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• W2892087904 abstract "To the Editor In this study, Karimi et al1 investigate the association of the risk of obstructive sleep apnea (OSA) as assessed by the Snoring, Tiredness, Observed apnea, high blood Pressure, Body mass index (BMI), Age, Neck circumference, and Gender (STOP-BANG) screening questionnaire and new-onset postcardiac surgery atrial fibrillation (PCSAF) in patients mostly undergoing valvular surgery. The authors should be commended for this work. There are several points as below that are noteworthy. 1. Although the use of the STOP-BANG questionnaire for screening of OSA has been validated, this does not replace the benefit of the granularity of data offered by polysomnography in terms of characterizing degree of OSA physiology aberration, central sleep apnea, degree of hypoxia, etc. 2. While the STOP-BANG questionnaire has been well validated compared to other OSA screening questionnaires, standard screening instruments have suboptimal performance in the cardiac population. For instance, those with cardiac disease are likely to have enhanced sympathetic activation and less likely to have symptoms of sleepiness; therefore, there is a potential for underestimation of OSA risk particularly when using screening tools that incorporate sleepiness symptoms. 3. Although a STOP-BANG cutoff of 4 was used in the sensitivity analyses, it is unclear why the standard threshold of 3 was not used to define low versus high OSA risk. Considering the STOP-BANG as a continuous variable in this study is not ideal because there may be different weighting of factors in terms of importance in OSA predictive ability. 4. Previous work, although limited by sample size, has shown an association of severity of OSA by Apnea-Hypopnea Index and oxygen desaturation index and higher odds of PCSAF in unadjusted analyses, but this association was mitigated after consideration of obesity defined by the body mass index (BMI). On further inspection, it was identified that the association of severity of OSA and higher odds of PCSAF was evident in more obese patients (BMI, >32 kg/m2) only, suggesting the possible role of OSA-related nonhypoxic mechanisms in atrial arrhythmogenecity in the postoperative period.2 Given the inclusion of BMI in the STOP-BANG assessment, it was not possible to effectively examine the influence of obesity on the association of OSA risk and PCSAF in this study. 5. The investigators then explore association between STOP-BANG and duration of postoperative mechanical ventilation, risk of reintubation, and intensive care unit length of stay, but rare outcomes were reported indicating either better postoperative monitoring in cardiac surgical patients or again a possible lack of association between severe hypoxia and new-onset PCSAF. We know, for example, that patients undergoing cardiac surgery routinely get preoperative arterial blood gases; echocardiograms are always assessed for pulmonary hypertension in contrast to patients who undergo noncardiac surgery. Therefore, the latter group can potentially be at higher risk of respiratory complications and new-onset atrial fibrillation (AF). 6. There are some challenges with predicting new-onset PCSAF inherent to the definition of this outcome of interest. Researchers are divided between excluding patients with any history of previous AF, no AF 30 days before surgery, or just normal sinus rhythm at the time of surgery. The Society for Thoracic Surgeons in its 2012 update allows to code for postoperative AF if a patient went to the operating room in normal sinus rhythm and then developed postoperative AF requiring treatment.3 The authors in this study used the Society for Thoracic Surgeons database and appropriately excluded those with previous history of AF. 7. Whether the presence of OSA is the common link that predisposes to higher risk of PCSAF is unknown, but the notion of a mediator or an explanatory variable has been entertained. In this study, the outcome of PCSAF was adjusted for moderate to severe left atrial dilation found in ≥50% of the cohort. Left atrial volume in the obese has been thought of as a potential common link in the development of PCSAF after cardiac surgery, but this area remains understudied. Investigation of sleep-disordered breathing and postcardiac surgery operative risk is an important area of focus as corroborated by the interesting findings of the authors. Future studies should target systematic (to minimize bias) prospective examination of sleep apnea ascertained via objective means to obtain a better sense of the influence of OSA on these outcomes and, as appropriate, inform targetable interventions to examine the impact of the reversal of OSA pathophysiology on postoperative morbidity and mortality. Roop Kaw, MDDepartments of Hospital Medicine and Outcomes Research, AnesthesiologyCleveland ClinicCleveland, Ohio[email protected] Reena Mehra, MDCenter for Sleep Disorders, Respiratory InstituteHeart and Vascular InstituteDepartment of Molecular CardiologyLerner Research InstituteCleveland ClinicCleveland, Ohio" @default.
• W2892087904 created "2018-09-27" @default.
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• W2892087904 date "2018-11-01" @default.
• W2892087904 modified "2023-09-28" @default.
• W2892087904 title "Obstructive Sleep Apnea and Risk of Postcardiac Surgery Atrial Fibrillation" @default.
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• W2892087904 doi "https://doi.org/10.1213/ane.0000000000003749" @default.
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