Screening for Obstructive Sleep Apnea in an Atrial Fibrillation Population: What's the Best Test?

Abstract

Background: Among individuals with nonvalvular atrial fibrillation (AF), the prevalence of obstructive sleep apnea (OSA) can be as high as 85%. Continuous positive airway pressure treatment for moderate or severe OSA might improve AF outcomes and quality of life, so early identification of OSA might be of value. However, screening questionnaires for OSA are suboptimal because they are weighted toward tiredness and loud snoring, which might be absent in AF patients. NoSAS (Neck, Obesity, Snoring, Age, Sex) is a new OSA questionnaire that excludes these parameters. Acoustic pharyngometry (AP) is a potential novel screening technique that measures pharyngeal cross-sectional area, which is reduced in patients with OSA.

Methods: We prospectively compared the accuracy of the NoSAS, the STOP-BANG questionnaire (Snoring, Tiredness, Observed apnea, blood Pressure, Body mass index, Age, Neck circumference and Gender), and AP with home sleep apnea testing (HSAT) in consecutive patients with nonvalvular AF.

Results: Of 188 participants, 86% had OSA and 49% had moderate or severe OSA. Mean Epworth Sleepiness Scale scores were low; 5.9 (SD, 3.9), indicating that most participants were not sleepy. Receiver operating characteristic curves for comparisons of screening tests with HSAT showed suboptimal accuracy. For moderate plus severe and severe only groups respectively, the area under the curve was 0.50 (95% confidence interval [CI], 0.42-0.58) and 0.42 (95% CI, 0.34-0.52) for AP, 0.65 (95% CI, 0.58-0.73) and 0.63 (95% CI, 0.52-0.74) for the STOP-BANG questionnaire, and 0.68 (95% CI, 0.60-0.75) and 0.69 (95% CI, 0.59-0.80) for the NoSAS.

Conclusions: AP and NoSAS are not sufficiently accurate for screening AF patients for OSA. Because of the high rates of OSA in this cohort, the potential benefits of OSA treatment, and the suboptimal accuracy of current screening questionnaires, cardiologists should consider HSAT for AF patients.

© 2020 Canadian Cardiovascular Society. Published by Elsevier Inc.

Figures

Figure 1

Patient participation in the study. AF, atrial fibrillation.

Figure 2

Study flow diagram. ESS, Epworth Sleepiness Scale; HSAT, home sleep apnea test; NoSAS, NoSAS (Neck, Obesity, Snoring, Age, Sex) questionnaire; SBQ, STOP-BANG (Snoring, Tiredness, Observed apnea, blood Pressure, Body mass index, Age, Neck circumference and Gender) questionnaire.

Figure 3

(Left) A demonstration of the acoustic pharyngometry technique. (Right) Graph generated from acoustic pharyngometry. The reflected acoustic waves create a curve of distance from the mouthpiece (x-axis) against cross-sectional area (y-axis) from which the positions of various oropharyngeal structures can be identified. Reproduced from Gelardi et al. with permission from lead author and under the Creative Commons Attribution 4.0 International Public License.

Figure 4

Receiver operating characteristic curves for NoSAS Questionnaire (Neck, Obesity, Snoring, Age, Sex), STOP-BANG (Snoring, Tiredness, Observed apnea, blood Pressure, Body mass index, Age, Neck circumference and Gender) questionnaire (SBQ), minimal circumferential area of the oropharynx (MCA), and Epworth Sleepiness Scale (ESS) compared with home sleep apnea test. Red indicates moderate and severe obstructive sleep apnea (apnea-hypopnea index ≥ 15); blue indicates severe obstructive sleep apnea (apnea-hypopnea index ≥ 30). For area under the curve values, see Table 3.