoxia and sleep disruption. OSA is very common in the US population—
recent data suggests that approximately 20 percent of the
population is affected. Multiple studies have demonstrated a strong association
between atrial fibrillation and OSA. Patients with OSA are
more likely to have atrial fibrillation than patients without OSA.
Furthermore,
in patients that undergo cardioversion for atrial fibrillation,
OSA—if present—has been associated with a high rate of atrial
fibrillation recurrence. Emerging data continues to elucidate
the pathophysiological relationship between OSA and atrial fibrillation.
The hypoxemia and hypercapnea that occur in OSA are known
to be arrhythmogenic. Other effects of the disorder, including increased
sympathetic drive and elevated C-reactive protein levels,
are associated with the pathogenesis of atrial fibrillation.
The Penn Sleep Centers have been using new CPAP technology
to improve patient adherence to therapy and allow physicians to
track information on patient’s sleeping patterns. In addition to alerting
the patient and Sleep Center staff when there is a mask leak, the
new technology provides information on whether apnea has been
eliminated and whether themachine is being used on a nightly basis.
CASE STUDY
Mr. J, a 49-year-old man presented to the Emergency Department
(ED) with palpitations, light-headedness and shortness of
breath. He denied chest pain. His symptoms had started 2 hours
prior, during the night (at approximately 11pm) and woke him from
sleep. His medical history was significant only for paroxysmal atrial
fibrillation and hypertension for which the patient was taking HCTZ
25mg once daily.
In the past, he had one episode of atrial fibrillation
confirmed by EKG at his primary physician’s office. The episode was
self-limited and resolved without specific intervention within 24
hours of onset. At that time, nuclear stress testing was negative for
ischemia and echocardiogram revealed left ventricular hypertrophy
and mildly elevated pulmonary artery pressure. Thyroid functions
were within normal limits.
Figure 1. Macroglossia and tongue ridging
in a patient with OSA.
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Examination in the ED revealed an obese
man, in respiratory distress with blood pressure of 77/45 and a heart
rate of 165/minute. EKG confirmed atrial fibrillation with rapid ventricular
response; ST segments appeared normal. Cardiac enzymes
were within normal limits. Cardioversion with 100J successfully converted
the patient to sinus rhythm.
A review of the patient’s history
found excessive daytime somnolence and loud snoring. Focused
upper airway examination revealed macroglossia, tongue ridging
and a crowded oropharynx (Fig. 1). Mr. J had an overnight
polysomnogram (Fig. 2) as an outpatient, which confirmed severe
obstructive sleep apnea associated with severe oxyhemoglobin
desaturation (oxyhemoglobin nadir = 75%). The apnea/hypopnea
index equaled 37 events per hour. CPAP therapy was commenced.
One year later, the patient continued to be compliant with CPAP
therapy. His excessive daytime somnolence had markedly improved,
his BMI had decreased after having initiated a regular exercise
routine and no further episodes of atrial fibrillation had occurred.
Figure 2. Polysomnogram demonstrating severe oxyhemoglobin
desaturation in a patient with OSA.
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Our Team of Faculty
Comprised of a consortium of clinicians from the departments of
medicine, neurology, psychiatry, otorhinolaryngology and oral and
maxillofacial surgery, the Penn Sleep Center is one of only three sleep
centers in the United States designated by the National Institutes of
Health as a specialized center for research in sleep. This concentration
of physicians from different departments permits a comprehensive
approach to the diagnosis and treatment of sleep disorders and their
comorbidities. With seven locations in the Philadelphia area, the Sleep
Center currently performs more than 5,000 sleep studies each year.
Allan I. Pack, MB, ChB, PhD
Chief, Division of Sleep Medicine
Professor of Medicine
Charles R. Cantor, MD, DABSM
Medical Director, Penn Sleep Centers
Clinical Associate Professor of Neurology
Maria Antoniou, MD, DABSM
Assistant Professor of Clinical Medicine
Eliot Friedman, MD
Instructor in Medicine
Philip Gehrman, PhD, CBSM
Assistant Professor of Psychiatry
Nalaka S. Gooneratne, MD, DABSM
Assistant Professor of Medicine
Indira Gurubhagavatula, MD, MPH
Assistant Professor of Medicine
Nirav Patel, MD
Assistant Professor of Clinical Medicine
Grace W. Pien, MD, MSCE, DABSM
Assistant Professor of Medicine
David M. Raizen, MD, PhD, DABSM
Assistant Professor of Neurology
Ilene M. Rosen, MD, MSCE, DABSM
Assistant Professor of Clinical Medicine
Aharon E. Sareli, MD
Assistant Professor of Clinical Medicine
Sharon L. Schutte-Rodin, MD, DABSM
Clinical Associate Professor of Medicine
Richard J. Schwab, MD, DABSM
Professor of Medicine
Sigrid C. Veasey, MD, DABSM
Associate Professor of Medicine
Mark Wu, MD, PhD
Instructor in Neurology
Access
Patient appointments are available at:
Penn Sleep Centers
Hospital of the University of Pennsylvania***†
11th Floor, Gates Building
3400 Spruce Street
Philadelphia, PA 19104
Penn Sleep Center*†
3624 Market Street, Suite 201
Philadelphia, PA 19104
Pennsylvania Hospital*
800 Spruce Street
Philadelphia, PA 19107
Penn Medicine at Radnor**†
250 King of Prussia Road
2nd Floor
Radnor, PA, 19087
Penn Sleep Center at the Sheraton University City Hotel***†
36th & Chestnut Streets
Philadelphia, PA 19104
Penn Sleep Center at the Pavilion at Doyestown Hospital***
599 West State Street, Suite 101
Doylestown, PA 18901
Penn Sleep Center at the Hilton Homewood Suites***†
681 Shannondell Blvd.
Audubon, PA 19403
† A facility of the Hospital of the University of Pennsylvania
* Indicates overnight sleep study site and sleep specialist site
** Indicates sleep specialist site
*** Indicates overnight sleep study site
To refer a patient and/or consult with a doctor:
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