Sinus Tachycardia: a Multidisciplinary Expert Focused Review.

Sinus tachycardia (ST) is ubiquitous, but its presence outside of normal physiological triggers in otherwise healthy individuals remains a commonly encountered phenomenon in medical practice. In many cases, ST can be readily explained by a current medical condition that precipitates an increase in the sinus rate, but ST at rest without physiological triggers may also represent a spectrum of normal. In other cases, ST may not have an easily explainable cause but may represent serious underlying pathology and can be associated with intolerable symptoms. The classification of ST, consideration of possible etiologies, as well as the decisions of when and how to intervene can be difficult. ST can be classified as secondary to a specific, usually treatable, medical condition (eg, pulmonary embolism, anemia, infection, or hyperthyroidism) or be related to several incompletely defined conditions (eg, inappropriate ST, postural tachycardia syndrome, mast cell disorder, or post-COVID syndrome). While cardiologists and cardiac electrophysiologists often evaluate patients with symptoms associated with persistent or paroxysmal ST, an optimal approach remains uncertain. Due to the many possible conditions associated with ST, and an overlap in medical specialists who see these patients, the inclusion of experts in different fields is essential for a more comprehensive understanding. This article is unique in that it was composed by international experts in Neurology, Psychology, Autonomic Medicine, Allergy and Immunology, Exercise Physiology, Pulmonology and Critical Care Medicine, Endocrinology, Cardiology, and Cardiac Electrophysiology in the hope that it will facilitate a more complete understanding and thereby result in the better care of patients with ST.

The differential impact of respiratory event scoring criteria on CPAP eligibility in women and men.

STUDY OBJECTIVES: Obstructive sleep apnea is more prevalent and severe in men than women. The American Academy of Sleep Medicine offers 2 definitions for scoring hypopneas: "acceptable" = associated with a ≥ 4% oxygen desaturation, adopted by Center for Medicare and Medicaid Services (CMS), and "recommended" = associated with a ≥ 3% oxygen desaturation and/or an arousal. We hypothesized that CMS vs American Academy of Sleep Medicine scoring criteria would differentially impact continuous positive airway pressure eligibility in women and men. METHODS: We conducted a retrospective review of adult diagnostic in-lab polysomnography at an urban academic institution. All polysomnographies were scored by both CMS and American Academy of Sleep Medicine scoring criteria, and an analysis by sex was performed that considered demographics and other polysomnography variables. RESULTS: Of 969 polysomnographies reviewed, 674 (69.6%) were in women. Women were younger (51.5 vs 53.3 years old) and had a higher body mass index (38.6 kg/m2 vs 33.8 kg/m2) but had similar Epworth Sleepiness Scale scores compared to men. The odds of an American Academy of Sleep Medicine apnea-hypopnea index > 5 events/h being missed by CMS scoring in women was 1.89 (95% confidence interval: 1.40-2.53; P < .001) compared to men and increased to 6.87 among women 40-60 years of age with a body mass index ≥ 40 kg/m2. After controlling for age, body mass index, % rapid eye movement sleep, and mean oxygen saturation, the sex effect remained significant (odds ratio 1.87; 95% confidence interval: 1.36-2.58; P < .001). CONCLUSIONS: CMS scoring criteria imparts a sex bias toward women, potentially resulting in denial of therapy to symptomatic women with obstructive sleep apnea. Larger, prospective cohort studies are needed to confirm these findings. CITATION: Khalid F, Ayache M, Auckley D. The differential impact of respiratory event scoring criteria on CPAP eligibility in women and men. J Clin Sleep Med. 2021;17(12):2409-2414.

High Interrater Reliability of Overnight Pulse Oximetry Interpretation Among Inexperienced Physicians Using a Structured Template.

STUDY OBJECTIVES: To assess the interrater reliability and accuracy of overnight pulse oximetry (OPO) interpretations by pulmonary fellows using a comprehensive structured template and after a brief educational session. METHODS: Using the template, four pulmonary and critical care (PCC) fellows interpreted OPO saturation waveforms and parameters extracted from 50 adult consecutive in-laboratory sleep studies. The template included three saturation parameters (mean saturation, oxygen desaturation index [ODI], and cumulative desaturation time) and description of the saturation waveform. A scoring system was proposed combining waveform characteristics and ODI to determine the suspicion for moderate to severe sleep apnea. Waveform description and mean saturation determined the suspicion for cardiopulmonary disease (CPD). Cumulative desaturation time determined need for oxygen prescription. Apnea-hypopnea index was extracted from the sleep study results. RESULTS: The overall interrater reliability for final recommendations (sleep apnea suspicion, presence of CPD, and oxygen prescription) was high (kappa = .81, 95% confidence interval [CI] .76-.88). Good agreement was noted in CPD evaluation and suspicion of moderate to severe sleep apnea (kappa = .70, 95% CI .46-.86 and kappa = .65, 95% CI .56-.77 respectively). The interrater reliability for oxygen prescription was in an excellent range (kappa = .98, 95% CI .91-1.00). The accuracy of a high sleep apnea suspicion score in detecting apnea-hypopnea index ≥ 15 events/h ranged from 88.0% to 94.0% (sensitivity 91.3% to 95.7%, specificity 81.5% to 92.6%). Desaturations due to CPD were identified by 75% of the raters as desaturations due to conditions other than sleep apnea. CONCLUSIONS: A structured template for OPO interpretation can produce a high interrater agreement and good accuracy, and make it a reliable clinical tool. COMMENTARY: A commentary on this article appears in this issue on page 497.

Massive hemorrhage after inspection bronchoscopy for carcinoid tumor.

Carcinoid tumor is a neuroendocrine tumor that can arise in the bronchial tree and can be hypervascular. Here we describe a case of bronchial carcinoid tumor in a 34-year-old previously healthy male who presented with hemoptysis and right lung mass. Inspection bronchoscopy revealed bronchus intermedius endobronchial lesion and was complicated by urgent intubation and placement of endobronchial blocker for massive hemorrhage. Subsequent angiography with embolization of the bronchial artery supplying the mass resulted in control of bleeding. While massive hemorrhage has been described with biopsy of bronchial carcinoid tumor, this case suggests that careful planning for inspection bronchoscopy is needed when carcinoid tumor is suspected.

Pulmonary Hemorrhage following Edge-to-Edge Mitral Valve Repair.

Mitral valve repair with the MitraClip device has emerged as an effective treatment option for patients with severe mitral regurgitation and contraindications for surgical interventions. While the procedure is not known to cause pulmonary complications, we describe two cases of pulmonary hemorrhage following percutaneous mitral valve repair. The patients did well with supportive care and reinitiation of anticlotting agents was well tolerated after resolution of bleeding.