Association between cardiovascular mortality and STOP-Bang questionnaire scores in a cohort of hospitalized patients: a prospective study.

OBJECTIVE: Obstructive sleep apnea (OSA) is associated with an increased risk of mortality and cardiometabolic diseases. The STOP-Bang questionnaire is a tool to screen populations at risk of OSA and prioritize complementary studies. Our objective was to evaluate the clinical utility of this questionnaire in identifying patients at an increased risk of mortality after discharge in a cohort of hospitalized patients. METHODS: This was a prospective cohort study involving consecutive patients admitted to an internal medicine unit between May and June of 2017 who were reevaluated three years after discharge. At baseline, we collected data on comorbidities (hypertension, obesity, diabetes, and fasting lipid profile) and calculated STOP-Bang scores, defining the risk of OSA (0-2 score, no risk; ≥ 3 score, risk of OSA; and ≥ 5 score, risk of moderate-to-severe OSA), which determined the study groups. We also recorded data regarding all-cause and cardiovascular mortality at the end of the follow-up period. RESULTS: The sample comprised 435 patients. Of those, 352 (80.9%) and 182 (41.8%) had STOP-Bang scores ≥ 3 and ≥ 5, respectively. When compared with the group with STOP-Bang scores of 0-2, the two groups showed higher prevalences of obesity, hypertension, diabetes, and dyslipidemia. Multivariate analysis showed an independent association between cardiovascular mortality and STOP-Bang score ≥ 5 (adjusted hazard ratio = 3.12 [95% CI, 1.39-7.03]; p = 0.01). Additionally, previous coronary heart disease was also associated with cardiovascular mortality. CONCLUSIONS: In this cohort of hospitalized patients, STOP-Bang scores ≥ 5 were able to identify patients at an increased risk of cardiovascular mortality three years after discharge.

Association between cardiovascular mortality and STOP-Bang questionnaire scores in a cohort of hospitalized patients: a prospective study / Associação entre mortalidade cardiovascular e pontuação do questionário STOP-Bang em uma coorte de pacientes hospitalizados: um estudo prospectivo

ABSTRACT Objective: Obstructive sleep apnea (OSA) is associated with an increased risk of mortality and cardiometabolic diseases. The STOP-Bang questionnaire is a tool to screen populations at risk of OSA and prioritize complementary studies. Our objective was to evaluate the clinical utility of this questionnaire in identifying patients at an increased risk of mortality after discharge in a cohort of hospitalized patients. Methods: This was a prospective cohort study involving consecutive patients admitted to an internal medicine unit between May and June of 2017 who were reevaluated three years after discharge. At baseline, we collected data on comorbidities (hypertension, obesity, diabetes, and fasting lipid profile) and calculated STOP-Bang scores, defining the risk of OSA (0-2 score, no risk; ≥ 3 score, risk of OSA; and ≥ 5 score, risk of moderate-to-severe OSA), which determined the study groups. We also recorded data regarding all-cause and cardiovascular mortality at the end of the follow-up period. Results: The sample comprised 435 patients. Of those, 352 (80.9%) and 182 (41.8%) had STOP-Bang scores ≥ 3 and ≥ 5, respectively. When compared with the group with STOP-Bang scores of 0-2, the two groups showed higher prevalences of obesity, hypertension, diabetes, and dyslipidemia. Multivariate analysis showed an independent association between cardiovascular mortality and STOP-Bang score ≥ 5 (adjusted hazard ratio = 3.12 [95% CI, 1.39-7.03]; p = 0.01). Additionally, previous coronary heart disease was also associated with cardiovascular mortality. Conclusions: In this cohort of hospitalized patients, STOP-Bang scores ≥ 5 were able to identify patients at an increased risk of cardiovascular mortality three years after discharge.

RESUMO Objetivo: A apneia obstrutiva do sono (AOS) está associada a um risco maior de mortalidade e doenças cardiometabólicas. O questionário STOP-Bang é uma ferramenta para rastrear populações em risco de AOS e assim priorizar estudos complementares. Nosso objetivo foi avaliar a utilidade clínica desse questionário na identificação de pacientes com risco aumentado de mortalidade após a alta em uma coorte de pacientes hospitalizados. Métodos: Estudo de coorte prospectivo com pacientes consecutivos internados em uma unidade de medicina interna entre maio e junho de 2017 que foram reavaliados três anos após a alta. No momento basal, coletamos dados sobre comorbidades (hipertensão, obesidade, diabetes e perfil lipídico em jejum) e calculamos as pontuações no STOP-Bang, definindo o risco de OSA (pontuação 0-2, sem risco; pontuação ≥ 3, risco de AOS; e pontuação ≥ 5, risco de AOS moderada a grave), que determinou os grupos de estudo. Também registramos dados sobre mortalidade por todas as causas e mortalidade cardiovascular ao final do período de acompanhamento. Resultados: Foram incluídos 435 pacientes. Desses, 352 (80,9%) e 182 (41,8%) apresentaram pontuações no STOP-Bang ≥ 3 e ≥ 5, respectivamente. Quando comparados com o grupo com pontuação no STOP-Bang de 0-2, os outros dois grupos apresentaram prevalências mais elevadas de obesidade, hipertensão, diabetes e dislipidemia. A análise multivariada mostrou uma associação independente entre mortalidade cardiovascular e pontuação no STOP-Bang ≥ 5 (razão de risco ajustada = 3,12 [IC95%, 1,39-7,03]; p = 0,01). Além disso, doença coronariana prévia também foi associada à mortalidade cardiovascular. Conclusões: Nesta coorte de pacientes hospitalizados, pontuações no STOP-Bang ≥ 5 foram capazes de identificar pacientes com risco aumentado de mortalidade cardiovascular três anos após a alta.

Insuflador-exsuflador mecânico versus manobra PEEP-ZEEP em pacientes em ventilação mecânica prolongada / Mechanical insufflator-exsufflator versus PEEP-ZEEP maneuver in patients on prolonged mechanical ventilation

Introdução: A presença da via aérea artificial, associada com a imobilidade no leito, resulta em um déficit na desobstrução das vias aéreas em pacientes sob ventilação mecânica (VM). Tal condição contribui para o desenvolvimento de quadros de hipoxemia e/ou infecções respiratórias, aumentando o trabalho respiratório e também as falhas de extubação. Objetivo: Comparar os efeitos da utilização do insuflador-exsuflador mecânico e da manobra PEEP-ZEEP em relação à mecânica respiratória em pacientes ventilados mecanicamente por tempo prolongado. Métodos: Ensaio clínico randomizado cruzado, incluindo pacientes em ventilação mecânica por mais de 10 dias. Os pacientes foram randomizados para receber a aplicação do insuflador-exsuflador mecânico e da manobra PEEP-ZEEP. Foram mensuradas complacência pulmonar, estática e dinâmica, e resistência pulmonar antes e após a aplicação de cada técnica. Resultados: Foram incluídos 22 pacientes. Na análise intragrupos observa-se aumento significativo na complacência dinâmica e complacência estática após a aplicação de ambas as técnicas. A resistência pulmonar variou significativamente apenas após a aplicação do insuflador-exsuflador mecânico. Não foram observadas diferenças significativas na análise intergrupos. Conclusão: O insuflador-exsuflador mecânico e a manobra de PEEP-ZEEP demonstraram ter efeito positivo tanto sobre a complacência estática quanto a dinâmica. Entretanto, a resistência pulmonar aumentou após a aplicação do insuflador-exsuflador mecânico. (AU)

Introduction: The presence of the artificial airway associated with immobility in the bed results in a deficit in the clearance of the airways in patients under mechanical ventilation (MV). This condition contributes to the development of hypoxemia and/or respiratory infections, increasing respiratory work and also extubation failures. Objective: To compare the effects of the use of mechanical insufflation-exsufflation and PEEP-ZEEP maneuver in relation to respiratory mechanics in patients on prolonged mechanical ventilation. Methods: Randomized cross-over trial, including patients on mechanical ventilation for more than 10 days. The patients were randomized to receive the application of mechanical insufflator-exsuflator and PEEP-ZEEP maneuver. Pulmonary compliance, static and dynamic, and pulmonary resistance were measured before and after the application of each technique. Results: 22 patients were included. In the intragroup analysis we observed a significant increase in the dynamic compliance and static compliance after the application of both techniques. Pulmonary resistance varied significantly only after application of the mechanical insufflation-exsufflation. No significant differences were observed in the inter-group analysis. Conclusion: The mechanical insufflator-exsuflator and the PEEP-ZEEP maneuver were shown to have a positive effect on both static and dynamic complacency. However, pulmonary resistance increased after the application of the mechanical insufflation-exsufflation.(AU)

Reducing regional flow stasis and improving intraventricular hemodynamics with a tipless inflow cannula design: An in vitro flow visualization study using the EVAHEART LVAD.

Due to the high stroke rate of left ventricular assist device (LVAD) patients, reduction of thrombus has emerged as an important target for LVAD support. Left ventricular blood flow patterns with areas of flow stasis and recirculation are associated with platelet aggregation, which is worsened by exposure to high shear stress. Previous reports of intraventricular thrombus in LVAD patients have identified the outside of the LVAD inflow cannula as a nidus for LV thrombus formation. Previous studies of LVAD inflow cannula design have shown a region of low blood velocity and pulsatility at the apex, adjacent to the cannula. One unresolved question is whether the standard practice of inserting the LVAD inflow cannula several mm into the LV could be revised to reduce thrombus formation. To address this, a "tipless" inflow cannula was designed for the EVAHEART LVAS, and assessed in a mock circulatory loop of the LVAD-supported heart. Customized transparent silicone models of a dilated LV were connected to the EVAHEART LVAS at the apex with a clear polycarbonate inflow cannula for flow visualization using particle image velocimetry (PIV). The "tipless" cannula was inserted flush with the endocardial border and did not protrude into the LV. This condition was compared to the standard cannula position with a 1-cm insertion into the LV. The Pre-LVAD condition corresponded to a severe heart failure patient (ejection fraction of 24%) with a dilated LV (180 mL). LVAD support was provided at speeds of 1.8 and 2.3 krpm. At the lower LVAD speed, 63% of the flow passed through the LVAD, with the remainder ejecting through the aortic valve. When LVAD speed was increased, nearly all flow (98%) left the LV through the LVAD. Both LVAD speed conditions produced a vortex ring similar to the Pre-LVAD condition in diastole. However, the protruding inflow cannula interrupted the growth and restricted the movement of the vortex, and produced areas of low velocity and pulsatility adjacent to the cannula. The tipless cannula exhibited an uninterrupted pattern of the mitral jet toward the LV apex, which allowed the diastolic vortex to grow and aid in the washout of this region. In addition, the tipless cannula increased aortic valve flow, which reduces stasis in the left ventricular outflow tract. The EVAHEART LVAS tipless inflow cannula design improved regional velocity, pulsatility, and vortex formation compared to the standard protruding design, which all reduce the risk of thrombus formation. The clinical significance of the differences observed in the flow field will be dependent on other factors such as the cannula material and surface characteristics, as well as the patients' coagulation status.

Do T90 and SaO2 nadir identify a different phenotype in obstructive sleep apnea?

INTRODUCTION: Severity of obstructive sleep apnea (OSA) is commonly based upon the apnea-hypopnea index (AHI). However, patients with similar AHIs may demonstrate widely varying comorbidities and risk for cardiovascular disease. These varying manifestations of disease may be related to nocturnal hypoxia and not AHI. We hypothesize that parameters of oxygenation may identify a different phenotype in OSA. PURPOSE: To explore potential associations between lowest SaO2 (SaO2 nadir) and total sleep time spent with arterial oxygen saturation (SaO2) < 90% (T90) with comorbidities and mortality in patients with moderate and severe OSA. METHOD: This was a retrospective study of patients between 2009 and 2014, with a new diagnosis of moderate-to-severe OSA without a concomitant respiratory disease. Data collection included demography, comorbidities, sleep study parameters, and mortality over a 5-year interval. Patients were categorized into two groups for analysis, group 1: SaO2 nadir < 75%, and group 2: T90 > 20%. RESULTS: Of the 365 patients, 163 (45%) recorded SaO2 nadir < 75% and 127 (35%) recorded T90 > 20%. These oxygenation parameters were associated with more severe OSA by AHI (p < 0.001). T90 > 20% was associated with an increased risk of hypertension (HT) OR 2.95 (CI 1.87-4.76, p < 0.001) in patients with both moderate and severe OSA. T90 > 20% was also associated with an increased risk of type 2 diabetes mellitus (T2DM) OR 2.14 (CI 1.35-3.38, p = 0.001) and mortality 2.70 (CI 1.37-5.22, p = 0.0048). CONCLUSION: The findings demonstrate a correlation between SaO2 nadir < 75% and T90 > 20% and increased severity of OSA. The findings also show a strong association between SaO2 nadir < 75% and T90 > 20% and increased risk for comorbidities of HT and T2DM as well as mortality at 5 years. This analysis suggests that parameters of oxygenation should be used to describe a high-risk phenotype of OSA.

Mitral Valve Prosthesis Design Affects Hemodynamic Stasis and Shear In The Dilated Left Ventricle.

Dilated cardiomyopathy produces abnormal left ventricular (LV) blood flow patterns that are linked with thromboembolism (TE). We hypothesized that implantation of mechanical heart valves non-trivially influences TE risk in these patients, exacerbating abnormal LV flow dynamics. The goal of this study was to assess how mitral valve design impacts flow and hemodynamic factors associated with TE. The mid-plane velocity field of a silicone dilated LV model was measured in a mock cardiovascular loop for three different mitral prostheses, two with multiple orientations, and used to characterize LV vortex properties through the cardiac cycle. Blood residence time and a platelet shear activation potential index (SAP) based on the cumulative exposure to shear were also computed. The porcine bioprosthesis (BP) and the bileaflet valve in the anti-anatomical (BL-AA) position produced the most natural flow patterns. The bileaflet valves experienced large shear in the valve hinges and recirculating shear-activated flow, especially in the anatomical (BL-A) and 45-degree (BL-45) positions, thus exhibited high SAP. The tilting disk valve in the septal orientation (TD-S) produced a complete reversal of flow and vortex properties, impairing LV washout and retaining shear-activated fluid, leading to the highest residence time and SAP. In contrast, the tilting disk valve in the free-wall position (TD-F) exhibited mid-range values for residence time and SAP. Hence, the thrombogenic potential of different MHV models and configurations can be collectively ranked from lowest to highest as: BP, BL-AA, TD-F, BL-A, BL-45, and TD-S. These findings provide new insight about the effect of fluid dynamics on LV TE risk, and suggest that the bioprosthesis valve in the mitral position minimizes this risk by producing more physiological flow patterns in patients with dilated cardiomyopathy.

The Effect of Inflow Cannula Length on the Intraventricular Flow Field: An In Vitro Flow Visualization Study Using the Evaheart Left Ventricular Assist Device.

Left ventricular assist device (LVAD) inflow cannula malposition is a significant risk for pump thrombosis. Thrombus development is influenced by altered flow dynamics, such as stasis or high shear that promote coagulation. The goal of this study was to measure the intraventricular flow field surrounding the apical inflow cannula of the Evaheart centrifugal LVAD, and assess flow stasis, vortex structures, and pulsatility for a range of cannula insertion depths and support conditions. Experimental studies were performed using a mock loop with a customized silicone left ventricle (LV) and the Evaheart LVAD. A transparent inflow cannula was positioned at 1, 2, or 3 cm insertion depth into the LV and the velocity field in the LV midplane was measured for 2 levels of LVAD support: 1800 and 2300 rpm. The LV velocity field exhibits a diastolic vortex ring whose size, path, and strength are affected by the flow conditions and cannula position. During diastole, the large clockwise midplane vortex grows, but its circulation and kinetic energy are reduced with cannula insertion depth. The counterclockwise vortex is smaller and exhibits more complex behavior, reflecting a flow split at 3 cm. Overall, the 1 cm cannula insertion depth produces the flow pattern that exhibits the least apical flow stasis and greatest pulsatility and should correlate to a lower risk of thrombus formation.

Mechanical ventilation weaning in inclusion body myositis: feasibility of isokinetic inspiratory muscle training as an adjunct therapy.

Inclusion body myositis is a rare myopathy associated with a high rate of respiratory complications. This condition usually requires prolonged mechanical ventilation and prolonged intensive care stay. The unsuccessful weaning is mainly related to respiratory muscle weakness that does not promptly respond to immunosuppressive therapy. We are reporting a case of a patient in whom the use of an inspiratory muscle-training program which started after a two-week period of mechanical ventilation was associated with a successful weaning in one week and hospital discharge after 2 subsequent weeks.