Case Study: Integrating OAT in Atrial Fibrillation Management for OSA Patients

As the prevalence of atrial fibrillation (AF) continues to rise, particularly among the aging population, its connection with obstructive sleep apnea (OSA) has become increasingly evident.¹ Patients with AF seeking treatment for OSA often present with a complex medical history that includes a number of comorbidities, such as hypertension, acid reflux, and asthma, which contributes to the overall complexity of their care.² This article will delve into the intricate relationship between AF and OSA, emphasizing the need for comprehensive management strategies and shedding light on the potential benefits of oral appliance therapy (OAT).

Understanding Atrial Fibrillation
AF, characterized by an irregular and often rapid heart rhythm originating from the atria, has become the most common persistent heart rhythm disorder in adults. Recent epidemiological data reveals a 2.0% occurrence in a random population sample, with prevalence increasing with age—from 0.2% in those ages 45–54 to 8.0% in those ages 75 and older.

Potential Complications of Atrial Fibrillation
Beyond the symptoms of fatigue or shortness of breath, AF poses an elevated risk of stroke, emphasizing the importance of preventive measures.³ The risk of stroke in AF patients is estimated between 1% and 20% annually, making the prevention of such episodes a key focus in treatment.

Treatment Options for Atrial Fibrillation
AF management strategies involve antiplatelet or anticoagulant therapy, medication to control heart rate, and interventions such as cardioversion and ablation. Recurrent AF after ablation is not uncommon, leading to repeat procedures in a significant percentage of patients.⁴ Complications of AF contribute to substantial healthcare costs, with patients incurring approximately $28,000 in additional annual healthcare costs compared to those without AF.⁴

The Interplay Between Sleep Apnea and Atrial Fibrillation
The correlation between OSA and AF is well known, with AF occurring in 5% of patients experiencing OSA. OSA is not only a risk factor for the onset and progression of AF but also diminishes the efficacy of antiarrhythmic drugs, electric cardioversion, and catheter ablation in AF. The prevalence of OSA is notably high in AF patients, ranging from 50% to 80%, surpassing the 30% to 60% observed in control groups.⁵

How OSA Contributes to Atrial Fibrillation
OSA and AF exhibit a robust association, as seen in animal and human studies. In animals, OSA-induced hypoxia and hypercapnia contribute to imbalances in the autonomic nervous system, potentially leading to atrial electrical changes and promoting AF. Studies in rats highlight that intrathoracic pressure fluctuations during OSA can result in structural remodeling in the heart, characterized by increased left atrial dilatation and fibrosis.

OSA’s impact on cardiac function and structure is significant. The repetitive struggle to breathe against a closed airway induces negative intrathoracic pressure, increasing cardiac afterload and resulting in atrial remodeling. This remodeling, marked by enlarged atria and elevated wall stress, creates a predisposition to arrhythmias. Additionally, severe intermittent hypoxemia, acidosis, and hypercapnia associated with OSA can lead to autonomic dysfunction, characterized by sympathetic activation, elevated heart rate, and blood pressure fluctuations, persisting into the daytime despite normal oxygen levels.

The release of vasoactive substances like endothelin during hypoxemia can contribute to long-term vascular damage, increasing the likelihood of hypertension. OSA-related hypoxemia also triggers inflammation, evidenced by elevated markers such as C-reactive protein. Autonomic stimulation, inflammation, oxidative stress, and involvement of the renin-angiotensin-aldosterone system collectively heighten susceptibility to arrhythmias.

The Role of Oral Appliance Therapy
Acknowledging the intimate connection between AF and OSA, the American Heart Association recommends screening all AF patients for OSA. Treatment options include continuous positive airway pressure (CPAP) for severe cases and oral appliances for those with mild to moderate OSA or CPAP-intolerant patients. Continuous follow-up sleep testing is essential to assess the effectiveness of treatment.

Research shows that important health outcomes, including quality of life, reduced daytime sleepiness, lowered blood pressure, heightened energy levels, and enhanced cognitive abilities, were similar after one month of optimal use of mandibular advancement devices (MAD) and CPAP treatment in patients with moderate-severe OSA.

The results may be explained by the greater efficacy of CPAP being offset by inferior compliance relative to MAD, resulting in similar effectiveness, known as mean disease alleviation.⁶ Both CPAP and MAD may be equally effective therapies in reducing the risk of fatal cardiovascular events in patients with severe OSA.^7-8

Case Study Introduction
Patient M’s case provides a compelling narrative that underscores the complexities of managing AF, especially when coupled with OSA. This case study illuminates the challenges patients face, explores various treatment modalities, and emphasizes the potential benefits of OAT in AF management.

 

 

Patient Background
Patient M, a 68-year-old male, initially sought treatment for mild OSA, characterized by nocturnal disruptions and confirmed AF episodes. Despite undergoing two ablation procedures and a Watchman FLX™ device insertion to mitigate stroke risk, AF persisted at an alarming frequency.

 

 

 

 

Clinical Profile

• Weight: 320 pounds; BMI: 48.7
• Blood pressure: 144/75
• Resting pulse: 50-60 bpm; During AF event: 100-130 bpm
• Nocturnal disruptions confirmed via the FibriCheck app
• SnoreLab app score: 31 (indicating snoring)
• Dry mouth, frequent nocturnal awakenings (three times per night) Visible dental attrition and temporomandibular joint (TMJ) attrition on 3-D X-ray. The teeth and the jaw joint show evidence of grinding or clenching, which can impact dental health and is usually associated with OSA (Figures 1-6).
• Medications: Wegovy^® (semaglutide) 2.4 mg injection; Ozempic^® (semaglutide) injection (prescribed by the patient’s primary care physician for weight loss to reduce BMI and promote a healthier lifestyle).
• Epworth Score: 4; Fatigue Score: 9
• Patient reported CPAP intolerance due to claustrophobia.
• Initial reluctance to exercise and low desire for physical activity.

 

 

 

 

 

 

 

 

 

 

 

 

 

Treatment Journey OAT (Figure 7)

Re-evaluation after one week of using the Respire Pink Micro AT (Dynaflex). Initial appliance fabrication did not alleviate AF episodes or encourage exercise. (Figures 8-10)

Introduction of self-titration (eight turns every other day equals 0.5 mm) and diary recording. The patient received direction to stop upon reaching 3 mm advancement from the initial protrusive setting.

 

 

 

 

 

 

 

 

 

 

Titration Progress
Follow-up and re-evaluation: One month of use revealed that the 3 mm titration led to improved sleep, reduced awakenings, and a notable decrease in AF episodes.

Sleep Study Referral
Referral for polysomnography (PSG) to evaluate sleep apnea severity and its correlation with AF. (See Table 1 for results.)

Table 1. Comparison with the OAT in place during the PSG recording at one month

Pre- and Post-Polysomnographic Comparison Results
	Baseline	After Active Treatment Phase
AHI	5.85	0.2
RDI	19.5	10.4
Supine AHI	11.0	0.0
Supine RDI	28.0	0.0
REM AHI	13.1	0.0
REM RDI	26.0	0.0
Non-Supine AHI	0.2	0.2
Nadir Oxygen	86	88

 

Follow-Up and Lifestyle Changes
The patient returned after three months, reporting only two AF episodes during that period. Subsequent long-term evaluation revealed a weight loss of 22 pounds (BMI 45.3).

The patient established a regular walking and daily exercise routine. (OAT contributes to increased daytime energy levels by promoting uninterrupted sleep. As a result, patients often find themselves more motivated to engage in regular exercise.)

The patient reported improved sleep quality with a blood pressure reading of 126/59.

Conclusion
Patient M’s case exemplifies the potential of a personalized, multi-modal approach in AF management. Integrating Wegovy, Ozempic, and OAT into the patient’s care contributed to weight loss, improved sleep, and reduced AF episodes. The case highlights the need for ongoing research to uncover specific benefits of OAT as an adjunct in AF treatment, offering hope for patients who may be reluctant to adhere to traditional CPAP treatment.

This nuanced approach acknowledges the individuality of each patient, emphasizing the importance of tailored strategies for optimal AF care.⁹

In titrating oral appliances for OSA and AF, regular nocturnal monitoring using wearables or smartphone apps proves invaluable. This continuous monitoring at various titration points allows for nuanced adjustments, optimizing the patient’s experience. The American Academy of Sleep Medicine provides guidance with regard to the use of consumer wearables in clinical practice.^10-11

Frequent communication between the patient and the cardiologist further refines the treatment approach, ensuring a tailored strategy. The positive impact is evident as patients express gratitude for uninterrupted sleep without AF episodes.

Crucially, follow-up overnight PSG with the appliance in place is pivotal at the most effective protrusion to maximize the airway. This step is essential to assess the appliance’s effectiveness in mitigating OSA and AF, providing critical insights for further adjustments and personalized care.

Understanding OSA and its intricate relationship with AF is key to ensuring the long-term success of interventions like catheter ablation.^12-13 Despite the numerous opportunities that cardiologists and arrhythmia specialists have in managing AF, systematic screening for OSA is yet to be universally established. This gap in awareness is compounded by the underestimation of OSA’s negative prognostic impact.¹⁴

Undiagnosed OSA stands out as a modifiable risk factor, necessitating appropriate therapeutic interventions to optimize the efficacy of AF treatments, including catheter ablation. The advent of smartphone applications and mobile devices for self-screening of OSA presents a promising avenue, offering a convenient tool for preliminary and ongoing assessments. While clinical diagnoses based solely on these devices warrant caution, the evolving technology holds the potential for streamlining OSA screening processes.

The formation of a comprehensive OSA care team, fostering collaboration between sleep disorder specialists and cardiologists, is advocated for efficient diagnosis and treatment. OSA emerges as a costly risk factor in both the screening and treatment phases of AF, emphasizing the economic burden associated with untreated OSA.

In response to the growing need for insights into the impact of oral appliances on cardiovascular health, the Oral Appliance Network on Global Effectiveness (ORANGE) study, supported by the American Academy of Dental Sleep Medicine, is underway. This multinational effort aims to evaluate the long-term effectiveness of OAT in OSA patients, shedding light on its potential implications for cardiovascular outcomes. As of November 2022, the study has enrolled 163 patients from four research centers.^15-16

It is evident that untreated sleep apnea poses a significant risk, leading to costly complications such as AF. The ongoing ORANGE study represents a step toward addressing this gap in knowledge, offering a platform to explore the potential benefits of OAT on AF and cardiovascular health.¹⁶

Public education becomes a cornerstone in this context, empowering individuals to utilize phone apps for health monitoring. Educating the public about the intricate link between sleep apnea, AF, and the role of innovative technologies fosters proactive health management. As we advance in research and technology, prospective clinical trials are anticipated to unveil the impact of OSA, the effectiveness of its treatment, and the cost-effectiveness of routine screening, contributing to a more informed and engaged public in the realm of AF care.

 

 

Maria Sokolina, DDS, is a diplomate of the American Academy of Dental Sleep Medicine and serves on their board. She is actively involved in dental sleep medicine, seeking solutions for sleep apnea through dental appliances and myofunctional therapy.

 

 

 

References

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