Sleep-Disordered Breathing and Sleep Fragmentation in Relation to Atrial Fibrillation Risk: A Systematic Review and Meta-Analysis

BACKGROUND: Atrial fibrillation (AF) is one of the most prevalent cardiac arrhythmias worldwide. This study aimed to evaluate the association between sleep-disordered breathing (SDB), primarily assessed using the apnea-hypopnea index (AHI), and AF risk, with additional analysis of sleep fragmentation parameters such as wake after sleep onset (WASO) and arousal index (AI). METHODS: This systematic review and meta-analysis followed Cochrane Handbook recommendations and PRISMA guidelines, with protocol registration in PROSPERO (No. 127490). Randomized controlled trials (RCTs) and observational cohort studies assessing sleep disturbances and AF were included. MEDLINE, Cochrane Library, and Scopus were searched from inception to February 2026. Extracted data included study characteristics, demographics, cardiovascular risk factors, and sleep metrics. Outcomes were incident and recurrent AF. A random-effects model was applied. RESULTS: Twenty-one cohort studies (611,898 participants) were included. SDB was associated with increased incident AF risk (RR 1.67, 95% CI 1.41-1.97; I ² = 66.5%), with consistent Bayesian estimates. A dose-response relationship showed a 2% increase in AF risk per unit rise in AHI. For AF recurrence, 11 studies (n = 1810) demonstrated a significant association (RR 1.55, 95% CI 1.40-1.72; I ² = 0%), supported by Bayesian analysis. CONCLUSION: Sleep disturbances are significantly associated with both incident and recurrent AF and may represent modifiable risk factors.