A Woman With AF After Husband’s Death, Grandkids’ Drug Abuse

Asim Kichloo, MD; Nadir Siddiqui, MD; Nazir Lone, MD, MPH; Mohamed A. Mohamed, MD


November 16, 2022


This patient's clinical picture of daytime fatigue associated with difficult-to-control hypertension, paroxysmal atrial fibrillation, and a high modified Mallampati score suggests the diagnosis of obstructive sleep apnea (OSA). OSA is a common sleep-related disorder in which repeated episodes of upper-airway obstruction occur during sleep, thereby causing limitations in airflow.[1] The prevalence of OSA is estimated to be 4% of men and 2% of women in the general population of Western society.[2]

A polysomnogram obtained in this patient revealed an average of 17 apneic episodes associated with oxygen desaturation, confirming the diagnosis of OSA. A positive airway pressure machine was subsequently prescribed for the patient.

The other diagnoses presented can be excluded on the basis of the clinical picture and the laboratory findings. The elevated Patient Health Questionnaire-9 score of 8 warrants close observation, especially considering the stresses the patient has been experiencing; however, starting antidepressants would be premature at this point.[3] Given that the patient did not have signs or symptoms of cyanosis or uncorrected congenital heart defects, right-to-left cardiac shunting is less likely. The clinical picture does not correspond to that of vocal cord granuloma because the patient did not have typical symptoms, such as hoarseness and odynophonia (pain on speaking). The normal thyroid-stimulating hormone and thyroxine levels exclude hypothyroidism, despite a mildly enlarged thyroid gland. In addition to depression and hypothyroidism, alternative diagnoses that may present similarly to OSA include anemia, narcolepsy, and obstructive airway diseases.

Patients with OSA may be completely asymptomatic. Typical signs and symptoms of OSA include loud snoring, gasping, choking, and breathing cessation while sleeping. Patients may also report morning headaches and daytime sleepiness.[4] Atypical OSA symptoms, which are more common in females, may include insomnia, nightmares, restless legs, and hallucinations.[5]

Risk factors for OSA include male gender, obesity, alcoholism, and smoking.[6] Although obesity with central adiposity is recognized as a strong risk factor for OSA, OSA should be considered as a possible diagnosis even in persons with a low or normal BMI if their clinical picture fits the characteristics of OSA.[7]


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