A 58-year-old man comes to the office complaining of feeling tired and having poor sleep. He was diagnosed with myocardial infarction (MI) three months ago and underwent percutaneous coronary revascularization. According to the patient, it was a "scary and life-changing experience". He also complains of occasional headaches in the morning, dry mouth, and sore throat. Sometimes he wakes up in the middle of the night with a choking sensation and pounding in his chest. He is afraid that he is going to have "another heart attack". His exercise tolerance is about three blocks and it is limited by weakness and shortness of breath. He denies any exertional chest pain.
His other medical problems include hypertension, hyperlipidemia, gout, and gastro-esophageal reflux disease (GERD) . He is a lifetime non-smoker. His mother suffers from diabetes mellitus. His father died of a stroke at age 70. His current medications include metoprolol, rosuvastatin, aspirin, clopidogrel, lisinopril, amlodipine, and esomeprazole.
His blood pressure is 142/86 mmHg and his heart rate is 81/min and regular, and his oxygen saturation is 94% at room air. His BMI is 39 kg/m². On physical examination, the heart sounds appear distant. Lungs are clear on auscultation. He has 1+ bilateral pitting lower extremity edema to the mid-calf.
Which of the following is the best next step in managing this patient?

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11ec193a_98c8_b2a7_853d_ab09af62f33d_MD0002_00 This patient's clinical presentation is most consistent with obstructive sleep apnea (OSA). This condition is more common in individuals who are current smokers, obese, males aged 18-60, or who have upper airway soft tissue abnormalities. OSA is also associated with hypertension, cardiovascular disease, cerebrovascular disease, type 2 diabetes, renal disease, and gastroesophageal reflux disease.Polysomnography (full-night, attended, in sleep lab) is the preferred modality to confirm the diagnosis of OSA, defined as > 15 events (predominantly obstructive apneas or hypopneas) per hour of sleep in an asymptomatic patient or > 5 events/hour in a symptomatic patient. Treatment is recommended in symptomatic patients with positive airway pressure (CPAP), weight loss (for overweight patients), or oral appliances to protrude the mandible forward or hold the tongue anteriorly. Surgery is reserved for patients who have a severe obstructing surgically correctable lesion or who fail non-surgical therapy. (Choice A) Although post-MI angina is possible in this patient, the lack of exertional angina makes this less likely. His symptoms are most consistent with OSA. (Choice C) GERD induced asthma is a possibility. However, his symptoms of night time choking (apnea), dry mouth, morning headaches, and day time tiredness along with obesity suggests OSA the most likely diagnosis. His peripheral edema could be from longstanding undiagnosed OSA resulting in pulmonary hypertension and cor pulmonale. (Choice D) Cardiac rehabilitation is indicated for deconditioned patients who had a MI in the past 12 months, CABG, stable angina, or percutaneous coronary intervention. Although this patient may benefit from cardiac rehab, he should first be investigated for the etiology of his current symptoms to rule out other medical causes. (Choice E) Selective serotonin reuptake inhibitors (SSRI) can help treat PTSD, which can manifest as recurrent images of a traumatic event that cause significant impairment of daily activities and difficulty falling asleep. This patient's fatigue and headaches are less consistent with PTSD and more consistent with OSA. Educational objective: OSA should be suspected in high-risk patients who complain of snoring or excessive daytime sleepiness. Polysomnography is the preferred test to diagnose OSA and non-surgical therapy (weight loss and CPAP) is the mainstay of treatment. __________ References: Clinical guideline for the evaluation, management and long-term care of obstructive sleep apnea in adults (http://www.ncbi.nlm.nih.gov/pubmed/19960649)

A 58-Year-Old Man Comes to the Office Complaining of Feeling