Predominant obstructive or central sleep apnea in patients with atrial fibrillation: influence of characterizing apneas versus apneas and hypopneas

Accepted Manuscript Predominant obstructive or central sleep-apnea in patients with atrial fibrillation: influence of characterizing apneas versus apneas and hypopneas Johanna Strotmann, Henrik Fox, Thomas Bitter, Florian Schindhelm, Klaus-J. Gutleben, Dieter Horstkotte, Olaf Oldenburg PII:

S1389-9457(17)30252-6

DOI:

10.1016/j.sleep.2017.06.003

Reference:

SLEEP 3416

To appear in:

Sleep Medicine

Received Date: 28 February 2017 Revised Date:

22 May 2017

Accepted Date: 12 June 2017

Please cite this article as: Strotmann J, Fox H, Bitter T, Schindhelm F, Gutleben K-J, Horstkotte D, Oldenburg O, Predominant obstructive or central sleep-apnea in patients with atrial fibrillation: influence of characterizing apneas versus apneas and hypopneas, Sleep Medicine (2017), doi: 10.1016/ j.sleep.2017.06.003. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

ACCEPTED MANUSCRIPT Predominant obstructive or central sleep-apnea in patients with atrial fibrillation: influence of characterizing apneas versus apneas and hypopneas

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Johanna Strotmann1, Henrik Fox1, Thomas Bitter1, Florian Schindhelm1, Klaus-J Gutleben1, Dieter Horstkotte1, Olaf Oldenburg1*

Herz- und Diabeteszentrum NRW, Dept. of Cardiology, University Hospital, Ruhr-

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University Bochum, Georgstraße 11, 32545 Bad Oeynhausen, Germany

* Corresponding author: Herz- und Diabeteszentrum NRW, Department of Cardiology, University Hospital, Ruhr-University Bochum, Georgstraße 11, 32545 Bad Oeynhausen,

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Germany. E-mail: [email protected]

E-mail addresses: [email protected] (J Strotmann), [email protected] (H Fox),

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[email protected] (T Bitter), [email protected] (F Schindhelm), kjgutleben@hdz-

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nrw.de (K-J Gutleben), [email protected] (D Horstkotte), [email protected] (O Oldenburg)

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ACCEPTED MANUSCRIPT ABSTRACT Objective/background: Sleep-disordered breathing (SDB) is common in patients with atrial fibrillation (Afib). Although a high proportion of respiratory events are hypopneas, previous studies have only used apneas to differentiate obstructive (OSA) from central (CSA) sleep

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apnea. This study investigated the impact of using apneas and hypopneas versus apneas only to define the predominant type of SDB in Afib patients with preserved ejection fraction.

Patients/methods: This retrospective analysis was based on high-quality cardiorespiratory

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polygraphy (PG) recordings (07/2007 to 03/2016) that were re-analyzed using 2012 American Academy of Sleep Medicine criteria, with differentiation of apneas and hypopneas as

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obstructive or central. Classification of predominant (>50% of events) OSA and CSA was defined based on apneas only (OSAAI and CSAAI) or apneas and hypopneas (OSAAHI and CSAAHI). SDB was defined as an apnea-hypopnea index ≥5/h.

Results: A total of 211 patients were included (146 male, age 68.7±8.5y). Hypopneas

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accounted for >50% of all respiratory events. Based on apneas only, 46% of patients had predominant OSA and 44% had predominant CSA. Based on apneas and hypopneas, the proportion of patients with OSA was higher (56%) and that with CSA was lower (36%). In

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the subgroup of patients with moderate to severe SDB (AHI ≥15/h), the proportion with

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predominant CSA was 55.2% based on apneas only versus 42.1% with apneas and hypopneas. Conclusions: In hospitalized patients with Afib and SDB, use of apneas and hypopneas versus apneas alone had an important influence on the proportion of patients classified as having predominant OSA or CSA.

Key words: atrial fibrillation; sleep-disordered breathing; obstructive sleep apnea; central sleep apnea; hypopnea

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ACCEPTED MANUSCRIPT Highlights • Classification of SDB using apneas and hypopneas changed the predominant apnea type • A quarter of atrial fibrillation patients had a change in classification

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• Predominant OSA was more common when apneas and hypopneas were assessed

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ACCEPTED MANUSCRIPT 1. Introduction Sleep-disordered breathing (SDB) is a highly prevalent and clinically relevant comorbidity in cardiac patients. The prevalence of SDB is 50% to 75% in these patients, depending on underlying cardiac disease and the severity definition used [1]. SDB is an umbrella term for a

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group of heterogeneous conditions that have varying etiology and therefore need to be managed differently. In cardiac patients, SDB can be classified into two main groups:

predominant obstructive sleep apnea (OSA) or predominant central sleep apnea (CSA).

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With a prevalence of 2-4% in the general, middle-aged population [2], OSA syndrome is the most common form of SDB. It occurs secondary to obstruction of the upper airways during

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sleep, resulting in airflow interruption and usually in hypoxemia. In contrast, CSA ischaracterized by an absence of or reduction in ventilatory effort associated with blood oxygen desaturation and/or arousal from sleep. One form of CSA, particularly common in cardiac disease patients, is Cheyne Stokes respiration (CSR). CSA/CSR has used as a marker

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of poor prognosis in patients with heart failure and reduced ejection fraction (HF-REF) [3-8]. However, recent debate has centered on whether CSR should be treated or whether it might be a compensatory mechanism in these patients [9-12]. Data on the role of CSR in patients with

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preserved ejection fraction is currently lacking.

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Atrial fibrillation (Afib) is the most common form of supraventricular tachyarrhythmia in the middle-aged population [13]. As for other forms of cardiac disease, SDB is also a common and clinically relevant comorbidity in patients with Afib. There are a number of risk factors that are common to both Afib and OSA, including increasing age, arterial hypertension, heart failure, obesity, and coronary disease [14-16]. OSA has been shown to be an independent risk factor for both the onset of Afib and its recurrence after electrical cardioversion, antiarrhythmic drug therapy or ablative treatment regimens [17-21]. As a result, recent guidelines recommend screening for and treatment of OSA in Afib patients [22].

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ACCEPTED MANUSCRIPT In contrast to OSA, the role of CSA in Afib patients is not fully understood. While CSA, and CSR in particular, are relatively rare in the general population, they appear to have a high prevalence in patients with Afib, which decreases slightly after electrical cardioversion [2325]. To our knowledge, there are no specific recommendations for screening and treatment of

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CSA and CSR in Afib patients.

Given these important differences, it seems appropriate to make a clear differentiation

between OSA and CSA in patients with Afib. To date, classification of SDB into predominant

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OSA or CSA has been based on apneas only. However, recent recommendations allow classification of hypopneas as well. This study investigated the impact of classifying

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hypopneas as well as apneas on phenotyping the predominant type of SDB in patients with Afib and determined the extent of Cheyne Stokes breathing pattern in Afib patients with predominant CSA. To reduce bias, only patients with preserved left ventricular ejection

2. Methods

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2.1 Patients

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fraction (ejection fraction >55%) were included.

Screening for SDB is clinical routine in our institution. This includes screening of stable

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cardiovascular disease patients with Afib before anti-arrhythmic therapy, as recommend by current guidelines. Out of this dataset we performed a retrospective study of cardiorespiratory polygraphy (PG) recordings made between July 2007 and March 2016. Inclusion criteria were first PG recording in patients with preserved left ventricular ejection fraction (PEF; left ventricular ejection fraction [LVEF] >55% measured using standardized echography) hospitalized with Afib (documented on 12-channel ECG at admission). Unattended PG was performed while patients were hospitalized and before specific treatment of Afib. Exclusion criteria included hemodynamically-relevant valvular diseases, previous valvular 5

ACCEPTED MANUSCRIPT reconstruction or replacement, any kind of implanted pacemakers or defibrillators except for event recorders, previous open heart surgery, specific interventional or operative arrhythmic therapy, acute cardiopulmonary decompensation, chronic obstructive (GOLD >2) or other structural lung disease (resting oxygen saturation [SpO2] <90%), pregnancy, or age <18 years.

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Cardiovascular stability in every patient at the time of the sleep study was ensured by treating cardiologists.

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2.2 Cardiorespiratory polygraphy

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SDB was evaluated using high-quality 6-channel PG, which has been shown to be a costefficient and adequate screening tool to determine the presence, severity and nature of SDB [26, 27]. As described previously, data were manually reviewed after automatic analysis [28]. A minimum of 240 minutes of artifact-free recording time was chosen because guidelines

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from several European countries deem a minimum of four hours to be sufficient [29]. PG recordings were analyzed using RemLogic-E version 3.2. by Embla systems (Broomfield, CO, USA) or DOMINO version 2.6.0 by Somnomedics (Randersacker, Germany).

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Respiratory events were classified by a single investigator (J.S.) using American Academy of Sleep Medicine (AASM) 2012 definitions in order to avoid intra-observer bias [30]. Apnea

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was scored if there was a drop in peak nasal airflow by ≥90% of pre-event baseline lasting for ≥10 seconds; events were scored as obstructive if apnea was associated with continuation of, or increase in, inspiratory effort, as central if there was an absence of inspiratory effort, and as mixed apnea if there was an absence of inspiratory effort during the first part of the event followed by effort later in the event. Hypopnea was scored if there was a drop in peak nasal airflow by ≥30% of pre-event baseline lasting for ≥10 seconds in combination with an oxygen desaturation of ≥3% from pre-event baseline. Hypopneas were classified as obstructive if there was either snoring at the time of the event, an increase of inspiratory flattening of nasal 6

ACCEPTED MANUSCRIPT airflow, or occurrence of associated thoracoabdominal paradox during, but not before, the event, according to AASM definitions [30]; central hypopnea was scored if none of the obstructive hypopnea criteria were met. SDB was defined as an apnea-hypopnea index (AHI; total number of apnea and hypopneas

moderate (AHI 15-29/h) or severe (AHI ≥30/h).

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per estimated hour of sleep) of ≥5/h. SDB severity was graded as mild (AHI 5-14/h),

CSR was defined as ≥3 consecutive episodes of central apneas and/or hypopneas connected

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by a crescendo-decrescendo variation in breathing amplitude with a cycle length of ≥40

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seconds with predominant CSA [30]. Furthermore, the breathing pattern had to occur in five central apneas and/or hypopneas per hour in two or more hours of recorded monitoring.

2.3 SDB classification

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SDB was classified in two different ways: based on the predominant type of apneas only (>50% central apneas [CSAAI] or >50% obstructive apneas [OSAAI]), or based on the predominant type of both apneas and hypopneas (>50% central hypopneas and apneas

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[CSAAHI] or >50% obstructive hypopneas and apneas [OSAAHI]). Where there was an equal

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proportion of central and obstructive events, SDB was considered non-classified.

2.4 Statistical analysis

Data are presented as absolute values and frequency, or as mean ± standard deviation. Discrete variables were analyzed using a z-test and continuous variables using a t-test for comparison between two groups or one-way analysis of variance (ANOVA) for comparison between three or more groups. All statistical analyses were performed using SigmaPlot 12.0 by Systat Software Inc.

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3. Results 3.1 Patient population

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Of 22135 PG and PSG recordings screened, a total of 211 patients had documented Afib at admission, were naïve to any SDB therapy and met all inclusion and no exclusion criteria (Fig. 1). Demographic and clinical data at baseline for the total study population and by type

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3.2 SDB classification – apneas

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of SDB are shown in Table 1. No SDB was found in 14 patients (6.6%).

Ninety-seven patients (46.0%) had OSAAI, which was mild, moderate and severe in 41 (19.4%), 32 (15.2%) and 24 (11.4%), respectively (Fig. 1). CSAAI was seen in 93 patients (44.1%), severity was mild in 24 (11.4%), moderate in 30 (14.2%) and severe in 39 (18.5%)

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(Fig. 2). The remaining seven patients (3.3%) were considered non-classified. CSA-CSR was documented in 58 patients, four of whom (1.9%) had mild CSA, 23 (10.9%) had moderate

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CSA and 31 (14.7%) had severe CSA.

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3.3. SDB classification – apneas & hypopneas In this analysis, 118 patients (55.9%) had OSAAHI and 77 (36.5%) had CSAAHI; SDB was classified as moderate to severe in 57.9% of patients with predominant OSA and 42.1% of those with predominant CSA. According to this classification two patients (1.0%) were considered non-classified.

3.4 Between-group comparisons

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ACCEPTED MANUSCRIPT Using apneas only, 44.8% of patients with moderate to severe SDB (AHI ≥15/h) were classified as having predominant OSA while 55.2% had predominant CSA. In contrast, taking apneas and hypopneas into account classified 57.9% of patients as having OSA and 42.1% as having CSA.

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There was a significantly higher proportion of males in patients with CSA based on both

apneas alone and apneas + hypopneas compared to patients without SDB (noSDB), and those in the OSAAI, OSAAHI and CSAAI groups had a significantly higher body mass index (BMI)

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than the no OSA group (Table 1). There were no significant differences in demographic and

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clinical characteristics between OSA and CSA patients classified using apneas alone versus apneas and hypopneas (Table 1). Total recording time and index time did not differ significantly between patient groups (Table 2).

All patients with SDB had lower oxygen saturation, higher oxygen desaturation index and greater time spent with oxygen saturation <90% compared with the no SDB group (Table 2).

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As per definition, patients classified as having OSA using either the apnea index (AI) or the AHI had a significantly higher obstructive apnea index (oAI) versus those with noSDB or

2).

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CSA, and those with CSA had a higher central apnea index than other patient groups (Table

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There were some differences in SDB parameters depending on whether classification was made using apneas or apneas/hypopneas. While recording and saturation parameters did not differ by classification method, patients with CSAAHI had a significantly higher central hypopnea index and significantly lower obstructive hypopnea index than those classified using apneas only (Table 2). In all patients with SDB (AHI ≥5/h), there was change in classification of the predominant type of SDB in 25.4% of patients when apneas and hypopneas versus apneas alone were used to classify patients (Fig. 3). When apneas and hypopneas were taken into account, there was a shift from central toward obstructive classification of SDB. 9

ACCEPTED MANUSCRIPT Apart from age being significantly higher in patients who did not change classification, there were no significant differences in basic demographic data between patients who did versus did not change classification when consideration of hypopneas was added. Patients who did not have a shift in the predominant type of apnea had a significantly higher AHI, oxygen

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desaturation index (ODI), AI, oAI and a significantly longer mean duration of apneas; no significant between-group differences were seen for hypopnea parameters. Patients who had the same classification using each approach spent significantly more time with oxygen

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saturation <90% and had significantly lower mean oxygen saturation compared to those whose apnea classification changed.

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When comparing the classifications in patients with moderate to severe SDB only, 24 (19.2%) showed a change in predominant SDB type, the majority of which were from predominantly central to obstructive. Shifters were significantly younger and more frequently male than non-

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4. Discussion

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shifters, and had a lower AI and a shorter mean duration of apneas.

Classification of SDB into predominant OSA or CSA has, to date, been based on

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classification of apneas only. However, recent recommendations allow classification of hypopneas as well. The present study, to our knowledge, is the first to investigate the impact of classifying both apneas and hypopneas into central or obstructive respiratory events. We found that this can significantly influence the classification of SDB compared with use of apneas alone in patients with SDB, Afib and preserved ejection fraction. In our cohort of hospitalized patients, hypopneas accounted for more than half of all respiratory events and classification of hypopneas in addition to apneas increased the proportion of patients with predominant OSA. However, proportion of CSR and time spent in CSR was unchanged. In 10

ACCEPTED MANUSCRIPT general, whatever classification system was used, patients with predominant CSA in our study tended to have more severe SDB than those with predominant OSA. OSA has been documented as an independent predictor of Afib and of arrhythmia recurrence after treatment with pulmonary vein isolation [17, 21, 31-33] and electrical cardioversion

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[19]. However, the criteria used to define OSA vary widely between studies. Only two previous studies have included hypopneas in the definition of OSA [17, 21] and the

proportion of events required to define predominant OSA differs (>50% in one study [33] and

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>80% in two others [21, 34]). Other criteria by which predominant OSA has been defined in clinical studies include no clear reduction of esophageal pressure [31] and high risk for OSA

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on the Berlin Questionnaire and AHI >10/h [32], while others do not specify exactly how the OSA diagnosis was established [19]; this underlines the need for uniform standards for classifying the predominant type of SDB.

To our knowledge, there are no data available on whether apneas and hypopneas have a

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different prognostic effect in patients with Afib. It is possible that the extent of hypoxemia, arousals and autonomic nervous system activation could be comparable, suggesting that the

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inclusion of hypopneas in any classification system is important. Indeed, hypopneas comprised more than half of all respiratory events in our population of Afib patients.

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In the current study, 50 patients (23.7%) had a change in the predominant type of SDB when hypopneas were added to the definition criteria. These patients were predominantly younger males with less severe SDB according to current metrics. In those with moderate to severe SDB, for whom treatment is indicated, a similar proportion had a change in predominant SDB type with the new classification. Precise classification of SDB and careful patient phenotyping is important in patients with Afib because the type of SDB plays an important role in defining the interaction between SDB and Afib, and in determining the best approach to treatment. Moreover, recent Afib 11

ACCEPTED MANUSCRIPT management guidelines recommend screening for OSA but not CSA, making the correct classification of SDB type essential. Treatment approaches also differ based on SDB type. First-line therapy of OSA--according to guidelines [35]--consists of application of continuous

should receive adaptive servo-ventilation (ASV) therapy [36].

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positive airway pressure (CPAP), whereas patients with CSA and preserved ejection fraction

Although treatment with CPAP did not significantly improve overall mortality or the overall cardiac event rate in patients with OSA and Afib, the progression of Afib was attenuated [37].

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CPAP has been shown to decrease recurrence of Afib after catheter ablation in patients with co-existing OSA [34]. Guidelines recommend optimization of OSA treatment for preventing

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Afib recurrence and improving the effectiveness of treatment [22]. Use of ASV for treating CSA in patients with Afib and preserved ejection fraction appears reasonable based on current data, but clinical trials are needed. The surprising results of the recent SERVE-HF study in heart failure patients with reduced ejection, in which ASV treatment of predominant CSA was

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associated with increased mortality [9], led to a debate about the requirement to treat CSA and the most appropriate treatment modality [10, 11]. Given the possibility that treatment of CSA may have negative effects in some patient subgroups, it has been recommended that CSA

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treatment (with conventional or emerging options) only be initiated at specialist centers [38].

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However, there has been no change in recommendations for OSA treatment [38]. This difference in recommendations emphasizes the need for correct classification of SDB and for randomized clinical trial data investigating the impact of therapies on hard clinical outcomes. Furthermore, emerging therapy modalities such as phrenic nerve stimulation are only appropriate for patients with CSA and therefore depend on correct classification of apnea and hypopnea type. In our study, >50% of respiratory events were hypopneas, making classification of these events essential for the reliable characterization of SDB as predominantly central or obstructive.

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ACCEPTED MANUSCRIPT There are several limitations that need to be taken into account when evaluating the findings of our study. The patients included were being treated at a tertiary center and there may be some differences compared with patients from primary care centers. PG evaluation of heart disease patients is routine clinical practice at our center, however there is still a possibility

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that not all patients were captured by our screening process. We used high-quality 6-channel PG to assess SDB, but this approach may underestimate the AHI because total recording time rather than total sleep time is used in the calculation. Furthermore, PG may overestimate the

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number of central events due to inclusion of those occurring physiologically during wake cycles [39].

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In conclusion, we found that inclusion of hypopneas to define the predominant form of SDB in patients with Afib had an important influence in the type of SDB found. Use of apneas and hypopneas versus apneas alone increased the proportion of patients with predominant OSA.

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The clinical implications of these findings remain to be determined.

Funding: This research did not receive any specific grant from funding agencies in the

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public, commercial, or not-for-profit sectors.

Acknowledgements: English language editing assistance was provided by Nicola Ryan, independent medical writer.

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38. Oldenburg O, Arzt M, Börgel J, Penzel T, Skobel CE, Fox H et al. Addendum zum Positionspapier "Schlafmedizin in der Kardiologie. Update 2014". Somnologie. 2017;21(1):51-2. 39. Randerath WJ, Hein H, Arzt M, Galetke W, Nilius G, Penzel T et al. [Consensus paper on the diagnosis and treatment of sleep disordered breathing]. Pneumologie. 2014;68(2):10623.

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Table 1

noSDB

OSAAI

CSAAI

OSAAHI

CSAAHI

(n=211)

(n=14)

(n=97)

(n=93)

(n=118)

(n=77)

Age, years

68.7± 8.6

66.6±11.1

69.8±8.1

67.9±8.5

68.4± 8.4

69.5±8.3

Male, n (%)

146 (69.2)

6 (42.9)

63 (64.9)

74 (79.6)a

82 (69.5)

58 (74.4)b

Systolic BP, mmHg

136.4±19.9

130.9±19.9

136.4±20.9

135.6±16.9

139.0±20.4

134.0±18.3

Diastolic BP, mmHg

83.7±13.8

83.7±17.5

83.4±13.8

83.6±13.3

84.5±14.0

82.9±12.8

Body mass index, kg/m²

29.6±5.0

26.2±4.0

29.9±5.5c

29.6±4.4a

30.2±5.1d

29.3±4.8

ESS score

7.2±3.6

8.3±2.6

6.8±3.9

7.4±3.4

6.8±3.8

7.3±3.3

Coronary artery disease, n (%)

74 (35.1)

5 (35.7)

35 (36.1)

33 (35.5)

43 (36.4)

26 (33.8)

Arterial hypertension, n (%)

177 (83.9)

13 (92.9)

81 (83.5)

77 (82.8)

100 (84.7)

62 (80.5)

Diabetes mellitus, n (%)

57 (27.0)

1 (7.1)

29 (29.9)

24 (25.8)

34 (28.8)

22 (28.6)

Smoker or ex-smoker, n (%)

65 (30.8)

3 (21.4)

26 (26.8)

34 (36.6)

34 (28.8)

28 (36.4)

EP

TE D

M AN U

SC

Total

RI PT

Demographics and clinical characteristics at baseline.

Values are mean ± standard deviation, or number of patients (%).

AC C

BP, blood pressure; CSAAHI, >50% central apneas based on classification of apneas and hypopneas; CSAAI, >50% central apneas based on classification of apneas only; ESS, Epworth Sleepiness Scale; noSDB, patients without sleep-disordered breathing; OSAAHI, >50% obstructive apneas based on classification of apneas and hypopneas; OSAAI, >50% obstructive apneas based on classification of apneas only. a

p<0.05 noSDB vs CSAAI; bp<0.05 noSDB vs CSAAHI; cp<0.05 noSDB vs OSAAI; dp<0.05 noSDB vs OSAAHI.

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Table 2.

noSDB

OSAAI

(n=211)

(n=14)

(n=97)

Total recording time, min

482.5±37.1

505.7±63.0

478.8±21.1

Index time, min

452.1±48.2

478.9±65.4

(n=93)

(n=118)

(n=77)

483.2±44.3

481.6±30.4

479.7±39.0

445.3±37.1

456.1±54.4

445.3±38.5

457.3±55.4

ab

bc

d

28.0±15.8

22.4±14.7

27.8±17.1f

8.3±12.4ab

13.1±13.5bc

8.1±11.5de

13.9±14.5ef

1.6±2.7ab

10.6±11.5bc

2.4±3.4de

11.3±12.4ef

4.5±6.6ab

1.2±1.8bc

3.8±6.0de

1.3±2.6ef

2.3±6.7a

1.3±2.6c

2.0±6.1d

1.3±2.8f

4.6±7.2

13.6±8.6a

14.9±9.3c

14.4±8.8d

13.8±9.0f

1.3±0.8

3.6±4.0ab

6.5±6.4bc

2.7±2.3

8.4±6.9ef

1.4±0.8

9.6±7.6a

7.8±7.3b

11.4 ±8.2df

4.8±3.8ef

94.1±1.2

92.8±1.7a

92.7±1.7b

92.9±1.7d

92.6±1.7f

3.2±1.4

22.0±15.8a

26.9±15.7b

22.6±15.1d

26.5±16.7f

82.8±6.2

87.7±3.4

81.9±6.5a

82.8±6.0b

82.7±5.7d

82.0±6.9f

38.5±64.6

7.3±16.7

38.6±64.1a

44.9±69.9b

33.6±55.3d

51.2±79.0f

3.2±1.1

Apnea index, h-1

9.6±12.8

0.5±0.4

Central apnea index, h-1

5.4±9.1

0.2±0.2

Obstructive apnea index h-1

2.6±5.0

0.3±0.3

Mixed apnea index, h-1

1.6±4.9

0.0±0.0

Hypopnea index, h-1

13.5±9.1

Central hypopnea index, h-1

4.7±5.3

Obstructive hypopnea index, h-1

8.2±7.5

Oxygen saturation, %

92.9±1.7

ODI3%, h-1

22.6±16.2

Minimum oxygen saturation, %

AC C

EP

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22.9±16.3

saturation <90%, min

CSAAHI

21.8±15.6

AHI, h

Time spent with oxygen

OSAAHI

M AN U

-1

CSAAI

SC

Total

RI PT

Sleep-disordered breathing parameters.

Values are mean ± standard deviation.

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AHI, apnea-hypopnea index; CSAAHI, >50% central apneas based on classification of apneas and hypopneas; CSAAI, >50% central apneas based on classification of apneas only; noSDB, patients without sleep-disordered breathing; ODI, oxygen desaturation index; OSAAHI, >50% obstructive a

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apneas based on classification of apneas and hypopneas; OSAAI, >50% obstructive apneas based on classification of apneas only. p<0.05 noSDB vs OSAAI; bp<0.05 OSAAI vs CSAAI; cp<0.05 noSDB vs CSAAI; dp<0.05 noSDB vs OSAAHI; ep<0.05 OSAAHI vs CSAAHI; fp<0.05

AC C

EP

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SC

noSDB vs CSAAHI.

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Fig. 1. Study flow-chart. Afib, atrial fibrillation; AVNRT, atrioventricular nodal re-entry

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tachycardia; LVEF, left ventricular ejection fraction; PG, polygraphy; PSG, polysomnography; SDB, sleep-disordered breathing; SpO2, oxygen saturation.

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Fig, 2. Changes in predominant type of sleep-disordered breathing with consideration of

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hypopneas.

Fig. 3. Proportion of Cheyne Stokes respiration pattern in patients with central sleep apnea

AC C

EP

TE D

classified by apneas, and apneas and hypopneas.

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