Preoperative sleep apnea screening protocol reduces medical emergency team activation in patients with atrial fibrillation.

STUDY OBJECTIVES: The association of in-hospital medical emergency team activation (META) among patients with atrial fibrillation (AF) at risk for obstructive sleep apnea (OSA) is unclear. This study evaluates the performance of the DOISNORE50 sleep questionnaire as an OSA screener for patients with AF and determines the prevalence of META among perioperative patients with underlying AF who have a diagnosis or are at risk for OSA. METHODS: A prospective perioperative cohort of 2,926 patients with the diagnosis of AF was assessed for DOISNORE50 questionnaire screening. Propensity-score matching was used to match patients' physical characteristics, comorbidities, length of stay, and inpatient continuous positive airway pressure device usage. META and intensive care unit admissions during the surgical encounter, 30-day hospital readmissions, and 30-day emergency department visits were evaluated. RESULTS: A total of 1,509 out of 2,926 AF patients completed the DOISNORE50 questionnaire and were enrolled in the OSA safety protocol. Following propensity-score matching, there were reduced adjusted odds of META in the screened group of 0.69 (95% confidence interval: 0.48-0.98, P < .001) in comparison to the unscreened group. The adjusted odds of intensive care unit admissions and emergency department visits within 30 days of discharge were statistically lower for the screened group compared with the unscreened group. CONCLUSIONS: Among perioperative AF patients, evidence supports DOISNORE50 screening and implementation of an OSA safety protocol for reduction of META. This study identified decreased odds of META, intensive care unit admissions, and emergency department visits among the screened group. The high-risk and known OSA group showed reduced odds of META following the implementation of an OSA safety protocol. CITATION: Saha AK, Sheehan KN, Xiang KR, et al. Preoperative sleep apnea screening protocol reduces medical emergency team activation in patients with atrial fibrillation. J Clin Sleep Med. 2024;20(5):783-792.

Pulmonary vein isolation with adjunctive left atrial ganglionic plexus ablation for treatment of atrial fibrillation: a meta-analysis of randomized controlled trials.

BACKGROUND: Adjunctive ganglionic plexus (GP) ablation may increase the efficacy of pulmonary vein isolation (PVI) for treatment of atrial fibrillation (AF). Prior meta-analyses examining PVI with adjunctive GP ablation have included non-randomized trials and have included trials evaluating thorascopic epicardial ablation. The objective of this study is to perform a meta-analysis of randomized controlled trials (RCTs) comparing endocardial catheter-based PVI to PVI with adjunctive GP ablation. METHODS: Summary odds ratio (OR) and 95% confidence intervals (CIs) were calculated. Heterogeneity was assessed with I2 values. Sub-group analysis was performed comparing arrhythmia recurrence between patients with paroxysmal versus persistent AF at trial baseline. Meta-regressions were performed with mean left atrial diameter and left ventricular ejection fraction at trial baseline as the moderator variables. RESULTS: Five RCTs were identified including 814 patients: 406 PVI + GP ablation and 408 PVI alone. The mean age of participants was 56.5 years and 74.7% were male. Four of these trials evaluated catheter-based endocardial ablation for a total of 574 patients: 289 PVI + GP ablation and 285 PVI alone. The odds of arrhythmia recurrence in patients undergoing adjunctive GP ablation with PVI compared with PVI alone were a reduced: odds ratio (OR) 0.58, 95% confidence interval (CI) 0.41-0.82, I2 = 40.2%. In the subgroup analysis, the odds of arrhythmia recurrence with adjunctive GP ablation were reduced in those with paroxysmal AF (OR 0.396, 95% CI 0.23-0.69, I2 = 0%). A non-significant trend to reduced arrhythmia recurrence was also observed in those with persistent AF (OR 0.726, 95% CI 0.475-1.112, I2 = 0%). When performing the meta-regression, increased left atrial diameter was associated with decreased treatment effect of adjunctive GP ablation (R2 index = 1.0, I2 = 0%). CONCLUSIONS: The addition of GP ablation to PVI was associated with reduced arrhythmia recurrence. Adjunctive GP ablation was more effective in paroxysmal AF and in patients with smaller atria. Larger RCTs are needed to confirm the efficacy of GP + PVI ablation.

Serum Cotinine and Silent Myocardial Infarction in Individuals Free from Cardiovascular Disease.

Serum cotinine is a sensitive and specific marker of tobacco exposure, including second-hand smoke exposure. We sought to explore the association of tobacco exposure determined by serum cotinine with electrocardiographic silent myocardial infarction (SMI). A total of 7,006 participants (59.0 ± 13.3 years; 52.6% women, 49.7% non-Hispanic whites) without cardiovascular disease from the Third National Health and Nutrition Examination Survey (NHANES III) were included in this analysis. SMI was defined as electrocardiographic evidence of MI in the absence of a history of MI. Multivariable logistic regression analysis was used to examine the association between SMI and serum cotinine tertiles. SMI was detected in 114 (1.63%) of the participants. The prevalence of SMI was higher among those with higher levels of serum cotinine (SMI prevalence was 1.25%, 1.49%, and 2.14% across serum cotinine lower [0.03 to 0.12 ng/ml], middle [0.12 to 1.39 ng/ml], and higher [1.40 to 1890 ng/ml] tertiles, respectively). In a model adjusted for potential confounders, participants within the highest serum cotinine tertile had significantly greater odds of SMI (odds ratio [95% confidence interval]: 2.51 [1.55 to 4.08]) compared with those with serum cotinine levels in the first tertile. Each 10 ng/ml increase in serum cotinine levels was associated with a 2% (p <0.0001) increase in the prevalence of SMI. This association was stronger in white than nonwhite participants (interaction p value = 0.05). In conclusion, elevated serum cotinine levels are associated with SMI. These findings further highlight the risk associated with passive and active smoking on cardiovascular health and underscore the potential utility of serum cotinine in identifying those at risk.

A review of important medical and surgical considerations for obese patients undergoing arthroscopic surgery.

Obesity represents a unique challenge in orthopaedic surgery, the impact of which is seen through all phases of injury: in the development of disease, during the operative procedure, and throughout the rehabilitation period. Given the high prevalence of obesity in the United States and around the world, this patient population represents a substantial proportion of patients in need of orthopedic care. The effects of this disease constrain both medical and financial resources. For obese patients undergoing orthopedic procedures, adequate steps must be taken to minimize the risks that occur before, during, and after surgical intervention. This literature review discusses the impact of obesity on arthroscopic procedures, with a focus on procedures involving the shoulder, hip, and knee. The management of obese patients during the perioperative period should address the specific concerns relating to these patients. Obesity is a risk factor for numerous comorbidities, is associated with surgical complications, and is a predictor of poor functional outcomes following arthroscopy. Efforts to minimize the negative impact of obesity on arthroscopic procedures are crucial.

Mechanistic characterization of nitrite-mediated neuroprotection after experimental cardiac arrest.

Nitrite acts as an ischemic reservoir of nitric oxide (NO) and a potent S-nitrosating agent which reduced histologic brain injury after rat asphyxial cardiac arrest (ACA). The mechanism(s) of nitrite-mediated neuroprotection remain to be defined. We hypothesized that nitrite-mediated brain mitochondrial S-nitrosation accounts for neuroprotection by reducing reperfusion reactive oxygen species (ROS) generation. Nitrite (4 µmol) or placebo was infused IV after normothermic (37°C) ACA in randomized, blinded fashion with evaluation of neurologic function, survival, brain mitochondrial function, and ROS. Blood and CSF nitrite were quantified using reductive chemiluminescence and S-nitrosation by biotin switch. Direct neuroprotection was verified in vitro after 1 and 4 h neuronal oxygen glucose deprivation measuring neuronal death with inhibition studies to examine mechanism. Mitochondrial ROS generation was quantified by live neuronal imaging using mitoSOX. Nitrite significantly reduced neurologic disability after ACA. ROS generation was reduced in brain mitochondria from nitrite- versus placebo-treated rats after ACA with congruent preservation of brain ascorbate and reduction of ROS in brain sections using immuno-spin trapping. ATP generation was maintained with nitrite up to 24 h after ACA. Nitrite rapidly entered CSF and increased brain mitochondrial S-nitrosation. Nitrite reduced in vitro mitochondrial superoxide generation and improved survival of neurons after oxygen glucose deprivation. Protection was maintained with inhibition of soluble guanylate cyclase but lost with NO scavenging and ultraviolet irradiation. Nitrite therapy results in direct neuroprotection from ACA mediated by reductions in brain mitochondrial ROS in association with protein S-nitrosation. Neuroprotection is dependent on NO and S-nitrosothiol generation, not soluble guanylate cyclase.

Depression and rehospitalization following acute myocardial infarction.

BACKGROUND: Elevated scores on depression symptom questionnaires predict rehospitalization after acute myocardial infarction (AMI). Whether the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, depressive disorders predict rehospitalization after AMI is unknown. METHODS AND RESULTS: Participants (n=766) in an Enhancing Recovery and Coronary Heart Disease ancillary study were classified by diagnostic interview as having no depression, minor depression, or major depression after AMI. Cardiac rehospitalizations were tracked for up to 42 months. Cox proportional hazards regression was used to model the effect of depressive disorder on time to first cardiac rehospitalization, controlling for mortality risk factors. Logistic regression was used to compare the accuracy with which rehospitalization could be predicted by depression diagnosis or by the Beck Depression Inventory (BDI). Secondary analyses examined the effects of depression on the cumulative number of all-cause rehospitalizations, length of stay, and emergency department visits. Compared with patients without depression, patients with either minor or major depression were hospitalized sooner (minor depression adjusted hazard ratio, 2.22; 95% CI, 1.59-3.08; P<0.001; major depression adjusted hazard ratio, 2.54; 95% CI, 1.84-3.53; P<0.001), had more hospitalizations (minor, P<0.001; major, P<0.001) and emergency department visits (minor, P=0.003; major, P<0.001), and spent more days in the hospital (minor, P<0.001; major, P<0.001). The interview and questionnaire methods of assessing depression did not significantly differ in their overall accuracy of predicting rehospitalization. CONCLUSIONS: Depressive disorders increase the risk of rehospitalization after AMI. Future work should focus on developing multivariable models to predict risk of rehospitalization after AMI, and depression should be included in these.