Influence of Sleep Apnea on Risk of Atrial Fibrillation (Safebeat)

The Elucidation of the Influence of Sleep Apnea on Risk of Atrial Fibrillation study. The study involves a case control design to investigate the extent to which there is an independent relationship of sleep disordered breathing (SDB) and paroxysmal atrial fibrillation (PAF). Cases will be defined as clinically identified patients with PAF and controls as those without AF. In order to rigorously address important biologic confounding influences, the cases and controls will be individually matched based upon age, gender, race, and body mass index. Those participants with both PAF and SDB (Apnea Hypopnea Index, AHI>=15) will be asked to return for a follow up exam after 3 months of SDB treatment in the Clinical Research Unit (CRU) for collection of the same measures collected at the baseline exam to observe for any significant changes with the purpose of collecting effect size data to inform future clinical trials. The total duration of the study is 4 years. The duration for any individual participant is up to from one to 13 weeks months, including a 3-month treatment period for those with moderate to severe SDB, i.e. AHI>15.

Sleep-disordered breathing (SDB) is common in patients with cardiovascular disease and its attendant hypoxemia and autonomic dysfunction create a milieu that is likely to enhance AF propensity. Thus, SDB may represent a novel target for AF prevention and treatment strategies. Although our prior cross-sectional work has shown a 2-4 fold higher odds of AF related to SDB, these and other reports have not included cardiac structural data or autonomic/biochemical measures, and have addressed only arrhythmic events occurring during an overnight sleep study. In this proposal, we will examine paroxysmal AF (PAF), an early stage risk factor for persistent AF, and relevant to this proposal because it occurs prior to extensive cardiac electrical remodeling/fibrosis. OUTLINE OF STUDY VISITS Baseline Visit (SA 1 and 2). After informed consent, eligible participants will be scheduled to arrive for an overnight visit in the CRU. During the evening, participants will undergo questionnaire administration, blood pressure measurements, and anthropometry. They will be provided dinner and undergo polysomnography (PSG). In the morning, participants will undergo fasting venipuncture, overnight urine collection, ECHO, 6 minute walk test, vascular measures and blood pressure measurements. For those with PAF (cases), hook-up for continuous ECG monitoring will be performed along with education regarding how to handle the device and bathing instructions, etc. All measurements in the DCRU/CRU will be performed blinded to PAF status. The only unblinded staff will be a dedicated research assistant who will perform the ECG monitoring hook-up. Blinded staff will collect and process data and perform data entry. After the baseline visit, participants with PAF (n=150) will undergo hook-up of the ECG monitor and an activity monitor at the baseline visit to wear for a 7-21 day period. Follow-Up Visit (SA3). Those with SDB (AHI>=15) without evidence of central apnea (central apnea index>5) or Cheyne Stokes Respirations via baseline visit PSG and who have PAF will undergo the following. A 5-7 day home-based auto-titration (APAP, Respironics Autopap System One with humidifier) to identify the optimal positive airway pressure (PAP) setting will be performed (with settings 4-20cm H2O). At the end of the 5-7 day titration, the goal will be to identify the pressure that results in an AHI<5 events/hour (optimally). The research assistant will re-set the device to deliver this optimal fixed pressure identified by the PI through the secure wireless web-site. An overnight DCRUCRU visit will be scheduled after 3 months of wearing CPAP during which the same measures performed at the baseline visit will be collected. STUDY PROCEDURES 2-DIMENSIONAL DOPPLER ECHOCARDIOGRAPHY. Parasternal, apical and subcostal 2-D views and apical 3D views will be obtained with transducer orientation and gain settings adjusted to optimally define endocardial surface of each cardiac chamber. POLYSOMNOGRAPHY (PSG). Procedure for PSG: Research PSG will be performed using the Compumedics E-series system (Abbottsford, AU) which will include 3 cortical encephalograms, bilateral electro-oculograms, a bipolar submental electromyogram, thoracic and abdominal respiratory inductance plethysmography, airflow (by nasal-oral thermocouple and nasal cannula pressure recording), oximetry (using highly sensitive finger pulse oximeter, sampling frequency 25Hz), electrocardiogram (ECG) at 250Hz (used to derive HRV measures of autonomic function); body position (mercury switch sensor), bilateral leg movements. EEGs are recorded at 125Hz. 3) 7-21 Day CONTINUOUS ECG MONITORING. Procedure: A 3-lead (2 channel), wireless, lightweight ECG monitoring device will be used to collect the ECG data over a 7-21 day period in those with PAF after the baseline and follow-up CRU visits. ACTIVITY MONITORING. Procedure: An accelerometer (GT3X+, Actigraph Co., Ft Walton Bch, Fl) will be used for 7-21 days, coincident with the time of continuous ECG monitoring. FASTING VENIPUNCTURE (52cc). Procedure: Phlebotomy will be performed the morning of the baseline and follow-up visits using standard techniques by trained research staff following written procedures. 6) DNA collection. Blood will be collected to extract RNA, which will be stored to test future hypotheses regarding genetic determinants of treatment response. OVERNIGHT URINE. Procedure: Overnight urine collection will be performed. ANTHROPOMETRY. Height (inches, cm), neck circumference (cm), waist circumference (cm), hip circumference (cm) will be obtained. Skinfolds are measured with calibrated metal calipers from 7 sites (chest, calf, thigh, calf, subscapular, midaxillary, suprailiac, abdominal). RESTING BLOOD PRESSURE (BP). BP will be measured after the participant has been sitting quietly for at least 5 minutes following standardized guidelines using a calibrated sphygmomanometer. Measurements will be repeated three times and recorded. QUESTIONNAIRES. The following will be collected: a) The Berlin Sleep Questionnaire, b) Epworth Sleepiness Scale, c) The Sleep Habits and Medical Condition Questionnaire d) The Medical Outcomes Survey-SF 36 (MOS-SF) e) Patient Health Questionnaire-9 (PHQ-9) f) Daily ECG/Activity Log g) Atrial Fibrillation Effect on Quality-of-life, a 20-item questionnaire that assesses the impact of atrial fibrillation on quality of life. 6 Minute Walk Test. Baseline oxygen saturation and heart rate will be recorded. If oxygen saturation >90%, then proceed with protocol. Using the BORG Scale record rate the symptoms of breathlessness and leg fatigue after a 6 minute walk at usual pace. Arterial Applanation Tonometry: Radial artery measurements will be performed after sphygmomanometric pressure is obtained with use of an applanation tonometry probe with a minimum of two consecutive measurements to obtain pulse wave analysis results. For pulse wave velocity, lead II ECG will be performed along with cardotid and femoral applanation tomometry.

Cases. Patients with Paroxysmal Atrial Fibrillation who present to Electrophysiology Clinic at UHCMC and the Cleveland Clinic Foundation will be approached for recruitment in the study. Cases found to have an apnea hypopnea index >=15 will be asked to continue in the study for 3 months wearing a Continuous Positive Airway Pressure (CPAP) machine.

Controls. Patients without AF will be recruited from General Cardiology and Internal Medicine clinics (geographically similar to controls). Selection bias will be minimized as there are a broad range of reasons for patients to present to these clinics.

Patients with diagnosis of PAF were defined as cases. PAF is the primary outcome of baseline analysis, which aimed to quantify the association of sleep apnea and PAF.

Increased left atrial volume and strain are known risk factors of AF and PAF. Echocardiography measurements were not available for some subjects due to image quality.

Increased left atrial volume and strain are known risk factors of AF and PAF. Left atrial volume index (LAVI) is left atrial size indexed to Body surface area (BSA). The reference range of LAVI is 16-28 mL/m^2. Mildly abnormal: 29-33 mL/m^2; Moderately abnormal: 34-39 mL/m^2; Severely abnormal: greater than or equal to 40 mL/m^2. Echocardiography measurements were not available for some subjects due to image quality.

Left atrial systolic strain, a measure of left atrial remodeling which is inversely related to fibrosis in PAF, is measured by 2-dimensional echocardiography. Apical four-chamber (A4C) and two-chamber (A2C) views are the most commonly used approaches to measure the strain rate (%) of left atrial.

Left atrial systolic strain, a measure of left atrial remodeling which is inversely related to fibrosis in PAF, is measured by 2-dimensional echocardiography. Apical four-chamber (A4C) and two-chamber (A2C) views are the most commonly used approaches to measure the strain rate (%) of left atrial.

Radial measurements were performed on the same arm using the SphygmoCor device after sphygmomanometric pressure was obtained with use of an applanation tonometry probe containing a solid state high fidelity Millar transducer over the radial artery with a minimum of two consecutive measurements to obtain pulse wave analysis results. For pulse wave velocity, lead II ECG (LL, LA, RA) was performed along with cardotid and femoral applanation tomometry. Orientation and pressure applied to the transducer were adjusted to optimize applanation of the artery between the transducer and the underlying tissue. Waveforms were processed using the SphygmoCor software (model EM3, version CvMS 9.0, Atcor Medical Pty, West Ryde, Australia).)

Augmentation Index (Alx) is an indication of systemic arterial stiffness and measures the contributions of wave reflection to central systolic pressure. Scores vary based on age and gender and in a normal, healthy population research has shown can range from -10% or less up to 50%. A negative augmentation index suggests low artery stiffness (late arriving wave reflections) and a positive index is a reflection of increase artery stiffness (reflective wave arriving early in the cardiac cycle). Waveforms will be processed using the SphygmoCor software (model EM3, version CvMS 9.0, Atcor Medical Pty, West Ryde, Australia) for this measurement. It is calculated at the onset of reflected wave, Alx = AP/PP x 100. Alx = Augmentation Index, the percentage of the pulse pressure due to the AP; PP = Pulse Pressure; AP = Augmentation Pressure, the contribution of the reflected wave to the pulse pressure.

Inclusion Criteria: Inclusion Criteria for Cases: PAF defined by recurrent episodes of AF, which self-terminate within a 7-day period (based upon AHA consensus statement 77) Age 18-80 years Individuals able to participate in > 2 overnight/daytime sleep and physiologic assessments over a 3 month period. Inclusion Criteria for Controls: Age 18 to 80 years Individuals in normal sinus rhythm (NSR) with no current AF or history of AF Individuals able to participate in an overnight/daytime sleep and physiologic assessment. Exclusion Criteria: Exclusion Criteria for Cases: PAF with rapid or uncontrolled rate (>120bpm) Post-operative PAF History of cardiac ablation or successful electro-cardioversion for PAF (ablation for other arrhythmias such as AVNRT and if PAF persists after cardioversion is acceptable ) Valvular stenosis, prosthesis or significant valvular insufficiency [i.e. those with moderate or greater severity of aortic stenosis (aortic valve area <1.5 cm2), mitral regurgitation which is moderate or more severe in degree (>20% regurgitant fraction) or moderate or greater severity mitral stenosis (mitral valve area <1.5 cm2)] Atrial septal defect Infiltrative/restrictive cardiomyopathy Sick sinus syndrome Previously diagnosed SDB on specific SDB treatments (CPAP, oral appliances) Severe chronic insomnia Circadian rhythm disorder (e.g. shift work sleep disorder, delayed or advanced sleep phase syndrome) Insufficient sleep syndrome defined by reported sleep duration < 4 hrs Supplemental oxygen use Unstable medical conditions (e.g., new onset or changing angina, a myocardial infarction or congestive heart failure exacerbation documented within the previous 3 months, systolic heart failure (Left Ventricular Ejection Fraction < 35%), high grade cardiac dysrhythmia/heart block, stroke with functional limitations, uncontrolled hypertension (BP>170/110), abdominal aneurysm >5.5 cm or >1 cm growth/year, uncontrolled diabetes mellitus (HbA1c>9.0), pulmonary hypertension, non-skin cancer diagnosis or treatment within the previous year, end stage renal and hepatic failure, immunodeficiencies (HIV, HCV), uncontrolled hypo- or hyperthyroidism) Psychiatric disorders which are inadequately treated Compromised competence Alcohol abuse (currently drinks >5 alcoholic drinks/day) Pregnancy Inability to provide informed consent Illicit drug use over last 6 months Rate controlling anti-arrhythmic medication (Classes I-III and V) with no further clinical occurrence of PAF Has a Pacemaker or Implantable cardioverter-defibrillator. Rationale for criteria: The goal of this study is to include those patients with PAF that is not secondary to the post-operative period or valvular disease and without ablation as these processes would result in alteration of atrial physiology and preclude assessment of independent SDB effects on AF which is independent of these conditions. Patients with sleep disorders will be excluded as sleep disorders may influence arrhythmogenesis. Those on treatment for SDB will be excluded because treatment would preclude assessment of SDB pathophysiologic effects on atrial arrhythmogenesis. Those with unstable medical conditions or rapid or uncontrolled heart rate will be excluded due to safety reasons. Note: Exclusion criteria for positive airway pressure (PAP) intervention: Central Apnea Index>5 noted on baseline examination sleep study or evidence of Cheyne Stokes Respirations/periodic breathing (cyclical crescendo and decrescendo change in breathing amplitude). Exclusion Criteria for Controls: Current or history of AF, otherwise the same exclusion criteria listed for cases.

May AM, Wang L, Kwon DH, Van Wagoner DR, Chung MK, Dalton JE, Mehra R. Sleep apnea screening instrument evaluation and novel model development and validation in the paroxysmal atrial fibrillation population. Int J Cardiol Heart Vasc. 2020 Sep 4;31:100624. doi: 10.1016/j.ijcha.2020.100624. eCollection 2020 Dec.