Mutual reinforcement of device detected atrial fibrillation and sleep apnea

Background

Atrial fibrillation (AF) and sleep apnoea (SA) frequently coexist, but the temporal direction of their relationship remains uncertain. Conventional studies cannot resolve whether AF precipitates SA, SA triggers AF, or both occur in a self-perpetuating cycle.

Purpose

To determine the day-to-day bidirectional associations between device-detected atrial fibrillation (DDAF) and severe device-detected sleep apnoea (DDSA) using continuous remote monitoring data.

Methods

Data were obtained from a prospective cohort of dual-chamber pacemaker recipients undergoing daily remote transmission. Patients with permanent AF or <30 days of follow-up were excluded. Severe DDSA was defined as a respiratory disturbance index (RDI) ≥20 events/hour (00:00–05:00), and DDAF as ≥6 minutes of AF burden per day. Two generalised linear mixed-effects models (GLMMs) tested cross-lagged temporal directions: Model A (AF → SA): previous-day DDAF predicting current-day severe DDSA. Model B (SA → AF): current-day severe DDSA predicting same-day DDAF.

Both models adjusted for age, sex, body mass index, heart failure, left ventricular ejection fraction, and the previous day’s event status.

Results

A total of 225 patients (median age 76 years; 37% female) contributed 93,475 valid patient-days. In Model A, a DDAF episode on the preceding day independently predicted severe DDSA on the following night (adjusted OR 2.15; 95% CI 1.96–2.37; p<0.001). In Model B, nocturnal severe DDSA independently predicted same-day DDAF (adjusted OR 1.74; 95% CI 1.53–1.98; p<0.001).

Stratified analyses showed both directions persisted after controlling for prior-day status. Epoch analysis of 1,681 DDAF episodes showed that mean RDI sharply increased on the day of DDAF onset and peaked the next night before returning toward baseline.

Conclusion

Continuous longitudinal device monitoring revealed a bidirectional, self-reinforcing relationship between AF and sleep apnoea: each condition acutely increases the risk of the other. These findings suggest that isolated management of either disorder may be insufficient, underscoring the need for integrated cardiovascular-respiratory care strategies.