Physicians are prone to suffering from acute and/or chronic sleep deprivation, which is a problem that has been mostly examined among medical trainees in relation to resident-physician work hours.^1-4 Limited research exists within interventional cardiology, with only three studies published to date on the impact of operator sleep deprivation on the outcomes among patients undergoing percutaneous coronary intervention (PCI).^5-7

Expert consensus recommendations suggest that adults should sleep a minimum of 7 hours per night on a regular night to promote optimal health.⁸ Sleep deprivation can be categorized as acute, defined as a reduction in usual total sleep time, or chronic when affecting individuals for at least 3 months.^9-10 It has been associated with adverse health outcomes; those affected may manifest fatigue, impaired performance, daytime sleepiness, cognitive deficits, reduced psychomotor vigilance, workplace errors and injuries, mood disturbances, personal conflicts, less empathy for patients, or poor communication skills with patients and family members (Figure 1).^9,11-13

Figure 1

Potential Impact on Patient Care

Whether sleep deprivation affects patient care and clinical or procedural outcomes, such as procedural time, procedural success, complication rates, and mortality, remains a matter of debate. Rothschild et al. examined procedures that were performed by surgeons and obstetricians/gynecologists the day after overnight work; overall complication rates were similar, although performance after ≤6 hours of sleep was associated with higher complication rates.¹⁴ Most studies examining the impact of sleep deprivation on the outcomes of PCI did not demonstrate an association with "hard" outcomes; however, other studies and a recent survey analysis suggest that other metrics may be affected.¹⁵

The largest study addressing sleep deprivation and PCI outcomes was a National Cardiovascular Data Registry analysis of 1,509,096 PCIs performed by 5,014 operators. Operators who had performed at least 1 middle-of-the-night PCI procedure earlier that day performed 2.4% of all daytime PCIs. The adjusted incidence of procedural death (odds ratio [OR] 1.02; 95% confidence interval [CI], 0.94-1.12; p = 0.61) or bleeding (OR 1.03; 95% CI, 0.98-1.08; p = 0.19) was similar for PCIs performed by sleep-deprived and non-sleep-deprived operators.⁷ A study by Iverson et al. found that among 12,680 daytime PCIs, 367 (2.9%) were performed by sleep-deprived operators. There was no significant difference in technical success (96.4% vs. 96.9%, p = 0.18), procedural success (94.3% vs. 94.6%, p = 0.34), major procedural complications (2.2% vs. 2.9%, p = 0.42), and bleeding events within 72 hours (3.9% vs. 2.9%, p = 0.29). However, procedures performed by operators who had long sleep interruptions were less likely to develop access site bleeding compared with those performed by operators who had short sleep interruptions (3.8% vs. 0.0%, p = 0.02).⁶ Crudu et al. in 2012 also found no evidence that middle-of-the-night procedures adversely affected safety or efficacy of procedures done by the same operator the next day.⁵

Overall, studies to date do not indicate an impact of sleep deprivation on patient and procedural outcomes. Data, however, show higher bleeding rates among operators with greater degrees of chronic sleep deprivation (OR 1.19; 95% CI, 1.05-1.34; p = 0.007); this area requires further study.

Potential Impact of Sleep Deprivation on Physician Health: An Occupational Hazard?

Sleep deprivation may impact not only patient care, but also physician health. Sleep deprivation has adverse metabolic impact and increases the risk for developing metabolic syndrome, type 2 diabetes mellitus, dyslipidemia, and hypertension.^16,17 It may also lead to motor vehicle accidents or near-miss incidents.¹⁸ The impact of these issues among interventional cardiologist has not received sufficient attention.

There are well-known occupational hazards in interventional cardiology, including orthopedic injuries, infectious hazards (needle sticks, sharp injuries), and radiation exposure.¹⁹ The negative health consequences of sleep deprivation suggest that sleep deprivation should be added to this list.

The Need for a Cultural Change: No Longer a Badge of Honor

Sleep deprivation does not exclusively affect the interventionalist. It also affects the entire on-call team, including nurses and technicians. Several recommendations have been proposed to minimize the impact of sleep deprivation (Table 1). Some practices allow "early leave" post-call for some cardiologists, but this method is not widespread and is also determined by the number of interventionalists in each practice.

Table 1: General Recommendations for the "Post-Call" Day

DOs	DON'Ts
Take advantage of break times to rest and nap.	Schedule complex PCI or chronic total occlusions.
Ask for help from partners if needed.	Drink excessive caffeine.
Eat healthy and exercise lightly if possible.	Drive long distances and avoid heavy traffic.
Leave home early the day after if your practice allows it.	Pick up another call the following night.
Go to sleep early that day.	Excessively use digital devices.

In conclusion, interventional cardiologists are prone to acute and chronic sleep deprivation,¹⁰ and there is a need for increased awareness and adoption of measures to prevent its negative impact on patient care and physician health.

References

1. Landrigan CP, Rothschild JM, Cronin JW, et al. Effect of reducing interns' work hours on serious medical errors in intensive care units. N Engl J Med 2004;351:1838-48.
2. Lockley SW, Cronin JW, Evans EE, et al. Effect of reducing interns' weekly work hours on sleep and attentional failures. N Engl J Med 2004;351:1829-37.
3. Arnedt JT, Owens J, Crouch M, Stahl J, Carskadon MA. Neurobehavioral performance of residents after heavy night call vs after alcohol ingestion. JAMA 2005;294:1025-33.
4. Ayas NT, Barger LK, Cade BE, et al. Extended work duration and the risk of self-reported percutaneous injuries in interns. JAMA 2006;296:1055-62.
5. Crudu V, Sartorious J, Berger P, Scott T, Skelding K, Blankenship J. Middle-of-the-night PCI does not affect subsequent day PCI success and complication rates by the same operator. Catheter Cardiovasc Interv 2012;80:1149-54.
6. Iverson A, Stanberry L, Garberich R, et al. Impact of sleep deprivation on the outcomes of percutaneous coronary intervention. Catheter Cardiovasc Interv 2018;Jan 3:[Epub ahead of print].
7. Aronow HD, Gurm HS, Blankenship JC, et al. Middle-of-the-night percutaneous coronary intervention and its association with percutaneous coronary intervention outcomes performed the following day: an analysis from the National Cardiovascular Data Registry. JACC Cardiovasc Interv 2015;8:49-56.
8. Consensus Conference Panel, Watson NF, Badr MS, Belenky G, et al. Recommended Amount of Sleep for a Healthy Adult: A Joint Consensus Statement of the American Academy of Sleep Medicine and Sleep Research Society. J Clin Sleep Med 2015;11:591-2.
9. Banks S, Dorrian J, Basner M, Dinges DF. "Sleep Deprivation." In: Kryger M, Roth T, Dement WC, eds. Principles and Practice of Sleep Medicine. 9th ed. Philadelphia: Elsevier; 2017:49-55.
10. American Academy of Sleep Medicine. International Classification of Sleep Disorders. 3rd ed. Darien, IL: American Academy of Sleep Medicine; 2014.
11. Sandoval Y, Lobo AS, Somers VK, et al. Sleep deprivation in interventional cardiology: Implications for patient care and physician-health. Catheter Cardiovasc Interv 2018;91:905-10.
12. Abrams RM. Sleep Deprivation. Obstet Gynecol Clin North Am 2015;42:493-506.
13. Gaba DM, Howard SK. Patient safety: fatigue among clinicians and the safety of patients. N Engl J Med 2002;347:1249-55.
14. Rothschild JM, Keohane CA, Rogers S, et al. Risks of complications by attending physicians after performing nighttime procedures. JAMA 2009;302:1565-72.
15. Lobo AS, Sandoval Y, Burke MN, et al. Sleep Deprivation in Cardiology: A Multidisciplinary Survey. J Am Coll Cardiol 2018;71:A2632.
16. Schmid SM, Hallschmid M, Schultes B. The metabolic burden of sleep loss. Lancet Diabetes Endocrinol 2015;3:52-62.
17. Kecklund G, Axelsson J. Health consequences of shift work and insufficient sleep. BMJ 2016;355:i5210.
18. Barger LK, Cade BE, Ayas NT, et al. Extended work shifts and the risk of motor vehicle crashes among interns. N Engl J Med 2005;352:125-34.
19. Chambers CE. Occupational health risks in interventional cardiology: expected inherent risk or preventable personal liability? JACC Cardiovasc Interv 2015;8:628-30.

Keywords: Angiography, Sleep Deprivation, Empathy, Sleep, Surgeons, Wakefulness, Patient Care, Percutaneous Coronary Intervention, Cognition, Metabolic Syndrome, Diabetes Mellitus, Type 2, Dyslipidemias, Risk, Hemorrhage, Registries, Hypertension

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