Association of Subjective and Objective Sleep Duration as well as Sleep Quality with Non-Invasive Markers of Sub-Clinical Cardiovascular Disease (CVD): A Systematic Review

Multidimensional Sleep Health: Definitions and Implications for Cardiometabolic Health: A Scientific Statement From the American Heart Association

Poor sleep health is associated with cardiometabolic disease and related risk factors, including heart disease, stroke, elevated blood pressure and lipid levels, inflammation, glucose intolerance, obesity, physical inactivity, poor diet, unhealthy substance use, poor mental health, and increased all-cause and cardiovascular mortality, and is associated with social determinants of cardiovascular health and health disparities. Therefore, sleep duration has been recognized by the American Heart Association as one of Life's Essential 8. Although chronic sleep duration is the sole metric used in Life's Essential 8, sleep health represents a multidimensional construct. This scientific statement outlines the concept of multidimensional sleep health (sleep duration, continuity, timing, regularity, sleep-related daytime functioning, architecture, and absence of sleep disorders) as it applies to cardiometabolic health. Considerations of how these dimensions are related to cardiometabolic health and patterned by sociodemographic status are explained, and knowledge gaps are highlighted. Additional data are needed to understand better how these various dimensions of sleep should be assessed and how interventions targeting sleep health in clinical and community settings can be leveraged to improve health.

A good night's rest: A contemporary review of sleep and cardiovascular health

Sleep is increasingly recognized as a significant contributor to the development of cardiovascular disease (CVD). Recent American Heart Association guidelines incorporate sleep duration into the "Life's Essential Eight" framework of ideal cardiovascular health. This article will review the evidence relating sleep duration, regularity, and quality with all-cause and cardiovascular mortality, cardiometabolic syndrome, and coronary artery disease in adults. Short sleep duration is strongly associated with cardiovascular mortality, cardiometabolic risk factors, and coronary artery disease. Limited studies also suggest a possible U-shaped association, with long sleep duration also associated with greater cardiovascular risk. Sleep regularity has emerged as a strong and independent risk factor for CVD-related mortality, cardiometabolic syndrome, and subclinical atherosclerosis. Less is known about the impact of sleep quality on CVD, though a number of observational studies suggest a possible association with metabolic syndrome and subclinical atherosclerosis. This review provides an update of the literature on the cardiovascular impact of sleep for the everyday clinician and highlights gaps in knowledge that warrant future research.

Better objective sleep quality is associated with higher gut microbiota richness in older adults

Aging is associated with disrupted sleep patterns, such as fragmented sleep and reduced efficiency, leading to negative health outcomes. There is evidence of a bidirectional relationship between sleep and gut microbiota, which plays a key role in the gut-brain axis and overall health. However, studies on this relationship in older adults have limited generalizability and show conflicting results, highlighting the need for further research. This study aimed to investigate the associations between sleep quality and gut microbiota composition in healthy Chinese older adults using subjective and objective sleep measures to capture various aspects of sleep quality and explore potential impacts on emotional well-being and cognitive performance. Subjective sleep quality was assessed using the Pittsburgh Sleep Quality Index (PSQI) questionnaire, while objective sleep quality was measured with actigraphy. Gut microbiota sequencing was performed on stool samples. The results show a robust positive association between gut microbiota richness and objective sleep quality in older adults, independent of subjective sleep quality and demographics, lifestyle, and health covariates. However, no significant link was found between gut microbiota richness and subjective sleep quality. Specific taxa like Bacteroidetes, Ruminococcus, Collinsella, Veillonella, and Holdemania were tentatively linked to sleep quality. These findings emphasize the connection between sleep quality and gut microbiota composition in older adults with potential research and clinical implications, improving our understanding of the mechanisms underlying the sleep-gut microbiota relationship and guiding the development of interventions for improving both sleep quality and gut health in older adults.

Role of toxic and essential elements in sleep duration of patients with cardiovascular diseases

Sleep disorders are a common aspect of cardiovascular diseases (CVDs) that can negatively impact a patient's quality of life, trigger coronary events, accelerate disease progression, and influence patient survival. This study aimed to investigate the relationship between essential and toxic elements with sleep duration among CVD patients. The study utilized cross-sectional data from 150 patients with CVDs (n = 150) from the Ravansar Non-Communicable Disease (RaNCD) Cohort Study. Serum concentrations of zinc (Zn), copper (Cu), Iron (Fe), arsenic (As), mercury (Hg), and nickel (Ni) were measured using a gas chromatography-mass spectrometry. The prevalence of short-sleep duration (< 7 h), normal sleep duration (7-8 h), and long-sleep duration (> 8 h) were 36%, 10.6%, and 53.3%, respectively. No significant differences were found among the three sleep duration categories in terms of serum concentrations of toxic and essential elements. The adjusted regression model showed that ORs for sleep duration across Zn quartiles Q1, Q2, Q3, and Q4 were 1.00 (reference), 0.32 (95% CI, 0.11-0.84), 0.31 (97.1% CI 0.11-0.81), and 0.33 (98.7% CI 0.12-0.88), respectively (p for trend = 0.006). Our findings suggest a significant relationship between serum zinc levels and sleep duration, with higher zinc concentrations being associated with optimal sleep duration.

Sleep Deficiency and Cardiometabolic Disease

Epidemiologic studies have demonstrated that short sleep duration is associated with an increased risk of cardio-metabolic health outcomes including cardiovascular disease mortality, coronary heart disease, type 2 diabetes mellitus, hypertension, and metabolic syndrome. Experimental sleep restriction studies have sought to explain these findings. This review describes the main evidence of these associations and possible mechanisms explaining them. Whether sleep extension reverses these now widely acknowledged adverse health effects and the feasibility of implementing such strategies on a public health level is discussed.

Ecologically Assessed Sleep Duration and Arterial Stiffness in Healthy Men and Women

OBJECTIVE

Among younger adults, to determine the associations of actigraph- and self-reported sleep duration with arterial stiffness (AS) assessed in clinic and in ecologically valid contexts, and to examine sex-specific associations.

METHODS

Healthy adults ( n = 282, median age = 29 years, 67% women) completed a state-of-the-art assessment of AS at rest (SphygmoCor; carotid femoral pulse wave velocity [cfPWV]; central augmentation index [cAIx]) and 7 days of actigraphy-assessed sleep with concurrent, momentary cAIx assessment for 36 hours (Oscar-2). Multivariable regressions were conducted on the full sample and sex-stratified to examine cross-sectional linear and quadratic associations of average sleep duration with resting PWV and cAIx, average cAIx while awake and asleep, and nocturnal cAIx dipping, adjusted for demographic and health covariates. Exploratory analyses included self-reported sleep duration with AS, and actigraphy and self-reported sleep duration with the ambulatory arterial stiffness index (AASI; Oscar-2).

RESULTS

Overall and by sex, associations of average sleep duration with resting cfPWV, resting cAIx, and awake cAIx were not significant. Sleep duration showed a positive, linear association with sleep cAIx in women (95% confidence interval =1.07 to 5.86, Δ R2 = 0.021). Among women, sleep duration was also inversely associated with cAIx dipping (95% confidence interval = -4.48 to -0.95, Δ R2 = 0.020). Analyses with self-reported sleep duration and AASI as alternate predictors and outcomes were not significant.

CONCLUSIONS

Certain sleep duration-AS associations may be sex-specific. Assessing sleep and momentary AS in ecologically valid conditions outside the research laboratory is valuable to understand these relations. Although this investigation should be replicated, findings raise the question of whether interventions to target sleep duration also reduce AS.

Gender Modulated the Association of Sleep Apnea and Sleep Duration with Arterial Stiffness: The ELSA-Brasil Study

Increased arterial stiffness is independently associated with cardiovascular risk. Obstructive sleep apnea (OSA) and sleep duration (SDUR) may contribute to increased arterial stiffness, but it is unclear whether this association is modulated by gender. We aimed to evaluate the potential impact of gender in modulating the association of OSA and SDUR with arterial stiffness. Participants from the ELSA-Brasil study performed sleep assessments with portable polygraph to define OSA severity and SDUR by 1-week wrist actigraphy. Pulse wave velocity (PWV) was measured using a standard technique without access to the sleep data. We studied 1863 participants (42.2% male, age: 49±8 years, respiratory disturbance index (RDI): 9.9 (4.5-19.4) events/h, SDUR: 6.5 (5.9-7.1) hours, mean PWV: 7.3 ± 1.2 m/s). We found that men had higher PWV, higher frequency of diabetes, and higher blood pressure when compared to women. The regression analysis showed an independent association between increased RDI and PWV in men (ß: 0.007; 95% CI: 0.001-0.012), but not in women. In contrast, an independent association between SDUR and increased arterial stiffness was observed only in women (ß: 0.068; 95% CI: 0.002-0.134). In conclusion, the association of sleep disorders with arterial stiffness showed a distinct gender pattern depending on the sleep variable studied.

Effectiveness of Intranasal Corticosteroids for Sleep Disturbances in Patients with Allergic Rhinitis: A Systematic Review and Meta-Analysis

INTRODUCTION

Allergic rhinitis (AR) is a chronic condition caused by an immunoglobulin E-mediated response to environmental allergens, which affects 10-40% of the global population. AR symptoms, such as nasal congestion and rhinorrhea, significantly reduce quality of life and are associated with sleep disturbances, further exacerbating the condition's burden. Despite the known impact of AR on sleep, the effects of intranasal corticosteroids on sleep quality have not been comprehensively reviewed. Therefore, this systematic review and meta-analysis aimed to investigate the efficacy of intranasal corticosteroids in improving sleep quality among patients with AR.

METHODS

This systematic review and meta-analysis followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The study protocol was registered with PROSPERO (CRD42023460698). A comprehensive search was conducted on PubMed, Cochrane Central Register of Controlled Trials, and Ichushi-Web. Randomized controlled trials (RCTs) comparing intranasal corticosteroids with placebos in patients with AR were included. Data extraction and risk of bias assessment were independently performed by two authors. The primary outcome was the improvement in sleep quality measured by standardized questionnaires. Meta-analyses were performed using a random-effects model. The risk of bias was assessed using the RoB2 tool.

RESULTS

Eighteen RCTs involving 6,019 participants were included. The meta-analysis of 12 comparisons from eight studies for the Rhinoconjunctivitis Quality of Life Questionnaire sleep domain showed significant improvement in sleep quality with a standardized mean difference (SMD) of 0.292 (95% confidence interval [CI]: 0.235-0.350, p < 0.0001, I2 = 0.0%). The Nocturnal Rhinoconjunctivitis Quality of Life Questionnaire also showed improvement with an SMD of 0.284 (95% CI: 0.164-0.404, p < 0.0001) based on two comparisons from one study. However, the Epworth Sleepiness Scale did not show significant results (SMD: 0.027, 95% CI: -0.429 to 0.483, p = 0.907) based on two comparisons from two studies. Sensitivity analysis, excluding two studies with high risk of bias according to RoB2, confirmed the robustness of these results. Subgroup analyses for patients with seasonal or perennial AR showed significant improvements in both groups.

CONCLUSION

This study demonstrates that intranasal corticosteroids significantly improve sleep quality in patients with AR. These findings support the use of intranasal corticosteroids as a first-line treatment for AR, not only for managing daytime symptoms but also for enhancing sleep quality. Future research should focus on sleep quality changes as a primary outcome and incorporate both subjective and objective measures to better understand the relationship between sleep and AR symptoms.

INTRODUCTION

Allergic rhinitis (AR) is a chronic condition caused by an immunoglobulin E-mediated response to environmental allergens, which affects 10-40% of the global population. AR symptoms, such as nasal congestion and rhinorrhea, significantly reduce quality of life and are associated with sleep disturbances, further exacerbating the condition's burden. Despite the known impact of AR on sleep, the effects of intranasal corticosteroids on sleep quality have not been comprehensively reviewed. Therefore, this systematic review and meta-analysis aimed to investigate the efficacy of intranasal corticosteroids in improving sleep quality among patients with AR.

METHODS

This systematic review and meta-analysis followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The study protocol was registered with PROSPERO (CRD42023460698). A comprehensive search was conducted on PubMed, Cochrane Central Register of Controlled Trials, and Ichushi-Web. Randomized controlled trials (RCTs) comparing intranasal corticosteroids with placebos in patients with AR were included. Data extraction and risk of bias assessment were independently performed by two authors. The primary outcome was the improvement in sleep quality measured by standardized questionnaires. Meta-analyses were performed using a random-effects model. The risk of bias was assessed using the RoB2 tool.

RESULTS

Eighteen RCTs involving 6,019 participants were included. The meta-analysis of 12 comparisons from eight studies for the Rhinoconjunctivitis Quality of Life Questionnaire sleep domain showed significant improvement in sleep quality with a standardized mean difference (SMD) of 0.292 (95% confidence interval [CI]: 0.235-0.350, p < 0.0001, I2 = 0.0%). The Nocturnal Rhinoconjunctivitis Quality of Life Questionnaire also showed improvement with an SMD of 0.284 (95% CI: 0.164-0.404, p < 0.0001) based on two comparisons from one study. However, the Epworth Sleepiness Scale did not show significant results (SMD: 0.027, 95% CI: -0.429 to 0.483, p = 0.907) based on two comparisons from two studies. Sensitivity analysis, excluding two studies with high risk of bias according to RoB2, confirmed the robustness of these results. Subgroup analyses for patients with seasonal or perennial AR showed significant improvements in both groups.

CONCLUSION

This study demonstrates that intranasal corticosteroids significantly improve sleep quality in patients with AR. These findings support the use of intranasal corticosteroids as a first-line treatment for AR, not only for managing daytime symptoms but also for enhancing sleep quality. Future research should focus on sleep quality changes as a primary outcome and incorporate both subjective and objective measures to better understand the relationship between sleep and AR symptoms.

Sleep Duration and the Risk of Atherosclerosis: A Mendelian Randomization Study

BACKGROUND

The association between the length of sleep and atherosclerosis has been reported in many observational studies. However, little is known about its significance as a risk factor for atherosclerosis or as a negative consequence of atherosclerosis.

OBJECTIVE

This study aimed to assess the causal association between sleep duration and the risk of atherosclerosis using publicly available genome-wide association studies (GWAS) summary statistics.

METHODS

We employed a two-sample Mendelian randomization (MR) method with 2 cohorts from MRC-IEU (n=460,099) and UK Biobank (n=361,194) to investigate the causal association between sleep duration and the risk of atherosclerosis. Three methods including the inverse-variance weighted (IVW) technique, Robust adjusted profile score (RAPS), and simple-and weighted-median approach were used to obtain reliable results, and an odds ratio with a 95% confidence interval (CI) was calculated. P<0.05 was considered as a statistical difference. In addition, MR-Egger regression, Radial MR, MR-PRESSO, and leave-one-out analyses were used to assess the possible pleiotropy effects.

RESULTS

No causal association of sleep duration with atherosclerosis was found [OR (95%CI): 0.90 (0.98-1.00), p = 0.186]. Leave-one-out, MR-Egger, and MR-PRESSO analyses failed to detect horizontal pleiotropy.

CONCLUSIONS

This MR analysis indicated no causal association between genetically predicted sleep duration and atherosclerosis across European populations.

The effect of time-restricted eating on arterial stiffness indices in men with metabolic syndrome: study protocol for a randomized controlled trial

BACKGROUND

Time-restricted eating (TRE) has been shown to be associated with improvements in some aspects of the metabolic syndrome. Nevertheless, only a few studies have addressed the effect of TRE on pulse wave velocity (PWV). We thus propose a randomized controlled trial to compare the effects of TRE with standard dietary advice on PWV and thereby present the protocol.

METHODS

Forty-eight participants will be assigned to either TRE or control groups using simple randomization. The TRE group will consume their meals during a 10-h period and experience 14 h of fasting. They will also be advised to consume their last meal no later than 20:00. Both groups will receive standard dietary advice. The participants will be followed for 6 weeks. The primary outcome will be changes in PWV. Laboratory measurements, including lipid profile, liver enzyme tests, fasting blood glucose (FBG), insulin concentrations, and insulin resistance, as well as anthropometric data, blood pressure, basal metabolic rate, appetite status, physical activity level, sleep quality, cognitive function, quality of life, and calorie intake, will be evaluated throughout the study.

DISCUSSION

The outcomes of this study will allow a comparison of the effects of TRE and standard dietary recommendations on PWV and other cardiometabolic factors in individuals with metabolic syndrome (MetS).

TRIAL REGISTRATION

Iranian Registry of Clinical Trials; code: IRCT20201230049889N1; registered on August 14, 2022. The registration of the trial is accessible at: https://www.IRCT.ir/trial/64485?revision=281341 .

Role of exercise in reducing the risk of cardiovascular diseases associated with sleep disorders

Cardiovascular diseases are the leading cause of death among urban and rural residents and have become a major global public health problem. The prevention and control of cardiovascular disease risk factors is crucial for preventing, stabilizing, and even reversing cardiovascular disease. Studies have found that certain sleep disorders are directly related to cardiovascular disease and may be induced through pathways such as endothelial dysfunction, dysregulation of autonomic homeostasis, inflammatory response, and metabolic dysfunction. Exercise helps improve sleep disorders and thus reduce the risk of cardiovascular disease, and has irreplaceable advantages over pharmacological treatments for improving sleep. Different types of sleep disorders should be adjusted by factors such as exercise mode, intensity, and duration of exercise. A good sleep state further reduces the risk of cardiovascular disease. Discussing the effect of exercise on the improvement of the risk of cardiovascular disease associated with sleep disorders, and elaborating the mechanism of action of exercise in reducing the risk of cardiovascular disease from the perspective of sleep, can lay a foundation for the treatment of sleep disorders by exercise and propose new directions for reducing cardiovascular disease risk.

Cognitive behavior therapy for insomnia for untreated hypertension with comorbid insomnia disorder: The SLEEPRIGHT clinical trial

Insomnia and poor sleep are associated with an increased risk of developing cardiovascular disease (CVD) and its precursors, including hypertension. In 2022, the American Heart Association (AHA) added inadequate sleep to its list of health behaviors that increase the risk for CVD. It remains unknown, however, whether the successful treatment of insomnia and inadequate sleep can reduce heightened CVD risk. SLEEPRIGHT is a single-site, prospective clinical trial designed to evaluate whether the successful treatment of insomnia results in improved markers of CVD risk in patients with untreated hypertension and comorbid insomnia disorder. Participants (N = 150) will undergo baseline assessments, followed by a 6-week run-in period after which they will receive cognitive behavior therapy for insomnia (CBT-I), comprised of 6 hourly sessions with an experienced CBT-I therapist over a 6-week period. In addition to measures of insomnia severity, as well as both subjective and objective measures of sleep, the primary outcome measures are nighttime blood pressure (BP) and BP dipping assessed by 24-h ambulatory BP monitoring (ABPM). Secondary outcomes include several CVD risk biomarkers, including clinic BP, lipid profile, vascular endothelial function, arterial stiffness, and sympathetic nervous system (SNS) activity. Data analysis will evaluate the association between improvements in insomnia and sleep with primary and secondary CVD risk biomarker outcomes. The SLEEPRIGHT trial (ClinicalTrials.Gov NCT04009447) will utilize CBT-I, the current gold standard treatment for insomnia disorder, to evaluate whether reducing insomnia severity and improving sleep are accompanied by improved biomarkers of CVD risk in patients with untreated hypertension.

Sedentary behavior, physical activity, sleep duration and obesity risk: Mendelian randomization study

BACKGROUND

Observational studies have suggested associations between sedentary behaviors (SB), physical activity (PA), sleep duration (SD), and obesity, but the causal relationships remain unclear.

METHODS

We used Mendelian randomization (MR) with genetic variation as instrumental variables (IVs) to assess the causality between SB/PA/SD and obesity. Genetic variants associated with SB/PA/SD were obtained from Genome-wide association study (GWAS), and obesity data came from FinnGen. The primary MR analysis used the instrumental variable weighted (IVW) method, with sensitivity tests including Cochran Q, MR-Egger intercepts, and MR-Radial. Expression Quantitative Trait Loci (eQTL) analysis was applied to identify significant genetic associations and biological pathways in obesity-related tissues.

RESULTS

The MR analysis revealed causal relationships between four SB-related lifestyle patterns and obesity. Specifically, increased genetic liability to television watching (IVW MR Odds ratio [OR] = 1.55, [95% CI]:[1.27, 1.90], p = 1.67×10-5), computer use ([OR] = 1.52, [95% CI]:[1.08, 2.13], p = 1.61×10-2), leisure screen time (LST) ([OR] = 1.62, [95% CI] = [1.43, 1.84], p = 6.49×10-14, and driving (MR [OR] = 2.79, [95% CI]:[1.25, 6.21], p = 1.23×10-2) was found to increase the risk of obesity. Our findings indicate that no causal relationships were observed between SB at work, sedentary commuting, PA, SD, and obesity. The eQTL analysis revealed strong associations between specific genes (RPS26, TTC12, CCDC92, NICN1) and SNPs (rs10876864, rs2734849, rs4765541, rs7615206) in both subcutaneous and visceral adipose tissues, which are associated with these SBs. Enrichment analysis further revealed that these genes are involved in crucial biological pathways, including cortisol synthesis, thyroid hormone synthesis, and insulin secretion.

CONCLUSIONS

Our findings support a causal relationship between four specific SBs (LST, television watching, computer use, driving) and obesity. These results provide valuable insights into potential interventions to address obesity effectively, supported by genetic associations in the eQTL and enrichment analysis. Further research and public health initiatives focusing on reducing specific SBs may be warranted.

Sleep Quality, Nutrient Intake, and Social Development Index Predict Metabolic Syndrome in the Tlalpan 2020 Cohort: A Machine Learning and Synthetic Data Study

This study investigated the relationship between Metabolic Syndrome (MetS), sleep disorders, the consumption of some nutrients, and social development factors, focusing on gender differences in an unbalanced dataset from a Mexico City cohort. We used data balancing techniques like SMOTE and ADASYN after employing machine learning models like random forest and RPART to predict MetS. Random forest excelled, achieving significant, balanced accuracy, indicating its robustness in predicting MetS and achieving a balanced accuracy of approximately 87%. Key predictors for men included body mass index and family history of gout, while waist circumference and glucose levels were most significant for women. In relation to diet, sleep quality, and social development, metabolic syndrome in men was associated with high lactose and carbohydrate intake, educational lag, living with a partner without marrying, and lack of durable goods, whereas in women, best predictors in these dimensions include protein, fructose, and cholesterol intake, copper metabolites, snoring, sobbing, drowsiness, sanitary adequacy, and anxiety. These findings underscore the need for personalized approaches in managing MetS and point to a promising direction for future research into the interplay between social factors, sleep disorders, and metabolic health, which mainly depend on nutrient consumption by region.

Causal Association Between Subtypes of Excessive Daytime Sleepiness and Risk of Cardiovascular Diseases

BACKGROUND

Excessive daytime sleepiness (EDS), experienced in 10% to 20% of the population, has been associated with cardiovascular disease and death. However, the condition is heterogeneous and is prevalent in individuals having short and long sleep duration. We sought to clarify the relationship between sleep duration subtypes of EDS with cardiovascular outcomes, accounting for these subtypes.

METHODS AND RESULTS

We defined 3 sleep duration subtypes of excessive daytime sleepiness: normal (6-9 hours), short (<6 hours), and long (>9 hours), and compared these with a nonsleepy, normal-sleep-duration reference group. We analyzed their associations with incident myocardial infarction (MI) and stroke using medical records of 355 901 UK Biobank participants and performed 2-sample Mendelian randomization for each outcome. Compared with healthy sleep, long-sleep EDS was associated with an 83% increased rate of MI (hazard ratio, 1.83 [95% CI, 1.21-2.77]) during 8.2-year median follow-up, adjusting for multiple health and sociodemographic factors. Mendelian randomization analysis provided supporting evidence of a causal role for a genetic long-sleep EDS subtype in MI (inverse-variance weighted β=1.995, P=0.001). In contrast, we did not find evidence that other subtypes of EDS were associated with incident MI or any associations with stroke (P>0.05).

CONCLUSIONS

Our study suggests the previous evidence linking EDS with increased cardiovascular disease risk may be primarily driven by the effect of its long-sleep subtype on higher risk of MI. Underlying mechanisms remain to be investigated but may involve sleep irregularity and circadian disruption, suggesting a need for novel interventions in this population.

Examining the U-shaped relationship of sleep duration and systolic blood pressure with risk of cardiovascular events using a novel recursive gradient scanning model

Background

Observational studies have suggested U-shaped relationships between sleep duration and systolic blood pressure (SBP) with risks of many cardiovascular diseases (CVDs), but the cut-points that separate high-risk and low-risk groups have not been confirmed. We aimed to examine the U-shaped relationships between sleep duration, SBP, and risks of CVDs and confirm the optimal cut-points for sleep duration and SBP.

Methods

A retrospective analysis was conducted on NHANES 2007-2016 data, which included a nationally representative sample of participants. The maximum equal-odds ratio (OR) method was implemented to obtain optimal cut-points for each continuous independent variable. Then, a novel "recursive gradient scanning method" was introduced for discretizing multiple non-monotonic U-shaped independent variables. Finally, a multivariable logistic regression model was constructed to predict critical risk factors associated with CVDs after adjusting for potential confounders.

Results

A total of 26,691 participants (48.66% were male) were eligible for the current study with an average age of 49.43 ± 17.69 years. After adjusting for covariates, compared with an intermediate range of sleep duration (6.5-8.0 h per day) and SBP (95-120 mmHg), upper or lower values were associated with a higher risk of CVDs [adjusted OR (95% confidence interval) was 1.20 (1.04-1.40) for sleep duration and 1.17 (1.01-1.36) for SBP].

Conclusions

This study indicates U-shaped relationships between SBP, sleep duration, and risks of CVDs. Both short and long duration of sleep/higher and lower BP are predictors of cardiovascular outcomes. Estimated total sleep duration of 6.5-8.0 h per day/SBP of 95-120 mmHg is associated with lower risk of CVDs.

Sleep Deficiency and Cardiometabolic Disease

Epidemiologic studies have demonstrated that short sleep duration is associated with an increased risk of cardio-metabolic health outcomes including cardiovascular disease mortality, coronary heart disease, type 2 diabetes mellitus, hypertension, and metabolic syndrome. Experimental sleep restriction studies have sought to explain these findings. This review describes the main evidence of these associations and possible mechanisms explaining them. Whether sleep extension reverses these now widely acknowledged adverse health effects and the feasibility of implementing such strategies on a public health level is discussed.

An Examination of the Associations between Nutritional Composition, Social Jet Lag and Temporal Sleep Variability in Young Adults

While dietary intake has previously been related to various indices of poor sleep (e.g., short sleep duration, poor sleep quality), to date, few studies have examined chrononutrition from the perspectives of the relationship between dietary intake and social jet lag and temporal sleep variability. Moreover, recently it has been suggested that previous methods of measuring social jet lag have the potential to lead to large overestimations. Together, this precludes a clear understanding of the role of nutritional composition in the pathophysiology of poor sleep, via social jet lag and temporal sleep variability, or vice versa. The aim of the present study was to determine the relationships between nutrient intake and social jet lag (using a revised index, taking account of intention to sleep and sleep onset and offset difficulties), and temporal sleep variability. Using a cross-sectional survey, 657 healthy participants (mean age 26.7 ± 6.1 years), without sleep disorders, were recruited via an online platform and completed measures of weekly dietary intake, social jet lag, temporal sleep variability, stress/sleep reactivity and mood. Results showed limited associations between nutritional composition and social jet lag. However, levels of temporal sleep variability were predicted by consumption of polyunsaturated fats, sodium, chloride and total energy intake. The results suggest further examinations of specific nutrients are warranted in a first step to tailoring interventions to manage diet and temporal variabilities in sleep patterns.

The relationship between sleep duration and arterial stiffness: A meta-analysis

Chronically short (<7 h) and long (>9 h) sleep duration may increase cardiovascular disease (CVD) risk relative to the recommended sleep duration (7-9 h). The objective of this study was to evaluate the effects of short and long sleep duration on arterial stiffness, a marker of CVD risk, in adults. Eleven cross-sectional studies were reviewed with a total sample size of 100,050 participants (64.5% male). Weighted mean differences (WMD) and 95% confidence intervals (95% CI) were calculated and pooled using random effects models, and standardized mean differences (SMD) were calculated to determine effect size magnitude. Compared to the recommended sleep duration, both short (WMD = 20.6 cm/s, 95% confidence intervals (CI): 13.8-27.4 cm/s, SMD = 0.02) and long sleep duration (WMD = 33.6 cm/s, 95% CI: 20.0-47.2 cm/s, SMD = 0.79) were associated with higher (detrimental) pulse wave velocity (PWV). The associations between short sleep and higher PWV in adults with cardiometabolic disease, and long sleep and higher PWV in older adults, were also significant in sub-group analysis. These findings indicate short and long sleep duration may contribute to subclinical CVD.

Exploring physical and biological manifestations of burnout and post-traumatic stress disorder symptoms in healthcare workers: a scoping review protocol

INTRODUCTION

The COVID-19 pandemic has strained the mental and physical well-being of healthcare workers (HCW). Increased work-related stress and limited resources have increased symptoms of anxiety, depression, insomnia and post-traumatic stress disorder (PTSD) in this population. Stress-related disorders have been strongly associated with long-term consequences, including cardiometabolic disorders, endocrine disorders and premature mortality. This scoping review aims to explore available literature on burnout, PTSD, and other mental health-associated symptoms in HCW to synthesise relationships with physiological and biological biomarkers that may be associated with increased risk of disease, creating an opportunity to summarise current biomarker knowledge and identify gaps in this literature.

METHODS AND ANALYSIS

This scoping review uses the Arksey and O'Malley six-step scoping review methodology framework. The research team will select appropriate primary sources using a search strategy developed in collaboration with a health sciences librarian. Three reviewers will initially screen the title and abstracts obtained from the literature searches, and two reviewers will conduct independent reviews of full-text studies for inclusion. The research team will be reviewing literature focusing on which burnout and/or PTSD-associated physiological and biological biomarkers have been studied, the methodologies used to study them and the correlations between the biomarkers and HCW experiencing burnout/PTSD. Data extraction forms will be completed by two reviewers for included studies and will guide literature synthesis and analysis to determine common themes.

ETHICS AND DISSEMINATION

This review does not require ethical approval. We expect results from this scoping review to identify gaps in the literature and encourage future research regarding improving biological and physiological biomarker research in HCW. Preliminary results and general themes will be communicated back to stakeholders. Results will be disseminated through peer-reviewed publications, policy briefs and conferences as well as presented to stakeholders to an effort to invest in HCW mental and physical health.

Exploring Physical and Biological Manifestations of Burnout and Post-Traumatic Stress Disorder Symptoms in Healthcare Workers: A Scoping Review Protocol

Introduction

The COVID-19 pandemic has strained the mental and physical well-being of healthcare workers (HCW). Increased work-related stress and limited resources has increased symptoms of anxiety, depression, insomnia, and post-traumatic stress disorder (PTSD) in this population. Stress-related disorders have been strongly associated with long-term consequences including cardiometabolic disorders, endocrine disorders and premature mortality. This scoping review aims to explore available literature on burnout, PTSD, and other mental health-associated symptoms in HCW to synthesize relationships with physiological and biological biomarkers that may be associated with increased risk of disease, creating an opportunity to summarize current biomarker knowledge and identify gaps in this literature.

Methods and Analysis

This scoping review uses the Arksey and O'Malley six-step scoping review methodology framework. The research team will select appropriate primary sources using a search strategy developed in collaboration with a health sciences librarian. Three reviewers will initially screen the title and abstracts obtained from the literature searches, and two reviewers will conduct independent reviews of full-text studies for inclusion. The research team will be reviewing literature focusing on which burnout and/or PTSD-associated physiological and biological biomarkers have been studied, the methodologies used to study them and the correlations between the biomarkers and HCW experiencing burnout/PTSD. Data extraction forms will be completed by two reviewers for included studies and will guide literature synthesis and analysis to determine common themes.

Ethics and Dissemination

This review does not require ethical approval. We expect results from this scoping review to identify gaps in the literature and encourage future research regarding improving biologic and physiologic biomarker research in HCW. Preliminary results and general themes will be communicated back to stakeholders. Results will be disseminated through peer-reviewed publications, policy briefs, and conferences, as well as presented to stakeholders to an effort to invest in HCW mental and physical health.

Strengths and Limitations of This Study

This will be the first scoping review to assess the current understanding of the biologic and physiological impact of burnout on healthcare workers. The target population is restricted to healthcare workers; however, identified research gaps may be used to guide future studies in other high-burnout occupations and industries.This scoping review will be guided by the Arksey and O'Malley six-step methodological framework and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Review checklist.Both peer reviewed manuscript and pre-prints/abstracts will be evaluated, but studies that have not been peer reviewed will be notated in the summary table. Conference abstracts are excluded.Preliminary and final themes and results identified by this scoping review will be communicated to stakeholders, including hospital staff and HCW, to ensure agreement with our interpretation and to convey knowledge gained with our population of interest.This review will advance the field's current understanding of mechanisms connecting the burnout and pathogenic stress to biologic and physiologic outcomes in healthcare workers and provide researchers with gaps in the literature to inform opportunities for future research.

Longitudinal association between perceived discrimination and sleep problems among young adults in the United States: Tests of moderation by race/ethnicity and educational attainment

RATIONALE

Although perceived discrimination is known to affect sleep, the findings of previous research are limited because they are mostly based on either cross-sectional data or non-generalizable samples, such as clinical samples. There is also little evidence on whether perceived discrimination differently affects sleep problems across different groups.

OBJECTIVE

This study examines whether perceived discrimination is related to sleep problems when considering unmeasured confounding factors and how that relationship varies by race/ethnicity and socioeconomic status from a longitudinal perspective.

METHODS

This study uses Waves 1, 4, and 5 of the National Longitudinal Study of Adolescent to Adult Health (Add Health) and conducts hybrid panel modeling to estimate both within- and between-individual effects of perceived discrimination on sleep problems.

RESULTS

First, the results of the hybrid modeling show that increased perceived discrimination in daily life is related to poorer sleep quality when accounting for unobserved heterogeneity as well as time-constant and time-varying covariates. Moreover, the moderation analyses and the subgroup analyses demonstrate that the association was not found among Hispanics and among those with a bachelor's degree or more. That is, Hispanic origin and college attainment weaken the associations between perceived discrimination and sleep problems, and the differences by race/ethnicity and socioeconomic status are statistically significant.

CONCLUSIONS

This study suggests a robust link between discrimination and sleep problems and further elaborates on whether this association varies among different groups. Efforts to reduce interpersonal and institutional discrimination (e.g., discrimination at the workplace or in the community) can help to improve sleep problems and thereby promote overall health. We also suggest that future research consider the moderating roles of susceptible and resilient factors in the relationships between discrimination and sleep.

Sleep Irregularity and Subclinical Markers of Cardiovascular Disease: The Multi-Ethnic Study of Atherosclerosis

Background Sleep irregularity has been linked to incident cardiovascular disease. Less is known about associations of sleep regularity with atherosclerosis. We examined cross-sectional associations of actigraphy-assessed sleep duration and sleep timing regularity with subclinical atherosclerosis in the community-based MESA (Multi-Ethnic Study of Atherosclerosis). Methods and Results MESA Sleep Ancillary Study participants (N=2032; mean age, 68.6±9.2 years; 37.9% White) completed 7-day wrist actigraphy. Participants underwent assessments of coronary artery calcium, carotid plaque presence, carotid intima-media thickness, and the ankle-brachial index. Sleep regularity was quantified by the 7-day with-in person SD of sleep duration and sleep onset timing. Relative risk regression models were used to calculate prevalence ratios and 95% CIs. Models are adjusted for demographics, cardiovascular disease risk factors, and other objectively assessed sleep characteristics including obstructive sleep apnea, sleep duration, and sleep fragmentation. After adjustment, compared with participants with more regular sleep durations (SD ≤60 minutes), participants with greater sleep duration irregularity (SD >120 minutes) were more likely to have high coronary artery calcium burden (>300; prevalence ratio, 1.33 [95% CI, 1.03-1.71]) and abnormal ankle-brachial index (<0.9; prevalence ratio, 1.75 [95% CI, 1.03-2.95]). Compared with participants with more regular sleep timing (SD ≤30 minutes), participants with irregular sleep timing (SD >90 minutes) were more likely to have high coronary artery calcium burden (prevalence ratio, 1.39 [95% CI, 1.07-1.82]). Associations persisted after adjustment for cardiovascular disease risk factors and average sleep duration, obstructive sleep apnea, and sleep fragmentation. Conclusions Sleep irregularity, particularly sleep duration irregularity, was associated with several measures of subclinical atherosclerosis. Sleep regularity may be a modifiable target for reducing atherosclerosis risk. Future investigation into cardiovascular risk reduction interventions targeting sleep irregularity may be warranted.

Habitual sleep duration and its relationship with cardiovascular health, healthcare costs, and resource utilization in a working population

OBJECTIVE

Little is known about the relationship between habitual sleep duration, cardiovascular health (CVH) and their impact on healthcare costs and resource utilization. We describe the relationship between sleep duration and ideal CVH, and the associated burden of healthcare expenditure and utilization in a large South Florida employee population free from known cardiovascular disease.

METHODS

The study used data obtained from a 2014 voluntary Health Risk Assessment among 8629 adult employees of Baptist Health South Florida. Health expenditures and resource utilization information were obtained through medical claims data. Frequencies of the individual and cumulative CVH metrics across sleep duration were computed. Mean and marginal per-capita healthcare expenditures were estimated.

RESULTS

The mean age was 43 years, 57% were of Hispanic ethnicity. Persons with 6-8.9hours and ≥9 hours of sleep were significantly more likely to report optimal goals for diet, physical activity, body mass index, and blood pressure when compared to those who slept less than 6 hours. Compared to those who slept less than 6 hours, those sleeping 6-8.9hours and ≥9hours had approximately 2- (odds ratio 2.1, 95% confidence interval: 1.9-3.0) and 3-times (odds ratio 3.0, 95% confidence interval: 1.6-5.6) higher odds of optimal CVH. Both groups with 6 or more hours of sleep had lower total per-capita expenditure (approximately $2000 and $2700 respectively), lower odds of visiting an emergency room, or being hospitalized compared to those who slept < 6 hours.

CONCLUSION

Sleeping 6 or more hours was associated with better CVH, lower healthcare expenditures, and reduced healthcare resource utilization.

Cardiovascular events in insomnia patients with post-traumatic stress disorder

BACKGROUND

Both post-traumatic stress disorder (PTSD) and insomnia are independently associated with a greater risk of cardiovascular mortality. The objective of this study is to determine whether PTSD plus insomnia is associated with a higher risk of major adverse cardiovascular events (MACEs) than either condition alone in a large cohort of veterans.

METHODS

We conducted a retrospective analysis of the national Veterans Health Administration (VHA) electronic medical records covering veterans 18 years or older with the diagnosis of PTSD, insomnia, or both from January 1, 2015, to December 31, 2020. MACE was defined as new-onset myocardial infarction (MI), transient ischemic attack (TIA) or stroke, based on ICD-9 and ICD-10 diagnosis codes from inpatient or outpatient encounters.

RESULTS

A total of 19,080 veterans, 1840 with PTSD plus insomnia and 17,240 with either PTSD or insomnia, were included in the analysis. Baseline mean (SD) age was 46.3 (11.5) years. During median follow-up of 3.9 (interquartile range, 2.4-5.1) years, 206 (1%) veterans developed incident MACE. Cumulative incidence for MI, TIA and/or stroke was larger in veterans with PTSD plus insomnia compared to PTSD and insomnia alone (p=0.008). In a Cox proportional hazards model, PTSD plus insomnia was significantly associated with greater risk of developing MACEs (hazard ratio [HR], 1.44; 95% CI, 1.38-1.50, p=0.01) than either condition after adjusting for multiple covariates including age, gender, smoking, hypertension, depression, and burden of comorbidities.

CONCLUSIONS

This cohort study found that PTSD plus insomnia is a risk factor for MACEs of greater magnitude than PTSD- or insomnia-alone.

Association between discrimination and poor sleep health outcomes among 2192 South Korean gay, lesbian, and bisexual adults: A nationwide cross-sectional survey

OBJECTIVE

The study aimed to assess the prevalence of poor sleep health outcomes and examine the associations between experiences of discrimination and the sleep health outcomes among lesbian, gay, and bisexual (LGB) adults in Korea.

DESIGN & SETTING

The study used data from Rainbow Connection Project I, a nationwide cross-sectional survey of Korean LGB adults, conducted via online in 2016.

MEASUREMENTS

Participants were asked about experiences of anti-LGB discrimination and discrimination based on other characteristics (ie, gender, age, place of origin, nationality/race, religion, appearance including height and weight, disability status, and other) in the past 12 months. Using the responses, the participants were categorized into 4 groups: those who experienced (1) none, (2) only anti-LGB discrimination, (3) only other types of discrimination, and (4) both anti-LGB and other types of discrimination. Past-week sleep quality, unrestful sleep, and long sleep latency were included as sleep health outcomes.

RESULTS

Of the 2192 participants, 740 (33.8%) had poor sleep quality, 1211 (55.2%) had unrestful sleep, and 681 (31.1%) had long sleep latency in the past week. Participants who experienced both anti-LGB and other types of discrimination had 1.65 times (95% confidence interval [CI] = 1.38-1.98), 1.30 times (95% CI = 1.16-1.45), and 1.58 times (95% CI = 1.31-1.90) higher prevalence of poor sleep quality, unrestful sleep, and long sleep latency, respectively, compared to those without any experiences of discrimination.

CONCLUSIONS

Experiencing discrimination may deprive Korean LGB adults of good quality sleep. Interventions that seek to prevent discrimination are needed to promote sleep health among Korean LGB individuals.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Dietary Risk Factors and Eating Behaviors in Peripheral Arterial Disease (PAD)

Dietary risk factors play a fundamental role in the prevention and progression of atherosclerosis and PAD (Peripheral Arterial Disease). The impact of nutrition, however, defined as the process of taking in food and using it for growth, metabolism and repair, remains undefined with regard to PAD. This article describes the interplay between nutrition and the development/progression of PAD. We reviewed 688 articles, including key articles, narrative and systematic reviews, meta-analyses and clinical studies. We analyzed the interaction between nutrition and PAD predictors, and subsequently created four descriptive tables to summarize the relationship between PAD, dietary risk factors and outcomes. We comprehensively reviewed the role of well-studied diets (Mediterranean, vegetarian/vegan, low-carbohydrate ketogenic and intermittent fasting diet) and prevalent eating behaviors (emotional and binge eating, night eating and sleeping disorders, anorexia, bulimia, skipping meals, home cooking and fast/ultra-processed food consumption) on the traditional risk factors of PAD. Moreover, we analyzed the interplay between PAD and nutritional status, nutrients, dietary patterns and eating habits. Dietary patterns and eating disorders affect the development and progression of PAD, as well as its disabling complications including major adverse cardiovascular events (MACE) and major adverse limb events (MALE). Nutrition and dietary risk factor modification are important targets to reduce the risk of PAD as well as the subsequent development of MACE and MALE.

Temporal Trends in the Practice Pattern for Sleep-Disordered Breathing in Patients With Cardiovascular Diseases in Japan - Insights From the Japanese Registry of All Cardiac and Vascular Diseases - Diagnosis Procedure Combination

BACKGROUND

After the publication of the Japanese Circulation Society guideline of sleep-disordered breathing (SDB) in 2010, with new evidence and changes to the health insurance system, trends in the practice pattern for SDB in patients with cardiovascular disease (CVD) might have changed.

METHODS AND RESULTS

This study evaluated the temporal changes in the practice pattern for SDB by using a nationwide claim database, the Japanese Registry of All Cardiac and Vascular Diseases - Diagnosis Procedure Combination (JROAD-DPC), from 2012 to 2019. The main findings were: (1) the number of CVD patients diagnosed with SDB increased (especially those with atrial fibrillation [AF] and heart failure [HF]); (2) the number of diagnostic tests for SDB performed during hospitalization increased for AF patients (from 1.3% in 2012 to 1.8% in 2019), whereas it decreased for other CVD patients; (3) the number of patients diagnosed with SDB increased in each type of CVD, except for patients with acute myocardial infarction (AMI); (4) continuous positive airway pressure (CPAP) treatment increased for AF patients (from 15.2% to 17.5%); (5) CPAP treatment decreased for patients with angina pectoris (AP) and AMI, and any treatment decreased for HF patients (from 46.1% to 39.7%); and (6) SDB was treated more often in HF patients than in AF, AP, and AMI patients (41.7% vs. 17.2%, 19.1% and 20.4%, respectively).

CONCLUSIONS

The practice pattern for SDB in CVD patients has changed from 2012 to 2019.

Causal Association of Cardiovascular Risk Factors and Lifestyle Behaviors With Peripheral Artery Disease: A Mendelian Randomization Approach

Background

We investigated the causal associations between the genetic liability to cardiovascular and lifestyle risk factors and peripheral artery disease (PAD), using a Mendelian randomization approach.

Methods and Results

We performed a 2‐sample inverse‐variance weighted Mendelian randomization analysis, multiple sensitivity analyses to assess pleiotropy and multivariate Mendelian randomization analyses to assess mediating/confounding factors. European‐ancestry genomic summary data (P<5×10⁻⁸) for type 2 diabetes, lipid‐fractions, smoking, alcohol and coffee consumption, physical activity, sleep, and education level were selected. Genetic associations with PAD were extracted from the Million‐Veteran‐Program genome‐wide association studies (cases=31 307, controls=211 753, 72% European‐ancestry) and the GoLEAD‐SUMMIT genome‐wide association studies (11 independent genome‐wide association studies, European‐ancestry, cases=12 086, controls=449 548). Associations were categorized as robust (Bonferroni‐significant (P<0.00294), consistent over PAD‐cohorts/sensitivity analyses), suggestive (P value: 0.00294–0.05, associations in 1 PAD‐cohort/inconsistent sensitivity analyses) or not present. Robust evidence for genetic liability to type 2 diabetes, smoking, insomnia, and inverse associations for higher education level with PAD were found. Suggestive evidence for the genetic liability to higher low‐density lipoprotein cholesterol, triglyceride‐levels, alcohol consumption, and inverse associations for high‐density lipoprotein cholesterol, and increased sleep duration were found. No associations were found for physical activity and coffee consumption. However, effects fully attenuated for low‐density lipoprotein cholesterol and triglycerides after correcting for apoB, and for insomnia after correcting for body mass index and lipid‐fractions. Nonsignificant attenuation by potential mediators was observed for education level and type 2 diabetes.

Conclusions

Detrimental effects of smoking and type 2 diabetes, but not of low‐density lipoprotein cholesterol and triglycerides, on PAD were confirmed. Lower education level and insomnia were identified as novel risk factors for PAD; however, complete mediation for insomnia and incomplete mediation for education level by downstream risk factors was observed.

Sleep Deficiency and Cardiometabolic Disease

Epidemiologic studies have demonstrated that short sleep duration is associated with an increased risk of cardio-metabolic health outcomes including cardiovascular disease mortality, coronary heart disease, type 2 diabetes mellitus, hypertension, and metabolic syndrome. Experimental sleep restriction studies have sought to explain these findings. This review describes the main evidence of these associations and possible mechanisms explaining them. Whether sleep extension reverses these now widely acknowledged adverse health effects and the feasibility of implementing such strategies on a public health level is discussed.

Resveratrol protects against atherosclerosis by downregulating the PI3K/AKT/mTOR signaling pathway in atherosclerosis model mice

Atherosclerosis is a cardiovascular disease, which is characterized by the interaction between carbohydrates, lipids, cells and various other molecules and genetic factors. Previous studies have demonstrated that resveratrol (RV) served protective roles in numerous types of human disease by regulating different signaling pathways. The aim of the present study was to investigate the therapeutic effects of RV and analyze the potential RV-mediated mechanism in umbilical vein endothelial cells (UVECS) in atherosclerosis model mice. Reverse transcription-quantitative PCR, western blotting and immunohistochemistry were used to analyze the therapeutic effects of RV both in vitro and in vivo. The results demonstrated that total cholesterol, triglycerides, low-density lipoprotein cholesterin and high-density lipoprotein cholesterin levels were significantly decreased in the RV group compared with the control group. RV demonstrated significant anti-atherosclerotic activity, which was determined through the atherogenic index, 3-hydroxy-3-methyl-glutaryl-Coa (HMG-CoA) reductase activity and marker enzymes, such as lactate dehydrogenase, creatine phosphokinase, aspartate transaminase, alanine transaminase and alkaline phosphatase. It was also observed that RV treatment significantly decreased the area of the arteriosclerotic lesion in the RV group compared with the control, as well as significantly decreasing the expression levels of matrix metalloproteinase-9 and CD40 ligand (CD40L) in arterial lesion tissue compared with the control group. Serum expression levels of tumor necrosis factor-α and C-reactive protein were also significantly decreased by RV treatment compared with the control group. Furthermore, RV treatment significantly decreased the expression levels of PI3K, AKT and mTOR in UVECS in vitro. In conclusion, these results suggested that the anti-atherosclerotic activity of RV may be due to its modulatory activity over the PI3K/AKT/mTOR signaling pathway. These findings suggested a potential novel treatment option for patients with atherosclerosis.

A Time to Rest, a Time to Dine: Sleep, Time-Restricted Eating, and Cardiometabolic Health

Cardiovascular disease (CVD) poses a serious health and economic burden worldwide. Modifiable lifestyle factors are a focus of research into reducing the burden of CVD, with diet as one of the most investigated factors. Specifically, the timing and regularity of food intake is an emerging research area, with approaches such as time-restricted eating (TRE) receiving much attention. TRE involves shortening the time available to eat across the day and is associated with improved CVD outcomes compared with longer eating windows. However, studies that have examined TRE have not considered the impact of sleep on CVD outcomes despite recent evidence showing that sleep duration can influence the timing and amount of food eaten. In this article, we argue that as TRE and sleep influence each other, and influence the same cardiometabolic parameters, experiencing inadequate sleep may attenuate any positive impact TRE has on CVD. We examine the relationship between TRE and CVD, with sleep as a potential mediator in this relationship, and propose a research agenda to investigate this relationship. This will provide necessary evidence to inform future interventions aimed at reducing the burden of CVD.

The impact of sleeping duration on atherosclerosis in the community: insights from the Corinthia study

PURPOSE

Sleep is an essential physiologic process whose disturbances have been regarded as a risk factor in various pathophysiologic processes, including atherosclerosis and cardiovascular disease. Although the negative influence of short sleep duration has been well-established, recent data suggest a possible harmful effect of prolonged sleeping pattern.

METHODS

In the setting of the Corinthia cross-sectional study, self-reported night sleep duration was recorded in 1752 apparently healthy individuals and was classified as normal sleep duration (NSD, 7-8 h), short sleep duration (SSD, 6-7 h), very short sleep duration (VSSD, < 6 h), and long sleep duration (LSD, > 8 h). Carotid duplex ultrasonography was performed in order to measure the mean and maximum carotid intima-media thickness (cIMT) as a non-invasive marker of atherosclerosis.

RESULTS

Subjects with LSD and VSSD had significantly higher mean cIMT (VSSD: 1.02 ± 0.45 mm, SSD: 0.95 ± 0.35, NSD: 0.96 ± 0.38 mm, LSD: 1.07 ± 0.52 mm; p < 0.001) and maximum cIMT (VSSD: 1.39 ± 0.9 mm, SSD: 1.25 ± 0.71 mm, NSD: 1.23 ± 0.76 mm, LSD: 1.41 ± 0.93 mm). Following a regression analysis adjusting for known cardiovascular risk factors, individuals with LSD and VSSD had higher mean cIMT by 0.054 mm and 0.067 mm respectively compared to those with NSD.

CONCLUSION

A balanced sleeping duration of 6-8 h is associated with decreased mean and maximum IMT while both very short sleep duration and long sleep duration are associated with increased carotid intima-media thickness, a marker of subclinical atherosclerosis.

Is self-reported short sleep duration associated with obesity? A systematic review and meta-analysis of cohort studies

CONTEXT

A possible association between self-reported short sleep duration and risk of obesity has been studied.

OBJECTIVE

To analyze the association between sleep duration and obesity.

METHODS

The LILACS, Medline, Central, Embase, and OpenGrey databases were searched from inception until July 2020. Two authors screened the studies independently according to the PECO strategy, as follows: participants: > 18 years old; exposure: short sleep duration; control: regular sleep; outcome: obesity). Only cohort studies were included. A total of 3286 studies were retrieved with the search strategy, but only 36 were included. Disagreements were resolved by a third author. The quality of studies was assessed with Newcastle-Ottawa Quality Assessment Form for Cohort Studies. The certainty of the evidence was assessed using Grading of Recommendations Assessment, Development, and Evaluation.

RESULTS

Thirty-six studies were included, and 22 contributed quantitative data. Most of the studies (n = 27) assessed sleep by self-report. The meta-analysis showed a significant association between self-reported short sleep and development of obesity, and the chances of developing obesity increased when self-reported sleep duration decreased.

CONCLUSIONS

Self-reported short sleep was significantly associated with a higher incidence of obesity, with moderate quality of evidence.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration no. CRD42019130143.

What Is “Chronic” in “Chronic Sleep Reduction” and What Are Its Consequences? A Systematic Scoping Review of the Literature

Purpose of Review

In this scoping review, we aimed to (1) provide an overview of chronic sleep reduction by systematically reviewing the existing literature (limited to systematic reviews and meta-analyses), (2) investigate the evidence of the effects of short sleep duration on daytime functioning, and (3) identify research gaps in this field.

Recent Findings

The results showed that (1) clear definitions of chronicity of sleep reduction are lacking—none of the included reviews/meta-analyses provided a full definition—and (2) short sleep duration appeared to be related to obesity and diabetes, whereas relations with cardiovascular disease (CVD), cognitive functioning, emotional problems, general health, and mortality, showed either small effects and appeared to be complex (e.g., for CVD and cognitive functioning), or studies were scarce or completely lacking (e.g., mortality in children/adolescents and emotional problems in adults).

Summary

Although short or insufficient sleep is highly prevalent and is associated with impaired mental and physical wellbeing, as well as pervasive negative consequences for daytime functioning, the concepts of “chronicity” and “chronic sleep reduction” have not been clearly defined and its effects on health are therefore still largely unknown. Moreover, there are large research gaps concerning studies on the relations between short sleep and health consequences. Further studies are recommended to define and operationalize chronicity of sleep reduction and develop measurements that adequately represent the complexity of the concept.

Application accuracy of the sleep decision tree to standardized patient cases by physiotherapists: An observational study

Background: Physiotherapists assess lifestyle factors, including sleep health, that contribute to poor health outcomes. Recommendations of sleep screening assessments have been provided; however, physical therapists' ability to successfully identify which patients would benefit from additional consultation has not been established.Objective: To determine if physiotherapists can accurately apply an evidence-based sleep decision tree to four hypothetical standardized patient cases.Methods: Participants applied the sleep decision tree to the four standardized cases via an online platform. Likert scales were used to assess perception of ease of use, likelihood of use, and how helpful they thought the sleep decision tree would be. Descriptive analyses and multiple linear regression models were conducted.Results: Eighty-eight individuals participated in the study. Most participants correctly answered the cases with 1 and 3 decision points (92% and 84%, respectively). In contrast, few participants correctly answered the cases with 4 and 5 decision points (7% and 14%, respectively). Seventy-four (84%) respondents indicated the sleep decision tree was easy to use; 57 (65%) answered they were likely to use the sleep decision tree in clinical practice; and 66 (75%) said the sleep decision tree would be helpful to their clients.Conclusions: Physiotherapists were able to accurately apply a sleep decision tree to simpler patient cases but were frequently unable to apply it to more complex patient cases. This may be due to lack of education, perceived ease of using, and relevance of the sleep decision tree to their clinical practice. The sleep decision tree may aid physiotherapists in assessing sleep health, screening for sleep disturbances, and referring for further assessment.

Association of Sleep Quality With Greater Left Ventricular Mass in Children Aged 9 to 11 Years

OBJECTIVE

Research has consistently found associations between sleep characteristics and cardiovascular disease risk in children, adolescents, and adults. Although primarily investigated in clinical samples (e.g., in those with sleep disorders), greater left ventricular mass is associated with poor sleep quality in nonclinical adult populations as well; however, this has not been evaluated in children or adolescents. Our study aim was to consider the relationship between objectively measured sleep characteristics and left ventricular mass in children.

METHODS

We assessed sleep and cardiac structure in a biracial sample of 9- to 11-year-old children (n = 176; 41% White, 59% Black; 50% female). Sleep was assessed with actigraphy for five nights. Cardiac dimensions were assessed using echocardiography.

RESULTS

After adjusting for covariates, we found that poor sleep quality was associated with significantly greater left ventricular mass (β = 0.13, t(167) = 2.14, p = .034, Cohen d = 0.16, for activity during sleep; β = 0.15, t(167) = 2.43, p = .016, Cohen d = 0.18, for sleep fragmentation). Other cardiac dimensions (namely, relative wall thickness and right ventricular dimension) were also significantly associated with sleep characteristics. Notably, associations did not differ as a function of sex or race.

CONCLUSIONS

The present findings are novel and unique because no prior reports have systematically documented the association between poor sleep quality with potentially detrimental cardiac remodeling in a nonclinical sample of children. However, the novelty and importance of these findings require additional research for confirmation.

Actigraphy-Derived Sleep Efficiency Is Associated With Endothelial Function in Men and Women With Untreated Hypertension

BACKGROUND

Poor sleep quality is increasingly recognized as an important and potentially modifiable risk factor for cardiovascular disease (CVD). Impaired endothelial function may be 1 mechanism underlying the association between poor sleep and CVD risk. The present study examined the relationship between objective measures of sleep quality and endothelial function in a sample of untreated hypertensive adults.

METHODS

Participants were 127 men (N = 74) and women (N = 53), including 55 African Americans and 72 White Americans, aged 40-60 years (mean age, 45.3 ± 8.5 years), with untreated hypertension (systolic blood pressure 130-159 mm Hg and/or diastolic blood pressure 85-99 mm Hg). Noninvasive brachial artery flow-mediated dilation (FMD) was assessed by ultrasound. Sleep parameters, including sleep efficiency (SE), total sleep time (TST), and subjective sleep quality, were assessed over 7 consecutive days by wrist actigraphy.

RESULTS

Participants averaged 7.76 ± 1 hours in bed, with an average SE of 78 ± 9%, and TST of 6 ± 1 hours. Brachial FMD averaged 3.5 ± 3.1%. In multivariate analyses controlling for sex, race, body mass index, clinic blood pressure, income, smoking, alcohol use, and baseline arterial diameter, SE was positively associated with FMD (β = 0.28, P = 0.012). Subjective sleep quality (β = -0.04, P = 0.63) and TST (β = -0.11, P = 0.25) were unrelated to FMD.

CONCLUSIONS

Poor sleep as indicated by low SE was associated with impaired FMD. These findings for SE are consistent with previous observations of other measures implicating poor sleep as a CVD risk factor. Interventions that improve sleep may also help lower CVD risk.

Obstructive Sleep Apnea, Sleep Duration, and Associated Mediators With Carotid Intima-Media Thickness: The ELSA-Brasil Study

[Figure: see text].

Correlation between OSAHS and Early Peripheral Atherosclerosis Indices in Patients with Type 2 Diabetes Mellitus in China: A Cross-Sectional Inpatient Study

OBJECTIVE

To analyze the differences of early atherosclerosis indices in type 2 diabetes mellitus (T2DM) patients with different degrees of obstructive sleep apnea-hypopnea syndrome (OSAHS) and explore the correlation between them, so as to provide a new clinical basis for the prevention and treatment of early atherosclerosis in patients with T2DM and OSAHS. Methods. A prospective study was conducted in 312 patients with T2DM and snoring who were hospitalized in the Department of Endocrinology, Peking University International Hospital from January 2017 to January 2020. According to the monitoring results, 312 patients were divided into 4 groups including the control group (208 cases), mild OSAHS group (18 cases), moderate OSAHS group (38 cases), and severe OSAHS group (48 cases). Multivariate logistic regression analysis was used to analyze the early atherosclerosis indices including brachial-ankle pulse wave velocity (PWV) and ankle-brachial index (ABI) in patients with T2DM coexistence with different degrees of OSAHS. Results. (1) As the degree of OSAHS increased, ABI decreased gradually and was lower than that in the control group, but PWV increased and was higher than that in the control group (p < 0.05, respectively). (2) The apnea-hypopnea index (AHI) positively correlated with PWV (r = 0.36, p < 0.05) and negatively correlated with ABI (r = -0.37, p < 0.05). (3) Multivariate logistic regression showed that after adjusting for age, gender, duration, BMI, blood pressure, blood glucose, blood lipid, and other factors, OSAHS was a risk factor of lower extremity arterial disease (LEAD) in patients with T2DM. With the increase of degree of OSAHS, the risk of lower extremity atherosclerosis gradually increased. Conclusion. OSAHS is an independent risk factor of LEAD in patients with T2DM, and with the increase of AHI, the ABI and PWV have changed, which provides a new clinical basis for the prevention and the treatment of early atherosclerosis in patients with T2DM and OSAHS.

The association between poor sleep quality and anxiety and depression symptoms in Chinese patients with coronary heart disease

Poor sleep quality might be a potentially modifiable predictor of prognosis in patients with coronary heart disease (CHD). Anxiety and depression symptoms are highly prevalent in these patients. Whether anxiety and depression symptoms are risk factors for poor sleep quality in Chinese patients with CHD is unclear. This study is intended to examine the prevalence of poor sleep quality in Chinese patients with CHD and its associations with anxiety and depression symptoms, and to explore whether sex, obesity and CHD type modify these associations. Three hundred and forty-eight participants were included. The Pittsburgh Sleep Quality Index (PSQI, >7 was defined as poor sleep quality) and Hospital Anxiety and Depression Scale (HADS) were used to assess sleep quality and psychological symptoms. 47.1% of the participants had poor sleep quality. Logistic regression analysis showed that poor sleep quality was independently associated with anxiety and depression symptoms adjusting for demographic and clinical factors. However, adjusted for anxiety symptoms, poor sleep quality was no longer associated with depression symptoms. Subgroup and interaction analysis showed that poor sleep quality was associated with markedly higher HADS anxiety and depression scores among patients with stable angina than those with acute coronary syndrome (ACS). These findings suggest that poor sleep quality was associated with both anxiety and depression symptoms in Chinese patients with CHD. However, in the case of concurrent anxiety and depression, anxiety was the main related factor of a high prevalence of poor sleep quality. The association between poor sleep quality and psychological symptoms was influenced by CHD type.

The impact of the 24-h movement spectrum on vascular remodeling in older men and women: a review

Aging is associated with increased risk of cardiovascular and cerebrovascular events, which are preceded by early, negative remodeling of the vasculature. Low physical activity is a well-established risk factor associated with the incidence and development of disease. However, recent physical activity literature indicates the importance of considering the 24-h movement spectrum. Therefore, the purpose of this review was to examine the impact of the 24-h movement spectrum, specifically physical activity (aerobic and resistance training), sedentary behavior, and sleep, on cardiovascular and cerebrovascular outcomes in older adults, with a focus on recent evidence (<10 yr) and sex-based considerations. The review identifies that both aerobic training and being physically active (compared with sedentary) are associated with improvements in endothelial function, arterial stiffness, and cerebrovascular function. Additionally, there is evidence of sex-based differences in endothelial function: a blunted improvement in aerobic training in postmenopausal women compared with men. While minimal research has been conducted in older adults, resistance training does not appear to influence arterial stiffness. Poor sleep quantity or quality are associated with both impaired endothelial function and increased arterial stiffness. Finally, the review highlights mechanistic pathways involved in the regulation of vascular and cerebrovascular function, specifically the balance between pro- and antiatherogenic factors, which mediate the relationship between the 24-h movement spectrum and vascular outcomes. Finally, this review proposes future research directions: examining the role of duration and intensity of training, combining aerobic and resistance training, and exploration of sex-based differences in cardiovascular and cerebrovascular outcomes.

Suboptimal sleep and incident cardiovascular disease among African Americans in the Jackson Heart Study (JHS)

BACKGROUND

Suboptimal sleep, including insufficient/long sleep duration and poor sleep quality, is a risk factor for cardiovascular disease (CVD) common but there is little information among African Americans, a group with a disproportionate CVD burden. The current study examined the association between suboptimal sleep and incident CVD among African Americans.

METHODS

This study included 4,522 African Americans without CVD at baseline (2000-2004) of the Jackson Heart Study (JHS). Self-reported sleep duration was defined as very short (<6 h/night), short (6 h/night), recommended (7-8 h/night), and long (≥9 h/night). Participants' self-reported sleep quality was defined as "high" and "low" quality. Suboptimal sleep was defined by low quality sleep and/or insufficient/long sleep duration. Incident CVD was a composite of incident coronary heart disease and stroke. Associations between suboptimal sleep and incident CVD were examined using Cox proportional hazards models over 15 follow-up years with adjustment for predictors of CVD risk and obstructive sleep apnea.

RESULTS

Sample mean age was 54 years (SD = 13), 64% female and 66% reported suboptimal sleep. Suboptimal sleep was not associated with incident CVD after covariate adjustment [HR(95% CI) = 1.18(0.97-1.46)]. Long [HR(95%CI) = 1.32(1.02-1.70)] and very short [HR(95% CI) = 1.56(1.06-2.30)] sleep duration were associated with incident CVD relative to recommended sleep duration. Low quality sleep was not associated with incident CVD (p = 0.413).

CONCLUSIONS

Long and very short self-reported sleep duration but not self-reported sleep quality were associated with increased hazard of incident CVD.

Restfulness from sleep and subsequent cardiovascular disease in the general population

We aimed to clarify the association between restfulness from sleep and subsequent risk of cardiovascular disease (CVD). Medical records of 1,980,476 individuals with neither prior history of CVD nor sleep disorders were extracted from the Japan Medical Data Center. Restfulness from sleep was subjectively assessed using information from the questionnaires at initial health check-ups. The mean age was 45 ± 11 years and 1,184,937 individuals were men. Overall, 1,197,720 individuals (60.5%) reported having good restfulness from sleep. The mean follow-up period was 1122 ± 827 days. Myocardial infarction, angina pectoris, stroke, heart failure, and atrial fibrillation occurred in 3673 (0.2%), 30,241 (1.5%), 13,546 (0.7%), 28,296 (1.4%), and 8116 (0.4%) individuals, respectively. Multivariable Cox regression analyses including age, sex, and other CVD risk factors after multiple imputation for missing values showed that good restfulness from sleep was associated with lower incidence of myocardial infarction (hazard ratio [HR] 0.89, 95% confidence interval [CI] 0.83-0.95), angina pectoris (HR 0.85, 95% CI 0.83-0.87), stroke (HR 0.85, 95% CI 0.82-0.88), heart failure (HR 0.86, 95% CI 0.84-0.88), and atrial fibrillation (HR 0.93, 95% CI 0.89-0.97). The association of restfulness from sleep with CVD events was pronounced in subjects with younger age and female sex. In conclusion, good restfulness from sleep may be associated with the lower risk of myocardial infarction, angina pectoris, stroke, heart failure, and atrial fibrillation. Further studies are required to clarify the underlying mechanism and to develop a novel preventive approach for CVD from the perspective of sleep.

The Impact of Sleep Disorders on Functional Recovery and Participation Following Stroke: A Systematic Review and Meta-Analysis

Background

Adequate sleep is vital for health and quality of life. People with stroke and a concomitant sleep disorder may have poorer outcomes than those without a sleep disorder.

Objective

To systematically evaluate the published literature to determine the impact of sleep disorders on physical, functional recovery at the activity and participation level after stroke.

Methods

A systematic review was conducted using PubMed, CINAHL, Scopus, and PsycINFO. Studies were selected that reported outcomes on physical, functional recovery at the activity and participation levels in participants with stroke and a diagnosed sleep disorder. A meta-analysis was performed on included studies that reported Barthel Index (BI) and modified Rankin Scale (mRS) scores. Results: A total of 33 studies were included in the systematic review with 9 of them in the meta-analysis. The mean mRS score was 0.51 points higher in participants with stroke and sleep disorders versus participants with stroke without sleep disorder [95% CI: 0.23-0.78]. The mean BI score was 10.2 points lower in participants with stroke and sleep disorders versus participants with stroke without sleep disorder [95% CI: −17.9 to −2.6].

Conclusions

People with stroke and a sleep disorder have greater functional limitations and disability than those without a sleep disorder. Rehabilitation professionals should screen their patients with stroke for potential sleep disorders and further research is needed to develop sleep and rehabilitation interventions that can be delivered in combination. PROSPERO registration number: CRD42019125562.

Sleep quality and disease activity in patients with inflammatory bowel disease: a systematic review and meta-analysis

Short sleep or insufficient sleep are significant health concerns among patients with inflammatory bowel disease (IBD). Although an association between sleep quality and disease activity has been reported, findings have been inconsistent. The aim of this systematic review and meta-analysis was to assess the association between sleep quality and disease activity in IBD patients by reviewing findings from cross-sectional and prospective cohort studies. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a systematic search was conducted in five electronic databases from inception to May 2020. Studies that examined the relationship between sleep quality and disease activity in IBD patients were screened for eligibility. Six studies were included for the analysis. Sleep quality was measured using subjective questionnaires in six studies and objective methods in three studies. Disease activity was diagnosed following standard guidelines. A significant association between subjective sleep quality and disease activity was observed (pooled OR = 3.52, 95%CI:1.82,6.83, P < 0.001). A significant association between sleep efficiency and disease activity was observed as well (pooled OR = 4.55, 95%CI:1.92,10.75, P = 0.001). Findings from this study indicate that both subjective and objective poor sleep quality were associated with an increased risk for disease activity. Larger studies with an experimental design are warranted to confirm the effects of sleep quality on intestinal pathological changes in IBD patients.