DID YOU KNOW...
that Sleep Apnea may contribute to Arrhythmias especially Atrial Fibrillation?

Prepared by John. A. Sawdon M.Sc. Public Education & Special Projects Director,
Cardiac Health Foundation of Canada

Introduction

This paper is an attempt to share with the reader some understanding of Sleep Apnea and the association of this sleep related breathing disorder with Atrial Fibrillation.

The word “apnea” means “no Breathing”. Sleep Apnea refers to “pauses in breathing”. Sleep apnea is a common disorder which is more prevalent in males than females and in which an individual experiences one or more pauses in breathing or shallow breathes during sleeping. These breathing pauses can last anywhere from a few seconds to several minutes, and can occur for up to 30 times during an hour. (1) Typically breathing then starts again with a loud snort or choking sound. Sleep apnea is a chronic sleeping disorder that causes excessive tiredness during the day.

There Are 3 types of Sleep Apnea

The most common sleep apnea is obstructive sleep apnea. During this condition the airway collapses or becomes blocked during sleep, often resulting in loud snoring and a drop in blood oxygen levels. Sleep apnea occurs when the muscles in the back of your throat relax. These muscles support the soft palate, the triangular piece of tissue hanging from the soft palate, the tonsils, the side walls of the throat and tongue. When these muscles relax your airway narrows or closes when you breathe in, this then cuts off your air way. As your brain senses this inability to breathe, it arouses you from sleep so that you can reopen your airway. This can be so brief you do not remember waking up. When air is blocked you may make a snorting, choking or gasping sound. This can be repeated up to 30 times a hour all night long. If you are overweight the extra soft fat tissue can thicken the wall of the windpipe, resulting in the interior of the windpipe narrowing which then makes it harder to keep it open.

Central sleep apnea is less commonly known and occurs if the area of your brain that controls breathing doesn’t send a signal to your breathing muscles. This results in you making no effort to breathe for brief periods of time. The aging process limits your brain’s signals and the ability to keep your throat muscles stiff during sleep. Thus your airway is more likely to narrow or collapse.

The third type of sleep apnea is called Complex Sleep Apnea Syndrome. This occurs when someone has both obstructive sleep apnea and central sleep apnea and is often referred to as “treatment emergent central sleep apnea”. (2)

Signs and Symptoms of Sleep Apnea

One of the most obvious signs of sleep apnea is loud and chronic snoring which is an indication of obstructive sleep apnea.. Pauses may occur in the snoring which is then followed by choking or gasping sounds. Snoring is loudest when on your back and tends to be reduced if you sleep on your side. Often individuals do not remember gasping for air, it is usually their partners who awaken during loud snoring and become aware of pauses in breathing followed by gasping for breath. Other signs and symptoms may include:

  • Excessive Daytime sleepiness
  • Abrupt awakenings followed a shortness of breath, which more likely indicates central sleep apnea
  • Morning headaches
  • Feeling irritable, depressed or having mood swings or personality changes
  • Awakening with a dry mouth or sore throat
  • Poor concentration and or memory-learning problems
  • Falling asleep while driving
  • Lowered sex drive

In children, sleep apnea (3) can cause hypertension, angry or hostile behaviour and lead to poor school performance. Children with sleep apnea have a tendency to breathe through their mouths instead of their noses during the day.

What Contributes to Developing Sleep Apnea

The following factors increase your risk of developing sleep apnea (4)

  • Being Overweight: people who are overweight have 4 times the risk of sleep apnea as those individuals who are at a normal or an appropriate weight for their height and size. Fat deposits around the upper respiratory airway may obstruct your breathing.
  • Neck circumference: people with thicker necks may have narrower airways. For men risk increases from 17 inches and for women risk increases from 15 inches.
  • A narrowed airway: you may have inherited a naturally narrow throat. Tonsils and adenoids may become enlarged and block the airway, this is particularly the case for children with sleep apnea.
  • Being male: men are twice as likely as women to develop sleep apnea. Women’s risk increases with obesity and after menopause.
  • Being older: sleep apnea increases with aging
  • Family history: if family members have sleep apnea you may be at increased risk
  • Alcohol, tranquilizers and sedatives: these relax the muscles in your throat leading to sleep apnea
  • Smoking: smokers have 3 times of the risk for sleep apnea. Smoking causes inflammation and fluid retention in the upper airway.
  • Nasal Congestion: if you have difficulty breathing through your nose from anatomical problems or allergies, you may be at greater risk for sleep apnea.

For Central Sleep apnea, these factors place individuals at higher risk:

  • Being older: middle aged and older are at greater risk for central sleep apnea
  • Heart Disorders: People with Congestive Heart Failure are more at risk
  • Narcotic pain medications: opioids including methadone place the individual at greater risk
  • Stroke: individuals who have had a stroke are at greater risk for sleep apnea
  • .

Prevalence of Sleep Apnea

In 2009 in Canada it was estimated that 858,900 Canadian adults or 3% of the Canadian population over 18 years had sleep apnea. Additionally 1 in 4 adults or 26% of the Canadian Population was also found to be at risk for sleep apnea at this time.(5). This compares to the United States as of September 29th 2014 whereby the National Sleep Study Project identified 25 million adults as having obstructive sleep apnea. Within this same study it was also estimated that 26% of adults between the ages of 30 and 70 years have sleep apnea (6) In Canada of those who reported that they had sleep apnea, 75% were over the age of 45.

Individuals with Sleep Apnea also have other Chronic Conditions (7)

  • High Blood Pressure or Heart Problems: sudden drops in Blood Oxygen Levels that occur during sleep apnea increase blood pressure and strain the cardiovascular system. If you have sleep apnea you are at greater risk for hypertension or high blood pressure than those without sleep apnea.
  • Atrial Fibrillation: Research indicates that sleep apnea contributes to Atrial Fibrillation, and may be causing stress to the Pulmonary Vein Opening.(9) Dr John Mandrola in his co-authored new book The Haywire Heart suggest that athletes’ who do not typically have the large neck of most people who have sleep apnea, have an athletes form of sleep apnea. (10) A Brazillian population study found that nocturnal cardiac arrhythmias occurred in 92% of patients with severe sleep apnea compared with 53% of people without sleep apnea. The prevalence of rhythm disturbance also increased with sleep apnea severity. (11)
  • Stroke and Heart Attack: Obstructive sleep apnea increases the risk of stroke and of recurrent heart attacks. If there is underlying heart disease, multiple episodes of low blood oxygen can lead to sudden death from an irregular heartbeat
  • Type 2 diabetes: in the Canadian sleep study Canadians with sleep apnea were 2.5 times more likely to develop insulin resistance and to have type 2 Diabetes.
  • Metabolic syndrome: Conditions that make up this disorder include hypertension, abnormal cholesterol, high blood sugar, and increased waist circumference. Individuals with sleep apnea at greater risk for metabolic syndrome.
  • Complications with medications and surgery are more frequent for those with sleep apnea.
  • Liver Problems: people with sleep apnea more likely to show liver scarring than those who do not have sleep apnea. This is known as non-alcoholic fatty liver disease. <./
  • Obesity: the prevalence of obstructive sleep apnea is directly related to body mass index, with 40% of obese patients having obstructive sleep apnea.

Effective Treatments/Strategies to Reduce/Eliminate Sleep Apnea

If you have experienced symptoms associated with either obstructive sleep apnea, complex sleep apnea or a combination of these two sleep disorders, immediately get an appointment with your Doctor. Often your sleep partner will be the first person to know your symptoms and what you have experienced. Take this person with you when you set up your Doctors appointment. They can provide detailed descriptions of your sleeping patterns.
Your Doctor may suggest a sleep study. The Nocturnal Polysomnography is a test that monitors your heart, lung, brain activity, breathing patterns, arm and leg movements, and blood oxygen levels while you sleep. Your Doctor can also order a home test in which heart rate; blood oxygen levels, airflow and breathing patterns are monitored.

Treatment options

  • Mild cases of Sleep apnea: this might include lifestyle changes only. You may be advised to lose weight, or quit smoking. This can also include sleeping on your side, stopping alcohol and starting to exercise on a daily basis.
  • Continuous Positive Airway Pressure: During your sleep apnea test you may be advised to get a CPAP machine. This has a mask that fits over your nose and mouth while you sleep. It forces air pressure to keep your upper airway passages open, preventing apnea and snoring.

  • Other Airway Pressure Devices: if a CPAP is a problem for you, your Doctor may advise you to use another machine that provides more pressure when you breathe and less when you exhale. This could include an Auto-CPAP or a BiPAP machine.
  • Expiratory Positive Airway Pressure: the EPAP are small single use devices which are placed over each nostril. The device is a valve which allows air to move freely.
  • Oral Appliances: an oral device works by opening your throat through shifting your jaw. A number of these devices are available through your Dentist.
  • Surgery: This can range from tissue removal at the rear of your mouth, to jaw repositioning and or creating a new air passageway.
  • Other therapies can range from weight loss surgery to treatment for associated problems to also using supplemental oxygen while you sleep.

The most promising outcome studies published by the American Academy of Sleep Medicine has found that CPAP machines have reduced high blood pressure, eliminated the sleep apnea, have reduced instances of Atrial Fibrillation and other arrhythmias as well. Equally untreated sleep apnea has resulted in cognitive decline, mood changes and lowered daytime alertness.

Conclusion

We have included this article due to the association of sleep apnea on heart disease and arrhythmias. We hope it provides some insight and it encourages you to seek out medical attention if you suspect you or a loved one might have sleep apnea. We encourage you to let us know if this article is helpful. We also encourage you to let us know what other areas related to cardiovascular disease, you wish to know more about. You can communicate with us by sending an e-mail to jsawdon@cardiachealth.ca.

References:

  1. National Heart, Lung and Blood Institute (NHLBI) Sleep Apnea https://www.nhlbi.nih.gov/book/export/html/4938
  2. Mayo Clinic Diseases and Conditions: Sleep Apnea http://www.mayoclinic.org/diseases-conditions/sleep-apnea/basics/definition/con-200202
  3. Public Health Agency of Canada, What is the Impact of Sleep Apnea on Canadians? Her Majesty the Queen in Right of Canada, 2010; cat: HP35-19/1-2010E-PDF; ISBN: 978-1-100-17359-7
  4. Mayo Clinic staff et al
  5. Public Health Agency of Canada, What is the impact of sleep apnea?
  6. Public Health Agency of Canada, Sleep Apnea, http://www.phac-aspc.gc.ca/cd-mc/sleepapnea-apneesommeil/index-eng.php
  7. Mayo Clinic staff et al
  8. Public Health Agency of Canada, What is the impact of sleep apnea?
  9. Ryan Steve S PhD. Beat You’re A-Fib: The Essential Guide to Finding Your Cure; 2012 . A-Fib Inc, 30765 Pacific Coast Hwy. Ste.259, Malibu, CA 90265, telephone 855-457-7146 ISBN -13: 978-0-9849514-0-6
  10. Case Chris, Mandrola John MD, Zinn Leonard; The Haywire Heart: How too Much exercise can kill you, and what you can do to protect your heart``,2017 Velo Press 3002 Sterling Circle, suite 100 Boulder, Colorado 80301-2338 USA, ISBN 978-1-937715-67-0
  11. American Academy of Sleep Medicine; Rising prevalence of sleep apnea in US threatens public health; http://www.aasmnet.org/articles.aspx?id=5043
  12. Chung Mina K; Foldvary-Schaefer Nancy, Somers Virend K, Freidman Paul A, Wang Paul J; Atrial Fibrillation, sleep apnea and obesity ; Nature Clinical Practise Cardiovascular Medicine, http://www.nature.com/clinicalpractisedoi:10.1038 /ncpcardio0027
  13. Gami Apoor S, Pressman Gregg, Caples Sean M, Kanagala Ravi, Gard Joseph J, Davison Diane E, Malouf Joseph F, Ammash Naser M, Freidman Paul A, Somers Virend K; Association of Atrial Fibrillation and Obstructive Sleep Apnea July 26, 2004, http://circ.ahajournals.org/content/110/4/364.full.print

The articles, on the Cardiac Health Foundation of Canada website, are presented with the understanding that the Foundation is providing information only and not rendering medical advice. Please check with your family physician, specialist or health care professional before implementing any of the ideas expressed in these articles.