Sleepless in the cath lab? Next-day patients still safe

Operators who pull an all-nighter in the cath lab don’t appear to put the patients they treat the next day at risk, according to one study. The likelihood of bleeding complications increased under the care of chronically sleep-deprived physicians, though.

Herbert D. Aronow, MD, MPH, of Michigan Heart in Ann Arbor, analyzed data from the National Cardiovascular Data CathPCI registry to compare outcomes in patients treated by interventional cardiologists who had performed a PCI the night before and operators who had not been on call the previous night. They defined a nighttime PCI as between midnight and 7 a.m. and the following day shift as 7 a.m. to midnight. Outcomes included risk-adjusted mortality and bleeding in the patients treated the next day.

They considered an operator to be acutely sleep deprived if he or she performed a middle-of-the-night procedure and then another procedure the next day between 7 a.m. and midnight. If he or she performed multiple nighttime and morning-to-midnight procedures over a week’s period, his or her status was considered chronically sleep deprived.

The study data spanned 2009 and 2012, with more than 1.5 million procedures done by 5,014 operators between 7 a.m. and midnight. Of those procedures, 2.4 percent were performed by interventional cardiologists who had treated a patient in the cath lab the middle of the night before and only 1.3 percent by chronically sleep-deprived operators.  

After adjusting for bleeding and mortality risks, Aronow et al found no difference in mortality, bleeding and PCI-related complications between sleep-deprived and rested operators. The chronically sleep-deprived operators also performed on par with rested operators on mortality but not bleeding. Adjusted bleeding rates for patients treated by chronically sleep-deprived physicians were 19 percent higher.

“[O]ur findings are reassuring for patients and practitioners alike that middle-of-the-night PCI does not appear to be associated with adverse patient outcome during subsequent day procedures, except in rare circumstances,” they wrote. “It is also reassuring that only a small proportion of PCI are performed by operators who also performed middle-of-the-night PCI procedures earlier on the same day.”

The researchers assumed that operators who burned the midnight oil and then performed procedures did not have any opportunities to sleep. In an accompanying editorial, Kirk N. Garratt, MD, MSc, of Lenox Hill Hospital in New York City, added that the researchers had no way of ascertaining that the “rested” physicians had sufficient sleep, either.

He described registry studies as “notoriously limited,” but wrote that the findings should give pause to advocates of policies to restrict physician activities in the cath lab based on late night and next day shifts. “Although these seem sensible and well meaning, no policy or legislation that restricts physician privileges can be justified without evidence of merit, and in the case of day-after angioplasty, the evidence is simply not there,” Garratt wrote.

The study was published in the January issue of the Journal of the American College of Cardiology: Cardiovascular interventions.