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Du M, Liu M, Liu J. Association of healthy sleep pattern with lower risk of acute myocardial infarction mortality among people with diabetes: A prospective cohort study. J Diabetes 2024; 16:e13528. [PMID: 38599883 PMCID: PMC11006613 DOI: 10.1111/1753-0407.13528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 10/21/2023] [Accepted: 12/25/2023] [Indexed: 04/12/2024] Open
Affiliation(s)
- Min Du
- Department of Epidemiology and Biostatistics, School of Public HealthPeking UniversityBeijingChina
| | - Min Liu
- Department of Epidemiology and Biostatistics, School of Public HealthPeking UniversityBeijingChina
- Key Laboratory of Epidemiology of Major Diseases (Peking University)Ministry of EducationBeijingChina
| | - Jue Liu
- Department of Epidemiology and Biostatistics, School of Public HealthPeking UniversityBeijingChina
- Key Laboratory of Epidemiology of Major Diseases (Peking University)Ministry of EducationBeijingChina
- PKU Institute for Global Health and DevelopmentPeking UniversityBeijingChina
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Zhuang S, Huang S, Huang Z, Zhang S, Al-Shaar L, Chen S, Wu S, Gao X. Prospective study of sleep duration, snoring and risk of heart failure. Heart 2023; 109:heartjnl-2022-321799. [PMID: 36593101 DOI: 10.1136/heartjnl-2022-321799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 12/15/2022] [Indexed: 01/03/2023] Open
Abstract
OBJECTIVE To investigate whether nighttime sleep duration and snoring status were associated with incident heart failure (HF). METHODS A prospective study was conducted based on Kailuan cohort including 93 613 adults free of pre-existing cardiovascular diseases. Sleep duration and snoring status were assessed by self-reported questionnaire. Incident HF cases were ascertained by medical records. Cox proportional hazards model was applied to calculate the HR and 95% CI of risk of developing HF. Mediation analysis was used to understand whether hypertension and diabetes mediated the association between sleep duration, snoring and HF. Data analysis was performed from 1 June 2021 to 1 June 2022. RESULTS During a median follow-up of 8.8 years, we documented 1343 incident HF cases. Relative to sleep duration of 7.0-7.9 hour/night, short sleep duration was associated with higher risk of developing HF: adjusted HR was 1.24 (95% CI 1.01 to 1.55) for <6 hours/night and 1.29 (95% CI 1.06 to 1.57) for 6.0-6.9 hours/night, after adjustment for potential confounders such as age, sex, smoking, hypertension and diabetes. A similar 20%-30% higher risk of incident HF was found in individuals reporting occasional or frequent snoring relative to never/rare snorers: adjusted HR was 1.32 for occasional snoring (95% CI 1.14 to 1.52) and 1.24 (95% CI 1.06 to 1.46) for frequent snoring. Presence of diabetes significantly mediated the association between both short sleep duration and snoring and HF risk and hypertension significantly mediated the snoring-HF relationship. CONCLUSION Short sleep duration and snoring were associated with high risk of HF.
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Affiliation(s)
- Sheng Zhuang
- Department of Neurology, the Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Shue Huang
- Department of Epidemiology and Biostatistics, University of California Irvine, Irvine, California, USA
| | - Zhe Huang
- Department of Cardiology, Kailuan General Hospital, Tangshan, Hebei, China
| | - Shun Zhang
- Department of Psychiatry, Kailuan Mental Health Center, Tangshan, Hebei, China
| | - Laila Al-Shaar
- Department of Public Health Sciences, The Pennsylvania State University College of Medicine, Hershey, Pennsylvania, USA
| | - Shuohua Chen
- Department of Cardiology, Kailuan General Hospital, Tangshan, Hebei, China
| | - Shouling Wu
- Department of Cardiology, Kailuan General Hospital, Tangshan, Hebei, China
| | - Xiang Gao
- Department of Nutrition and Food Hygiene, School of Public Health, Institute of Nutrition, Fudan University, Shanghai, China
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The relationship between self-reported habitual snoring and hyperuricemia among Chinese urban adults: a cross-sectional study. Sleep Med 2019; 68:207-212. [PMID: 32143022 DOI: 10.1016/j.sleep.2019.11.1257] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Revised: 11/20/2019] [Accepted: 11/26/2019] [Indexed: 12/16/2022]
Abstract
BACKGROUND Growing evidence suggests an independent relationship between habitual snoring and metabolic abnormalities. Currently, there are few data available on the association between snoring and hyperuricemia. Therefore, we evaluated the cross-sectional association between snoring and serum uric acid (UA) concentration and ascertain the effects of different snoring intensities on hyperuricemia among Chinese urban adults in Nanjing. METHODS We performed a cross-sectional study including 7699 participants (4197 men and 3502 women) from Nanjing Drum Tower Hospital aged ≥18 years over a two year (ie, 2016-2018) period. All participants were divided into four groups based on Snoring scores. Questionnaires, physical examinations and biochemical tests were conducted. Hyperuricemia was defined as levels of serum UA > 6.8 mg/dL in males and >6.0 mg/dL in females. We used a generalized linear model to investigate the association between snoring and serum UA concentration and logistic regression model to investigate the association between snoring and likelihood of having hyperuricemia in the age-, sex-adjusted model and in a multivariable model adjusting for demographic factor, plasma lipid profiles, blood glucose, blood pressure, smoking, and alcohol consumption. RESULTS The prevalence of hyperuricemia was 10.05% in the studied population and gradually increased across the snoring scores (P < 0.0001). We found that mild snoring, moderate, and severe snoring intensity were associated with high serum UA in the age-, sex-adjusted model and in a multivariable model adjusting for demographic and lifestyle/behavioral risk factors. The association was insisted with the addition of variables related to clinical outcomes such as diabetes, hypertension, and high-cholesterol levels. CONCLUSIONS Our results showed self-reported habitual snoring was associated with higher serum UA concentration among Chinese urban adults. Findings of this study indicate the significance of early detection and treatment of snoring to prevent hyperuricemia.
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Suzuki M, Shimamoto K, Sekiguchi H, Harada T, Satoya N, Inoue Y, Yamaguchi K, Kawana M. Arousal index as a marker of carotid artery atherosclerosis in patients with obstructive sleep apnea syndrome. Sleep Breath 2019; 23:87-94. [PMID: 29779142 DOI: 10.1007/s11325-018-1664-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Revised: 03/19/2018] [Accepted: 04/11/2018] [Indexed: 02/07/2023]
Abstract
PURPOSE It was shown in a previous cohort study that men with internal carotid artery (ICA) plaque, defined as focal wall thickness of ≥ 1.5 mm, had a threefold higher risk of stroke than those without plaque. We examined the relationship between arousal indices and sleep stages in patients with obstructive sleep apnea syndrome (OSAS) and carotid atherosclerosis. METHODS Carotid atherosclerosis severity was evaluated using the maximal carotid wall intima-media thickness of the ICA (ICA-maxIMT) and plaque in 83 patients with OSAS. RESULTS The ICA-maxIMT values were positively correlated with the apnea hypopnea index (AHI) (ρ = 0.294, P = 0.007), arousal index (ρ = 0.289, P = 0.008), oxygen desaturation index (ρ = 0.298, P = 0.006), percentage of visually scored total sleep time spent in nocturnal oxygen saturation < 90% (SpO2 < 90%) (ρ = 0.246, P = 0.025), and the percentage of visually scored total sleep time spent in non-REM sleep stage 1 (ρ = 0.326, P = 0.003) and were negatively correlated with the percentage of visually scored total sleep time spent in non-REM sleep stages 2 and 3. Arousal index, diabetes mellitus, and age were found to be independent predictors of ICA plaque presence (OR 1.052, P = 0.003; OR 8.705, P = 0.026; OR 1.064, P = 0.023, respectively). CONCLUSIONS Several PSG variables that are indicative of sleep fragmentation, sleep disordered breathing, and poor sleep quality correlated with the occurrence of atherosclerosis, but total arousal index was the only independent predictive factor.
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Affiliation(s)
- Mayumi Suzuki
- Division of Comprehensive Sleep Medicine, Tokyo Women's Medical University Hospital, 8-1 Kawada-cho, Shinjyuku-ku, Tokyo, 162-8666, Japan.
| | - Ken Shimamoto
- Department of General Medicine, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjyuku-ku, Tokyo, 162-8666, Japan
| | - Haruki Sekiguchi
- Division of Comprehensive Sleep Medicine, Tokyo Women's Medical University Hospital, 8-1 Kawada-cho, Shinjyuku-ku, Tokyo, 162-8666, Japan
| | - Takamitsu Harada
- Central Clinical Laboratories, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Natsumi Satoya
- Central Clinical Laboratories, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Yuji Inoue
- Central Clinical Laboratories, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Kazuhiro Yamaguchi
- Division of Comprehensive Sleep Medicine, Tokyo Women's Medical University Hospital, 8-1 Kawada-cho, Shinjyuku-ku, Tokyo, 162-8666, Japan
| | - Masatoshi Kawana
- Department of General Medicine, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjyuku-ku, Tokyo, 162-8666, Japan
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Nairz F, Meisinger C, Kirchberger I, Heier M, Thilo C, Kuch B, Peters A, Amann U. Association of sleep disturbances within 4 weeks prior to incident acute myocardial infarction and long-term survival in male and female patients: an observational study from the MONICA/KORA Myocardial Infarction Registry. BMC Cardiovasc Disord 2018; 18:235. [PMID: 30545305 PMCID: PMC6293505 DOI: 10.1186/s12872-018-0969-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Accepted: 11/27/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Sleep-related investigations in acute myocardial infarction (AMI) patients are rare. The aim of this study was to examine sex-specific associations of patient-reported sleep disturbances within 4 weeks before AMI and long-term survival. METHODS From a German population-based, regional AMI registry, 2511 men and 828 women, aged 28-74 years, hospitalized with a first-time AMI between 2000 and 2008 and still alive after 28 days, were included in the study (end of follow-up: 12/2011). Frequency of any sleep disturbances within 4 weeks before AMI was inquired by a 6-categorical item summarized to 'never', 'sometimes' and 'nightly'. Cox regression models were calculated. RESULTS Over the median follow-up time of 6.1 years (IQR: 4.1) sleep disturbances were reported by 32.3% of male and 48.4% of female patients. During the observation period, 318 men (12.7%) and 131 women (15.8%) died. Men who 'sometimes' had sleep disturbances showed a 56% increased mortality risk compared to those without complaints in an age-adjusted model (HR 1.56; 95%-CI 1.21-2.00). Additional adjustment for confounding variables attenuated the effect to 1.40 (95%-CI 1.08-1.81). Corresponding HRs among women were 0.97 (95%-CI 0.65-1.44) and 0.99 (95%-CI 0.66-1.49). HRs for patients with nightly sleep disturbances did not suggest any association for both sexes. CONCLUSIONS Our study found that nightly sleep disturbances have no influence on long-term survival in male and female AMI patients. Contrary to women, men who reported sometimes sleep disturbances had a higher mortality. Further investigations on this topic taking into account the role of obstructive sleep apnoea are needed.
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Affiliation(s)
- Franziska Nairz
- Central Hospital of Augsburg, MONICA/KORA Myocardial Infarction Registry, Augsburg, Germany.,Helmholtz Zentrum München, German Research Center for Environmental Health (GmbH), Institute of Epidemiology II, Neuherberg, Germany.,Institute for Medical Informatics, Biometry and Epidemiology (IBE), LMU Munich, Munich, Germany
| | - Christa Meisinger
- Central Hospital of Augsburg, MONICA/KORA Myocardial Infarction Registry, Augsburg, Germany.,Helmholtz Zentrum München, German Research Center for Environmental Health (GmbH), Institute of Epidemiology II, Neuherberg, Germany.,Ludwig-Maximilians-Universität München, UNIKA-T, Augsburg, Germany
| | - Inge Kirchberger
- Central Hospital of Augsburg, MONICA/KORA Myocardial Infarction Registry, Augsburg, Germany.,Helmholtz Zentrum München, German Research Center for Environmental Health (GmbH), Institute of Epidemiology II, Neuherberg, Germany.,Ludwig-Maximilians-Universität München, UNIKA-T, Augsburg, Germany
| | - Margit Heier
- Central Hospital of Augsburg, MONICA/KORA Myocardial Infarction Registry, Augsburg, Germany.,Helmholtz Zentrum München, German Research Center for Environmental Health (GmbH), Institute of Epidemiology II, Neuherberg, Germany
| | - Christian Thilo
- Central Hospital of Augsburg, Department of Internal Medicine I - Cardiology, Augsburg, Germany
| | - Bernhard Kuch
- Central Hospital of Augsburg, Department of Internal Medicine I - Cardiology, Augsburg, Germany.,Hospital of Nördlingen, Department of Internal Medicine/Cardiology, Nördlingen, Germany
| | - Annette Peters
- Helmholtz Zentrum München, German Research Center for Environmental Health (GmbH), Institute of Epidemiology II, Neuherberg, Germany
| | - Ute Amann
- Central Hospital of Augsburg, MONICA/KORA Myocardial Infarction Registry, Augsburg, Germany. .,Helmholtz Zentrum München, German Research Center for Environmental Health (GmbH), Institute of Epidemiology II, Neuherberg, Germany. .,Ludwig-Maximilians-Universität München, UNIKA-T, Augsburg, Germany. .,KORA-Herzinfarktregister im Klinikum Augsburg/Helmholtz Zentrum München, Stenglinstr. 2, 86156, Augsburg, Germany.
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Wang H, Li Z, Chen Y, Ye N, Wang P, Sun Y. Sex-specific association between serum uric acid and self-reported snoring in rural China: a cross-sectional study. Sleep Breath 2017; 21:939-947. [DOI: 10.1007/s11325-017-1515-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Revised: 05/05/2017] [Accepted: 05/22/2017] [Indexed: 10/19/2022]
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Zhang N, Chen Y, Chen S, Jia P, Guo X, Sun G, Sun Y. Self-Reported Snoring Is Associated with Dyslipidemia, High Total Cholesterol, and High Low-Density Lipoprotein Cholesterol in Obesity: A Cross-Sectional Study from a Rural Area of China. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2017; 14:E86. [PMID: 28106727 PMCID: PMC5295337 DOI: 10.3390/ijerph14010086] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Revised: 01/11/2017] [Accepted: 01/12/2017] [Indexed: 02/01/2023]
Abstract
Studies to explore the relationship between self-reported snoring and dyslipidemia, especially high total cholesterol (TC) and high low-density lipoprotein cholesterol (LDL-C), in the general population are still lacking. Our study was designed to examine whether self-reported snoring is significantly associated with dyslipidemia and ascertain the effects of different snoring intensities on dyslipidemia. There were 10,139 participants in our study. After adjustment for all confounding factors, self-reported snoring (OR = 1.207; p = 0.003), moderate (OR = 1.229; p = 0.015), strong (OR = 1.222; p = 0.033), and very strong (OR = 1.467; p = 0.012) snoring intensity, but not low (OR = 1.110; p = 0.224) snoring intensity, were significantly associated with dyslipidemia among adults with BMI (body mass index) ≥ 25 kg/m². In addition, self-reported snoring was significantly associated with high TC (OR = 1.167; p = 0.048) and high LDL-C (OR = 1.228; p = 0.044), rather than low HDL-C (OR = 1.171; p = 0.057) and high triglyceride (TG) (OR = 1.110; p = 0.141). In conclusion, adults with BMI ≥ 25 kg/m² and who experience snoring, especially moderate, strong, and very strong intensity levels of snoring, should be on the alert regarding the possibility of dyslipidemia, especially high LDL-C and high TC.
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Affiliation(s)
- Naijin Zhang
- Department of Cardiology, the First Hospital of China Medical University, Shenyang 110001, China.
| | - Yintao Chen
- Department of Cardiology, the First Hospital of China Medical University, Shenyang 110001, China.
| | - Shuang Chen
- Department of Cardiology, the First Hospital of China Medical University, Shenyang 110001, China.
| | - Pengyu Jia
- Department of Cardiology, the First Hospital of China Medical University, Shenyang 110001, China.
| | - Xiaofan Guo
- Department of Cardiology, the First Hospital of China Medical University, Shenyang 110001, China.
| | - Guozhe Sun
- Department of Cardiology, the First Hospital of China Medical University, Shenyang 110001, China.
| | - Yingxian Sun
- Department of Cardiology, the First Hospital of China Medical University, Shenyang 110001, China.
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Khayat RN, Jafari B. Snoring in the Morning Light. J Clin Sleep Med 2016; 12:1581-1582. [PMID: 27855747 DOI: 10.5664/jcsm.6332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Accepted: 11/07/2016] [Indexed: 11/13/2022]
Affiliation(s)
- Rami N Khayat
- The Sleep Heart Program, The Ohio State University, Columbus, OH
| | - Behrouz Jafari
- Long Beach VA and the University of California-Irvine, Irvine, CA
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Wannamethee SG, Papacosta O, Lennon L, Whincup PH. Self-Reported Sleep Duration, Napping, and Incident Heart Failure: Prospective Associations in the British Regional Heart Study. J Am Geriatr Soc 2016; 64:1845-50. [PMID: 27351127 PMCID: PMC5031211 DOI: 10.1111/jgs.14255] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Objectives To examine the associations between self‐reported nighttime sleep duration and daytime sleep and incident heart failure (HF) in men with and without preexisting cardiovascular disease (CVD). Design Population‐based prospective study. Setting General practices in 24 British towns. Participants Men aged 60–79 without prevalent HF followed for 9 years (N = 3,723). Measurements Information on incident HF cases was obtained from primary care records. Assessment of sleep was based on self‐reported sleep duration at night and daytime napping. Results Self‐reported short nighttime sleep duration and daytime sleep of longer than 1 hour were associated with preexisting CVD, breathlessness, depression, poor health, physical inactivity, and manual social class. In all men, self‐reported daytime sleep of longer than 1 hour duration was associated with significantly greater risk of HF after adjustment for potential confounders (adjusted hazard ratio (aHR) = 1.69, 95% CI = 1.06–2.71) than in those who reported no daytime napping. Self‐reported nighttime sleep duration was not associated with HF risk except in men with preexisting CVD (<6 hours: aHR = 2.91, 95% CI = 1.31–6.45; 6 hours: aHR = 1.89, 95% CI = 0.89–4.03; 8 hours: aHR = 1.29, 95% CI = 0.61–2.71; ≥9 hours: aHR = 1.80, 905% CI = 0.71–4.61 vs nighttime sleep of 7 hours). Snoring was not associated with HF risk. Conclusion Self‐reported daytime napping of longer than 1 hour is associated with greater risk of HF in older men. Self‐reported short sleep (<6 hours) in men with CVD is associated with particularly high risk of developing HF.
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Affiliation(s)
- S Goya Wannamethee
- Department of Primary Care and Population Health, University College, London, United Kingdom.
| | - Olia Papacosta
- Department of Primary Care and Population Health, University College, London, United Kingdom
| | - Lucy Lennon
- Department of Primary Care and Population Health, University College, London, United Kingdom
| | - Peter H Whincup
- Population Health Research Institute, St George's, University of London, London, United Kingdom
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Zhang N, Ye N, Chen Y, Guo X, Sun G, Sun Y. The relationship between snoring and left ventricular hypertrophy of China: a cross-sectional study. BMC Cardiovasc Disord 2016; 16:15. [PMID: 26772538 PMCID: PMC4714535 DOI: 10.1186/s12872-016-0185-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2015] [Accepted: 01/07/2016] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Population-based investigations studying the association between snoring and left ventricular hypertrophy (LVH) are lacking. Therefore, our study aims to investigate whether snoring is significantly associated with LVH, and to make clear the effect of varying degrees of snoring intensity on LVH. METHODS A total of 10,139 participants were involved in this cross-sectional study. Snoring status and snoring intensity were evaluated by a structured questionnaire. LVH was defined as left ventricular mass index ≥ 51 g/m(2.7) for both men and women. RESULTS The total prevalence of LVH was 10.0%. the prevalence increased significantly in snorers according to snoring intensity, including low (10.3%), normal (13.1%), strong (14.7%) and very strong (16.7%). After adjustment for age, race, gender, educational status, physical activity, annual income, current smoking status, current drinking status, sleep duration, hypertension, body mass index, waist circumference, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, triglyceride, total cholesterol and fasting plasma glucose, snoring (OR, 1.371; 95% CI, 1.147-1.637, P < 0.001) was significantly associated with LVH. In addition, among the four kinds of intensity of snoring, normal (OR, 1.436; 95% CI, 1.126-1.832, P = 0.004), strong (OR, 1.462; 95% CI, 1.124-1.902, P < 0.001) and very strong (OR, 1.813; 95% CI, 1.273-2.684, P < 0.001), rather than low (OR, 1.094; 95% CI, 0.834-1.434, P = 0.518) were significantly associated with LVH. CONCLUSIONS Snoring is independently associated with LVH. What's more, with the rise in snoring intensity, snoring will exert an increasing effect on LVH.
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Affiliation(s)
- Naijin Zhang
- Department of Cardiology, The First Hospital of China Medical University, 155 Nanjing North Street, Heping District, 110001, Shenyang, Liaoning, China.
| | - Ning Ye
- Department of Cardiology, The First Hospital of China Medical University, 155 Nanjing North Street, Heping District, 110001, Shenyang, Liaoning, China.
| | - Yintao Chen
- Department of Cardiology, The First Hospital of China Medical University, 155 Nanjing North Street, Heping District, 110001, Shenyang, Liaoning, China.
| | - Xiaofan Guo
- Department of Cardiology, The First Hospital of China Medical University, 155 Nanjing North Street, Heping District, 110001, Shenyang, Liaoning, China.
| | - Guozhe Sun
- Department of Cardiology, The First Hospital of China Medical University, 155 Nanjing North Street, Heping District, 110001, Shenyang, Liaoning, China.
| | - Yingxian Sun
- Department of Cardiology, The First Hospital of China Medical University, 155 Nanjing North Street, Heping District, 110001, Shenyang, Liaoning, China.
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Brietzke SE, Pusz MD. An anatomically based analysis of objectively measured pediatric snoring: a pilot study. Otolaryngol Head Neck Surg 2014; 152:561-6. [PMID: 25550224 DOI: 10.1177/0194599814564543] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To assess pediatric habitual snoring (PS) using home sleep test (HST) technology and attempt to correlate the objective components of PS to specific upper airway anatomy. In addition, the effects of adenotonsillectomy (±turbinoplasty) on objective measures of PS were evaluated. STUDY DESIGN Prospective cohort study. SETTING Tertiary medical center. SUBJECTS AND METHODS Pediatric patients with a chief complaint of snoring and probable obstructive sleep apnea underwent an HST (SNAP Diagnostics, Wheeling, Illinois) with a detailed acoustical snoring analysis prior to adenotonsillectomy (±turbinoplasty). During surgery, detailed anatomical measurements were performed and correlated to snoring analysis results. After surgery, patients were offered another HST with snoring analysis. Data analysis was performed using descriptive statistics and statistical correlation with attention to the multiple-comparisons paradox. RESULTS Twenty-two patients (45% male; mean age, 5.4 years [range, 2.4-8.4 years]) completed the preoperative HST and operative measurements. Unlike typical adult snoring, only a minority of PS was from palatal flutter (mean palatal component, 24%; median, 10%). The resistance occurrence percentage (ROP, percentage of breathing events with snoring noise) was associated with body mass index (BMI; Spearman ρ=0.55; P=.017), subjective turbinate size (0.54; P=.032), palatal obstruction (0.63; P=.008), and mean oxygen saturation (-0.729; P=.0003) but not adenotonsillar hypertrophy. Twelve patients (54%) completed a postoperative HST. The ROP was significantly reduced (median, 20.5% vs 6.5%; P=.006, sign rank test) postoperatively. The magnitude of the ROP reduction was proportional to the volume of the removed tonsils (0.74; P=.022). CONCLUSION Pediatric snoring has different acoustical characteristics than adult snoring. Objective PS is associated with BMI, turbinate size, and palatal obstruction. Adenotonsillectomy (±turbinoplasty) may significantly reduce objective PS.
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Affiliation(s)
- Scott E Brietzke
- Walter Reed National Military Medical Center, Bethesda, Maryland, USA Uniformed Services University of the Health Sciences Bethesda, Maryland, USA
| | - Max D Pusz
- Walter Reed National Military Medical Center, Bethesda, Maryland, USA
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Holmlund T, Levring-Jäghagen E, Franklin KA, Lindkvist M, Berggren D. Effects of Radiofrequency versus sham surgery of the soft palate on daytime sleepiness. Laryngoscope 2014; 124:2422-6. [PMID: 24390800 DOI: 10.1002/lary.24580] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2013] [Revised: 12/03/2013] [Accepted: 12/30/2013] [Indexed: 11/09/2022]
Abstract
OBJECTIVES/HYPOTHESIS To evaluate the effect of radiofrequency surgery of the soft palate on daytime sleepiness in snoring men with mild or no sleep apnea. STUDY DESIGN Randomized controlled trial. METHODS Thirty-five men were recruited from consecutive patients referred to the Ear, Nose, and Throat Clinic due to snoring and complaints of daytime sleepiness. The inclusion criteria were an apnea-hypopnea index (AHI) of ≤ 15, male gender, and age 18 to 65 years. Patients were randomized to either radiofrequency or sham surgery of the soft palate. All but one chose and received the option of three treatments. All patients participated in a follow-up, including an overnight sleep apnea recording and questionnaires 12 months after the last treatment. The primary outcome was daytime sleepiness measured with the Epworth Sleepiness Scale (ESS) and other questionnaires. Secondary outcomes were effects on the AHI and subjective snoring. RESULTS Thirty-two of 35 patients-19 of 20 patients in the radiofrequency surgery group and 13 of 15 patients in the sham surgery group-completed the study. No differences between the two groups in relation to the ESS or AHI were found at follow-up. CONCLUSION Radiofrequency surgery of the soft palate has no effect on daytime sleepiness, snoring, or apnea frequency in snoring men with mild or no sleep apnea 1 year after surgery. LEVEL OF EVIDENCE 1b. Laryngoscope 124:2422-2426, 2014.
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Affiliation(s)
- Thorbjorn Holmlund
- Department of Otorhinolaryngology, Umeå School of Business and Economics, Sweden
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Deary V, Ellis JG, Wilson JA, Coulter C, Barclay NL. Simple snoring: not quite so simple after all? Sleep Med Rev 2014; 18:453-62. [PMID: 24888523 DOI: 10.1016/j.smrv.2014.04.006] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2013] [Revised: 03/07/2014] [Accepted: 04/29/2014] [Indexed: 01/26/2023]
Abstract
Simple snoring (SS), in the absence of obstructive sleep apnoea (OSA), is a common problem, yet our understanding of its causes and consequences is incomplete. Our understanding is blurred by the lack of consistency in the definition of snoring, methods of assessment, and degree of concomitant complaints. Further, it remains contentious whether SS is independently associated with daytime sleepiness, or adverse health outcomes including cardiovascular disease and metabolic syndrome. Regardless of this lack of clarity, it is likely that SS exists on one end of a continuum, with OSA at its polar end. This possibility highlights the necessity of considering an otherwise 'annoying' complaint, as a serious risk factor for the development and progression of sleep apnoea, and consequent poor health outcomes. In this review, we: 1) highlight variation in prevalence estimates of snoring; 2) review the literature surrounding the distinctions between SS, upper airway resistance syndrome (UARS) and OSA; 3) present the risk factors for SS, in as far as it is distinguishable from UARS and OSA; and 4) describe common correlates of snoring, including cardiovascular disease, metabolic syndrome, and daytime sleepiness.
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Affiliation(s)
- Vincent Deary
- Northumbria Centre for Sleep Research, Northumbria University, Newcastle upon Tyne, UK
| | - Jason G Ellis
- Northumbria Centre for Sleep Research, Northumbria University, Newcastle upon Tyne, UK
| | - Janet A Wilson
- Department of Otolaryngology, Head and Neck Surgery, Newcastle University, Freeman Hospital, Newcastle upon Tyne, UK
| | | | - Nicola L Barclay
- Northumbria Centre for Sleep Research, Northumbria University, Newcastle upon Tyne, UK.
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Clark A, Lange T, Hallqvist J, Jennum P, Rod NH. Sleep impairment and prognosis of acute myocardial infarction: a prospective cohort study. Sleep 2014; 37:851-8. [PMID: 24790263 DOI: 10.5665/sleep.3646] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
STUDY OBJECTIVES Impaired sleep is an established risk factor for the development of cardiovascular disease, whereas less is known about how impaired sleep affects cardiovascular prognosis. The aim of this study is to determine how different aspects of impaired sleep affect the risk of case fatality and subsequent cardiovascular events following first-time acute myocardial infarction (AMI). DESIGN Prospective cohort study. SETTING The Stockholm Heart Epidemiology Program, Sweden. PARTICIPANTS There were 2,246 first-time AMI cases. MEASUREMENTS AND RESULTS Sleep impairment was assessed by the Karolinska Sleep Questionnaire, which covers various indices of impaired sleep: disturbed sleep, impaired awakening, daytime sleepiness, and nightmares. Case fatality, defined as death within 28 days of initial AMI, and new cardiovascular events within up to 10 y of follow-up were identified through national registries. In women, disturbed sleep showed a consistently higher risk of long-term cardiovascular events: AMI (hazard ratio [HR] = 1.69; 95% confidence interval [CI] 0.95-3.00), stroke (HR = 2.61; 95% CI: 1.19-5.76), and heart failure (HR = 2.43; 95% CI: 1.18-4.97), whereas no clear effect of impaired sleep on case fatality was found in women. In men, a strong effect on case fatality (odds ratio = 3.27; 95% CI: 1.76-6.06) was observed in regard to impaired awakening; however, no consistent effect of impaired sleep was seen on long-term cardiovascular prognosis. CONCLUSION Results suggest sex-specific effects of impaired sleep that differ by short- and long-term prognosis. Sleep complaints are frequent, easily recognizable, and potentially manageable. Evaluation of sleep complaints may, even if they represent prognostic markers rather than risk factors, provide additional information in clinical risk assessment that could benefit secondary cardiovascular prevention.
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Affiliation(s)
- Alice Clark
- Section of Social Medicine, Department of Public Health, University of Copenhagen, Copenhagen, Denmark ; The Copenhagen Stress Research Center, Copenhagen, Denmark
| | - Theis Lange
- Section of Biostatistics, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Johan Hallqvist
- Department of Public Health Sciences, Division of Social Medicine, Karolinska Institute, Stockholm, Sweden ; Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden
| | - Poul Jennum
- Danish Center for Sleep Medicine, Department of Clinical Neurophysiology, Center for Healthy Aging, Faculty of Health Sciences, University of Copenhagen, Glostrup Hospital, Copenhagen, Denmark
| | - Naja Hulvej Rod
- Section of Social Medicine, Department of Public Health, University of Copenhagen, Copenhagen, Denmark ; The Copenhagen Stress Research Center, Copenhagen, Denmark
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Kim J, Pack A, Maislin G, Lee SK, Kim SH, Shin C. Prospective observation on the association of snoring with subclinical changes in carotid atherosclerosis over four years. Sleep Med 2014; 15:769-75. [PMID: 24841110 DOI: 10.1016/j.sleep.2014.03.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2013] [Revised: 01/27/2014] [Accepted: 03/04/2014] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Although there is a growing interest in the independent effect of snoring on carotid atherosclerosis, few studies have observed the relationship between snoring and change in carotid atherosclerosis prospectively. Therefore, the present study aimed to prospectively examine the association of snoring with subclinical changes in carotid atherosclerosis during a four-year period. METHODS Participants in an ongoing prospective cohort study (n=3129) were enrolled. Subclinical changes in carotid atherosclerosis were assessed using: (i) mean and maximum intima-media thickness (IMT) on both common carotid arteries; (ii) prevalence of elevated IMT (maximum IMT > or = 1.0 mm); and (iii) presence of plaque. Measurement was performed using B-mode ultrasonogram at baseline and after two and four years. Subjects were classified into three groups, based on self-reported snoring frequency at baseline: habitual, occasional, and non-snorer. RESULTS After adjustment for conventional cardiovascular risk factors and self-reported witnessed sleep apnea, the present study found significant cross-sectional differences in mean and maximum IMT between female snorers and non-snorers at baseline only. The changes in IMTs and presence of plaque over four years, however, did not differ by three groups, with different snoring frequency in both genders. CONCLUSIONS Snoring did not accelerate subclinical change in carotid atherosclerosis during a four-year follow-up, although baseline difference in IMT between snorers and non-snorers was significant in women, independent of witnessed sleep apnea. Additional longer-term studies with objective assessment of snoring are needed.
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Affiliation(s)
- Jinyoung Kim
- University of Pennsylvania School of Nursing, Philadelphia, PA, USA.
| | - Allan Pack
- Center for Sleep and Circadian Neurobiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Division of Sleep Medicine/Department of Medicine, University of Pennsylvania, PA, USA
| | - Greg Maislin
- Center for Sleep and Circadian Neurobiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Division of Sleep Medicine/Department of Medicine, University of Pennsylvania, PA, USA
| | - Seung Ku Lee
- Institute of Human Genomic Study, Korea University Ansan Hospital, Ansan, South Korea
| | - Seong Hwan Kim
- Division of Cardiology, Department of Internal Medicine, Korea University Ansan Hospital, Ansan, South Korea
| | - Chol Shin
- Institute of Human Genomic Study, Korea University Ansan Hospital, Ansan, South Korea; Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Korea University Ansan Hospital, Ansan, South Korea
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16
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Chen YL, Su MC, Liu WH, Wang CC, Lin MC, Chen MC. Influence and predicting variables of obstructive sleep apnea on cardiac function and remodeling in patients without congestive heart failure. J Clin Sleep Med 2014; 10:57-64. [PMID: 24426821 DOI: 10.5664/jcsm.3360] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
STUDY OBJECTIVE Obstructive sleep apnea syndrome (OSAS) has been considered to be an important predisposing factor for cardiovascular disease. This study aims to investigate the impact of OSAS on cardiac function and remodeling in patients without congestive heart failure. METHODS A total of 79 patients with sleep disordered breathing, preserved systolic function, and normal pro-brain natriuretic peptide level were enrolled. Sixty-five patients were classified to have moderate to severe OSAS (apnea-hypopnea index [AHI] ≥ 15/h), while the other 14 patients with mild or no OSAS (AHI < 15/h) served as control subjects. Baseline clinical and polysomnographic variables as well as tissue Doppler imaging and three-dimensional echocardiographic parameters were obtained. RESULTS The body mass index, neck circumference, Epworth Sleepiness Scale, desaturation index, arousal index, and snoring index were significantly higher in patients with moderate to severe OSAS than those without (p < 0.05). The left atrial size, mitral A-wave velocity, and left ventricular end-diastolic volume were significantly larger, while E/A ratio was lower in patients with moderate to severe OSAS than those without (p < 0.05). Notably, AHI in REM sleep was significantly correlated with the aortic root size, E/A ratio, left ventricular volume, and stroke volume. In addition, the area under the receiver operator characteristic curve for AHI in REM sleep ≥ 32.3/h was 0.647 (95% CI [0.525, 0.769]) in predicting the development of left ventricular diastolic dysfunction. AHI in REM sleep ≥ 32.3/h was the only independent variant in predicting diastolic dysfunction after adjusting the variables including age, gender, hypertension, and body mass index. CONCLUSIONS Patients with moderate to severe OSAS tend to have cardiac dysfunction revealed by echocardiography. High AHI in REM sleep is significantly associated with cardiovascular remodeling and ventricular diastolic dysfunction, and may be a potential variable to predict cardiac dysfunction.
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Affiliation(s)
- Yung-Lung Chen
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Mao-Chang Su
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Wen-Hao Liu
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chin-Chou Wang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Meng-Chih Lin
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Mien-Cheng Chen
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
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Rich J, Raviv A, Raviv N, Brietzke SE. An epidemiologic study of snoring and all-cause mortality. Otolaryngol Head Neck Surg 2011; 145:341-6. [PMID: 21493281 DOI: 10.1177/0194599811402475] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Snoring is a common problem that is often associated with obstructive sleep apnea syndrome (OSAS). However, it is suggested that snoring may itself be harmful. Patients with objectively measured snoring were matched against a mortality database and associations were explored. STUDY DESIGN Database study. SETTING Community-based use of a portable sleep study device. SUBJECTS AND METHODS More than 77,000 patients who underwent a portable sleep study (SNAP Test, SNAP Labs Inc, Wheeling, Illinois) with a detailed, acoustical snoring analysis were matched to the Social Security Death Master File to establish mortality (1653 deaths matched). Snoring indices to include amount (snoring events per hour), volume (dB), and palatal versus nonpalatal snoring were correlated to mortality using stepwise multivariate logistic regression and survival analysis. RESULTS As expected, increasing age (odds ratio [OR] = 1.84; 95% confidence interval [CI], 1.76-1.93; P < .001), body mass index (BMI) (OR = 1.23; 95% CI, 1.18-1.28; P < .001), and male sex (OR = 1.38; 95% CI, 1.2-1.56; P < .001) were associated with increased all-cause mortality. The presence of increasing OSAS confounded the relationship between snoring and mortality. For patients without OSAS (apnea–hypopnea index [AHI] < 5) and with a BMI < 30 (n = 5955), increasing snoring was associated with an age- and sex-adjusted increase in mortality (OR = 1.16; 95% CI, 1.01-1.32; P = .034). For all patients, increasing nonpalatal snoring was associated with an increase in mortality (OR = 1.21; 95% CI, 1.09-1.35; P < .001) after adjustment for age, sex, BMI, and AHI. Survival analysis produced identical results to logistic regression. CONCLUSION In patients without OSAS and with a BMI less than 30, increasing snoring was associated with a significant increase in all-cause mortality. Nonpalatal snoring is associated with an increase in observed all-cause mortality controlling for age, sex, BMI, and AHI.
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Affiliation(s)
- Jeremy Rich
- Walter Reed Army Medical Center, Department of Otolaryngology, Washington, DC 20307, USA
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18
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Sun L, Pan A, Yu Z, Li H, Shi A, Yu D, Zhang G, Zong G, Liu Y, Lin X. Snoring, inflammatory markers, adipokines and metabolic syndrome in apparently healthy Chinese. PLoS One 2011; 6:e27515. [PMID: 22110665 PMCID: PMC3217970 DOI: 10.1371/journal.pone.0027515] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2011] [Accepted: 10/17/2011] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVE Chronic low-grade inflammation and adipokines dysregulation are linked to mechanisms underscoring the pathogenesis of obesity-related metabolic disorders. Little is known about roles of these cytokines on the association between snoring and metabolic syndrome (MetS). We aimed to investigate whether a cluster of cytokines are related to snoring frequency and its association with MetS in apparently healthy Chinese. METHODS Current analyses used a population-based sample including 1059 Shanghai residents aged 35-54 years. Self-reported snoring frequency was classified as never, occasionally and regularly. Fasting plasma glucose, lipid profile, insulin, C-reactive protein, interleukin-6, interleukin-18, lipopolysaccharide binding protein, high-molecular-weight adiponectin and leptin were measured. MetS was defined by the updated National Cholesterol Education Program Adult Treatment Panel III criteria for Asian-Americans. RESULTS Overweight/obese subjects had significantly higher prevalence of regular snorers than their normal-weight counterparts (34.8% vs. 11.5%, P<0.001). Regular snoring was associated with unfavorable profile of inflammatory markers and adipokines. However, those associations were abolished after adjustment for body mass index (BMI) or waist circumference. The MetS risk (multivariate-adjusted odds ratio 5.41, 95% confidence interval 3.72-7.88) was substantially higher in regular snorers compared with non-snorers. Controlling for BMI remarkably attenuated the association (2.03, 1.26-3.26), while adjusting for inflammatory markers and adipokines showed little effects. CONCLUSION Frequent snoring was associated with an elevated MetS risk independent of lifestyle factors, adiposity, inflammatory markers and adipokines in apparently healthy Chinese. Whether snoring pattern is an economic and no-invasive indicator for screening high-risk persons needs to be addressed prospectively.
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Affiliation(s)
- Liang Sun
- Key Laboratory of Nutrition and Metabolism, Institute for Nutritional Sciences, Shanghai Institutes for Biological Sciences, Graduate School of the Chinese Academy of Sciences, Shanghai, China
| | - An Pan
- Department of Nutrition, Harvard School of Public Health, Boston, Massachusetts, United States of America
| | - Zhijie Yu
- Key Laboratory of Nutrition and Metabolism, Institute for Nutritional Sciences, Shanghai Institutes for Biological Sciences, Graduate School of the Chinese Academy of Sciences, Shanghai, China
- SIBS-Novo Nordisk Translational Research Centre for PreDiabetes, Shanghai Institutes for Biological Sciences, Chinese Academy of Sciences, Shanghai, China
| | - Huaixing Li
- Key Laboratory of Nutrition and Metabolism, Institute for Nutritional Sciences, Shanghai Institutes for Biological Sciences, Graduate School of the Chinese Academy of Sciences, Shanghai, China
| | - Aizhen Shi
- Shanghai Municipal Center for Disease Control and Prevention, Shanghai, China
| | - Danxia Yu
- Key Laboratory of Nutrition and Metabolism, Institute for Nutritional Sciences, Shanghai Institutes for Biological Sciences, Graduate School of the Chinese Academy of Sciences, Shanghai, China
| | - Geng Zhang
- Key Laboratory of Nutrition and Metabolism, Institute for Nutritional Sciences, Shanghai Institutes for Biological Sciences, Graduate School of the Chinese Academy of Sciences, Shanghai, China
| | - Geng Zong
- Key Laboratory of Nutrition and Metabolism, Institute for Nutritional Sciences, Shanghai Institutes for Biological Sciences, Graduate School of the Chinese Academy of Sciences, Shanghai, China
| | - Yong Liu
- Key Laboratory of Nutrition and Metabolism, Institute for Nutritional Sciences, Shanghai Institutes for Biological Sciences, Graduate School of the Chinese Academy of Sciences, Shanghai, China
| | - Xu Lin
- Key Laboratory of Nutrition and Metabolism, Institute for Nutritional Sciences, Shanghai Institutes for Biological Sciences, Graduate School of the Chinese Academy of Sciences, Shanghai, China
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Biering-Sørensen F, Jennum P, Laub M. Sleep disordered breathing following spinal cord injury. Respir Physiol Neurobiol 2009; 169:165-70. [DOI: 10.1016/j.resp.2009.08.014] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2009] [Revised: 08/26/2009] [Accepted: 08/26/2009] [Indexed: 01/02/2023]
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20
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Affiliation(s)
- Atul Malhotra
- Pulmonary & Critical Care and Sleep Medicine Divisions, Brigham and Women's Hospital and Harvard Medical School, 75 Francis Street, Boston, MA, USA.
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