Night terrors and atrial fibrillation - A hypothesis

Sleep apnoea is a sleep disorder characterised by abnormal pauses in breathing or instances of abnormally low breathing, during sleep. Each pause in breathing, called an apnea, can last from a few seconds to minutes, and may occur 5 to 30 times or more an hour. Similarly, each abnormally low breathing event is called a hypopnea. Sleep apnoea is diagnosed with an overnight sleep test called a polysomnogram, or "sleep study".

Night terrors and atrial fibrillation - A hypothesis

Postby themsforum.org » Wed, 08 Apr 2020, 12:13 pm

Night terrors and atrial fibrillation - A hypothesis on cause and possible remedy

Night terrors typically revolve around dreams where the sufferer experiences very realistic looking scenes about various threats e.g. a wild animal attacking them, the experience of them or a close relation drowning or an intruder in the bedroom attacking them.

The fear during an episode is intense and terrifying. The sufferer tries to wake up but feels paralysed unable to produce a sound or movement. When finally able to, the sufferer might wake up in a state of terror, screaming and often gasping for air.

A companion sharing the bedroom is often not able to get them out of their state for a few seconds even when grabbing and shaking them awake.

On waking, there may be profound sweatiness, a fast heart rate and a high blood pressure reading.

Most people recover from the experience, remembering little of the nightmare, but in others, the real horror starts if their rapidly beating heart goes into fibrillation towards the end of such an occurrence.

Little research has been done on night terrors because of the nature of the problem. PET scans of the brain are impossible while the patient is experiencing such a trauma. Some hypotheses attribute the cause to environmental triggers, others suggest it is genetic while yet more suggest it is a chemical imbalance amenable to treatment with anti-depressants.

Anti-depressants fail to help but may cause serious adverse reactions. Considering the high blood pressure component of the experience some patients are prescribed beta-blockers.

While researching the internet I came across the epidemiology of night terrors where it appears that patients suffering from Obstructive Sleep Apnoea (OSA) have a higher incidence of night terrors than those not suffering from OSA. The key feature of OSA is the deprivation of sufficient breathing capacity and consequently insufficient oxygenation.

Such patients have a poor sleep quality and are often very tired during the day not having had a deep restful sleep because they are constantly fighting to breathe adequately throughout the night.

It probably follows that hypo-oxygenation in patients suffering from OSA is perhaps more likely to be the driver for the night terrors.

If this is correct then prescribing such patients beta-blockers can seriously aggravate the condition due to their propensity to cause bronchospasms further depriving the body of oxygen and causing a racing heart.

When there is insufficient oxygen because of depressed breathing ability, which is at its worst when a patient is asleep, the heart has to beat faster to supply the body with oxygen. The rapidly beating heart is also short of oxygen itself and this deprivation may upset its rhythm sending it into an arrhythmia.

At the same time, there is also hypo-perfusion of the brain especially the cerebellum. I suggest the possible cerebellar involvement because many night terrors leave the patient paralysed unable to physically wake themselves up to get rid of this terror. Fine motor movement is a function of the cerebellar areas of the brain.

A possible explanation is derived from patient experiences. They find that their jaws are not comfortable. They often report multiple health problems like migraines, neck pain, back pain, chronic fatigue etc.

Examining the patients shows generally that the patients' teeth are in an asymmetric position which gives rise to Temporo-mandibular joint dysfunction (TMJD). This causes the Atlas vertebrae (The first vertebrae on which the skull rests) to rotate compensating for the jaw asymmetry.

This rotation leads to occipital (the base of the skull) asymmetry which lifts one side of the occiput upwards, affecting the contents of this part of the skull which is the cerebellum. Jaw picture
The function of the cerebellum is further affected because the transverse process of the rotated Atlas vertebrae which pinches the neurological and vascular structures which lie in the proximity of this bone.

Diminished blood flows through the Internal Carotid Artery (ICA), the Vertebral Artery (VA) and also the drainage through the Internal Jugular Vein (IJV) on the affected side.

The obstruction of blood flow through the IJV is a serious issue as it creates back pressure in the brain affecting cerebrospinal fluid flow also and is implicated in instances of 'Multiple Sclerosis'. 'MS' causation, however, is not the subject of this article.

The reduced oxygenation and reduced blood flow probably leads to hypo-perfusion of the cerebellum and higher brain centres on the affected side perhaps temporarily causing the incapacity to move, patients experience during a night terror.

The heart initially becomes tachycardic to enable better oxygenation of the body in the presence of diminished lung ventilation but when further deprived of oxygen the heart muscle starts beating erratically which may eventually precipitate atrial fibrillation in some patients. The patient is unable to recover from this situation and has to be hospitalised.

It is my contention that the brain starts the nightmare terror to try and wake up the patient from this impending harm from a low oxygen level. Repeated episodes of AF result in regular hospitalisations and a serious worry for the patients and their families. Heart ablation procedures follow!

The recommended preventive measure is a dental intervention to help restore breathing capability when asleep. This strategy has lead to amazing recovery in the first two patients I have seen to recently as per the testimonial below:

"Dear Dr Amir,

I presented at your office a year ago when during one of my visits with my wife, you kindly consented to have a quick look at my back pain which had been plaguing me for the previous 25 years.

At the time, I mentioned that I had previously suffered from atrial fibrillation [AF] and I had been treated with cardioversion [a procedure to electrically shock the heart back into sinus rhythm].

At the time, what I failed to tell you is that I had had not one, but two sets of cardioversion, The first one was in November 2018 and while successful I only remained in normal sinus rhythm for 5 days after which my AF returned.

At that point, I was referred back to my consultant cardiologist who suggested a second cardioversion but gave little hope for a successful outcome and was very concerned that I would almost certainly require an 'Ablation procedure' if my AF recurred following the second cardioversion. He had warned me how dangerous such a procedure could turn out to be and I was petrified of getting another attack of AF.

I proceeded to have the second cardioversion in February 2019 this was again successful in returning my heart into a normal rhythm but both my cardiologist and I were very anxious that the AF would return.

As luck would have it, it was just a few days later that you first examined me for my ongoing back problems and I mentioned to you that I was also suffering from horrific nightmares.

After examining me and establishing a cause for my backache you also commented that I could not breathe adequately. You were very keen to treat me for both the backache and possibly for my nightmares. You did warn me that your hypothesis for nightmares and AF may not work out.

I had written to you before, that I recovered from my 25-year backache within a few days of starting the treatment. Another sign that led me to believe that you were on the right track was that for as long as I can remember whenever I lay down to sleep I would find myself struggling to breathe through my nose and would ultimately need to open my mouth to try and get enough air, I had always assumed this was normal.

The very first night that I wore the brace that you made for me I was able to lie down and sleep the night through, comfortably breathing through my nose with my mouth firmly shut. This has continued to this day, a whole year since you first started treating me.

I now wish to inform you that since starting the treatment I have had no nightmares, no fast heart rate and no episodes of Atrial Fibrillation. In fact, my nightmares have turned into pleasant dreams which I can remember on waking up. My private cardiologist is equally intrigued. Your intervention has been a saviour at a very perilous moment in my life.

Thank you for getting me out of my nightmares and my AF episodes.
Stuart"

Comment: If my hypothesis turns out to be correct it could save thousands from very serious life-threatening atrial fibrillations, the risk of stroke and possible premature disability or even death. It could save patients from having an ablation procedure with its inherent dangers and unpredictable outcomes. It would reduce A&E admissions and save the NHS billions of pounds over the years.
Please read my hypothesis on "Visual Snow" which turned out to be very viable.

http://dramir.com/blog/categories/139-Visual-Snow

Conducting some scientific research I was very interested to find that the link between Sleep apnoea and Atrial Fibrillation is well established.
Only proper treatment with a dental appliance to prevent the apnoeic episodes is lacking!
It was also interesting to note is the study below, the increase in blood pressure in apnoeic patients.

It is, more than likely that one needs to restore the breathing function to control sleep apnoea, Atrial fibrillation and high Blood pressure.

Please read the full text on this very interesting article.

Mansukhani MP, Wang S, Somers VK. Sleep, death, and the heart. Am J Physiol Heart Circ Physiol. 2015;309(5):H739–H749. doi:10.1152/ajpheart.00285.2015
Apnoec cardiovascular events:
"Obstructive and central sleep apnea have been associated with increased risk of adverse cardiovascular events and mortality......... Sleep apnea increases the risk of arrhythmias, myocardial ischemia/infarction, stroke, and heart failure, all of which may increase mortality risk. A higher incidence of nocturnal arrhythmias, cardiac ischemia, and sudden death has been noted in subjects with sleep-disordered breathing (SDB).
Systemic Hypertension:
OSA is very closely associated with pulmonary (62) and systemic hypertension. Approximately half of the patients with systemic hypertension have co-existing OSA ........
Furthermore, treatment of OSA with continuous PAP (CPAP) oral appliances, tracheostomy, and maxillo-mandibular advancement surgery has been shown to decrease BP...........".
Please read more >>

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