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CLINICAL RESEARCH: CARDIAC EFFECTS OF SLEEP APNEA

Triggering of Nocturnal Arrhythmias by Sleep-Disordered Breathing Events

Ken Monahan, MD^_*, Amy Storfer-Isser, MS, Reena Mehra, MD, MS, Eyal Shahar, MD, MPH, Murray Mittleman, MD, DrPH, Jeff Rottman, MD^_*, Naresh Punjabi, MD, PhD^¶, Mark Sanders, MD^#, Stuart F. Quan, MD^||,_**, Helaine Resnick, PhD and Susan Redline, MD, MPH^,_*

^_* Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
Department of Medicine and Center for Clinical Investigation, Case School of Medicine, Cleveland, Ohio
Division of Epidemiology and Biostatistics, University of Arizona Mel and Enid Zuckerman College of Public Health, Tucson, Arizona
Departments of Medicine and Epidemiology, Harvard Medical School, Boston, Massachusetts
^|| Division of Sleep Medicine, Harvard Medical School, Boston, Massachusetts
^¶ Departments of Medicine and Epidemiology, Johns Hopkins School of Medicine, Baltimore, Maryland
^# Division of Pulmonology, Allergy, and Critical Care, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
^_** Arizona Respiratory Center, University of Arizona College of Medicine, Tucson, Arizona
Department of Medicine, Georgetown University School of Medicine, Washington, DC

Manuscript received March 13, 2009; revised manuscript received June 2, 2009, accepted June 16, 2009.

^_* Reprint requests and correspondence: Dr. Susan Redline, Case Western Reserve University, Center for Clinical Investigation, Iris S. & Bert L. Wolstein Building, 2103 Cornell Road, Room 6129, Cleveland, Ohio 44106-7291 (Email: susan.redline{at}case.edu).

Objectives: This study sought to evaluate respiratory disturbances as potential triggers for arrhythmia in patients with sleep-disordered breathing (SDB).

Background: SDB is associated with an increased risk of atrial fibrillation and nonsustained ventricular tachycardia (NSVT) as well as a predilection for sudden cardiac death during nocturnal sleeping hours. However, prior research has not established whether respiratory disturbances operate as triggers for nocturnal arrhythmias.

Methods: Overnight polysomnograms from the Sleep Heart Health Study (n = 2,816) were screened for paroxysmal atrial fibrillation and NSVT. We used the case-crossover design to determine whether apneas and/or hypopneas are temporally associated with episodes of paroxysmal atrial fibrillation or NSVT. For each arrhythmia, 3 periods of sinus rhythm were identified as control intervals. Polysomnograms were examined for the presence of respiratory disturbances, oxygen desaturations, and cortical arousals within a 90-s hazard period preceding each arrhythmia or control period.

Results: Fifty-seven participants with a wide range of SDB contributed 62 arrhythmias (76% NSVT). The odds of an arrhythmia after a respiratory disturbance were nearly 18 times (odds ratio: 17.5; 95% confidence interval: 5.3 to 58.4) the odds of an arrhythmia occurring after normal breathing. The absolute rate of arrhythmia associated with respiratory disturbances was low (1 excess arrhythmia per 40,000 respiratory disturbances). Neither hypoxia nor electroencephalogram-defined arousals alone increased arrhythmia risk.

Conclusions: Although the absolute arrhythmia rate is low, the relative risk of paroxysmal atrial fibrillation and NSVT during sleep is markedly increased shortly after a respiratory disturbance. These results support a direct temporal link between SDB events and the development of these arrhythmias.

Key Words: sleep • arrhythmia • obesity

Abbreviations and Acronyms   AHI = apnea-hypopnea index   CHD = coronary heart disease   CI = confidence interval   EEG = electroencephalogram   NREM = non–rapid eye movement   NSVT = nonsustained ventricular tachycardia   OR = odds ratio   PAF = paroxysmal atrial fibrillation   PSG = polysomnogram   REM = rapid eye movement   SCD = sudden cardiac death   SDB = sleep-disordered breathing   TST = total sleep time

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