Sleep disturbance in association with elevated pulse rate for prediction of mortality--consequences of mental strain?

Home Care Workers' Objective and Subjective Recovery From Work

OBJECTIVE

The aim of this cross-sectional study was to examine the recovery from work in Finnish home care nurses with objective and subjective recovery measures.

METHODS

Heart rate and heart rate variability recordings were performed in home care nurses over a period of one work shift and the following night. Following the measurements, the participants ( N = 91) answered a questionnaire including questions about their self-rated recovery from work and sleep disturbances.

RESULTS

The objectively measured recovery was within the recommended heart rate variability range, yet the self-rated recovery from work was only mediocre. Subjective recovery was not associated with objectively measured recovery.

CONCLUSIONS

There is a discrepancy between objectively and subjectively measured recovery from work. Therefore, an additional objective method in occupational field studies, along with questionnaires, is recommended to measure physiological recovery.

The risk of major adverse cardiovascular events associated with the use of hypnotics in patients with insomnia

OBJECTIVES

To examine whether hypnotic use in patients with insomnia reduces major adverse cardiovascular events, including all-cause mortality and nonfatal major adverse cardiovascular events.

METHODS

Using the Veterans Affairs Corporate Data Warehouse, we conducted a retrospective cohort study of 16,064 patients who were newly diagnosed with insomnia between January 1, 2010, and December 31, 2019. A pair of 3912 hypnotic users and nonusers were selected based on a 1:1 propensity score methodology. The primary outcome was extended major adverse cardiovascular events, a composite of the first occurrence of all-cause mortality or nonfatal major adverse cardiovascular events.

RESULTS

During the median follow-up of 4.8 years, a total of 2791 composite events occurred, including 2033 deaths and 762 nonfatal major adverse cardiovascular events. Although the incidence rates of major adverse cardiovascular events were comparable between hypnotic users and nonusers in the propensity-matched cohort, users of benzodiazepines and Z-drugs had a higher risk of all-cause mortality (hazard ratio 1.47 [95% CI, 1.17-1.88] and 1.20 [95% CI, 1.03-1.39], respectively), while serotonin antagonist and reuptake inhibitors users had a survival advantage (hazard ratio 0.79 [95% CI, 0.69-0.91]) compared with nonusers. There were no differences in the risk of nonfatal major adverse cardiovascular events between all classes of hypnotics. Male patients and those aged 60 years or younger who were using benzodiazepines or Z-drugs experienced higher major adverse cardiovascular events than their counterparts.

CONCLUSIONS

In patients with newly diagnosed insomnia, treatment with hypnotics resulted in higher extended major adverse cardiovascular events but not nonfatal major adverse cardiovascular events with benzodiazepine and Z-drug users compared with nonusers. The use of serotonin antagonist and reuptake inhibitors agents had a protective effect against major adverse cardiovascular events warranting further investigation.

Potential of Polyphenols for Improving Sleep: A Preliminary Results from Review of Human Clinical Trials and Mechanistic Insights

Global epidemiologic evidence supports an interrelationship between sleep disorders and fruits and vegetable ingestion. Polyphenols, a broad group of plant substances, are associated with several biologic processes, including oxidative stress and signaling pathways that regulate the expression of genes promoting an anti-inflammatory environment. Understanding whether and how polyphenol intake is related to sleep may provide avenues to improve sleep and contribute to delaying or preventing the development of chronic disease. This review aims to assess the public health implications of the association between polyphenol intake and sleep and to inform future research. The effects of polyphenol intake, including chlorogenic acid, resveratrol, rosmarinic acid, and catechins, on sleep quality and quantity are discussed to identify polyphenol molecules that may improve sleep. Although some animal studies have investigated the mechanisms underlying the effects of polyphenols on sleep, the paucity of trials, especially randomized controlled trials, does not allow for conducting a meta-analysis to reach clear conclusions about the relationships among these studies to support the sleep-improving effects of polyphenols.

Association between sleep duration and sleep quality with arterial stiffness: A systematic review and meta-analysis

BACKGROUND

Altered sleep parameters, such as duration and quality, play an important role in the pathogenesis and progression of cardiovascular diseases, as well as in all-cause morbidity and mortality. It has been suggested that the specific mechanisms underlying this association could be through the influence of sleep parameters on vascular markers, such as arterial stiffness (AS), although this remains unclear. Thus, in this meta-analysis, we aimed to assess the association between sleep duration and sleep quality with AS in adults.

METHODS

PubMed, Scopus, Web of Science and Cochrane Library databases were searched from inception to July 30, 2021. The DerSimonian and Laird method was used to compute pooled effect size estimates and their respective 95% confidence intervals (95% CIs) of the association of sleep duration and sleep quality with AS. The Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies from the United States National Institute of Health National Heart, Lung, and Blood Institute was used to assess the risk of bias.

RESULTS

Finally, 14 studies (8 cross-sectional studies and baseline data from 6 prospective longitudinal studies) involving 97,837 individuals between 18 and 92 years of age were included. Our results showed that increased sleep duration, as continuous values, does not influence AS (effect size [ES]: 0.00; 95% CIs: -0.15, 0.15) in the general population. However, when sleep duration was longer than 8 hours (ES: 0.21; 95% CIs: 0.06, 0.36), according to sleep categories, a significant increase in pulse wave velocity was shown. Poor sleep quality was associated with increased AS (ES: 0.13; 95% CIs: 0.04, 0.21) in the general population. The overall risk of bias for studies examining sleep duration was fair in 77.8% of the included studies and the overall risk of bias for studies examining sleep quality was fair in 55.6%.

CONCLUSIONS

Our findings showed that both long sleep duration and poor sleep quality were associated with AS in adults. These findings underscore the influence of sleep on vascular health markers, specifically AS, as a possible pathway to explain the increased cardiovascular morbidity and mortality associated with sleep disorders.

Associations between Sleep Quality and Heart Rate Variability: Implications for a Biological Model of Stress Detection Using Wearable Technology

INTRODUCTION

The autonomic nervous system plays a vital role in the modulation of many vital bodily functions, one of which is sleep and wakefulness. Many studies have investigated the link between autonomic dysfunction and sleep cycles; however, few studies have investigated the links between short-term sleep health, as determined by the Pittsburgh Quality of Sleep Index (PSQI), such as subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, use of sleeping medication, and daytime dysfunction, and autonomic functioning in healthy individuals.

AIM

In this cross-sectional study, the aim was to investigate the links between short-term sleep quality and duration, and heart rate variability in 60 healthy individuals, in order to provide useful information about the effects of stress and sleep on heart rate variability (HRV) indices, which in turn could be integrated into biological models for wearable devices.

METHODS

Sleep parameters were collected from participants on commencement of the study, and HRV was derived using an electrocardiogram (ECG) during a resting and stress task (Trier Stress Test).

RESULT

Low-frequency to high-frequency (LF:HF) ratio was significantly higher during the stress task than during the baseline resting phase, and very-low-frequency and high-frequency HRV were inversely related to impaired sleep during stress tasks.

CONCLUSION

Given the ubiquitous nature of wearable technologies for monitoring health states, in particular HRV, it is important to consider the impacts of sleep states when using these technologies to interpret data. Very-low-frequency HRV during the stress task was found to be inversely related to three negative sleep indices: sleep quality, daytime dysfunction, and global sleep score.

Behavioral plasticity: Role of neuropeptides in shaping feeding responses

Behavioral plasticity refers to changes occurring due to external influences on an organism, including adaptation, learning, memory and enduring influences from early life experience. There are 2 types of behavioral plasticity: "developmental", which refers to gene/environment interactions affecting a phenotype, and "activational" which refers to innate physiology and can involve structural physiological changes of the body. In this review, we focus on feeding behavior, and studies involving neuropeptides that influence behavioral plasticity - primarily opioids, orexin, neuropeptide Y, and oxytocin. In each section of the review, we include examples of behavioral plasticity as it relates to actions of these neuropeptides. It can be concluded from this review that eating behavior is influenced by a number of external factors, including time of day, type of food available, energy balance state, and stressors. The reviewed work underscores that environmental factors play a critical role in feeding behavior and energy balance, but changes in eating behavior also result from a multitude of non-environmental factors, such that there can be no single mechanism or variable that can explain ingestive behavior.

Associations of Abnormal Sleep Duration with Occupational and Leisure-time Physical Activity in the Working Population: A Nation-wide Population-based Study

Background

The present study investigated the association between two domains of physical activity (occupational physical activity [OPA] and leisure-time physical activity [LTPA]) and sleep duration.

Methods

We investigated 3,421 paid workers from the Korea National Health and Nutrition Examination Survey, 2014–2015. Sleep duration was categorized into three categories (short for less than 5 h, optimal for 5–9 h, and long for more than 9 h). OPA and LTPA were defined in terms of answers to relevant questions. Odds ratios were calculated for sleep duration according to each physical activity domain using multinomial logistic regression models.

Results

There were 464 subjects (13.6%) who showed short sleep duration, and 169 subjects (4.9%) who showed long sleep duration. Prevalence of OPA and LTPA was higher in male workers than in female workers (for OPA: 3.67% and 1.76%, respectively, p = 0.0108; for LTPA: 16.14% and 6.07%, respectively, p < 0.0001). The odds ratio of OPA for long sleep duration in female workers was 3.35 (95% confidence interval, 1.37–8.21). Otherwise, LTPA was not associated with sleep duration in female paid workers, nor both physical activity domains in male paid workers.

Conclusion

Female paid workers with work-related physical activity were at risk of oversleeping. These findings also suggested that physical activity has distinct associations with sleep duration according to the physical activity domains and sex.

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.

Resting Heart Rate as a Predictor of Cancer Mortality: A Systematic Review and Meta-Analysis

This work was aimed to synthetize the evidence available about the relationship between resting heart rate (RHR) and the risk of cancer mortality. A computerized search in the Medline, EMBASE, Web of Science, and Cochrane Library databases from their inception to 24 September 2020 was performed. We performed three meta-analyses: (1) cancer mortality comparing the "less than 60 bpm" and "more than 60 bpm" categories; (2) cancer mortality comparing "less than 60 bpm", "60 to 80 bpm", and "more than 80 bpm" categories; and (3) analysis for 10-12 and 20 bpm increase in RHR and risk of cancer mortality. Twenty-two studies were included in the qualitative review, and twelve of them met the inclusion criteria for the meta-analysis. Our results showed a positive association between RHR and the risk of cancer mortality. This association was shown in a meta-analysis comparing studies reporting mean RHR values below and above 60 bpm, when comparing three RHR categories using less than 60 bpm as the reference category and, finally, in dose response analyses estimating the effect of an increase of 10-12 bpm in RHR, both in men and in women. In conclusion, a low RHR is a potential marker of low risk of cancer mortality.

Beyond single sleep measures: A composite measure of sleep health and its associations with psychological and physical well-being in adulthood

RATIONALE

Sleep is important for many functions including body and mind restoration. Studies report the association of sleep with stress and physical deterioration, often focusing only on sleep duration; yet, sleep health needs to be understood by multiple dimensions to comprehensively capture its impact on well-being.

OBJECTIVE

This study examined cross-sectional and longitudinal associations of multidimensional sleep health with perceived stress and chronic physical conditions.

METHODS

We used a sample of 441 adults (M age = 57 years) who participated in the biomarker project of the Midlife in the United States Study. Participants provided self-report and actigraphy sleep data in 2004-2009 (T1). We created a composite score of sleep health (Range = 0-6; higher indicating more sleep problems) encompassing: actigraphy-measured regularity, timing, efficiency, duration, and self-reported satisfaction and alertness. Participants responded to the perceived stress scale and chronic physical conditions checklist at T1; chronic physical conditions were reassessed in 2013-2015 (T2).

RESULTS

Cross-sectionally, a composite score of sleep health problems was uniquely associated with higher perceived stress and more chronic conditions, explaining additional variance that each individual sleep variable did not explain. Sleep duration - one of the most commonly researched dimensions of sleep - was not associated with either perceived stress or chronic conditions. Longitudinally, for individuals who had fewer chronic conditions at T1, having more sleep health problems was associated with an increase in chronic conditions at T2. Among the multiple dimensions, sleep satisfaction was most consistently and strongly associated with the outcomes.

CONCLUSION

Findings suggest the importance of considering multiple sleep dimensions concerning psychological and physical well-being in adulthood.

Health-related quality of life of middle-aged and elderly people with hypertension: A cross-sectional survey from a rural area in China

OBJECTIVE

To evaluate health-related quality of life (HRQoL) of middle-aged and elderly people with hypertension in Enshi, China, and to explore the important correlates defining HRQoL.

METHODS

From April through July 2018, a self-monitoring intervention program for hypertension control was implemented in a remote area of central China. Participants completed a cross-sectional survey which included demographic characteristics, the Health-related Quality of Life Survey, and the Pittsburgh Sleep Quality Index Survey. Univariate analysis was performed by analysis of variance, and multiple linear regression analysis was used to analyze the influencing factors of HRQoL in middle-aged and elderly hypertensive patients. In the multivariate analysis, the variables with P≤0.05 in the single factor analysis were combined with the professional significance to establish a multiple linear regression model.

RESULTS

Information from 500 participants was available for analysis. Among them, the scores of PCS and MCS was 31.66 ± 9.50 and 41.38 ± 10.69, respectively. Multivariable regression analyses showed that higher education and sleep quality, and moderate physical activity (30 minutes for at least five days a week) had a positive influence on PCS scores. Higher monthly family income (3,000-5,000 ¥) and sleep quality, regular tea-drinking, having 30 minutes of moderate physical activity at least five days a week were positively associated with MCS scores.

CONCLUSION

The overall HRQoL for rural middle-aged and elderly hypertensive patients in Xuan'en county of Hubei province was poor. Effective relevant measures for the above factors were urgently needed to improve the quality of life for the elderly in rural areas. Awareness of these relevant factors could help health care professionals provide better supportive care.

Let Sleeping Patients Lie, avoiding unnecessary overnight vitals monitoring using a clinically based deep-learning model

Impaired sleep for hospital patients is an all too common reality. Sleep disruptions due to unnecessary overnight vital sign monitoring are associated with delirium, cognitive impairment, weakened immunity, hypertension, increased stress, and mortality. It is also one of the most common complaints of hospital patients while imposing additional burdens on healthcare providers. Previous efforts to forgo overnight vital sign measurements and improve patient sleep used providers’ subjective stability assessment or utilized an expanded, thus harder to retrieve, set of vitals and laboratory results to predict overnight clinical risk. Here, we present a model that incorporates past values of a small set of vital signs and predicts overnight stability for any given patient-night. Using data obtained from a multi-hospital health system between 2012 and 2019, a recurrent deep neural network was trained and evaluated using ~2.3 million admissions and 26 million vital sign assessments. The algorithm is agnostic to patient location, condition, and demographics, and relies only on sequences of five vital sign measurements, a calculated Modified Early Warning Score, and patient age. We achieved an area under the receiver operating characteristic curve of 0.966 (95% confidence interval [CI] 0.956–0.967) on the retrospective testing set, and 0.971 (95% CI 0.965–0.974) on the prospective set to predict overnight patient stability. The model enables safe avoidance of overnight monitoring for ~50% of patient-nights, while only misclassifying 2 out of 10,000 patient-nights as stable. Our approach is straightforward to deploy, only requires regularly obtained vital signs, and delivers easily actionable clinical predictions for a peaceful sleep in hospitals.

Long sleep duration and risk of increased arterial stiffness in a Chinese population

To examine the relationship between self-reported sleep duration and arterial stiffness in a large Chinese population from Kailuan.From July 2010 to December 2015, a total of 17,018 participants aged 18 to 98 years were enrolled after excluding those with a history of cerebrovascular events and coronary artery disease. Participants were divided into 5 categories according to self-reported night sleep duration: ≤5.0, 6.0, 7 (ref), 8, and ≥9.0 hours. A brachial-ankle pulse wave velocity ≥1400 cm/s was considered to represent arterial stiffness. Multivariate logistic regression models were used to calculate the odds ratio (OR) and confidence interval (CI) for arterial stiffness according to the sleep duration.Using 7 hours of sleep as the reference group, the multivariable adjusted ORs (95% CI) for arterial stiffness were 1.00 (0.87-1.16), 1.00 (0.90-1.11), 1.0 (ref), 1.03 (0.93-1.14), and 1.48 (1.05-2.08) from the lowest to highest category of sleep duration, respectively. Secondary analysis showed no evidence of interactions between sleep duration and age/sex on the risk of arterial stiffness (P-interaction = .390/.198).A long night sleep duration was associated with increased arterial stiffness.

Poor sleep quality is associated with cardiac autonomic dysfunction in treated hypertensive men

Hypertensives present cardiac autonomic dysfunction. Reduction in sleep quality increases blood pressure (BP) and favors hypertension development. Previous studies suggested a relationship between cardiovascular autonomic dysfunction and sleep quality, but it is unclear whether this association is present in hypertensives. Thus, this study evaluated the relationship between sleep quality and cardiac autonomic modulation in hypertensives. Forty-seven middle-aged hypertensive men under consistent anti-hypertensive treatment were assessed for sleep quality by the Pittsburgh Sleep Quality Index (PSQI-higher score means worse sleep quality). Additionally, their beat-by-beat BP and heart rate (HR) were recorded, and cardiac autonomic modulation was assessed by their variabilities. Mann-Whitney and t tests were used to compare different sleep quality groups: poor (PSQI > 5, n = 24) vs good (PSQI ≤ 5, n = 23), and Spearman's correlations to investigate associations between sleep quality and autonomic markers. Patients with poor sleep quality presented lower cardiac parasympathetic modulation (HR high-frequency band = 26 ± 13 vs 36 ± 15 nu, P = .03; HR total variance = 951 ± 1373 vs 1608 ± 2272 ms2 , P = .05) and cardiac baroreflex sensitivity (4.5 ± 2.3 vs 7.1 ± 3.7 ms/mm Hg, P = .01). Additionally, sleep quality score presented significant positive correlation with HR (r = +0.34, P = .02) and negative correlations with HR high-frequency band (r = -0.34, P = .03), HR total variance (r = -0.35, P = .02), and cardiac baroreflex sensitivity (r = -0.42, P = .01), showing that poor sleep quality is associated with higher HR and lower cardiac parasympathetic modulation and baroreflex sensitivity. In conclusion, in treated hypertensive men, poor sleep quality is associated with cardiac autonomic dysfunction.

A contemporary review of obstructive sleep apnea

PURPOSE OF REVIEW

This review provides a contemporary review of sleep apnea with emphasis on definitions, epidemiology, and consequences.

RECENT FINDINGS

Amyloid β-42 is one of the main peptides forming amyloid plaques in the brains of Alzheimer patients. Poorer sleep quality and shorter sleep duration have been associated with a higher amyloid burden. Decreased sleep time in the elderly is a precipitating factor in amyloid retention. Studies have shown that the dysregulation of the homeostatic balance of the major inhibitory and excitatory amino acid neurotransmitter systems of gamma-aminobutyric acid (GABA) and glutamate play a role in sleep disordered breathing (SDB).

SUMMARY

Untreated sleep disordered breathing (obstructive sleep apnea and/or central sleep apnea) are an important cause of medical mortality and morbidity. OSA is characterized by recurrent episodes of partial or complete collapse of the upper airway during sleep followed by hypoxia and sympathetic activation. Apneic events are terminated by arousal, followed by increases in pulse and blood pressure, and re-oxygenation and the release of inflammatory factors. Individuals with OSA have an increased risk of developing atrial fibrillation. Hypoxemia and poor sleep quality because of OSA increase the risk of cognitive decline in the elderly.

Heart rate as a predictor of cardiovascular risk

Heart rate is a parameter that is very easy to measure and is widely used both in clinic and during daily life activities. Its value gained more relevance with the evidence, in prospective studies and meta-analysis, of association between elevated heart rate values and diseases and outcomes.The increased knowledge of physiological mechanisms of heart rate control and the pathophysiological mechanisms responsible for its dysfunction allows to identify the cut-off value of normalcy providing info for non-pharmacological and pharmacological treatments to reduce the cardiovascular risk both in general population and in pathophysiological conditions. This paper overviews the knowledges of the role of resting heart rate as predictor of cardiovascular risk.

Overnight pulse wave analysis to assess autonomic changes during sleep in insomnia patients and healthy sleepers

Insomnia has been associated with increased cardiovascular (CV) risk, which may be linked to sympathetic activation. Non-invasive overnight pulse wave analysis may be a useful tool to detect early signs of autonomic changes during sleep in insomniacs. Fifty-two participants (26 men, 37±13 years, BMI: 24±5 kg/m², 26 insomniacs/ 26 controls) underwent overnight polysomnography with pulse oximetry and pulse wave analysis including pulse rate, vascular stiffness (pulse propagation time, PPT), and a composite cardiac risk index based on autonomic function and overnight hypoxia. We identified two subgroups of insomniacs, with and without objectively disturbed sleep (sleep efficiency SE≤80%, n = 14 vs. SE>80%, n = 12), and observed increased pulse rate and vascular stiffness in insomnia cases when diagnosis was based on both, subjective and objective criteria. Both insomnia groups were associated with higher overnight pulse rate than controls (median/ IQR: low-SE (low sleep efficiency): 67/ 58-70bpm; high-SE: 66/ 63-69bpm; controls: 58/ 52-63bpm; p = 0.01). Vascular stiffness was higher (reduction of PPT) in low-SE insomniacs compared with high-SE insomniacs and controls (169/ 147-232ms; 237/ 215-254ms; 244/ 180-284ms; p = 0.01). The cardiac risk index was increased in low-SE insomniacs (0.2/ 0.0–0.7; 0.0/ 0.0–0.4; 0.0/ 0.0–0.3; p = 0.05). Our results suggest a hyperarousal state in young and otherwise healthy insomniacs during sleep. The increased pulse rate and vascular stiffness in insomniacs with low SE suggest early signs of rigid vessels and potentially, an elevated CV risk. Overnight pulse wave analysis may be feasible for CV risk assessment in insomniacs and may provide a useful tool for phenotyping insomnia in order to provide individualized therapy.

Heart rate as cardiovascular risk factor

Heart rate is a parameter that is widely used by the general population as a marker of health. The availability of wearable electronic heart rate monitoring devices and use of specific apps are widely used both at rest and during daily life activities. Resting heart rate values gained more relevance with the evidence of association between elevated heart rate values at rest and diseases and adverse events. Also longitudinal studies demonstrated a clear association between increase in heart rate over time and cardiovascular and all-cause mortality. The increased knowledge of physiological mechanisms of heart rate control and the pathophysiological mechanisms responsible for its dysfunction allows identification of the cutoff value of normalcy. This information can be used to select non-pharmacological and pharmacological interventions to reduce the cardiovascular risk both in the general population and in patients with pathophysiological conditions. This review provides an overview of the current knowledge of resting heart rate as cardiovascular risk factor.

Insomnia symptoms and risk of cardiovascular diseases among 0.5 million adults: A 10-year cohort

OBJECTIVE

To examine the associations of individual insomnia symptoms with risks of incident cardio-cerebral vascular diseases (CVD) and possible moderating factors among Chinese adults.

METHODS

The China Kadoorie Biobank is a prospective cohort study that recruited participants from 10 areas across China. Data from 487,200 adults 30 to 79 years of age who were free of stroke, coronary heart disease, and cancer at baseline were analyzed. Three insomnia symptoms were assessed with self-reported difficulties in initiating or maintaining sleep, early morning awakening, and daytime dysfunction for at least 3 d/wk at baseline. Incidences of CVD were followed up through disease registries and national health insurance databases until 2016.

RESULTS

During a median of 9.6 years of follow-up, 130,032 cases of CVD were documented. Cox regressions showed that 3 insomnia symptoms were associated with increased risk of total CVD, with respective adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) of 1.09 (95% CI 1.07-1.11), 1.07 (95% CI 1.05-1.09), and 1.13 (95% CI 1.09-1.18). Participants with individual symptoms also had higher risks of ischemic heart disease (IHD; HR 1.13, 1.09, and 1.17) and ischemic stroke but not hemorrhagic stroke. Participants with all 3 symptoms were at an 18%, 22%, or 10% higher risk of CVD, IHD, or ischemic stroke compared to nonsymptomatic adults. Associations between 3 symptoms and CVD incidence were consistently stronger in younger adults or those without baseline hypertension (p for interaction <0.05).

CONCLUSIONS

Individual and coexisting insomnia symptoms are independent risk factors for CVD incidence, especially among young adults or adults who have not developed hypertension.

Insomnia and risk of mortality from all-cause, cardiovascular disease, and cancer: Systematic review and meta-analysis of prospective cohort studies

Growing evidence indicates that insomnia may be associated with mortality. However, these findings have been inconsistent. We systematically searched MEDLINE and EMBASE to identify prospective cohort studies that assessed the association between insomnia disorder/individual insomnia symptoms and the risk of mortality among adults aged ≥18 yrs. We addressed this association using summary hazard ratios (HRs) and 95% confidence intervals (CIs) calculated using random-effects meta-analysis, and the GRADE approach to rate the certainty of evidence. Twenty-nine cohorts including 1,598,628 individuals (55.3% men; mean age 63.7 yrs old) with a median follow-up duration of 10.5 yrs proved eligible. Difficulty falling asleep (DFA) and non-restorative sleep (NRS) were associated with an increased risk of all-cause mortality (DFA: HR = 1.13, 95%CI 1.03 to 1.23, p = 0.009, moderate certainty; NRS: HR = 1.23, 95%CI 1.07 to 1.42, p = 0.003, high certainty) and cardiovascular disease mortality (DFA: 1.20, 95%CI: 1.01, 1.43; p = 0.04, moderate certainty; NRS: HR = 1.48, 95%CI 1.06 to 2.06, p = 0.02, moderate certainty). Convincing associations between DFA and all-cause mortality were restricted to the mid to older-aged population (moderate credibility). Insomnia disorder, difficulty maintaining sleep, and early morning awakening proved to be unassociated with all-cause and cardiovascular disease mortality. No insomnia symptoms proved to be associated with cancer-related mortality.

Resistant Hypertension: Detection, Evaluation, and Management: A Scientific Statement From the American Heart Association

Resistant hypertension (RH) is defined as above-goal elevated blood pressure (BP) in a patient despite the concurrent use of 3 antihypertensive drug classes, commonly including a long-acting calcium channel blocker, a blocker of the renin-angiotensin system (angiotensin-converting enzyme inhibitor or angiotensin receptor blocker), and a diuretic. The antihypertensive drugs should be administered at maximum or maximally tolerated daily doses. RH also includes patients whose BP achieves target values on ≥4 antihypertensive medications. The diagnosis of RH requires assurance of antihypertensive medication adherence and exclusion of the "white-coat effect" (office BP above goal but out-of-office BP at or below target). The importance of RH is underscored by the associated risk of adverse outcomes compared with non-RH. This article is an updated American Heart Association scientific statement on the detection, evaluation, and management of RH. Once antihypertensive medication adherence is confirmed and out-of-office BP recordings exclude a white-coat effect, evaluation includes identification of contributing lifestyle issues, detection of drugs interfering with antihypertensive medication effectiveness, screening for secondary hypertension, and assessment of target organ damage. Management of RH includes maximization of lifestyle interventions, use of long-acting thiazide-like diuretics (chlorthalidone or indapamide), addition of a mineralocorticoid receptor antagonist (spironolactone or eplerenone), and, if BP remains elevated, stepwise addition of antihypertensive drugs with complementary mechanisms of action to lower BP. If BP remains uncontrolled, referral to a hypertension specialist is advised.

Insomnia and hypertension: A systematic review

Insomnia is a prevalent sleep disorder that is associated with a multitude of health consequences. Particularly, insomnia has been associated with cardiovascular disease and its precursors, such as hypertension and blood pressure (BP) non-dipping. The present systematic review aimed to summarize the evidence on the concurrent and prospective associations between insomnia and hypertension and/or BP. Using electronic search engines (PubMed, SCOPUS, PsycINFO), 5,618 articles published from January 1970 to December 2017 were identified, and 64 met the inclusion criteria (26 to 162,121 participants; age range: 18-100; 46.4% male). Insomnia was based on diagnostic or non-diagnostic criteria. Hypertension was based on self-or physician-reports, antihypertensive medication use, and/or measured BP. Findings indicate that when insomnia is frequent, chronic, and/or accompanied with short sleep duration or objective markers of arousal, there is a strong association with hypertension/BP. Based on limited studies, hypertension did not significantly predict future insomnia in middle-aged adults, but did in older adults. Based on a majority of case-control studies, no differences in BP were found between participants with and without insomnia. Further research is needed to identify putative pathophysiological mechanisms underlying the link between insomnia and hypertension. The impact of insomnia therapy on BP should also be further examined in the future.

Sleep Quality and Its Associated Factors among Low-Income Adults in a Rural Area of China: A Population-Based Study

BACKGROUND

There is limited population-based research focusing on sleep quality among low-income Chinese adults in rural areas. This study aimed to assess sleep quality among low-income adults in a rural area in China and identify the association between sleep quality and sociodemographic, lifestyle and health-related factors.

METHODS

The study was conducted from September to November in 2017 using a cross-sectional survey questionnaire. A total of 6905 participants were recruited via multistage, stratified cluster sampling. Data were collected using the Chinese versions of Pittsburgh Sleep Quality Index and Food Frequency Questionnaire, while we also determined the sociodemographic profiles of the participants.

RESULTS

The mean age of the sample was 58.71 ± 14.50 years, with 59.7% being male, while the mean duration of daily sleep was 5.95 ± 1.31 h, with 56.7% reportedly experiencing poor sleep quality. Multiple regression analysis revealed that older age, unemployment, lower income, disability and chronic disease comorbidities were significant factors associated with an increased risk of poor sleep quality for both genders. Moreover, married and higher education level were associated with decreased risk of poor sleep quality for females, while a meat-heavy diet and illness during the past two weeks increased the risk of poor sleep quality for males.

CONCLUSIONS

Sociodemographic, lifestyle and health-related factors had an impact on the frequently poor sleep quality of low-income Chinese adults in rural areas. Thus, comprehensive measures must be developed to address the modifiable predictive factors that can possibly enhance sleep quality.

Associations of Insomnia Symptoms With Blood Pressure and Resting Heart Rate: The HUNT Study in Norway

OBJECTIVE

Although elevated heart rate and blood pressure might represent biologically plausible links for the association of insomnia symptoms with increased risk of cardiovascular disease (CVD), few large studies have investigated the associations of insomnia symptoms with these factors. Our aim was to investigate the associations of self-reported insomnia symptoms with systolic and diastolic blood pressure and resting heart rate in a large population-based study.

PARTICIPANTS

Self-reported information on insomnia symptoms, including sleep initiation problems, frequent awakening and early awakenings during night, and measurements of resting heart rate and blood pressure were collected from a total of 50,806 men and women who participated in the third wave of the Nord-Trøndelag Health Study (HUNT-3) in 2006-2008.

METHODS

In multivariable analyses, we adjusted for sociodemographic factors, lifestyle factors, established CVD risk factors, and snoring or breathing pauses.

RESULTS

Compared to participants reporting none of the insomnia symptoms, those having all three insomnia symptoms several times a week had lower diastolic blood pressure (-0.80 [95% CI: -1.47 to -0.14] mmHg, p = 0.02), lower systolic blood (-1.69 [95% CI: -2.76 to -0.63) mmHg, p < 0.001), and higher resting heart rate (0.83 [95% CI: 0.11 to 1.55] beats/minute, p = 0.02).

CONCLUSIONS

We found a modest positive association of insomnia symptoms with resting heart rate, and a modest inverse association of insomnia with blood pressure. However, the actual differences were small, and likely of less clinical importance. Prospective studies are needed to establish whether the potential link between insomnia and CVD is mediated through changes in heart rate and/or blood pressure.

Sleep quality and its association with postural stability and fear of falling among Spanish postmenopausal women

OBJECTIVE

To analyze the association of sleep quality with postural balance, as measured with objective stabilometric parameters, and fear of falling (FoF), among Spanish postmenopausal women.

METHODS

In all, 250 women (60 ± 8 years) took part in this cross-sectional study. Sociodemographic and anthropometric data were collected, as well as information concerning history of falls and FoF. Anxiety and depression were assessed using the Hospital Anxiety and Depression Scale, and the Pittsburgh Sleep Quality Index was used to analyze sleep quality. Measurements of sway area (S), velocity (V), and mediolateral (RMSX) and anteroposterior (RMSY) displacements of the center of pressure were obtained with a resistive multisensor platform under both eyes-open (EO) and eyes-closed (EC) conditions to assess postural control. The independent associations of sleep quality with FoF and postural control were evaluated by multivariate linear and logistic regressions, respectively, adjusting for potential confounding variables.

RESULTS

SEO was independently associated (adjusted R = 0.073) with sleep duration (P < 0.001) and subjective sleep quality (P = 0.001), VEO (adjusted R = 0.156) with daytime dysfunction (P = 0.006) and sleep duration (P = 0.013), RMSXEO (adjusted R = 0.118) with subjective sleep quality (P = 0.005), and RMSYEO (adjusted R = 0.166) with sleep duration (P = 0.001) and daytime dysfunction (P = 0.046). Under EC condition, SEC (adjusted R = 0.014) was independently related with anxiety (P = 0.034), VEC (adjusted R = 0.148) with daytime dysfunction (P = 0.002) and sleep duration (P = 0.024), RMSXEC (adjusted R = 0.134) with subjective sleep quality (P < 0.001), and RMSYEC (adjusted R = 0.128) with sleep duration (P = 0.013) and daytime dysfunction (P = 0.033). Logistic regression showed that time since menopause (P = 0.003), body mass index (P = 0.001), and anxiety (P < 0.001), unlike sleep quality, were independently associated with FoF. The effect size of the model was medium (adjusted R= 0.162).

CONCLUSIONS

In Spanish postmenopausal women, sleep duration, subjective sleep quality, and daytime dysfunction were independent risk factors for worsened postural stability. FoF, anxiety, time since menopause onset, and body mass index, unlike sleep quality, were independently associated with poor postural stability.

Genome-wide association analysis of insomnia complaints identifies risk genes and genetic overlap with psychiatric and metabolic traits

Persistent insomnia is among the most frequent complaints in general practice. To identify genetic factors for insomnia complaints, we performed a genome-wide association study (GWAS) and a genome-wide gene-based association study (GWGAS) in 113,006 individuals. We identify three loci and seven genes associated with insomnia complaints, with the associations for one locus and five genes supported by joint analysis with an independent sample (n = 7,565). Our top association (MEIS1, P < 5 × 10-8) has previously been implicated in restless legs syndrome (RLS). Additional analyses favor the hypothesis that MEIS1 exhibits pleiotropy for insomnia and RLS and show that the observed association with insomnia complaints cannot be explained only by the presence of an RLS subgroup within the cases. Sex-specific analyses suggest that there are different genetic architectures between the sexes in addition to shared genetic factors. We show substantial positive genetic correlation of insomnia complaints with internalizing personality traits and metabolic traits and negative correlation with subjective well-being and educational attainment. These findings provide new insight into the genetic architecture of insomnia.

Hypertension with unsatisfactory sleep health (HUSH): study protocol for a randomized controlled trial

BACKGROUND

Insomnia is common in primary care medical practices. Although behavioral treatments for insomnia are safe, efficacious, and recommended in practice guidelines, they are not widely-available, and their effects on comorbid medical conditions remain uncertain. We are conducting a pragmatic clinical trial to test the efficacy of two cognitive behavioral treatments for insomnia (Brief Behavioral Treatment for Insomnia (BBTI) and Sleep Healthy Using the Internet (SHUTi)) versus an enhanced usual care condition (EUC).

METHODS/DESIGN

The study is a three-arm, parallel group, randomized controlled trial. Participants include 625 adults with hypertension and insomnia, recruited via electronic health records from primary care practices affiliated with a large academic medical center. After screening and baseline assessments, participants are randomized to treatment. BBTI is delivered individually with a live therapist via web-interface/telehealth sessions, while SHUTi is a self-guided, automated, interactive, web-based form of cognitive behavioral therapy for insomnia. Participants in EUC receive an individualized sleep report, educational resources, and an online educational video. Treatment outcomes are measured at 9 weeks, 6 months, and 12 months. The primary outcome is patient-reported sleep disturbances. Secondary outcomes include other self-reported sleep measures, home blood pressure, body mass index, quality of life, health functioning, healthcare utilization, and side effects.

DISCUSSION

This randomized clinical trial compares two efficacious insomnia interventions to EUC, and provides a cost-effective and efficient examination of their similarities and differences. The pragmatic orientation of this trial may impact sleep treatment delivery in real world clinical settings and advance the dissemination and implementation of behavioral sleep interventions.

TRIAL REGISTRATION

ClinicalTrials.gov (Identifier: NCT02508129 ; Date Registered: July 21, 2015).

Resting heart rate and the risk of cardiovascular disease, total cancer, and all-cause mortality - A systematic review and dose-response meta-analysis of prospective studies

BACKGROUND AND AIM

Epidemiological studies have reported increased risk of cardiovascular disease, cancer and all-cause mortality with greater resting heart rate, however, the evidence is not consistent. Differences by gender, adjustment for confounding factors, as well as the potential impact of subclinical disease are not clear. A previous meta-analysis missed a large number of studies, and data for atrial fibrillation have not been summarized before. We therefore aimed to clarify these associations in a systematic review and meta-analysis of prospective studies.

METHODS AND RESULTS

PubMed and Embase were searched up to 29 March 2017. Summary RRs and 95% confidence intervals (CIs) were calculated using random effects models. Eighty seven studies were included. The summary RR per 10 beats per minute increase in resting heart rate was 1.07 (95% CI: 1.05-1.10, I² = 61.9%, n = 31) for coronary heart disease, 1.09 (95% CI: 1.00-1.18, I² = 62.3%, n = 5) for sudden cardiac death, 1.18 (95% CI: 1.10-1.27, I² = 74.5%, n = 8) for heart failure, 0.97 (95% CI: 0.92-1.02, I² = 91.4%, n = 9) for atrial fibrillation, 1.06 (95% CI: 1.02-1.10, I² = 59.5%, n = 16) for total stroke, 1.15 (95% CI: 1.11-1.18, I² = 84.3%, n = 35) for cardiovascular disease, 1.14 (95% CI: 1.06-1.23, I² = 90.2%, n = 12) for total cancer, and 1.17 (95% CI: 1.14-1.19, I² = 94.0%, n = 48) for all-cause mortality. There was a positive dose-response relationship for all outcomes except for atrial fibrillation for which there was a J-shaped association.

CONCLUSION

This meta-analysis found an increased risk of coronary heart disease, sudden cardiac death, heart failure, atrial fibrillation, stroke, cardiovascular disease, total cancer and all-cause mortality with greater resting heart rate.

Relation of Higher Resting Heart Rate to Risk of Cardiovascular Versus Noncardiovascular Death

Higher resting heart rate (RHR) is associated with increased risk of all-cause and cardiovascular mortality, with some reports showing the magnitude of association with all-cause mortality being stronger than that with cardiovascular mortality. This suggests that RHR association with mortality may not be limited to cardiovascular death. We compared the association between RHR with cardiovascular and noncardiovascular mortality in 6,743 participants (mean age 58.7 years, 52% women, 48% non-Hispanic whites) from the Third National Health and Nutrition Examination Survey (NHANES-III) after excluding those on antiarrhythmic drugs or with missing data. RHR data were obtained from standard 12-lead electrocardiogram recorded on the NHANES participants during a physical examination. National Death Index was used to identify the date and cause of death. Multivariable Cox proportional hazards analysis was used to calculate the hazard ratios (HRs) and 95% CIs for cardiovascular mortality and noncardiovascular mortality, separately, associated with 10 beats/min increase in RHR. During a median follow-up of 13.9 years, 906 cardiovascular deaths and 1,306 noncardiovascular deaths occurred. In models adjusted for age, gender, race, hypertension, diabetes, obesity, dyslipidemia, previous cardiovascular disease, smoking, cancer, chronic obstructive airway disease, thyroid disease, and serum creatinine, higher RHR was associated with increased risk of both cardiovascular mortality and noncardiovascular mortality with a relatively similar magnitude of risk (HR 1.19, 95% CI 1.12 to 1.26 and HR 1.23, 95% CI 1.17 to 1.29, respectively). In conclusion, higher RHR is associated with both cardiovascular mortality and noncardiovascular mortality suggesting that RHR is probably a marker of overall well-being rather than a marker of cardiovascular health.

Biological rhythms, metabolic syndrome and current depressive episode in a community sample

The purpose of this study was to assess the disruption in biological rhythms and metabolic syndrome (MetS) in individuals with depressive episode. This was a cross-sectional, population-based study with a representative sample of 905 young adults. Current depressive episode were confirmed by a psychologist using the Mini International Neuropsychiatric Interview (MINI)-Plus. Self-reported biological rhythms were assessed using the Biological Rhythms Interview of Assessment in Neuropsychiatry (BRIAN). MetS was defined using modified NCEP/ATPIII criteria. Significant main effects of current depressive episode (p<0.001, η(2)=0.163) and MetS (p=0.001, η(2)=0.011) were observed on total BRIAN score. There was a significant interaction between depression and MetS in total biological rhythm scores (p=0.002, η(2)=0.011) as well as sleep (p=0.001, η(2)=0.016) and social domains (p<0.001, η(2)=0.014). In the depressive group, subjects with MetS had a higher disruption in total BRIAN scores (p=0.010), sleep domain (p=0.004), social domain (p=0.005) and in the eating pattern domain approached the level of significance (p=0.098), when compared to subjects with no MetS. The results of the present study showed that self-reported disruptions in biological rhythms are associated with key components of the MetS in community adults with MDD. The understanding of the complex interactions between biological rhythms, MetS and depression are important in the development of preventive and therapeutic strategies.

Insomnia symptoms and heart rate recovery among patients in cardiac rehabilitation

Insomnia symptoms (i.e., difficulty falling asleep, difficulty staying asleep, and early morning awakenings) are common among people with cardiovascular disease, and have been linked to adverse cardiovascular health outcomes. Reduced parasympathetic tone is one pathway through which risk may be conferred. The purpose of this study was to evaluate whether insomnia symptoms are associated with lower parasympathetic tone in cardiac rehabilitation patients with suspected insomnia. Participants (N = 121) completed a self-report measure of insomnia severity. 1-min heart rate recovery (HRR), an index of parasympathetic tone, was obtained during a maximal exercise test. Difficulty falling asleep, but not difficulty staying asleep or early awakenings, was associated with attenuated 1-min HRR. When analyses were restricted to participants with moderate and severe insomnia severity (n = 51), the strength of this association increased. In a sample of cardiac rehabilitation patients with insomnia, only the symptom of difficulty falling asleep was associated with lower parasympathetic tone, suggesting that individual insomnia symptoms may show specificity in their associations with physiological mechanisms.

Insomnia Symptoms Are Not Associated with Dyslipidemia: A Population-Based Study

STUDY OBJECTIVES

The purpose of this study was to examine whether or not insomnia symptoms were associated with measured dyslipidemia.

METHODS

This was a population-based multiyear cross-sectional study, using data from 2005-2008 United States National Health and Nutrition Examination Surveys. Survey participants ages 20 y and older self-reported the frequency of difficulty falling asleep, prolonged nocturnal awakening, and undesired early morning awakening over the preceding month. One-time venipuncture was performed and a low-density lipoprotein cholesterol (LDL-C) of ≥ 160 mg/ dL, triglycerides of ≥ 200 mg/dL, and a high-density lipoprotein cholesterol (HDL-C) of < 40 mg/dL denoted dyslipidemia. Descriptive statistics and multiple logistic regression were used.

RESULTS

Data on LDL-C, triglycerides, and HDL-C was available for 4,635, 4,757, and 9,798 individuals, respectively. There were no significant associations between having any insomnia symptom at least five times in the past month and high LDL-C (odds ratio [OR] 1.20, 95% confidence interval [CI] 0.92-1.55) or low HDL-C (OR 0.92, 95% CI 0.82-1.04) in unadjusted analyses, or with high triglycerides after adjusting for covariates (OR 1.03, 95% CI 0.78-1.37). Recipients of sleeping pills who also had insomnia symptoms had significantly increased adjusted odds of elevated LDL-C (OR 2.18, 95% CI 1.14-4.15).

CONCLUSIONS

Insomnia symptoms were generally not associated with dyslipidemia, but receipt of sleeping pills in the setting of insomnia was associated with elevated LDL-C. Further research is needed to confirm a possible link between sleeping pill use and dyslipidemia and to delineate if an association with atherosclerosis exists with specific types of sleeping pills or with all sedative medications more broadly.

Concomitant Sleep Disorders Significantly Increase the Risk of Cardiovascular Disease in Patients with Psoriasis

Background

The increased rates of cardiovascular morbidity and mortality in patients with psoriasis are not adequately explained by traditional risk factors. Whether concomitant sleep disorders (SDs) modify the risk of cardiovascular disease (CVD) in patients with psoriasis remains unknown.

Methods

Using the Taiwan National Health Insurance Research Database (NHIRD), we conducted a cohort study to investigate the association between concomitant SDs and CVD risk in patients with psoriasis. Data from 99,628 adults who received a psoriasis diagnosis during the period from 2004 to 2010 were analyzed. Cox proportional hazards regression analysis models were used to compare the risks of ischemic heart disease (IHD) and stroke between patients with and without SDs.

Results

Psoriasis patients with a concomitant SD had significantly higher risks of IHD (adjusted hazard ratio [aHR], 1.25; 95% confidence interval [CI], 1.22–1.28) and stroke (aHR, 1.24; 95% CI, 1.16–1.33) as compared with psoriasis patients without SDs. All psoriasis patient subgroups, including those with mild and severe psoriasis and those with and without arthritis, had increased HRs for IHD and stroke. The increases in IHD and stroke risks conferred by SDs were proportional to the dose of hypnotics used. The effect of SDs on the risks of IHD and stroke was greater in young adults than in middle-aged and older adults.

Conclusions

The risks of IHD and stroke were higher for psoriasis patients with SDs than for those without SDs. Clinicians should carefully evaluate CVD risk, particularly in young patients with psoriasis.

Resting heart rate and all-cause and cardiovascular mortality in the general population: a meta-analysis

BACKGROUND

Data on resting heart rate and risk of all-cause and cardiovascular mortality are inconsistent; the magnitude of associations between resting heart rate and risk of all-cause and cardiovascular mortality varies across studies. We performed a meta-analysis of prospective cohort studies to quantitatively evaluate the associations in the general population.

METHODS

We searched PubMed, Embase and MEDLINE from inception to Jan. 1, 2015. We used a random-effects model to combine study-specific relative risks and 95% confidence intervals (CIs). We used restricted cubic spline functions to assess the dose-response relation.

RESULTS

A total of 46 studies were included in the meta-analysis, involving 1 246 203 patients and 78 349 deaths for all-cause mortality, and 848 320 patients and 25 800 deaths for cardiovascular mortality. The relative risk with 10 beats/min increment of resting heart rate was 1.09 (95% CI 1.07-1.12) for all-cause mortality and 1.08 (95% CI 1.06-1.10) for cardiovascular mortality. Compared with the lowest category, patients with a resting heart rate of 60-80 beats/min had a relative risk of 1.12 (95% CI 1.07-1.17) for all-cause mortality and 1.08 (95% CI 0.99-1.17) for cardiovascular mortality, and those with a resting heart rate of greater than 80 beats/min had a relative risk of 1.45 (95% CI 1.34-1.57) for all-cause mortality and 1.33 (95% CI 1.19-1.47) for cardiovascular mortality. Overall, the results did not differ after adjustment for traditional risk factors for cardiovascular disease. Compared with 45 beats/min, the risk of all-cause mortality increased significantly with increasing resting heart rate in a linear relation, but a significantly increased risk of cardiovascular mortality was observed at 90 beats/min. Substantial heterogeneity and publication bias were detected.

INTERPRETATION

Higher resting heart rate was independently associated with increased risks of all-cause and cardiovascular mortality. This indicates that resting heart rate is a predictor of all-cause and cardiovascular mortality in the general population.

A warmer indoor environment in the evening and shorter sleep onset latency in winter: The HEIJO-KYO study

Difficulty in initiating sleep is an important problem because it is associated with an increased incidence of depression, diabetes, myocardial infarction, and higher all-cause mortality. Although experimental studies in controlled settings have shown that warm skin temperature of the extremities (feet and hands) before bedtime is associated with shorter sleep onset latency (SOL), evidence from real life situations is limited. We assessed the relationship between indoor temperatures in the evening (2h before bedtime) and SOL among 861 home-dwelling elderly participants. Subjective SOL was determined according to a self-administered sleep diary. Actigraphic (objective) SOL, indoor temperature, and bed temperature were simultaneously measured at participants' homes for 48h during the colder seasons (October-April). The association between evening indoor temperature and SOL was assessed using a multilevel linear regression model with random intercept for individual participants. Evening indoor temperature showed a significant inverse association with log-transformed subjective SOL (β=-0.021, P<0.01) and actigraphic SOL (β=-0.019, P<0.01), independent of potential confounders including gender, insomnia medication, evening physical activity, and bedtime. Higher bed temperature during the 2h after bedtime was significantly associated with shorter log-transformed actigraphic SOL (β=-0.028, P<0.01). These significant associations were maintained even after adjustment for evening outdoor temperature. The clinically important findings of the present study indicate that SOL may be shortened by modification of evening indoor temperature and bed temperature for 2h after bedtime.

Retrospective Assessment of Home Ventilation to Reduce Rehospitalization in Chronic Obstructive Pulmonary Disease

BACKGROUND

Healthcare systems are attempting to reduce hospital readmissions due to chronic obstructive pulmonary disease (COPD).

METHODS

A retrospective study of a quality improvement (QI) program performed at a single center whose multifaceted intervention included nocturnal administration of advanced positive airway pressure (PAP) modality (or noninvasive positive pressure ventilation [NIPPV]) called averaged volume assured pressure support (AVAPS-AE) initiation by a respiratory therapist (RT), medication reconciliation by a pharmacist, adequate provision of oxygen, and ongoing RT-led care. In this QI program, consecutive patients who had been hospitalized twice in a single year with an acute COPD exacerbation underwent such interventions after they met specific selection criteria.

RESULTS

Three-hundred ninety-seven consecutive patients were eligible for the program because they had two or more hospitalizations in the previous year. The proportion of patients who were readmitted on two or more occasions decreased from 100% (397 of 397) in the year prior to initiation of intervention to 2.2% (9 of 397) in the following year (χ(2) = 758, p < 0.0001). Seventy patients died over the one year following initiation of the multifaceted intervention. A composite outcome of rehospitalization and death was associated with inhaled steroids (adjusted odds ratio [adjOR] of 2.13; 95% confidence interval [CI] 1.09, 4.17; p = 0.02), whereas inhaled antimuscarinics tended to be associated with less risk for rehospitalization or death (adjOR 0.56; 95% CI 0.34, 1.03; p = 0.06).

CONCLUSION

In a retrospective cohort study of a QI initiative undertaken at a single center, we have observed that a multifaceted intervention that involved initiation of nocturnal advanced PAP (NIPPV) modality, RT-led respiratory care, medication reconciliation, appropriate oxygen therapy initiation, and patient education led to significant reduction in rehospitalization.

Associations of a Short Sleep Duration, Insufficient Sleep, and Insomnia with Self-Rated Health among Nurses

Epidemiological evidence suggests that sleep duration and poor sleep are associated with mortality, as well as with a wide range of negative health outcomes. However, few studies have examined the association between sleep and self-rated health, particularly through the combination of sleep complaints. The objective of this study was to examine whether self-rated health is associated with sleep complaints, considering the combination of sleep duration, insomnia, and sleep sufficiency. This cross-sectional study was performed in the 18 largest public hospitals in the city of Rio de Janeiro, Brazil. A total of 2518 female nurses answered a self-filled multidimensional questionnaire. The adjusted odds ratios and 95% confidence intervals (CIs) estimated the chance of poor self-rated health in the presence of different combinations of sleep duration and quality. Compared with women who reported adequate sleep duration with no sleep quality complaints (reference group), the odds ratios (95% CI) for poor self-rated health were 1.79 (1.27–2.24) for those who reported only insufficient sleep, 1.85 (0.94–3.66) for only a short sleep duration, and 3.12 (1.94–5.01) for only insomnia. Compared with those who expressed all three complaints (short sleep duration, insomnia, and insufficient sleep), the odds ratio for poor self-rated health was 4.49 (3.25–6.22). Differences in the magnitude of the associations were observed, depending on the combination of sleep complaints. Because self-rated health is a consistent predictor of morbidity, these results reinforce the increasing awareness of the role of sleep in health and disease. Our findings contribute to the recognition of sleep as a public health matter that deserves to be better understood and addressed by policymakers.

Higher vagal activity as related to survival in patients with advanced breast cancer: an analysis of autonomic dysregulation

OBJECTIVE

High levels of high-frequency heart rate variability (HF-HRV), related to parasympathetic-nervous-system functioning, have been associated with longer survival in patients with myocardial infarction and acute trauma and in patients undergoing palliative care. From animal studies linking higher vagal activity with better immune system functioning and reduced metastases, we hypothesized that higher HF-HRV would predict longer survival in patients with metastatic or recurrent breast cancer (MRBC).

METHODS

Eighty-seven patients with MRBC participated in a laboratory task including a 5-minute resting baseline electrocardiogram. HF-HRV was computed as the natural logarithm of the summed power spectral density of R-R intervals (0.15-0.50 Hz). In this secondary analysis of a study testing whether diurnal cortisol slope predicted survival, we tested the association between resting baseline HF-HRV on survival using Cox proportional hazards models.

RESULTS

A total of 50 patients died during a median follow-up of 7.99 years. Higher baseline HF-HRV predicted significantly longer survival, with a hazard ratio of 0.75 (95% confidence interval = 0.60-0.92, p = .006). Visceral metastasis status and baseline heart rate were related to both HF-HRV and survival. However, a combination of HF-HRV and heart rate further improved survival prediction, with a hazard ratio of 0.64 (95% confidence interval = 0.48-0.85, p = .002).

CONCLUSIONS

Vagal activity of patients with MRBC strongly predicted their survival, extending the known predictive window of HF-HRV in cancer beyond palliative care. Vagal activity can be altered by behavioral, pharmacological, and surgical interventions and may be a promising target for extending life expectancy in patients with metastasizing cancer.

Persistent insomnia is associated with mortality risk

BACKGROUND

Insomnia has been associated with mortality risk, but whether this association is different in subjects with persistent vs intermittent insomnia is unclear. Additionally, the role of systemic inflammation in such an association is unknown.

METHODS

We used data from a community-based cohort to determine whether persistent or intermittent insomnia, defined based on persistence of symptoms over a 6-year period, was associated with death during the following 20 years of follow-up. We also determined whether changes in serum C-reactive protein (CRP) levels measured over 2 decades between study initiation and insomnia determination were different for the persistent, intermittent, and never insomnia groups. The results were adjusted for confounders such as age, sex, body mass index, smoking, physical activity, alcohol, and sedatives.

RESULTS

Of the 1409 adult participants, 249 (18%) had intermittent and 128 (9%) had persistent insomnia. During a 20-year follow-up period, 318 participants died (118 due to cardiopulmonary disease). In adjusted Cox proportional-hazards models, participants with persistent insomnia (adjusted hazards ratio [HR] 1.58; 95% confidence interval [CI], 1.02-2.45) but not intermittent insomnia (HR 1.22; 95% CI, 0.86-1.74) were more likely to die than participants without insomnia. Serum CRP levels were higher and increased at a steeper rate in subjects with persistent insomnia as compared with intermittent (P = .04) or never (P = .004) insomnia. Although CRP levels were themselves associated with increased mortality (adjusted HR 1.36; 95% CI, 1.01-1.82; P = .04), adjustment for CRP levels did not notably change the association between persistent insomnia and mortality.

CONCLUSIONS

In a population-based cohort, persistent, and not intermittent, insomnia was associated with increased risk for all-cause and cardiopulmonary mortality and was associated with a steeper increase in inflammation.

Sleep disturbances and dementia

Sleep is a complex behavioural state, the ultimate functions of which remain poorly understood. It becomes more fragmented as we age, with more night-time awakenings and greater tendency for daytime sleep. The magnitude of disordered sleep among individuals affected by dementia has been clearly demonstrated, and disturbed sleep is a major clinical problem in dementia. Comorbid insomnia and other sleep disturbances are common in patients with neurodegenerative disorders, such Alzheimer's disease and other dementing disorders. How and when sleep problems manifest themselves can depend on the type of dementia involved as well as the stage of the dementia. However, differences in sleep pattern presentation show more variation during the initial stages of dementias than they do during the later stages. Effective, pragmatic interventions are largely anecdotal and untested.

Preoperative sleep complaints are associated with poor physical recovery in the months following cardiac surgery

BACKGROUND

Sleep disturbance is associated with poorer outcomes in cardiac patients, but little is known about the independent role of sleep quality in coronary artery bypass graft (CABG) patients.

PURPOSE

This study aims to examine the relationship between preoperative sleep complaints and post-operative emotional and physical recovery in CABG surgery patients, independently of demographic, clinical and mood factors.

METHODS

Two hundred thirty CABG patients (aged 67.81 ± 9.07 years) completed measures of self-reported sleep complaints before surgery and health-related quality of life (HRQoL), physical symptoms and pain 2 months after surgery.

RESULTS

Greater sleep complaints prior to surgery were associated with greater physical symptoms, poorer physical HRQoL and greater sensory pain after surgery (p < 0.05), but not with affective pain or mental HRQoL. Preoperative mood was not able to explain these associations.

CONCLUSIONS

Sleep complaints may be implicated in physical recovery from CABG surgery but further work is needed to understand the role of causal pathways.

Disentangling the effects of insomnia and night work on cardiovascular diseases: a study in nursing professionals

Cardiovascular diseases (CVDs) are known to be associated with poor sleep quality in general populations, but they have not been consistently associated with specific work schedules. Studies of CVD generally do not simultaneously consider sleep and work schedules, but that approach could help to disentangle their effects. We investigated the association between insomnia and a self-reported physician diagnosis of CVD in day and night workers, considering all sleep episodes during nocturnal and diurnal sleep. A cross-sectional study was conducted in 1307 female nursing professionals from 3 public hospitals, using baseline data from the “Health and Work in Nursing - a Cohort Study.” Participants were divided into two groups: i) day workers with no previous experience in night shifts (n=281) and whose data on insomnia were related to nocturnal sleep and ii) those who worked exclusively at night (n=340) and had data on both nocturnal and diurnal sleep episodes, as they often sleep at daytime. Multiple logistic regression analysis was performed. Among day workers, insomnia complaints increased the odds of CVD 2.79-fold (95% CI=1.01-6.71) compared with workers who had no complaints. Among night workers, reports of insomnia during both nocturnal and diurnal sleep increased the odds of reported CVD 3.07-fold (95% CI=1.30-7.24). Workers with insomnia had similar probabilities of reporting CVD regardless of their work schedule, suggesting a relationship to insomnia and not to night work per se. The results also highlighted the importance of including evaluation of all sleep episodes (diurnal plus nocturnal sleep) for night workers.

Long sleep duration associated with a higher risk of increased arterial stiffness in males

STUDY OBJECTIVES

We aimed to examine the association between sleep duration and arterial stiffness among adults of different ages, because to date there has been only one study on this relationship, which was confined to middle-aged civil servants.

DESIGN

Cross-sectional study.

SETTING

A health examination center in National Cheng Kung University Hospital, Taiwan.

PARTICIPANTS

A total of 3,508 subjects, age 20-87 y, were enrolled after excluding those with a history of cerebrovascular events, coronary artery disease, peripheral artery disease, and taking lipid-lowering drugs, antihypertensives, hypoglycemic agents, and anti-inflammatory drugs, from October 2006 to August 2009.

INTERVENTIONS

N/A.

MEASUREMENTS AND RESULTS

SLEEP DURATION WAS CLASSIFIED INTO THREE GROUPS: short (< 6 h), normal (6-8 h) and long (> 8 h). Arterial stiffness was measured by brachial-ankle pulse-wave velocity (baPWV), and increased arterial stiffness was defined as baPWV ≥ 1400 cm/sec. The sleep duration was different for subjects with and without increased arterial stiffness in males, but not in females. In the multivariate analysis for males, long sleepers (odds ratio [OR] 1.75, P = 0.034) but not short sleepers (OR 0.98, P = 0.92) had a higher risk of increased arterial stiffness. In addition, age, estimated glomerular filtration rate, hypertension, diabetes, total cholesterol/high-density lipoprotein cholesterol ratio, cigarette smoking, and exercise were also independently associated factors. However, in females, neither short nor long sleep duration was associated with increased arterial stiffness.

CONCLUSIONS

Long sleep duration was associated with a higher risk of increased arterial stiffness in males. Short sleepers did not exhibit a significant risk of increased arterial stiffness in either sex.

CITATION

Tsai TC, Wu JS, Yang YC, Huang YH, Lu FH, Chang CJ. Long sleep duration associated with a higher risk of increased arterial stiffness in males. SLEEP 2014;37(8):1315-1320.