Sleep and Breathing

, Volume 23, Issue 4, pp 1275–1281 | Cite as

Signal-averaged P wave area increases during respiratory events in patients with paroxysmal atrial fibrillation and obstructive sleep apnea

  • Ken MonahanEmail author
  • Edward Hodges
  • Arpit Agrawal
  • Raghu Upender
  • Robert L. Abraham
Sleep Breathing Physiology and Disorders • Original Article



P wave characteristics change during simulated apneic events in individuals with atrial fibrillation (AF). This study sought to assess whether similar changes occur during nocturnal respiratory events in patients with AF and obstructive sleep apnea (OSA).


Thirty-five individuals with severe OSA who underwent formal polysomnography and subsequent AF ablation were compared to a matched group without AF. Electrocardiographic segments from each polysomnogram corresponding to the following events were identified: period of wakefulness closest to the initial onset of sleep (baseline-awake), first respiratory event, respiratory event with the lowest nadir oxygen saturation, longest respiratory event, and last respiratory event. Signal-averaged P wave duration and signal-averaged positive P wave area (amplitude*duration for positive P wave amplitudes) were extracted using custom software. P wave characteristics during respiratory events and the baseline-awake condition were compared.


Compared to the baseline-awake condition, the signal-averaged positive P wave area was significantly greater during the longest event and the event with the lowest oxygen saturation in those with AF, but not in those without AF. There were no significant differences in signal-averaged P wave duration for any respiratory event compared to the baseline-awake condition, regardless of AF status.


In patients with paroxysmal AF and obstructive sleep apnea, the signal-averaged positive P wave area is greater during certain respiratory events than during wakefulness. This finding may reflect the acute impact on right atrial volume of increased venous return associated with respiratory events and could be useful to assess AF risk in sleep apnea and to monitor response to treatment.


Obstructive sleep apnea Atrial fibrillation Electrocardiogram P wave 



The authors wish to thank Melissa Francis for expert assistance in obtaining the polysomnographic data.

Funding information

This work was supported by CTSA award no. UL1TR000445 from the National Center for Advancing Translational Sciences.

Compliance with ethical standards

This study has been approved by the Vanderbilt Medical Center Institutional Review Board and has therefore been performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments. The manuscript does not contain clinical studies.


The contents for this work are solely the responsibility of the authors and do not necessarily represent official views of the National Center for Advancing Translational Sciences or the National Institutes of Health.

Conflict of interest

The authors declare that they have no conflict of interest.


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Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  1. 1.Division of Cardiovascular MedicineVanderbilt Medical CenterNashvilleUSA
  2. 2.Department of Neurology, Division of Sleep MedicineVanderbilt Medical CenterNashvilleUSA

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