Dr. Hitendra Patel, board certified in internal medicine, pulmonary disease, critical care and sleep medicine, and Medical Director of the WellStar Sleep Program in Georgia, would like to see his specialty partner more closely with cardiologists. Dr. Patel believes that when sleep specialists like himself work in tandem with cardiologists, they can help identify and prevent cardiovascular risks that can lead to stroke, sudden death and other cardiovascular threats to their patients’ lives.
Links between heart disease and sleep disorders have been clearly established, Dr. Patel said. And more links continue to be identified, he said. “We are learning more recently about the relationship between atrial fibrillation (AFib) and central sleep apnea. We all know that congestive heart failure and cardiomyopathy are related to central sleep apnea, but now we know AFib as well,” he said.
Dr. Patel has no doubt that the vast majority of cardiologists are aware of the links between the heart diseases they treat and sleep disorders, especially between obstructive sleep apnea (OSA) and atrial fibrillation (AFib), both of which are on the rise across the country. Because time is at such a premium in today’s medical practices and increasingly patients are presenting with comorbidities, logistics may prevent them from taking time to routinely add screening for OSA to their protocols.
The good news, Dr. Patel said, is such screening can be added with a reliable, concise, and easy-to-use questionnaire that takes no more than 2 minutes to administer to each patient. The questions are referred to as STOP-BANG for Snoring, Tiredness, Observed apnea, high blood Pressure, Body mass index, Age, Neck circumference, and Gender.1 Staff can ask the eight yes-no questions before cardiologists examine their patients and, if the results show a risk for moderate to severe OSA, cardiologists can know to order sleep testing at that visit.
SLEEP NAVIGATORS COULD BE THE SOLUTION FOR THE CARDIOLOGY PRACTICE
If cardiologists are afraid that they don’t have the time or staff to administer the test, they may be able to follow a model being considered at Wellstar, where appropriate sleep screening can be hard-wired into the cardiologists’ office. A sleep navigator can help facilitate this process. WellStar’s sleep navigator is a respiratory therapist. It’s a great start to a much-needed healthcare professional addition, Dr. Patel said.
Sleep specialists have seen a significant uptick in referrals from the sleep navigator taking on this role. “You clearly could see a direct correlation,” Dr. Patel said. “And the administration backed the position because the pro forma was there,” he added. The increase in referrals for sleep testing indicated that the cardiologists were flagging possible OSA in a good number of their patients that they might not have otherwise, he said.
Having someone from the sleep medicine department in the cardiologists’ office doesn’t interfere with the day-to-day workflow, Dr. Patel noted. “Cardiologists are aware of the sleep problem. They appreciate that someone is taking care of it for them.”
After review of the STOP-BANG results, cardiologists have three options: 1) refer the patient for an in-lab sleep test, 2) refer the patient for an at-home sleep test, or 3) refer the patient to a sleep specialist. Cardiologists will meet much less resistance from their patients when they refer them for an at-home sleep test, Dr. Patel said. Patients prefer the at-home test because it means they can sleep in their own bed and they find the home device very easy to use, Dr. Patel said. Also, the cost (co-pay) is likely lower for the home test than it is for the sleep lab test, Dr. Patel said. The quality of the at-home test results is comparable to in-lab tests, he noted.
COLLABORATION BETWEEN CARDIOLOGIST AND SLEEP SPECIALIST MAKES IT EASY FOR ALL
The cardiologist should have the results of the at-home sleep test within 24 hours, 48 hours at the most, Dr. Patel said. If the results show moderate to severe sleep apnea or other sleep disorders, the cardiologist can refer the patient to a sleep specialist. “As sleep specialists, we work in partnership with cardiologists. We ensure that that their patients get appropriate follow-up care for their sleep disorders,” Patel said. “We copy the cardiologist on the patient record and keep them informed as to how we are treating their patient. They are very happy with this type of collaboration. Cardiologists don’t have time to deal with the sleep aspect of their patients’ care. We try to make it as convenient as possible for the cardiologist.”
Dr. Patel believes that not just cardiologists but all specialists are seeing the tip of the iceberg when it comes to patients with sleep disorders. “I firmly believe there’s a huge undiagnosed population of patients with a variety of sleep disorders, and more and more comorbidities are identified every year as well as their relationships with other diseases. Heart issues are one of the longest established comorbidities for sleep disorders, and we are seeing more nuances on the relationship between sleep and the heart. As we learn more about sleep and how it’s affecting all parts of us, including the heart, we will see an increasing need to be vigilant about screening people for sleep disorders. Many patients walking around may be asymptomatic, but they could have sleep disorders that are affecting their heart and overall health.”
Dr. Patel is working to convince cardiologists that sleep testing is not just “an extra task to put on their plate,” but rather a valuable step they should incorporate in their practices to treat “the whole patient.” Sleep apnea may not be a cardiac condition per se, Dr. Patel said, but “it is a significant risk when cardiologists are treating patients for congestive heart failure, or atrial fibrillation, or really any other cardiac disease.”
Sleep may be “the new kid on the block” when compared to other health conditions that have been studied for centuries, Dr. Patel said. “It’s relatively a new field and we need to do ongoing research to discover more about sleep disorders because, you name it, sleep touches it. We do know that heart disease and sleep are closely related and that attention must be paid to this relationship. Sleep isn’t as ‘sexy’ a topic for people as the heart, but we have to take the relationship very seriously.”
Given the mounting evidence and the growing number of heart patients with sleep disorders, Dr. Patel said, it’s time for cardiologists and sleep specialists to work together and make screening for sleep disorders the standard of care.