Bidirectional Temporal Association of Device-Detected Atrial Fibrillation and Sleep Apnea

BACKGROUND: The relationship between atrial fibrillation (AF) and sleep apnea (SA) is well established, but the day-to-day temporal direction of this association remains uncertain. OBJECTIVE: To examine the bidirectional day-to-day association between device-detected AF (DDAF) and device-detected sleep apnea (DDSA), while distinguishing DDAF episode onset from continuation of ongoing episodes. METHODS: Data were obtained from the prospective ACaSA study in pacemaker patients undergoing continuous remote monitoring. Data collected from September 2020 through August 2025 were analyzed. Severe DDSA was defined as a respiratory disturbance index (RDI) ≥ 20, and a DDAF episode as daily burden ≥ 6 minutes. Three day-level, time-stratified intra-individual case-crossover analyses were performed: Pathway 1 related preceding-day DDAF burden to incident severe DDSA on the subsequent night; Pathway 2 related preceding-night severe DDSA to incident DDAF episode onset the following day; and Pathway 3 related preceding-night severe DDSA to continuation of an already active DDAF episode. Generalized linear mixed-effects models were used as secondary analyses. RESULTS: A total of 112,242 patient-days from 218 patients were analyzed. Incident severe DDSA was preceded by higher odds of elevated DDAF burden on the prior day in a graded manner, with odds ratios (OR) of 1.38 (95% confidence interval [CI] 1.10 - 1.74) for 6 minutes - 1 hour, 1.81 (95% CI 1.52 - 2.15) for 1 - 12 hours, and 2.52 (95% CI 1.97 - 3.22) for ≥ 12 hours (all p ≤ 0.005). Both incident DDAF episode onset and the continuation of ongoing DDAF episodes were preceded by higher odds of severe DDSA on the prior night (OR 1.35; 95% CI 1.10 - 1.64; p = 0.003, and OR 2.39; 95% CI 1.47 - 3.88; p < 0.001, respectively). CONCLUSION: Continuous monitoring identified a bidirectional temporal association between DDAF and DDSA. Incident severe DDSA was preceded by higher odds of elevated DDAF burden, whereas both incident DDAF episode onset and continuation of ongoing episodes were preceded by higher odds of severe DDSA.