Sleep Apnea With Afib

Snoring Obstructive Sleep Apnea and Treatment Animation

Snoring and sleep apnea.In normal breathing, air enters the nostrils and goes through the throat and the tracheato the lungs. In people who snore this airway is partiallyobstructed by excess tissue of the throat, such as large tonsils, large soft palate ortongue. Another common cause of obstruction is the dropping of the tongue into the throatdue to over relaxation of tongue muscles during sleep. Air currents competing throughnarrow spaces in the throat cause the soft palate essentially a piece of soft tissuehanging in the throat to vibrate. This vibration is the source of the noise we hear when someoneis snoring.

Sleep apnea happens when the airway is completelyobstructed, no air can go through and the person stops breathing. This cessation ofbreathing triggers the brain to respond by waking up the person just enough to take abreath. This repeats itself again and again during the course of the night and may resultin sleep deprivation. Snoring and mild sleep apnea may be treatedwith a mandibular advancement device. This device is designed to move the lower jaw andthe tongue slightly forward and thus making the space in the back of the throat larger.

2015 Atrial Fibrillation Patient Conference Managing AF Risk Factors Panel

Wilber: Well thank you. This is really,I think, a topic that I look forward to talking to people about and I think more and moreit's assuming increasing importance in how we take care of patients. We're going to tryto do a broad overview. We're going to focus specifically on diabetes, sleep apnea andexercise as 00:00:30 potential risk factors and how they can be modified in our care ofpatients with atrial fibrillation, but we'll try to give your broad overview of some ofthe other topics as well. So although I'm going to mostly talk about obesity today andatrial fibrillation, we'll talk about a couple of other things as well.

There are a variety of risk factors for atrialfibrillation and this was initially, I think, mostly of interest to epidemiologists, peoplewho study how disease, what the prevalence of it is, and how it comes to pass. I thinknow we've really begun to understand that central role, not only in sort of understandingthe disease but really in treating it, and if we don't consider these as we treat patientsthen I think our outcomes are not nearly as good as they might be otherwise. This is the traditional list and I think thereare probably even a few more. I've starred a few of them where I think that the evidencenow is becoming very clear that these are

potentially modifiable and that's really whatI want you to take home today. These aren't static risk factors that cause something andthen there's nothing you can do about it but treat the consequences, but in fact by intervening,both early and late, you have a chance to modify the disease and improve outcomes. What that means for you as patients is thatyou have to participate in your care and that's really something I want to emphasize; andif you're not invited to do so, then you must insist on doing it. Because I think your outcomesfor atrial fibrillation really depend on how you address each of these risk factors asthey apply to you individually.

Just to briefly talk about hypertension; wewon't spend a lot of time. It's certainly important; it's one of the most common riskfactors associated with atrial fibrillation. Somewhere between 60% and 80% of patientswho have atrial fibrillation in large populations studies have at least hypertension as a riskfactor, and by itself may account for the 20% to 25% of the overall risk of new onsetatrial fibrillation. There's some evidence that systolic bloodpressure probably plays a more important role than diastolic blood pressure, but there'sno clear threshold value. When you look in large population studies, each increment insystolic blood pressure is associated with

the increasing risk of atrial fibrillation.There's no sort of magic number necessarily that if you get below, your risk of atrialfibrillation goes away. It's probably reasonable and what I like to use as a therapeutic targetis somewhere around below 13080. What that means is that that's even below the sort oftraditional guidelines for treatment of hypertension, but it's very clear that even mild elevationsof blood pressure within the range of what we would call normal can still confer afibrisk. There's no clear superiority of one drug overanother although the control of atrial fibrillation certainly can improve the symptoms and thefrequency with which you have atrial fibrillation.

It's not clear that any single drug is absolutelybetter. There's some evidence that ACE inhibitors and ARBs, which are drugs that many of youmay be on to treat your hypertension, may be particularly beneficial, particularly whenyou have relatively advanced hypertension with end organ involvement like thickeningof the heart muscle, the left ventricular hypertrophy, as we call it. But there's also evidence that uncontrolledhypertension as you start antiarrhythmic drug treatment and after catheter ablation, ifyou enter into that with poorly controlled blood pressure, in fact, you have much pooreroutcomes than if your blood pressure is controlled.

What lifestyle changes help manage AFib and prevent stroke

Curtis, what are the lifestyle modifications that you discuss with your patientsé There are a few things you might consider doing. Certainly if someone is smoking they shouldn't be smoking, for a whole host of reasons including risk of stroke and atrial fibrillation. But aside from that, if you have hypertension then modifying the salt in your diet may be somewhat helpful in keeping your blood pressure normal.

If you have sleep apnea, the disorder where you tend to stop breathing at night and that's been diagnosed, then there are treatments that can help with that, various kinds of machines that are used at night to help prevent the stopping of the breathing. So that's one thing you can do Interestingly, extreme exercise sometimes is related to the development of atrial fibrillation, and that's rare but it does happen and in those cases then maybe backing off a bit can be helpful in preventing it. But I think what are the most important points to make about this is that

there are many patients who's atrial fibrillation comes and goes, and it has absolutely nothing to do with lifestyle, and so the idea that just modifying a lifestyle or sticking to a particular diet or something like that is going to cure this is probably unrealistic in most people. I agree. And I think within the treatment of atrial fibrillation, the most important thing they need to adhere to is if it's appropriate for them to take the chronic anticoagulation blood thinners, to prevent strokes. Right, and even if we know that someone's had atrial fibrillation before,

even if they seem to be doing well now, and they're not having symptomatic recurrences, they need to stay on those blood thinners. And particularly a point I don't think we've emphasized enough yet is that some patients sometimes have symptomatic episodes where they can feel it, but many of them can be asymptomatic. And the fact that a patient isn't feeling like they've had any problems with their rhythm and then falsely thinks they can stop the blood thinners could be a real problem. So if you've been diagnosed as having a risk, you want to make sure you stay on those drugs,

so that way if you have silent episodes of atrial fibrillation you don't put yourself at risk of having a stroke.

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