Sleep-disordered breathing as a risk factor for unnecessary pacemaker implantation
Abstract
Background: Sleep-disordered breathing (SDB) is a risk factor for bradyarrhythmia, which is reversible with positive airway pressure therapy.
Aims: The study aims to evaluate the occurrence and number of severe sinus bradycardia and advanced atrioventricular block (AVB) in patients with cardiovascular diseases and SDB risk factors.
Methods: The analysis covered 207 patients with cardiovascular diseases aged 59.4 (standard deviation [SD], 10.49) years, including 177 men (85.51%), hospitalized in the Department of Electro-cardiology and the Day Stay Cardiac Rehabilitation Ward Upper-Silesian Medical Centre in Katowice, Poland. The inclusion criterion was a high risk of SDB, in particular obstructive sleep apnea (OSA), in one of the following questionnaires: the Four-Variable Screening Tool, the STOP-Bang Questionnaire, and the Epworth Sleepiness Scale. Both level-3 portable sleep tests and electrocardiogram Holter recordings were made simultaneously.
Results: SDB was confirmed in 175 (84.5%) patients, including severe in 74 (35.7%), moderate in 42 (20.3%), and mild in 59 (28.5%) participants. The dominant type of SDB was OSA, which was found in 158 (76.3%) participants. The severe SDB was a predictor of third-degree AVB (odds ratio [OR], 11.61; 95% confidence interval [CI], 1.37–98.60), second-degree AVB type 2 (Mobitz) (OR, 4.51; 95% CI, 1.17–18.08), pauses above 3 seconds (OR, 10.26; 95% CI, 2.18–48.40), and sinus bradycardia below 40 bpm (OR, 3.00; 95% CI, 1.36–6.60) during sleep.
Conclusions: SDB, with particular emphasis on OSA, is a risk factor for sinus bradycardia and advanced AVB during sleep, which may lead to a hasty qualification for pacemaker implantation. The severity of SDB determines the frequency and number of bradyarrhythmic episodes.
Keywords: conduction disorderspacemaker implantationsleep-disordered breathing
References
- Shahar E, Whitney CW, Redline S, et al. Sleep-disordered breathing and cardiovascular disease: cross-sectional results of the Sleep Heart Health Study. Am J Respir Crit Care Med. 2001; 163(1): 19–25.
- Guilleminault C, Connolly SJ, Winkle RA. Cardiac arrhythmia and conduction disturbances during sleep in 400 patients with sleep apnea syndrome. Am J Cardiol. 1983; 52(5): 490–494.
- Gami AS, Olson EJ, Shen WK, et al. Obstructive sleep apnea and the risk of sudden cardiac death: a longitudinal study of 10,701 adults. J Am Coll Cardiol. 2013; 62(7): 610–616.
- Salman LA, Shulman R, Cohen JB. Obstructive sleep apnea, hypertension, and cardiovascular risk: epidemiology, pathophysiology, and management. Curr Cardiol Rep. 2020; 22(2): 6.
- Gottlieb DJ, Punjabi NM. Diagnosis and management of obstructive sleep apnea: a review. JAMA. 2020; 323(14): 1389–1400.
- Peppard PE, Young T, Barnet JH, et al. Increased prevalence of sleep-disordered breathing in adults. Am J Epidemiol. 2013; 177(9): 1006–1014.
- Arzt M, Woehrle H, Oldenburg O, et al. Prevalence and predictors of sleep-disordered breathing in patients with stable chronic heart failure: the schlahf registry. JACC Heart Fail. 2016; 4(2): 116–125.
- Somers VK, Dyken ME, Mark AL, et al. Parasympathetic hyperresponsiveness and bradyarrhythmias during apnoea in hypertension. Clin Auton Res. 1992; 2(3): 171–176.
- Simantirakis EN, Schiza SI, Marketou ME, et al. Severe bradyarrhythmias in patients with sleep apnoea: the effect of continuous positive airway pressure treatment: a long-term evaluation using an insertable loop recorder. Eur Heart J. 2004; 25(12): 1070–1076.
- Abe H, Takahashi M, Yaegashi H, et al. Efficacy of continuous positive airway pressure on arrhythmias in obstructive sleep apnea patients. Heart Vessels. 2010; 25(1): 63–69.
- Marin JM, Carrizo SJ, Vicente E, et al. Long-term cardiovascular outcomes in men with obstructive sleep apnoea-hypopnoea with or without treatment with continuous positive airway pressure: an observational study. Lancet. 2005; 365(9464): 1046–1053.
- Myllylä M, Hammais A, Stepanov M, et al. Nonfatal and fatal cardiovascular disease events in CPAP compliant obstructive sleep apnea patients. Sleep Breath. 2019; 23(4): 1209–1217.
- Wickwire EM, Bailey MD, Somers VK, et al. CPAP adherence reduces cardiovascular risk among older adults with obstructive sleep apnea. Sleep Breath. 2021; 25(3): 1343–1350.
- Takegami M, Hayashino Y, Chin K, et al. Simple four-variable screening tool for identification of patients with sleep-disordered breathing. Sleep. 2009; 32(7): 939–948.
- Pivetta B, Chen L, Nagappa M, et al. Use and performance of the STOP-Bang questionnaire for obstructive sleep apnea screening across geographic regions: a systematic review and meta-analysis. JAMA Netw Open. 2021; 4(3): e211009.
- Johns MW. A new method for measuring daytime sleepiness: the Epworth sleepiness scale. Sleep. 1991; 14(6): 540–545.
- Rosen IM, Kirsch DB, Carden KA, et al. Clinical Use of a Home Sleep Apnea Test: An Updated American Academy of Sleep Medicine Position Statement. J Clin Sleep Med. 2018; 14(12): 2075–2077.
- American Academy of Sleep Medicine. The AASM manual for the scoring of sleep and associated events: rules, terminology and technical specification. Version 2.6. Am Acad Sleep Med 2020. Available online: American Academy of Sleep Medicine. The AASM manual for the scoring of sleep and associated events: rules, terminology and technical specification. Version 2.6. Am Acad Sleep Med 2020. https://aasm.org/clinical-resources/scoring-manual/. [Access: September 2021].
- Steinberg JS, Varma N, Cygankiewicz I, et al. 2017 ISHNE-HRS expert consensus statement on ambulatory ECG and external cardiac monitoring/telemetry. Ann Noninvasive Electrocardiol. 2017; 22(3): e55–e96.
- Szymański FM, Płatek AE, Karpiński G, et al. Obstructive sleep apnoea in patients with atrial fibrillation: prevalence, determinants and clinical characteristics of patients in Polish population. Kardiol Pol. 2014; 72(8): 716–724.
- Gonzaga C, Bertolami A, Bertolami M, et al. Obstructive sleep apnea, hypertension and cardiovascular diseases. J Hum Hypertens. 2015; 29(12): 705–712.
- Seiler A, Camilo M, Korostovtseva L, et al. Prevalence of sleep-disordered breathing after stroke and TIA: A meta-analysis. Neurology. 2019; 92(7): e648–e654.
- Pływaczewski R, Bednarek M, Jonczak L, et al. Sleep-disordered breathing in a middle-aged and older Polish urban population. J Sleep Res. 2008; 17(1): 73–81.
- Pływaczewski R, Bieleń P, Bednarek M, et al. Influence of neck circumference and body mass index on obstructive sleep apnoea severity in males [article in Polish]. Pneumonol Alergol Pol. 2008; 76(5): 313–320.
- Garrigue S, Pépin JL, Defaye P, et al. High prevalence of sleep apnea syndrome in patients with long-term pacing: the European Multicenter Polysomnographic Study. Circulation. 2007; 115(13): 1703–1709.
- Velasco A, Hall C, Perez-Verdia A, et al. Association of high-risk scores for obstructive sleep apnea with symptomatic bradyarrhythmias. J Cardiovasc Med (Hagerstown). 2014; 15(5): 407–410.
- Zwillich C, Devlin T, White D, et al. Bradycardia during sleep apnea. Characteristics and mechanism. J Clin Invest. 1982; 69(6): 1286–1292.
- Koehler U, Becker HF, Grimm W, et al. Relations among hypoxemia, sleep stage, and bradyarrhythmia during obstructive sleep apnea. Am Heart J. 2000; 139(1 Pt 1): 142–148.
- Fleg JL, Kennedy HL. Cardiac arrhythmias in a healthy elderly population: detection by 24-hour ambulatory electrocardiography. Chest. 1982; 81(3): 302–307.
- Roche F, Xuong AN, Court-Fortune I, et al. Relationship among the severity of sleep apnea syndrome, cardiac arrhythmias, and autonomic imbalance. Pacing Clin Electrophysiol. 2003; 26(3): 669–677.
- Mehra R, Benjamin EJ, Shahar E, et al. Sleep Heart Health Study. Association of nocturnal arrhythmias with sleep-disordered breathing: The Sleep Heart Health Study. Am J Respir Crit Care Med. 2006; 173(8): 910–916.
- Mujović N, Marinković M, Mihajlović M, et al. Risk factor modification for the primary and secondary prevention of atrial fibrillation. Part 2. Kardiol Pol. 2020; 78(3): 192–202.
- Marti-Almor J, Marques P, Jesel L, et al. Incidence of sleep apnea and association with atrial fibrillation in an unselected pacemaker population: Results of the observational RESPIRE study. Heart Rhythm. 2020; 17(2): 195–202.
- Defaye P, de la Cruz I, Martí-Almor J, et al. A pacemaker transthoracic impedance sensor with an advanced algorithm to identify severe sleep apnea: the DREAM European study. Heart Rhythm. 2014; 11(5): 842–848.
- Kusumoto FM, Schoenfeld MH, Barrett C, et al. 2018 ACC/AHA/HRS Guideline on the Evaluation and Management of Patients With Bradycardia and Cardiac Conduction Delay: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Circulation. 2019; 140(8): e382–e482.
- Glikson M, Nielsen JC, Kronborg MB, et al. ESC Scientific Document Group. 2021 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy. Eur Heart J. 2021; 42(35): 3427–3520.
- Patil SP, Ayappa IA, Caples SM, et al. Treatment of Adult Obstructive Sleep Apnea with Positive Airway Pressure: An American Academy of Sleep Medicine Clinical Practice Guideline. J Clin Sleep Med. 2019; 15(2): 335–343.
- Mehrtash M, Bakker JP, Ayas N. Predictors of continuous positive airway pressure adherence in patients with obstructive sleep apnea. Lung. 2019; 197(2): 115–121.
