Impact of positive airway pressure therapy on arrhythmia recurrence and hospitalization rate in patients with obstructive sleep apnea and paroxysmal atrial fibrillation

Aim. To analyze atrial fibrillation (AF) recurrence during positive airway pressure (PAP) therapy in patients with a combination of obstructive sleep apnea (OSA) and paroxysmal AF, using various treatment strategies.

Material and methods. The study included 145 patients with paroxysmal AF and moderate to severe OSA. Patients were divided into four ageand sex-matched groups as follows: group 1 — patients receiving antiarrhythmic drug therapy (ADT) and PAP therapy (ADT+PAP therapy, n=42); group 2 — patients receiving ADT (ADT, n=39); group 3 — patients after pulmonary vein ablation (PVA) receiving PAP therapy (PVA+PAP therapy, n=36); group 4 — patients after PVA (PVA, n=28). All patients underwent a clinical examination, questionnaires, standard electrocardiography, echocardiography, and 24-hour electrocardiographic monitoring before PAP therapy and after 6-month treatment.

Results. In the ADT+PAP therapy group, the AF recurrence rate was 43,9% vs 73% in the ADT group. After 6 months, the ADT+PAP therapy group had a 2,3-fold decrease in the odds of paroxysmal AF episodes compared to patients in the ADT group (odds ratio (OR) 0,43; 95% confidence interval (CI): 0,24-0,79, p=0,009). In the PVA+PAP therapy and PVA groups, the proportion of patients with AF recurrence reached 5,6 and 40,7%, respectively. The odds of AF recurrence in the PVA group were >9,1 times compared to the PVA+PAP therapy group (OR 0,11; 95% CI: 0,02-0,48, p=0,001). The hospitalization rate for AF recurrence in the ADT+PAP therapy group (17,1%) was <3,3 times lower than in the ADT group (40,5%) (OR 0,3; 95% CI: 1,164-9,418, p=0,021). In the groups after catheter therapy, the differences in hospitalization rates were insignificant (p=0,305).

Conclusion. The addition of PAP therapy to pharmacological and/ or interventional treatment of AF can reduce the rate of arrhythmia recurrence and intensive care unit admissions, thereby reducing the burden on the healthcare system.

1. Odutayo A, Wong CX, Hsiao AJ, et al. Atrial fibrillation and risks of car­diovascular disease, renal disease, and death: systematic re­view and meta-analysis. BMJ. 2016;354:i4482. doi:10.1136/bmj.i4482.

2. Antikainen RL, Peters R, Beckett NS, et al. Atrial fibrillation and the risk of cardiovascular disease and mortality in the Hypertension in the Very Elderly Trial. J Hypertens. 2020;38(5):839. doi:10.1097/HJH.0000000000002346.

3. Berdysheva VA, Ionin VA, Vakulenko AS, et al. Atrial fibrillation and obstructive sleep apnea syndrome: results of a retrospective study. "Arterial’naya Gipertenziya" ("Arterial Hypertension"). 2024;30(1):58-69. (In Russ.) doi:10.18705/1607-419X-2024-2395.

4. Stevenson IH, Teichtahl H, Cunnington D, et al. Prevalence of sleep disordered breathing in paroxysmal and persistent atrial fibrillation patients with normal left ventricular function. Eur Heart J. 2008;29(13):1662-9. doi:10.1093/eurheartj/ehn214.

5. Abumuamar AM, Dorian P, Newman D, et al. The prevalence of obstructive sleep apnea in patients with atrial fibrillation. Clin Cardiol. 2018;41(5):601-7. doi:10.1002/clc.22933.

6. Moula AI, Parrini I, Tetta C, et al. Obstructive Sleep Apnea and At­rial Fibrillation. J Clin Med. 2022;11(5):1242. doi:10.3390/jcm11051242.

7. Agaltsov MV, Drapkina OM, Davtyan KV, et al. The prevalence of sleep breathing disorders in patients with atrial fibrillation under­going catheter treatment. Rational Pharmacotherapy in Car­diology. 2019;15(1):36-42. (In Russ.) doi:10.20996/1819-6446-2019-15-1-36-42.

8. Stevenson IH, Roberts-­Thomson KC, Kistler PM, et al. Atrial elec­tro­physiology is altered by acute hypercapnia but not hypoxemia: implications for promotion of atrial fibrillation in pulmonary disease and sleep apnea. Heart Rhythm. 2010;7(9):1263-70. doi:10.1016/j.hrthm.2010.03.020.

9. Golitsyn SP, Panchenko EP, Mironov NYu, et al. Eurasian clinical guidelines for the diagnosis and treatment of atrial fibrillation in adult patients (2025). Eurasian Heart Journal. 2025;(3):6-77. (In Russ.) doi:10.38109/2225-1685-2025-3-6-77.

10. Litvin AYu, Chazova IE, Elfimova EM, et al. Eurasian Association of Cardiology (EAC)/ Russian society of somnologists (RSS) guidelines for the diagnosis and treatment of obstructive sleep apnea in patients with cardiovascular diseases (2024). Eurasian Heart Journal. 2024;(3):6-27. (In Russ.) doi:10.38109/2225-1685-2024-3-6-27.

11. May AM, Mehra R. Obstructive sleep apnea: role of intermittent hypoxia and inflammation. Semin Respir Crit Care Med. 2014;35(5):531-44. doi:10.1055/s-0034-1390023.

12. Iwasaki Y. Mechanism and management of atrial fibrillation in the patients with obstructive sleep apnea. J Arrhythm. 2022;38(6):974-80. doi:10.1002/joa3.12784.

13. Berdysheva VA, Ionin VA, Baranova EI. Clinical outcomes and dynamics of brain natriuretic peptide, blood biomarkers of fibrosis and inflammation, echocardiographic parameters during non-invasive respiratory therapy in patients with atrial fibrillation and obstructive sleep apnea. Arterial’naya Gipertenziya. 2025;31(1):6-18. (In Russ.) doi:10.18705/1607-419X-2025-2477.

14. Monahan K, Brewster J, Wang L, et al. Relation of the severity of obstructive sleep apnea in response to anti-arrhythmic drugs in patients with atrial fibrillation or atrial flutter. Am J Cardiol. 2012;110(3):369-72. doi:10.1016/j.amjcard.2012.03.037.

15. Ng CY, Liu T, Shehata M, et al. Meta-analysis of obstructive sleep apnea as predictor of atrial fibrillation recurrence after catheter ablation. Am J Cardiol. 2011;108(1):47-51. doi:10.1016/j.amjcard.2011.02.343.

16. Sterling KL, Alpert N, Malik AS, et al. Association Between Sleep Apnea Treatment and Health Care Resource Use in Patients With Atrial Fibrillation. J Am Heart Assoc. 2024;13(9):e030679. doi:10.1161/JAHA.123.030679.

17. Traaen GM, Aakerøy L, Hunt T-E, et al. Effect of Continuous Positive Airway Pressure on Arrhythmia in Atrial Fibrillation and Sleep Apnea: A Randomized Controlled Trial. Am J Respir Crit Care Med. 2021;204(5):573-82. doi:10.1164/rccm.202011-4133OC.

18. Hunt T-E, Traaen GM, Aakerøy L, et al. Effect of continuous positive airway pressure therapy on recurrence of atrial fibrillation after pulmonary vein isolation in patients with obstructive sleep apnea: A randomized controlled trial. Heart Rhythm. 2022;19(9):1433-41. doi:10.1016/j.hrthm.2022.06.016.

19. Parati G, Lombardi C, Hedner J, et al. Recommendations for the ma­na­gement of patients with obstructive sleep apnoea and hyper­tension. Eur Respir J. 2013;41(3):523-38. doi:10.1183/09031936.00226711.

20. Colish J, Walker J, Elmayergi N, et al. Obstructive Sleep Apnea: Effects of Continuous Positive Airway Pressure on Cardiac Re­mo­deling as Assessed by Cardiac Biomarkers, Echocardio­graphy, and Cardiac MRI. Chest. 2012;141(3):674-81. doi:10.1378/chest.11-0615.

21. Qureshi WT, Nasir U, Alqalyoobi S, et al. Meta-­Analysis of Continuous Positive Airway Pressure as a Therapy of Atrial Fibrillation in Obstructive Sleep Apnea. Am J Cardiol. 2015; 116(11):1767-73. doi:10.1016/j.amjcard.2015.08.046.

22. Kanagala R, Murali NS, Friedman PA, et al. Obstructive sleep apnea and the recurrence of atrial fibrillation. Circulation. 2003;107(20):2589-94. doi:10.1161/01.CIR.0000068337.25994.21.

23. Li X, Zhou X, Xu X, et al. Effects of continuous positive airway pressure treatment in obstructive sleep apnea patients with atrial fibrillation: A meta-analysis. Medicine (Baltimore). 2021; 100(15):e25438. doi:10.1097/MD.0000000000025438.