Atrial fibrillation, sleep apnea and obesity

Background: A 60-year-old male with obesity (body-mass index 43 kg/m ²) presented with recurrent symptomatic atrial fibrillation (AF), which he had had since age 41 years. The AF was refractory to treatment with antiarrhythmic drugs. Pacemaker implantation for tachycardia-bradycardia syndrome was required as well as ablation for atrial flutter, and the patient underwent a total of four DC cardioversions. Sleep studies showed mild to moderate obstructive sleep apnea, but continuous positive airway pressure was not tolerated. Pacemaker interrogations demonstrated mode-switch episodes, indicating continuing AF. He was scheduled for catheter ablation targeting pulmonary vein antral isolation. He embarked on a weight-loss program, which successfully reduced AF burden. Investigations: Echocardiography, stress testing, polysomnography, pacemaker interrogations and C-reactive protein. Diagnosis: AF, atrial flutter, tachycardia-bradycardia syndrome, obstructive sleep apnea and morbid obesity. Management: Antiarrhythmic drug therapy, DC cardioversion, anticoagulation, atrial flutter ablation, permanent pacemaker implantation, continuous positive airway pressure and weight loss.