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A 68-year-old woman with a history of hypothyroidism, hypertension, and obstructive sleep apnea (OSA) not on current treatment was referred to the sleep clinic for treatment of OSA. She was diagnosed with OSA in 2008 and started on continuous positive airway pressure (CPAP). On PAP she slept much better and was well rested. Subsequently she had problems with eye dryness attributed to a mask leak that could not be corrected, so she stopped CPAP. In the clinic, she reports loud snoring, witnessed apneas, difficulty maintaining sleep, and a desire to have her OSA treated. Epworth Sleepiness Scale was 2 of 24. On examination, the Mallampati score was 4, neck circumference was 16 in., and body mass index was 45.52 kg/m 2 . An oral examination was significant for normal dentition, no missing teeth, and orthognathic bite. Medications included lisinopril and levothyroxine.

A 26-year-old woman with a history of autoimmune epilepsy presented to the hospital for further management of seizures, which were increasing in frequency. Phenytoin was being tapered because it was thought to be causing side effects such as ataxia. Her first seizures were reported in 2014 and were refractory, requiring vagal nerve stimulator placement and multiple antiepileptics. Physical examination revealed a thin woman, alert, oriented, with good muscle strength, and positive only for bilateral nystagmus horizontally. Laboratory data revealed an elevated bicarbonate level at 30 mmol/L in 2015. It

Introduction Sleep stage architecture and amount of REM sleep have been associated with mortality and clinical recovery, without clear etiology. Patients recovering from critical illness frequently experience sleep disturbances, episodic arrhythmogenesis, EKG changes. This case aims to add to current field of study and describes an unusual pattern of sleep stage dependent, hypoxia independent, ST segment variation, which may benefit from further exploration and utilization of polysmongoraphy (PSG) in the immediate post acute MI period. Report of case(s) 46 year old female with history of smoking, obesity, and diabetes presented for a sleep medicine evaluation, four days following a hospitalization for non ST elevation myocardial infarction (NSTEMI) and percutaneous coronary intervention. Her split night PSG data revealed severe obstructive sleep apnea (OSA) with apnea hypopnia index (AHI) of 131. Patient did not report acute cardiac symptoms during overnight sleep evaluation. On close observation of PSG data, the patient had grossly evident baseline ST segment depression during wake period. The ST depression persisted through stages 1 and 2 with unchanged morphology. During Stage 3, the ST segment showed progressive elevation to near the isoelectric line. During REM sleep without positive airway pressure (PAP), ST segment was noted at or near isoelectric line, even in the setting of hypoxia with saturation (Sao2) of 75%. During REM Sleep with PAP, the ST segment remained at the isoelectric line, and returning to baseline depression during wake phase while on BiPAP. Conclusion Residual ST segment deviation, and its resolution, are strong predictors of prognosis in patients with MI. Prior studies focused on hypoxic tolerance and sleep disordered breathing, with limited attention on specific sleep stage evaluation. REM sleep has been described as potentially having restorative effect on ischemic myocardium. Additionally, the transition period from non REM to REM sleep was reported to provide potential for myocardial restoration. PSG with cardiac monitoring remains a unique tool in further assessment of a possible association. This case aims to bring attention to the potential association of EKG ST segment variation with sleep stages, especially REM and S3, independent of hypoxia. Support (if any):