Impact of CPAP therapy adherence on atrial fibrillation recurrence and progression in patients with severe obstructive sleep apnea

Background

Obstructive sleep apnea (OSA) is a major modifiable risk factor for atrial fibrillation (AF), promoting arrhythmogenesis through intermittent hypoxia, autonomic activation, and atrial remodeling. Although continuous positive airway pressure (CPAP) effectively treats OSA, real-world evidence linking objectively measured CPAP adherence to clinically relevant AF recurrence and progression remains limited.

Aims

To evaluate the association between CPAP adherence and atrial fibrillation recurrence as the primary endpoint, and progression to permanent AF as the secondary endpoint, in patients with severe OSA.

Materials and Methods: In this prospective observational cohort (2017–2024), consecutive hospitalized and outpatient adults with severe OSA (apnea–hypopnea index >30 events/h) and documented paroxysmal AF were enrolled. OSA was assessed using home sleep apnea testing (ApneaLink), and all patients initiated CPAP therapy, with objective adherence data obtained via telemonitoring. Patients with permanent AF, central sleep apnea, left ventricular ejection fraction <50%, end-stage chronic kidney disease, or inability to maintain CPAP therapy were excluded. Follow-up was 12 months. The primary endpoint was time to first documented AF recurrence, and the secondary endpoint was progression to permanent AF. Time-to-event analyses were performed using Kaplan–Meier estimates with log-rank testing, and Cox proportional hazards regression.

Results

The final analysis included 93 patients (mean age 62.0 ± 8.3 years; 67.7% men). Mean nightly CPAP use was ≥4 h/night in 49 patients and <4 h/night in 44 patients, with comparable baseline characteristics between groups. Paroxysmal AF recurrence occurred in 12/49 patients (24.5%) using CPAP ≥4 h/night compared with 18/44 patients (40.9%) using CPAP <4 h/night. Kaplan–Meier analysis demonstrated significantly longer arrhythmia-free survival in patients with higher CPAP adherence (log-rank p = 0.039). In multivariable Cox regression, mean nightly CPAP use remained independently associated with delayed AF recurrence (hazard ratio 0.67 per additional hour of nightly CPAP use, p = 0.012), indicating a dose-dependent effect. Progression to permanent AF occurred in 3/49 patients (6.1%) using CPAP ≥4 h/night versus 8/44 patients (18.2%) using CPAP <4 h/night. When CPAP use was analysed as a continuous variable, each additional hour of nightly CPAP use was associated with an approximately 50% lower risk of progression to permanent AF (odds ratio 0.49 per hour, p = 0.018).

Conclusion

Higher CPAP adherence is associated with longer arrhythmia-free survival and reduced progression to permanent AF in patients with severe OSA and paroxysmal AF. In the era of catheter ablation, optimisation of sleep-disordered breathing may represent an important adjunctive and potentially disease-modifying strategy, warranting further prospective randomised studies.