Heart Rhythm problems and OSA/CA - can one cause the other?

[TexasTiger]

First, a little history - On a stormy 1939 spring late night I - no! Not that far back...

I slept fine until my Navy enlistment put me on a WWII almost obsolete picket destroyer in the SE Asia waters sleeping flat on my back with nothing but a piece of canvas held between two iron rods squeezed between two other men on racks 4 racks high with no other sleeping position possible which created major snoring issues by the time I left the Navy. A very heavy snorer from there on. 

My wife woke me up many times not from the snoring but telling me I had stopped breathing which I didn't believe until being told by a doctor waking me up on one of my weekly flights to somewhere that I had stopped breathing and needed to go see my doctor for further evaluation. I was evaluated with a sleep study having mild 75% OSA and 25% CA. Well, 20+ years later and a number of different machines still trying to get less than 5 events per hour - I think I am there but only after a complicated heart procedure which leads me to the question - is there a connection between sleep events and heart arrhythmia? 

My past posts attempting to lower my events show the problems I was having but after the procedures my events have greatly decreased with now less than 5/hour on average. Heart problems were only mildly high BP and cholesterol until about 5 years ago when heart rhythm problems started (did not think they were a problem until 3 years ago) with what was diagnosed originally as AF but changed to SVT (supravenriculartachycardia) after wearing a holter monitor which showed periods of 200+ rate for up to 30 min. long. 9 months ago my regular heart check-up EKG showed full AF so I was put on blood thinners (Eliquis) and scheduled to see an electrophysiologist for follow-up. 

I saw one a month later and scheduled for what he called a complex procedure what with having now AF, constant all day A-Flutter, periodic bradycardia, periodic tachycardia, mild chest pains, and almost constant shortness of breath. That doctor cancelled the procedure 4 times 2 of which on the day of the procedure so I switched to a better doctor but had to wait almost two months for the procedure for him to schedule when he could have additional time for electrical mapping the heart with so many problems. 

The procedure was done 2 weeks ago with great results so far. I have a Kardia mobile device which shows normal sinus rhythm now (always showed possible AF every time before the procedure). The procedure was for "Atrial Fibrillation ablation w/carto, Transesophageal Echocardiogram and anesthesia". The doctor said that he had to burn in 4 veins and 6 places within the heart itself. The first 3 days after the procedure many time periods were 0 events and now the daily average is 3 or less. I will attach a few charts for comparison (and comment if the bi-level needs adjustment). Looking for comment on connection between heart rhythm problems and sleep apnea.

[BuzzaJim]

There is, according to both the electrophysiologist I see for my heart rhythm issues and the neurologists I see for OSA.  I was first diagnosed with congestive heart failure and Afib in 2014.  I ended up seeing both a cardiologist and an electrophysiologist. Even though they all work in the same clinic, they separate their work as “plumbers” and “electricians” and would frequently suggest I address my questions to the other.  Pretty frustrating since it took months to schedule a visit with either.

After an ablation and many cardio versions, I was at wits end and my sleep quality kept getting worse.  I had addressed all the known triggers for Afib except for OSA but my “old friend” kept coming back.  Finally, last year I saw a Nurse Practitioner who was filling in for the “plumber” I normally saw.  She suggested I consider the possibility I might have sleep apnea and I should have my Family Doc make a referral for a sleep study. I won’t get on the soapbox for why it took the cardiology clinic 8 years to make that recommendation or why I had to see my PCP to get a referral to be screened.

Before the first sleep study was ordered, I had to see a neurologist who pronounced I had OSA just based on my answers to the initial screening survey and was very clear that OSA was contributing to my recurring Afib.  His diagnosis was verified by the in lab diagnostic sleep study.  My blood oxygen levels plummeted with each apnea/hypopnea event.  Apparently, the brain tries to correct for this by speeding up the heart rate which can result in various arrhythmias and arousals.

Before my first visit to the neurologist, I had a second ablation and Afib stayed away until a few days before I got my BiPap machine.  The results were immediate.  My sleep quality is better than it has been for years.  I have a lot more energy during the day.

I’ve worn an Apple Watch for years, especially when I sleep so I’ve established a pretty good baseline for heart rate and blood oxygen. Before PAP therapy, my heart rate fluctuated a lot as I slept and oxygen levels would drop to the low 80s.  That was with normal sinus rhythm. With therapy, the fluctuations cease and oxygen levels stay above 92%.  When in Afib the fluctuations are especially extreme but oxygen still stays above 90%.  PAP therapy has not fixed my Afib but it sure has made it more tolerable.

The problem is cardioversions are elective.  I had to wait 35 days in Afib.  A poorly pumping heart can’t eliminate fluids.  Retain enough fluids and pulmonary edema results.  Then you get an ambulance ride to the ER in the middle of the night, argue between gasps with the doc over why they need to use BiPap and not CPap to administer oxygen and become amazed at how much urine can be produced in just a few hours.  I explained the pressures I use with my machine and they adjusted their machine accordingly.  Breathing got a lot better very soon after and I was off oxygen by morning.

This all happened a week ago and I’m still in rhythm, despite that drama.  I’m not sure how much of this answers your question, but PAP therapy is worth the effort.  Even in the midst of Afib, my AHI stayed consistently below 1.5 and I slept pretty well.

[TexasTiger]

Thanks BuzzaJim for this reply and your experience with both problems. Yes, my clinic also separated into "plumbers" & "electricians" but they at least talked to each other, just could not see fit to get my ablation done. From your experience it seems that AF can cause apnea and the other way around in my case. Do you have any CA's (Central Apnea)? Just trying to find out if that may have any effect on this. My last sleep study was AHI 64 and RDI 70 so the sleep doctors just tell me that getting under 5/hour is not possible and just live with it. It is good to hear that you are able to keep yours lower and it is still a puzzle that the AF seemed to keep my events higher - begs the thought that I possible had AF for a very long time. I check my possible AF often now with the 6 lead Kardia device and I'm glad that it continues to show normal sinus rhythm after the ablation. If it stays normal I can get off thinners in 2 months - here's hoping!

[BuzzaJim]

Undiagnosed Afib is definitely a thing, just like undiagnosed Obstructive Sleep Apnea.  Last year, I had an uncle who nearly died from a blood clot in his mesentary artery.  My cousin later explained it was caused by undiagnosed Afib.  Clots that form in the left atrium break loose and can travel anywhere.  Usually it’s to the brain causing a stroke but in his case it was his intestines.  It sounds like we’re taking the same anti-coagulant but the only way I should stop them is to have the Watchman procedure.  No serious side effects so far, a lot less bleeding than when I was taking one baby aspirin per day.

I was diagnosed with congestive heart failure and Afib at the same time.  I’m convinced that if I’d been screened for OSA then, I would have began PAP therapy years sooner.  I was a lot larger and less active.  I had all the classic symptoms of OSA which are very similar to those of CHF. We can speculate on which came first but all I know for sure is I have to manage all three today and all three are interrelated.  I do believe if my OSA had been addressed sooner, my Afib would be less persistent today.

I haven’t experienced any central apneas or unusual breathing patterns, just OSA.  The two in-lab studies I’ve had were negative for CAs and CSR, which according to the experts on this forum, are often associated with heart failure.

It sounds like we have pretty much the same equipment, including very similar pressure settings on our AirCurves.  I use my Kardia 6L to verify my watch ECG and the two always agree.  The Watch is a lot more convenient but I’ve gotten to the point I can tell if I’m in rhythm by just checking my wrist pulse.

There are over 100,000 members on this forum and I’m encouraged that many have experiences similar to ours.  I’ve done numerous searches of past threads using keywords “AFib” and “congestive heart failure” and am never disappointed.  We are not alone.

[TexasTiger]

Thanks again BuzzaJim for the really great personal input.  Yes, we are definitely not alone with this, and I'm sure that input from others will better help us understand our personal paths and adjustments to make the best of it.  Any input from others with both AFib & PAP conditions will also be greatly appreciated.

[JoyD.]

Hello BuzzaJim & Texas Tiger . . .

I'm about a year and half late to respond, but wanted to say that I too deal with OSA, AFib & CHF.

Diagnosed with OSA, and more recently with persistent AFib (chose rate control rather than go on anti-arrhythmics at age 83, but not sure if that was a smart choice because I ended up with worsening TriCuspid Valve Regurgitation which is now Severe & needs Transcatheter repair). Since the TVR turned Severe, I noticed difficulty walking for any distance w/o difficulty breathing. Then a BNP lab test of a shocking 1890 confirmed that CHF was now in play. I was put on furosemide (half a 20mg tab because of my age), and I seem to get less tired walking now.

I meet with the Valve surgeon next week. Have lost of questions for him, including what they'll do about all that erratic fibrillation going on while they are doing delicate transcatheter repair with a Mitrial clip!!! Also, concern about my OSA (esp if supine) . . . and if I will be on a ventilator, etc. to normalize my breathing while anesthetized during the repair.

Have either of you had valve repair/surgery, or other surgery with your OSA, HF, & AFib . . . and did you get put on a ventilator? Any problems develop?

Getting old sure is a challenging experience!

[BuzzaJim]

Joy D,
   I’ve had two ablations for Afib but no other procedures.  The second ablation seems to be working so far, probably because we added a very low dose anti-arrhythmic.  The CHF is something I need to manage with diet and exercise.  Along with 100% CPAP compliance it’s all working for me.  Everyone’s situation is different though.

[TexasTiger]

HI Joy D.

Yes, OSA is certainly a negative contributor to probably all heart problems.  My last sleep study still has me at extremely severe with an RDA of 70.  Still struggling to get any days under 5 with some at 20+.  With Centrals mixed in I need a something better than my BI-Pap!  I am far luckier than you as I caught my afib early on using a Kardia Mobile device almost daily plus feel that I had a really good doctor for the ablation done almost right away after finding the problem.  Mine started out as just a rapid heartbeat on occasion that they diagnosed as SVT (Supra Ventricular Tachycardia) with the rate jumping to 200+ BPM for 5-30 minutes.  I was keeping it pretty well in control for over 2 years with heart rate meds (Metoprolol) before it turned into afib.  Once it became SVT I was suggested to do daily BPM and pressure checks at least daily.  Also put on Eliquis the same day as the afib verified in my specialist's office.  I'm very lucky as I was able to convince the heart surgeon that after 6 months of checking/proving that the afib did not return I was able to get off the blood thinners with the promise that I would continue doing daily checks with the Kardia.  That was 1-1/2 years ago and now at age 86 I'm doing my best to get up and around keeping as busy as these old bones will allow!

Are you able to get your sleep events to an acceptable level?  The expert talent on this forum can definitely help get the performance the best possible with the OSA gear that you have and let you know if something different might be needed.  I wish you all the best of medical assistance and hope that you find some confidence in getting these heart related issues improved on this forum hearing from others with some similar problems.