2026 ECNP Congress

PS04-4247

Sleep-disordered breathing and sleep fragmentation in relation to atrial fibrillation risk: a systematic review and meta-analysis

Walquiria Parreira — A. Zuffo Yabrude, I. Gonçalves Baylão · Centro Universitário de Valença, Internal Medicine, Valença, Brazil

2026 ECNP Congress

Atrial fibrillation is the most prevalent sustained cardiac arrhythmia worldwide, with incidence projected to increase substantially through 2050. Traditional risk factors are well established; however, sleep-disordered breathing and fragmented sleep continuity have emerged as potentially modifiable contributors to arrhythmogenesis through autonomic dysfunction, systemic inflammation, and atrial remodelling [1,3]. Despite growing recognition of sleep as a fundamental component of cardiometabolic health [5], the quantitative relationship between objectively measured sleep fragmentation and atrial fibrillation risk remains uncertain [2]. This systematic review and meta-analysis aimed to evaluate the association between sleep-disordered breathing severity, sleep fragmentation parameters, and incident and recurrent atrial fibrillation in adults.We prospectively registered the protocol with PROSPERO and searched MEDLINE, Cochrane Library, and Scopus from inception through February 2026. Two independent reviewers screened records against predefined eligibility criteria. We included randomised controlled trials and prospective and retrospective cohort studies that assessed sleep disturbances using polysomnography, portable monitors, actigraphy, or validated wearables before outcome ascertainment, with atrial fibrillation confirmed by electrocardiography, ambulatory monitoring, or validated administrative algorithms. Twenty-one longitudinal cohort studies comprising 665,457 participants were included. Random-effects meta-analyses were performed with Bayesian sensitivity analyses, two-stage dose-response modelling, and meta-regression. Risk of bias was assessed using ROBINS-E, and publication bias was evaluated using funnel plots and Egger’s test.Sleep-disordered breathing was associated with significantly increased incident atrial fibrillation risk (risk ratio 1.67, 95% confidence interval 1.41 to 1.97; I² = 66.5%), with consistent effects across apnoea-hypopnoea index thresholds of 5 and 15 events per hour [4]. A significant dose-response relationship was observed, with each one-unit increase in apnoea-hypopnoea index associated with approximately a 2% increase in risk. For recurrent atrial fibrillation, eleven studies demonstrated a robust association (risk ratio 1.55, 95% confidence interval 1.40 to 1.72; I² = 0%). Bayesian analyses corroborated these findings, with posterior median risk ratios of 1.65 and 1.57 for incident and recurrent atrial fibrillation respectively, and posterior probabilities exceeding 99%. Patients who developed incident atrial fibrillation exhibited significantly greater wake after sleep onset (mean difference 12.95 minutes, 95% confidence interval 7.05 to 18.85) [2], higher apnoea-hypopnoea index (mean difference 4.17 events per hour, 95% confidence interval 1.29 to 7.06), and reduced total sleep time (mean difference −23.86 minutes, 95% confidence interval −43.52 to −4.20) compared with controls. No significant publication bias was detected.These findings indicate that sleep-disordered breathing is independently associated with both incident and recurrent atrial fibrillation, with a linear dose-response gradient. Sleep fragmentation metrics, particularly wake after sleep onset, may represent additional modifiable risk markers beyond apnoea burden. Although residual confounding and the observational design preclude causal inference, these results support integrating comprehensive sleep assessment into atrial fibrillation risk stratification and highlight sleep health as a potential therapeutic target. Future interventional studies evaluating continuous positive airway pressure therapy and behavioural sleep interventions are warranted to determine whether modifying sleep architecture reduces atrial fibrillation burden.

References

  1. Mehra, R., Chung, M.K., Olshansky, B., Dobrev, D., Jackson, C.L., Kundel, V., et al., 2022. Sleep-disordered breathing and cardiac arrhythmias in adults: mechanistic insights and clinical implications: a scientific statement from the American Heart Association. Circulation. 146, e119-e136.
  2. Wang, L., Hui, X., Huang, R., Xiao, Y., 2025. The association between sleep fragmentation and incident atrial fibrillation: a prospective cohort study in a community population. J. Clin. Sleep Med. 21, 1191-1200.
  3. Gami, A.S., Pressman, G., Caples, S.M., Kanagala, R., Gard, J.J., Davison, D.E., et al., 2004. Association of atrial fibrillation and obstructive sleep apnea. Circulation. 110, 364-367.
  4. Cadby, G., McArdle, N., Briffa, T., Hillman, D.R., Simpson, L., Knuiman, M., et al., 2015. Severity of OSA is an independent predictor of incident atrial fibrillation hospitalization in a large sleep-clinic cohort. Chest. 148, 945-952.
  5. St-Onge, M.P., Aggarwal, B., Fernandez-Mendoza, J., Johnson, D., Kline, C.E., Knutson, K.L., et al., 2025. Multidimensional sleep health: definitions and implications for cardiometabolic health: a scientific statement from the American Heart Association. Circ. Cardiovasc. Qual. Outcomes. 18, e000139.