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Kusumoto et al 2018 Bradycardia Clinical Practice Guidelines

August 20, 2019 Circulation. 2019;140:e382–e482. DOI: 10.1161/CIR.0000000000000628 e402

CLINICAL STATEMENTS AND GUIDELINES 4.2.7. Sleep Apnea Evaluation and Treatment in Patients With Documented or Suspected Bradycardia or Conduction Disorders

Recommendations for Sleep Apnea Evaluation and Treatment in Patients With Documented or Suspected Bradycardia or Conduction Disorders Referenced studies that support recommendations are summarized in Online Data Supplement 5.

COR LOE Recommendations

I B-NR 1.  In patients with documented or suspected bradycardia or conduction disorder during sleep, screening for symptoms of sleep apnea syndrome is recommended with subsequent confirmatory testing directed by clinical suspicion.S4.2.7-1–S4.2.7-11

I B-NR 2.  In patients with sleep-related bradycardia or conduction disorder and documented obstructive sleep apnea, treatment directed specifically at the sleep apnea (eg, continuous positive airway pressure and weight loss) is recommended.S4.2.7-12–S4.2.7-16

IIa B-NR 3.  In patients who have previously received or are being considered for a PPM for bradycardia or conduction disorder, screening for sleep apnea syndrome is reasonable.S4.2.7-10,S4.2.7-11

Synopsis

Nocturnal bradyarrhythmias are common in both health and disease. Sinus bradycardia is the most common bradyarrhythmia encountered during sleep. However, sinus arrest, sinus exit block, all degrees of atrioventricular block, junctional rhythm, and periods of asystole also occur on occasion.S4.2.7-17–S4.2.7-19 These are particularly common in the young and in the conditioned athlete and can be profound.S4.2.7-20–S4.2.7-23 In most circumstances these are physiological, vagally mediated, asymptomatic events which require no intervention. The frequency of nocturnal bradyarrhythmias appears to decline in middle-aged and older healthy individuals.S4.2.7-17–S4.2.7-19 Those who manifest sleep apnea syndrome, however, demonstrate a higher prevalence of sleep-related bradycardia and conduction disorders, primarily during apneic episodes.S4.2.7-1–S4.2.7-11 In such individuals, wakeful bradyarrhythmias are uncommon and these nocturnal arrhythmias are usually asymptomatic. In patients with sleep apnea and sleeprelated bradyarrhythmias, frequency of episodes is decreased with continuous positive airway pressure and patients are unlikely to develop symptomatic bradycardia in long-term follow-up.S4.2.7-12–S4.2.7-15 Treating the underlying sleep apnea not only alleviates apnea-related symptoms and improves cardiovascular outcome, it also eliminates the need for pacemaker implantation in most patients. Recommendation-Specific Supportive Text

1.	 Sleep disordered breathing is common with an estimated prevalence in the United States of 24% in men and 9% in women, much of which is either asymptomatic or unrecognized.S4.2.7-24 The prevalence is higher in populations with cardiovascular diseases, ranging as high as 47% to 83%, depending on the specific disorder.S4.2.7-25 Estimated rates of profound nocturnal sinus bradycardia range from 7.2% to 40%. Rates of second- or third-degree atrioventricular block range from 1.3% to 13.3%, and rates of sinus pauses range from 3.3% to 33%.S4.2.7-1–S4.2.7-3,S4.2.7-5–S4.2.7-9 The prevalence of these arrhythmias appears to increase with the severity of sleep apnea.S4.2.7-

1,S4.2.7-2,S4.2.7-5 A stereotypical pattern of progressive bradycardia during apnea/hypopnea (often profound) followed by tachycardia and hypertension during partial arousal (presumably precipitated by hypoxia) has been frequently described and cited by some as an electrocardiographic means of indirectly diagnosing the condition.S4.2.7-1,S4.2.7-26 2.	 Because both sleep disordered breathing and nocturnal bradyarrhythmias are relatively common, and treatment of sleep apnea not only dramatically reduces the frequency of these arrhythmias but also may offer cardiovascular benefits,S4.2.7-25 the presence of nocturnal bradyarrhythmias should prompt screening for sleep apnea, starting with solicitation of suspicious symptoms and pursuing additional testing if appropriate. 3.	 Nocturnal arrhythmias associated with obstructive sleep apnea are effectively suppressed with treatment of the underlying sleep apnea. Small studies assessing the frequency and distribution of arrhythmias during polysomnography before and after initiating continuous positive airway pressure (and/or bilevel positive airway pressure) consistently demonstrate dramatic improvements in both metrics of sleep disordered breathing and sleep-related bradyarrhythmias with continuous positive airway pressure.S4.2.7-12–S4.2.7-15 Episodes of profound sinus bradycardia, prolonged sinus pauses, and atrioventricular conduction block are reduced by 72% to 89% in these studies. One of these studies followed their patients for 54±10 months on continuous positive airway pressure therapy (with 58% complete compliance rate). None of the 17 participants without pacemakers experienced symptomatic bradycardia during this time.S4.2.7-14

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