Occurrence of atrial fibrillation in pacemaker patients and its association with sleep apnea and heart rate variability


      • Pacemaker-diagnosed sleep apnea is associated with higher atrial fibrillation risk.
      • Indices of sympathovagal imbalance further stratify patients for atrial fibrillation risk.
      • These markers may provide an early warning for atrial fibrillation risk.
      • These markers may allow to tailor effective treatment to mitigate risk.



      Sleep apnea (SA) is a risk factor for atrial fibrillation (AF) occurrence. Sympathovagal imbalance is a mechanism that predisposes to the development of AF and that occurs in SA. Some pacemakers can detect SA events and continuously measure a time domain measure of heart rate variability (HRV), i.e. the standard deviation of 5-min median atrial–atrial sensed intervals (SDANN). We evaluated the association between the occurrence of AF and device-detected SA and SDANN in patients who received pacemakers.


      We enrolled 150 consecutive patients undergoing implantation of a dual-chamber pacemaker, capable of SA and SDANN estimation. The SA was defined as severe if the Respiratory Disturbance Index was ≥30 episodes/h for at least one night during the first week after implantation.


      Sixteen patients in permanent AF were excluded from our analysis. During follow-up, AF (cumulative device-detected AF duration > 6 h/day) occurred in 24(18%) patients out of the remaining 134 patients. Severe SA was detected in 84 patients. SDANN values were available in 74 patients and the median value was 76 ms [25°–75°percentile:58–77]. The risk of AF was higher in patients with severe SA (log-rank test; p = .033). The presence of either or both conditions (severe SA and SDANN < 76 ms) was associated with shorter time to AF event (p = .042) and was an independent predictor of AF (hazard ratio: 2.37; 95%CI:1.08 to 5.21; p = .033).


      In pacemaker patients, device-diagnosed severe SA and reduced SDANN are associated with a higher risk of AF.


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