Late-Night Calls Do Not Adversely Affect Operators’ Next-Day PCI

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Being called out in the middle of the night for emergent percutaneous coronary intervention (PCI) does not seem to impair an operator’s ability to perform safely the next day, according to a small single-center study published online March 30, 2012, ahead of print in Catheterization and Cardiovascular Interventions.

Vitalie Crudu, MD, and colleagues of Geisinger Medical Center (Danville, PA), looked at 3,944 PCIs performed at their center by 4 operators over a 5-year period from 2005 through 2009, identifying 167 instances in which the same operator performed a procedure between 11:00 p.m. and 7:00 a.m. and another the next workday. The latter cases, which were considered sleep-deprived, were compared with 3,644 non-sleep-deprived cases for procedural efficacy and complications.

The 2 groups were similar with respect to demographics, comorbidities, and procedural characteristics, although previous PCIs were more common in the non-sleep-deprived group (27.3% vs. 19.8%; P = 0.04).

PCI ‘the Day After the Night Before’

Although there were differences in efficacy outcomes (as defined by the National Cardiovascular Data Registry) between the non-sleep-deprived and sleep-deprived groups, they were small and went in different directions, leading the authors to conclude that the differences are likely not clinically significant (table 1).

Table 1. Efficacy of Sleep-Deprived vs. Non-Sleep Deprived PCI

 

Non-Sleep-Deprived
(n = 3,644)

Sleep-Deprived
(n = 167)

P Valued

Complete Successa

96.2%

96.4%

0.03

Partial Successb

1.2%

3.0%

Complete Failurec

2.7%

0.6%

a All lesions treated successfully with residual stenosis of < 50%.
b At least one attempted lesion with residual stenosis of 50% or more.
c All attempted lesions with residual stenosis of 50% or more.
d For all 3 interdependent categories.

Overall, rates of several operator-dependent complications were similar between sleep-deprived and non-sleep-deprived cases (adjusted OR 0.61; 95% CI 0.31-1.22; P = 0.16). Intraprocedural death occurred more frequently in the sleep-deprived group, but after multivariable adjustment the difference was no longer significant (adjusted OR 6.83; 95% CI 0.66-39.63; P = 0.11). Paradoxically, excessive access site bleeding was more common in the non-sleep-deprived cases (table 2).

Table 2. Operator-Dependent Complications

 

Non-Sleep-Deprived
(n = 3,644)

Sleep-Deprived
(n = 167)

P Value

Intrprocedural Death

0.2%

1.2%

0.04

Emergent CABG

0.3%

0

0.99

Coronary Artery Perforation

0.5%

0

0.99

Periprocedural MI

3.5%

1.8%

0.66

Vessel Dissection

1.3%

1.2%

0.99

Excessive Access Site Bleeding

2.7%

0

0.02


In addition, the incidence of any complication before discharge for the 4 operators ranged from 10.4% to 12.7%, with no differences among them (P = 0.4).

In a telephone interview with TCTMD, Sorin J. Brener, MD, of Weill Cornell Medical College (New York, NY), said that although this analysis has significant weaknesses, it is of interest because—unlike studies that have simply looked at outcomes of off-hour procedures—it specifically examined next-day procedures done by sleep-deprived operators.

Results May Not Be Representative

But in a telephone interview with TCTMD, William J. French, MD, of the David Geffen School of Medicine at UCLA (Los Angeles, CA), questioned how representative the results are of the wider interventional community.

Dr. Crudu did not disagree. He told TCTMD in a telephone interview that “even though the results are quite reassuring at our institutional level, we should be cautious about concluding that operator fatigue doesn’t play a role in PCI procedures.”

Specifically, he observed that, unlike in this study, interventionalists at high-volume centers may have to come in more than once during a night and so may be more fatigued the next day, which could potentially have a significant impact on the safety of any procedures they perform.

Dr. French also noted that as interventional cardiologists expand their practice to include 24-hour STEMI receiving centers, they have to accept the fact that they need rest.

“When you are tired, you are not going to do the same kind of meticulous work as when you are not tired,” he said. “We have to get the idea that you can’t work forever and expect to have the same results.”

Dr. Crudu recommended that future research mine large databases for a possible relationship between sleep deprivation and compromised PCI safety and efficacy. He also suggested evaluating other procedural characteristics such as fluoroscopy times, amount of contrast used, and overall duration of the procedure, which may be more sensitive markers of operator fatigue.

Meanwhile, it would be prudent for sleep-deprived interventionalists to minimize risk by handing off emergency cases to rested colleagues whenever possible and avoiding ad hoc elective high-risk PCI, the authors say.

Study Details

Each operator was on call 1 night in 4 and had sleep interrupted by a night-time primary PCI case approximately once in every 6 call nights. All the interventionalists lived within 10 minutes of the hospital and took call from home. For an after-hours PCI, the typical time from out of bed to back in bed was about 3 hours, although some operators routinely had trouble falling asleep after a procedure.

 


Source:
Crudu V, Sartorius J, Berger P, et al. Middle-of-the-night PCI does not affect subsequent day PCI success and complication rates by the same operator. Catheter Cardiovasc Interv. 2012;Epub ahead of print.

 

 

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Disclosures
  • Drs. Crudu, Brener, and French report no relevant conflicts of interest.

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