Can Inspire use cause bradycardia?

Inspire Use and Bradycardia

Yes, Inspire hypoglossal nerve stimulator use can cause bradycardia as a potential adverse event, though it is not among the most commonly reported complications.

Mechanism and Evidence

The Inspire device is an implantable hypoglossal nerve stimulator used for obstructive sleep apnea. While bradycardia is not listed among the most frequently reported adverse events in FDA MAUDE database reviews, it is biologically plausible due to:

1. Potential vagal stimulation effects during implantation or use
2. Possible autonomic nervous system interactions during sleep

The FDA MAUDE database reviews from 2020 and 2021 identified the most common adverse events as 1, 2:

• Infection (34.2%)
• Neuropraxia (15.1%)
• Hematoma/seroma (11.6%)
• Device migration

While bradycardia was not specifically highlighted in these reviews, autonomic effects can occur with nerve stimulation devices.

Management of Bradycardia if it Occurs

If bradycardia develops during Inspire use, management should follow established guidelines:

Assessment

• Determine if bradycardia is symptomatic (hypotension, altered mental status, chest pain, shortness of breath, dizziness) 3
• Check vital signs and assess for hemodynamic compromise

Treatment Algorithm

1. For asymptomatic bradycardia (heart rate >40 bpm without signs of hypoperfusion):

   • Generally requires no immediate treatment
   • Focus on identifying and addressing underlying causes 3
   • Consider temporarily adjusting Inspire settings

2. For symptomatic bradycardia:

   • Ensure adequate oxygenation and ventilation
   • Establish IV access
   • Administer atropine as first-line therapy:
     • Dose: 0.5-1 mg IV
     • Repeat every 3-5 minutes as needed
     • Maximum total dose: 3 mg 3, 4

3. If bradycardia persists after atropine:

   • Consider dopamine 5-20 mcg/kg/min IV infusion
   • Start at 5 mcg/kg/min and increase by 5 mcg/kg/min every 2 minutes as needed 3
   • Alternative agents:
     • Epinephrine: 2-10 mcg/min IV infusion 3
     • Isoproterenol: 2-10 mcg/min IV infusion (with caution) 3

4. For refractory cases:

   • Consider temporary pacing if bradycardia is persistent and symptomatic 5, 3

Prevention and Monitoring

For patients with Inspire devices:

• Monitor heart rate during device titration and adjustment
• Be particularly cautious in patients with:
  • Pre-existing cardiac disease
  • Conduction abnormalities
  • Concurrent use of medications that can cause bradycardia (beta-blockers, non-dihydropyridine calcium channel blockers, digoxin) 3

Clinical Considerations

• Patients with a history of bradyarrhythmias may need closer monitoring when using the Inspire device
• If bradycardia occurs repeatedly with device use, consider consultation with both sleep medicine and cardiology specialists
• Device setting adjustments may be necessary to balance effective OSA treatment with avoiding bradycardia

In cases where bradycardia persists despite management, temporary discontinuation of the Inspire device may be necessary until the underlying cause is identified and addressed.