Introduction: The sleep apnea syndrome (SAS) is the most common respiratory disturbance and it aff ects all age groups, especially elderly persons. It occurs in ~ 5-10% of the general population, but in patients with cardiovascular diseases the prevalence is between 47% and 83%. Structural changes that occur in SAS activates hypoxic and hypercapnic refl exes, which are responsible for the associated cardiovascular diseases, such as brady- and tachyarrhythmias within sick sinus syndrome (SSS).We present the pacient G.M.,66 years old, female, ex-smoker, hypertensive, dyslipidemic, diabetic and obese. She has heart failure,VVI permanent pacing for SSS, permanent AF, SAS, asymmetrical hypertrophic cardiomyopathy and total thyroidectomy.Methods: Her symptoms were recurrent syncope (4 in the last 2 months), dyspnea on minimal effort and chest pain nitroglycerin responsive. At physical examination we ascertained 1st degree obesity, irregular heart sounds, 3rd degree systolic murmur best heard over the apex.The ECG shows permanent pacing rhythm with paced QRS and native QRS complexes and AF.Th e echocardiography revealed undilated LV, with LVH with normal systolic function and dilated LA; moderate mitral regurgitation with the flow towards LS wall, moderate tricuspid regurgitation with the fl ow towards interatrial septum and mild aortic regurgitation. After we examined the pacemaker function we ascertained that its battery is running low and it needed urgent replacemant of pacemaker’s pulse generator. Results: The diagnose is: chronic HF, asymmetric LVH,VVI permanent pacing for SSS, permanent AF, SAS with severe respiratory dysfunction, moderate mitral regurgitation, mild aortic regurgitation, moderate tricuspid regurgitation, diabetes mellitus type 2, severe hypertension, mixed dyslipidemia, obesity and total thyroidectomy. During hospitalization we performed urgent replacemant of pacemaker’s pulse generator with excellent results and with subsiding of the symptoms. Since she has been diagnosed with SAS (December 2012), she has been treated with nasal continuous positive airway pressure (CPAP), 10 cm H2 O, without additional oxygen intake, with positive outcome. Conclusions: This case is peculiar because: – sick sinus syndrome (which can cause atrial fibrillation and sinus arrest) is associated with sleep apnea syndrome and the last one could lead to arrhythmias such as atrial fibrillation and it can be worsened by heart failure and obesity; – the pacient has multiple risk factors responsible for generating or worsening the sleep apnea syndrome such as age, atrial fibrillation, use of diuretics, but also different disorders which are oft en related with this syndrome as heart failure and atrial fi brillation.