Is a history of open heart surgery a reason to order a sleep study in a patient with potential cardiovascular disease?

History of Open Heart Surgery and Sleep Study Indication

A history of open heart surgery alone is not a reason to order a sleep study, but patients with prior cardiac surgery who have cardiovascular disease should be screened for obstructive sleep apnea (OSA) symptoms, and those with nocturnal symptoms or risk factors warrant formal polysomnography. 1

Risk-Based Screening Approach

The decision to order a sleep study depends on the clinical context rather than surgical history alone:

High-Risk Patients Who Warrant Sleep Testing

Patients with cardiovascular disease and nocturnal symptoms should undergo sleep testing, including those with: 1

• Coronary artery disease with nocturnal symptoms (snoring, witnessed apneas, gasping/choking at night) 1
• Systolic or diastolic heart failure (Standard recommendation) 1
• History of stroke or transient ischemic attacks (Option recommendation) 1
• Significant tachyarrhythmias or bradyarrhythmias (Guideline recommendation) 1
• Congestive heart failure with persistent nocturnal symptoms despite optimal medical management (Standard recommendation) 1
• Hypertension that remains uncontrolled despite optimal medical management 1

Specific Symptoms That Trigger Sleep Study Consideration

The following nocturnal symptoms in a patient with prior cardiac surgery warrant diagnostic polysomnography: 1

• Witnessed apneas or respiratory pauses 1
• Snoring 1
• Nonrestorative sleep and/or excessive daytime sleepiness 1
• Early morning headaches 1
• Unexplained desaturation or hypoxemia during sleep or while awake 1
• History of poorly controlled hypertension or congestive heart failure 1
• Memory loss or difficulty with concentration 1

Clinical Rationale

OSA is highly prevalent in cardiovascular disease populations and significantly impacts perioperative outcomes. The 2024 AHA/ACC guidelines note that approximately 34% of men and 17% of women aged 40-60 years meet diagnostic criteria for OSA, with even higher prevalence in those with cardiovascular disease. 1

In cardiac surgical populations specifically, the incidence of unrecognized OSA is remarkably high at 61.4%, with 43.5% having moderate to severe disease. 2 This underscores the importance of symptom-based screening rather than routine testing.

OSA is associated with serious cardiovascular complications including hypertension, atrial fibrillation, heart failure, coronary artery disease, stroke, and increased cardiovascular mortality. 1 In surgical patients, OSA increases the risk of postoperative myocardial injury, cardiac death, heart failure, thromboembolism, atrial fibrillation, and stroke within 30 days of surgery. 1

When NOT to Order a Sleep Study

Routine screening polysomnography is not recommended for asymptomatic patients, even those with prior cardiac surgery. 1 The American Society of Hematology guidelines (applicable to general populations) suggest against screening with formal polysomnography in asymptomatic individuals, emphasizing instead a comprehensive sleep history and review of systems. 1

For patients undergoing future low-risk surgery, no additional cardiac or sleep testing is indicated regardless of cardiac history if they are asymptomatic and in optimal medical condition. 3, 4

Practical Implementation

Use validated screening tools first: The STOP-Bang questionnaire has 75.8% sensitivity in predicting apnea-hypopnea index ≥5/hour and should be the initial screening approach. 2 Other validated tools include the Epworth Sleepiness Scale and Pittsburgh Sleep Quality Index. 1

Order polysomnography only when: 1

• Screening questionnaires identify high-risk patients with nocturnal symptoms
• The patient has cardiovascular disease with uncontrolled symptoms despite optimal medical management
• Results will change perioperative management or lead to initiation of positive airway pressure therapy

Critical Pitfall to Avoid

Do not order routine sleep studies in all patients with prior cardiac surgery. This represents low-value care and is not supported by guidelines. 1 Instead, focus on symptom-directed evaluation using validated screening questionnaires, reserving formal polysomnography for those with positive screens or high-risk features. 1