Screening For Sleep-disordered Breathing Research Articles

Association between sleep-disordered breathing and post-stroke fatigue in patients with ischemic stroke

ObjectivesPost-stroke fatigue (PSF) is common and often disabling. Sleep-disordered breathing (SDB) is highly prevalent among stroke survivors and can cause fatigue. We explored the relationship between SDB and PSF over time. Materials and MethodsIschemic stroke (IS) patients within the BASIC project were offered SDB screening with a well-validated cardiopulmonary sleep apnea test at 0, 3-, 6-, and 12-months post-stroke. The primary exposure was the respiratory event index (REI; sum of apneas plus hypopneas per hour). The primary outcome was PSF, measured by the SF-36 vitality scale. Associations between REI and PSF were evaluated using linear regression including time-by-REI interactions, allowing the effect of REI to vary over time. ResultsOf the 411 IS patients who completed at least one outcome interview, 44 % were female, 61 % Mexican American (MA), 26 % non-Hispanic white, with a mean age of 64 (SD 10). Averaged across timepoints, REI was not associated with PSF. In a time-varying model, higher REI was associated with greater PSF at 3-months (β = 1.75, CI = 0.08, 3.43), but not at 6- or 12-months. Across timepoints, female sex, depressive symptoms, and comorbidity burden were associated with greater PSF, whereas MA ethnicity was associated with less PSF. ConclusionsHigher REI was associated with modestly greater PSF in the early post-stroke period, but no association was observed at 6 months and beyond. SDB may be a modest modifiable risk factor for early PSF, but its treatment is unlikely to have a substantial impact on long-term PSF. MA ethnicity seems to be protective against PSF.

Screening for Sleep Disordered Breathing in Three Distinct Neurological Diseases in the Bulgarian Population

Sleep disordered breathing (SDB) is a common medical problem in the general population. Neurological disorders such as ischemic stroke (IS), myasthenia gravis (MG), or multiple sclerosis (MS) seem to be of higher risk of SDB. Nevertheless, the implementation of screening for SDB in such disorders has not been well studied. Therefore, the aim of this study was to explore screening parameters for SDB in IS, MG and MS, in our region. We included prospectively patients with diagnosed IS, MG and MS. Psychometric tools such as the Epworth Sleepiness Scale (ESS), the STOP-BANG, and the Berlin questionnaire were implemented. For the respiratory screening portable recording device was used. Seventy-two patients, 25 with IS (mean age 66.3 years), 24 with MG (mean age 47.9 years), and 23 with MS (mean age 40.1 years) were enrolled. Basic anthropometric parameters such as BMI, neck and waist circumference were higher in IS than in MG and MS ($$p<0.001$$). The ESS scores were 5.5±3.2 for IS, 5.6±3.3 for MG, and 5.9±4.5 for MS, but without significant difference between the groups. Contrariwise, STOP-BANG scores in IS were 4.8±1.3, significantly higher ($$p<0.0001$$) than both MG (2.1±1.4) and MS (1.2±0.9). A high risk for OSA in BQ was calculated in 68% of IS, much higher ($$p<0.0001$$) than in MG (33.3%) and in MS (13%). In the respiratory screening, the mean apnea-hypopnea index in the IS group (20±18.3) was statistically higher than in MG (8.1±12.7, $$p<0.005$$), and in MS patients (2.3±4.9, $$p<0.001$$). Oxygen desaturation index in IS (19.3±19) differed statistically from the one in MG (8.1±12.9, $$p<0.005$$), and in MS (2.6±5.5, $$p<0.001$$). The oxygen saturation (SO2) showed difference only between IS and MS in all three measured values – baseline SO2 ($$p<0.001$$), median SO2 ($$p<0.05$$) and lowest SO2 ($$p<0.05$$). IS, MG and MS, as distinct neurological entities, show different clinical profiles with respect to screening for SDB. These should be taken into consideration in the individual evaluation for sleep disordered breathing.

Sleep apnea in patients undergoing coronary artery bypass grafting: Impact on perioperative outcomes.

Sleep-disordered breathing is common in patients with coronary artery disease undergoing coronary artery bypass grafting. Sleep-disordered breathing is associated with increased perioperative morbidity, arrhythmias (e.g. atrial fibrillation) and mortality. This study investigated the impact of sleep-disordered breathing on the postoperative course after coronary artery bypass grafting, including development of atrial fibrillation. This prospective single-centre cohort study included adults undergoing coronary artery bypass grafting. All were screened for sleep-disordered breathing (polygraphy) and atrial fibrillation (electrocardiogram) preoperatively; those with known sleep-disordered breathing or atrial fibrillation were excluded. Endpoints included new-onset atrial fibrillation, duration of mechanical ventilation, time in the intensive care unit, and postoperative infection. Regression analysis was performed to identify associations between sleep-disordered breathing and these outcomes. A total of 508 participants were included (80% male, median age 68 years). The prevalence of any (apnea-hypopnea index ≥ 5 per hr), moderate (apnea-hypopnea index = 15-30 per hr) and severe (apnea-hypopnea index > 30 per hr) sleep-disordered breathing was 52.9%, 9.3% and 10.2%, respectively. All-cause 30-day mortality was 0.98%. After adjustment for age and sex, severe sleep-disordered breathing was associated with longer respiratory ventilation support (crude odds ratio [95% confidence interval] 5.28 [2.18-12.77]; p < 0.001) and higher postoperative infection rates (crude odds ratio 3.32 [1.45-7.58]; p < 0.005), but not new-onset atrial fibrillation or mortality. New-onset atrial fibrillation was significantly associated with postoperative infection and prolonged hospital stay. The significant associations between sleep-disordered breathing and several adverse outcomes after coronary artery bypass grafting support the need for preoperative sleep-disordered breathing screening in individuals undergoing cardiac surgery.

Abstract 140: Sleep-Disordered Breathing Shortly After Stroke Does Not Predict Post-Stroke Fatigue at 3-months

Background: Post-stroke fatigue (PSF) is a common and often disabling symptom, the causes of which are poorly understood. Sleep-disordered breathing (SDB) is highly prevalent among stroke survivors, and can cause fatigue. We examined whether SDB measured shortly after stroke predicted PSF at 3-months, and thus whether SDB might represent an intervention target for the treatment/prevention of PSF. Methods: Ischemic stroke (IS) patients within the Brain Attack Surveillance in Corpus Christi (BASIC) project were identified through active and passive surveillance, and were offered SDB screening with a well-validated cardiopulmonary sleep apnea testing device. The primary exposure was the respiratory event index (REI; sum of apneas plus hypopneas per hour of recording), measured shortly after stroke. The primary outcome was PSF, measured 3-months post-stroke, using the SF-36 vitality scale. Linear regression was used to evaluate the association between baseline REI and 3-month PSF, adjusting for clinical and sociodemographic factors listed in the Table, which were obtained from chart review and interviews. Results: A total of 355 IS participants completed baseline SDB screening and 3-month PSF assessments from May 2016 to December 2019. Participants were 44% female, 60% Mexican American (MA), and had a median NIHSS of 2 (IQR: 1-5). Multivariable regression model results are presented in the Table. No association between baseline REI and 3-month PSF was observed in unadjusted (β=0.95, 95% CI=-1.16, 3.05) or fully adjusted models (β=0.66, 95% CI=-1.40, 2.73). In the fully adjusted model, female sex and depression were associated with greater fatigue, while older age and MA ethnicity were associated with less fatigue. Conclusions: SDB in the immediate post-stroke period, at least in this predominantly MA sample, does not predict PSF at 3-months. Though identification and treatment of post-stroke SDB may be important, these efforts are unlikely to impact PSF.

Occurrence of sleep-disordered breathing in children with pulmonary hypertension.

Obstructive sleep apnea (OSA) has been associated with pulmonary hypertension (PH) through a complex and bidirectional relationship. The prevalence of OSA and other forms of sleep-disordered breathing (SDB) among children with PH is not well understood. A better understanding could help elucidate contributing factors for PH, guide diagnostic testing, and inform therapies. We therefore determined the proportion of SDB codiagnosis and OSA risk factors among a cohort of children with PH. Retrospective chart review was performed for children 0-21 years old with PH who underwent polysomnography (PSG) between 1 January2010 and 31 August2020. The primary outcome was OSA occurrence and risk based on demographics, diagnoses, and PH classification. The secondary outcome was occurrence and risk of other SDB diagnoses based on PH classification. Among 89 children identified, diagnoses included OSA (N = 79, 89%), central sleep apnea (N = 11, 12%), sleep-related hypoventilation (N = 6, 7%), and non-apneic hypoxemia (N = 28, 31%). Trisomy 21 diagnosis (N = 38, 43%) was associated with increased OSA risk (RR: 1.24, 95% CI: [1.09-1.42]) and age >12 months at PSG was associated with decreased OSA risk (N = 52, 58%, RR: 0.60, 95% CI: [0.45-0.81]). There was no difference in SDB risk based on Group 1 (N = 56, 63%) or Group 3 (N = 33, 37%) PH and no difference in OSA severity based on demographics and diagnoses. OSA was diagnosed among a majority of children with PH, and other SDB diagnoses were identified in a significant proportion of children. These findings support routine screening for SDB with PSGin children with PH.

Association of hypoxic burden metrics with cardiovascular outcomes in heart failure and sleep-disordered breathing.

Heart failure (HF) and sleep-disordered breathing (SDB) frequently coexist. We aimed to compare the prognostic value of different nocturnal hypoxic burden metrics in hospitalized HF patients. HF patients underwent polygraphy screening for SDB in this prospective cohort. Hypoxic burden metrics assessed using pulse oximetry included time<90% oxygen saturation (T90), proportion of total recording time<90% oxygen saturation (TRT90), oxygen desaturation index (ODI), and mean oxygen saturation (meanSO2 ). The prespecified endpoints were the composite of cardiovascular death or admission for worsening HF. This study included 764 hospitalized HF patients, 16.5% and 36.6% of whom had obstructive and central sleep apnoea, respectively. With a median follow-up time of 2.2years, endpoint events occurred in 410 (53.7%) patients. In univariate and multivariate analyses, T90, TRT90, and meanSO2 were substantially associated with the composite outcome, whereas ODI was not. After multivariate Cox model adjustment, patients with 5.0≤T90≤52.0min [hazard ratio (HR) 1.32, 95% confidence interval (CI): 1.02-1.71, P=0.034] or T90>52.0min (HR 1.56, 95% CI: 1.21-2.02, P=0.001) had a greater risk of the composite outcome than those with T90<5.0min. The TRT90 and T90 results were similar. Compared with meanSO2 >95%, meanSO2 <93% (HR 1.47, 95% CI: 1.16-1.88, P=0.002) was correlated with adverse outcomes. The hypoxic burden metrics T90, TRT90, and meanSO2 , but not ODI, were independent predictors of cardiovascular death or readmission for worsening HF. Indicators of duration and severity, not just the frequency of nocturnal hypoxaemia, should be valued and considered for intervention to improve outcomes in HF patients.

Screening for sleep disordered breathing among children hospitalized for asthma exacerbation.

Sleep disordered breathing (SDB) may exacerbate asthma and is a treatable comorbidity. To design and implement a screening process for SDB in patients hospitalized for asthma exacerbation using quality improvement (QI) methods. We sought to improve screening for SDB from zero to 60% from July 2019 to December 2020. A multidisciplinary team used QI methods to screen for SDB using the Michigan pediatric sleep questionnaire (PSQ) in patients 2-18 years hospitalized for asthma exacerbation. Key interventions included: pairing the PSQ screen with another element of routine care (the asthma risk factor screen), educating staff and physicians, engaging respiratory therapists to complete the PSQ and document scores, and modifying the electronic medical record (asthma order set and flowsheet for PSQ score documentation). A run chart tracked progress and descriptive statistics were generated. There were 2067 patients admitted for asthma exacerbation during this project. The PSQ was completed for 1531 patients (74%) overall. Of screened patients, 360 (24%) had a positive PSQ; the mean age was 8.6 years. Approximately 14 months after the project began, ~90% of children admitted for asthma were being screened; subsequently, >80% of patients were being screened until May 2022. Screening with the PSQ occurred approximately 90% of the time when routine asthma risk screens were completed. A screening process for SDB was successfully implemented and appeared feasible and sustainable. The high proportion of positive screens reinforces the importance of evaluating for SDB in the high-risk population of children requiring hospitalization for asthma exacerbation.

The impact of obstructive sleep apnea in children with sickle cell disease and asthma.

Asthma and obstructive sleep apnea (OSA) are chronic diseases that disproportionately affect children with sickle cell disease (SCD). The literature describes the negative impact that both conditions have on children with SCD separately; however, the effect of OSA on asthmatic children with OSA is less specific. We hypothesized that the presence of OSA in children with SCD and asthma is associated with specific hematologic markers, worse clinical outcomes, and greater healthcare utilization. We retrospectively evaluated children with both SCD and asthma who underwent polysomnography (PSG). We assessed their demographic information, PSG data, hematologic indices, and healthcare utilization based on the concurrent presence of OSA. Fifty-nine percent of the cohort had OSA with a lower oxygen saturation (SpO2 ) nadir (87% vs. 93%, p < 0.001) and a lower median daytime SpO2 (96.5% vs. 98.5%, p < 0.05); those with OSA were more likely to have the hemoglobin SS genotype (86% vs. 46.5%, p = 0.03). Additionally, those with OSA had a higher mean corpuscular volume (87 vs. 77.2 fL, p = 0.03) and reticulocyte count (10.1% vs. 5.5%, p < 0.01). There was no difference in asthma severity or healthcare utilization between those with OSA and those without OSA. Overall, children with SCD and asthma might be at increased risk for developing OSA, and screening for sleep-disordered breathing should be incorporated as part of their routine care.

Risk Assessment of Sleep Disordered Breathing in Cleft Lip and/or Palate.

Children with cleft lip and/or palate (CL/P) are at increased risk for Sleep Disordered Breathing (SDB), particularly Obstructive Sleep Apnea (OSA). At our institution, routine screening for SDB is performed using the Chevrin Pediatric Sleep Questionnaire (PSQ). This analysis is a practice audit looking at the outcomes of screening children with CL/P. A single-center, retrospective analysis was done of all non-syndromic patients with CL/P over the age of 36 months over a 4-year period. Children with known OSA were eliminated from analysis. Univariate logistic regression was used to assess predictors for SDB (PSQ score > 8) amongst various patient, disease, and treatment characteristics. Outcomes of those screened were tracked. Of the 239 patients in the study cohort, 43 (18%) had positive PSQs. These subjects were more likely to have class III dental occlusion with maxillary retrusion (OR = 2.65, 95% CI: 1.2-5.8, p = 0.02). There were no differences amongst age, type of cleft, Veau classification, BMI, or history of pharyngeal surgery. One third of the group did not complete recommended testing. Twenty-five subjects with positive sleep screening underwent subsequent polysomnography and 21 (84%) had OSA. Routine screening reveals a significant proportion of patients with CL/P with symptoms suggestive of OSA. While several patients did not complete confirmatory testing, those who completed a PSG had a high rate of identification of OSA. After excluding children with known OSA, patients with SDB are also likely to have class III dental occlusion and maxillary retrusion.

Contactless sleep monitoring using the Sonomat in children with Down syndrome

BackgroundChildren with Down syndrome (DS) require multiple sleep studies throughout childhood to diagnose and monitor sleep disordered breathing (SDB). Previous research suggests sensors applied during polysomnography (PSG) are poorly tolerated by children with DS. The Sonomat is a contactless device previously validated in typically developing children, and adult populations. Our study aimed to compare simultaneous Sonomat and PSG recordings in children with DS to determine the suitability of the Sonomat for use in this population. MethodsFifty children with DS undergoing diagnostic PSG were recruited from the Queensland Children's Hospital sleep laboratory. Agreement for sleep and respiratory parameters were assessed using concordance correlation coefficients (CCC), while detection and classification of SDB were assessed using indicators such as sensitivity, specificity, likelihood ratios, and receiver operator characteristic curves. ResultsComparison of parameters including the apnea-hypopnea index (CCC=89%; 95%CI 76, 93), and obstructive events index (CCC=74%; 95%CI 44, 88) showed reasonable agreement between Sonomat and PSG. The Sonomat showed outstanding ability to differentiate between the presence and absence of SDB (area under the curve [AUC]=0.97; 95%CI 0.93, 1.00), though we are uncertain of its ability to classify SDB profile and severity due to sample size limitations resulting in wide confidence intervals. ConclusionsThe easy-to-use, non-invasive nature of the Sonomat make it ideal for use in the screening of SDB in children with DS. Further data are needed to determine its suitability for classifying SDB profile and severity, including within the home, and for its use in other neurodevelopmental groups.

Sleep-disordered Breathing in Children With Craniofacial Anomalies.

Sleep-disordered breathing (SDB) is a common disorder in children, characterized by snoring and/or increased breathing force due to narrowing and increased upper airway collapse while sleeping. Over the last decade, it has been recognized that SDB occurs more frequently in children with craniofacial anomalies, but data in Thailand is quite limited. This study retrospective descriptive study aims to find the prevalence of SDB among children with craniofacial anomalies in Thailand and associated risk factors by collecting data among Thai children with congenital craniofacial anomalies younger than 15 years old who visited the Princess Sirindhorn Craniofacial Center at King Chulalongkorn Memorial Hospital between 2016 and 2021. All children were defined into syndromic and nonsyndromic groups. Data collected from the electronic medical record includes baseline characteristics, diagnosis of craniofacial anomalies, associated risk factors, diagnosis of SDB, diagnostic tools, and treatment. Total of 512 children, there were 80 children (15.4%) who had SDB. The most diagnosis was 51 (10%) obstructive sleep apnea followed by 27 (5.3%) primary snoring and 2 (0.4%) obstructive hypoventilation. The prevalence of SDB in the syndromic group was 43 (46.7%) while the nonsyndromic group was 37 (8.6%), ( P <0.001). The risk factors associated with SDB were overweight, allergic rhinitis, tonsillar hypertrophy, high arch palate, micrognathia, and syndromic craniofacial anomalies. The prevalence of SDB is higher in children with syndromic craniofacial anomalies than in the nonsyndromic group. Knowledge of the prevalence and related factors can lead to better care, including early screening and monitoring of SDB in craniofacial patients.

0805 Targeting Sleep Disordered Breathing Screening During the SARS-CoV2 Pandemic: Parents or Providers?

Abstract Introduction Sleep-disordered breathing (SDB) can significantly impact a child’s physical and psychological well-being. Primary care teams are strongly positioned to first note the signs of SBD and the American Academy of Pediatrics recommends routine screening for snoring at all well-child visits (WCV). However, the literature demonstrates low rates of application of this recommendation. This is likely multifactorial as noted by previous studies on the subject. This study aimed to assess if providing an electronic questionnaire to families ahead of the WCV would increase the snoring screening rate. Methods This quality improvement (QI) program consisted of a convenience sample (control n=504, program n=222) of 726 children, age 2-17 years presenting for their new or well-child-visit (WCV) over six weeks during the SARS-CoV2 pandemic. The Pediatric Sleep Questionnaire (PSQ) was delivered to parents via the electronic patient portal (EPP) 1-2 weeks before their child's appointment. The questionnaire was then auto imported into the physician's note at the time of the appointment. Results The QI program showed a lower overall SDB screening rate (16.7%) than the pre-program control (21%), however, 3 of 4 (75%) of the participating physicians saw an increase in SDB screening during the program. Statistical significance was seen in two physicians (X2 (1, N=262) = 27.150, p=.000, Phi = .332 and Fisher exact test p=.000, 2-tailed, Phi = .366. Conclusion The screening rate for snoring significantly increased among physicians when electronic questionnaires were provided to families prior to scheduled WCV. This is an early but promising pattern. The electronic patient portal can serve as an important asynchronous tool for providers to gather valuable information about the sleep quality of children in their practice, aligning with AAP goals and better supporting families. Support (if any) none

1045 Resolution of Sexsomnia with Positive Airway Pressure

Abstract Introduction Sexsomnia is an infrequently encountered non-rapid eye movement (NREM) arousal disorder that can overlap with obstructive sleep apnea (OSA). Treatment of underlying OSA has been reported to resolve sexsomnia episodes. Report of case(s) A 26-year-old overweight man was referred to our Sleep Disorders Center for evaluation of possible “REM sleep behavior disorder.” The patient’s wife reported that he would fondle her breasts while he slept. Episodes began 6 months prior to his referral and occurred once every 1-2 months. During episodes, the patient did not get out of bed. He did not recall the events and denied dream recall. The patient had an infant at home with resultant sleep deprivation. He slept between 5-7 hours a night and stated episodes were more common with decreased total sleep time. Additionally, he reported recent increase in stressors after moving in with his in-laws. On evaluation, patient endorsed bruxism for which he wore a mouth guard. He reported history of sleepwalking in elementary school. He denied excessive daytime sleepiness, snoring, witnessed apneas, gasping arousals, morning headaches, unrefreshing sleep, insomnia, or substance use. He was advised to increase total sleep time and pursue a baseline polysomnogram to evaluate for sleep-disordered breathing. The polysomnogram demonstrated moderate OSA (apnea/hypopnea index of 17). Excessive arousals out of N3 sleep were not reported. He was initiated on auto-titrating positive airway pressure (APAP) and maintained moderate adherence for 2 months. At his follow-up visit, he reported no further episodes of nocturnal fondling after PAP initiation despite persistent sleep deprivation and home stressors. Conclusion This case highlights the importance of screening for sleep-disordered breathing which can coexist with NREM parasomnias such as sexsomnia. Even in patients without clear symptoms of sleep-disordered breathing, the evaluation, diagnosis, and treatment of possible OSA could decrease the frequency of sexsomnia episodes. Although this case study was mainly limited by short follow-up duration, the patient’s resolution of sexsomnia in that time demonstrates the importance of treatment of concurrent sleep-related breathing disorders. Support (if any) None.

Abstract WP75: Association Between Sleep-disordered Breathing And Post-stroke Fatigue

Background: Post-stroke fatigue (PSF) is a common and often disabling symptom, the etiology of which is poorly understood. Sleep-disordered breathing (SDB) is also highly prevalent among stroke survivors. We explored the relationship between SDB and PSF over time in a bi-ethnic cohort. Methods: Ischemic stroke (IS) patients within the Brain Attack Surveillance in Corpus Christi (BASIC) project were identified through active and passive surveillance, and were offered home SDB screening with a well-validated cardiopulmonary sleep apnea testing device, the ApneaLink Plus. The primary exposure was the respiratory event index (REI). The primary outcome was PSF as measured by the SF-36 vitality scale (lower scores reflect greater fatigue). SDB and PSF were measured at baseline, 3, 6, and 12 months post-stroke. A linear regression model, using GEE to account for repeated measures, was used to examine the associations between REI and PSF at each time point adjusting for sociodemographics, stroke severity, depressive symptoms, pre-stroke fatigue, and comorbidities. Results: SDB screening and at least one PSF assessment were completed by 462 IS patients, who were 44% female, 61% Mexican American (MA), 26% non-Hispanic white, 7% Black, and 5% other race/ethnicity. Median NIHSS was 2 (IQR: 1-4). Multivariable regression model results are presented in the Table. Higher REI at 3 months was associated with greater PSF at 3 months (β= -1.87, 95%CI -3.47, -0.27), but there was no association between REI and PSF at 6 or 12 months. Across timepoints, female sex, depressive symptoms at time of assessment, pre-stroke medication for depression, higher levels of pre-stroke fatigue, and vascular risk factor burden were associated with greater PSF, whereas MA ethnicity was associated with less PSF. Conclusions: Higher REI was associated with greater PSF in the early post-stroke period, but no association was observed at 6 months and beyond. MA ethnicity seems to be protective against PSF.

A Narrative Review of Sex and Gender Differences in Sleep Disordered Breathing: Gaps and Opportunities.

Sleep disordered breathing (SDB) is a common condition, associated with multiple comorbidities including cardiovascular and metabolic disease. It has been previously established that SDB is more prevalent in men than women, shifting the literature's focus away from the latter population. As such, underdiagnosis, and thus undertreatment, of SDB in women exists. To establish the differences in prevalence, clinical presentation, and pathophysiology of SDB between the two sexes, a narrative review of the current literature was performed. Rates of SDB are higher among men, likely driven by differences in symptom presentation between men and women, with women presenting with more "atypical" symptoms, and lack of sensitivity in SDB screening tools to detect SDB in women. In addition to the cardiovascular risks of SDB, women with SDB may have worse quality of life, higher prevalence of insomnia, and respiratory issues. More research is needed to better define the unique pathophysiology and clinical presentation of SDB in women. In addition, an increased awareness among health care providers and the lay public of the SDB-specific sex and gender differences will serve to minimize disparities in identification and treatment of SDB in women.

We all know A and B, but what about C? Exploring the management of modifiable risk factors in patients with atrial fibrillation

Abstract Background The European Society of Cardiology (ESC) guidelines for the management of atrial fibrillation (AF) advise to treat AF according to the ABC pathway: A, anticoagulation, B, better symptom control, and C, comorbidities and cardiovascular risk factor management. Optimal treatment of comorbidities and risk factors slows AF progression and improves success rates of rhythm interventions for AF. However, several studies report underdiagnosis and therefore possible undertreatment for common cardiovascular comorbidities. Purpose This study aims to evaluate how common modifiable cardiovascular risk factors are managed in AF patients referred for catheter ablation. Methods This is a substudy of the ISOLATION study, a prospective cohort study including consecutive patients with paroxysmal or persistent AF referred for AF ablation. Screening for common modifiable risk factors for AF is structurally embedded in the work-up for AF ablation in the two participating centres. In the present study the prevalence of the following risk factors at this screening moment was assessed: (1) body mass index (BMI) above the target BMI for ablation (≥27 kg/m2), (2) hypertension, defined as on-site systolic blood pressure &amp;gt;130 mmHg and/or diastolic blood pressure &amp;gt;80 mmHg, (3) decreased glucose tolerance or diabetes mellitus, defined as HbA1c ≥6.5%, (4) dyslipidaemia, defined as low-density lipoprotein (LDL) ≥2.5 mmol/l, (5) regular alcohol consumption, defined as self-reported consumption of &amp;gt;15 standardized units/week, and (6) sleep disordered breathing (SDB), defined as apnoea-hypopnoea index (AHI) ≥15 assessed with home sleep tests (subset of patients). Results Among the 981 patients studied (median age 65 [59–71] years old, 64% male, 69% paroxysmal AF), previously diagnosed comorbidities were common (46% hypertension, 7% diabetes, 22% dyslipidaemia, 10% SDB), and a large proportion of patients received targeted treatment (Table 1). However, non-optimally managed risk factors remained significant (Figure 1). BMI ≥27 kg/m2 was present in 56% of patients. High systolic and diastolic blood pressure were present in 62% and 51% of patients, respectively, and any form of high blood pressure (either systolic or diastolic) was seen in 72% of patients. HbA1c was found to be above target ranges in 9% patients and LDL in 56%. A weekly alcohol consumption of ≥15 units was reported by 4% of patients. Screening for SDB was performed in a subset of patients (n=287), for whom AHI was ≥15 in 52%. Overall, 9% of patients had 4 or more non-optimally controlled modifiable risk factors, whereas the median number of modifiable risk factors was 2 [1–3]. Conclusions Structural screening revealed a high prevalence of non-optimally controlled modifiable cardiovascular risk factors in patients referred for AF catheter ablation. According to recent ESC guidelines, improving treatment of comorbidities may improve AF ablation success rates and even reduce mortality. Funding Acknowledgement Type of funding sources: None.

The prognostic value of sleep disordered breathing and the hypoxemic burden in HFpEF patients

Abstract Background Heart failure with preserved ejection fraction (HFpEF) is an important health care problem, responsible for a decreased quality of life, high health care costs, and a poor prognosis. Sleep disordered breathing (SDB) is suggested to be an important comorbidity in HFpEF, but its prevalence is probably underestimated due to limited SDB screening in clinical practice. Currently, no parameter reflects the full complexity and prognostic effect of SDB in HFpEF. Time spent with an oxygen saturation below 90% (T90), representing the hypoxemic burden, is an independent predictor of mortality and is superior compared to the widely accepted apnoea hypopnea index (AHI) in patients with HF with reduced ejection fraction (HFrEF). However, this association has not been explored in HFpEF patients. Purpose This study investigates the prevalence of SDB, comprising the diagnoses obstructive sleep apnoea and central sleep apnoea, in a HFpEF cohort. Moreover, the prognostic association of hypoxemic burden in SDB, expressed as T90, with more frequent HF hospitalizations or all-cause mortality is assessed in HFpEF patients. Methods Patients were prospectively included from our specialised HFpEF outpatient clinic from August 2017 until July 2021. All patients underwent a detailed diagnostic workup. An at home sleep monitoring device was used to obtain oximetry data, including T90, and information on respiratory effort, nasal flow and snoring. The patients were divided into tertiles based on T90 or AHI. In these tertiles pairwise Kaplan-Meier analysis was conducted to compare the probability of the composite endpoint of HF hospitalization or all-cause mortality. A Bonferroni correction was made with a statistical significance of p&amp;lt;0.0167. Results This analysis comprises 126 HFpEF patients, with a median age of 75 [70–80] years, 86 (68.3%) patients were female. In total 60 (47.6%) patients were diagnosed with SDB. The median T90 value was 13.7 minutes, with tertiles low (&amp;lt;2.8 min), middle (2.8–31.2 min), and high (&amp;gt;31.2 minutes). The mean follow up time was 40 months (95% CI 37 to 42) and in total 22 patients (17.5%) reached the composite endpoint. Kaplan-Meier analysis showed a gradual higher probability of HF hospitalization or death with higher T90 tertiles, with a significant difference in the highest compared to the lowest T90 tertile (χ2=7.4, p=0.006) (figure 1). Kaplan Meier analysis comparing tertiles based on the AHI (AHI &amp;lt;5.8; 5.8–12.2; &amp;gt;12.2) showed no different probability of the composite endpoint (χ2=3.1 p=0.208). Conclusion SDB is highly prevalent in HFpEF and the hypoxemic burden (expressed as T90) is an important prognostic factor. T90 may be a superior prognostic marker in HFpEF compared to the widely accepted AHI. Future research should evaluate whether targeting the hypoxemic burden in HFpEF treatment is effective in improving the prognosis. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Dutch Heart Foundation

Sleep-Disordered Breathing and Cardiac Arrhythmias in Adults: Mechanistic Insights and Clinical Implications: A Scientific Statement From the American Heart Association.

Sleep-disordered breathing (SDB), characterized by specific underlying physiological mechanisms, comprises obstructive and central pathophysiology, affects nearly 1 billion individuals worldwide, and is associated with excessive cardiopulmonary morbidity. Strong evidence implicates SDB in cardiac arrhythmogenesis. Immediate consequences of SDB include autonomic nervous system fluctuations, recurrent hypoxia, alterations in carbon dioxide/acid-base status, disrupted sleep architecture, and accompanying increases in negative intrathoracic pressures directly affecting cardiac function. Day-night patterning and circadian biology of SDB-induced pathophysiological sequelae collectively influence the structural and electrophysiological cardiac substrate, thereby creating an ideal milieu for arrhythmogenic propensity. Cohort studies support strong associations of SDB and cardiac arrhythmia, with evidence that discrete respiratory events trigger atrial and ventricular arrhythmic events. Observational studies suggest that SDB treatment reduces atrial fibrillation recurrence after rhythm control interventions. However, high-level evidence from clinical trials that supports a role for SDB intervention on rhythm control is not available. The goals of this scientific statement are to increase knowledge and awareness of the existing science relating SDB to cardiac arrhythmias (atrial fibrillation, ventricular tachyarrhythmias, sudden cardiac death, and bradyarrhythmias), synthesizing data relevant for clinical practice and identifying current knowledge gaps, presenting best practice consensus statements, and prioritizing future scientific directions. Key opportunities identified that are specific to cardiac arrhythmia include optimizing SDB screening, characterizing SDB predictive metrics and underlying pathophysiology, elucidating sex-specific and background-related influences in SDB, assessing the role of mobile health innovations, and prioritizing the conduct of rigorous and adequately powered clinical trials.

P-41647404-243 - Undiagnosed nasal obstruction and our role in screening for sleep disordered breathing.

<h3>Background</h3> Sleep disordered breathing (SDB) exists as a spectrum and can be a continuum from a non-hypoxic to the hypoxic form (OSA). In the susceptible individual that makes up the group in which it exists as a continuum, it has been postulated that it may be a part of an undiagnosed breathing disorder that existed from the active craniofacial growth phase. This brings forward the important role of an unobstructed nasal breathing and the balance interplay between nasal resistance, proper tongue seal and the absence of chronic mouth breathing. <h3>Objective</h3> To identify the prevalence of undiagnosed nasal obstruction among young healthy dental outpatient attendees to explore the role of oral health practitioners in sleep disordered breathing screening. <h3>Material and Methods</h3> Dental outpatient attendees were sequentially selected for 6 months. The first phase encompassed subjective patient assessment using the SNOT 22 questionnaire and clinical dental examination. The second phase involved nasal endoscopy to objectively confirm nasal obstruction by an otorhinolaryngologist. <h3>Results</h3> 156 subjects were involved with a prevalence of 90.4% was found for undiagnosed nasal obstruction. Deviation from normal dental morphometry and a significant association with an allergy history, tongue scalloping and snoring was more commonly noted clinical finding in susceptible individuals. <h3>Conclusions</h3> Our study shows that dentists can be important screeners to enhance early intervention to treat nasal obstruction and prevent ill effects of prolonged sleep disordered breathing. SNOT-22 is a reliable and simple questionnaire that can be used for screening in a dental setting.

Fusion of Whole Night Features and Desaturation Segments Combined with Feature Extraction for Event-Level Screening of Sleep-Disordered Breathing.

PurposeMisdiagnosis and missed diagnosis of sleep-disordered breathing (SDB) is common because polysomnography (PSG) is time-consuming, expensive, and uncomfortable. The use of recording methods based on the oxygen saturation (SpO2) signals detected by wearable devices is impractical and inaccurate for extracting signal features and detecting apnoeic events. We propose a method to automatically detect the apnoea-based SpO2 signal segments and compute the apnoea–hypopnea index (AHI) for SDB screening and grading.Patients and MethodsFirst, apnoea-related desaturation segments in raw SpO2 signals were detected; global features were extracted from whole night signals. Then, the SpO2 signal segments and global features were fed into a bi-directional long short-term memory convolutional neural network model to identify apnoea-related and non-apnoea-related events. The apnoea-related segments were used to assess the AHI.ResultsThe model was trained on 500 individuals and tested on 8131 individuals from two public hospitals and one private centre. In the testing data, the classification accuracy for apnoea-related segments was 84.3%. Individuals with SDB (AHI n ge n 15) were identified with a mean accuracy of 88.95%.ConclusionUsing automatic SDB detection based on SpO2 signals can accurately screen for SDB.