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• W2900419212 abstract "We agree with Drs Mehra and Wazni1Mehra R. Wazni O. Point: Should all patients with atrial fibrillation who are about to undergo pulmonary vein ablation be evaluated for OSA?.Yes. Chest. 2018; 154: 1008-1010Scopus (3) Google Scholar that atrial fibrillation (AF) and OSA are highly prevalent in the general population, are associated with significant adverse consequences, and that OSA is increasingly prevalent in patients with AF. As previously stated, we acknowledge that there are experimental data demonstrating the likely pathophysiologic mechanisms by which OSA may lead to the development of AF and that there are epidemiologic studies linking OSA and AF. At this time, as noted by Drs Mehra and Wazni,1Mehra R. Wazni O. Point: Should all patients with atrial fibrillation who are about to undergo pulmonary vein ablation be evaluated for OSA?.Yes. Chest. 2018; 154: 1008-1010Scopus (3) Google Scholar there is supporting but not confirmatory evidence of a temporal association between OSA and AF. Not every apnea, regardless of how severe, induces AF; thus, although causality can be surmised, it remains unproven, and is likely multifactorial. In the study by Gami et al,2Gami A.S. Hodge D.O. Herges R.M. et al.Obstructive sleep apnea, obesity, and the risk of incident atrial fibrillation.J Am Coll Cardiol. 2007; 49: 565-571Crossref PubMed Scopus (816) Google Scholar a decrease in nocturnal oxyhemoglobin saturation, but not apnea-hypopnea index, was predictive of incident AF in subjects < 65 years of age. To date, there are no large prospective longitudinal studies elucidating the nature and direction of the relationship between OSA and AF. We concur with the points discussing the usefulness of pulmonary vein ablation to treat AF. Regarding the predictors of failure of pulmonary vein ablation such as hypertension and increased left atrial diameter in the study referenced by Drs Mehra and Wazni,1Mehra R. Wazni O. Point: Should all patients with atrial fibrillation who are about to undergo pulmonary vein ablation be evaluated for OSA?.Yes. Chest. 2018; 154: 1008-1010Scopus (3) Google Scholar however, it is worth noting that although OSA is associated with these factors, it has not been conclusively shown to be a predictor of postablation AF independent of these factors.3Berruezo A. Tamborero D. Mont L. et al.Pre-procedural predictors of atrial fibrillation recurrence after circumferential pulmonary vein ablation.Eur Heart J. 2007; 28: 836-841Crossref PubMed Scopus (310) Google Scholar The literature regarding untreated OSA as an independent risk factor for the recurrence of AF postablation is conflicting.4Bazan V. Grau N. Valles E. et al.Obstructive sleep apnea in patients with typical atrial flutter: prevalence and impact on arrhythmia control outcome.Chest. 2013; 143: 1277-1283Abstract Full Text Full Text PDF PubMed Scopus (45) Google Scholar, 5Dewire J. Calkins H. Impact of obstructive sleep apnea on outcomes of catheter ablation of atrial fibrillation.J Atrial Fibrillation. 2013; 5: 777Google Scholar, 6Craig S. Pepperell J.C. Kohler M. Crosthwaite N. Davies R.J. Stradling J.R. Continuous positive airway pressure treatment for obstructive sleep apnoea reduces resting heart rate but does not affect dysrhythmias: a randomised controlled trial.J Sleep Res. 2009; 18: 329-336Crossref PubMed Scopus (55) Google Scholar, 7Matiello M. Nadal M. Tamborero D. et al.Low efficacy of atrial fibrillation ablation in severe obstructive sleep apnoea patients.Europace. 2010; 12: 1084-1089Crossref PubMed Scopus (111) Google Scholar With respect to the argument for CPAP treatment to lower BP before pulmonary vein ablation, the magnitude of BP reduction with CPAP has been observed to be modest at best (reduction in diurnal systolic BP of about 2.5 mm Hg); therefore, antihypertensive medications are still the mainstay of BP management in the majority of patients with systemic hypertension.8Walia H.K. Griffith S.D. Foldvary-Schaefer N. et al.Longitudinal effect of CPAP on BP in resistant and nonresistant hypertension in a large clinic-based cohort.Chest. 2016; 149: 747-755Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar, 9Montesi S.B. Edwards B.A. Malhotra A. Bakker J.P. The effect of continuous positive airway pressure treatment on blood pressure: a systematic review and meta-analysis of randomized controlled trials.J Clin Sleep Med. 2012; 8: 587-596Crossref PubMed Scopus (237) Google Scholar We have presented much of the same data as Drs Mehra and Wazni1Mehra R. Wazni O. Point: Should all patients with atrial fibrillation who are about to undergo pulmonary vein ablation be evaluated for OSA?.Yes. Chest. 2018; 154: 1008-1010Scopus (3) Google Scholar regarding the risk of recurrence of AF after pulmonary vein ablation in patients with OSA treated with CPAP, but reiterate that the information available is mostly based on observational reports. In most of these studies, ascertainment of compliance with positive airway pressure was either not clearly described or was based on subjective report. Finally, notwithstanding the wisdom of Hill’s criteria for establishing causality in public health, we would assert that, in clinical medicine, a key consideration of any causal relationship is the effect size of treatment on the dependent outcome. Even if one concedes that the evidence that OSA causes AF is irrefutable, the real question is whether treatment of OSA prevents AF recurrence. In the case of OSA and AF, there are no randomized controlled trials demonstrating any such benefit of OSA treatment. We have previously cited only a few of multiple prior instructive studies showing no benefit, and sometimes harm, from interventions otherwise supported by extensive circumstantial evidence of benefit; hence, one cannot reasonably circumvent the need for definitive proof before adding even further to the already daunting breadth and expense of medical testing and intervention. Even if all patients, symptomatic or not, are screened for OSA before pulmonary vein ablation, guidance for the clinician is lacking. Who do we treat? With what modality? How much adherence to CPAP is adequate to prevent AF recurrence, if CPAP is indeed effective at all? Given the unsettling results of Treatment of Predominant Central Sleep Apnoea by Adaptive Servo Ventilation in Patients With Heart Failure (SERVE-HF), it would be irresponsible to discount any possibility of harm related to a standard of care application of positive airway pressure therapy in the patient with AF. We do not object to individualized evaluation and therapy of postablation patients for other reasons, such as sleepiness or resistant hypertension; however, taking into account the reservations we outline here, universal screening for OSA, with an eye toward treating with CPAP so as to prevent AF recurrence in patients undergoing ablation, is currently unjustified. COUNTERPOINT: Should All Patients With Atrial Fibrillation Who Are About to Undergo Pulmonary Vein Ablation Be Evaluated for OSA? NoCHESTVol. 154Issue 5PreviewIn many respects, atrial fibrillation (AF) carries serious implications, with an increased associated risk of stroke, heart failure, and even death.1-3 For the patient who, despite attempts at restoration of rhythm by electrical or chemical means, has an arrhythmia that persists to the point of consideration for pulmonary vein ablation, the stakes are often raised. It is no wonder, then, that given the association between AF and OSA, some may advocate for universal screening for OSA of such patients in the hopes of a successful rhythm outcome. Full-Text PDF POINT: Should All Patients With Atrial Fibrillation Who Are About to Undergo Pulmonary Vein Ablation Be Evaluated for OSA? YesCHESTVol. 154Issue 5PreviewData over the past several decades have amassed supporting the role of OSA as an instigator of atrial fibrillation (AF) and specifically as an important factor to consider in the management of AF. AF is projected to increase 5 fold, afflicting up to 16 million individuals by the year 2050, with > $6.7 billion in costs annually.1-3 OSA is also highly prevalent (15%-30%) in the general population,4 with estimates even higher in those with cardiac arrhythmia such as AF, the latter with a prevalence upwards of 50%. Full-Text PDF Rebuttal From Drs Mehra and WazniCHESTVol. 154Issue 5PreviewWe appreciate the comments of our colleagues, Drs Mansukhani, Somers, and Caples,1 who present compelling arguments against the universal evaluation of OSA for patients with atrial fibrillation (AF) with planned pulmonary vein ablation. Although there are areas of common ground, there are several points that warrant further discussion. Full-Text PDF" @default.
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