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CLINICAL RESEARCH

Physiologic Pacing in Patients With Obstructive Sleep Apnea

A Prospective, Randomized Crossover Trial

Andrew D. Krahn, MD^_*,_*, Raymond Yee, MD^_*, Mark K. Erickson, BSc, Toby Markowitz, BSEE, Lorne J. Gula, MD^_*, George J. Klein, MD^_*, Allan C. Skanes, MD^_*, Charles F.P. George, MD^_* and Kathleen A. Ferguson, MD^_*

^_* Cardiology and Respirology, University of Western Ontario, London, Canada
Medtronic Inc., Minneapolis, Minnesota

Manuscript received May 13, 2005; revised manuscript received August 4, 2005, accepted September 8, 2005.

^_* Reprint requests and correspondence: Dr. Andrew D. Krahn, London Health Sciences Center, University Campus, 339 Windermere Road, London, Ontario N6A 5A5, Canada (Email: akrahn{at}uwo.ca).

OBJECTIVES: This study was designed to assess the impact of prevention of bradycardia with physiologic pacing on the severity of obstructive sleep apnea.

BACKGROUND: Apneic episodes during sleep are associated with slowing of the heart rate during apnea and tachycardia with subsequent arousal. Patients with permanent pacemakers may have reduced episodes of sleep apnea when their pacemaker rate is set faster than their spontaneous nocturnal heart rate.

METHODS: We conducted a prospective, randomized, single-blind crossover trial of temporary atrial pacing in obstructive sleep apnea to reduce the apnea hypopnea index (AHI). Fifteen patients (age 60 ± 13 years, 12 men) with moderate to severe obstructive sleep apnea (AHI 34 ± 14) underwent insertion of an externalized atrial permanent pacing system via the left subclavian vein. Patients underwent overnight respiratory sleep studies in hospital, during atrial pacing at 75 beats/min, and with pacing turned off. The order of pacing mode was randomized, with crossover the subsequent night to the other mode. Patients were blinded to pacing mode, and the analysis of sleep recordings was blind to pacing mode.

RESULTS: Pacing was tolerated without complications in all patients. Overnight physiologic pacing did not affect the AHI (pacing 39 ± 21/h vs. control 42 ± 21/h, p = 0.23, 95% confidence interval –9.3 to 2.5 for difference), desaturation time (pacing 3.8 ± 6.0% vs. control 3.5 ± 4.3%, p = 0.70), or the minimum SaO₂ (pacing 75 ± 10% vs. control 77 ± 11%, p = 0.38). There was a borderline significant reduction in circulatory time with pacing (pacing 23.4 ± 3.2 s vs. control 25.5 ± 4.4 s, p = 0.09).

CONCLUSIONS: Temporary atrial pacing does not appear to improve respiratory manifestations of obstructive sleep apnea. Permanent atrial pacing in this patient population does not appear to be justified.

Abbreviations and Acronyms   AHI = apnea hypopnea index   CPAP = continuous positive airway pressure   ECG = electrocardiogram   EMG = electromyogram   ESS = Epworth Sleepiness Scale   OSA = obstructive sleep apnea   SaO2 = oxygen saturation

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