FA et Apnée du Sommeil

Transcription

1 FA et Apnée du Sommeil La Réunion Octobre 2017 Pascal Defaye CHU Grenoble-Alpes

2 Obstructive Sleep Apnea and AF Incidence of atrial fibrillation (AF), based on presence or absence of OSA. Cumulative frequency curves for incident AF for subjects <65 years of age with and without OSA during an average 4.7 years of follow-up (P=0.002). HR 2,18 Richard L. Verrier, and Mark E. Josephson Circ Arrhythm Electrophysiol. 2009;2:

3 Gami AS et al.circulation 2004;110: Prevalence and incidence OSA screening in a general cardiology population (554 patients) 49% 32% Association between AF and OSA (uni and multivariate analysis)

4 First data in 1983 : Prevalence and incidence 400 patients with severe SAS : AF prevalence : 2,5%, Mean FU : 3 years Guilleminault et al. Am J Cardiol 52(5): Sleep Heart Health Study : AF prevalence 4,8 % in case of SAS < > 0,9% without Mehra R et coll. Am J respir Crit Care Med 2006;173:

5 Epidemiology of SAS : patients with pacemaker 44 pts 70 8y, 32 M BMI LVEF 43 21% Epworth (15% > 10) This population was not known to have SAS Circulation 2007; 115:

6 There is no significant correlation between the AHI and the Epworth score Garrigue, Pepin, Defaye, Circulation 2007; 115:

7 133 patients, 82 (62%) had SDB Kreuz J et al. Am J Cardiol 2013;111:

8 Pathophysiological mechanisms contributing to AF in OSA Arrhythmia & Electrophysiology Review 2015;4(1):14 8

9 Mechanisms of arrhythmias in OSA Vasoconstriction Acute BP elevations Acute tachycardia Somers V J Clin Invest 1995;96:

10 Mechanisms of atrial fibrillation in OSA Goyal SK World J Cardiol 2013;5:

11 Increased respiratory efforts with large variations in intrathoracic pressures Conduction impairment related to increased vagal tone owing to persistent breathing efforts against UA collapse obstructive central Acute diastolic dysfunction Left atrial enlargment mixed

12 Mechanisms of atrial fibrillation in OSA Goyal SK World J Cardiol 2013;5:

13 Atrial remodeling in obstructive sleep apnea AF ablation : 20 patients with SAS/ 20 reference patients Electroanatomic voltage maps Atrial enlargement, Reduction in voltage, site specific and widespread conduction abnormalities, and longer sinus node recovery Dimitri H Heart Rhythm ;9:321-7

14 Electroanatomical maps and electrophysiological parameters in different AF substrate Circulation 2017;136:

15 J Am Coll Cardiol 2014; 64:

16 Sleep apnea is a multimorbid disease. Obstructive Sleep Apnea: A CardioMetabolic Risk in Obesity and Metabolic Syndrome Drager LF, JACC 2013:62:569-76

17 Association of risk factors with AF development. Chamberlain AM, et al. Metabolic syndrome and incidence of atrial fibrillation among blacks and whites in the Atherosclerosis Risk in Communities (ARIC) Study. Am Heart J. 2010;159:

18 Atrial Fibrillation during OSA Stevenson I. Eur Heart J 2008; 29: Atrial fibrillation burden increases with sleep apnea severity

19 The rate of non-response to pharmacologic treatment increases with the increase in OSA severity Monahan K Am J Cardiol 2012, 110:369-72

20 Recurrence of atrial fibrillation (%) Direct current cardioversion Controls CPAP OSA Kanagala et al.circulation 2003;107:

21 OSA prevalence in stroke patients Johnson KG et al. J Clin Sleep Med 2010; 6:131-7

22 Incident stroke and sleep apnea In the mild to moderate range (OAHI 5 to 25), one unit increase in OAHI in men was estimated to increase stroke risk by 6% 5422 participants followed median 8.7 years 193 incident ischemic strokes observed Redline S et al. AJRCCM 2010;182:269-77

23 Olmsted county Patients with OSA who had a stroke had higher rates of AF even after accounting for potential confounders Sleep Med 2013;14:

24 Hazard ratio of each variable of the CHA 2 DS 2 Vasc score to predict stroke is similar or lower to the hazard ratio of OSA (with the exception of prior stroke) Modify CHA 2 DS 2 Vasc score by adding one extra S at the end (CHA 2 DS 3 Vasc )? Barone DA Curr Atheroscler Rep. 2013;15:334

25 Am J Cardiol 2015;116:

26 Am J Cardiol 2015;116:

27 Major AF mechanisms related to risk factors. Circulation 2017;136:

28 Cardiometabolic risk factors contribute to the development and consequences of AF and can be modified by weight loss, exercise, and management of comorbid cardiac risk factors J Am Coll Cardiol 2015;66:

29 Kaplan-Meier curves of various lifestyle modifications Components of risk factor modification in ARREST-AF and LEGACY studies Lau DH. Circulation. 2017;136:

30 Europace 2010; 12:

31 Recurrence factor after ablation failure 3000 AF ablation With SAS screening HR Ablation result improvement if treatment of SAS with CPAP Patel D et al. Circ Arrhythm Electrophysiol 2010;3:445-51

32 Concomitant obstructive sleep apnea increases the recurrence of atrial fibrillation following RF catheter ablation Patients with untreated OSA have a higher recurrence of AF after ablation N=153, prospective study Naruse Y et al. Heart Rhythm 2013;10:

33 OSA and risk of recurrence of AF Patients with OSA had a 31% greater risk of AF recurrence after catheter ablation than did patients without OSA Europace 2014 ; 16 :

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36 Relationship of CPAP with recurrence risk of atrial fibrillation Am J Cardiol 2015;116:

37 Heart Rhythm, October 2017

38 Conclusion SAS has an significant impact on the occurrence of AF For AF therapy (drugs, electrical CV & AF ablation) OSAS is an independent predictive factor of failure The association between OSA and stroke may, in part, be due to the increased incidence of atrial fibrillation Treatment with CPAP has the potential to : reduce or eliminate AF be a complement to AAR drugs or ablation to improve the result of the treatment Implantable devices (ICD++, PM) may be useful in the diagnostic and followup of SAS and AF prevalence in patients with pacing/icd indication Cardiologist should care about sleep apnea in case of AF and particularly failure of AF ablation

39 SAS Fourth pillar of AF care.