Review of the Relationship Between Obstructive Sleep Apnea and Atrial Fibrillation

Obstructive sleep apnea (OSA) is among the most prevalent chronic medical conditions in the United States and has long been associated with cardiac arrhythmias, most notably atrial fibrillation (AF). Recurrent apneic episodes and their associated negative thoracic pressure swings produce acute fluctuations in autonomic signaling, generating spikes in parasympathetic and sympathetic activity that may promote AF by altering refractoriness, conduction velocity, and atrial filling. Over longer periods of time, intermittent hypoxia, inflammation, and mechanical stresses on the atrium contribute to structural and electrical remodeling of the atrium, including alterations in gap junction distribution and fibrosis. In turn, these modifications contribute to conduction heterogeneity and fractionation of atrial signaling, creating a stable substrate for AF that may subsequently be triggered by the acute effects of OSA. Clinically, untreated OSA has been associated with decreased efficacy of antiarrhythmic drugs and catheter ablation. Treatment with continuous positive airway pressure seems to improve outcomes postcatheter ablation, though further research is needed on the subject. The significant influence of OSA on atrial remodeling and treatment response underscores the importance of improving screening and facilitating earlier diagnosis and treatment.