Strategy for Management of AFib Once OSA is Discovered

A 51-year-old Caucasian man with a history notable for dyslipidemia and paroxysmal Atrial Fibrillation (AF) presents to the clinic for second opinion regarding his AF. Patient reports history of AF since two years and has been refractory to drug therapy including Sotalol and Dofetilide. He was symptomatic with palpitations and significant fatigue. The patient's current medications included Metoprolol tartrate 100 mg twice a day, Atorvastatin 10 mg daily, Aspirin 325 mg daily. The risks to an ablation were discussed in details including but not limited to bleeding, infection, stroke, heart attack, phrenic nerve paresis, atrioesophageal fistula and thrombus formation. He elected to proceed and was scheduled for the following month.

Physical exam: Pleasant middle-aged male in no acute distress. Blood pressure135/85 mm Hg, heart rate 84 beats/minute, respiratory rate 18, body mass index 37kg/m2, and pulse oximetry 90%. Breath sounds are diminished, heart sounds are distant, with an unremarkable exam. He had no evidence of jugular venous distension, or lower extremity edema.

Laboratory testing: normal hematology, chemistry profile, thyroid-stimulating hormone. Arterial blood gas (ABG) analysis findings; pH=7.30; pCO2=55 mm Hg; pO2=60mmHg; bicarbonate=31. ECG: (Figure1).

Echocardiogram: The left and right ventricles are normal in size. The LV ejection fraction appears to be 55 to 60%. Evidence of grade II diastolic dysfunction. The right atrial cavity is normal in size, left atrial cavity is moderately enlarged. There are no major valvular abnormalities.

Nocturnal Polysomnography: Moderate sleep apnea with apnea-hypopnea index of 20 episodes/hour with several hypopneic episodes.

Figure 1

Figure 1
Atrial fibrillation with an average ventricular response at rest of about 84/min (range about 70-120/min). Relatively low voltage is present diffusely, a non-specific finding that may be seen with obesity. Borderline left axis deviation is also present.11

How would you manage Atrial Fibrillation in this patient once OSA is discovered?

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