Interactions of Sleep Apnea, the Autonomic Nervous System, and Its Impact on Cardiac Arrhythmias
- 17 Downloads
Purpose of Review
Sleep-disordered breathing (SDB) is an independent risk factor for cardiovascular disease. SDB-related changes in the autonomic nervous system (ANS) and the association between obstructive sleep apnea and atrial fibrillation (Afib) have been extensively researched. SDB has also been associated with occurrence of ventricular arrhythmias. We evaluated the effects of SDB on the ANS and its relationship with ventricular and supraventricular arrhythmias.
The ANS is an important regulator of the cardiovascular system and contributes to the development of cardiovascular diseases including hypertension and coronary artery disease. SDB has an important influence on the ANS and contributes to electromechanical remodeling of the left atrium via a number of mechanisms, increasing susceptibility to Afib. There is evidence that these mechanisms also affect the ventricular myocardium and therefore lead to ventricular arrhythmias. Effective treatment of SDB reduces the rate of Afib recurrence and seems to reduce ventricular arrhythmogenicity.
SDB has an important impact on the ANS and therefore plays a major role in the development of cardiac arrhythmias. Although SDB screening of patients with Afib is recommended by current guidelines, SDB remains underdiagnosed. Additional research is needed to clarify the role of SDB and its treatment in ventricular arrhythmias.
KeywordsSleep-disordered breathing Ventricular arrhythmias Supraventricular arrhythmias Atrial fibrillation Autonomic function
Compliance with Ethical Standards
Conflict of Interest
Fabian Roder, Johanna Strotmann, Henrik Fox, Thomas Bitter, Dieter Horstkotte, and Olaf Oldenburg declare no conflict of interest.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
- 4.Bitter T, Oldenburg O, Horstkotte D. Schlafbezogene Atmungsstörungen und kardiale Arrhythmien. Somnologie. 2014;18:9–12.Google Scholar
- 8.Bitter T, Westerheide N, Prinz C, Hossain MS, Vogt J, Langer C, et al. Cheyne-Stokes respiration and obstructive sleep apnoea are independent risk factors for malignant ventricular arrhythmias requiring appropriate cardioverter-defibrillator therapies in patients with congestive heart failure. Eur Heart J. 2011;32:61–74.PubMedGoogle Scholar
- 17.Go AS, Hylek EM, Phillips KA, Chang Y, Henault LE, Selby JV, et al. Prevalence of diagnosed atrial fibrillation in adults: national implications for rhythm management and stroke prevention: the AnTicoagulation and Risk Factors in Atrial Fibrillation (ATRIA) Study. JAMA. 2001;285:2370–5.PubMedGoogle Scholar
- 23.Kirchhof P, Benussi S, Kotecha D, Ahlsson A, Atar D, Casadei B, et al. ESC guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J. 2016;2016(37):2893–962.Google Scholar
- 24.Calkins H, Kuck KH, Cappato R, Brugada J, Camm AJ, Chen SA, et al. 2012 HRS/EHRA/ECAS expert consensus statement on catheter and surgical ablation of atrial fibrillation: recommendations for patient selection, procedural techniques, patient management and follow-up, definitions, endpoints, and research trial design: a report of the Heart Rhythm Society (HRS) Task Force on Catheter and Surgical Ablation of Atrial Fibrillation. Developed in partnership with the European Heart Rhythm Association (EHRA), a registered branch of the European Society of Cardiology (ESC) and the European Cardiac Arrhythmia Society (ECAS); and in collaboration with the American College of Cardiology (ACC), American Heart Association (AHA), the Asia Pacific Heart Rhythm Society (APHRS), and the Society of Thoracic Surgeons (STS). Endorsed by the governing bodies of the American College of Cardiology Foundation, the American Heart Association, the European Cardiac Arrhythmia Society, the European Heart Rhythm Association, the Society of Thoracic Surgeons, the Asia Pacific Heart Rhythm Society, and the Heart Rhythm Society. Heart Rhythm. 2012;9(4):632–96.e21.PubMedPubMedCentralGoogle Scholar
- 29.Naruse Y, Tada H, Satoh M, Yanagihara M, Tsuneoka H, Hirata Y, et al. Concomitant obstructive sleep apnea increases the recurrence of atrial fibrillation following radiofrequency catheter ablation of atrial fibrillation: clinical impact of continuous positive airway pressure therapy. Heart Rhythm. 2013;10:331–7.PubMedGoogle Scholar
- 33.Tung P, Levitzky YS, Wang R, Weng J, Quan SF, Gottlieb DJ, et al. Obstructive and central sleep apnea and the risk of incident atrial fibrillation in a community cohort of men and women. J Am Heart Assoc 2017;6.Google Scholar
- 48.Orban M, Bruce CJ, Pressman GS, Leinveber P, Romero-Corral A, Korinek J, et al. Dynamic changes of left ventricular performance and left atrial volume induced by the Mueller maneuver in healthy young adults and implications for obstructive sleep apnea, atrial fibrillation, and heart failure. Am J Cardiol. 2008;102:1557–61.PubMedPubMedCentralGoogle Scholar
- 51.Lammers WJ, Kirchhof C, Bonke FI, Allessie MA. Vulnerability of rabbit atrium to reentry by hypoxia. Role of inhomogeneity in conduction and wavelength. Am J Phys. 1992;262:H47–55.Google Scholar
- 52.Lin YK, Lai MS, Chen YC, Cheng CC, Huang JH, Chen SA, et al. Hypoxia and reoxygenation modulate the arrhythmogenic activity of the pulmonary vein and atrium. Clin Sci (Lond). 2012;122:121–32.Google Scholar
- 65.Lam DC, Lam KS, Ip MS. Obstructive sleep apnoea, insulin resistance and adipocytokines. Clin Endocrinol. 2015;82:165–77.Google Scholar
- 68.•• Linz D, Linz B, Hohl M, Böhm M. Atrial arrhythmogenesis in obstructive sleep apnea: Therapeutic implications. Sleep Med Rev. 2016;26:87–94. This recent review provides an overview on obstructive sleep apnea and its pathomechanisms which may lead to the development of atrial fibrillation, including the autonomic nervous system PubMedGoogle Scholar
- 72.Kistler PM, Sanders P, Dodic M, Spence SJ, Samuel CS, Zhao C, et al. Atrial electrical and structural abnormalities in an ovine model of chronic blood pressure elevation after prenatal corticosteroid exposure: implications for development of atrial fibrillation. Eur Heart J. 2006;27:3045–56.PubMedGoogle Scholar
- 73.• Chen PS, Chen LS, Fishbein MC, Lin SF, Nattel S. Role of the autonomic nervous system in atrial fibrillation: pathophysiology and therapy. Circ Res. 2014;114:1500–15. This is a detailed review of the autonomic nervous system describing its impact on atrial arrhythmogenesis as well as therapeutic implications by neuromodulation. PubMedPubMedCentralGoogle Scholar
- 76.Somers VK, Mark AL, Zavala DC, Abboud FM. Influence of ventilation and hypocapnia on sympathetic nerve responses to hypoxia in normal humans. J Appl Physiol (1985). 1989;67:2095–100.Google Scholar
- 81.Naughton MT, Floras JS, Rahman MA, Jamal M, Bradley TD. Respiratory correlates of muscle sympathetic nerve activity in heart failure. Clin Sci (Lond). 1998;95:277–85.Google Scholar
- 83.Yu L, Li X, Huang B, Zhou X, Wang M, Zhou L, et al. Atrial fibrillation in acute obstructive sleep apnea: autonomic nervous mechanism and modulation. J Am Heart Assoc 2017;6.Google Scholar
- 102.Nakao YM, Ueshima K, Yasuno S, Sasayama S. Effects of nocturnal oxygen therapy in patients with chronic heart failure and central sleep apnea: CHF-HOT study. Heart Vessel. 2016;31:165–72.Google Scholar
- 103.Yoshihisa A, Suzuki S, Yamaki T, Sugimoto K, Kunii H, Nakazato K, et al. Impact of adaptive servo-ventilation on cardiovascular function and prognosis in heart failure patients with preserved left ventricular ejection fraction and sleep-disordered breathing. Eur J Heart Fail. 2013;15:543–50.PubMedGoogle Scholar
- 104.Pokorney D, Tasissa G, Anstrom K, Oldenburg O, Punjabi N, Fiuzat M, et al. Adaptive servo-ventilation reduces atrial fibrillation burden in patients with heart failure and sleep apnea: results from the CAT-HF Arrhythmia Substudy. Late-Breaking Clinical Trial update. Presented at: Heart Failure Society of America Scientific Assembly. 2016; Orlando, FL, USA.Google Scholar