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Association of Sleep Apnea and Snoring With Incident Atrial Fibrillation in the Multi-Ethnic Study of Atherosclerosis

Lin, G.M., Colangelo, L.A., Lloyd-Jones, D.M., Redline, S., Yeboah, J., Heckbert, S.R., Nazarian, S., Alonso, A., Bluemke, D.A., Punjabi, N.M., Szklo, M., Liu, K.

Am J Epidemiol. 2015;182(1):49-57. (Epub 2015 May 13).

PMID: 25977516

       The association between sleep apnea and atrial fibrillation (AF) has not been examined in a multiethnic adult population in prospective community-based studies. From 2000 to 2011, prospectively were investigated the  associations of physician-diagnosed sleep apnea (PDSA), which is considered more severe sleep apnea, and self-reported habitual snoring without PDSA, a surrogate for mild sleep apnea, with incident of AF, in a Multi-Ethnic Study of Atherosclerosis (MESA) who were free of clinical cardiovascular disease at baseline (2000-2002).

       Cox proportional hazard models were used to assess the associations, with adjustment for socioeconomic status, traditional vascular disease risk factors, race/ethnicity, body mass index, diabetes, chronic kidney disease, alcohol intake, and lipid-lowering therapy. Out of 4,395 responders to a sleep questionnaire administered in MESA, 181 reported PDSA, 1,086 reported habitual snoring (HS), and 3,128 reported neither HS nor PDSA. Over an average 8.5-year follow-up period, 212 AF events were identified. As compared with unaffected participants, PDSA was associated with incident AF in the multivariable analysis, but HS was not (PDSA: hazard ratio= 1.76, 95%CI: 1.03-3.02; Habitual snoring: hazard ratio= 1.02, 95% CI: 0.72-1.44). PDSA, a marker of more severe sleep apnea, was associated with higher risk of incident AF in this analysis of MESA data.

Perspectives: Sleep apnea has been associated with intermittent hypoxemia or hypercapnia, metabolic abnormalities, inflammation, poor control of hypertension, and left atrial and ventricular remodeling, which may lead to an increased risk of cardiovascular diseases and AF. Recent evidence has suggested that the severity of OSA is correlated with left atrium size and dysfunction and that continuous positive airway pressure (CPAP) could improve left atrial remodeling, which may reduce the occurrence of AF. In addition, in this current study, there was a tendency for the association of PDSA with incident AF to be stronger in middle-aged or obese persons and in women. In addition, Gami et al. have postulated that the presence of multiple cardiovascular risk factors and cardiac dysfunction in older people may attenuate the associations of sleep apnea with occurrence of AF. Moreover, it is also possible that differences in autonomic nervous system responses to sleep apnea in older persons as compared with younger persons also may influence sleep apnea-related arrhythmia.

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