Atrial Fibrillation (AFIB) and Sleep Apnea

By Anh – Licensed Practical Nurse

Sleep apnea is a common disorder that affects millions of people all around the world. Sleep apnea is when you have pauses of breathing in the night, which may be caused by obstructions in the airway or disturbances in the brain’s respiratory center. 

Obstructive sleep apnea (OSA) is when you have a physical obstruction, which may be caused by your tongue falling back and blocking your airway (especially for back sleepers). 

Another example of a physical obstruction is when the tissues in your neck relax to a point where your airway collapses temporarily. Your body should then send a signal to your brain which will trigger a breath to open your airway up again. 

Sometimes this may wake you up completely or result in a lighter level of sleep where you’re not in a paralysis state. Central sleep apnea (CSA) is when your brain doesn’t send the proper signals to the muscles that control your breathing. 

Atrial Fibrillation (AFIB) is a type of heart arrhythmia. An arrhythmia is when the heart quivers or beats either too slowly, too fast, or irregularly. The problem with AFIB is that when you’re having an episode, blood can pool in the upper left atrium of the heart. 

This could lead to a blood clot forming, and if it were to dislodge, it could enter the bloodstream and into the brain, potentially causing a stroke.

Patients who have AFIB unfortunately have a higher stroke risk, upwards of 5 times higher than someone who does not have AFIB.

Some common symptoms of AFIB include:

• Chest discomfort, including pain or pressure
• General fatigue
• Irregular heartbeat, which may be rapid, irregular, or has a fluttering or pounding sensation
• Dizziness
• Fatigue from exerting yourself, such as exercising
• Feeling faint or confused
• Anxiety with shortness of breath.

Studies have shown that about 50% of the time people with AFIB also have sleep apnea. People who have sleep apnea are 4x more likely to develop AFIB if left untreated. 

The correlation appears to be the strain/stress on the heart from sleep apnea, which can eventually confuse your heart into beating irregularly at random points during the day, leading to AFIB.

Sleep apnea itself already causes a lot of stress and strain on your heart. Let’s dive into the actual process a little bit. Let’s say someone with sleep apnea sleeps on their back and then their tongue falls back and blocks their airway. 

When you are in REM sleep, for example, your body is in a paralysis state. This is so you don’t act out your dreams. What we see happen next is the airway is cut off and no new oxygen is coming in, so the body will conserve the oxygen already in the bloodstream. 

The heart does this by slowing the heart rate so that oxygen is not depleted quite as fast. Once your oxygen levels get down to a certain point, your body will react by putting you in a fight-or-flight response.

Your body has to sort of wake you up into a lighter level of sleep where you’re no longer in the paralysis state or wake you up completely so that you initiate a breath again. This is why many people with sleep apnea are restless at night, often rolling around or moving a lot during the night.

They may also wake up at certain times, or more frequently, at night. Some people complain they wake up 3-4 times during the night to use the washroom, but don’t have much to empty in their bladder. 

This is likely because sleep apnea wakes them up, and they go to the washroom to empty their bladder anyway since they are awake. This can be confusing to some people as many may think they have a urinary issue as opposed to sleep apnea.

When testing for sleep apnea, you can actually see the stress on your heart as well. When someone has apnea, clinicians can usually pinpoint when it happens. We often see a drop in oxygen saturation and heart rate and then a sudden spike in heart rate and increase in oxygen saturation.

If this happens multiple times in the course of the night, it is easier for clinicians to gauge how severe sleep apnea is. If more moderate or severe, we often see a saw-toothing pattern on the tracings.

The heartbeat now fluctuates from low to high in a very short period of time, when your heart should actually be generally slower and more relaxed at night. It’s as if you were doing interval training in your sleep.

Patients who are suspected to have AFIB are initially sent home with a Holter monitor to wear for 24 hours to help physicians determine what could be triggering the AFIB and when it occurs.

If you have sleep apnea and AFIB, your risk for stroke is much higher, so it is important to know the warning signs of a stroke. A group of emergency medical professionals in the UK developed the acronym “FAST” to help detect if someone is having a stroke:

• Facial drooping – does it look like one side of the face is numb or drooping? Have the person try to smile to see if part of their face is drooping
• Arm weakness – does one of your arms feel numb or weak? Try to raise both arms. Does one arm start to fall or drift downward?
• Speech difficulty/dysphasia – is the person slurring their speech, are they unable to voice their concerns, are they difficult to understand? Try having them repeat sentences and see if they are repeated correctly
• Time to call 911

Treatment of OSA is very important if you are diagnosed with AFIB, but there are other procedures that are used to help “reset” your heart rhythm. Initially, patients are often placed on a blood thinner to prevent blood clots. Cardioversion and Cardiac Ablation are two popular treatments used to treat AFIB.

Electrical Cardioversion is a procedure in which you will receive a sedative, so you won’t feel pain during the procedure, and two paddles will be used to provide an electrical shock to your heart. 

The physician may apply both paddles to your chest, or one to your chest and the other to your back. The shock often lasts less than a second and should be enough to restart your heart rhythm.

Most people only need one treatment, but some will need multiple treatments in one session. In most cases, patients will wake up without remembering any sort of shock occurring. The procedure usually takes about 30 minutes. 

After the procedure, you will stay in recovery while a nurse makes sure there are no adverse effects from the treatment. Most people go home on the same day.

Some patients will feel discomfort or irritation when the paddles were applied. Someone should be with you for 24 hours following the procedure to also monitor for any abnormalities.

Cardiac Ablation is a procedure that is used to reset or correct the heart rhythm. Any disruption in the pathway signals can trigger arrhythmia (abnormal heartbeat).

The procedure generally starts with a sedative being administered intravenously. Depending on your current health condition, the procedure may be done when you’re awake/semi-awake to fully asleep. 

A catheter is inserted by a physician through your blood vessel leading to the heart. Most commonly, the physician uses the blood vessel in your groin as the point of access, but less rarely, this can be your shoulder or neck, as well.

Sometimes dye is injected, which makes it easier to see the blood vessels on an XRAY image. The tips of the catheters that are inserted have sensors that can send electrical impulses to your heart and also record the current pattern.

This information is used to help the physician identify the area of concern and where to apply the ablation. There are two forms of techniques that will be used, which we will refer to as Heat or Cold. 

The heat method is referred to as radiofrequency energy, and the cold method is cryoablation. The procedure itself usually lasts 3-6 hours, but the duration may vary. You will likely have to stay in bed for at least 2-6 hours to decrease the risk of bleeding.

Neither of these treatments is a guarantee that your heart will stay at a more normal heart rhythm indefinitely. In some cases, patients will have to undergo treatment multiple times.

That being said, treatments can sometimes be frequent but also years apart. Some patients have a single treatment and do not need another one for a very long time, if at all. It is important to monitor your health and follow up with your physician as needed. 

Treating these conditions early could very well prevent the worsening of your current health conditions and lower the risk of developing other cardiac conditions. You could even prevent a heart attack or stroke, which is very important.

If you have Sleep Apnea and AFIB, please make sure you use your CPAP every night, as this will help your heart better relax during the night. If you have questions about your therapy or need to replace your machine, please let us know. We are here to help.