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Randomized Controlled Trial
. 2021 May 1;17(5):1015-1024.
doi: 10.5664/jcsm.9098.

Clinical screening tools for obstructive sleep apnea in a population with atrial fibrillation: a diagnostic accuracy trial

Anna M Mohammadieh  1   2 , Kate Sutherland  1   2 , Logan B Kanagaratnam  3   4 , David W Whalley  3   4 , Mark J Gillett  4   5 , Peter A Cistulli  1   2
Affiliations
Randomized Controlled Trial

Clinical screening tools for obstructive sleep apnea in a population with atrial fibrillation: a diagnostic accuracy trial

Anna M Mohammadieh et al. J Clin Sleep Med. .

Abstract

Study objectives: Although obstructive sleep apnea (OSA) is a known risk factor for atrial fibrillation (AF), there is a paucity of data around its diagnosis and management in patients with AF. The objectives of this study were to compare the diagnostic accuracy of commonly used OSA screening tools in an AF population, including a level 3 portable sleep study device, and to examine the epidemiology of OSA in a hospital cohort with AF.

Methods: One hundred seven patients with AF recruited from 2 tertiary centers underwent a panel of OSA screening tools and in-laboratory polysomnography in randomized order.

Results: Oxygen desaturation index derived from a level 3 portable sleep study device performed best for moderate to severe and severe OSA, with excellent diagnostic accuracy (area under the curve, 0.899; 95% confidence interval, 0.838-0.960 and area under the curve, 0.925; 95% confidence interval, 0.859-0.991, respectively). Sixty-seven patients (62.6%) were newly diagnosed with OSA (31.8% mild, 18.7% moderate, 12.1% severe).

Conclusions: Undiagnosed OSA is highly prevalent in a hospital AF cohort. However, it is characterized by a relative paucity of symptoms, markedly limiting the usefulness of history or screening questionnaires. This is the first study to find that a level 3 home sleep study device shows excellent diagnostic accuracy in patients with AF. This finding may inform AF management guidelines.

Clinical trial registration: Registry: Australian New Zealand Clinical Trials Registry; Name: The validity and reliability of a portable device for the diagnosis of Obstructive Sleep Apnoea in patients with Atrial Fibrillation; URL:https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=371024; Identifier: ACTRN12616001016426.

Keywords: ApneaLink; apnea-hypopnea index; level 3 sleep study; oxygen desaturation index; polygraphy.

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Conflict of interest statement

All authors have seen and approved the manuscript. Work for this study was performed at the Royal North Shore Hospital, Sydney, Australia, and the Charles Perkins Centre, University of Sydney, Sydney, Australia. AMM received research grants from the Ramsay Research and Teaching Fund, Sydney, Australia, and the ResMed Foundation/Sleep Health Foundation Research Entry Scholarship administered through the Royal Australasian College of Physicians, Sydney, Australia. AMM reports that in-kind support for this study (loan of ApneaLink Air diagnostic study devices) was received from Resmed Pty Ltd, Sydney, Australia. Resmed played no role in the design or implementation of the study. PAC has an appointment to an endowed academic chair at the University of Sydney that was created from ResMed funding; he receives no personal fees, and this relationship is managed by an oversight committee of the university. PAC has received research support from ResMed, SomnoMed, Zephyr Sleep Technologies, and Bayer; is a consultant/adviser to Zephyr Sleep Technologies, ResMed, SomnoMed, and Signifier Medical Technologies; and has a pecuniary interest in SomnoMed related to a previous role in research and development. KS reports in-kind support from SomnoMed in donation of oral appliances for a previous investigator-initiated research study. The remaining authors report no conflicts of interest.

Figures

Figure 1
Figure 1. Study flowchart.
*Reasons for study ineligibility (n = 231): 67 (29.0%) patients had significant geriatric health issues (eg, falls, frequent urinary tract infections, impaired mobility); 43 (18.6%) had no definite history of documented AF; 29 (12.6%) had active malignancy; 25 (10.8%) had repeat presentation; 24 (10.4%) were geographically remote and unable to travel to the study; 12 (5.2%) had end-stage organ disease; 8 (3.5%) had significant cognitive impairment; 7 (3.0%) had significant mental illness; 6 (2.6%) had active substance abuse; 1 (0.4%) was deceased; 1 (0.4%) was intubated; and 8 (3.5%) were otherwise unable to provide written informed consent. †Patient-reported reasons for declining study participation (n = 103): 30 (29.1%) patients had no reason given; 22 (21.4%) were too busy/had no time; 16 (15.6%) were not interested; 9 (8.7%) said a diagnostic sleep study was already performed; 7 (6.8%) were too unwell to participate/had too many medical appointments; 6 (5.8%) had no OSA symptoms; 4 (3.9%) were already diagnosed with OSA (not on treatment); and 10 (1.0%) disclosed “other reason.” AF = atrial fibrillation, CPAP = continuous positive airway pressure, OSA = obstructive sleep apnea, PSG = polysomnography, PVI = pulmonary vein isolation.
Figure 2
Figure 2. ROC curves depicting the diagnostic accuracy of OSA screening tools at various levels of severity.
A level 3 portable sleep study device had good to excellent diagnostic accuracy for all levels of OSA severity (AUC, 0.896–0.925). For moderate to severe OSA, snoring and self-reported hypersomnolence measured via the ESS both performed with poor diagnostic accuracy. All ROC AUC results are detailed in Table 2. AF = atrial fibrillation, AHI = apnea-hypopnea index, AUC = area under the curve, ESS = Epworth Sleepiness Scale, ODI = oxygen desaturation index, OSA = obstructive sleep apnea, ROC = receiver operating characteristic.
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