A 55-year-old African-American man with history of symptomatic atrial fibrillation (AF), ischemic cardiomyopathy with EF of 45%, hypertension, hyperlipidemia, obesity and hypothyroidism presents for follow-up in clinic. Four weeks ago, he underwent pulmonary vein isolation (PVI) by radio frequency ablation (RFA) for his paroxysmal AF.
He is currently on metoprolol XL 50 mg daily, lisinopril 20 mg daily, aspirin 81 mg daily, rivaroxaban 20 mg daily, levothyroxine 100 mcg daily, and atorvastatin 40 mg daily. He was on amiodarone 200 mg daily prior to his ablation which was discontinued at discharge after his ablation procedure.
He has no symptoms of chest discomfort, palpitations, or dyspnea but continues to report daytime fatigue. EKG shows normal sinus rhythm with borderline LVH.
Vitals:
A febrile, HR 86, BP 142/74, RR 14, weight 302 lbs, height 66 inches.
Exam:
General: pleasant obese male.
- HEENT: thick neck (18 inches circumference), otherwise normal.
- CV: regular rate and rhythm, normal S1 and S2, systolic ejection murmur 1/6 at RUSB. No pericardial rub.
- RESP: clear to auscultation, no wheezing or rales.
- ABD: obese abdomen (belt size 48 inches), normal bowel sounds.
- EXT: well healed femoral vein access site, warm and well perfused, no edema.
- NEURO: mentation intact, gait normal.
The correct answer is: D. Order a polysomnograph and initiate CPAP if it reveals OSA.
The best strategy is to avoid recurrence of atrial fibrillation is to screen for obstructive sleep apnea (OSA). This patient meets several features for sleep apnea — daytime fatigue, neck circumference >35 cm and age over 50.1 The incidence of atrial fibrillation is three fold higher in the OSA population compared to the general population. There are multiple mechanisms including endothelial dysfunction, autonomic dysfunction, worsening of cardiovascular risk factors, inflammatory mileu and atrial enlargement which predispose patients with OSA to development and recurrence of atrial fibrillation.2, 3 A recent study showed a significantly higher AF recurrence rate in patients with undiagnosed/untreated OSA compared to patients without OSA.3 The additional risk conferred by presence of OSA can be eliminated by consistent CPAP use.This led to similar AF recurrence rates in CPAP users compared to those without OSA 3. Therefore, the diagnosis of OSA and CPAP compliance play an integral role in reducing the recurrence rate of AF after PVI.
Restarting amiodarone is not ideal due to its long side effects in young individuals similar to our patient (choice A). Given the patient's diagnosis of ischemic cardiomyopathy, evidence based beta blockers (carvedilol or metoprolol XL) should be continued (choice B). Colchicine has recently shown promising results suggesting reduce recurrence of atrial fibrillation after ablation therapy 4; however no studies have evaluated initiation 4 weeks post-procedure (choice C). Screening for metabolic syndrome may be appropriate given patient's obesity and other clinical characteristics, but it does not directly impact recurrence of atrial fibrillation (choice D).
References
- Persaud N. APNEIC: an easy-to-use screening tool for obstructive sleep apnea. Can Fam Physician 2010;56(9):904-5.
- Oza N, Baveja S, Khayat R, Houmsse M. Obstructive sleep apnea and atrial fibrillation: understanding the connection. Expert Rev Cardiovasc Ther 2014;12(5):613-21.
- Digby GC, Baranchuk A. Sleep apnea and atrial fibrillation; 2012 update. Curr Cardiol Rev 2012;8(4):265-72.
- Fein AS, Shvilkin A, Shah D, Haffajee CI, Das S, Kumar K, Kramer DB, Zimetbaum PJ, Buxton AE, Josephson ME, Anter E. Treatment of obstructive sleep apnea reduces the risk of atrial fibrillation recurrence after catheter ablation. J Am Coll Cardiol 2013;62(4):300-5.
- Deftereos S, Giannopoulos G, Efremidis M, Kossyvakis C, Katsivas A, Panagopoulou V, Papadimitriou C, Karageorgiou S, Doudoumis K, Raisakis K, Kaoukis A, Alexopoulos D, Manolis AS, Stefanadis C, Cleman MW. Colchicine for prevention of atrial fibrillation recurrence after pulmonary vein isolation: Mid-term efficacy and effect on quality of life. Heart Rhythm 2014;11(4):620-8.
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