Daytime sleepiness and risk of stroke and vascular disease: findings from the Northern Manhattan Study (NOMAS)

Joint effects of physical activity and sleep quality on all-cause and cardiovascular disease mortality in stroke survivors: a population-based cohort study from the UK-Biobank

BACKGROUND

Stroke survivors exhibit a higher prevalence of sleep disturbances and physical activity (PA) deficiencies. The joint effects of the two behaviors on mortality risk among stroke survivors remains unclear. This study aimed to explore the joint association of PA and sleep quality with the all-cause and cardiovascular disease ( CVD ) mortality risk in stroke survivors.

METHODS

A total of 5,507 stroke survivors from the UK Biobank were included to assess the independent or joint associations of sleep score and PA with mortality. PA levels were categorized as meeting recommended moderate-to-vigorous physical activity (MVPA) and not meeting recommended MVPA. Sleep quality was classified as healthy, poor/intermediate based on a novel sleep score, leading to the identification of four distinct PA-sleep combinations. Cox proportional hazard models were employed to estimate hazard ratio (HR) for all-cause and cardiovascular disease (CVD) mortality, with data ascertained through October 2021. The dose-response relationship between PA or sleep duration and mortality risk were explored by plotting restricted cubic splines. Sensitivity analyses were conducted to examine the robustness of the results.

RESULTS

After an average follow-up of 12.55 years, healthy sleep score group were associated with an decreased all-cause mortality risk compared to poor/intermediate sleep score group (HR: 0.873; 95% CI: 0.767-0.995). Compared to individuals who did not meet the recommended MVPA levels, those who did achieve the recommended MVPA levels was exhibited a significantly lower risk of all-cause mortality (HR, 0.729; 95% CI, 0.640-0.831) and CVD mortality (HR, 0.786; 95% CI, 0.627-0.986). PA levels exhibit an L-shaped association with mortality(cut off value = 2,000 MET-minutes per week). Participants meeting MVPA recommendations and/or reporting healthy sleep scores reduced 28.5-35.9% risk of all-cause mortality.

CONCLUSIONS

Poor sleep quality is associated with a elevated risk of all-cause mortality. Stroke survivors meeting recommended MVPA levels exhibit lower mortality risk, even among those with poor sleep quality. Future intervention studies are needed to establish whether increasing PA to recommended levels among stroke survivors directly reduces mortality risk linked to poor sleep quality.

Aminoacetone is associated with sleep latency

INTRODUCTION

This study conducted a targeted analysis of metabolites involved in inflammatory, oxidative stress, and neuronal pathways that were previously implicated with sleepiness based on our prior work identifying metabolites in these pathways in persons with OSA. We examine associations between sleep latency (based on the Pittsburgh Sleep Quality Index) which is an important indicator of sleep quality and daytime sleepiness, and metabolic concentrations to identify potential mechanisms linking the two.

METHODS

This cross-sectional study included 88 participants newly diagnosed and untreated for OSA who underwent an overnight in-lab or at home sleep study recruited from the Emory Mechanisms of Sleepiness Symptoms Study (EMOSS). Fasting morning blood plasma samples were collected after the overnight sleep study. A multiple linear regression model was utilized to examine the association between metabolites of interest and sleep latency, controlling for baseline covariates of age, sex, body mass index (BMI), race, smoking status, and apnea hypopnea index (AHI).

RESULTS

Among the targeted metabolites, aminoacetone showed a significant association with sleep latency (adjusted mean (SE) = -0.39 (0.11); p = 0.00072). Participants with sleep onset latency >60 min had lower levels of aminoacetone than patients with sleep onset latency <15 min.

CONCLUSION

This is the first study to evaluate the relationship between aminoacetone and sleep latency in participants with newly diagnosed OSA. Our findings suggests that aminoacetone is associated with sleep latency in participants with OSA.

Association of Sleep Traits With Venous Thromboembolism: Prospective Cohort and Mendelian Randomization Studies

Previous research indicates an association between sleep traits and venous thromboembolism (VTE) risk, though causal relationships remain uncertain. This study evaluated combined and independent associations between sleep traits and VTE risk using UK Biobank data and explored the causal associations between sleep traits and VTE through two-sample Mendelian randomization (MR) analyses. Hazard ratios (HRs) and 95% confidence intervals (95% CIs) for the associations between the healthy sleep score, as well as individual sleep traits (including sleep duration, insomnia, daytime sleepiness, snoring, and chronotype), and VTE risk were calculated using Cox proportional hazards regression models. Additionally, the two-sample MR analyses used the inverse-variance weighted method to determine odds ratios (ORs) and 95% CIs for causal associations. In the cohort analysis, 314 077 VTE-free participants were followed for a median of 12.3 years, during which 7176 VTE cases occurred. In comparison to those with a sleep score of 0-1, participants with a score of 5 were associated with a 30% lower risk of VTE (HR: 0.70; 95% CI: 0.61-0.80). A U-shaped association was noted between sleep duration and VTE risk. Both short (≤ 6 h) and long (≥ 9 h) sleep durations increased VTE risk. Excessive daytime sleepiness, snoring, and evening chronotype also elevated VTE risk. MR analyses supported a causal relationship for short sleep duration (OR: 1.24; 95% CI: 1.04-1.47) with VTE risk, while other sleep traits showed no causal association. These findings underscore the importance of optimal sleep in reducing VTE risk.

Age modulates the predictive value of self-reported sleepiness for all-cause mortality risk: insights from a comprehensive national database of veterans

STUDY OBJECTIVES

Excessive daytime sleepiness is prevalent and overwhelmingly stems from disturbed sleep. We hypothesized that age modulates the association between excessive daytime sleepiness and increased all-cause mortality.

METHODS

We utilized the Veterans' Health Administration data from 1999-2022. We enrolled participants with sleep related International Classification of Diseases 9/10 codes or sleep services. A natural language processing pipeline was developed and validated to extract the Epworth Sleepiness Scale (ESS) as a self-reported tool to measure excessive daytime sleepiness from physician progress notes. The natural language processing's accuracy was assessed through manual annotation of 470 notes. Participants were categorized into normal-ESS (ESS 0-10) and high-ESS (ESS 11-24). We created 3 age groups: < 50 years, 50 to < 65 years, and ≥ 65 years. The adjusted odds ratio of mortality was calculated for age, body mass index, sex, race, ethnicity, and the Charlson Comorbidity Index, using normal-ESS as the reference. Subsequently, we conducted age stratified analysis.

RESULTS

The first ESS records were extracted from 423,087 veterans with a mean age of 54.8 (± 14.6), mean body mass index of 32.6 (± 6.2), and 90.5% male. The adjusted odds ratio across all ages was 17% higher (1.15, 1.19) in the high-ESS category. The adjusted odds ratio s only became statistically significant for individuals aged ≥ 50 years in the high-ESS compared to the normal-ESS category (< 50 years: 1.02 [0.96, 1.08], 50 to < 65 years 1.13[1.10, 1.16]; ≥ 65 years: 1.25 [1.21, 1.28]).

CONCLUSIONS

High-ESS predicted increased mortality only in participants aged 50 and older. Further research is required to identify this differential behavior in relation to age.

CITATION

Maghsoudi A, Azarian M, Sharafkhaneh A, et al. Age modulates the predictive value of self-reported sleepiness for all-cause mortality risk: insights from a comprehensive national database of veterans. J Clin Sleep Med. 2024;20(11):1785-1792.

Trajectories of self-reported daytime sleepiness post-ischemic stroke and transient ischemic attack: A propensity score matching study versus non-stroke patients

INTRODUCTION

Severe sleep apnea (SA) affects one-third of stroke patients. Sleepiness, one of the cardinal symptoms of SA, negatively impacts functional stroke outcomes. The impact of continuous positive airway pressure (CPAP) on post-stroke sleepiness is poorly described. We aimed to compare through a propensity score matching the trajectories of self-reported sleepiness post-stroke with matched individuals including SA patients adherent or not to CPAP.

PATIENTS AND METHODS

Sixty five (80.2%) ischemic stroke and 16 (19.8%) TIA patients (median [Q1;Q3] age = 67.0 [58.0;74.0] years, 70.4% male, body mass index [BMI] = 26.1 [24.5;29.8] kg·m-2, admission NIHSS = 3.0 [1.0;5.0]), with polysomnography and an Epworth Sleepiness Scale (ESS) performed within 1 year following stroke and with a follow-up ESS (delay = 236 [147;399] days) were included in the analysis. A 2:1 propensity score matching based on age, gender, BMI, and the apnea-hypopnea index was performed to identify 162 matched individuals referred for SA suspicion, free of stroke or TIA. Multivariable negative binomial regression models were performed to identify the determinants of sleepiness trajectories post-stroke.

RESULTS

Baseline ESS was comparable between stroke/TIA and matched individuals (median [Q1; Q3] ESS = 7 [4;10] versus 6 [4;10], p = 0.86). The range of improvement in ESS was higher in stroke patients compared to controls (∆ESS = -2 [-4;1] vs -1 [-3;2], p = 0.03). In multivariable analysis, comorbid SA and CPAP treatment did not influence trajectories of sleepiness post-stroke.

DISCUSSION AND CONCLUSION

Sleepiness improvement was unexpectedly higher in stroke patients compared to matched individuals, with no significant influence of comorbid SA and CPAP on its trajectory. Sleepiness may not be primarily indicative of SA in stroke or TIA patients.

Sleep Patterns and Traditional Cardiovascular Health Metrics: Joint Impact on Major Adverse Cardiovascular Events in a Prospective Cohort Study

BACKGROUND

This study examines the association between traditional cardiovascular health (CVH) metrics and major adverse cardiovascular events (MACE) incidence in individuals with diverse sleep patterns.

METHODS AND RESULTS

We analyzed data from 208 621 participants initially free of cardiovascular disease (CVD) in the UK Biobank study. Sleep patterns were assessed using scores for chronotype, duration, insomnia, snoring, and daytime dozing. Traditional CVH scores were derived from the Life's Simple 7 metrics. Cox proportional hazards multivariate regression assessed associations between distinct combinations of CVH and sleep scores and MACE, including nonfatal myocardial infarction, nonfatal stroke, and CVD mortality. Over a mean follow-up of 12.73 years, 9253 participants experienced incident MACE. Individuals with both a healthy sleep pattern and ideal CVH levels had the lowest MACE risk compared with those with a poor sleep pattern and poor CVH levels (hazard ratio, 0.306 [95% CI, 0.257-0.365]; P<0.001). Elevated CVH scores were associated with a reduced risk of MACE across different sleep patterns. Similar trends were observed for individual MACE components, heart failure, and all-cause mortality. These findings remained robust in sensitivity analyses and across various subgroups.

CONCLUSIONS

In individuals without known CVD, maintaining a favorable sleep pattern and achieving optimal CVH levels, as measured by traditional metrics, were associated with the lowest MACE risk. Enhanced CVH significantly reduced CVD risk, even in individuals with a poor sleep pattern. These results emphasize the importance of considering multiple dimensions of sleep health alongside CVH to mitigate CVD risk.

REGISTRATION

URL: https://www.ukbiobank.ac.uk; Unique identifier: 91090.

Increased susceptibility to new-onset atrial fibrillation in diabetic women with poor sleep behaviour traits: findings from the prospective cohort study in the UK Biobank

BACKGROUND

Diabetic individuals often encounter various sleep-related challenges. Although the association between sleep duration and atrial fibrillation (AF) have been explored, the association of other sleep traits with the incidence of AF remains unclear. A comprehensive understanding of these traits is essential for a more accurate assessment of sleep conditions in patients with diabetes and the development of novel AF prevention strategies.

METHODS

This study involved 23,785 patients with diabetes without any pre-existing cardiovascular disease, drawn from the UK Biobank. Sleep behaviour traits examined encompassed sleep duration, chronotype, insomnia, snoring and daytime sleepiness. Sleep duration was categorised into three groups: low (≤ 5 h), proper (6-8 h) and long (≥ 9 h). We assessed associations using multivariate Cox proportional risk regression models. Furthermore, four poor sleep behaviours were constructed to evaluate their impact on the risk of new-onset AF.

RESULTS

Over a mean follow-up period of 166 months, 2221 (9.3%) new cases of AF were identified. Short (hazard ratio (HR), 1.28; 95% confidence interval (CI) 1.10-1.50) and long sleep durations (HR 1.16; 95% CI 1.03-1.32) consistently exhibited an elevated risk of AF compared to optimal sleep duration. Early chronotype, infrequent insomnia and daytime sleepiness were associated with 11% (HR 0.89; 95% CI 0.82-0.97), 15% (HR 0.85; 95% CI 0.77-0.95) and 12% (HR 0.88; 95% CI 0.81-0.96) reduced risk of new-onset AF, respectively. However, no significant association was found between snoring and the incidence of AF (HR 0.99; 95% CI 0.91-1.07).

CONCLUSIONS

In diabetic populations, sleep duration, chronotype, insomnia and daytime sleepiness are strongly associated with AF incidence. An optimal sleep duration of 6-8 h presents the lowest AF risk compared to short or long sleep duration. Additionally, poor sleep patterns present a greater risk of new-onset AF in women than in men.

Sleep patterns and risks of incident cardiovascular disease and mortality among people with type 2 diabetes: a prospective study of the UK Biobank

BACKGROUND

To explore the relationship between sleep patterns and cardiovascular disease (CVD) incidence and mortality risk in a population with type 2 diabetes through a UK Biobank sample.

METHODS

A total of 6860 patients with type 2 diabetes were included in this study. Five sleep factors (including Chronotype, sleep duration, insomnia, daytime sleepiness, and snoring) were collected as a questionnaire. The calculation generates a sleep score of 0-5, and then three sleep patterns were defined based on the sleep scores: poor sleep pattern (0-2), Intermediate sleep pattern (3-4), and healthy sleep pattern (5). HRs and 95% confidence intervals were calculated by multivariate COX proportional risk model adjustment. Restricted cubic splines were used to validate linear associations between sleep scores CVD events.

RESULTS

Our results found a reduced risk of CVD events in individuals with healthy sleep patterns compared to participants with poor sleep patterns. CVD Mortality (HR, 0.690; 95% CI 0.519-0.916), ASCVD (Atherosclerosis CVD) (HR, 0.784; 95% CI 0.671-0.915), CAD (Coronary Artery Disease) (HR, 0.737; 95% CI 0.618-0.879), PAD (Peripheral Arterial Disease) (HR, 0.612; 95% CI 0.418-0.896), Heart Failure (HR, 0.653; 95% CI 0.488-0.875). Restricted cubic spline responded to a negative linear correlation between sleep scores and CVD Mortality, ASCVD, CAD, PAD, and Heart Failure.

CONCLUSIONS

Healthy sleep patterns are significantly associated with a reduced risk of CVD Mortality, ASCVD, CAD, PAD, and Heart Failure in the diabetes population.

Different dimensions of daytime sleepiness predicted mortality in older adults: Sex and muscle power-specific risk in Yilan Study, Taiwan

OBJECTIVES

This study aimed to investigate the relationship between daytime sleepiness and mortality risk among older adults. The moderating effects of sex and physical function were examined.

METHODS

This 9-year follow-up study was conducted with community-dwelling individuals aged ≥65 years. Daytime sleepiness was evaluated using the Epworth Sleepiness Scale (ESS). Exploratory factor analysis (EFA) was used to examine the ESS factors. Handgrip strength was measured to assess physical function, and the highest quartile was defined as good muscle power. Cox regression analysis was used to estimate the 9-year all-cause mortality risk. The interaction terms were examined to evaluate their moderating effect.

RESULTS

In total, 2588 individuals participated in the study. The EFA explored two factors: the passive factor (PF) and the active factor (AF). After controlling for various covariates, the cutoff-defined daytime sleepiness (ESS≥11), total raw scores, and factor scores of the ESS all failed to predict mortality risk. The 3-way interaction terms showed statistical significance in terms of [sex × PF × muscle power (p = 0.03)] but not for [sex × AF × muscle power (p = 0.11)]. Specifically, PF predicted mortality risk in women with good muscle power (hazard ratio (HR): 1.48; 95 % confidence interval (CI): 1.04-2.10), which is female-specific. In contrast, AF predicted mortality risk only in men with good muscle power (HR: 1.35; 95 % CI: 1.02-1.78).

CONCLUSIONS

The ESS-measured daytime sleepiness in older adults is multidimensional. The mortality risk for each dimension was determined based on sex and physical function.

Association of sleep disorder with cardiovascular risk in the Chilean adult population

Background: sleep disorder can be considered as a relevant factor in patients with cardiovascular risk.Objective: the main objective of this study is to associate sleep disorder as a determining factor for the decrease or increase in cardiovascular risk in the adult population.Methods: transversal analytical study based on secondary records obtained from the database of the third National Health Survey from 2016-2017, with a total of 6 233 respondents aged 15 years and over, through a random and complex selection (stratified and multistage by conglomerates). Data from the Epworth Scale and cardiovascular risk classification were used. Binary logistic regression was applied with the R 3.2.2 “svy” package.Results: a statistically significant association was found between high cardiovascular risk and Epworth scores between 11-21 points (compared with 0-10 points) adjusted for sex and age (ß= 0,63; p=0,002).Conclusion: there is observational evidence that allows associating the sleep disorder with a higher risk of developing and / or dying from cardiovascular disease in the Chilean adult population

Immune Markers Are Associated With Asymptomatic Intracranial Large Artery Stenosis and Future Vascular Events in NOMAS

BACKGROUND

Inflammation contributes to atherosclerosis but is incompletely characterized in intracranial large artery stenosis (ICAS). We hypothesized that immune markers would be associated with ICAS and modify the risk ICAS confers on future vascular events.

METHODS

This study included a subsample of stroke-free participants in the prospective NOMAS (Northern Manhattan Study), who had blood samples analyzed with a 60-plex immunoassay (collected from 1993 to 2001) and ICAS assessment with time-of-flight magnetic resonance angiography (obtained from 2003 to 2008). We dichotomized ICAS as either ≥50% stenosis or not (including no ICAS). We ascertained post-magnetic resonance imaging vascular events. We used least absolute shrinkage and selection operator procedures to select immune markers independently associated with ICAS. Then, we grouped selected immune markers into a derived composite Z score. Using proportional odds regression, we quantified the association of the composite immune marker Z score, ICAS, and risk of vascular events.

RESULTS

Among 1211 participants (mean age, 71±9 years; 59% women; 65% Hispanic participants), 8% had ≥50% ICAS. Using least absolute shrinkage and selection operator regression, we identified CXCL9 (C-X-C motif chemokine ligand 9), HGF (hepatocyte growth factor), resistin, SCF (stem cell factor), and VEGF-A(vascular endothelial growth factor A) to have the strongest positive relationships with ≥50% ICAS in fully adjusted models. Selected markers were used to derive a composite immune marker Z score. Over an average follow-up of 12 years, we found that each unit increase in immune marker Z scores was associated with an 8% (95% CI, 1.05-1.11), 11% (95% CI, 1.06-1.16), and 5% (95% CI, 1.01-1.09) increased hazard of death, vascular death, and any vascular event, respectively, in adjusted models. We did not find a significant interaction between immune marker Z scores and ICAS in their relationship with any longitudinal outcome.

CONCLUSIONS

Among a diverse stroke-free population, selected serum immune markers were associated with ICAS and future vascular events. Further study is needed to better understand their role in the pathogenesis of ICAS and as a potential therapeutic target in stroke prevention.

Association between snoring, daytime sleepiness and cardiovascular disease in Chinese rural adults

BACKGROUNDS AND AIMS

Evidence on the association between habitual snoring, excessive daytime sleepiness (EDS), and cardiovascular diseases (CVDs) remains uncertain and limited. The study aimed to explore the independent and joint association between habitual snoring, EDS, and CVDs in rural Chinese adults.

METHODS AND RESULTS

A total of 28,140 participants from the Henan rural cohort study were included. Sleep status information was obtained by self-reported. Based on their sleep status, the participants were classified into four groups: "no snoring and no EDS (NSNS) (reference group)", "snoring and no EDS (SNS)", "no snoring and EDS (NSS)", "snoring and EDS (SS)." The logistic regression models were used to calculate independent and joint odds ratios (OR) and 95% confidence intervals (CI) between the snoring, EDS status and stroke, CHD, and CVD. Of the 28,140 participants, 740 subjects reported snoring and sleepiness. The ORs and (95% CIs) for CVDs in the adjusted model were 1.31 (1.20-1.43) for participants who snored frequently and 2.44 (1.76-3.39) for frequent sleepiness compared with no snoring and no sleepiness. Individuals with both snoring and sleepiness had higher odds of CVDs compared with no snoring and no sleepiness (OR: 2.18, 95%CI: 1.80-2.62).

CONCLUSION

Habitual snoring and excessive daytime sleepiness were independently and jointly associated with CVDs in the Chinese rural population. More studies are needed to explore the mechanisms of the relationship.

CLINICAL TRIAL REGISTRATION

The Henan Rural Cohort Study has been registered at the Chinese Clinical Trial Register (Registration number: ChiCTR-OOC-15006699). Date of registration: 2015-52 07-06. http://www.chictr.org.cn/showproj.aspx?proj=11375.

Association between Daytime Sleepiness, Fatigue and Autonomic Responses during Head-Up Tilt Test in Multiple Sclerosis Patients

We aimed to assess dynamic changes in hemodynamic and autonomic function in response to the head-up tilt test (HUTT) in patients with multiple sclerosis (MS) compared to healthy controls (HCs) and evaluate its relationship with the patients' reported daytime sleepiness and fatigue symptoms. A total of 58 MS patients and 30 HCs were included in the analysis. Fatigue and sleepiness were evaluated using the Chalder Fatigue Scale (CFQ) and the Epworth Sleepiness Scale (ESS), respectively. Hemodynamic response, baroreflex sensitivity, heart rate variability, and systolic and diastolic blood pressure (BP) variability (SBPV, DBPV) parameters were calculated at rest, and in response to the HUTT. The MS patients displayed attenuated BP responses coupled with a more pronounced decrease in cardiac index as well as a reduced increase in the low frequency (LFnu) of DBPV (p = 0.021) and the sympathovagal ratio (p = 0.031) in the latter-phase orthostatic challenge compared to HCs. In MS patients, the ESS score showed no correlation with CFQ or clinical disease outcomes, but exhibited a moderate correlation with LFnu of BPVrest. Fatigue and disease variants predicted blood pressure response to HUTT. These findings underscore the importance of subjective daytime sleepiness and fatigue symptoms and their role in blood pressure regulation in MS patients.

Sleep Duration Is Associated With Subclinical Carotid Plaque Burden

BACKGROUND

Sleep duration is associated with stroke risk and is 1 of 8 essential components of cardiovascular health according to the American Heart Association. As stroke disproportionately burdens Black and Hispanic populations in the United States, we hypothesized that long and short sleep duration would be associated with greater subclinical carotid atherosclerosis, a precursor of stroke, in the racially and ethnically diverse NOMAS (Northern Manhattan Study).

METHODS

NOMAS is a study of community-dwelling adults. Self-reported nightly sleep duration and daytime sleepiness were collected between 2006 and 2011. Carotid plaque presence, total plaque area, and intima-media thickness were measured by ultrasound between 1999 and 2008. Linear and logistic regression models examined the cross-sectional associations of sleep duration groups (primary exposure) or daytime sleepiness (secondary exposure) with measures of carotid atherosclerosis. Models adjusted for age, time between ultrasound and sleep data collection, sex, race and ethnicity, education, health insurance, smoking, alcohol use, physical activity, body mass index, hypertension, diabetes, hypercholesterolemia, and cardiac disease.

RESULTS

The sample (n=1553) had a mean age of 64.7±8.5 years and was 61.9% female, 64.8% Hispanic, and 18.2% non-Hispanic Black. Of the sample, 55.6% had carotid plaque, 22.3% reported nightly short sleep (<7 hours), 66.6% intermediate sleep (≥7 and <9 hours), and 11.1% had long sleep (≥9 hours). Compared with intermediate sleep, long sleep was associated with greater odds of carotid plaque presence relative to plaque absence (odds ratio, 1.6 [95% CI, 1.1-2.4]) and larger total plaque area (odds ratio, 1.4 [95% CI, 1.0-1.9]) after full covariate adjustment. Short sleep and daytime sleepiness were not significantly associated with any carotid measures.

CONCLUSIONS

The association between long sleep and subclinical carotid atherosclerosis may explain prior associations between long sleep and stroke.

Association of sleep patterns and cardiovascular disease risk is modified by glucose tolerance status

AIMS

To investigate whether the association between sleep patterns and cardiovascular disease (CVD) risk differs according to glucose tolerance status.

MATERIALS AND METHODS

This prospective study included 358,805 participants initially free of CVD from the UK Biobank. We created a sleep score based on five sleep factors (sleep duration, chronotype, insomnia, snoring, and daytime sleepiness) with one point for each unhealthy factor. Cox proportional hazards models were used to examine the association between sleep and incident CVD, including coronary heart disease (CHD) and stroke, according to normal glucose tolerance (NGT), prediabetes, and diabetes.

RESULTS

During a median follow-up of 12.4 years, 29,663 incident CVD events were documented. There was a significant interaction between sleep score and glucose tolerance status on CVD (P for interaction = 0.002). Each 1 point increment in sleep score was associated with a 7% (95% confidence interval 6%-9%), 11% (8%-14%), and 13% (9%-17%) higher risk of CVD among participants with NGT, prediabetes, and diabetes, respectively. Similar interaction patterns were observed for CHD and stroke. Among the individual sleep factors, sleep duration and insomnia significantly interacted with glucose tolerance status on CVD outcomes (all P for interaction <0.05). All five unhealthy sleep factors accounted for 14.2% (8.7%-19.8%), 19.5% (7.4%-31.0%), and 25.1% (9.7%-39.3%) of incident CVD cases among participants with NGT, prediabetes, and diabetes, respectively.

CONCLUSIONS

The CVD risk associated with a poor sleep pattern was exacerbated across glucose intolerance status. Our findings emphasise the importance of integrating sleep management into a lifestyle modification programme, particularly in people with prediabetes or diabetes.

Louis EK, Chahal AA, Schulte PJ, Mansukhani MP, Xie J, Lipford MC, Li N, Ramar K, Caples SM, Gay PC, Olson EJ, Silber MH, Li J, Somers VK. Sex-specific associations between daytime sleepiness, chronic diseases and mortality in obstructive sleep apnea

Objective

Excessive daytime sleepiness (EDS) is common in obstructive sleep apnea (OSA) and has been linked to adverse outcomes, albeit inconsistently. Furthermore, whether the prognostic impact of EDS differs as a function of sex is unclear. We aimed to assess the associations between EDS and chronic diseases and mortality in men and women with OSA.

Methods

Newly-diagnosed adult OSA patients who underwent sleep evaluation at Mayo Clinic between November 2009 and April 2017 and completed the Epworth Sleepiness Scale (ESS) for assessment of perceived sleepiness (N = 14,823) were included. Multivariable-adjusted regression models were used to investigate the relationships between sleepiness, with ESS modeled as a binary (ESS > 10) and as a continuous variable, and chronic diseases and all-cause mortality.

Results

In cross-sectional analysis, ESS > 10 was independently associated with lower risk of hypertension in male OSA patients (odds ratio [OR], 95% confidence interval [CI]: 0.76, 0.69-0.83) and with higher risk of diabetes mellitus in both OSA men (OR, 1.17, 95% CI 1.05-1.31) and women (OR 1.26, 95% CI 1.10-1.45). Sex-specific curvilinear relations between ESS score and depression and cancer were noted. After a median 6.2 (4.5-8.1) years of follow-up, the hazard ratio for all-cause death in OSA women with ESS > 10 compared to those with ESS ≤ 10 was 1.24 (95% CI 1.05-1.47), after adjusting for demographics, sleep characteristics and comorbidities at baseline. In men, sleepiness was not associated with mortality.

Conclusion

The implications of EDS for morbidity and mortality risk in OSA are sex-dependent, with hypersomnolence being independently associated with greater vulnerability to premature death only in female patients. Efforts to mitigate mortality risk and restore daytime vigilance in women with OSA should be prioritized.

Self-reported sleepiness associates with greater brain and cortical volume and lower prevalence of ischemic covert brain infarcts in a community sample

STUDY OBJECTIVES

We evaluated if self-reported sleepiness was associated with neuroimaging markers of brain aging and ischemic damage in a large community-based sample.

METHODS

Participants from the Framingham Heart Study Offspring cohort (n = 468, 62.5 ± 8.7 years old, 49.6%M) free of dementia, stroke, and neurological diseases, completed sleep questionnaires and polysomnography followed by magnetic resonance imaging (MRI), 3 years later on average. We used linear and logistic regression models to evaluate the associations between Epworth Sleepiness Scale (ESS) scores and total brain, cortical and subcortical gray matter, and white matter hyperintensities volumes, and the presence of covert brain infarcts.

RESULTS

Higher sleepiness scores were associated with larger total brain volume, greater cortical gray matter volume, and a lower prevalence of covert brain infarcts, even when adjusting for a large array of potential confounders, including demographics, sleep profiles and disorders, organic health diseases, and proxies for daytime cognitive and physical activities. Interactions indicated that more sleepiness was associated with larger cortical gray matter volume in men only and in APOE ε4 noncarriers, whereas a trend for smaller cortical gray matter volume was observed in carriers. In longitudinal analyses, those with stable excessive daytime sleepiness over time had greater total brain and cortical gray matter volumes, whereas baseline sleepiness scores were not associated with subsequent atrophy or cognitive decline.

CONCLUSION

Our findings suggest that sleepiness is not necessarily a marker of poor brain health when not explained by diseases or sleep debt and sleep disorders. Rather, sleepiness could be a marker of preserved sleep-regulatory processes and brain health in some cases.

Daytime napping and cardiovascular risk factors, cardiovascular disease, and mortality: A systematic review

Associations between night sleep duration and cardiovascular risk factors in adults have been well documented. However, the associations for daytime napping remain unclear. In this review, six databases were searched for eligible publications to April 8, 2022. A total of 11 articles were identified for umbrella review on the association of daytime napping with diabetes, metabolic syndrome (MetS), cardiovascular disease (CVD), and mortality in adults, 97 for systematic review on the association with CVD and several CVD risk factors. Our umbrella review showed that the associations of daytime napping with diabetes, MetS, CVD, and mortality in most meta-analyses were mainly supported by weak or suggestive evidence. Our systematic review showed that long daytime napping (≥1 h/d) was associated with higher odds of several CVD risk factors, CVD, and mortality, but no significant association was found between short daytime napping and most of the abovementioned outcomes. Our dose-response meta-analyses showed that daytime napping <30 min/d was not significantly associated with higher odds of most CVD risk factors and CVD among young and middle-aged adults. However, among older adults aged >60 years, we observed significant dose-response associations of daytime napping with higher odds of diabetes, dyslipidemia, MetS, and mortality starting from 0 min/d.

Reduced serum vitamin D levels are associated with poor sleep quality in early stroke patients

Background

Poor sleep quality and vitamin D deficiency are common in stroke patients. Our aim was to evaluate the possible association between vitamin D and sleep quality in acute ischemic stroke (AIS) patients.

Methods

A total of 301 AIS patients were screened and completed 1-month follow-up. Serum 25-hydroxyvitamin D [25(OH)D] was used to assess the vitamin D status by a competitive protein-binding assay at baseline. All patients were divided into equal quartile according to the distribution of 25(OH)D. One month after stroke, sleep quality was evaluated by using Pittsburgh Sleep Quality Index (PSQI) and Epworth Sleepiness Scale (ESS) questionnaire; depression status was confirmed by 17-item Hamilton Depression Scale (HAMD).

Results

There were 89 (29.6%) AIS patients with poor sleep quality 1-month post-event. Within 24 h after admission, serum 25(OH)D levels were significantly lower in patients with poor sleep quality after stroke (P &lt; 0.001). In the results of multivariate-adjusted logistic regression analysis, the odds ratio (OR) of poor sleep quality was 6.199 (95% CI, 2.066–18.600) for the lowest quartile of 25(OH)D compared with the highest quartile. In patients without depression, reduced 25(OH)D were still significantly associated with poor sleep quality (OR = 8.174, 95% CI = 2.432–27.473). Furthermore, 25(OH)D and HAMD score were combined to enhance the diagnostic accuracy of poor sleep quality, with the area under the receiver operating characteristic curve of 0.775.

Conclusion

Reduced serum levels of vitamin D at admission were independently and significantly associated with poor sleep quality at 1 month after stroke. Our findings suggested the combination of vitamin D and depression status could provide important predictive information for post-stroke sleep quality.

Investigation and management of residual sleepiness in CPAP-treated patients with obstructive sleep apnoea: the European view

Excessive daytime sleepiness (EDS) is a major symptom of obstructive sleep apnoea (OSA), defined as the inability to stay awake during the day. Its clinical descriptors remain elusive, and the pathogenesis is complex, with disorders such as insufficient sleep and depression commonly associated. Subjective EDS can be evaluated using the Epworth Sleepiness Scale, in which the patient reports the probability of dozing in certain situations; however, its reliability has been challenged. Objective tests such as the multiple sleep latency test or the maintenance of wakefulness test are not commonly used in patients with OSA, since they require nocturnal polysomnography, daytime testing and are expensive. Drugs for EDS are available in the United States but were discontinued in Europe some time ago. For European respiratory physicians, treatment of EDS with medication is new and they may lack experience in pharmacological treatment of EDS, while novel wake-promoting drugs have been recently developed and approved for clinical use in OSA patients in the USA and Europe. This review will discuss 1) the potential prognostic significance of EDS in OSA patients at diagnosis, 2) the prevalence and predictors of residual EDS in treated OSA patients, and 3) the evolution of therapy for EDS specifically for Europe.

Adherence to a Healthy Sleep Pattern and Incidence of Cardiometabolic Multimorbidity Among Hypertensive Patients: A Prospective Study of UK Biobank

Study Objectives

To investigate whether a healthy sleep pattern would reduce the risk of cardiometabolic multimorbidity (CMM) among hypertensives.

Methods

This is a prospective cohort analysis from the UK Biobank. A total of 69 524 hypertensives without a history of diabetes mellitus, coronary heart disease, or stroke at baseline were enrolled. Five dimensions of healthy sleep at baseline including early chronotype, sleep 7–8 h/d, free of insomnia, no snoring, and no frequent excessive daytime sleepiness were used to generate a healthy sleep score ranging from 0 to 5 (one point was given for each dimension of healthy sleep). A higher score indicated a healthier sleep pattern. We set five groups corresponding to the healthy sleep score of 5, 4, 3, 2, and 0–1, respectively. The primary outcome was the incidence of overall CMM among enrolled hypertensives. We assessed the adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) by Fine-Gray subdistribution hazard models.

Results

We found the full-adjusted HR (95% CI) for overall CMM was 0.93 (0.91–0.95) for a 1-point increase in the healthy sleep score. Compared to hypertensives with a healthy sleep score of 0–1, those with a score of 5 had a 27% lower risk of overall CMM, and 37%, 23%, and 20% lower risks of diabetes mellitus, coronary heart disease, and stroke, respectively, after adjusting for sociodemographic characteristic, lifestyle, and clinical factors.

Conclusions

Our results indicated that a healthy sleep pattern was associated with lower risks of CMM outcomes among hypertensives.

Excessive daytime sleepiness: an emerging marker of cardiovascular risk

Excessive daytime sleepiness (EDS) is classically viewed as a consequence of insufficient sleep or a symptom of sleep disorders. Epidemiological and clinical evidence have shown that patients reporting EDS in tandem with sleep disorders (e.g., obstructive sleep apnoea) are at greater cardiovascular risk than non-sleepy patients. While this may simply be attributable to EDS being present in patients with a more severe condition, treatment of sleep disorders does not consistently alleviate EDS, indicating potential aetiological differences. Moreover, not all patients with sleep disorders report EDS, and daytime sleepiness may be present even in the absence of any identifiable sleep disorder; thus, EDS could represent an independent pathophysiology. The purpose of this review is twofold: first, to highlight evidence that EDS increases cardiovascular risk in the presence of sleep disorders such as obstructive sleep apnoea, narcolepsy and idiopathic hypersomnia and second, to propose the notion that EDS may also increase cardiovascular risk in the absence of known sleep disorders, as supported by some epidemiological and observational data. We further highlight preliminary evidence suggesting systemic inflammation, which could be attributable to dysfunction of the gut microbiome and adipose tissue, as well as deleterious epigenetic changes, may promote EDS while also increasing cardiovascular risk; however, these pathways may be reciprocal and/or circumstantial. Additionally, gaps within the literature are noted followed by directions for future research.

Associations Between Sleep Quality and 10-Year Cardiovascular Disease Risk Among Female Nurses in Hong Kong: A Cross-sectional Study

BACKGROUND

Sleep problems are common among nurses compared with the general population. Poor sleep quality increases the risk of developing cardiovascular disease (CVD). The relationship between sleep quality and CVD risk has not been previously investigated among Hong Kong female nurses.

OBJECTIVE

The authors of this study explored the association between sleep quality and CVD risk among Hong Kong female nurses.

METHODS

Data were collected from the Hong Kong Women's Health Study cross-sectional survey between 2019 and 2020. Questionnaires were sent to female nurses (≥aged 30 years). Ten-year CVD risk was measured using the Framingham 10-year risk score, and the Pittsburgh Sleep Quality Index (PSQI) was used to evaluate sleep quality. Relationships were evaluated using adjusted multiple linear regression and binary logistic regression.

RESULTS

In 1344 respondents, the mean age was 46.12 ± 10.47 years, average PSQI score was 6.02 (3.35), and 52.4% reported poor sleeping quality (global PSQI score > 5). The mean 10-year CVD risk was 3.6% (3.3%). The 10-year CVD risk was significantly associated with sleep disturbance (β = 0.006) and daytime dysfunction (β = -0.002) (both Ps < .01). Participants who reported sleep disturbance had a higher CVD risk (odds ratio, 1.82; 95% confidence interval, 1.04-3.18). High daytime dysfunction decreased CVD risk (odds ratio, 0.63; 95% confidence interval, 0.46-0.85). Subgroup analysis showed stronger associations between sleep quality and Framingham 10-year risk score among those unemployed, undergoing postmenopause, or with a family history of CVDs.

CONCLUSIONS

Sleep disturbance and daytime dysfunction were associated with the 10-year CVD risk among Hong Kong female nurses. Nurses who were unemployed, were undergoing postmenopause, or with a family history of CVD were those with the highest risk.

Determinants and Outcomes of Asymptomatic Intracranial Atherosclerotic Stenosis

BACKGROUND

Intracranial atherosclerotic stenosis (ICAS) is one of the most common causes of stroke worldwide and confers a high risk of stroke recurrence, despite aggressive management of risk factors.

OBJECTIVES

This study identified the role of risk factors and risk of vascular events in subjects with asymptomatic ICAS for improved risk stratification.

METHODS

Stroke-free participants in the NOMAS (Northern Manhattan Study) trial, prospectively followed since 1993, underwent a brain magnetic resonance angiogram from 2003 to 2008. The study rated stenosis in 11 brain arteries as: 0: no stenosis; 1: <50% or luminal irregularities; 2: 50%-69%; and 3: ≥70% stenosis or flow gap. The study ascertained vascular events during the post-magnetic resonance imaging (MRI) period. Proportional odds regression quantified the association of pre-MRI exposures, and proportional hazard adjusted models were built to identify the risk of events in the post-MRI period.

RESULTS

The included sample included 1,211 participants from NOMAS (mean age: 71 ± 9 years; 59% women; 65% Hispanic; 45% had any stenosis). Older age (OR: 1.02 per year; 95% CI: 1.01 to 1.04), hypertension duration (OR: 1.01 per year; 95% CI: 1.00 to 1.02), higher number of glucose-lowering drugs (OR: 1.64 per each medication; 95% CI: 1.24 to 2.15), and high-density lipoprotein (OR: 0.96 per mg/dL; 95% CI: 0.92 to 0.99) were associated with ICAS. The highest event risk was noted among participants with ICAS ≥70% (5.5% annual risk of vascular events; HR: 2.1; 95% CI:1.4 to 3.2; compared with those with no ICAS).

CONCLUSIONS

ICAS is an imaging marker of established atherosclerotic disease in stroke-free subjects, and incidental diagnosis of ICAS should trigger a thorough assessment of vascular health.

Lower 24-h urinary potassium excretion is negatively associated with excessive daytime sleepiness in the general population

OBJECTIVES

Uncertainty remains about the association of potassium (K) intake and sleepiness. Therefore, we aimed to explore the relationship between K excretion using 24-h urine samples and excessive daytime sleepiness (EDS) in the general population.

METHODS

In a cross-sectional study, we used multi-stage proportional random sampling to obtain a study sample aged ≥ 18 years from Emin, China between March and June 2019. We collected timed 24-h urine specimens and conducted EDS assessments using the Epworth Sleepiness Scale (ESS) questionnaire. Subjects were divided into two groups by the median of 24-h urinary potassium (24-h UK). EDS was defined as ESS score ≥ 10. Multi-variable linear regression was used to examine the association between the 24-h UK and the odds of prevalent EDS. We performed a sensitivity analysis by excluding subjects under anti-hypertensive treatment and those with sleep disordered breathing by the NoSAS scale.

RESULTS

A total of 470 participants with complete 24-h urine samples and ESS data (62% women, mean age 49.6 years, mean ESS score of 9.0 ± 5.2) were enrolled. The mean ESS score was significantly lower in the upper half of 24-h UK group than in the lower half (9.5 ± 5.3 vs 8.5 ± 5.1, P = 0.044), and accordingly, prevalent EDS was significantly greater in the lower half than in the higher half (49% vs 40%, P = 0.039). In further improving the propensity matching score, the results remained consistent with the overall results. In multiple linear regression, 24-h UK was negatively correlated with ESS score (β =  - 0.180 (- 0.276, - 0.085), < 0.001). Sensitivity analysis demonstrated augmented results in those without anti-hypertensive treatment.

CONCLUSION

Lower potassium intake, as suggested by lower UK excretion, may be implicated in the presence of EDS in the general population.

Associations Between Sleep Quality and Health Span: A Prospective Cohort Study Based on 328,850 UK Biobank Participants

OBJECTIVE

To examine the associations between sleep quality and health span using a prospective cohort design based on the UK Biobank (UKB).

MATERIALS AND METHODS

This longitudinal cohort study enrolled 328,850 participants aged between 37 and 73 years from UKB to examine the associations between sleep quality and risk of terminated health span. End of health span was defined by eight events strongly associated with longevity (cancer, death, congestive heart failure, myocardial infarction, chronic obstructive pulmonary disease, stroke, dementia, and diabetes), and a sleep score was generated according to five sleep behavioral factors (sleep duration, chronotype, sleeplessness, daytime sleepiness, and snoring) to characterize sleep quality. The hazard ratio (HR) and 95% confidence intervals (CIs) were calculated by multivariate-adjusted Cox proportional hazards model. Moreover, we calculated population attributable risk percentage (PAR%) to reflect the public health significance of healthy sleep quality.

RESULTS

Compared with poor sleep quality, participants with healthy sleep quality had a 15% (HR: 0.85, 95% CI: 0.81-0.88) reduced risk of terminated health span, and those of less-healthy sleep quality had a 12% (HR: 0.88, 95% CI: 0.85-0.92) reduced risk. Linear trend results indicated that the risk of terminated health span decreased by 4% for every additional sleep score. Nearly 15% health span termination events in this cohort would have been prevented if a healthy sleep behavior pattern was adhered to (PAR%: 15.30, 95% CI: 12.58-17.93).

CONCLUSION

Healthy sleep quality was associated with a reduced risk of premature end of health span, suggesting healthy sleep behavior may extend health span. However, further studies are suggested for confirmation of causality and potential mechanism.

Investigation of the relationships between sleep behaviors and risk of healthspan termination: a prospective cohort study based on 323,373 UK-Biobank participants

OBJECTIVES

To examine the associations between four sleep behaviors and the risk of healthspan termination.

METHODS

This study included 323,373 participants, free of terminated healthspan at baseline, from the UK-Biobank (UKB). We applied multivariable-adjusted Cox regression models to estimate the risk of terminated healthspan based on four sleep behaviors (insomnia/sleeplessness, napping, daytime sleepiness, and difficulty getting up from bed), which were self-reported and measured on Likert scales from "usually" to "never/rarely" experiences. In this study, healthspan was defined based on eight events that are strongly associated with longevity (congestive heart failure, myocardial infarction, chronic obstructive pulmonary disease, stroke, dementia, diabetes, cancer, and death).

RESULTS

Participants who reported the following unhealthy sleep behaviors had a significantly higher risk of terminated healthspan: "usually experience sleeplessness/insomnia" (HR = 1.05, 95% CI: 1.03-1.07; P < 0.001); "usually nap" (HR = 1.22, 95% CI: 1.18-1.26; P < 0.01); "excessive daytime sleepiness" (HR = 1.25, 95% CI: 1.19-1.32; P < 0.001); and "difficult getting up from bed" (HR = 1.08, 95% CI: 1.05-1.10; P < 0.001). The corresponding population attributable risk percentage (PAR%) indicated that about 7% of healthspan termination in this cohort would have been eliminated if all participants had healthy sleep behaviors.

CONCLUSION

Participants who reported "usually experience sleeplessness/insomnia," "usually nap," "excessive daytime sleepiness," and "difficult getting up from bed" had increased risk of shortened healthspan. Therefore, adherence to healthy sleep behavior is significant for the extension of healthspan.

Daytime Napping Duration Is Positively Associated With Risk of Hyperuricemia in a Chinese Population

CONTEXT

Loss of sleep or disturbance of sleep-wake cycles has been related to metabolic impairments. However, few studies have investigated the association between daily sleep duration and hyperuricemia.

OBJECTIVE

We investigated daily sleep duration (daytime napping and nocturnal sleep) with hyperuricemia risk.

METHODS

We cross-sectionally analyzed data from the China Multi-Ethnic Cohort (CMEC), Yunnan region. A total of 22 038 participants aged 30 to 79 years were recruited in 2018. Hyperuricemia was defined as serum uric acid (SUA) above 7.0 mg/dL in men and above 6.0 mg/dL in women. Outcomes were associations between daily sleep duration and hyperuricemia.

RESULTS

We found that the longest daytime napping duration was associated with a higher risk of hyperuricemia in the crude model (odds ratio [OR] [95% CI], 2.22 [1.88-2.61], P < .001) and in a multivariable adjustment model (OR, 1.69; 95% CI, 1.41-2.01, P < .001) after adjusting for demographic, sleep habits, and metabolic risk factors. The association was moderately attenuated with additionally adjusted for serum creatinine (OR, 1.54; 95% CI, 1.28-1.86, P < .001). Longer daytime napping duration was also related to higher risk of hyperuricemia combined with metabolic syndrome (MetS). Respondents in the group with daytime napping duration greater than or equal to 90 minutes presented with a higher risk of hyperuricemia combined with MetS (OR, 1.39; 95% CI, 1.06-1.79; P < .001) in the fully adjusted model. We did not observe any relation between nocturnal sleep duration and risk of hyperuricemia in the study.

CONCLUSION

Longer daytime napping duration (but not nocturnal sleep duration) was independently associated with risk of hyperuricemia in a Chinese population.

Association between daytime napping and stroke: A dose-response meta-analysis

Daytime napping is common in many regions around the world and has been an important part of people's daily life. Daytime napping has attracted increasing attention in recent years. Thus, we conducted a meta-analysis to evaluate the relationship between daytime napping and stroke, and help reduce the risk of stroke by improving living habits. The Embase, PubMed, Web of Science and PsycINFO databases were searched for cohort studies published before October 2020 and eight eligible studies with 524,408 participants and 5,875 stroke cases were included in the final analysis. The pooled relative risk (RR) of stroke was 1.47 (95% confidence interval [CI]: 1.24-1.74; p < .001) with significant heterogeneity (I²  = 58%, p for heterogeneity = 0.02). However, the heterogeneity decreased when the study in which adjusting for sleep duration and stratifying the results based on sleep duration was not performed was excluded (RR: 1.38; 95% CI: 1.19-1.60, I²  = 44%, p for heterogeneity = 0.10). In dose-response analysis, the linear trend indicated that for every 10-min increase in daytime napping, the risk of stroke increased by 3%. Further well-designed large studies are needed to explore the effects of daytime napping on stroke and the underlying biological mechanisms.

A novel parameter is better than the AHI to assess nocturnal hypoxaemia and excessive daytime sleepiness in obstructive sleep apnoea

To evaluate whether the percentage of total sleep time spent with apnoea and hypopnoea duration time (AHT%) is better than the apnoea-hypopnoea index (AHI) for the assessment of nocturnal hypoxaemia and excessive daytime sleepiness (EDS) in patients with obstructive sleep apnoea (OSA). Patients with suspected OSA were enrolled. Polysomnography, Epworth Sleepiness Scale, self-administered surveys and anthropometric measures were performed. The efficiency of AHT% and the AHI was evaluated for nocturnal hypoxaemia and EDS. A total of 160 eligible participants were analysed. The median AHT% in normal, mild, moderate and severe OSA patients was significantly different in the four-group patients with OSA. Spearman rank correlations analysis found that the associations were stronger between AHT% with percentage of total sleep time and O₂ saturation of < 90% and minimum nocturnal oxygen saturation than these parameters with the AHI. AHT% had a greater area under the curve than the AHI for predicting EDS in patients with OSA. AHT% was significantly higher in the EDS group. We present a novel parameter, AHT%, to evaluate nocturnal hypoxaemia and EDS in OSA patients. AHT% partially compensates for the shortcomings of the AHI. AHT% is better than the AHI for assessing nocturnal hypoxaemia and EDS. AHT% reflects different clinical characteristics associated with OSA from a new perspective.

Cardiovascular disorders in narcolepsy: Review of associations and determinants

Narcolepsy type 1 (NT1) is a lifelong disorder of sleep-wake dysregulation defined by clinical symptoms, neurophysiological findings, and low hypocretin levels. Besides a role in sleep, hypocretins are also involved in regulation of heart rate and blood pressure. This literature review examines data on the autonomic effects of hypocretin deficiency and evidence about how narcolepsy is associated with multiple cardiovascular risk factors and comorbidities, including cardiovascular disease. An important impact in NT1 is lack of nocturnal blood pressure dipping, which has been associated with mortality in the general population. Hypertension is also prevalent in NT1. Furthermore, disrupted nighttime sleep and excessive daytime sleepiness, which are characteristic of narcolepsy, may increase cardiovascular risk. Patients with narcolepsy also often present with other comorbidities (eg, obesity, diabetes, depression, other sleep disorders) that may contribute to increased cardiovascular risk. Management of multimorbidity in patients with narcolepsy should include regular assessment of cardiovascular health (including ambulatory blood pressure monitoring), mitigation of cardiovascular risk factors (eg, cessation of smoking and other lifestyle changes, sleep hygiene, and pharmacotherapy), and prescription of a regimen of narcolepsy medications that balances symptomatic benefits with cardiovascular safety.

Prevalence of Major Cardiovascular Disease Events Among People Diagnosed With Schizophrenia Who Have Sleep Disturbance, Sedentary Behavior, or Muscular Weakness

Objective

To estimate prevalence of major cardiovascular events among people with schizophrenia who had experience of sleep disturbance, sedentary behavior or muscular weakness, and assess evidence for raised prevalence in these individuals compared to people with schizophrenia without these characteristics.

Methods

UK Biobank data on individuals diagnosed with schizophrenia (n = 1544) were used to examine the prevalence of major cardiovascular events, specifically myocardial infarction, stroke, heart failure and cardiovascular death, among participants with candidate risk factors. Generalized linear models were fitted to estimate prevalence ratios (PRs) for major cardiovascular events among participants with self-reported sleep disturbance, self-reported sedentary behavior, and muscular weakness measured using a handgrip dynamometer. These ratios were adjusted for QRISK3 score—a validated cardiovascular risk prediction algorithm for the UK population.

Results

Prevalence of major cardiovascular events was significantly higher among participants with daytime sleepiness, independent of QRISK3 score, and snoring, a proxy for sleep-disordered breathing (adjusted PR 1.26; 95% CI 1.03, 1.55, P = .03). Prevalence was also independently higher among participants with low muscular strength (adjusted PR1.36; 95% CI 1.05, 1.75, P = .02). The adjusted prevalence ratios among participants with short or prolonged sleep duration, insomnia, or sedentary behavior did not indicate independently raised prevalence among these groups.

Conclusion

Prevalence of major cardiovascular events among people with schizophrenia was higher in participants with muscular weakness and sleep disturbance evidenced by daytime sleepiness. Further research is required to determine how these factors can be routinely identified and addressed in the clinical management of cardiovascular risk among patients with schizophrenia.

Fidelity of Information Processing on a Psychomotor Vigilance Task Predicts Changes in Self-Reported Sleepiness Ratings

INTRODUCTION

Daytime sleepiness is a common problem. Although sleepiness is primarily assessed at the self-report unit of analysis, factors that contribute to an individual's experience and report of sleepiness remain poorly understood. While sleepiness is known to impact vigilance performance, the impact of vigilance performance on sleepiness reports is less well understood. We aimed to explore how performance on a psychomotor vigilance task (PVT) relates to changes in self-reported sleepiness in a rested condition.

METHODS

Participants were 66 adults (Mdn=23, range 18-49 years old), 47% female, 88% white, with a wide range of insomnia symptoms. Participants rated their sleepiness on a scale from 1 (not sleepy) to 10 (extremely sleepy) at the start (pre) and the end (post) of a 10-minute computerized PVT. Ordinal regression determined whether mean reciprocal reaction time, a measure of overall performance, or the log-transformed signal-to-noise ratio (LSNR), a measure of fidelity of information processing, predicted post-sleepiness, adjusting for pre-sleepiness, insomnia, and potential confounds.

RESULTS

Lower LSNR predicted greater change in sleepiness (pre-to-post PVT) and higher post-sleepiness even after adjusting for pre-sleepiness, mean reciprocal reaction time, insomnia, and other potential confounds (p<0.05).

DISCUSSION

When adjusting for insomnia symptoms and potential confounds, participants with lower fidelity of information processing reported higher sleepiness than they had reported at the start of the PVT. Possible mechanisms and explanations are discussed in relation to a 3-factor model of sleep-wake states. This line of research may contribute to innovative approaches to assessing and treating sleepiness.

Excessive Daytime Sleepiness and Cardiovascular Mortality in US Adults: A NHANES 2005-2008 Follow-Up Study

PURPOSE

Excessive daytime sleepiness is highly prevalent and has been associated with increased risk of cardiovascular diseases, but evidence for its association with cardiovascular mortality is limited and inconsistent. We aimed to determine whether excessive daytime sleepiness is independently associated with cardiovascular mortality in general adult population.

PATIENTS AND METHODS

A prospective study of 10,330 adult participants (aged ≥20 years) from National Health and Nutrition Examination Survey (NHANES) 2005-2006 and 2007-2008 was followed up until December 31st, 2015. Excessive daytime sleepiness was defined as the self-reported feeling of being overly sleepy often or always during the day. Cox proportional hazard ratios (HRs) with 95% confidence interval (CI) were estimated to assess risk for cardiovascular mortality.

RESULTS

A total of 10,330 participants with mean age of 47.3 years (95% CI, 46.0 to 48.1) were included in this analysis. Approximately, 18.5% of US adults reported excessive daytime sleepiness. Over a mean follow-up of 8.3 years, 262 cardiovascular deaths occurred. Participants with excessive daytime sleepiness had 2.85-times greater risk (95% CI, 1.33-6.09) of cardiovascular death than those without daytime sleepiness in multivariable analysis corrected for sociodemographic factors, comorbidities and cardiovascular risk factors including depression. Further adjustment for self-reported sleep disorders and sleep duration only slightly attenuated this association (HR, 2.55; 95% CI, 1.23-5.27). No interactions between excessive daytime sleepiness and age, sex or cardiovascular disease at study entry were observed (all Ps>0.05).

CONCLUSION

Excessive daytime sleepiness is highly prevalent among US adults and is independently associated with an approximately two-and-a-half-fold increased risk of cardiovascular mortality in a large national sample. Screening for excessive daytime sleepiness may be a simple and cost-effective tool for identifying individuals at high risk of cardiovascular death.

Sleep and Association With Cardiovascular Risk Among Midwestern US Firefighters

INTRODUCTION

Cardiovascular disease is the leading cause of on-duty fatalities among U.S. firefighters. Research has demonstrated that many modifiable risk factors are contributors to the high prevalence of cardiometabolic risk factors. The current study aimed to assess whether sleep is associated with cardiometabolic risk factors among Indianapolis firefighters. The findings could support improving sleep hygiene in this population.

MATERIAL AND METHODS

This cross-sectional study was conducted from the baseline data of eligible firefighters enrolled in "Feeding America's Bravest", a Mediterranean diet lifestyle intervention within the Indiana Fire Departments. Participants' sleep quality was categorized as "good" (≤ 8 points) or "bad" (>8 points) by a sleep quality questionnaire based on some questions from Pittsburgh Sleep Quality Index. In addition, firefighters' sleep duration was stratified based on the number of hours slept per night (≤6 as "short sleep" or >6 hours as normal). Linear and logistic regression models were used to examine the association of sleep with cardiometabolic risk factors.

RESULTS

A total of 258 firefighters were included. Bad sleepers had higher weight, greater waist circumference, higher body mass index (BMI), and increased body fat (all p<0.01) compared to good sleepers. Similarly, participants with short sleep duration were heavier (p<0.02), had greater BMI (p<0.02) and increased body fat (p<0.04) compared with participants with normal sleep duration. Both bad and short sleepers had a higher prevalence of hypertension and obesity (p <0.05).

CONCLUSIONS

Our study supports that both sleep quality and quantity are associated with cardiometabolic risk among firefighters.

Daytime sleepiness predicts inflammation and ambulatory blood pressure in sleep apnoea

Introduction

Sleepiness in obstructive sleep apnoea is associated with cardiovascular risk; however, the biological mechanisms are not known. This study explored whether those with subjective sleepiness have increased plasma tumour necrosis factor-related protein 1 (C1qTNF1), a novel adipose-derived hormone (adipokine), and 24-h ambulatory blood pressure (ABP) compared to those without sleepiness in newly diagnosed, treatment-naïve participants with obstructive sleep apnoea.

Methods

Overall, 94 participants were included in the analysis. Participants completed the Epworth Sleepiness Scale (ESS), 24-h ABP was monitored, and plasma C1qTNF1 was measured. Sleepy participants were defined as ESS≥10 and nonsleepy as ESS<10. Multiple linear regression was used to explore differences in C1qTNF1, and 24-h mean arterial pressure (MAP) between sleepy and nonsleepy participants, adjusting for age, sex, body mass index, apnoea–hypopnoea index, and smoking status.

Results

C1qTNF1 was significantly higher in sleepy participants (n=57) compared to nonsleepy participants (n=37) (β=0.41 NPX, 95% CI 0.02, 0.80; p=0.04). The 24-h MAP was significantly higher in sleepy participants compared to nonsleepy participants (β=4.06 mmHg, 95% CI 0.36, 7.77; p=0.03).

Conclusions

Our findings show that sleepiness is associated with inflammation and higher 24-h MAP in sleep apnoea.

Excessive sleepiness experienced by treatment-naïve patients with obstructive sleep apnoea is associated with inflammation, higher daily systolic ambulatory blood pressure and higher 24 h mean arterial pressurehttps://bit.ly/3goeqGD

Continuous monitoring of sleep-disordered breathing with pacemakers: Indexes for risk stratification of atrial fibrillation and risk of stroke

BACKGROUND

Sleep apnea (SA) is a risk factor for atrial fibrillation (AF). Advanced pacemakers are now able to calculate indexes of SA severity.

HYPOTHESIS

We investigated the changes in pacemaker-measured indexes of SA, we assessed their predictive value for AF occurrence and the associated risk of stroke and death at long-term.

METHODS

We enrolled 439 recipients of a pacemaker endowed with an algorithm for the calculation of a Respiratory Disturbance Index (RDI). The RDI variability was measured over the first 12 months after implantation, as well as its potential association with the occurrence of AF, defined as device-detected cumulative AF burden ≥6 hoursours in a day.

RESULTS

The individual RDI mean was 30 ± 18 episodes/h, and the RDI maximum was 59 ± 21 episodes/h. RDI ≥30 episodes/h was detected in 351 (80%) patients during at least one night. The proportion of nights with RDI ≥30 episodes/h was 14% (2%-36%). AF ≥6 hours was detected in 129 (29%) patients during the first 12 months. The risk of AF was higher in patients with RDI maximum ≥63 episodes/h (HR:1.74; 95%CI: 1.22-2.48; P = .001) and with RDI mean ≥ 46 episodes/h (HR:1.63; 95%CI: 1.03-2.57; P = .014). The risk of all-cause death or stroke was higher in patients with AF burden ≥6 hours (HR:1.75; 95%CI: 1.06-2.86; P = .016). Moreover, among patients with no previous history of AF the risk was higher in those with RDI maximum ≥63 episodes/h (HR:1.96; 95%CI: 1.06-3.63; P = .031).

CONCLUSIONS

Pacemaker-detected SA showed a considerable variability during follow-up. We confirmed the association between RDI and higher risk of AF, and we observed an association between higher RDI maximum and all-cause death or stroke among patients with no previous history of AF.

Stroke Disparities: From Observations to Actions: Inaugural Edward J. Kenton Lecture 2020

Numerous epidemiological studies have demonstrated stroke disparities across race and ethnic groups. The goal of the NOMAS (Northern Manhattan Study) was to evaluate race and ethnic differences in stroke within a community with 3 different race-ethnic groups. Starting as a population-based incidence and case-control study, the study evolved into a cohort study. Results from NOMAS have demonstrated differences in stroke incidence, subtypes, risk factors, and outcomes. Disparities in ideal cardiovascular health can help explain many differences in stroke incidence and call for tailored risk factor modification through innovative portals to shift more diverse subjects to ideal cardiovascular health. The results of NOMAS and multiple other studies have provided foundational data to support interventions. Conceptual models to address health disparities have called for moving from detecting disparities in disease incidence, to determining the underlying causes of disparities and developing interventions, and then to testing interventions in human populations. Further actions to address race and ethnic stroke disparities are needed including innovative risk factor interventions, stroke awareness campaigns, quality improvement programs, workforce diversification, and accelerating policy changes.

Narrative review of sleep and stroke

Sleep disorders, such as sleep-disordered breathing (SDB), insomnia or restless legs syndrome (RLS), are common in the general population and after stroke. In some cases, sleep disturbances are pre-existing, but can also appear de novo as a direct consequence of brain damage or due to stroke-related complications. Furthermore, some sleep conditions may act as a risk factor of stroke. This review explores the available evidence of the two-way relationship between sleep and stroke. Cardiovascular physiological changes during sleep are described, as well as the evidence on the relationship between stroke and sleep duration, SDB, RLS, insomnia, excessive daytime sleepiness (EDS), and circadian rhythm alterations. Potential changes on sleep architecture, and the links that may exist between sleep and functional outcomes after stroke are also discussed. Importantly, sleep-related disturbances may be associated with worse stroke recovery outcomes and increased cerebrovascular morbidity. It is therefore relevant that the bidirectional association between stroke and sleep is taken into consideration by clinicians taking care of these patients. Future research may focus on this mutual relationship for a better understanding of the impact of stroke on sleep, the importance of sleep in stroke incidence and recovery, and have further evidence on treatment strategies that may improve functional outcome after stroke.

Siesta and Risk for Ischemic Stroke: Results from a Case-Control Study

Background and objectives: Siesta, which is a short afternoon nap, is a habit that is commonly practiced in the Mediterranean and tropical areas. Data on the association between siesta and coronary artery disease has been conflicting. A protective effect has been demonstrated in the countries that commonly practice siesta, but a harmful effect has been observed in the countries that infrequently practice the siesta habit. Information on the association between siesta and ischemic stroke has been, however, lacking. Hence, the purpose of our study was to determine the effect of siesta on ischemic stroke. Materials and Methods: This was a case-control study, conducted on the patients with acute ischemic stroke who came for their first follow-up visit to the neurology clinic. Controls were randomly selected from the patients visiting the neurology clinic on the same day as the patients with ischemic stroke. In addition to basic demographics and the occurrence of established stroke risk factors, information about siesta practice was also collected from both groups. A multivariate logistic regression analysis was utilized to determine the relationship between siesta practice and ischemic stroke. Results: A total of 206 patients were recruited from the neurology clinic of King Khalid university hospital; of which only 194 subjects were included in the analysis (98 ischemic stroke cases and 96 controls). The mean age of the participants was 59.68 ± 13.75 years and 98 (50.52%) were male. Interestingly, 43% of the whole study cohort practiced regular siesta. However, when compared to the stroke population, the control group practiced siesta more frequently (30% vs. 56%). In a multivariate logistic regression analysis, hypertension, diabetes mellitus, excess body weight (body mass index > 25 kg/m2) and dyslipidemia were found to increase the risk of ischemic stroke (OR 2.12, 95% CI: 1.02-4.66, p = 0.005; OR 2.72, 95% CI: 1.94-4.88, p = 0.014; OR 2.94, 95% CI: 1.5164-5.7121 p = 0.0014; OR 3.27, 95% CI: 2.42-5.199, p ≤ 0.001, respectively). On the contrary, the practice of regular siesta lowered the risk of ischemic stroke (OR 0.58, 95% CI: 0.3551-0.9526, p = 0.031). Conclusions: Siesta was associated with a reduced risk for the occurrence of ischemic stroke. Large prospective longitudinal studies should be conducted to verify the protective effect of siesta on stroke.

Sleep patterns, genetic susceptibility, and incident cardiovascular disease: a prospective study of 385 292 UK biobank participants

AIMS

To quantify the association of combined sleep behaviours and genetic susceptibility with the incidence of cardiovascular disease (CVD).

METHODS AND RESULTS

This study included 385 292 participants initially free of CVD from UK Biobank. We newly created a healthy sleep score according to five sleep factors and defined the low-risk groups as follows: early chronotype, sleep 7-8 h per day, never/rarely insomnia, no snoring, and no frequent excessive daytime sleepiness. Weighted genetic risk scores of coronary heart disease (CHD) or stroke were calculated. During a median of 8.5 years of follow-up, we documented 7280 incident CVD cases including 4667 CHD and 2650 stroke cases. Compared to those with a sleep score of 0-1, participants with a score of 5 had a 35% (19-48%), 34% (22-44%), and 34% (25-42%) reduced risk of CVD, CHD, and stroke, respectively. Nearly 10% of cardiovascular events in this cohort could be attributed to poor sleep pattern. Participants with poor sleep pattern and high genetic risk showed the highest risk of CHD and stroke.

CONCLUSION

In this large prospective study, a healthy sleep pattern was associated with reduced risks of CVD, CHD, and stroke among participants with low, intermediate, or high genetic risk.

Metabolomics, sleepiness, and sleep duration in sleep apnea

PURPOSE

Although the mechanism is unclear, daytime sleepiness, a common sequela of obstructive sleep apnea (OSA), has been found to be correlated with a adverse cardiovascular outcomes. Reviewing metabolomics mechanisms of sleep disturbances and cardiovascular disease may help to explain this correlation.

METHODS

This review examines the current literature on the relationships between sleepiness, sleep duration, and metabolites in sleep apnea.

RESULTS

Although there is a lack of comprehensive literature in this emerging area, existing studies point to a variety of metabolites in different pathways that are associated with sleepiness and sleep duration.

CONCLUSION

Advancing metabolomics research in sleep apnea will guide symptom research and provide alternate and novel opportunities for effective treatment for patients with OSA.

Classification of Covert Brain Infarct Subtype and Risk of Death and Vascular Events

Background and Purpose- To test the hypothesis that covert brain infarcts (CBIs) are more likely to be located in noneloquent brain areas compared with clinical strokes and that CBI etiological subtypes carry a differential risk of vascular events compared with people without CBI. Methods- We used brain magnetic resonance imaging from 1290 stroke-free participants in the NOMAS (Northern Manhattan Study) to evaluate for CBI. We classified CBI as cardioembolic (ie, known atrial fibrillation), large artery atherosclerosis (extracranial and intracranial), penetrating artery disease, and cryptogenic (no apparent cause). CBI localized in the nonmotor areas of the right hemisphere were considered noneloquent. We then evaluated risk of events by CBI subtype with adjusted Cox proportional models. Results- At the time of magnetic resonance imaging, 236 participants (18%) had CBI (144 [61%] distal cryptogenic, 29 [12%] distal cardioembolic, 26 [11%] large artery atherosclerosis, and 37 [16%] penetrating artery disease). Smaller (per mm, odds ratio, 0.8 [0.8-0.9]) and nonbrain stem infarcts (odds ratio, 0.2 [0.1-0.6]) were more likely to be covert. During the follow-up period (10.4±3.1 years), 398 (31%) died (162 [13%] of vascular death) and 117 (9%) had a stroke (99 [85%]) were ischemic. Risks of events varied by CBI subtype, with the highest risk of stroke (hazard ratio, 2.2 [1.3-3.7]) and vascular death (hazard ratio, 2.24 [1.29-3.88]) noted in participants with intracranial large artery atherosclerosis-related CBI. Conclusions- CBI can be classified into subtypes that have differential outcomes. Certain CBI subtypes such as those related to intracranial large artery atherosclerosis have a high risk of adverse vascular outcomes and could warrant consideration of treatment trials.

Comparing acupressure with aromatherapy using Citrus aurantium in terms of their effectiveness in sleep quality in patients undergoing percutaneous coronary interventions: A randomized clinical trial

INTRODUCTION

Poor sleep quality is prevalent in candidates for percutaneous coronary interventions (PCIs). The present study was conducted to compare aromatherapy with acupressure in terms of their effectiveness in sleep quality in patients undergoing PCIs.

MATERIALS AND METHODS

The present study was conducted on 85 patients undergoing PCIs and randomly assigned, using block randomization, to five groups, namely (1)aromatherapy, (2)placebo aromatherapy, (3)acupressure, (4)placebo acupressure (acupressure applied to a point not traditionally associated with improving sleep) and (5)control. The intervention groups received aromatherapy or acupressure or placebo from 10pm to 8am the following day. The control group received only routine care. Sleep quality was measured in the patients using a visual analog scale (VAS) that was completed by them before and after the intervention.

RESULTS

The mean pretest score of sleep quality was 2.91 ± 0.53 in the aromatherapy group, 2.84 ± 0.47 in the placebo aromatherapy group, 2.98 ± 0.59 in the acupressure group, 2.75 ± 0.41 in the placebo acupressure group and 2.88 ± 0.41 in the controls. ANOVA suggested no significant differences among these groups in the pretest (P = 0.746). The mean posttest score of sleep quality was 3.72 ± 1.84 in the aromatherapy group, 3.70 ± 1.83 in the placebo aromatherapy group, 7.35 ± 0.99 in the acupressure group, 2.67 ± 0.41in the placebo acupressure group and 2.72 ± 0.34 in the controls, suggesting significant differences among the five groups based on the ANOVA results showed significant differences among the five groups (P < 0.001). The mean posttest score of sleep quality was higher than the pretest score by 4.37 in the acupressure group compared to in the other groups (P < 0.001).

CONCLUSION

The present findings provided scientific evidence for the benefits of using different methods, including acupressure, for sleep quality in patients undergoing PCIs.

IRANIAN REGISTRY OF CLINICAL TRIALS NUMBER

IRCT201707248665N6.

Obstructive Sleep Apnea, Sleepiness, and Glycemic Control in Type 2 Diabetes

STUDY OBJECTIVES

Self-reported sleepiness is common in patients with obstructive sleep apnea (OSA) and is being increasingly recognized as an effect modifier of the association between OSA and cardiovascular outcomes. However, data on whether sleepiness modifies the association between OSA and glycemic outcomes are lacking. The current study sought to characterize the association between glycemic control and sleepiness in people with OSA and type 2 diabetes.

METHODS

Adults with non-insulin requiring type 2 diabetes and undiagnosed moderate to severe OSA were recruited from the community. Demographic data, Epworth Sleepiness Scale (ESS), hemoglobin A1c (HbA1c), as well a type III home sleep test were obtained. The association between self-reported sleepiness and glycemic control was examined using quantile regression.

RESULTS

The study cohort included 311 participants with 56% of the sample being men. Stratified analyses by sex demonstrated that self-reported sleepiness was associated with a higher HbA1c level, but this association was present only in men with a body mass index (BMI) < 35 kg/m². Mean HbA1c levels were higher by 0.57% (95% confidence interval: 0.11, 1.02) in men with an ESS ≥ 11 compared to men with an ESS < 11. No such association was observed in men with a BMI ≥ 35 kg/m² or in women of any BMI category.

CONCLUSIONS

The association between self-reported sleepiness and glycemic control in people with type 2 diabetes and moderate to severe OSA varies a function of BMI and sex. The noted differences in association should be considered when assessing possible treatment effects of therapy for OSA on metabolic outcomes.

Body Silhouette Trajectories Over the Lifespan and Insomnia Symptoms: The Paris Prospective Study 3

Insomnia symptoms are highly prevalent and associated with several adverse medical conditions, but only few determinants, including non-modifiable ones, have been highlighted. We investigated associations between body silhouette trajectories over the lifespan and insomnia symptoms in adulthood. From a community-based study, 7 496 men and women aged 50–75 years recalled their body silhouette at age 8, 15, 25, 35 and 45, and rated the frequency of insomnia symptoms on a standardized sleep questionnaire. An Epworth Sleepiness Scale ≥11 defined excessive daytime sleepiness (EDS). Using a group-based trajectory modeling, we identified five body silhouette trajectories: a ‘lean-stable’ (32.7%), a ‘heavy-stable’ (8.1%), a ‘moderate-stable’ (32.5%), a ‘lean-increase’ (11%) and a ‘lean-marked increase’ (15.7%) trajectory. In multivariate logistic regression, compared to the ‘lean-stable’ trajectory, the ‘lean-marked increase’ and ‘heavy-stable’ trajectories were associated with a significant increased odd of having ≥1 insomnia symptoms as compared to none and of having a proxy for insomnia disorder (≥1 insomnia symptom and EDS). The association with the ‘lean-marked increase' trajectory’ was independent from body mass index measured at study recruitment. In conclusion, increasing body silhouette over the lifespan is associated with insomnia symptoms in adulthood, emphasizing the importance of weight gain prevention during the entire lifespan.

ASSOCIATION OF CIRCADIAN RHYTHM WITH MYOCARDIAL INFARCTION

- Cardiovascular diseases are the world's leading cause of death. Human physiologic activities and state during illness are under the control of circadian rhythm. The aim of the study was to determine the potential association of chronotype and daytime sleepiness with susceptibility to myocardial infarction. We conducted a case-control study on 200 patients hospitalized due to myocardial infarction and 200 healthy controls. Systematic information on the past and present medical history was obtained from all participants. Chronotype was assessed using the Morningness-Eveningness Questionnaire (MEQ), and daytime sleepiness was assessed by the Epworth Sleepiness Scale (ESS). The mean age of the study population was 64±13 years, and 54.5% were male. There was no significant difference in MEQ (58.88±6.52 vs. 58.46±7.78, p=0.601) or ESS (5 (interquartile range, IQR 4-7.5) vs. 6 (IQR 3-8), p=0.912) score between patients and controls. Nevertheless, we found statistically significant differences related to risk factors for cardiovascular diseases, such as hypertension, dyslipidemia, and diabetes mellitus. However, there was no association of MEQ and ESS score with myocardial infarction in the study population.