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Pacemaker Therapy for Sleep Apnea Syndrome?

We might start to see sleep-apnea therapy from a whole new angle because of this study.

Sleep apnea syndrome (SAS), characterized by frequent episodes of apnea or hypopnea during sleep, affects more than 10% of people older than 65. Treatments with nasal continuous positive airway pressure, theophylline, or surgical ablative therapy have notable drawbacks. These researchers found that SAS patients with pacemakers fared better during nights when their devices were in atrial overdrive.

Of 47 pacemaker patients with symptoms suggestive of SAS who were screened, 26 agreed to participate in this trial. Polysomnographic recordings revealed SAS in 15 (mean age, 69; 73% male). All 15 presented with episodes of both central and obstructive apnea. Each patient underwent 3 sleep studies: the first for baseline evaluation (basic pacing rate, 55 to 60 bpm) and then, in random order, 1 night primarily in spontaneous rhythm (VVI pacing, 40 bpm; "no-pacing" phase) and 1 night with atrial pacing 15 bpm faster (mean, 72 bpm) than the mean baseline heart rate (atrial-overdrive phase).

The difference in total sleep duration with atrial-overdrive pacing versus "no pacing" was not significant. Mean sleep-apnea severity, as assessed with the hypopnea index, was reduced from 9 in spontaneous rhythm to 3 in atrial overdrive. In 13 of 15 patients, the apnea-hypopnea index was reduced by more than 50% with atrial-overdrive pacing, regardless of whether the sleep apnea was primarily central or obstructive. In every patient, atrial-overdrive pacing improved measures on the central- and obstructive-apnea indexes.

Comment: These truly remarkable results, which show that pacemaker therapy may benefit patients with SAS, are nonetheless preliminary. The study population was small, and all patients already had conventional indications for pacemakers. Whether pacemaker therapy will benefit SAS patients without such indications is an open question, as is the mechanism of this novel therapy in SAS. The authors speculate that overdrive pacing altered vagal tone, but this is far from clear, as an editorialist notes. Only further research can answer the many questions raised by this study's fascinating clinical findings.

— Hugh Calkins, MD

Published in Journal Watch Cardiology March 1, 2002

Citation(s):

Garrigue S et al. Benefit of atrial pacing in sleep apnea syndrome. N Engl J Med 2002 Feb 7; 346:404-12.

• Medline abstract (Free)

Gottlieb DJ. Cardiac pacing -- A novel therapy for sleep apnea? N Engl J Med 2002 Feb 7; 346:444-5.

• Medline abstract (Free)

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