1307 Administrative Delays in Re-Institution of PAP Therapy for Severe Sleep Apnea May be Associated with New-Onset Atrial Fibrillation

Abstract Introduction Central sleep apnea (CSA) produces cyclic changes in intrathoracic pressure, intermittent hypoxia, and heightened sympathetic activation, all of which may increase susceptibility to atrial arrhythmias. Adaptive servo-ventilation (ASV) stabilizes ventilation in CSA; however, insurance-related barriers often delay device replacement when machines malfunction. We describe the development of new-onset atrial fibrillation during a prolonged interruption of ASV therapy. Report of case(s) A 79-year-old male with a past medical history significant for Wallenburg stroke complicated by complex sleep apnea requiring ASV, coronary artery disease, and asthma presented to the sleep medicine clinic in October with report of ASV device malfunction. He endorsed the return of snoring, witnessed apneas, and nonrestorative sleep. Despite a decade of documented benefit and adherence, his insurer required full requalification, including home sleep apnea testing (HST) and titration polysomnogram. HST demonstrated Apnea-Hypopnea Index of 48.3 events per hour and an Oxygen Desaturation Index of 49.2 events per hour. Oxygen nadir was 74% with 147.8 minutes spent with oxygen saturation less than 88%. A March titration polysomnogram confirmed ongoing central apnea and a continued need for ASV. His new device was ultimately dispensed in May. Delays in scheduling, authorization, and durable medical equipment processing resulted in months without therapy. Seven months into the untreated interval, he developed cough, congestion, fatigue, and palpitations. Evaluation by his primary care physician revealed new-onset atrial fibrillation, confirmed by electrocardiogram. He was started on anticoagulation and treated empirically for a respiratory infection. Conclusion There is emerging literature that moderate to severe sleep apnea may be associated with the development of cardiac arrhythmias such as atrial fibrillation. Exactly which clinical factors may contribute to arrhythmia onset and how long sleep apnea must remain untreated or fail to be mitigated are unknown variables. This case identified a patient with both obstructive and central severe apnea who experienced administrative delays in seeking a new ASV machine due to it becoming nonfunctional. This patient experienced an approximate 8-month delay in obtaining an ASV device which may be associated with the development of atrial fibrillation. Streamlined replacement policies and insurance approval processes may help prevent avoidable therapy lapses and their downstream cardiorespiratory effects. Support (if any)