Snoring and lack of REM sleep is associated with same-day atrial arrhythmias in a cohort of patients with atrial fibrillation: initial results of TriggersAF
Authors: Bacevicius J , Stankeviciute G , Kersnauskaite D , Dvinelis E , Sokas D , Zarembaite G , Kiseliute M , Taparauskaite N , Kundelis R , Abramikas Z , Vrublevska G , Burneikaite G , Badaras I , Jasiunas E , Aidietis A 
Published: November 2023

Abstract

Introduction
Sleep-disordered breathing (SDB) is a known risk factor for the development of atrial fibrillation (AF). Few studies analyse the temporal relation between snoring, sleep phases and atrial arrhythmia episodes.

Purpose
The TriggersAF trial (NCT05526170) investigates the temporal relation between atrial arrhythmias and potential triggers. In this preliminary analysis, the authors hypothesised that snoring and disturbance of sleep phases may be associated with same-day atrial arrhythmias.

Methods
In a single-centre prospective cohort study patients with previously diagnosed AF were recruited for home monitoring of 7 days. A single-lead continuous electrocardiogram (ECG) of the reference Holter monitor (Bittium, Kuopio, Finland) documented the cardiac rhythm. The recordings were manually annotated as: 1) AF, 2) atrial tachycardia or flutter (AT), 3) frequent premature atrial contractions (PAC), defined as bigeminy, trigeminy, quadrigeminy or couplets, and 4) no arrhythmia. Sleep disorders were evaluated using a validated sleep tracking mat (Withings Sleep Analyzer, Issy-les-Moulineaux, France) and described by the number of snoring episodes, durations of snoring, light, deep, and rapid-eye-movement (REM) phases. Heart echocardiography with strain imaging of left atrium (LA) was performed to further characterize the subjects.

Results
The study consisted of 49 patients, aged 55.8±11.7 years, 67.3% male. All patients were with previously diagnosed non-permanent AF and sinus rhythm at the moment of inclusion. The monitoring duration yielded a total of 300 days. The occurrence of AF, AT and PAC was detected in 32/300, 108/300 and 85/300 of days, respectively.
As revealed by the sleep analysis a greater number of snoring episodes was associated with the same-day episodes of AF when compared to patients with no AF (5.0 (2-10.2) vs. 2.0 (0-7), P=0.029, respectively). A longer snoring duration was associated with the same-day episodes of AF (36 (6-80) min vs. 12 (0-52) min, P=0.057). A shorter duration of the REM phase was associated with AT (63 (28-93) min vs. 79 (42-105) min, P=0.032) and PAC (60 (32-91) min vs. 79 (37-102) min, P= 0.058). No significant relations were observed between the durations of light or deep phases and any type of arrhythmias.
A smaller mean conduit strain of LA was highly associated with AF (-7,5 (-12,5, -7,5)) compared to patients with no AF (-11,0 (-14,8, -8,5), P= 0.002). In the Fast-and-Frugal Decision Tree for the prediction of same-day AF, a model combining the mean conduit strain of less than -9, a body mass index of more than 27.8, and a snoring duration of more than 29 minutes yielded a sensitivity of 97%, a specificity of 59% and a balanced accuracy of 78%.

Conclusions
The higher frequency and duration of snoring, as well as reduced REM phase of sleep are linked to same-day atrial arrhythmias. Long-term SDB monitoring and LA strain imaging predict the episodes of AF with high accuracy.Number of snoring episodes vs. AFAF by LA strain, BMI and snoring