afib and severe OSA

[trek2020]

I self diagnosed OSA after I had an episode of afib out of the blue 5 years ago. At that time I was in my 50's and in very good physicial condition. The physicians I consult with originally chalked it up to hypertension, but I had been seen int ehri clinic for 20 years, had many blood pressures taken, and nobody every suggested that I had hypertension.

I was cardioverted with a medication 5 years ago and went back to intense workouts. About a week ago I had another episode and was electrically cardioverted back to normal sinus rhythm. During the cardioversion the docs told my wife: "Your husband has severe sleep apnea" - probably because I was apneic on the sedation. I think this episode came about because I got tired using a chin strap with my nasal CPAP and went without it. Would appreciate any input from people with similar experience especially:

1. Is the heart damage (mild atrial enlargement) irreversible? Confusion here Is that this is also a change that can be seen with intense training on a bike. I am 100$ compliant with CPAP.

2. Does anyone use overnight oximetry as a double cheack on the CPAP set up. My company checks everything once a year - but I could have had a lot of desaturation by then and not known about it.

3. Can anyone recommend a realible oximeter with an alarm?

4. Even though I am 100% compliant with CPAP x 5 years I still have significant insomnia even after using all of the sleep hygience measures. I routinely sleep 4 - 5 hours night max. My guess is that it is due to years of conditioning when I could not breathe. I tried zolpidem for one week and slept a perfect 8 hours each night. My primary care MD does not want me to use zolpidem chronically. Are there sleep experts out there who would?

Thanks

[Physician]

1, Your atrial fibrillation need not be related to OSA. Most people with AFib do not have OSA>

2. Right atrial enlargement: What that diagnosed by EKG (prolonged "P" wave) and/or ultrasound ? RAE by itself does not mean disease. One must look for the underlying reason for RAE. How much was your RAE ? Do you have mitral insufficiency or stenosis ?

3. While not approved for long term insomnia, triazolam is an excellent sleep medication. Most Sleep Docs still seem to prefer Ambien® or Roserem®.

4. Are you doing all the other things suggested for inducing a good night's sleep ?

[trek2020]

It is LAE and cardiologist says it is "mild to moderate" by US. In the process of getting a repeat US for comparison to the baseline 5 years ago. At that time had both an echo and stress echo and saw a cardiologist who was also a sports physiologist. He said the LAE was no big deal. He encouraged me to resume high intensity exercise. I don't know if there is a way to attach images here - if there is I could attach one of my typical workouts in terms of HR x duration.

Have tried all of the usual sleep hygiene stuff to no avail. I think if I could break the cycle of being hyperalert at night it would help.

[Physician]

So you have LAE in the absence of valvular disease ?

[trek2020]

yes - I have LAE in absense of valvular disease

[mellanie]

Trek2020,

I'm sorry you're experiencing afib and sleep apnea. It's a very common combination as we're learning how sleep apnea often leads to afib, and we now know that up to half of those with afib also have sleep apnea. In addition, untreated sleep apnea is a common reason that cardioversions fail. (For more info, & lots of related links on sleep apnea and afib, see: Sleep Apnea Multiplies Risk of Arrhythmias Like Atrial Fibrillation: <http://stopafib.org/newsitem.cfm/NEWSID/211>)

Left atrial enlargement is very common in those with afib, especially prolonged afib, as "afib begets afib". It doesn't seem to matter if it's afib with underlying heart disease or lone afib, which it sounds like you have since you have no vascular disease. Intense exercise is a common reason for lone afib, and some of that enlargement could be due to exercise.

We also know that stopping the afib can lead to some diminishing of the enlargement, though it likely won't return to normal. You didn't mention how much enlargement there is, but I know that most electrophysiologists and surgeons don't want to do procedures on those with a left atrium larger than 5.5 (sometimes 5.0) cm.

Good luck with it.

Mellanie

[cobra4x4]

Since being on cpap I have not had an episode of AFIB, prior to cpap almost nightly (several times in fact) and during the daytime on the odd rare occassion.

[trek2020]

Thanks Mellanie,

I guess it is good to know that it doesn't matter if LAE is due to excercise or an unhealthy heart. At this point the echo is pending. The consensus of the cardiologists that I talk to seems to be to resume exercise even at a vigorous level. That always includes some degree HTN as a physiological response to exercise.

When you mention the CT surgeons and the electrophysiologists - I am assuming you are talking about ablation procedures. If the atrium is too big is atrioplasty ever a viable option for someone who wants to continue to exercise?

[mellanie]

Trek2020,

Here are several articles that may be of interest to you regarding your questions. The first is an article we just published about the impact of sleep apnea on catheter ablations. The second is about a presentation by Dr. Riccardo Cappato to afib doctors about how catheter ablation may be better for athletes than medications for afib, and the third is a video interview with him where he discusses this.

1) Severe Obstructive Sleep Apnea Predicts Atrial Fibrillation Ablation Failure, New Study Says
http://www.stopafib.org/newsitem.cfm/NEWSID/270

2) Catheter Ablation May be Better Atrial Fibrillation Treatment than Drugs for Serious and Professional Athletes
http://www.stopafib.org/newsitem.cfm/NEWSID/234

3) Interview with Dr. Riccardo Cappato at Boston Atrial Fibrillation Symposium 2010
http://www.stopafib.org/newsitem.cfm/NEWSID/242

From what I've seen, surgeons are more likely than electrophysiologists (EP) to take on larger atriums. EPs do catheter ablation and surgeons do mini maze (surgical ablation). Here are links to more info on each:

Catheter Ablation: http://stopafib.org/catheter.cfm

Mini Maze Surgery: http://stopafib.org/mini-maze.cfm

Hope this helps.

Mellanie

[BlackSpinner]

You don't say what machine you are using or if it has data that allows you to check your AHI to see if what therapy you are getting is effective.
100% compliant is useless if the pressure is wrong or the leaks are really big.

[profoundapena]

I am no heart doctor, but I would suggest you see a lung doctor or pulmonologist regaring your OSA. Mine turned out to be OSA and CSA and profound. During the sleep study, they titrate your levels and monitor everything. My heart actually stopped during the night. Those with high pressures are normally prescribed bipaps. The doctor can also prescribe an oximeter test, and this was all covered by my insurance. I paid $0. The overall experience wasn't bad, so I encourage you to do so.

There is an abundance of information online about atrial fibrillation AF afib. It's very interesting and seems to be innocuous except that it greatly increases your stroke risk. The goals of therapy are to reduce incidents and prevent stroke. But you're seeing cardiologists, and I would follow their advice, except that I read that ablation should be the last resort after drug therapy and electrical treatment.

As for the insomnia: Since I was laid off, I have gotten up later and later and insomnia has become a problem. I have a theory that retirees have the same dilemma. The exercise no doubt gives you lots of energy, and by bedtime you have not exhausted this energy. Also, for years experts have said that since we regenerate less as we age, we need less and less sleep. So 5 hours may be sufficient for you and you may find you need less as the years go by. The body is self regulating as much as it can be. Sometimes 6 hours feels good to me; sometimes I need 10, but I pay attention to my body. You can tell when you're tired--you're cranky and can't concentrate. Futhermore, I would suggest all the usual tricks: a cool bedroom, doing nothing but sleeping in the bedroom, no eating, drinking, or exercise several hours before bed. I would also recommend volunteer work. In the absence of a regular "job" I find that a lot of people get out of sorts and experience insomnia--including my retired dad and uncle. I, myself, am doing all kinds of projects around the house, like refinishing furniture. It tires me out, gives me that sense of accomplishment, and gets stuff done. I also exercise 1 to 2 hours per day. So when I hit the bed, I am normally beat. But still sometimes worrying about my situation keeps me up. I don't volunteer because I live in the country and any volunteering would cost precious gas money. Also, you could email your congressmen and tell them to continue unemployment. THey cut it off in June and over a million of us are suffering. I've only been out of work 6 months and just when I was about to get some federal money, they cut it all off without warning. Most unjust!

Good luck.

[mellanie]

profoundapena,

Regarding your comments below, I must respectfully disagree.

You said: "There is an abundance of information online about atrial fibrillation AF afib. It's very interesting and seems to be innocuous except that it greatly increases your stroke risk. The goals of therapy are to reduce incidents and prevent stroke. But you're seeing cardiologists, and I would follow their advice, except that I read that ablation should be the last resort after drug therapy and electrical treatment."

There is a lot of old information online about afib, but the more we learn the more we know that it's not benign. It not only leads to stroke (#3 killer & #1 cause of permanent disability), but it also leads to heart failure from overworking the heart and to Alzheimer's disease and dementia from depriving the brain of oxygen, just like apnea does. We know that by the time you reach 40, you have a 1 in 4 chance of having afib, and 1/3 of those with afib will have a stroke at some time in their life. Thus afib is certainly not innocuous.

Regarding ablation being last resort, that is definitely not true. AV node ablation is last resort, but catheter ablation and surgical ablation are becoming first line treatment more and more often, especially for athletes.

As an atrial fibrillation survivor myself (I've been afib-free for 4 1/2 years) and someone with sleep apnea, I'd encourage reading the latest information at places like http://stopafib.org (my site--my labor of love to wipe out afib-related strokes) as well as the many resources listed on our Patient Resources page.

Atrial fibrillation is definitely not something to fool around with as it can actually be as deadly, or more so, than sleep apnea. Cardiologists are not the right doctors to treat afib as they are "plumbers" and you need to see an "electrician" (electrophysiologist).

Mellanie

[Slinky]

... Cardiologists are not the right doctors to treat afib as they are "plumbers" and you need to see an "electrician" (electrophysiologist).

I'll vouch for that, Mellanie!!! Of course, in addition to OSA, I have long standing COPD just to throw another monkey wrench into the fire but .... the cardiologist I was referred to is enamoured of the fancy nuclear stress tests that revealed nothing.

Even the alternating sleep pulmos at my sleep lab ... I was started on CPAP in Oct 06 and switched to bi-level in Mar 08 - they were satisfied w/a relatively low AHI and had no interest in or concern about my high leak rates. I had to get pretty pushy, almost snarky before one of them woke up and smelled the coffee.

It was an RPSGT I had shared some of my VPAP Auto printouts with who suggested that I talk to a cardiologist. The sleep pulmos didn't pick up on what the RPSGT saw.

It was my family doctor who scripted a lowly echocardiogram that revealed the pulmonary hypotension. It was my family doctor who recommended a 24 hour Holter monitor. I declined at the time since I only experienced very mild, short episodes of butterfly like flutters and very rarely.

But then 07 Mar this year I had a fairly lengthy episode of STRONG, ERRATIC heartbeats when I hadn't experienced any "flutters" in months. When I had a second episode of strong, erratic heartbeats, tho not so long lasting, I did mention it to my family doctor and he again suggested a Holter. I suggested we wait to see if it happened again since it had been somewhat more than a month since that first episode. He did ask what I was doing when they occurred. Even the few "flutter episodes" I'd had as well as these two strong episodes always occurred when I was just sitting around at the 'puter, reading a book, watching TV. Never w/exercise or activity.

I had 5 episodes of the strong, erratic heartbeats (no more gentle "flutter" episodes) between 07 Mar and 23 Jul. On the 23rd I had an episode strong enough and long enough including SOB and went to ER. By that time things had slowed down some, 100 - 160 bpms whereas I was fluctuating from as low as 54 to as high as 247 according to my Nonin Onyx oximeter. A bag of IV fluids and 4 baby aspirin and two blood tests 4 hours apart and I was released to my family doctor's care the first thing Monday.

He was not going to be put off this time (nor was I even thinking of declining) when he said he was ordering a 30 day event monitor. Tuesday I got a call from eCardio out of Houston, TX and Wednesday morning (('m in Michigan) I had the 30 day recording event monitor. Given only 5 events between early March and late July I wasn't real hopeful anything was going to show up.

But - Thursday I'll be darned if I didn't have another episode of strong, erratic heartbeats, a phone call from eCardio and a call from a cardiologist and told to go to ER. I declined since this episode was already passing and not lasting anywhere near so long as on the 23rd when I did go to ER. That was 29 July. So far the event monitor and I are getting along just fine w/no more events that I am aware of.

I've never even heard of an "electrophysiologist", where do you find one of those critters?

God bless my family doctor and that RPSGT!!

[mellanie]

I'm glad that your family doctor figured it out and found the problems. I know eCardio--they are very interested in making sure that irregular heartbeats get found and diagnosed. After all, afib--if that is what it is--can lead to stroke, congestive heart failure, and even Alzheimer's disease.

An electrophysiologist (EP) is often in practice with cardiologists. Here are a couple of suggestions of where to find them:

1) I have some EPs listed on my afib patient site at http://www.stopafib.org/find.cfm - they are not all listed there as they have to set themselves up in order for me to know that they have given permission to be listed.

2) Search at http://hrsonline.org/PatientInfo/specialist_locator.cfm - that's the Heart Rhythm Society, the professional association for EPs. The most experienced ones will have a FHRS (Fellow of the Heart Rhythm Society) designation after their name.

Hope this helps.

Mellanie

[Slinky]

Thanks yet again, Mellanie. Your site has two near Detroit which is about a 2 hour drive for me. Not out of the question if needed as I've been driving 12 hours to Mayo Clinic, Rochester, for some 50 years for my family and/or myself.

However, the Heart Rhythm Society has two listed who are affiliated w/Michigan Cardiovascular Institute which is where the cardiologist I've seen also practices. I happen to HATE that place! Not the cardiologist, the facility. Some of their techs leave a lot to be desired, its colder than sin, etc., etc.