6

Cardiac Arrhythmias
ROBERT J. THOMAS, SUDHANSU CHOKROVERTY,
MEETA BHATT, AND TAMMY GOLDHAMMER

The polysomnogram (PSG) provides a good opportunity

to evaluate cardiac rhythms. Although medically threatening abnormalities are seen less frequently today than in the
past, sleep specialists and technicians must be able to rec-

ognize the basic abnormalities. The following 1Q PSG segments show some of the cardiac arrhythmias seen during
overnight PSG recording.

171

172

Cardiac Arrhythmias
Alte - HOST v 1.6.03 FUlplronlca C 2001

STAG

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FIGURE 6-1. Severe disease-related bradyarrhythmia in rapid eye movement (REM) sleep, A 56-year-old man with severe daytime
sleepiness. The left side of the snapshot shows a heart rate less than 50, the termination of an apnea, and severe hypoxia (saturation in
the mid-70s). Just prior to the arousal, there is a 4-second period with no electrocardiographs (EKG) rhythm (possible sinus arrest or
sinoatrial exit block), followed by a ventricular escape, and post-arousal tachycardia, with a near doubling of heart rate. The EKG R
wave amplitude also shows fluctuations that track respiratory effort: This EKG-derived respiration signal is secondary to changes in the
cardiac axis generated by positional variation of the heart in the thoracic cavity associated with respiration.

Cardiac Arrhythmias

173

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10-

15"

20"

25"

30"

FIGURE 6-2. Ventricular ectopy in REM sleep. Bigeminy and trigeminy is noted in this 26-year-old woman who presented with
nonhypoxic obstructive sleep-disordered breathing. This finding was not seen in non-REM (NREM) sleep. There was excessive use of
caffeine (four to five large cups of strong coffee across the day). The patient has no palpitations during the day or night.

174

Cardiac Arrhythmias

ABce - HOST v 1.8.03 Raspironlcs C 2001

BODY

SR SR SR SR SR SR SR SR SR SR SR SR SR SR SR SR SR SR SR SR SR SR SR SR SR SR SR 5R SR SR

C4A1

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4:37:51 AM

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FIGURE 6-3. Second-degree heart block, Wenckebach. Progressive increase in PR interval preceding dropped beats in a 48-year-old
patient with delayed sleep phase syndrome, seen unchanged during wake and sleep. This is an innocent arrhythmia and requires no
treatment.

Cardiac Arrhythmias

175

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FIGURE 6-4. Supraventricular tachycardia. Atrial tachycardia with varying block or a run of atrial flutter with varying block. The
abrupt change in P wave morphology is not associated with any change in QRS morphology. The ability of a single EKG channel in
precisely determining the origin of rhythms can be limited. This patient was not on any medication such as digitalis.

(Rem

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FIGURE 6-5. REM-bradyarrhythmia. A 26-year-old asymptomatic man presented for the evaluation of snoring. Complete heart
block.

CHEST

ABDOMEN

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FIGURE 6-6. Postarousal tachycardia. A 36-year-old woman presents for the. evaluation of excessive sleepiness in the setting of refractory depression. This pattern of postaronsal bursts of heart rate increase was noted throughout the study. Such cyclic variations in heart
rate have been used to develop EKG-based screening tools for sleep-disordered breathing. One disadvantage of such tools is that severity information cannot be assessed from the degree of heart rate change, and some patients with the worst disease (e.g., heart failure)
may show very little RR variability.

Cardiac Arrhythmias

177

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FIGURE 6-7. EKG-derived respiration signal. Cyclic variation in RR amplitude (rather than interval) induced by respiratory-related
fluctuations in cardiac positions. This signal has also been evaluated as a noninvasive EKG-derived method to assess sleep respiration.
The disadvantages are similar to RR variabilityit is rarely as prominent as in this sample.

178

Montage:

Cardiac Arrhythmias

PSG Umbs-PFLOW

High Cut: 70 Hz

Low Cut:

0 . 5 3 Hz

Sensitivity:

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30 s/page

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Unscored

FIGURE 6-8. Venfricu/ar premature contractions. A 30-second epoch from an overnight PSG study of a 40-year-old woman with a
history of restless legs syndrome reveals the presence of ventricular ectopic beats. The patient reported occasional palpitations. This phenomenon may be rate dependent, and a faster heart rate may not be associated with the ventricular ectopic beats. Sinus arrhythmia is
also noted.

Cardiac Arrhythmias

Montage:

PSG limbs-PFLOW

High Cut:

70 Hz

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Sensitivity:

179

7 iiV/nrn

Speed:

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FIGURE 6-9. Atrial fibrillation. A 47-year-old man with a history of atrial fibrillation was referred for evaluation of sleep apnea. A 30second epoch of REM sleep from an overnight PSG demonstrates the presence of atrial fibrillation. The association of sleep apnea and
recurrence/triggering of atrial fibrillation has been reported.

180

Cardiac Arrhythmias

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FIGURE 6-10. Aberrant conduction. A 51-year-old woman was referred for the evaluation of sleep apnea. A 30-second epoch from the
PSG shows premature ventricular complexes with slight widening of the QRS but maintained axis. This may be an aberrant beat
secondary to ajunctional ectopic.