This theoretically focused paper aims to move beyond the rhetoric of espousing the importance and timeliness of a model of palliative care for the neonatal population, to explore how what is known already can influence health and social policy. While this paper is largely informed by current events at Senate level within Australian Government, the research – empirical and otherwise – and the strong societal voice that informs the need to move the neonatal palliative care agenda forward transects borders and nations and therefore has relevance to all westernised countries.

In recent years, there has been increasing awareness regarding the need for evidence-based neonatal palliative care, yet despite literature supporting neonatal palliative care practice, and the availability of protocols to inform practice, neonatal palliative care in the clinical environment remains extemporized.

A recent Commonwealth of Australia Senate enquiry into palliative care in Australia (Wilkinson et al., 2012) invited a submission regarding neonatal palliative care, bringing this widely neglected aspect of neonatal care to the forefront for the first time in our country.

In recent years, palliative care for the neonatal population has become increasingly topical and part of the lexicon of contemporary neonatal nursing practice. An evidence-based protocol (Catlin & Carter, 2002) has been available for a decade to inform this model of care, yet in reality, provision of palliative care to newborns is ad hoc (Cignacco & Zeitschrift-Für, 2004; Maginnes, 2002), and components of this protocol have been difficult to implement. The reasons why engaging in a palliative model of care were unclear, but now the barriers to a neonatal palliative model of care have been well defined to the point where this knowledge can inform policy (Kain, 2011; Kain et al., 2009).

Babies die too

At a societal level, death and dying in infancy is driven by high emotional content because the death of a newborn is considered a life that has ended too soon: illness and death are unexpected for a newborn and are devastating and life-altering events for the family. Society in general does not know how to respond to the death of a newborn, and therefore have few established social norms to help a family cope with such loss. Society more readily accepts deaths of adults and even of children. Complicating these ethical concerns is the notion that the death of a newborn in this highly curative environment is a failure of medical science.. Whilst this highly technical environment saves the lives of newborns, healthcare needs to provide for the needs of newborns who will die before they leave the hospital. Due to a lack of coordinated interdisciplinary services, dying children are often deprived of the benefits of palliative care (Carter et al., 2004), yet evidence of an increasing societal demand for palliative care provision to the neonatal population is reported in the literature (Maginnes, 2002; Romesberg, 2003; Conway and Moloney-Harmon, 2004).

This paper concerns itself with the sobering fact that babies die too, however. Newborns and infants have the highest death rate in the paediatric population (Pierucci et al., 2001). In Australia, 4 out of every 1,000 infants die before their first birthday (Australian Bureau of Statistics, 2011). This is equal to almost 1,200 deaths across Australia each year. In the United Kingdom in 2010, the infant mortality rate was 4.3 deaths per 1,000 live births. For very low birth-weight babies (under 1,500 grams) and low birth-weight babies (under 2,500 grams), mortality rates were 164.9 and 36.8 deaths per 1,000 live births respectively (Office for National Statistics, 2010). In United States data from 2009, the infant mortality rate was higher, with 6.39 deaths per 1,000 live births (Centers for Disease Control and Prevention, 2011). These epidemiological data highlight that even in developed countries, infancy remains one of the most dangerous periods of human life, and according to one source, the death rate in the first year of life is only exceeded by those over the age of 55 (Maternal Perinatal and Infant Mortality Committee, 2011).

According to the data sources above, the infant mortality rates are marginally decreasing. However, increasing survival rates are balanced by increasing morbidity issues. Since the escalation of technology and medical advances – including antenatal corticosteroids and postnatal surfactant treatment (Walther, 2005) – treatment options for newborn infants have increased, thus enabling healthcare professionals to provide care to newborns who previously would not have been intubated, or were presumed to be dying (Pierucci et al., 2001). Advances in life-sustaining medical technology present ethical concerns with a strong emotional component, including when it is appropriate to withhold or withdraw intensive care therapies (Walther, 2005). Advances in neonatal medicine have resulted in the survival of extremely preterm infants previously considered non-viable. To summarise, despite technological advances, increases in the margins of viability, and highly skilled healthcare delivery, some newborns will still die in the neonatal intensive care unit [NICU], often as a result of extreme prematurity and other complex medical problems (Yam et al., 2001).

Neonatal palliative care in context

To engage in objective and balanced discussion, it is first necessary to address the assumption that palliative care is inherently beneficial for all patient populations who may require it. Some literature offers a critique of the palliative approach, arguing that the emphasis of palliative care should not be on extinguishing the denial of death but on the relief of suffering (Zimmermann, 2004). Such philosophical debate argues that the palliative approach may result in the ‘social death’ of a person before their actual death. This results in the ideal of ‘living until you die’ being unfulfilled (McKechnie et al., 2007). McKechnie et al (2007) argue that whether a dying person experiences a ‘good death’ or not is determined not only by the management of the dying process by health professionals, but also by the way in which the dying person is perceived by others. The palliative approach may be interpreted as being somewhat prescriptive, yet there are no guidelines for the dying role; everybody dies differently and individually (McKechnie et al., 2007). Such debate suggests that healthcare professionals should be mindful of the palliative approach leading to the ‘social death’ of a dying baby prior to its actual, physical death.

In context, neonatal palliative care involves active treatment aiming to ensure that newborns receive care in a comfortable environment, free from pain and distressing symptoms, with emotional and practical support for both parents, and healthcare professionals. When the decision to withhold resuscitation, discontinue resuscitation, or forgo other life-supporting treatments are made, compassion for the family and their needs become paramount. This humane and compassionate care should include careful handling of the newborn, maintaining warmth, avoiding invasive procedures, and unobtrusive monitoring.

Moving beyond rhetoric: the difficulties

Death is a part of life in any NICU, and any healthcare service provider associated with labour and delivery and the care of newborns would inevitably experience perinatal death and bereavement (Leuthner, 2004). Furthermore, there is a neonatal population that would benefit from this model of care, recognised under three broad categories: newborns born at the limits of viability; newborns born with a lethal anomaly and/or malformation; and newborns who have received intensive care in the NICU but for whom this model of care has become inappropriate. These categories of newborns have low rates of survival and high morbidity on the occasions that they do survive, and palliative care may be the best approach (Carter, 2004).

Despite this, palliative care principles are difficult to apply to neonatology. The social stigma of denying neonatal death coupled with the paradox of providing palliative care in a curative setting present a compelling research problem. However, it is possible for palliative care to coexist with curative treatment modes because palliative care has become an area of expertise within many other health disciplines, such as in adult intensive care. Yet, advances in palliative care have not yet been integrated effectively into standard paediatric/adolescent clinical practice, and even less so into neonatal clinical practice. Therefore, the precepts of palliation should be a basic component of the attitudes, knowledge base and practice skills of all health care professionals (National Association of Neonatal Nurses www.nann.org, 2005). The previous section suggests that the clinical application of palliative care should be seemingly straightforward. However, when one explores these clinical ideologies in the context of contemporary neonatology, the notion of neonatal palliative care raises a myriad of issues and controversies.

Whilst it is noted that there have been remarkable achievements in newborn survival and these advances have increased the possibility of sustaining life, this paper has highlighted that more newborns die in the neonatal period than at any other time in childhood. Despite this, there is much that is unknown about both the needs and the care of these critically ill newborns (Field and Behrman, 2003). To illustrate, 34% of all childhood deaths occur within the neonatal period (Carter, 2004). It would be a reasonable assumption, then, that when death becomes inevitable for a marginally viable and critically ill newborn, that decisions to prolong suffering be reassessed and a transition to palliative care at least be considered (Carter, 2004). Again, such a rationale is not straightforward. This notion necessitates that aggressive, curative treatment be withheld, or withdrawn: yet how does this translate into actual practise. When is it appropriate to withhold or withdraw curative care and, in doing so, what are the needs of the dying newborn, the family, and the staff to provide a humane and compassionate death. The literature suggests that confusion exists about what palliative care constitutes, and when – if ever – it is appropriate to withhold aggressive, curative care. In Catlin’s (1999) research of neonatologists’ resuscitation practices of extremely low-birth weight (ELBW) preterm newborns, one fourth of participants stated that withholding resuscitation attempts wasn’t an option for them. Emotive terms such as ‘executing’, ‘killing’ and ‘pulling the trigger’ were used to describe the practice of ‘doing nothing’ (Catlin, 1999: p 271). Attempting resuscitation even on the smallest ELBW fetal-newborns was described as a neutral action for which they were simply trained to do: there was no training in terms of when ‘not to do’. One neonatologist recalled: ‘there’s no one telling you the rules, because there aren’t any rules’ (Catlin, 1999: p 271).

There is often difficulty in accepting a palliative model of care in contemporary healthcare. There is a focus upon curative treatment regimens, with a drive to offer aggressive interventions. This may be because the serious nature of disease is still evolving or perhaps to postpone the acceptance that death has become inevitable. Healthcare needs to consider when no potentially curative intervention exists, or their benefits have become exhausted. This can lead to a feeling of hopelessness that there is nothing left to offer the newborn (Craig and Goldman, 2003). There is a notion of curing at all costs, and it is stated that in acute care settings the purpose of treatment is generally to cure, and it is for this reason that facing the death of a patient and providing palliative care can be ‘uncomfortable’, and engender a sense of failure (Davies et al., 1996; Hartline, 2002; Lo et al., 1999).

In some countries, such as the Netherlands (Moro et al., 2006), euthanasia of certain newborns is considered a viable option for marginally viable and critically ill newborns in countries. Discreetly practiced active euthanasia, although technically illegal, has been tolerated in countries such as the Netherlands for over 30 years. There is no mention in the law of active euthanasia for newborns and small children, which remains illegal. However, in the Netherlands neonatal and infant deaths preceded by the deliberate administration of life reducing medication are known to take place, although infrequently (Cuttini et al., 2004). This paper does not seek to advocate or condemn such practices, however in order to locate palliative care in contemporary neonatal care, such discussion is necessary.

In a study by Provoost and Cools (2005) a death-certificate audit was performed for all deaths of newborns and infants in Flanders over a 12-month period. With a response rate of 253 (87%), 121 (69%) of the 175 neonatologists also responded to a series of attitude questions. An end-of-life decision was possible in 194 of the 253 deaths studied, and such a decision was made in 143 cases. Lethal drugs had been administered in 15 cases among 117 early neonatal deaths and in two cases among 77 later deaths. Furthermore, the attitude study demonstrated that 95 of the 121 neonatologists reported that their professional duty at times included the prevention of unnecessary suffering by hastening death and 69 of 120 supported legalization of life termination in some cases. This research reported that within its sampling frame, the majority of neonatologists favored the legalization of the use of lethal drugs in certain cases.

The EURONIC study (Arlettaz et al., 2005) demonstrated that the administration of lethal drugs with the aim of terminating life was reported in the Netherlands and France, in contrast to other European countries. This report reasoned that the prevention of suffering at times justifiably demanded the use of lethal drugs and that non-treatment unnecessarily prolonged suffering. The study found that most of the neonatologists participating in the research supported a change in the law, permitting the termination of life (Provoost and Cools, 2005). However, these guidelines, known as the Groningen Protocol, relate to newborns who would continue to survive after the withdrawal of medical care. Under the auspices of such a protocol, the decision to terminate the life of a newborn is based upon perceived intractable suffering (Verhagen and Sauer, 2005) and in this decision-making process, the prognosis, the expected outcome of treatment in terms of quality of life, and the burden placed on the patient by the treatment (pain, discomfort and physical limitation) play an equal role (Arlettaz et al., 2005).

In summary, intensive care can be an unpleasant, uncomfortable experience for newborns even when it is appropriate. As stated by Yu (2005) a ‘proactive policy to initiate intensive care must take into consideration that a decision to withdraw intensive care might have to be made in selective newborns at a later stage in the course of the newborn’s treatment. In the event that the newborn’s subsequent clinical course indicates that further curative efforts are futile or lack compensating benefit, intensive care should be discontinued and palliative care, which provides symptomatic relief and comfort, should be introduced’ (Yu, 2005: p 746 – 747).

Given this, the initiation or continuation of treatment which is considered futile is unlikely to be in the best interests of the newborn. Even so, many healthcare professionals find it difficult to accept that palliative care may be a more appropriate course of action (Craig and Goldman, 2003). The NICU environment has changed dramatically in past decades and continues to do so into the new millennium, with advances in technology and prenatal screening. These advances mean that many newborns who might once have died are now surviving (Handley, 2003). Therefore, the concept of providing palliative care to newborns is an emerging one, but as argued, it is a concept that is proving difficult to incorporate into contemporary neonatal care.

How can what is known already influence policy?

To inform policy on any level, it is imperative that health professionals in the NICU are knowledgeable about legislative priorities and any public concerns regarding palliative care for neonates. There are several priorities for moving this model of care forwards, which include legislation that supports access to care such as development and funding support of perinatal hospices, continuity of care, caregiver support, research and in particular education for the healthcare professionals caring for dying babies and their families.

It is remiss to overlook that neonatal palliative care is emotionally and ethically laden: When considering moving this model of care forward from an evidence base, it is useful to remember that health care requires that practitioners speak in ‘two different languages-the language of science with its quantifiable outcomes . . . as well as the language of people’ (Leight, 2002: p. 109).

The strong societal voice is at the epicentre of social care policy when considering palliative care models for the neonatal population. Opinion in the literature suggests that society perceives medicine as entering an age of ‘miracles’ and ‘wonder’, and this is all upon public display in the NICU (Levy Guyer, 2006; Tisdale, 2003). Given these influences, parents often have unrealistic expectations with what can be offered to their child in terms of medical intervention. This may lead to the belief in the ‘medical miracle’ to explain a technological solution for everything (Levy Guyer, 2006; Paris, DeLisser, & Savani, 2000). Extremely premature newborns have survived, and so there is an unsound basis for parental requests that everything possible be done to ‘save’ their babies. Due to reports of these so-called ‘miracle babies’ (The Age., 2007) the public may expect more from the NICU now that some newborns born at 22 weeks gestation have survived. It is expected that modern medicine can save every newborn born beyond this milestone (Levy Guyer, 2006; Paris et al., 2000).

To summarise, policy directives in the area of caring for marginally viable and critically ill newborns needs to be conversant across the multiple paradigms and perspectives that inform this area of neonatal practice. This includes an understanding of the psychological, social, cultural, ethical and political dimensions of caring for marginally viable and critically ill newborns. This approach generates breadth of knowledge and a depth of understanding of both nursing and societal perspectives of caring for these babies. The discourse of these perspectives makes an important contribution to the development of our knowledge about palliative care in a neonatal context. As described, the context of providing care to marginally viable and critically ill newborns is emotive, and controversial. Regardless of decisions made on behalf of these newborns, and by whom, there are a myriad of stakeholders affected by these decisions. Ultimately, these stakeholders are represented within society as parents and families, and are buoyed, influenced and even encumbered by the greater influences of societal mores, public opinion and the media.

Conclusions

Changes in societal attitudes and models of care are necessary to achieve any real gain in quality end-of-life care for any population (Field and Cassel, 1997), and this is perhaps the most challenging aspect of moving palliative care forward as an international agenda for dying babies. This paper has referred to the education, research initiatives, that potentially could contribute to a stronger social consensus regarding this model of care.

Health care professionals in the NICU need to continue to strive to improve care for those who are most vulnerable in society, in this context dying babies and their families. Healthcare professionals and policymakers need to work together to make a difference in the lives of the babies they care for who are approaching the end of life.

Funding

The research received no specific funding for any funding agency in the public, commercial or not-for-profit sectors.

Conflict of interest statement

None declared.

Key points

Victoria Kain is a neonatal intensive care nurse and academic from the School of Nursing and Midwifery, The University of Queensland. Her research interests include many aspects of neonatal care, but in particular end of life and palliative care. Her professional profile can be found at http://www.nursing-midwifery.uq.edu.au/dr-victoria-kain-133083.

Obstructive sleep apnea and Atrial fibrillation

Abstract

Obstructive sleep apnea (OSA) is a growing concern in our population, due to its close association with obesity, which is becoming more prevalent by the year in America. There are many sequalae of this devastating disease, ranging from slight headaches, to cardiac problems which would in turn lead to death. One of these cardiac issues that could be incurred as a sequalae of OSA is paroxysmal atrial fibrillation (PAF). Currently, there are no guidelines for testing or monitoring patients who are diagnosed with OSA, and not experiencing symptoms of PAF, however, many patients with PAF can experience episodes of this debilitating disease without feeling the irregular heartbeats (silent atrial fibrillation). Patients who have silent atrial fibrillation will still experience the sequalae of PAF, however they will not experience the palpitations, and this will lead to them feeling tired, irritable and a plethora of other symptoms. The issue with this is that many of these symptoms overlap with the same symptoms of OSA, which would lead the patient to not suspect the possibility of having PAF. Guidelines must be put into place for patients who have been diagnosed with OSA to be tested in a sufficient manner for PAF.

Thesis Overview

Introduction

Obstructive sleep apnea is a disease which can cause many other medical issues for the patients who have it, one of the most dangerous being PAF, which is observed in about 50% of all patients suffering from OSA

¹

. When suffering from PAF, the patient will experience irregularly irregular heartbeats, which can lead to a clot formation in the heart (most commonly in the left atrial appendage) which can then go to the brain causing a stroke which can effect the patient in many ways, including death. Though there are many ways to test for OSA, and there are many ways to test for PAF, there are no guidelines, in or set methods place for testing patients who suffer from OSA regularly and vigilantly for PAF. While the link between OSA and PAF is still not widely known to many medical providers, it is extremely important to properly test and monitor patients suffering from OSA for development of PAF.

Research Problem

The difficulty in diagnosing a patient with PAF is where most of the problem lies. PAF is an intermittent form of atrial fibrillation, which, while the patient is not in the arrythmia, is completely undetectable. The best way to diagnose this possibly fatal arrythmia is to catch it in the act. The problem with this is that unless the patient knows specifically what their trigger is, they do not know when they will go into an episode of AF. The testing methods for PAF include EKG, Ambulatory electrocardiogram (AECG), event monitor, and an implantable loop recorder of which the latter is considered to be more invasive yet, has much higher success rates in catching episodes of PAF,  while the first three are far less likely to capture an episode of PAF.

Research Question

Following a diagnosis of OSA, 50% of patients will develop PAF. How can the initiation of aggressive testing and monitoring of this population of patients through an implantable loop recorder help lower the morbidity and mortality in the population of patients who suffer from OSA? Can episodes of PAF be more consistently caught through an implantable loop recorder, rather than the other methods of testing for it? Can earlier detection of PAF in patients who suffer from OSA, and earlier initiation of preventative measures such as anticoagulation or EP study and ablation lead to lower morbidity and mortality rates?

Hypothesis

The hypothesis is that through initiating a protocol to implant a loop recorder in every patient who is diagnosed with OSA, at first diagnosis of OSA, it could be possible to catch a diagnosis of PAF at an earlier and more treatable stage. This would lead to an improved quality of life, as well as significantly lower morbidity and mortality rates in patients who are diagnosed with OSA.

Purpose of research

The purpose of this research is to determine if there should be new guidelines in place for patients who are diagnosed with OSA to have an implantable loop recorder placed to help diagnose the sequalae of PAF in this population of patients who suffer from this at a higher than normal rate. While the implantation of a loop recording device is considered invasive, it is still questionable as to whether the benefits outweigh the risks in this subset of patients.

Methodology

Peer reviewed articles obtained from the Nova Southeastern University Alvin Sherman Library were used heavily in the research for this study. National Center for Biotechnology Information (NCBI) was the main database used to search for the peer reviewed articles used to gather information for this report.

Physiology: Atrial Fibrillation

Atrial fibrillation is a common arrhythmia which arises from the atrium. In fact, it is so common, that 6.1 million people in the United States have been diagnosed with this condition, and it is actually the most common tachyarrhythmia encountered by physicians. The arrhythmia is caused by an abnormality in the electrical pathways of the atrium of the heart which cause rapid misfiring of the ectopic cells, which lead to an irregularly irregular heart beat. With the normal conduction pathway of the heart going from the SA node, to the AV node and down to the ventricles from there, Atrial fibrillation differs in the sense that the electronic signals do not pass through the AV node into the ventricles in the normal predictable patterns, and instead cross through the AV node in an unpredictable and disorganized pattern, thus leading to the irregularly irregular heartbeat. This arrhythmia will lead to an insufficient cardiac output, which could eventually lead to a cardioembolic formation, which can then travel to the brain through the aorta, and carotid arteries, causing a potentially fatal stroke. Atrial fibrillation can be paroxysmal which means that the patient will experience episodes of paroxysmal atrial fibrillation intermittently and the episodes will likely resolve on their own with no intervention. There is also persistent atrial fibrillation, as well as silent atrial fibrillation. In persistent atrial fibrillation, the patient will not spontaneously convert back to normal sinus rhythm, and will need intervention of either antiarrhythmics, or synchronized cardioversion. Silent atrial fibrillation is when a patient will experience episodes of atrial fibrillation, however they do not feel any of the symptoms of atrial fibrillation, and most patients who have silent atrial fibrillation do not even know they suffer from this arrhythmia.

Physiology: Obstructive Sleep Apnea

Obstructive Sleep Apnea (OSA) is when the patient experiences intermittent apneic episodes through the night while they sleep. This is caused by the collapse of the pharyngeal airway during the patients sleep. The amount of times this happens throughout the night is measured by the apnea hypopnea index (AHI) which is the amount of apneic episodes the patient experiences per hour through the night. An apneic episode is defined by the patient not breathing for at least 10 seconds during their sleep. The apneic episode will lead to a drop in the patients Oxygen saturation, which can lead to a plethora of medical conditions ranging from hypertension, congestive heart failure, and atrial fibrillation.

Correlation: OSA and PAF

Positive correlations between patients who suffer from OSA and those who suffer from PAF, with the PAF being developed in the patient subsequent to the development of OSA. In fact in one study it was shown that there was a four hundred percent increase in the odds of developing atrial fibrillation in patients who experience sleep disordered breathing, opposed to those who do not have these medical issues

²

.  This study also showed a positive correlation between patients with OSA and cardiac remodeling, which means that the longer a patient has OSA, the more likely they are to experience PAF. There are many mechanisms which are theorized as to why patients with OSA have a higher risk of PAF, which include intrathoracic pressure changes, and decreased oxygen saturation which lead to fluctuating blood pressures and cardiac remodeling.

Correlation: OSA and CVA

It has already been established that PAF is more prevalent in patients who experience OSA, however it is worth noting that the incidence of patients who suffer from CVA is also significantly higher in this patient population. In one study, it was proven that the group of patients with OSA being studied had a higher incidence rate of CVA than the control group

³

. The incidence of these strokes were suggested to have a higher incidence rate because they have a cardioemblic origin secondary to the PAF which had been developed in the patient. This study showed that when the patients in this study were treated in a sufficient amount of time with anticoagulation therapy, that the incidence rate for stroke was far lower than in the patients that had PAF and had not been treated in time with anticoagulation therapy. In the same study, it was shown that there was a direct correlation to the development of PAF, as well as the occurrence of strokes in the patient population which had been diagnosed with OSA.

Testing for PAF

As stated before, there are multiple ways to test a patient for PAF, including electrocardiogram (ECG), ambulatory electrocardiogram (AECG), Event monitor, loop recorder and even an electrophysiology study (EPS). The issue with ECG, event monitors and AECG however is that if the patient is not currently experiencing the episode of PAF, there will be no evidence of previous episodes left behind. While the ECG, AECG, and event monitors are all the most minimally invasive and most cost effective, the EPS is the most invasive in the fact that a catheter is threaded into the left atrium, and the arrhythmia is elicited through multiple methods. The test involving the loop recorder is somewhat more invasive than the ECG, AECG, and event monitor, however not nearly as invasive as the EPS. The procedure includes placing the loop recorder just under the skin in the chest wall, and is effective in its monitoring for up to three years. Because this device is constantly recording for the duration of its lifetime, this leads to an improved capture rate of an arrhythmia when compared to the other methods discussed.

Literature review

One study done in 2019 helped to prove the correlation between the increased Apnea Hypopnea Index (AHI) seen in patients with OSA, and left atrial abnormalities. The study was done with a cohort of 261 patients with a mean age of 57 years old, and 52% males. The study would be considered a case report study, where the researchers searched through the records of patients who have received sleep studies, as well as 12 lead EKG’s, and this data was used to measure any change in the patients P wave area in V1 (PWAV1). This is significant if the fact the due to the pathophysiology of PAF, any change in the P wave area in V1 would be a significant risk factor for patients to develop PAF

⁴

The study showed (with a P value of 0.005) that there was in fact a clear correlation between patients having OSA and changes in their PWAV1. Not only were these changes noted, but there was also evidence that patients with OSA in this study also showed a significant drop in O2 saturation due to the apneic events, showing that this lowered state of oxygenation also contributes to the PWAV1 changes over time, thus leading to the formation of electrical pathways in the atrium which are the cause of PAF.

According to another study done in 2019, it was shown that out of the 25 patients who were fitted with an AECG to test for signs of PAF secondary to OSA, all 25 did not show any sign of PAF, however with implantable loop recorders in place in the same cohort of patients, 5 of these patients did show episodes of PAF

⁵

. This study was conducted with a cohort of 25 patients who had recently been diagnosed with severe OSA (AHI >30) with no history of atrial fibrillation and are over the age of 18. These patients underwent two 24 hour AECG tests, one month apart, followed by an implantation of a loop recorder, and follow up appointments for the next 3 years, every 6 months.

The episodes of PAF in these patients were greater than 10 seconds in length, and the average duration of the episodes lasting 4.8 hours. The average time for the loop recorder to pick up an episode of PAF was between 4-18 months, which may seem like a large range, however when it is taken into account that the patients wearing the AECG only wore them for a total of 24 hours, it becomes clear that with the range being 4-18 months, and the episodes only lasting an average of 48 hours, to catch an episode of PAF, one 24 hour monitor is insufficient. In most cases, the use of a 24 hour monitor is the only testing a patient will receive for PAF, and the initial treatment is not until the patient first suffers from a transient ischemic attack (TIA).

Showing the relationship between PAF and OSA is also quite important in coming to a conclusion on the appropriate treatment plan for patients who suffer from PAF secondary to OSA. According to a study done by Kamel Hooman, and Jeff Healy in 2018, cardioembolic embolism is responsible for a significant proportion of ischemic strokes. With further information being gathered over recent years, ischemic strokes that had previously been attributed to an idiopathic origin, are now being attributed to the presence of PAF. This study goes on to explain that many previous studies required two separate episodes of PAF on two separate occasions to be monitored on EKG to be considered for antithrombotic therapy, however with implantable devices such as pacemakers and defibrillators becoming more prevalent, the detection of episodes of silent PAF has become significantly more common through these modalities

⁶

. According to the same study, it only takes one 6 minute episode of PAF to form the possibly life threatening emboli.

Anticoagulation in patients with PAF is of the utmost importance to prevent a stroke, and the sooner the patient is started on the anticoagulation therapy, the lower the chances of developing a stroke of cardioembolic origin. The method to assess if the patient is indeed in need of anticoagulation therapy is the CHA2DS2-VASc score, where many factors are taken into account such as congestive heart failure, hypertension, age, diabetes, or previous stroke (or transient ischemic attack (TIA)), and sex. If the patient has a CHA2DS2 score of 1 then they are at low/ intermediate risk, and anticoagulation therapy should be considered, while a score of 2 is a moderate to high risk and anticoagulation is strongly recommended

⁷

.

According to the AHA guidelines, the first line therapy for patients with atrial fibrillation, wither persistent or paroxysmal, is warfarin therapy, titrated to an INR of between 2-3. For patients who are not willing to, can not use warfarin, the option of apixaban is the next choice, however there is currently no approved reversal agent for this therapy

⁸

.The sooner the patient is started on anticoagulation therapy after being diagnosed with the atrial fibrillation, the lower their risk of actually suffering from the debilitating effects of a cardioembolic event.

Discussion

Implications for the PA profession

The ability to catch episodes of PAF, in a more timely manner will lead to the provider being able to start life preserving measures sooner rather than later in the course of the patients treatments. The earlier detection of episodes of PAF (even more so silent episodes of PAF) through the use of an implantable loop recorder will significantly improve the outcome of the patient, and reduce the further treatment being needed from the provider due to further sequalae of the cardioembolic effects of PAF. By creating a new guideline to implant a loop recorder in all patients at first diagnosis of OSA who do not already have a diagnosis of PAF, this would lead to a more comprehensive, and thorough examination of the patient rather than intermittent testing for PAF as seen with an EKG, AECG, or event monitor.

Strengths of research

When analyzing the articles for this report, it was noted that the articles had many strengths associated with them. The articles included many explanations of mechanisms, from mechanisms of action, or pathophysiology of the disease states, the mechanisms were all stated and explained well. Furthermore, the data was presented with complete transparency, and well organized. The methods of research in all the reports were well explained and the most recent data was used as resources for their studies, which shows that proper research protocol was followed.

Weaknesses of research

There was not much weakness which was observed through the research which was being conducted, however there was one incidence of weakness which stood out the most to me. In the study which shows the issue with using AECG opposed to an implantable loop recorder to test for PAF, the cohort only included 25 people, and while 20% of the patients showed episodes of PAF with an implantable loop recorder, and this is a significant value, it is not strong evidence in the fact that it is based on such a small cohort. Furthermore, while that study did involve intense follow up with the patients, many of the studies which were included did not show this as part of their research.

Recommendations for future research

In future research it would be quite beneficial to include intensive follow up on the patients who do have OSA, but were not observed to have an episode of PAF. Some patients will tend to develop this issue over many years (>10 years), and the longest study involved in the research only went up to three years. If further follow up with these patients showed episodes of PAF as the OSA developed, it could show more of a correlation between OSA and PAF. In future research, larger cohorts could be used to give the study a stronger power.

Conclusion

The correlation between OSA and the development of PAF has been well proven, as well as the correlation between PAF and CVA, thus showing the correlation between OSA and CVA. With proper management of anticoagulation therapy in a timely manner secondary to detecting the arrhythmia through implantable loop recorder, the morbidity and mortality related to PAF secondary to OSA could be reduced significantly.

References

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