Screening AF Patients for Obstructive Sleep Apnea: Interview with Dr. Vijay Swarup

In this interview, we speak with Vijay Swarup, MD, FACC, FHRS, Director of the Arizona Heart Rhythm Center in Phoenix, about his process for patients with atrial fibrillation (AF) to be screened and treated for obstructive sleep apnea (OSA).

Tell us about your EP program at the Arizona Heart Rhythm Center. 

We do most of our cases at Arizona Heart Hospital, which has two EP labs and a dedicated staff. We have a reasonably sized program, and probably have one of the largest in terms of AF ablation volume. We are very involved in clinical research as well; we get most of the clinical trials in AF arrhythmias, including the trials evaluating left atrial appendage closure devices.

What is the association between obstructive sleep apnea and atrial fibrillation? Approximately how many patients with AF have OSA?

From our experience alone, we find that around 30-40% of people have some kind of sleep apnea syndrome. So the question for us is to look at whether ablation works and what the long-term success rates are. Our five-year recurrence rates are probably in the 20% range after successful ablation, so we tend to screen all of our patients before ablation. 

Why is screening important for AF patients with OSA? What does untreated OSA put patients at risk for? 

It puts patients at increased risk for multiple problems — arrhythmias are just a piece of it. If they are not sleeping well then they’re tired, are at risk for pulmonary hypertension and shortness of breath, and have an association with pain syndromes such as fibromyalgia. They also have higher instances of dementia later on in life. Sleep, especially restful sleep, is very important to our well-being long term. I think sleep should be addressed at multiple levels, and since we deal mostly with arrhythmias, it’s especially important for us. 

Is the prevalence of OSA on the rise? 

Yes, we’re seeing a higher prevalence of OSA in our arrhythmia and heart failure population. We’re diagnosing more today, and in general we’ve also seen an epidemic of obesity, heart problems, and type 2 diabetes in patients. 

Tell us about your innovative approach in screening this patient population. 

A lot of our arrhythmia patients with diagnosed AF come for an ablation procedure. After they are undergo AF ablation, we begin to implement lifestyle modification and treatment for all their risk factors to achieve a more long-term success rate. These risk factors include treating hypertension and diabetes, creating an exercise and weight loss program, and often, addressing sleep. You cannot modify a patient’s genetic makeup, and it’s difficult to reduce stress levels in their environment. Other factors that are modifiable — such as relaxation techniques and avoidance of all stimulants like alcohol — all play a good-sized role, but sleep is one of the main factors that is modifiable. 

How do you determine which of your AF patients have obstructive sleep apnea? Do you use the WatchPAT test from Itamar Medical? How many patients with OSA and AF have you treated using this method?

We have tried multiple products in the past, but many of the home sleep tests are not very user-friendly, and the acceptance rate has not been great. WatchPAT is a much more tolerable procedure because it is placed on the finger and wrist, and gives us great data to help get patients into a sleep program, prescribe them a sleep apnea machine, and modify their sleep habits in general. We’ve had great success with WatchPAT. In our arrhythmia practice, we screen a minimum of at least 30 patients a month. We adopted this method about a year and a half ago. 

What are the components of the WatchPAT solution? 

The WatchPAT is a wrist-mounted device with a disposable finger sensor. There is also a microphone sensor that records snoring sounds, and whether (and how much) the patient sleeps in a supine position (which is where most of the problems happen), on their side, or in a prone position. 

What difference have you seen in patients post-OSA therapy?

Most people think that they’re not going to tolerate treatment with a CPAP machine, but that has not been our experience. We have found most patients do tolerate the CPAP machine pretty well. However, we also do refer people for mandibular advancement devices, which is prescribed by a dentist. In most cases, people feel better, sleep better, have more energy the next day, and are just more productive in their life. We believe we are seeing less arrhythmia episodes, ectopy, and episodes of fibrillation, and that it may play a role in decreasing the progression of the disease itself. 

Why is WatchPAT a good solution for cardiologists? How can this solution offer a more streamlined pathway for effective treatment? 

As a screening tool, the data that WatchPAT collects rivals most comprehensive sleep studies. Therefore, by using the WatchPAT, you can have a comprehensive sleep program in which you’re able to refer patients directly for sleep therapy without requiring a full-fledged sleep study, which can be really cumbersome and expensive, as well as difficult to get approval for from the insurance companies. In these ways, WatchPAT is more effective. 

How can other electrophysiologists successfully implement this OSA screening process?

Electrophysiologists should be aware of the issue of sleep apnea and its involvement in disease progression and a decreased overall long-term success rate. They should screen appropriate patients for sleep apnea, and once identified, EPs should get them into a sleep clinic for effective treatment. Taking these steps will help electrophysiologists accomplish their goal of keeping their patients arrhythmia free for the longest amount of time.

Disclosure: Dr. Swarup has no conflicts of interest to report regarding the content herein.