Very early screening for sleep-disordered breathing in acute coronary syndrome in patients without acute heart failure

Prevalence of Undiagnosed Obstructive Sleep Apnea Among Patients Hospitalized for Cardiovascular Disease and Associated In-Hospital Outcomes: A Scoping Review

BACKGROUND

Obstructive sleep apnea (OSA) is associated with long-term cardiovascular morbidity and is highly prevalent in patients with cardiovascular disease (CVD). The objectives of this scoping review were to determine the prevalence of OSA inpatients hospitalized for CVD and to map the range of in-hospital outcomes associated with OSA.

METHODS

We searched MEDLINE(R), Embase, and Cochrane Databases for articles published from 1946-2018. We included studies involving non-surgical adults with OSA or at high risk of OSA who were hospitalized for CVD. The outcomes were considered as in-hospital if they were collected from admission up to 30 days post-discharge from hospital.

RESULTS

After the screening of 4642 articles, 26 studies were included for qualitative synthesis. Eligible studies included patients presenting with acute coronary syndromes (n = 19), congestive heart failure (n = 6), or any cardiovascular disease (n = 1). The pooled prevalence of OSA in cardiac inpatients was 48% (95% CI: 42-53). The in-hospital outcomes reported were mortality (n = 4), length of stay (n = 8), left ventricular ejection fraction (n = 8), peak troponin (n = 7), peak B-type natriuretic peptide (n = 4), and composite cardiovascular complications (n = 2).

CONCLUSIONS

OSA is highly prevalent in the cardiac inpatient population. The outcomes reported included mortality, cardiac function, cardiac biomarkers, and resource utilization. There are significant knowledge gaps regarding the effect of treatment and OSA severity on these outcomes. The findings from this review serve to inform further areas of research on the management of OSA among patients with CVD.

Obstructive sleep apnea and hypopnea syndrome in patients admitted in a tertiary hospital in Cameroon: Prevalence and associated factors

PURPOSE

Obstructive sleep apnea and hypopnea syndrome (OSAHS) is poorly documented in Sub-Saharan Africa, especially in the hospital setting. The aim of this study was to determine its prevalence and to investigate the associated factors in patients admitted in a tertiary referral hospital in Cameroon.

METHODS

In this cross-sectional study conducted in the Cardiology, Endocrinology and Neurology departments of the Yaounde Central Hospital; all patients aged 21 and older were included consecutively. A sample of randomly selected patients was recorded using a portable sleep monitoring device (PMD). OSAHS was defined as apnea-hypopnea index (AHI) ≥ 5/hour (with > 50% of events being obstructive) and moderate to severe OSAHS as an AHI > 15/hour. Logistic regression was used to identify factors associated to OSAHS.

RESULTS

Of the 359 patients included, 202 (56.3%) patients were women. The mean age (standard deviation) was 58 (16) years. The prevalence of OSAHS assessed by PMD (95% CI) was 57.7% (48.5-66.9%), 53.8% in men and 62.7% in women (p = 0.44). The median (25th-75th percentiles) AHI, body mass index and Epworth Sleepiness Scale score of OSAHS patients were 17 (10.6-26.9)/hour, 27.4 (24.7-31.6) kg/m2 and 7 (5-9) respectively. The only factor associated to moderate to severe OSAHS was hypertension [odds ratio (95% CI)]: 3.24 (1.08-9.72), p = 0.036.

CONCLUSION

OSAHS is a common condition in patients in this health care centre of Cameroon. In the hospital setting, screening for OSAHS in patients with hypertension is recommended.

Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU

OBJECTIVE

To update and expand the 2013 Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium in Adult Patients in the ICU.

DESIGN

Thirty-two international experts, four methodologists, and four critical illness survivors met virtually at least monthly. All section groups gathered face-to-face at annual Society of Critical Care Medicine congresses; virtual connections included those unable to attend. A formal conflict of interest policy was developed a priori and enforced throughout the process. Teleconferences and electronic discussions among subgroups and whole panel were part of the guidelines' development. A general content review was completed face-to-face by all panel members in January 2017.

METHODS

Content experts, methodologists, and ICU survivors were represented in each of the five sections of the guidelines: Pain, Agitation/sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption). Each section created Population, Intervention, Comparison, and Outcome, and nonactionable, descriptive questions based on perceived clinical relevance. The guideline group then voted their ranking, and patients prioritized their importance. For each Population, Intervention, Comparison, and Outcome question, sections searched the best available evidence, determined its quality, and formulated recommendations as "strong," "conditional," or "good" practice statements based on Grading of Recommendations Assessment, Development and Evaluation principles. In addition, evidence gaps and clinical caveats were explicitly identified.

RESULTS

The Pain, Agitation/Sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption) panel issued 37 recommendations (three strong and 34 conditional), two good practice statements, and 32 ungraded, nonactionable statements. Three questions from the patient-centered prioritized question list remained without recommendation.

CONCLUSIONS

We found substantial agreement among a large, interdisciplinary cohort of international experts regarding evidence supporting recommendations, and the remaining literature gaps in the assessment, prevention, and treatment of Pain, Agitation/sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption) in critically ill adults. Highlighting this evidence and the research needs will improve Pain, Agitation/sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption) management and provide the foundation for improved outcomes and science in this vulnerable population.

Sleep Disturbances in Patients With Coronary Heart Disease: A Systematic Review

STUDY OBJECTIVES

Investigation into sleep and coronary heart disease (CHD) has predominantly been focused on sleep disturbances as a risk factor for developing CHD. Objectively measured and self-reported sleep at a patient level has only been sparsely and not systematically reported. Therefore, we set out to review the literature for studies using objectively measured and self-reported sleep in patients with CHD. The review focuses on patients with acute coronary syndrome (ACS) and stable CHD.

METHODS

A systematic review performed in four databases adhering to the PRISMA guidelines applying a qualitative synthesis of evidence.

RESULTS

Following ACS, we found sleep architecture to be significantly disturbed with changes normalizing over a period of up to 6 months. With increasing severity of CHD, sleep disturbances were more pronounced; however, the modulating effects of sleep-disordered breathing and ejection fraction on sleep in patients with CHD are conflicting. Overall, studies were predominantly cross-sectional in design and of low methodological quality. Polysomnography was the predominant outcome assessment tool and validated self-reported assessment tools were limited.

CONCLUSIONS

Future investigations in sleep and CHD applying both a longitudinal design and investigating objective and self-reported sleep assessments are warranted.

SYSTEMATIC REVIEW REGISTRATION

Registry: PROSPERO, Title: Sleep measures in relation to coronary heart disease: a systematic review, Identifier: CRD42017056377, URL: https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=56377.

Telemedicine in the diagnosis and treatment of sleep apnoea

Telemedicine (TM) is a current tool in the landscape of medicine. It helps to address public health challenges such as increases in chronic disease in an ageing society and the associated burden in healthcare costs. Sleep TM refers to patient data exchange with the purpose of enhancing disease management. Obstructive sleep apnoea (OSA) syndrome is a chronic disorder associated with a significant morbidity, mainly cardiometabolic, and mortality. Obtaining adequate compliance to continuous positive airway pressure (CPAP) remains the greatest challenge related to OSA treatment, and the adoption of TM to support OSA management makes sense. In addition, the prevalence of OSA is growing and OSA is associated with increased healthcare costs that could be streamlined by the application of TM. In OSA, multiple modalities of TM are utilised, such as telediagnostics, teleconsultation, teletherapy and telemonitoring of patients being treated with CPAP. In the present article, I aim to provide an overview of current practice and the recent developments in TM for OSA management. Concerns related to TM use will also be addressed.

ECG derived Cheyne-Stokes respiration and periodic breathing are associated with cardiorespiratory arrest in intensive care unit patients

BACKGROUND

Cheyne-Stokes respiration and periodic breathing (CSRPB) have not been studied sufficiently in the intensive care unit setting (ICU).

OBJECTIVES

To determine whether CSRPB is associated with adverse outcomes in ICU patients.

METHODS

The ICU group was divided into quartiles by CSRPB (86 patients in quartile 1 had the least CSRPB and 85 patients in quartile 4 had the most CSRPB). Adverse outcomes (emergent intubation, cardiorespiratory arrest, inpatient mortality and the composite of all) were compared between patients with most CSRPB (quartile 4) and those with least CSRPB (quartile 1).

RESULTS

ICU patients in quartile 4 had a higher proportion of cardiorespiratory arrests (5% versus 0%, (p=.042), and more adverse events over all (19% versus 8%, p=.041) as compared to patients in quartile 1.

CONCLUSIONS

CSRPB can be measured in the ICU and it's severity is associated with adverse outcomes in critically ill patients.

Prevalence of obstructive sleep apnoea in acute coronary syndrome: Routine screening in intensive coronary care units

INTRODUCTION

Increased evidence has shown that, despite the maximum care afforded to patients admitted with acute coronary syndromes (ACS), a residual risk of mortality remains, in which obstructive sleep apnoea (OSA) appears to be a largely undiagnosed factor, particularly in the intensive cardiac care unit (ICCU). The purpose of this study is to determine whether the systematic screening for sleep-disordered breathing (SDB) is feasible and may be recommended. The aims of our study are to determine: (1) The estimated prevalence of OSA in patients admitted to the ICCU for ACS determined by a validated, user-friendly portable screening device; (2) The feasibility of the screening in this context; (3) To assess any negative impact of OSA on the severity of ACS.

PATIENTS AND METHODS

This is an observational study of 101 patients admitted to the ICCU for ACS showing no clinical evidence of heart failure (HF). In the 24-72hours following admission, they underwent an overnight sleep study using a 3-channel portable screening device with automatic analysis.

RESULTS

Sixty-two out of the 101 patients proved positive to the screening test, and its feasibility was acceptable. OSA patients tended to have greater peak levels of hs-cTnT (3685±3576ng/L versus 2830±3333ng/L, P=0.08) than the non-OSA group. Compared with the non-OSA group, OSA patients presented more severe ACS, with a greater average GRACE score at admission of 112.2±26.3 (versus 98.4±19.2, P<0.001). In the OSA group, we found a statistically significant inverse correlation between the apnoea-hypopnea index (AHI) and the left ventricular ejection fraction (LVEF) in the linear regression analysis (r=-0.26; P=0.037).

CONCLUSIONS

A systematic screening of patients in the ICCU is acceptable. OSA is frequently found in the acute phase of ischaemic heart disease and its presence is associated with more severe ACS and a poorer left ventricle systolic function.

ECG-derived Cheyne-Stokes respiration and periodic breathing in healthy and hospitalized populations

BACKGROUND

Cheyne-Stokes respiration (CSR) has been investigated primarily in outpatients with heart failure. In this study we compare CSR and periodic breathing (PB) between healthy and cardiac groups.

METHODS

We compared CSR and PB, measured during 24 hr of continuous 12-lead electrocardiographic (ECG) Holter recording, in a group of 90 hospitalized patients presenting to the emergency department with symptoms suggestive of acute coronary syndrome (ACS) to a group of 100 healthy ambulatory participants. We also examined CSR and PB in the 90 patients presenting with ACS symptoms, divided into a group of 39 (43%) with confirmed ACS, and 51 (57%) with a cardiac diagnosis but non-ACS. SuperECG software was used to derive respiration and then calculate CSR and PB episodes from the ECG Holter data. Regression analyses were used to analyze the data. We hypothesized SuperECG software would differentiate between the groups by detecting less CSR and PB in the healthy group than the group of patients presenting to the emergency department with ACS symptoms.

RESULTS

Hospitalized patients with suspected ACS had 7.3 times more CSR episodes and 1.6 times more PB episodes than healthy ambulatory participants. Patients with confirmed ACS had 6.0 times more CSR episodes and 1.3 times more PB episodes than cardiac non-ACS patients.

CONCLUSION

Continuous 12-lead ECG derived CSR and PB appear to differentiate between healthy participants and hospitalized patients.

Prevalence of sleep-disordered breathing in acute coronary syndrome: a systemic review and meta-analysis

PURPOSE

This study aimed to review the literature on the prevalence of sleep-disordered breathing (SDB) in patients with acute coronary syndrome (ACS).

METHODS

Relevant studies were searched on PubMed, EMBASE, and Cochrane Library through December 2014. Data were extracted using standardized forms. Pooled prevalence of all SDB (apnea-hypopnea index (AHI) > 5), moderate-to-severe SDB (AHI > 15), and severe SDB (AHI > 30) in ACS patients was calculated using DerSimonian-Laird random-effects model. Sensitivity analysis was performed based on races and diagnostic methods of SDB.

RESULTS

A total of 32 studies were included in the present meta-analysis, examining 3360 patients. The meta-analysis indicated that pooled prevalence of all SDB (AHI > 5), moderate-to-severe SDB (AHI > 15), and severe SDB (AHI > 30) in ACS patients were 69 % (95 % confidence interval (CI) = 61, 77 %), 43 % (95 % CI = 36, 49 %), and 25 % (95 % CI = 17, 33 %), respectively. Sensitivity analysis indicated that the pooled prevalence of SDB in Western population was similar to that in Asian population. However, diagnostic methods of SDB seemed to have various impacts on the prevalence of all SDB (AHI > 5), moderate-to-severe SDB (AHI > 15), and severe SDB (AHI > 30).

CONCLUSIONS

High prevalence of all SDB, moderate-to-severe SDB, and severe SDB was found in ACS patients. It is clinically important to screen for SDB in patients with ACS.

Technical Developments and Clinical Use of Telemedicine in Sleep Medicine

The use of assistive technology and telemedicine is likely to continue to shape our medical practice in the future, notably in the field of sleep medicine, especially within developed countries. Currently, the number of people suffering from obstructive sleep apnea syndrome (OSAS) is increasing. Telemedicine (TM) can be used in a variety of ways in sleep medicine: telediagnostics, teleconsultation, teletherapy and telemonitoring of patients being treated with positive pressure devices. In this review, we aim to summarize the recent scientific progresses of these techniques and their potential clinical applications and give consideration to the remaining problems related to TM application.