Background: Sleep-disordered breathing (SDB) is highly prevalent in patients with atrial fibrillation (AF). However, it is often underestimated as patients with AF report low SDB-related symptoms. Untreated SDB is associated with reduced success rates of heart rhythm control strategies and contributes to progression of AF. Therefore, screening for SDB including sleep apnea in this cohort is recommended. One of the commonly used screening tools is the STOP-BANG Questionnaire (Snoring, Tiredness, Observed apnoea, (high blood) Pressure, BMI, Age, Neck circumference, and Gender). Data suggest that subjective assessment of some parameters included in this questionnaire limits its validity to detect SDB in this key population.

Aim: Herein we assess the performance of the STOP-BANG Questionnaire to detect SDB, using sleep reports received from a mobile-health based portable home sleep test as the reference.

Methods and results: A remote SDB management pathway via a virtual sleep laboratory was previously introduced in two AF outpatient clinics in the Netherlands. Consecutive AF patients, who were planned for AF catheter ablation, were included prospectively if they were without diagnosis of SDB and did not undergo previous SDB screening. First, an educational (tele-) consultation between patient and referring physician about the impact of concomitant SDB on AF progression was performed. After this, a digital referral to a sleep physician was initiated. A portable home sleep test (WatchPAT, Itamar), with sensitivity of 85-89% and specificity of 63-77% to detect sleep apnea, was sent to patients’ homes. After instruction, patients used WatchPAT for one night. The sleep recordings were accessed by the sleep physician via a secured cloud, analyzed and discussed with the patient. Sleep reports were further shared with the cardiologist and were discussed within a multidisciplinary team in case of complex cases. When applicable, treatment recommendations were discussed and digitally referred to a home-care provider who initiated treatment and training at the patients’ home. Patients were asked to complete the STOP-BANG Questionnaire at the baseline visitation. In a preliminary data analysis, a total of 156 patients was included. According to results from the WatchPAT home sleep test, a total of 83 patients (53.2%) were diagnosed with at least moderate-to-severe SDB (AHI ≥15). A total of 25 patients (16.0%) were diagnosed with severe SDB (AHI ≥30). When used as a screening tool for clinically relevant sleep apnea (AHI ≥15), the STOP-BANG Questionnaire performed poorly with an area under the receiver operator characteristic (AUROC) curve of 0.661 (0.574-0.748).

Conclusion: In a cohort of AF patients scheduled for AF catheter ablation, structured SDB testing via a virtual sleep apnoea management pathway resulted in a high number of previously unknown SDB. Preliminary data suggests that STOP-BANG Questionnaire may not be sufficient as screening tool for clinically relevant SDB in patients with AF and may lead to a number of undetected SDB cases in this cohort. These results highlight the need for a systematical SDB screening approach in patients with AF.