Obstructive sleep apnea, atrial fibrillation, and erectile dysfunction: are they only coexisting conditions or a new clinical syndrome? The concept of the OSAFED syndrome

Obstructive sleep apnea, atrial fibrillation, and erectile dysfunction... 701 Clinical scenarios A 55-year-old man with diabetes and hypertension was admitted for the ablation of a source of AF.He had been diagnosed with paroxysmal AF 4 years before.His AF attacks caused palpitations, reduced exercise capacity, and breathlessness, and flared as often as once every 3 to 6 months.The symptoms were classified as being European Heart Rhythm Association (EHRA) class III.The patient said that, apart from arterial hypertension and diabetes, he was otherwise healthy.He was taking warfarin, metformin 500 mg bid, ramipril 5 mg od, with good glucose and blood pressure control.AF was recorded both on standard electrocardiogram (ECG) and during 24-hour ambulatory ECG monitoring.He was admitted 1 day prior to the procedure.During the night, other patients complained that he snored very loudly and had episodes of apnea.When he was interviewed, he reported that his wife often complained about his loud snoring and that he experienced daytime sleepiness.He also said that he had been having erectile problems for about 2 years.We decided to proceed with the ablation and scheduled polysomnography after the procedure, and he was referred for further consultation.After performing a transesophageal echocardiography (which did not reveal any thrombi in the left atrial appendage, but showed an enlargement of the left atrium, confirmed also later with transthoracic echocardiography with the following results: left atrium, 5.9 × 6.8 cm; area, 33.7 cm 2 ; volume 135 cm 3 ); the pulmonary vein was isolated.Polysomnography showed an apnea-hypopnea index (AHI) of 43.8/h and a mean night-time blood oxygen saturation of 91.3%.After the diagnosis of severe