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Obstructive Sleep Apnea Is a Risk Factor for Stroke and Atrial Fibrillation FREE TO VIEW

Karin G. Johnson, MD; Douglas C. Johnson, MD
Author and Funding Information

From the Bay State Medical Center (Dr K. G. Johnson) and the Spaulding Rehabilitation Hospital (Dr D. C. Johnson).

Correspondence to: Karin G. Johnson, MD, Bay State Medical Center, 3300 Main St, Suite 3C, Springfield, MA 01199; email: karin.johnson@bhs.org


Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestpubs.org/site/misc/reprints.xhtml).


© 2010 American College of Chest Physicians


Chest. 2010;138(1):239. doi:10.1378/chest.10-0513
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In a recent issue of CHEST (February 2010), the study by Lip et al1 helps with the assessment of risk for stroke and thromboembolism in patients with atrial fibrillation (AF). Unfortunately, the Euro Heart Survey did not evaluate patients for obstructive sleep apnea (OSA), which we believe is a significant risk factor.

OSA is believed to increase the risk of stroke through endothelial damage and hypercoagulability as well as to increase the risk of AF. OSA with an apnea-hypopnea index (AHI) > 5 is an independent risk factor for stroke, with a hazard ratio of 1.97 when adjusted for race, sex, smoking, alcohol use, BMI, diabetes, AF, hypertension, and lipids.2 In a metaanalysis of studies on stroke and sleep apnea, we found that 72% of patients with stroke and transient ischemic attack (TIA) have OSA with an AHI > 5, and 38% have OSA with an AHI > 20.3 Further, we cite studies finding that treatment with continuous positive airway pressure (CPAP) reduces the rate of recurrent stroke and mortality in patients with OSA.

Among the Sleep Heart Health Study cohort, 4.8% of patients with OSA (AHI > 5) have AF compared with only 0.9% of patients without OSA.4 OSA increases the 12-month recurrence of AF after cardioversion from 53% of patients without OSA to 82% of patients with untreated OSA vs 42% of those treated with CPAP.5 OSA could increase the risk of paroxysmal AF.

OSA is thought to predispose patients to AF because of effects on the parasympathetic and sympathetic nervous systems that occur in the setting of hypoxemia, acidosis, apneas, and arousals. Additionally, mechanical effects of negative intrathoracic pressure promote cardiac stretch, which may predispose arrhythmias through mechanical-electrical feedback mechanisms.4

Given the increased risk of stroke and TIA in patients with AF and in patients with OSA, a strong case can be made that patients with both AF and OSA are at high risk and should receive oral anticoagulation for stroke prevention. Further studies are needed to better assess this risk.

Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Lip GYH, Nieuwlaat R, Pisters R, Lane DA, Crijns HJGM. Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel risk factor-based approach: the Euro Heart Survey on atrial fibrillation. Chest. 2010;1372:263-272. [CrossRef] [PubMed]
 
Yaggi HK, Concato J, Kernan WN, Lichtman JH, Brass LM, Mohsenin V. Obstructive sleep apnea as a risk factor for stroke and death. N Engl J Med. 2005;35319:2034-2041. [CrossRef] [PubMed]
 
Johnson KG, Johnson DC. Frequency of sleep apnea in stroke and TIA patients: a meta-analysis. J Clin Sleep Med. 2010;62:131-137. [PubMed]
 
Mehra R, Benjamin EJ, Shahar E, et al; Sleep Heart Health Study Sleep Heart Health Study Association of nocturnal arrhythmias with sleep-disordered breathing: The Sleep Heart Health Study. Am J Respir Crit Care Med. 2006;1738:910-916. [CrossRef] [PubMed]
 
Kanagala R, Murali NS, Friedman PA, et al. Obstructive sleep apnea and the recurrence of atrial fibrillation. Circulation. 2003;10720:2589-2594. [PubMed]
 

Figures

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References

Lip GYH, Nieuwlaat R, Pisters R, Lane DA, Crijns HJGM. Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel risk factor-based approach: the Euro Heart Survey on atrial fibrillation. Chest. 2010;1372:263-272. [CrossRef] [PubMed]
 
Yaggi HK, Concato J, Kernan WN, Lichtman JH, Brass LM, Mohsenin V. Obstructive sleep apnea as a risk factor for stroke and death. N Engl J Med. 2005;35319:2034-2041. [CrossRef] [PubMed]
 
Johnson KG, Johnson DC. Frequency of sleep apnea in stroke and TIA patients: a meta-analysis. J Clin Sleep Med. 2010;62:131-137. [PubMed]
 
Mehra R, Benjamin EJ, Shahar E, et al; Sleep Heart Health Study Sleep Heart Health Study Association of nocturnal arrhythmias with sleep-disordered breathing: The Sleep Heart Health Study. Am J Respir Crit Care Med. 2006;1738:910-916. [CrossRef] [PubMed]
 
Kanagala R, Murali NS, Friedman PA, et al. Obstructive sleep apnea and the recurrence of atrial fibrillation. Circulation. 2003;10720:2589-2594. [PubMed]
 
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