Role of arousal in diagnosing sleep apnea in atrial fibrillation patients

Obstructive sleep apnea syndrome (OSAS) is highly prevalent in patients with atrial fibrillation (AF) and may influence rhythm control outcomes. Accurate diagnosis is essential but depends on the criteria used to define respiratory events. This study aimed to evaluate how the inclusion of EEG arousals in hypopnea scoring affects the diagnosis and severity classification of OSAS in patients with AF.

We conducted a prospective analysis of 88 consecutive patients with AF (paroxysmal or persistent) referred for sleep evaluation with ambulatory type II polysomnography (PSG). Hypopneas were scored according to two criteria: [1] ≥ 3% oxygen desaturation, and [2] ≥ 3% desaturation or EEG-defined arousal. Apnea-hypopnea index (AHI) and OSAS severity were compared across both definitions.

Participants had a mean age of 63 ± 9.7 years, were predominantly male (68%), and had a mean BMI of 30 ± 4.8 kg/m². OSAS was diagnosed in 100% of patients. Using the desaturation-only criterion, OSAS severity was classified as mild in 24.7%, moderate in 31.8%, and severe in 43.5% of patients. In contrast, scoring hypopneas based on desaturation or arousal led to reclassification: 5.7% mild, 17.0% moderate, and 77.3% severe. Thirty-one patients classified as severe OSAS were missed using desaturation-only scoring. The number of hypopneas detected was significantly higher when arousals were included (200.0 ± 105.6 vs. 81.9 ± 48.9; p < 0.001), with a moderate positive correlation between the two methods (r = 0.436).

The use of arousal-inclusive criteria significantly increases OSAS detection and alters severity classification in patients with AF. Relying solely on oxygen desaturation may lead to underdiagnosis and misclassification, particularly in non-desaturating patients. Incorporating EEG arousals into hypopnea scoring provides a more accurate assessment of disease burden and may support more effective, individualized treatment strategies.