Only a small number of percutaneous coronary intervention (PCI) procedures are performed by operators who had completed at least one in the middle of the night, and there were no significant differences in mortality between acutely sleep-deprived and non-sleep-deprived operators, according to a study published Jan. 19 in JACC: Cardiovascular Interventions. The study did, however, find an increased risk of bleeding associated with procedures performed by those with chronic sleep deprivation.

Using data from the ACC's CathPCI Registry, researchers assessed more than 1.5 million procedures performed by 5,014 operators between 7 a.m. and midnight from July 1, 2009, through June 30, 2012. Operators were considered acutely sleep-deprived if they began a middle-of-the-night PCI between midnight and 6:59 a.m. and performed a next-day PCI between 7 a.m. and midnight. Researchers defined operators as chronically sleep-deprived if they had a performed multiple middle-of-the-night procedures during the previous seven days. Researchers also made the assumption that later start times for procedures performed the day after a night on-call involved the most sleep-deprived operators.

The study found that 2.4 percent of all daytime procedures, involving 36,049 patients, were performed by operators who had conducted at least one PCI in the middle of the night. This represents a small number – less than one in 40. When looking at mortality and bleeding outcomes after adjusting for risks, researchers found no significant differences for either variable between sleep-deprived and non-sleep-deprived operators. Of the 1.3 percent of all daytime procedures performed by operators with greater degrees of chronic sleep deprivation, they did see a significantly greater adjusted risk of bleeding – about a 20 percent increase.

"Although extended work hours among physicians have been associated with poor psychomotor performance, reduced alertness, and increased likelihood of medical errors, [we found] that operator sleep status is unlikely to influence in-hospital outcome following a PCI procedure," said the study's lead author, Herbert Aronow, MD, MPH, FACC, director of the comprehensive cardiovascular program at Michigan Heart in Ann Arbor, MI. "Both cardiovascular doctors and patients should be reassured [by these findings].”

In an accompanying editorial, Kirk N. Garratt, MSc, MD, FACC, of the Department of Cardiovascular Medicine at Lenox Hill Hospital in New York, raises an important question: "Why doesn't short-term sleep deprivation affect interventionalist performance?" In trying to answer that question, he wonders whether we have adapted to disrupted sleep or if "sleep deprivation is so pervasive that our baseline performance (the non-sleep-deprived cohort in this study) reflects chronic fatigue, making differences immeasurable."  While these issues are unresolved, sleep research shows that "newly learned skills are more vulnerable to the effects of sleep deficiency, whereas the accuracy of better-established skills may be maintained." Garratt also notes that in another study, bleeding complications were actually less common among sleep-deprived physicians, pointing to the need for "better understanding of the specific practice elements that affected bleeding" in this study.

Garratt concludes that "no signals of compelling safety concerns for short-term, sleep deprived interventional cardiologists have been found.” As a result, "no policy or legislation that restricts physician privileges can be justified... [because] in the case of day-after angioplasty, the evidence is simply not there.

Keywords: Angioplasty, Medical Errors, Michigan, New York, Percutaneous Coronary Intervention, Psychomotor Performance, Registries, Research, Research Personnel, Risk, Sleep, Sleep Deprivation

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