Background: Acute intraoperative hypercapnia and respiratory acidosis, which can occur during monitored anaesthesia care (MAC), pose significant cardiopulmonary risks for patients with aortic stenosis undergoing transcatheter aortic valve replacement (TAVR). The goal of the present study is to assess the incidence, risk factors and impact of intraoperative hypercapnia during MAC for patients undergoing transfemoral TAVR.
Methods: Data was collected retrospectively from the electronic medical record of 201 consecutive patients with available intraoperative arterial blood gas (ABG) data who underwent percutaneous transfemoral TAVR with MAC using propofol and dexmedetomidine. ABGs (pH, arterial partial pressure of carbon dioxide (PaCO2) and arterial partial pressure of oxygen) were performed at the start of each case (baseline), immediately prior to valve deployment (ValveDepl), and on arrival to the postanaesthesia care unit. Data was analysed using Fisher's exact test, unpaired Student's t-test, Wilcoxon rank sum or univariate linear regression as appropriate based on PaCO2 and pH during ValveDepl (PaCO2-ValveDepl, pH-ValveDepl) and change in PaCO2 and pH from baseline to ValveDepl (PaCO2-%increase, pH-%decrease) to determine their association with preoperative demographic data, intraoperative anaesthetic and vasoactive medications and postoperative outcomes.
Results: PaCO2 increased by a mean of 28.4% and was higher than baseline in 91% of patients. Younger age, male sex, increased weight and increased propofol dose contributed to higher PaCO2-ValveDepl and greater PaCO2-%increase. Patients with PaCO2-ValveDepl>60 mm Hg, pH≤7.2 and greater pH-%decrease were more likely to receive vasoactive medications, but perioperative PaCO2 and pH were not associated with adverse postoperative outcomes.
Conclusions: Transient significant hypercapnia commonly occurs during transfemoral TAVR with deep sedation using propofol and dexmedetomidine. Although the incidence of postoperative outcomes does not appear to be affected by hypercapnia, the need for vasopressors and inotropes is increased. If deep sedation is required for TAVR, hypercapnia and the need for haemodynamic and ventilatory support should be anticipated.
Background: Studies comparing the safety of orexin receptor antagonists and other hypnotic types for older patients with heart failure (HF) remain lacking. This study aimed to compare orexin receptor antagonists (suvorexant) with benzodiazepines or Z-drugs for sleep treatment and investigate the risk of acute HF-related rehospitalisation in older patients with HF.
Methods: This study used a cohort design to analyse data from an administrative claims database from April 2008 to December 2020. The study population was determined based on inclusion and exclusion criteria from a cohort of 1 159 937 patients aged ≥65 years, selected through random sampling. The follow-up period was censored based on multiple criteria, including outcome occurrences and hypnotic classification changes. Kaplan-Meier survival analysis and Cox proportional hazards models were conducted for risk assessment.
Results: The analysis included 1858 patients, aged ≥65 years and experiencing their first HF-related hospitalisation. These patients were categorised based on the initially prescribed hypnotic classification, including suvorexant, benzodiazepines and Z-drugs in 490, 606 and 762 patients, respectively. The average age and SD were similar across all hypnotic classes at 82.7±7.6 years. Kaplan-Meier curves indicated a higher trend of rehospitalisation risk for benzodiazepines and Z-drugs than for suvorexant. The adjusted HRs were 2.77 (95% CI 1.17 to 6.52) for benzodiazepines and 2.98 (95% CI 1.33 to 6.68) for Z-drugs.
Conclusions: Suvorexant administration for sleep treatment in older patients with HF shows a potentially reduced risk of acute HF-related rehospitalisation compared with benzodiazepines and Z-drugs. The results of this study provide valuable information for selecting hypnotics in older patients with HF having concurrent sleep disorders.
Background: The COVID-19 pandemic disrupted cardiovascular disease management in primary care in England.
Objective: To describe the impact of the pandemic on blood pressure screening and hypertension management based on a national quality of care scheme (Quality and Outcomes Framework, QOF) across key demographic, regional and clinical subgroups.
Methods: With NHS England approval, a population-based cohort study was conducted using OpenSAFELY-TPP on 25.2 million NHS patients registered at general practices (March 2019 to March 2023). We examined monthly changes in recorded blood pressure screening in the preceding 5 years in patients aged ≥45 years and recorded the hypertension prevalence and the percentage of patients treated to target (≤140/90 mmHg for patients aged ≤79 years and ≤150/90 mmHg for patients aged ≥80 years) in the preceding 12 months.
Results: The percentage of patients aged ≥45 years who had blood pressure screening recorded in the preceding 5 years decreased from 90% (March 2019) to 85% (March 2023). Recorded hypertension prevalence was relatively stable at 15% throughout the study period. The percentage of patients with a record of hypertension treated to target in the preceding 12 months reduced from a maximum of 71% (March 2020) to a minimum of 47% (February 2021) in patients aged ≤79 years and from 85% (March 2020) to a minimum of 58% (February 2021) in patients aged ≥80 years before recovery. Blood pressure screening rates in the preceding 5 years remained stable in older people, patients with recorded learning disability or care home status.
Conclusions: The pandemic substantially disrupted hypertension management QOF indicators, which is likely attributable to general reductions of blood pressure measurement including screening. OpenSAFELY can be used to continuously monitor changes in national quality-of-care schemes to identify changes in key clinical subgroups early and support prioritisation of recovery from care disrupted by COVID-19.
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