The Association between Hypertension and Insomnia: A Bidirectional Meta-Analysis of Prospective Cohort Studies

The role of insomnia in the development of resistant hypertension in uncontrolled hypertensive patients with obstructive sleep apnea: A prospective study

OBJECTIVES

To investigate the independent predictive value of insomnia for resistant hypertension (RH) in uncontrolled hypertensive patients with obstructive sleep apnea (OSA).

METHODS

This prospective follow-up study enrolled 386 OSA patients with uncontrolled blood pressure (BP) using 1 or 2 classes of antihypertensive drugs visiting Sleep Medicine Center from April 2021 to August 2022. Information on demographic characteristics, comorbidities, BP control and classes of antihypertensive medication, sleep related symptoms and sleep parameters was collected. Insomnia was assessed using DSM-V criteria and the Insomnia Severity Index (ISI). RH incidence according to the BP control and classes of antihypertensive drugs data during the 5 months follow-up was collected. Logistic regression models were used to assess the association between insomnia and RH, adjusting for potential confounders.

RESULTS

After 5 months follow-up, 301 participants were included for final data analysis. Insomnia was prevalent in 23.9 % of the participants and was associated with a higher risk of RH (adjusted ORs around 2.0, all P < 0.05). Participants with clinical insomnia (ISI >14) had a 4-6 times higher risk of RH compared to those without insomnia. Insomnia treatment improved ISI score significantly, but didn't reduce the incidence of RH significantly. Effective insomnia treatment was associated with antihypertensive drugs reduction (OR, 5.57; 95 % CI, 1.24-25.01).

CONCLUSIONS

Insomnia is an independent predictor of RH in uncontrolled hypertensive patients with OSA. Addressing insomnia may be crucial for managing RH in this patient population.

Development of a Qigong Used for Insomnia Therapy (QUIT) Program for Improving Sleep Quality and Blood Pressure in Chinese Women With Menopause: Pre-Post Pilot Test of Feasibility

Background

Around 20%-50% of Chinese menopausal women experience insomnia, which is associated with elevated blood pressure (BP). Despite this, the population remains understudied. Qigong, a simple form of Chinese exercise, has been shown to improve insomnia and BP but has not been explicitly used to address menopausal symptoms in Chinese women. This study aims to test the feasibility of a Qigong-based intervention in enhancing sleep quality and BP control in this population.

Objective

This study aimed to develop and pilot test the feasibility of a culturally sensitive Qigong Used for Insomnia Therapy (QUIT) intervention in improving sleep quality and BP among Chinese menopausal women.

Methods

From August 2023 to May 2024, this study used a 1-group pretest-posttest design (N=22) to evaluate the QUIT intervention. The intervention consisted of a 10-minute Qigong demonstration video, a 10-minute practice and return demonstration and a 5-minute insomnia counseling session at baseline. Participants were instructed to engage in daily 10-minute Qigong practice for 1 month. Outcome measures, including sleep quality and BP, were assessed at baseline and at the 1-month follow-up. Data on demographics were collected via self-reported questionnaires. At the end of the study, participants were interviewed using semistructured questions to assess their perception of the intervention's feasibility. Qualitative data were analyzed using content analysis, with interviews transcribed and coded independently by the principal investigator and research assistant. Categories related to feasibility, adherence, and barriers were identified. Quantitative data were analyzed using SPSS 27.0 (IBM Corp), using descriptive statistics and paired sample t tests to assess changes in sleep quality and BP, with statistical significance set at .05.

Results

The mean age of participants was 53.78 (SD 8.79, range 42-74) years. Most participants lived with relatives or friends (20/22, 91%), were employed (16/22, 73%), were married (19/22, 86%), and had at least high school education (19/22, 86%). The mean 23-item Sleep Quality Scale score significantly improved from 18.59 (SD 11.41) at baseline to 15.64 (SD 9.65; mean difference 2.96, SD 7.04; t21=1.97, P=.03) after 1 month, indicating better sleep quality (the 23-item Sleep Quality Scale was reversely scored). There was a trend toward reduced systolic BP from 115.47 (SD 14.95) at baseline to 113.59 (SD 13.93; mean difference -0.89, SD 1.64; t21=-1.15, P=.26) after 1 month. Diastolic BP also improved from 74.69 (SD 10.81) at baseline to 71.41 (SD 16.82) at 1 month (mean difference -3.28, SD 4.04; t21=-0.81, P=.43).

Conclusions

The QUIT intervention was culturally sensitive, low-cost, and easy to implement. It showed significant improvements in sleep quality and trends toward reduced BP in Chinese menopausal women. Further investigation is recommended to further test the QUIT intervention to establish a robust program across different states. Once validated, the QUIT intervention may be implemented in various clinical settings to help Chinese menopausal women achieve optimal sleep quality and BP management.

Efficacy and mechanism of long-snake moxibustion for treating insomnia in breast cancer survivors: study protocol for a randomized controlled trial

Background

Insomnia (difficulty falling or staying asleep) is a common issue among breast cancer survivors, significantly impacting their quality of life. Current treatments, primarily pharmacological and psychological, have limitations: the former often causes side effects, while the latter faces accessibility barriers. Long-snake moxibustion (LSM), a traditional Chinese medicine (TCM) technique, involves applying moxibustion along the governor vessel, which is an important meridian in TCM that plays a key role in regulating brain function. LSM is characterized by its minimal side effects, ease of application, and cost-effectiveness, with preliminary studies supporting its potential for treating insomnia. This study aims to further investigate the therapeutic effectiveness of LSM in alleviating insomnia among breast cancer survivors and to explore its underlying mechanisms.

Methods

This single-center, rater-masked, randomized controlled trial will enroll 100 breast cancer survivors with chronic insomnia, who will be randomly assigned in a 1:1 ratio to either the LSM group or a waitlist control group. During the 4-week treatment period, all participants will receive standard care, with the LSM group additionally receiving LSM treatment twice a week. The primary efficacy outcome is the change in Insomnia Severity Index (ISI) score at the end of the intervention. Secondary outcomes include changes in hypnotic medication use, Pittsburgh Sleep Quality Index (PSQI) scores, Piper Fatigue Scale (PFS) scores, and Functional Assessment of Cancer Therapy-Breast (FACT-B) scores. Mechanistic evaluations will assess serum biochemical markers, gut microbiota composition, and metabolomic profiles.

Discussion

If proven effective, this trial will provide critical clinical evidence supporting LSM as a viable and accessible treatment for insomnia among breast cancer survivors. The findings could influence clinical practice by offering a non-pharmacological treatment option, improving patient outcomes, and reducing dependence on pharmacological interventions. Furthermore, exploring the underlying mechanisms may enhance our understanding of how LSM works, paving the way for future research.

Clinical trial registration

http://itmctr.ccebtcm.org.cn/, identifier ITMCTR2024000578.

Cardiovascular risk factors for the diagnosis of insomnia in end-stage renal disease

BACKGROUND

Insomnia, a known cardiovascular risk factor, is common in end-stage renal disease (ESRD) patients. There is growing acknowledgment of a potential bidirectional relationship between cardiovascular diseases and sleep disorders. We previously assessed the risk factors for common sleep disorders in ESRD patients. This follow-up study assesses the demographic and clinical cardiovascular-related risk factors for insomnia diagnosis in ESRD patients, given their increased cardiovascular burden.

METHODS

This study is a retrospective analysis of the United States Renal Data System to evaluate risk factors for insomnia diagnosis. All patients in the USRDS who started dialysis between 2005 and 2019 were eligible for inclusion. Demographic risk factors analyzed were age, race, sex, ethnicity, dialysis modality, and access type. Cardiovascular risk factors, including obstructive sleep apnea (OSA) and central sleep apnea (CSA), were also evaluated.

RESULTS

Female sex, OSA, CSA, myocardial infarction, congestive heart failure, peripheral vascular disease, cerebrovascular disease, diabetes, chronic obstructive pulmonary disease, obesity, and hypertension were associated with an increased risk of insomnia. Increasing age, non-white race, Hispanic ethnicity, and catheter or other/peritoneal dialysis access type were associated with a decreased risk of an insomnia diagnosis.

CONCLUSION

Various cardiovascular diseases were independent risk factors for an insomnia diagnosis in this retrospective cohort. Further study is indicated to investigate potential mechanisms underlying this connection.

Associations between insomnia and cardiovascular diseases: a meta-review and meta-analysis of observational and Mendelian randomization studies

STUDY OBJECTIVES

Observational studies suggest associations between insomnia and cardiovascular diseases (CVDs), but the causal mechanism remains unclear. We investigated the potential causal associations between insomnia and CVDs by a combined systematic meta-review and meta-analysis of observational and Mendelian randomization studies.

METHODS

We searched PubMed, Web of Science, and Embase for English-language articles from inception to July 11, 2023. Two reviewers independently screened the articles to minimize potential bias. We summarized the current evidence on the associations of insomnia with coronary artery disease, atrial fibrillation, heart failure, myocardial infarction, hypertension, and stroke risk by combining meta-analyses of observational and Mendelian randomization studies.

RESULTS

Four meta-analyses of observational studies and 9 Mendelian randomization studies were included in the final data analysis. A systematic meta-review of observational studies provided strong evidence that insomnia is an independent risk factor for many CVDs, including atrial fibrillation, myocardial infarction, and hypertension. A meta-analysis of Mendelian randomization studies revealed that insomnia may be potentially causally related to coronary artery disease (odds ratio [OR] = 1.14, 95% confidence interval [CI] = 1.10-1.19, I2 = 97%), atrial fibrillation (OR = 1.02, 95% CI = 1.01-1.04, I2 = 94%), heart failure (OR = 1.04, 95% CI = 1.03-1.06, I2 =97%), hypertension (OR = 1.16, 95% CI = 1.13-1.18, I2 = 28%), large artery stroke (OR = 1.14, 95% CI = 1.05-1.24, I2 = 0%), any ischemic stroke (OR = 1.09, 95% CI = 1.03-1.14, I2 = 60%), and primary intracranial hemorrhage (OR = 1.16, 95% CI = 1.05-1.27, I2 = 0%). No evidence suggested that insomnia is causally associated with cardioembolic or small vessel stroke.

CONCLUSIONS

Our results provide strong evidence supporting a possible causal association between insomnia and CVD risk. Strategies to treat insomnia may be promising targets for preventing CVDs.

CITATION

Zhang X, Sun Y, Ye S, et al. Associations between insomnia and cardiovascular diseases: a meta-review and meta-analysis of observational and Mendelian randomization studies. J Clin Sleep Med. 2024;20(12):1975-1984.

Relationship of Suboptimal and Disordered Sleep with Cardiovascular Disease and Its Risk Factors - A Narrative Review

BACKGROUND

Cardiovascular disease (CVD), including coronary heart disease and cerebrovascular disease, is already amongst the leading causes of morbidity and mortality worldwide, but its burden continues to rise. Over time, relevant risk factors for CVD have been identified, many of which are modifiable. More recently, the relationship of sleep and CVD has been of interest, specifically increased rates of disrupted and disordered sleep, which have been found to be associated with CVD. Longitudinal studies have linked sleep difficulties to a predisposition of vascular risk factors, suggesting a potential role for sleep improvement in primary and secondary CVD.

SUMMARY

In the present narrative review article, we summarize the current body of research linking suboptimal sleep (e.g., short/long sleep, fragmented sleep) as well as nonbreathing-related sleep disorders (i.e., insomnia, restless legs syndrome/peripheral leg movements of sleep, narcolepsy) to modifiable CVD risk factors and CVD outcomes (morbidity and mortality).

Objective sleep characteristics and hypertension: a community-based cohort study

Objective

The link between sleep quality and hypertension risk is well-established. However, research on the specific dose-relationship between objective sleep characteristics and hypertension incidence remains limited. This study aims to explore the dose-relationship association between objective sleep characteristics and hypertension incidence.

Methods

A community-based prospective cohort study design was employed using data from the Sleep Heart Health Study (SHHS). A total of 2,460 individuals were included in the study, of which 780 had hypertension. Baseline personal characteristics and medical history were collected. Objective sleep characteristics were obtained through polysomnography (PSG). Multivariate logistic regression models were utilized for analysis. Restricted cubic splines (RCS) were used to examine dose-relationship associations.

Results

After adjusting for covariates, the percentage of total sleep duration in stage 2 (N2%) was positively associated with hypertension incidence, while the N3% was negatively associated with hypertension incidence Odds ratio (OR) = 1.009, 95% confidence interval (CI) [1.001, 1.018], P = 0.037; OR = 0.987, 95% CI: [0.979, 0.995], P = 0.028, respectively. For every 10% increase in N2 sleep, the risk of developing hypertension increases by 9%, while a 3% decrease in N3 sleep corresponds to a 0.1% increase in the incidence of hypertension. In the subgroup of non-depression, a positive association between N2% and hypertension was significant statistically (OR = 1.012, 95%CI, 1.002, 1.021, P = 0.013, Pinteraction = 0.013). RCS demonstrated that the risk of developing hypertension was lower when N2% ranged from 38% to 58% and rapidly increased thereafter (P = 0.002, non-linear P = 0.040). The lowest risk for hypertension incidence risk of N3% occurring at 25%, and a significant increase below 15% or above 40% (P = 0.001, non-linear P = 0.008).

Conclusions

There's a negative association between N3% and the incidence of hypertension, and a positive association between N2% and the incidence of hypertension, particularly among non-depression individuals. These associations exhibit strong non-linear dose-response relationships.

Association of sleep duration, chronotype, social jetlag, and sleep disturbance with phenotypic age acceleration: A cross-sectional analysis

OBJECTIVE

Sleep is a critical health-related behavior; research evidence has shown that sleep duration, poor sleep quality and insomnia are associated with aging and relevant age-related diseases. However, the associations between sleep duration, chronotype, sleep disturbance, and biological age have not been comprehensively assessed. This study aimed to examine sleep characteristics with biological age.

METHODS

The study included 6534 participants aged 20 years and older from the National Health and Nutrition Examination Survey between 2017 and March 2020. Sleep questionnaires were used to collect information on sleep duration and wake behavior on workdays and workfree days and sleep disturbance. Phenotypic age acceleration (PhenoAgeAccel) was estimated as a biological age measure using 9 blood chemistry biomarkers.

RESULTS

Long sleep (>9 hours) and extremely short sleep (≤4 hours) on workdays were positively associated with PhenoAgeAccel, compared with optimal sleep duration (7-8 hours). Similar positive associations with PhenoAgeAccel were observed for sleep duration on workfree days and across the whole week. Both slightly evening and evening chronotypes were associated with faster PhenoAgeAccel compared to morning chronotype. Social jetlag and sleep disturbance were not associated with PhenoAgeAccel, while long corrected social jetlag was associated with faster PhenoAgeAccel. The associations of sleep duration, chronotype, and corrected social jetlag with PhenoAgeAccel appeared stronger among females than among males.

CONCLUSIONS

Findings suggest a U-shape relationship between sleep duration and biological aging; slightly evening and evening chronotypes may be risk factors for aging. Further studies are needed to confirm these findings.

Comparative efficacy of exercise modalities on sleep quality in populations with sleep disorders: A systematic review and network meta-analysis

The effect of various exercise modalities on people with sleep disorders remains unclear. This network meta-analysis aims to explore the effects of various exercise modalities in improving sleep quality in people with sleep disorders. Four electronic databases were searched from inception to April 8, 2023. We conducted pairwise meta-analyses and frequentist network meta-analyses with random effects models. A total of 17 randomized controlled trials enrolled 1090 participants were included. Compared with passive control, with moderate-to-low certainty of evidence, mind-body exercise combined with treatment as usual [standard mean difference (SMD) = -2.26, 95% confidence interval (CI) (-3.29, -1,24)], moderate aerobic exercise combined with light strength exercise [SMD = -1.26, 95% CI (-2.22, -0.31)], mind-body exercise [SMD = -0.81, 95% CI (-1.37, -0.25)] and moderate aerobic exercise [SMD = -0.75, 95% CI (-1.38, -0.13)] were more effect in improving sleep disorders. Various exercise modalities have favorable effects on sleep quality for people with sleep disorders compared with passive control. However, due to the low quality of evidence, well-designed trials should be conducted to elucidate these promising findings in the future.

[Management of patients with insomnia and polymorbidity: expert consensus]

Sleep disorders are becoming increasingly important due to the high comorbidity with other diseases and a significant impact on the patient's quality of life. Insomnia is the most common sleep disorder both in the general population and in patients with multimorbid pathology. Its prevalence in the general population is 6-15%, while in patients with somatic diseases it increases up to 20-40% and can reach 90% in patients with comorbid mental disorders. Another problem is the development of drug-induced insomnia. Insomnia has negative impact on the prognosis of comorbid diseases, including an increased risk of death, more severe disease, and a worse quality of life. The presence of sleep disorders makes it difficult to effectively treat the underlying disease, so it is extremely important to identify and correct these disorders in the early stages, therefore recommendations for the diagnosis of insomnia in polymorbid patients are proposed. Modern methods of treating acute and chronic insomnia and features of insomnia treatment in polymorbid patients are also discussed.