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Ron Pisters, MD; Robby Nieuwlaat, PhD; Deirdre A. Lane, PhD; Harry J. G. M. Crijns, MD; Gregory Y. H. Lip, MD
Author and Funding Information

From the Department of Cardiology (Drs Pisters, Nieuwlaat and Crijns), Maastricht University Medical Centre; and the University of Birmingham Centre for Cardiovascular Sciences (Drs Lip and Lane), City Hospital.

Correspondence to: Gregory Y. H. Lip, MD, Centre for Cardiovascular Sciences, City Hospital, Birmingham, B18 7QH, England; e-mail: g.y.h.lip@bham.ac.uk


Financial/nonfinancial disclosures: The authors have reported to CHEST the following conflicts of interest: Dr Lane is in receipt of an investigator-initiated educational grant from Bayer Healthcare. Dr Lane has received sponsorship to attend the ESC 2009 from AstraZeneca. Dr Lip has served as a consultant for Bayer, Astellas, Merck, AstraZeneca, Sanofi, Aryx, and Boehringher and has been on the speakers bureau for Bayer, Boehringher, and Sanofi. Drs Pisters, Nieuwlaat, and Crijns have reported that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

© 2010 American College of Chest Physicians. 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):239-240. doi:10.1378/chest.10-0545
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To the Editor:

Johnson and Johnson suggest the routine use of oral anticoagulation (OAC) in patients with both atrial fibrillation (AF) and obstructive sleep apnea (OSA) because they consider these patients to be at high risk for stroke. Although we lack data on OSA in the Euro Heart Survey on AF, the use of OAC in these patients is more likely to be highly prevalent, given the associated comorbidities, such as hypertension, in this population. Although the OSA-related pathophysiologic mechanisms pointed out by Johnson and Johnson might influence the risk of stroke, there is no evidence that OSA is an independent risk factor for stroke in AF.

In the article by Yaggi et al,1 the hazard ratio of 1.97 does not hold true for OSA in relation to stroke but for the composite end point of stroke and death from any cause. Considering fatality was the major contributor of the combined end point, OSA was no longer a significant predictor of death as the single end point after correction for known confounders.1

Emphasis should lie on the high prevalence of OSA in general and its coexistence with underlying cardiovascular disease.2 Apart from OSA leading to hypertension3 no causal data exist; it is, therefore, much more likely that a “compromised” cardiovascular patient results in OSA than vice versa.4 Thus, the underlying cardiovascular conditions reflect the risk of stroke.

The novel CHA2DS2-VASc score, a point-based acronym to assess stroke risk in patients with AF (consisting of congestive heart failure, hypertension, age ≥ 75 years [2 points], diabetes, stroke [2 points], vascular disease [coronary artery disease, peripheral vessel disease], age [65-74 years], and sex category [female]) takes the broad spectrum of cardiovascular disease and risk factors into account.5 As mentioned previously, considering the vast prevalence of underlying heart disease among patients with AF6 and of OSA in cardiovascular disease, patients are more likely to have an OAC-qualifying CHA2DS2-VASc score of ≥ 2, reducing the additive value of OSA in antithrombotic decision making in patients with AF to nil.

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]
 
Young T, Palta M, Dempsey J, Skatrud J, Weber S, Badr S. The occurrence of sleep-disordered breathing among middle-aged adults. N Engl J Med. 1993;32817:1230-1235. [CrossRef] [PubMed]
 
Peppard PE, Young T, Palta M, Skatrud J. Prospective study of the association between sleep-disordered breathing and hypertension. N Engl J Med. 2000;34219:1378-1384. [CrossRef] [PubMed]
 
Porthan KM, Melin JH, Kupila JT, Venho KKK, Partinen MM. Prevalence of sleep apnea syndrome in lone atrial fibrillation: a case-control study. Chest. 2004;1253:879-885. [CrossRef] [PubMed]
 
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]
 
Nieuwlaat R, Capucci A, Camm AJ, et al; European Heart Survey Investigators European Heart Survey Investigators Atrial fibrillation management: a prospective survey in ESC member countries: the Euro Heart Survey on Atrial Fibrillation. Eur Heart J. 2005;2622:2422-2434. [CrossRef] [PubMed]
 

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References

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]
 
Young T, Palta M, Dempsey J, Skatrud J, Weber S, Badr S. The occurrence of sleep-disordered breathing among middle-aged adults. N Engl J Med. 1993;32817:1230-1235. [CrossRef] [PubMed]
 
Peppard PE, Young T, Palta M, Skatrud J. Prospective study of the association between sleep-disordered breathing and hypertension. N Engl J Med. 2000;34219:1378-1384. [CrossRef] [PubMed]
 
Porthan KM, Melin JH, Kupila JT, Venho KKK, Partinen MM. Prevalence of sleep apnea syndrome in lone atrial fibrillation: a case-control study. Chest. 2004;1253:879-885. [CrossRef] [PubMed]
 
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]
 
Nieuwlaat R, Capucci A, Camm AJ, et al; European Heart Survey Investigators European Heart Survey Investigators Atrial fibrillation management: a prospective survey in ESC member countries: the Euro Heart Survey on Atrial Fibrillation. Eur Heart J. 2005;2622:2422-2434. [CrossRef] [PubMed]
 
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