The STOP-BANG questionnaire shows an insufficient specificity for detecting obstructive sleep apnea in patients with atrial fibrillation

Obstructive sleep apnea in the patient with atrial fibrillation: current knowledge and remaining uncertainties

PURPOSE OF REVIEW

Obstructive sleep apnea (OSA) is highly prevalent in patients with atrial fibrillation and plays a causal role for OSA in the pathogenesis of atrial fibrillation. The presence of OSA in atrial fibrillation is associated with increased symptom burden and increased risk of hospitalizations. Furthermore, untreated OSA is associated with an increased risk of atrial fibrillation recurrence post ablation or cardioversion, and observational studies suggest that continuous positive airway pressure (CPAP) therapy can attenuate this risk. This review describes our current understanding of the relationship between OSA and atrial fibrillation with an emphasis on emerging evidence.

RECENT FINDINGS

Recent studies have identified novel screening questionnaires, which may be superior to traditional questionnaires in identifying OSA in atrial fibrillation populations. Significant night-to-night variability in OSA severity has been shown in atrial fibrillation patients, which has implications for diagnostic testing. While several small, randomized control trials (RCTs) have not shown CPAP therapy to be effective in reducing atrial fibrillation burden, one RCT did show CPAP can attenuate the atrial substrate with implications for long-term outcomes.

SUMMARY

Further RCTs, appropriately powered, and focused on well defined cohorts, are required to guide management decisions regarding screening and treatment of OSA in atrial fibrillation populations.

Atrial fibrillation-specific refinement of the STOP-Bang sleep apnoea screening questionnaire: insights from the Virtual-SAFARI study

BACKGROUND

Sleep-disordered breathing (SDB) is prevalent in up to 50% of patients referred for atrial fibrillation (AF) catheter ablation (CA). Currently, it remains unclear how to improve pre-selection for SDB screening in patients with AF.

AIM

We aimed to (1) assess the accuracy of the STOP-Bang screening questionnaire for detection of SDB within an AF population referred for CA; (2) derive a refined, AF-specific SDB score to improve pre-selection.

METHODS

Consecutive AF patients referred for CA without a history of SDB and/or SDB screening were included. Patients were digitally referred to the previously implemented Virtual-SAFARI SDB screening and management pathway including a home sleep test. An apnoea-hypopnoea index (AHI) of  ≥ 15 was interpreted as moderate-to-severe SDB. Logistic regression analysis was used to assess characteristics associated with moderate-to-severe SDB to refine pre-selection for SDB screening.

RESULTS

Of 206 included patients, 51% were diagnosed with moderate-to-severe SDB. The STOP-Bang questionnaire performed poorly in detecting SDB, with an area under the receiver operating characteristic curve (AUROC) of 0.647 (95% Confidence-Interval (CI) 0.573-0.721). AF-specific refinement resulted in the BOSS-GAP score. Therein, BMI with cut-off point ≥ 27 kg/m2 and previous stroke or transient ischaemic attack (TIA) were added, while tiredness and neck circumference were removed. The BOSS-GAP score performed better with an AUROC of 0.738 (95% CI 0.672-0.805) in the overall population.

CONCLUSION

AF-specific refinement of the STOP-Bang questionnaire moderately improved detection of SDB in AF patients referred for CA. Whether questionnaires bring benefits for pre-selection of SDB compared to structural screening in patients with AF requires further studies.

TRIAL REGISTRATION NUMBER

ISOLATION was registered NCT04342312, 13-04-2020.

Diagnosis of Obstructive Sleep Apnea in Patients with Associated Comorbidity

Obstructive sleep apnea (OSA) is a heterogeneous disease with many physiological implications. OSA is associated with a great diversity of diseases, with which it shares common and very often bidirectional pathophysiological mechanisms, leading to significantly negative implications on morbidity and mortality. In these patients, underdiagnosis of OSA is high. Concerning cardiorespiratory comorbidities, several studies have assessed the usefulness of simplified screening tests for OSA in patients with hypertension, COPD, heart failure, atrial fibrillation, stroke, morbid obesity, and in hospitalized elders.The key question is whether there is any benefit in the screening for the existence of OSA in patients with comorbidities. In this regard, there are few studies evaluating the performance of the various diagnostic procedures in patients at high risk for OSA. The purpose of this chapter is to review the existing literature about diagnosis in those diseases with a high risk for OSA, with special reference to artificial intelligence-related methods.

The value of screening questionnaires/scoring scales for obstructive sleep apnoea in patients with atrial fibrillation

BACKGROUND

Obstructive sleep apnoea (OSA) is an important modifiable risk factor for atrial fibrillation (AF) but is underdiagnosed in this population. Currently, polysomnography is the gold standard for diagnosing OSA, but is expensive and requires overnight examination. Alternatively, home sleep apnoea testing can be used as a diagnostic tool, but also requires a complete data review. Therefore, these OSA diagnostic modalities are not ideal screening methods. Several OSA screening tools exist, but their value in patients with AF remains unclear.

AIM

To test the performance of existing screening questionnaires/scales for clinically relevant OSA in patients with AF referred for diagnostic polysomnography.

METHODS

This prospective study compared the performance of seven screening tools (Epworth Sleepiness Scale, Berlin Questionnaire, Sleep Apnea Clinical Score, NoSAS, OSA50, STOP-Bang and MOODS) with polysomnography in the detection of clinically relevant OSA in consecutive patients with AF referred to two sleep clinics.

RESULTS

A total of 100 patients referred for polysomnography and known previous AF were included. Polysomnography indicated at least clinically relevant OSA (i.e., apnoea-hypopnoea index≥15 events/hour) in 69% of cases, and 33% had severe OSA (apnoea-hypopnoea index>30 events/hour). In screening for clinically relevant OSA, only the SACS and NoSAS scores had fair areas under the curve (0.704 and 0.712, respectively). None of the seven screening tools was performant enough (i.e., had a fair area under the curve>0.7) in the detection of severe OSA.

CONCLUSIONS

In this AF cohort referred for polysomnography, clinically relevant OSA was prevalent. None of the selected screening tools showed sufficient performance as a good discriminative screening tool for clinically relevant OSA in patients with AF. Given these findings, other screening modalities for OSA should be considered in the work-up of patients with AF.

Baseline sleep as a predictor of delirium after surgical aortic valve replacement: A feasibility study

OBJECTIVE

The goal is to assess the feasibility of conducting unattended (type II) sleep studies before surgical aortic valve replacement (SAVR) to examine the relationship between baseline sleep measures and postoperative delirium.

METHODS

This single-site study recruited 18 of 20 study referrals with aortic stenosis undergoing first lifetime SAVR. Subjects completed a home-based type II sleep study. Delirium was assessed postoperative days 1-5. Exact logistic regression was used to determine whether sleep efficiency or apnea/hypopnea index predicts delirium.

RESULTS

Of 18 study participants, 15 successfully completed a home sleep study (mean age: 71.7 +/- 8.1 years old; 10 male subjects). Five subjects (33.3%) developed delirium. Preliminary analyses found that greater sleep efficiency was associated with a large reduction in delirium odds but was not statistically significant (OR = 0.31, 95% CI: 0.06, 1.03, p = 0.057). The point estimate of the relationship between apnea/hypopnea index and delirium was not similarly sizeable (OR 1.10, 95% CI: 0.35, 3.37, p = 0.85).

CONCLUSIONS

Our findings suggest that home type II sleep studies before SAVR are feasible, and they support adequately powered studies investigating type II home sleep studies as a predictor of postoperative delirium and other important postsurgical outcomes.

The Impact of Obstructive Sleep Apnea on the Sleep of Critically Ill Patients

Obstructive sleep apnea is becoming increasingly prevalent in society and thus critical care practitioners need to be prepared to care for these patients in the intensive care unit. Preparation begins with equipping the critical care nurse with the knowledge necessary to provide interventions which can enhance patient outcomes and mitigate complications.

An Update on Obstructive Sleep Apnea for Atherosclerosis: Mechanism, Diagnosis, and Treatment

The occurrence and development of atherosclerosis could be influenced by intermittent hypoxia. Obstructive sleep apnea (OSA), characterized by intermittent hypoxia, is world-wide prevalence with increasing morbidity and mortality rates. Researches remain focused on the study of its mechanism and improvement of diagnosis and treatment. However, the underlying mechanism is complex, and the best practice for OSA diagnosis and treatment considering atherosclerosis and related cardiovascular diseases is still debatable. In this review, we provided an update on research in OSA in the last 5 years with regard to atherosclerosis. The processes of inflammation, oxidative stress, autonomic nervous system activation, vascular dysfunction, platelet activation, metabolite dysfunction, small molecule RNA regulation, and the cardioprotective occurrence was discussed. Additionally, improved diagnosis such as, the utilized of portable device, and treatment especially with inconsistent results in continuous positive airway pressure and mandibular advancement devices were illustrated in detail. Therefore, further fundamental and clinical research should be carried out for a better understanding the deep interaction between OSA and atherosclerosis, as well as the suggestion of newer diagnostic and treatment options.

Validation of the STOP-Bang questionnaire as a screening tool for obstructive sleep apnoea in patients with cardiovascular risk factors: a systematic review and meta-analysis

Introduction

Obstructive sleep apnoea (OSA) is highly prevalent in patients with cardiovascular risk factors and is associated with increased morbidity and mortality. This review presents the predictive parameters of the STOP-Bang questionnaire as a screening tool for OSA in this population.

Methods

A search of databases was performed. The inclusion criteria were: (1) use of the STOP-Bang questionnaire to screen for OSA in adults (>18 years) with cardiovascular risk factors; (2) polysomnography or home sleep apnoea testing performed as a reference standard; (3) OSA defined by either Apnoea–Hypopnoea Index (AHI) or Respiratory Disturbance Index; and (4) data on predictive parameters of the STOP-Bang questionnaire. A random-effects model was used to obtain pooled predictive parameters of the STOP-Bang questionnaire.

Results

The literature search resulted in 3888 articles, of which 9 papers met the inclusion criteria, involving 1894 patients. The average age of the included patients was 58±13 years with body mass index (BMI) of 30±6 kg/m², and 64% were male. The STOP-Bang questionnaire has a sensitivity of 89.1%, 90.7% and 93.9% to screen for all (AHI ≥5), moderate-to-severe (AHI ≥15) and severe (AHI≥30) OSA, respectively. The specificity was 32.3%, 22.5% and 18.3% and the area under the curve (AUC) was 0.86, 0.65 and 0.52 for all, moderate-to-severe and severe OSA, respectively.

Conclusion

The STOP-Bang questionnaire is an effective tool to screen for OSA (AHI≥5) with AUC of 0.86 in patients with cardiovascular risk factors.

Diagnostic accuracy and suitability of instruments that screen for obstructive sleep apnoea, insomnia and sleep quality in cardiac patients: a meta-analysis

BACKGROUND

A number of clinical guidelines recommend that all cardiac rehabilitation patients should be screened for potential sleep disorders with a validated screening instrument. There is currently no consensus on what specific tools should be used.

OBJECTIVE

To identify tools that are practical to use in the clinical environment and have high diagnostic accuracy.

METHODS

We systematically searched online databases to identify patient reported outcome instruments that have been used in published research studies to assess the likelihood of obstructive sleep apnoea (OSA) in cardiac patients. In studies that provided diagnostic data, these data were extracted and verified via an evidence-based diagnostic calculator. Where sufficient numbers of studies were available, a meta-analysis was conducted to determine pooled estimates of specificity, sensitivity and diagnostic odds ratios. Selected papers were qualitatively assessed using the Standards for Reporting Diagnostic accuracy studies (STARD).

RESULTS

Of the 21 instruments identified, six detected likelihood of OSA, two assessed daytime sleepiness, five assessed insomnia and eight examined sleep quality. A meta-analysis of 14 studies that assessed diagnostic accuracy of moderate OSA, revealed moderate sensitivity for the Berlin Questionnaire, Sens = 0.49 (95% CI 0.45-0.52) and good sensitivity for the Stop-BANG, Sens = 0.93 (95% CI 0.87-0.96) but poor specificity at standard cut-off criteria.

CONCLUSION

There are promising practical tools available to screen patients with OSA and other sleep disorders in cardiac rehabilitation settings, but specificity could be improved. Additional assessment of sleep quality may enhance prognostic ability with both OSA and insomnia screening.

Obstructive sleep apnea screening in young people: Psychometric validation of a shortened version of the STOP-BANG questionnaire using categorical data methods

BACKGROUND:

The STOP-BANG is an easily administrable questionnaire for the screening of obstructive sleep apnea in adults, which may be adapted for use by young people. Here, we assessed the psychometric properties of the STOP-BN, a shortened version of the STOP-BANG questionnaire, using categorical data methods.

METHODS:

Four hundred and three young people (age 20.71 ± 1.93 years) were selected by random sampling to participate in this cross-sectional study. Participants completed the STOP-BN, a tool for recording social and demographic characteristics, and the Epworth Sleepiness Scale (ESS), a measure of daytime sleepiness. The obtained data were analyzed using categorical data methods.

RESULTS:

A two-factor model was identified for the STOP-BN, using the Kaiser's criteria (eigenvalue >1) and the screen test. However, the parallel analysis based on minimum rank, and the cumulative variance criteria (>40%) identified an one-factor model. Factor loadings ranged from 0.364 to 0.745. The identified two-factor model showed acceptable fit as the reported goodness of fit index and weighted root mean square residual were in the ideal range, and the comparative fit index was close to the ideal range. Greatest lower bound to reliability for two factors of the STOP-BN was 0.67 and 0.67, indicating an acceptable internal consistency. A weak to a nonsignificant correlation between the ESS and the STOP-BN score was demonstrated, favoring STOP-BN's divergent validity.

CONCLUSION:

Categorical methods support the psychometric validity of the STOP-BN in the study population.

Screening for Obstructive Sleep Apnea in an Atrial Fibrillation Population: What's the Best Test?

Background

Among individuals with nonvalvular atrial fibrillation (AF), the prevalence of obstructive sleep apnea (OSA) can be as high as 85%. Continuous positive airway pressure treatment for moderate or severe OSA might improve AF outcomes and quality of life, so early identification of OSA might be of value. However, screening questionnaires for OSA are suboptimal because they are weighted toward tiredness and loud snoring, which might be absent in AF patients. NoSAS (Neck, Obesity, Snoring, Age, Sex) is a new OSA questionnaire that excludes these parameters. Acoustic pharyngometry (AP) is a potential novel screening technique that measures pharyngeal cross-sectional area, which is reduced in patients with OSA.

Methods

We prospectively compared the accuracy of the NoSAS, the STOP-BANG questionnaire (Snoring, Tiredness, Observed apnea, blood Pressure, Body mass index, Age, Neck circumference and Gender), and AP with home sleep apnea testing (HSAT) in consecutive patients with nonvalvular AF.

Results

Of 188 participants, 86% had OSA and 49% had moderate or severe OSA. Mean Epworth Sleepiness Scale scores were low; 5.9 (SD, 3.9), indicating that most participants were not sleepy. Receiver operating characteristic curves for comparisons of screening tests with HSAT showed suboptimal accuracy. For moderate plus severe and severe only groups respectively, the area under the curve was 0.50 (95% confidence interval [CI], 0.42-0.58) and 0.42 (95% CI, 0.34-0.52) for AP, 0.65 (95% CI, 0.58-0.73) and 0.63 (95% CI, 0.52-0.74) for the STOP-BANG questionnaire, and 0.68 (95% CI, 0.60-0.75) and 0.69 (95% CI, 0.59-0.80) for the NoSAS.

Conclusions

AP and NoSAS are not sufficiently accurate for screening AF patients for OSA. Because of the high rates of OSA in this cohort, the potential benefits of OSA treatment, and the suboptimal accuracy of current screening questionnaires, cardiologists should consider HSAT for AF patients.

The role of dry mouth in screening sleep apnea

PURPOSE OF THE STUDY

Effective screening questionnaires are essential for early detection of obstructive sleep apnea (OSA). The STOP-Bang questionnaire has high sensitivity but low specificity. Dry mouth is a typical clinical sign of OSA. We hypothesised that adding dry mouth in the STOP-Bang questionnaire would improve its specificity.

STUDY DESIGN

A survey of the incidence of dry mouth was performed in a general population group and suspected sleep apnea clinical population group. Patients with suspected OSA were assessed by laboratory polysomnography and STOP-Bang questionnaire was performed. Adding the option of dry mouth to the OSA screening questionnaire resulted in a new quesionnaire, where cut-off value, diagnostic efficacy and the predictive parameters (sensitivity, specificity, positive predictive value and negative predictive value) were explored.

RESULTS

(In the 912 general population group, the incidence of dry mouth in the snoring group (54.0%) was much higher than that in the non-snoring group (30.5%) (p<0.05). In 207 patients with suspected OSA, the incidence of dry mouth in the OSA group was much higher than that in the non-OSA group (p<0.05). The sensitivity and specificity of the STOP-Bang questionnaire were 88.8% and 23.7% for identifying OSA, and 92.2% and 23.1% for identifying moderate and severe OSA, respectively. Adding the option of dry mouth (dry mouth every morning) to the STOP-Bang questionare resulted in a new questionnaire (STOP-Bang-dry-mouth questionnarie) with 9 items. Its sensitivity and specificity were 81.70% and 42.10% for identifying OSA, and 89.10% and 42.30% for identifying moderate and severe OSA, respectively.

CONCLUSIONS

The dry mouth symptom correlated with snoring and sleep apnea. The specificity of the STOP-Bang questionnaire can be improved by integrating dry mouth. The diagnostic accuracy of the STOP-Bang-dry mouth questionnaire is yet to be further verified in prospective studies.

Sleep apnea screening instrument evaluation and novel model development and validation in the paroxysmal atrial fibrillation population

Standard sleep apnea (SA) screening instruments perform suboptimally in the atrial fibrillation (AF) population. We evaluated and optimized common OSA screening tools in the AF population. Participants of the Sleep Apnea and Atrial Fibrillation Biomarkers and Electrophysiologic Atrial Triggers (SAFEBEAT, NCT02576587) age (±5 years)-, sex-, body mass index (BMI ± 5 kg/m²)-matched case control study (n = 150 each group) completed concurrent questionnaires and overnight polysomnography. Models based on STOP, STOP-BANG, Berlin, NoSAS and Epworth Sleepiness Scale and also models with STOP-BANG predictors with resting heart rate or left atrial volume were constructed. “Best subset” analysis was used to select a predictor subset for evaluation. We assessed test performance for two outcome thresholds: apnea-hypopnea index (AHI) ≥ 5 and AHI ≥ 15. Paroxysmal AF participants were: 61.3 ± 12.1 years, BMI = 31.2 ± 6.6 kg/m² with median AHI = 11.8(IQR: 3.8, 24.5); 65 (43.3%) with AHI ≥ 15. Only STOP and STOP-BANG did not perform worse in AF relative to controls. For AHI ≥ 15, STOP-BANG (AUC 0.71, 95%CI:0.55–0.85) did not perform as well as NABS – a composite of neck circumference, age, and BMI as continuous variables and snoring (AUC 0.88, 95%CI:0.76–0.96). Optimal model for AHI ≥ 15 was NABS (sensitivity = 45%, specificity = 97%). For AHI ≥ 5, NABS was also the best performing (AUC 0.82, 95%CI:0.68–0.92, sensitivity = 78%, specificity = 67%). We identify a novel, short-item SA screening instrument for use in paroxysmal AF, i.e. NABS, with improved discriminative ability compared to commonly-used instruments. Further validation studies are needed to assess utility in other AF subtypes.

Trial registration: clinicaltrials.gov NCT02576587.

Screening for obstructive sleep apnea amongst patients with retinal vein occlusion

OBJECTIVE

To evaluate the prevalence and varying severity of obstructive sleep apnea (OSA) amongst those newly diagnosed with retinal vein occlusion (RVO), and screen patients with the use of 2 in-office-administered questionnaires validated against polysomnography.

DESIGN

Prospective cross-sectional study.

PARTICIPANTS

Consecutive adult patients (≥18 years of age) with a new diagnosis of RVO confirmed with intravenous fluorescein angiography were enrolled.

METHODS

The study was conducted at a tertiary academic centre between March 22, 2017, and April 7, 2018. Patients completed the Berlin and STOP-BANG questionnaires screening for OSA at presentation. Diagnostic test properties of the 2 questionnaires compared with polysomnography at a certified sleep laboratory centre as the gold standard for detection of OSA were calculated.

RESULTS

A total of 27 patients (37% females) with a mean (standard deviation) age of 69.6 (11.5) years completed the study. The diagnosis of OSA based on polysomnography was made in 96% (41% severe OSA) of patients with RVO. The Berlin questionnaire had a sensitivity of 43% (confidence interval [CI]: 22%-66%) and specificity of 67% (CI: 22%-96%). The STOP-BANG questionnaire had a sensitivity of 86% (CI: 64%-97%) and specificity of 50% (CI: 12%-88%).

CONCLUSIONS

Given the high prevalence of severe OSA amongst those with a new diagnosis of RVO, all patients should be strongly considered for polysomnography. The use of in-office questionnaires may aid in triaging urgency of referrals.

Driving with undiagnosed obstructive sleep apnea (OSA): High prevalence of OSA risk in drivers who experienced a motor vehicle crash

Objective: Obstructive sleep apnea (OSA) is a risk factor for motor vehicle crashes (MVC), and patients with diagnosed OSA have a higher likelihood of being involved in a traffic accident. OSA, however, is often underdiagnosed in the general population. The purpose of this study was to assess the risk of undiagnosed OSA among hospitalized patients involved in MVCs.Methods: This is a prospective, observational pilot study of adult trauma patients admitted to a Level 1 trauma center after being the driver in a MVC. Patients were administered the STOP-Bang to assess risk of OSA and were asked questions about the circumstances of the MVC. Patients with a STOP-Bang score 5-8 were considered to be at high risk for OSA. Differences between variables were assessed using independent t-tests and chi-square.Results: Eighty patients participated in the study, and 26% (n = 21) were considered to be at high risk for OSA based on the STOP-Bang score. Compared to patients at low and intermediate risk, patients at high risk for OSA were significantly older (p < .001), had longer hospitalization (p = .06), and were less likely to discharge home from the hospital (p = .01). Patients at moderate and high risk had higher rates of hospital readmission within 1 year of discharge, when compared to the low risk group. Eighty-four percent of all crashes involved a single occupant (driver) in the vehicle, 58% involved only a single vehicle, and 40% occurred on a rural road. There were no significant differences between risk groups for number of vehicles involved in the accident, location of the accident, or number of vehicle occupants.Conclusions: Results of this pilot study suggest that more than one-quarter of drivers hospitalized after motor vehicle crashes were at high risk for OSA. Diagnosed or undiagnosed OSA is a significant public health concern and an established risk factor for motor vehicle accidents. Standardized screening for risk of sleep apnea should be considered by primary care physicians when guiding patients on health and behavior decisions, particularly in regards to driving and road safety.

Update on obstructive sleep apnea for neuro-ophthalmology

PURPOSE OF REVIEW

Obstructive sleep apnea (OSA) is increasing in prevalence. The intermittent hypoxia of OSA has wide-ranging effects on a patient's general health outcomes. However, gold-standard investigations and treatment are expensive and a significant burden on patients. Therefore, OSA research remains focused on improving the means of diagnosing and treating OSA, in high-risk-associated conditions. This review is to provide an update on the advances in the field of OSA.

RECENT FINDINGS

There has been recent debate about the best practice for diagnosis and treatment of OSA. Further work has been done on conditions associated with OSA including hypertension, atherosclerosis, various types of dementia and intracranial aneurysms. Inflammatory and vascular risk factors associated with OSA increase stroke risk and alter outcomes for recovery. OSA should definitely be considered in patients presenting with nonarteritic anterior ischemic optic neuropathy, and perhaps those with intracranial hypertension.

SUMMARY

Newer home-based sleep-apnea testing can be implemented via physician clinics, with oversight by a certified sleep physician. Although continuous positive airway pressure (CPAP) is the gold-standard, management should include diet and exercise. It is important to test for, and treat OSA in patients with a range of neurological diseases. However, further studies into the long-term impact of CPAP on health outcomes are still needed.

The utility of STOP-BANG questionnaire in the sleep-lab setting

Polysomnography (PSG) is considered the gold standard in obstructive sleep apnea-hypopnea syndrome (OSAS) diagnostics, but its availability is still limited. Thus, it seems useful to assess patients pre-diagnostic risk for OSAS to prioritize the use of this examination. The purpose of this study was to assess positive (PPV) and negative (NPV) predictive values of the STOP BANG questionnaire (SBQ) in patients with presumptive diagnosis of OSAS. From a database of 1,171 (880 men) patients of a university based sleep center, 1,123 (847 men) met eligibility criteria and their SBQ scores were subject to the Bayesian analysis. The analysis of PPV and NPV was conducted at all values of SBQ for all subjects, but also separately for males and females, and for total sleep time (TS) and for sleep in the lateral position (LP). The probability of OSAS (AHI ≥ 5) and at least moderate OSAS (AHI ≥ 15) for TS was 0.766 and 0.516, while for LP the values were 0.432 and 0.289, respectively. Overall, due to low specificity, SBQ had low PPV for TS and LP. Negative test result (SBQ < 3) revealed NPV of 0.620 at AHI < 5 and 0.859 at AHI < 15 for TS, while in LP NPV values were 0.935 at AHI < 5 and 1.0 at AHI < 15, (n = 31), while SBQ < 4 generated NPV of 0.943 in LP (n = 105). SBQ did not change probabilities of OSAS to confirm or rebut diagnosis for TS. However, it is highly probable that SQB can rule out OSAS diagnosis at AHI ≥ 15 for LP.

Cardiac effects of CPAP treatment in patients with obstructive sleep apnea and atrial fibrillation

PURPOSE

Obstructive sleep apnea (OSA) has been recognized as an independent risk factor for the development and progression of atrial fibrillation (AF). We aimed to investigate the changes in heart rate and atrial and ventricular ectopy after continuous positive airway pressure (CPAP) treatment in patients with OSA and AF.

METHODS

Consecutive patients with AF underwent ambulatory sleep monitoring, and OSA was defined as an Apnea-Hypopnea-Index (AHI) ≥ 5/h. Treated patients completed in-laboratory CPAP titration study. A 24-h ECG Holter was performed at baseline and at 3 and 6 months after CPAP treatment.

RESULTS

One hundred patients (70% males) with AF were included in the final analysis. OSA was diagnosed in 85% of patients. There were no significant changes in mean 24-h heart rate in patients with paroxysmal or permanent AF at 3 and 6 months of treatment compared to baseline. In patients with paroxysmal AF (n = 29), atrial and ventricular ectopy counts/24 h significantly decreased at 3 months compared to baseline (median (IQR) 351 (2049) to 57 (182), P = 0.002; 68 (105) to 16 (133), P = 0.01 respectively). At 6 months follow-up, the atrial ectopy count/24 h significantly decreased in patients with paroxysmal AF compared to baseline (median (IQR) 351 (2049) to 31 (113), P = 0.016, n = 14). In patients with permanent AF (n = 15), there was a significant reduction in ventricular ectopy count/24 h at 3 months compared to baseline (median (IQR) 100 (1116) to 33 (418), P = 0.02).

CONCLUSIONS

There is a significant decrease in atrial and ventricular ectopy count/24 h in patients with AF and OSA at 3 and 6 months of CPAP treatment compared to baseline.

A narrative review of interventions for improving sleep and reducing circadian disruption in medical inpatients

Sleep and circadian disruptions are frequently observed in patients across hospital wards. This is alarming, since impaired nocturnal sleep and disruption of a normal circadian rhythm can compromise health and disturb processes involved in recovery from illness (eg, immune functions). With this in mind, the present narrative review discusses how patient characteristics (sleep disorders, anxiety, stress, chronotype, and disease), hospital routines (pain management, timing of medication, nocturnal vital sign monitoring, and physical inactivity), and hospital environment (light and noise) may all contribute to sleep disturbances and circadian misalignment in patients. We also propose hospital-based strategies that may help reduce sleep and circadian disruptions in patients admitted to the hospital.

Sleep-disordered breathing in patients with cardiovascular diseases cannot be detected by ESS, STOP-BANG, and Berlin questionnaires

Sleep-disordered breathing (SDB) is highly prevalent in patients with cardiovascular diseases (CVD) and associated with poor outcome. At least 50% of heart failure (HF) patients present with SDB, equally divided in obstructive sleep apnea (OSA) and central sleep apnea (CSA). CVD patients with SDB do not always present with typical SDB symptoms. Therefore, we asked whether established questionnaires allow for the reliable detection of SDB. In this prospective cohort study, 89 CVD patients (54 male, 59 ± 15 years, BMI 30 ± 6 kg/m²) in stable clinical state underwent an ambulatory polygraphy. SDB was defined as an apnea-hypopnea index (AHI) ≥ 15/h. We evaluated the Epworth Sleepiness Scale (ESS), STOP-BANG and Berlin questionnaires as well as anthropometric data and comorbidities regarding their ability to predict SDB. The ESS showed no correlation with SDB. The sensitivity of the Berlin Questionnaire to detect SDB was 73%, specificity was 42%. The STOP-BANG questionnaire showed a sensitivity of 97% while specificity was 13%. Coronary heart disease and/or history of myocardial infarction, hyperuricemia and age significantly contributed to a logistic regression model predicting presence of SDB. However, our regression model explains only 36% of the variance regarding the presence or absence of SDB. The approach to find variables, which would allow an early and reliable differentiation between patients with CVD and coexistence or absence of SDB, failed. Thus, as CVD patients show a high SDB prevalence and poor outcome, only a systematic screening based on measures of respiration-related parameters (i.e., respiratory flow, blood oxygen saturation, etc.) allows for a reliable SDB assessment.