The association between insomnia symptoms and cardiovascular risk factors in patients who complete outpatient cardiac rehabilitation

Pulmonary rehabilitation improves sleep efficiency measured by actigraphy in poorly sleeping COPD patients

Chronic insomnia is reported by up to 50% of chronic obstructive pulmonary disease (COPD) patients. This may be attributable to several factors including nocturnal dyspnea, reduced physical activity, and less time outside. Pulmonary rehabilitation (PR) is recommended in COPD to improve both physical and psychological conditioning. The aim of this study was to assess the effect of PR on sleep efficiency (SE, measured by actigraphy) in COPD patients. COPD eligible for PR were prospectively included. Baseline and post PR (30 sessions) assessments included incremental and maximal exercise testing, 6-min walking distance test (6MWT), actigraphy, and questionnaires [Pittsburgh Sleep Quality Index (PSQI), Hospital Anxiety Depression scale, St George Respiratory, and modified Medical Research Council dyspnea scale]. Sixty-one patients were included, and 31 patients completed the study protocol (68% of males, age 63 ± 9 y, FEV1 44.2 ± 12.3%). After PR, SE remained unchanged, p = 0.07, as well as PSQI score (p = 0.22), despite improvements in exercise capacity (incremental exercise test, 6MWT) and dyspnea. However, SE improved significantly in the poor sleeper subgroup (SE < 85%, n = 24, p = 0.02), whereas the PSQI remained unchanged. The present study shows, in COPD patients included in a PR program, that improvement in exercise capacity was disappointingly not associated with a better SE assessed by actigraphy. Subjective sleep quality was also unchanged at the end of PR program. However, SE improved significantly in the poor sleeper subgroup (SE < 85%). Further studies are required to better characterize the origin of sleep disturbances in COPD and the potential benefit of some (non-)pharmacologic interventions.

An evaluation of the role of the exercise training dose for changes in exercise capacity following a standard cardiac rehabilitation program

BACKGROUND

To retrospectively characterize and compare the dose of exercise training (ET) within a large cohort of patients demonstrating different levels of improvement in exercise capacity following a cardiac rehabilitation (CR) program.

METHODS

A total of 2310 patients who completed a 12-week, center-based, guidelines-informed CR program between January 2018 and December 2019 were included in the analysis. Peak metabolic equivalents (MET_peak) were determined pre- and post-CR during which total duration (ET time) and intensity [percent of heart rate peak (%HR_peak)] of supervised ET were also obtained. Training responsiveness was quantified on the basis of changes in MET_peak from pre- to post-CR. A cluster analysis was performed to identity clusters demonstrating discrete levels of responsiveness (i.e., negative, low, moderate, high, and very-high). These were compared for several baseline and ET-derived variables which were also included in a multivariable linear regression model.

RESULTS

At pre-CR, baseline MET_peak was progressively lower with greater training responsiveness (F_(4,2305) = 44.2, P < 0.01, η²_p = 0.71). Likewise, average training duration (F_(4,2305) = 10.7 P < 0.01, η²_p = 0.02) and %HR_peak (F_(4,2305) = 25.1 P < 0.01, η²_p = 0.042) quantified during onsite ET sessions were progressively greater with greater training responsiveness. The multivariable linear regression model confirmed that baseline MET_peak, training duration and intensity during ET, BMI, and age (P < 0.001) were significant predictors of MET_peak post-CR.

CONCLUSIONS

Along with baseline MET_peak, delta BMI, and age, the dose of ET (i.e., training duration and intensity) predicts MET_peak at the conclusion of CR. A re-evaluation of current approaches for exercise intensity prescription is recommended to extend the benefits of completing CR to all patients.

Evaluating the Feasibility and Efficacy of A Novel CBTi/SMT Treatment Protocol for Cardiac Rehab Patients: A Non-Randomized Pilot Trial

INTRODUCTION

Cardiac patients and those with chronic medical conditions often suffer from comorbidities such as insomnia and mood disorders. Previous treatment protocols have focused on resolving symptoms of anxiety and depression in this population using Stress Management Training (SMT). However, these treatments have neglected the importance of sleep problems in these patients. This pilot trial sought to address this by examining the feasibility of a novel CBTi/SMT treatment protocol.

METHODS

42 participants attending a Cardiac Rehab (CR) exercise program registered in this 7-week non-randomized pilot trial. The primary objective of the pilot trial was to determine the feasibility of the protocol for retention and adherence rates. Secondarily, the authors sought to examine the potential efficacy of the program in terms of treating insomnia, depression, anxiety, emotion dysregulation, and arousal.

RESULTS

29 participants attended at least 1 class, with 21 participants completing the program. The average attendance for the program completers was 6 out of 7 classes (SD = 0.8) with four days of practice each week (SD = 1.6) for 33 minutes daily (SD = 16.8). Moreover, the number of participants meeting clinical threshold for insomnia, anxiety, and/or depression was significantly reduced at post-treatment and follow-up. Similarly, raw scores on the relevant scales were significantly reduced at both timepoints.

CONCLUSION

This pilot trial provided preliminary evidence for the feasibility and efficacy of targeting sleep improvement with a combined CBTi/SMT protocol. This provides the groundwork for future RCTs to establish the effectiveness of targeting insomnia in a range of medical populations.

Prevalence, Impact, and Trajectories of Sleep Disturbance in Cardiac Rehabilitation: A NARRATIVE REVIEW AND SUGGESTIONS FOR EVALUATION AND TREATMENT

OBJECTIVE

The aim of this review was to summarize literature examining the prevalence, impact, and trajectories of sleep disturbance in cardiac rehabilitation (CR) patients and discuss how CR programs may incorporate targeted evaluation and interventions to promote sleep health.

REVIEW METHODS

A narrative review of literature allowed for an examination of the prevalence of sleep disturbance in CR patients, the effects of sleep disturbance on CR outcomes, and trajectories of sleep disturbance in CR.

SUMMARY

Sleep disturbance is prevalent in CR patient populations and is related to clinical and functional outcomes. Sleep may be an important biobehavioral process to target in CR to improve important patient outcomes and achieve secondary prevention goals.

Insomnia and Poor Sleep in CKD: A Systematic Review and Meta-analysis

Rationale & Objective

Poor sleep quality and insomnia are pervasive among patients with advanced chronic kidney disease (CKD); however, these health issues have not been systematically evaluated.

Study Design

Systematic review and meta-analysis.

Setting & Study Populations

Adult patients with CKD not receiving kidney replacement therapy (KRT), as well as adults receiving KRT, including hemodialysis, peritoneal dialysis, and kidney transplantation.

Selection Criteria for Studies

A systematic literature search using PubMed, Embase, and PsycNET, was conducted for articles published between January 1, 1990, and September 28, 2018.

Data Extraction

Data on the prevalences of poor sleep quality and insomnia in patients with CKD, including those receiving and not receiving KRT, were extracted.

Analytical Approach

Pooled prevalences were estimated using a random-effects meta-analysis and were stratified according to age, CKD stage, World Health Organization region, risk of bias, Pittsburgh Sleep Quality Index score, and the different criteria for insomnia that were used at diagnosis.

Results

Of 3,708 articles, 93 were selected, and significant methodological heterogeneity was present. The pooled prevalences of poor sleep quality for CKD without KRT, hemodialysis, peritoneal dialysis, and kidney transplantation were 59% (95% CI, 44%-73%), 68% (95% CI, 64%-73%), 67% (95% CI, 44%-86%), and 46% (95% CI, 34%-59%), respectively. The corresponding prevalences of insomnia were 48% (95% CI, 30%-67%), 46% (95% CI, 39%-54%), 61% (95% CI, 41%-79%), and 26% (95% CI, 9%-49%), respectively. Insomnia was significantly more prevalent among patients aged 51-60 years and those aged >60 years than among those aged <50 years. The prevalence of insomnia in the European region was the lowest of all World Health Organization regions.

Limitations

High interstudy heterogeneity.

Conclusions

Approximately half of the patients with advanced CKD had poor sleep quality or insomnia, and the prevalence was even higher among those who received KRT. Kidney transplantation may reduce the burden of poor sleep quality and insomnia.

Association between sleep insufficiency and dyslipidemia: a cross-sectional study among Greek adults in the primary care setting

Objective

To investigate the potential association between sleep insufficiency and dyslipidemia (DL) in the primary care setting using self-reported questionnaires.

Material and Methods

957 adults aged between 19 and 86 years old from the rural area of Thrace, Greece were enrolled in this cross-sectional study. Multistage stratifed cluster sampling was used and the subjects were classifed into three groups according to sleep duration [short (<6h), normal (6-8h), and long (>8h) sleep duration]. DL was defined by a positive response to the question "Have you ever been told by a doctor or health professional that your blood cholesterol or triglyceride levels were high?", or if they were currently taking antilipidemic agents. Sleep quality, utilizing Epworth sleepiness scale, Athens insomnia scale, Pittsburgh sleep quality index and Berlin questionnaire, was also examined.

Results

DL prevalence was significantly associated with short sleep duration (aOR=2.18, p<0.001) and insomnia (aOR=1.43, p=0.050), while its relation with poor sleep quality (aOR=1.31, p=0.094) and risk for obstructive sleep apnea (aOR=1.32, p=0.097) were of marginal statistical significance. Concerning insomnia subtypes, DL was significantly associated with difficulties maintaining sleep (aOR=2.99, p<0.001) and early morning awakenings (aOR=1.38, p=0.050), but not difficulties initiating sleep (aOR=1.18, p=0.328).

Conclusion

This study reveals an association between sleep pathology and DL. Thus, early pharmacological and cognitive or behavioral interventions that improve sleep are deemed necessary in order to decrease DL burden.

The association between insomnia and the risk of metabolic syndrome: A systematic review and meta-analysis

OBJECTIVE

The purpose of this study was to perform a systematic review and meta-analysis on the association between insomnia and the risk of developing into metabolic syndrome (including hypertension, hyperglycemia, hyperlipidemia and obesity).

METHOD

We conducted our research according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta Analyses). After the search term was determined, we searched Pubmed and Embase databases until December 1, 2020 for the observational studies. We used random effects models to aggregate risk estimates for individual studies and the odds ratio (OR) as well as 95% confidence intervals (CI) were calculated for pooled data. Heterogeneity in this study was assessed by using I2 statistic.

RESULTS

12 studies were eventually included in this meta-analysis which contained metabolic syndrome related symptoms (hypertension, hyperglycemia, hyperlipidemia and obesity). The combined OR value and 95% CI of the hypertension group was 1.41 (1.19-1.67). The hyperglycemia group was 1.29 (1.11-1.50). The hyperlipidemia group was 1.12 (0.92-1.37) and the obesity group was 1.31 (1.03-1.67).

CONCLUSION

The risk of insomnia patients suffering from hypertension, hyperglycemia, hyperlipidemia and obesity in metabolic syndrome was 1.41 times, 1.29 times and 1.31 times than people without insomnia respectively.

[Deletion polymorphism of GSTT1 gene and lipid peroxidation hyperactivation in menopausal insomnia]

OBJECTIVE

A comparative analysis of the parameters of lipid peroxidation - antioxidant defense system in menopausal women with- and without insomnia, depending on the GSTT1 polymorphism.

MATERIAL AND METHODS

The study included 181 menopausal Caucasian women (ethnic group - Russians), who according to the results of the clinical-anamnestic examinations were divided into insomnia group (n=120, age 53.68±4.61 years, body mass index 26.47±3.73 kg/m²) and control group (n=61, age 52.64±4.91 years, body mass index 27.69±3.11 kg/m²). The insomnia group was formed according to the clinical guidelines for the diagnosis and treatment of chronic insomnia in adults, and scores of the Insomnia Severity Index. The study of the GSTT1 gene polymorphism was carried out using polymerase chain reaction. The lipid peroxidation - antioxidant system parameters were determined by spectrofluorophotometric methods.

RESULTS

In the insomnia group, carriers of the normal GSTT1 genotype had higher diene conjugates with lower glutathione peroxidase activity as compared to controls. When comparing groups of women with the deletion in GSTT1, an increase in the content of substrates and lipid peroxidation products was observed at all stages of lipid peroxidation, oxidized glutathione, glutathione S-transferase activity with a decrease in the content of reduced glutathione and retinol in the insomnia group as compared to controls. In the insomnia group, carriers of the deletion genotype had a higher content of ketodienes/conjugated trienes and active products of thiobarbituric acid, a lower content of retinol and α-tocopherol as compared to the patients with normal GSTT1 genotype. Conclusions. Insomnia in the menopausal women is accompanied with the intensification of lipid peroxidation only in the carriers of the GSTT1 deletion genotype.

Diagnostic accuracy and suitability of instruments that screen for obstructive sleep apnoea, insomnia and sleep quality in cardiac patients: a meta-analysis

BACKGROUND

A number of clinical guidelines recommend that all cardiac rehabilitation patients should be screened for potential sleep disorders with a validated screening instrument. There is currently no consensus on what specific tools should be used.

OBJECTIVE

To identify tools that are practical to use in the clinical environment and have high diagnostic accuracy.

METHODS

We systematically searched online databases to identify patient reported outcome instruments that have been used in published research studies to assess the likelihood of obstructive sleep apnoea (OSA) in cardiac patients. In studies that provided diagnostic data, these data were extracted and verified via an evidence-based diagnostic calculator. Where sufficient numbers of studies were available, a meta-analysis was conducted to determine pooled estimates of specificity, sensitivity and diagnostic odds ratios. Selected papers were qualitatively assessed using the Standards for Reporting Diagnostic accuracy studies (STARD).

RESULTS

Of the 21 instruments identified, six detected likelihood of OSA, two assessed daytime sleepiness, five assessed insomnia and eight examined sleep quality. A meta-analysis of 14 studies that assessed diagnostic accuracy of moderate OSA, revealed moderate sensitivity for the Berlin Questionnaire, Sens = 0.49 (95% CI 0.45-0.52) and good sensitivity for the Stop-BANG, Sens = 0.93 (95% CI 0.87-0.96) but poor specificity at standard cut-off criteria.

CONCLUSION

There are promising practical tools available to screen patients with OSA and other sleep disorders in cardiac rehabilitation settings, but specificity could be improved. Additional assessment of sleep quality may enhance prognostic ability with both OSA and insomnia screening.

ADVERSE EFFECT OF INSOMNIA ON BLOOD LIPIDS IN PATIENTS WITH HYPERTENSION

Insomnia is a risk factor for the development of arterial hypertension, obesity, type 2 diabetes mellitus, cardiac rhythm disorders, and myocardial infarction. At the same time, insomnia is one of the most frequent non-cardiac complaints in patients with cardiovascular diseases. The aim of the work was to study the presence of possible relationships between insomnia and the level of blood lipids. Materials and methods. A cross-sectional study involving 118 patients was conducted. Criteria for inclusion in the study were age over 45 years, the presence of essential hypertension. All patients included the study underwent sampling of 7 ml of venous blood in the morning under fasting conditions. The content of total cholesterol (TCS), triglycerides (TG), high-density lipoprotein cholesterol (HDL CS) was determined by enzymatic method on a biochemical analyser Humalyzer 2000. The patient was interviewed by a pre-trained study doctor.  Results. In the article a relationship between total cholesterol, low-density lipoprotein cholesterol and the presence of insomnia has been established and proved by statistical model. The overall statistical model accuracy is 89.6 % and statistical significance p < 0.005. Accuracy of insomnia prediction is 85.7 % by level of total cholesterol (TCS) and patient interview data. Only one model with best accuracy exists and it was estimated at the article. Conclusions. Relationship between total cholesterol, low-density lipoprotein cholesterol and the presence of insomnia has been established and proved by statistical model. Accuracy of insomnia prediction is 85.7 % by level of total cholesterol (TCS) and patient interview data.

State and trait anxiety in islander cardiac patients: associated factors and the impact of perceived social support

Introduction

Cardiac patients frequently experience elevated levels of anxiety, which may influence clinical outcomes. Perceived social support is a precious resource with which to minimise anxiety. The aim of the study was to explore levels of perceived social support, levels of anxiety (state and trait), and the associated factors as well as the impact of patents’ characteristics and social support on anxiety.

Material and methods

The study sample consisted of 82 island inhabitant patients with cardiac problems (49 men and 33 women). Data collected by the completion of the State-trait anxiety inventory (STAI) and the Multidimensional scale of perceived social support questionnaire (MSPSS). The statistical significance level was set at p < 0.05.

Results

Regarding state and trait anxiety, half of the patients scored below 37 and 38, respectively, (medians) while 25% of participants scored more than 50 and 48, respectively. These values indicate moderate levels of anxiety. Regarding social support, at least 50% of patients scored over 27, 27, and 20 (median) on support from significant ones, family, and friends, respectively. In addition, 25% of patients scored above 28, 28, and 26, respectively. These values indicate high levels of social support. The association between anxiety and social support was found to be linearly negative, meaning that the more support a patient felt, the less anxiety they also experienced.

Conclusions

Enhancing perceived social support may be a key-element in alleviating anxiety among cardiac patients.

Comparison between acupuncture and cognitive behavioral therapy for primary insomnia: A protocol for systematic review and network meta-analysis

BACKGROUND

Primary insomnia (PI) is a common disease affecting human health. As the side effects of drug therapy were revealed, people began to seek more safe and effective non-drug therapies. Cognitive behavioral therapy for insomnia (CBT-I) and acupuncture are 2 commonly used non-drug therapies. However, there are few comparative studies on the efficacy of these 2 therapies. Therefore, this study aims to compare the efficacy and safety of the 2 therapies through network meta-analysis.

METHODS

We will search the following electronic bibliographic databases: PubMed, EMBASE, The Cochrane Library, Web of Science, China National Knowledge Infrastructure, Chinese Biomedical Literature Database, Chongqing VIP database, and Wanfang database. Randomized controlled trials in which the intervention was acupuncture or CBT, and in which the control group was any of the above, western medicine or blank control, would be included. The primary outcome will be the changes of the Pittsburgh Sleep Quality Index, and the additional outcomes will include the changes in Insomnia Severity Index, quality of life, clinical effective rate and adverse events. Two independent authors will screen the literature in the above database, extract data and cross-check. Heterogeneity and inconsistencies are detected before using a network meta-analysis method based on frequency analysis. The risk of bias will be assessed in accordance with the Cochrane risk of bias tool, and the strength of the recommendations will be assessed by the Grading of Recommendations Assessment, Development and Evaluation.

ETHICS AND DISSEMINATION

This network meta-analysis will provide a reference for clinicians and PI patients to choose a more appropriate non-drug regimen among multiple kinds of acupuncture or CBT-I therapies. This review does not require ethical approval and will be reported in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

PROSPERO CRD42020155327.

Free Radical Oxidation and Sleep Disorders in Andro- and Menopause (Literature Review)

This review presents data on changes in the physiology of sleep during reproductive aging. It is noted that insomnia and obstructive sleep apnea syndrome (OSAS) are the main sleep disorders. The results of foreign and domestic studies in the field of free radical oxidation during sleep deprivation in animal models are presented, indicating the dependence of processes on the duration of sleep deprivation. The largest number of studies of free radical processes in a person with somnological pathology was carried out in the study of OSAS. Blood, urine, saliva, condensate of exhaled air can be biomaterial for determining the parameters of free radical oxidation. It was shown that the intensity of oxidative stress depends on the severity of OSAS, as evidenced by the positive correlation of the level of active products of thiobarbituric acid, the products of oxidation of proteins and carbonyl groups with the apnea/hypopnea index, determining the development of not only oxidative, but also carbonyl stress in patients with a severe degree OSAS. Biomarkers such as thioredoxin, malondialdehyde, superoxide dismutase, and reduced iron have shown a more stable relationship between increased oxidative stress and OSA. Despite the results obtained, the question of the association of oxidative stress and hypoxia in OSA remains debatable, which is associated with the opposite results of some studies. Insomnia, which occurs mainly in females, is accompanied by a high level of end products of lipid peroxidation with a decrease in the activity of antioxidants such as paraoxonase, an enzymatic component of the glutathione system. Along with this, menopausal women present low levels of uric acid, which correlates with high scores of the Pittsburgh sleep quality index questionnaire. Recent studies have identified an association between the activity of the «lipoperoxidation – antioxidants» system and the Clock 3111T/C gene polymorphism in menopausal Caucasian women, indicating the protective role of the minor allele.

A Systematic Review of the Diagnostic Accuracy of Depression Questionnaires for Cardiac Populations: IMPLICATIONS FOR CARDIAC REHABILITATION

PURPOSE

Depression is overrepresented in patients with cardiovascular disease and increases risk for future cardiac events. Despite this, depression is not routinely assessed within cardiac rehabilitation. This systematic review sought to examine available depression questionnaires to use within the cardiac population. We assessed each instrument in terms of its capability to accurately identify depressed patients and its sensitivity to detect changes in depression after receiving cardiac rehabilitation.

METHODS

Citation searching of previous reviews, MEDLINE, PsycInfo, and PubMed was conducted.

RESULTS

The Beck Depression Inventory-II (BDI-II) and the Hospital Anxiety and Depression Scale (HADS-D) are among the most widely used questionnaires. Screening questionnaires appear to perform better at accurately identifying depression when using cut scores with high sensitivity and specificity for the cardiac population. The BDI-II and the HADS-D showed the best sensitivity and negative predictive values for detecting depression. The BDI-II, the HADS-D, the Center for Epidemiological Studies-Depression Scale, and the 15-item Geriatric Depression Scale best captured depression changes after cardiac rehabilitation delivery.

CONCLUSIONS

The BDI-II is one of the most validated depression questionnaires within cardiac populations. Health practitioners should consider the BDI-II for depression screening and tracking purposes. In the event of time/cost constraints, a briefer 2-step procedure (the 2-item Patient Health Questionnaire, followed by the BDI-II, if positive) should be adopted. Given the emphasis on cut scores for depression diagnosis and limited available research across cardiac diagnoses, careful interpretation of these results should be done. Thoughtful use of questionnaires can help identify patients in need of referral or further treatment.

Oral Delivery of Honokiol Microparticles for Nonrapid Eye Movement Sleep

Honokiol (HNK) is a small-molecule lignin extracted from Magnolia Officinalis, demonstrating high potency in promoting nonrapid eye movement (NREM) sleep by modulating the benzodiazepine site of the GABA_A receptor. However, the clinical use of HNK in the treatment of insomnia is restricted by its extremely low oral bioavailability. In the present work, enhanced oral bioavailability of HNK was achieved by loading it into poly lactide-glycolide acid microparticles (HNK-MP). After oral administration, HNK-MP demonstrated 15-fold increase of AUC_0-12 h in comparison to free HNK. The maximum blood concentration ( C_max) of HNK in HNK-MP-treated rats was 3.6 μg/mL at 2 h after oral administration, which was 6.5-fold of that in free HNK-treated rats. Oral administration of HNK-MP (20 mg/kg) efficiently increased NREM sleep by 60% by enhancing the transition from wakefulness to NREM sleep in rats. The biosafety of HNK-MP was assessed in vivo, and no damage occurred in the gastrointestinal tract. The present study provides a promising oral HNK formulation for the treatment of insomnia.