TABLE VII.A.5.

Association between atrial fibrillation and OSA

Study	Year	LOE	Study design	Study groups	Clinical endpoints	Conclusion
Gami et al.716	2004	3b	Case–control study	1) 151 consecutive patients undergoing electrocardioversion for AF 2) 312 consecutive patients without AF referred to a general cardiology practice	Presence of OSA identified based on a Berlin Questionnaire score of 2–3	Adjusted OR of 2.19 (95% CI 1.40–3.42) for the association of AF and OSA
Porthan et al.717	2004	4	Case–control study	1) 59 patients with AF identified from hospital records, free of known causes of AF 2) 56 age- and sex-matched controls from general population registry, free of AF or known causes of AF	Presence of “sleep apnea syndrome” based on AHI from in-lab cardiorespiratory polygraphy and sleep apnea symptoms	No significant difference between groups in prevalence of sleep apnea syndrome (32% in AF versus 29% in control)
Mehra et al.719	2006	3b	Nested case–control study within a community-based cohort study	Participants in the Sleep Heart Health Study 1) 228 subjects with AHI ≥30 on home polysomnography 2) 338 subjects with AHI <5, frequency-matched on age, sex, race/ethnicity, BMI	Presence of arrhythmias on bipolar lead I ECG recorded on home polysomnography	Atrial fibrillation was present in 4.8% of severe OSA group and 0.9% of controls, with adjusted OR 4.02 (95% CI 1.03–15.74) for the association of AF and severe OSA
Stevenson et al.715	2008	3b	Case–control study	1) 90 patients with paroxysmal or persistent AF 2) 45 patients referred to the same tertiary care center without AF, frequency match for age, and sex	AHI >15 on home polysomnography	Mean AHI was higher in the AF group than the control group (23.2 [SD 19.3 vs. 14.7 [SD 12.4]), with adjusted OR 3.04 (95% CI1.24–7.46) for the association of AF and OSA
Braga et al.707	2009	3b	Case–control study	1) 57 consecutive patients with chronic persistent AF in Sao Paulo, Brazil 2) 32 age-, sex-, and BMI-similar subjects from the Sao Paolo general population participating in the Epidemiologic Sleep Study (EPISONO)	From in-lab polysomnography: 1) AHI 2) Sleep time with SaO2 <90%	No significant difference between groups in mean AHI (24.3 [SD 16.5] vs. 19.1 [SD 15.3]), but higher prevalence of AHI ≥10 (81.6% vs. 60%, p = 0.03) and longer time with SaO2 <90% in the AF group
Bitter et al.706	2009	4	Case series	150 patients with persistent AF and normal left ventricular ejection fraction	AHI from cardiorespiratory polygraphy, classified as central or obstructive based on the predominant event type	OSA was present in 42.7% (18% mild, 12% moderate, 12.7% severe); an additional 31.3% had central sleep apnea
Mehra et al.720	2009	3b	Community-based cross-sectional cohort study	2911 participants in the Outcomes of Sleep Disorders in Older Men Study	Association of nocturnal arrhythmias present on home polysomnography with total AHI, obstructive AHI (obstructive apneas plus all hypopneas), and central apnea index	There was a progressive increase in prevalence of AF with increasing quartile of total AHI, from 3.2% to 7.3%. The adjusted OR in the highest AHI quartile was 2.15 (95% CI 1.19–3.89). This effect was stronger for the central apnea index, and was non-significant for the obstructive AHI in adjusted analyses
Pathak et al.330	2014	4	Case series	149 patients referred for pulmonary vein isolation procedure for AF	Presence of severe OSA (AHI ≥30) on in-lab polysomnography	86 of 149 patients (57.7%) had severe OSA
Kwon et al.718	2015	3b	Community-based cross-sectional cohort study	2048 participants in the Multi-Ethnic Study of Atherosclerosis Sleep Study	Association of AHI from in-home polysomnography at MESA exam 5 with AF based on International Classification of Disease codes or ECG recordings over the preceding approximately 10 years (n = 92) or present on the polysomnogram ECG (an additional n = 8)	There was an increase in AF prevalence from 4.0% in those with none to mild OSA, 6.0% in those with moderate OSA, and 7.5% in those with severe OSA. The adjusted OR was 1.22 (95% CI 0.99–1.49) for each 1 SD increase in AHI.
Abuammar et al.704	2018	4	Case series	100 consecutive patients with AF without prior diagnosis of OSA recruited from arrhythmia clinics	Presence and severity of OSA from mean of 2 nights of home polysomnography	OSA was present in 85% of subjects (38% mild, 23% moderate, and 24% severe)
Traaen et al.710	2019	4	Case series	579 patients with paroxysmal AF admitted for pulmonary vein isolation procedure, without known OSA	Presence and severity of sleep apnea from mean of 2 nights of cardiorespiratory polygraphy	Sleep apnea was present in 83% of subjects (41% mild, 30% moderate, and 12% severe); this was OSA in 97.5% of those with sleep apnea, central sleep apnea in 2.5%
Gami et al.414	2007	2b	Retrospective cohort study	3542 adults without history of AF referred for diagnostic polysomnography 1) OSA defined as AHI ≥5 (n = 2626), with group mean AHI 36 (SD 32) 2) No OSA	Incidence of AF based on electronic medical record review, with mean follow-up of 4.7 years	AF occurred in 2.1% of those without OSA, 4.3% of those with OSA, with unadjusted HR 2.18 (95% CI 1.34–3.54). This effect was restricted to those under age 65. In multivariate analysis, the difference between awake and asleep oxygen saturation was a strong predictor of incident AF. It is not clear in this study whether measures of OSA per se are independently associated with incident AF
Cadby et al.724	2015	2b	Retrospective cohort study	6841 adults without history of AF referred for diagnostic polysomnography 1) OSA defined as AHI 0≥5 (n = 4352) 2) No OSA	Incidence of hospitalization for AF based on review of Western Australia Hospital Morbidity and Mortality Data, with median follow-up of 11.9 years	AF occurred in 8.6% of those with OSA and 3.3% of those without OSA, with adjusted HR 1.55 (95% CI 1.21–2.00) for the association of OSA with incident AF. There was a modest dose–response relationship, with adjusted HR increasing from 1.48 in those with mild OSA to 1.73 in those with severe OSA. Both AHI and time at SaO2 <90% were associated with incident AF
May et al.725	2016	2b	Community-based cohort study	Of 2316 participants in the Outcomes of Sleep Disorders in Older Men Study who were free of AF at baseline, 852 had a follow-up sleep study after approximately 6 years and 843 of these had outcome data and were analyzed	Association of AHI from baseline in-home polysomnography with incident adjudicated or self-reported AF (the proportion of adjudicated versus self-report AF is not stated)	AF occurred in 10.0% of those with AHI <15 and 14.2% of those with AHI ≥15 (adjusted OR 1.15 [95% CI 0.72–1.84]). There was no association of AF with obstructive AHI; however, a central apnea index ≥5 was present in 48 participants at baseline and the incidence of AF in this group was 22.9% (adjusted OR 2.34 [95% CI 1.14–4.77])
Tung et al.726	2017	2b	Community-based cohort study	Of 6441 participants in the Sleep Heart Health Study, 3346 had repeat polysomnography after approximately 5 years. Of these 388 were excluded due to restrictions on data use and 46 due to prevalent AF at baseline, yielding an analytic sample of 2912 participants.	Association of OSA and central sleep apnea with incident AF based on parent cohort adjudication or 12-lead ECG at the time of the second polysomnogram; median follow-up was 5.3 years; OSA was classified based on the obstructive AHI (OAHI, obstructive apneas plus all hypopneas per hour of sleep)	AF incidence increased with OSA severity from 9.6% of those with OAHI <5% to 16.4% with AHI ≥30; however, adjusting for age, sex, race and BMI there was no positive association of OSA with AF. Central apnea index ≥5 was present in 74 participants at baseline, and the incidence of AF in this group was 25.7% (adjusted OR 1.71, 95% CI 0.89–3.30, increasing to 3.00, 95% CI 1.40–6.44, with further adjustment for hypertension, diabetes, and cardiovascular disease)
Kendzerska et al.723	2018	2b	Retrospective cohort study	8256 patients without prior history of arrhythmia referred for diagnostic polysomnography 1) 2263 with AHI < 5 2) 2260 with 5 ≤ AHI < 15 3) 1823 with 15 ≤ AHI ≤ 30 4) 2263 with AHI > 30	Time to first hospitalization with a diagnosis of AF or atrial flutter, using Ontario Provincial Health Administrative Administrative Data, with median follow-up of 10 years	In unadjusted analyses, incident hospitalized AF increased with increasing severity of OSA based on either AHI or percent time at SaO2 < 90%; however, in multivariate models that included BMI these associations were not significant, with hazard ratios < 1.0 for each OSA severity compared to AHI <5. Only when comparing those with more than 30% of sleep time at SaO2 < 90% (n = 463) to those with less severe hypoxemia, was the adjusted HR significant (1.77, 95% CI 1.15–2.74).
Mazza et al.714	2009	1b	Clinic-based cohort study	158 consecutive patients admitted for electrocardioversion for AF; all had polysomnography the night prior to cardioversion 1) AHI ≥15 (n = 49) 2) AHI <15 (n = 109)	Recurrence of AF over 1-year follow-up	AF recurred in 69% of patients with AHI ≥15 and in 43% of those with AHI <15 (adjusted OR 3.04, 95% CI 1.45–6.36)
Matiello et al.727	2010	1b	Clinic-based cohort study	174 consecutive patients undergoing pulmonary vein isolation procedure for AF; all screened with Berlin Questionnaire, and the 51 with score of 2–3 underwent home cardiorespiratory polygraphy 1) Low risk Berlin Questionnaire or AHI <10 on polygraphy (n = 132) 2) AHI 10–<30 (n = 17) 3) AHI ≥30 (n = 25)	Recurrence of AF over mean follow-up of 17 (SD 11.5) months	Estimated 1-year recurrence free survival was 48.5% in the low-risk group, 30.4% in those with AHI 10–<30, and 14.3% in those with AHI ≥30. Adjusted OR for recurrence was 1.57 (95% CI 0.83–3.00) for AHI 10–<30 and 1.87 (95% CI 1.11–3.16) for AHI ≥30
Bitter et al.711	2012	1b	Clinic-based cohort study	82 consecutive patients undergoing pulmonary vein isolation procedure for AF, 75 evaluable; all underwent in-hospital cardiorespiratory polygraphy 1) AHI <15 (n = 53) 2) AHI ≥15 (n = 22, of which 15 were predominantly obstructive and seven were predominantly central)	Recurrence of AF over a median follow-up of 12 months	AF recurred in 45.5% of those with AHI ≥15 and 24.5% of those with AHI <15. The adjusted HR for AF recurrence in those with AHI ≥15 was 3.20 (95% CI 1.14–8.95) compared to those with AHI <15. Not analyzed separately by obstructive versus central pattern
Szymanski et al.709	2015	1b	Clinic-based cohort study	290 consecutive patients admitted for pulmonary vein isolation procedure for AF; in-hospital cardiorespiratory polygraphy the night prior to the procedure; polygraphy was inadequate in 22 patients and ablation was not performed in 14; 3 patients with central sleep apnea excluded 1) AHI <5 (n = 136) 2) AHI ≥5 (n = 115)	Recurrence of AF over a mean follow-up of 30 months	AF recurred in 65.2% of those with AHI ≥5 and 45.6% of those with AHI <5. AF recurrence increased progressively with more severe OSA, to 81.8% in those with AHI ≥30. The adjusted OR for AF recurrence in those with AHI ≥5 was 2.58 (95% CI 1.91–4.10)
Kawakami et al.713	2016	1b	Clinic-based cohort study	133 consecutive patients admitted for pulmonary vein isolation procedure for AF; in-hospital cardiorespiratory polygraphy the night prior to the procedure 1) AHI <15 (n = 69) 2) AHI 15–<30 (n = 39) 3) AHI ≥30 (n = 16)	Recurrence of AF over a mean follow-up of 13 (SD 7) months	AF recurred in 25% of those with AHI <15, 49% of those with AHI 15–<30, and 69% of those with AHI ≥30. However, in multivariate analysis, the association of AHI with recurrent AF was significant only in the subgroup with paroxysmal AF (adjusted HR 1.04, 95% CI 1.002–1.065)