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Sleep and the Heart

Sleep and the Heart. Barbara Phillips, MD, MSPH Sept 3, 2009. Sleep and the Heart. Overview of sleep Sleep duration and outcomes Insomnia and the heart What about napping?. States of Being. Wake. NREM Sleep. REM Sleep. EEG States of Being.

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Sleep and the Heart

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  1. Sleep and the Heart Barbara Phillips, MD, MSPH Sept 3, 2009

  2. Sleep and the Heart • Overview of sleep • Sleep duration and outcomes • Insomnia and the heart • What about napping?

  3. States of Being Wake NREM Sleep REM Sleep

  4. EEG States of Being

  5. Normal Human Sleep • Normal sleep latency: 20-30 minutes • Normal sleep structure • 75% nREM • 5% stage 1 • 50% stage 2 • 15-25 % stage 3 (slow wave sleep, aka “delta” sleep) • 25% REM • Napping occurs at the beginning and the end of life (in our culture)

  6. Physiologic Variable Heart rate Respiratory rate Blood pressure Skeletal muscle tone Brain 02 consumption Ventilatory response Temperature Sexual changes NREMREM Regular Irregular Regular Irregular Regular Variable Preserved Absent Reduced Increased Normal Reduced Normal Poikilothermic Rare Frequent REM vs. nREM Sleep

  7. REM vs. nREM Sleep • nREM: a stable time • Physical restoration • Driven by homeostatic pressure • Quiet brain, active body • The deepest stage of nREM is Stage 3, also known as Slow Wave or Delta sleep • REM: an unstable time • Mental restoration • Driven by circadian pressure • Active brain, quiet body

  8. Sleep and the Heart: non REM • Stage 1 • Stable autonomic regulation • Marked sinus arrhythmia • Stage 2 • Bursts of sympathetic activity • Increased HR and BP • Stage 3/4 (SWS) • Decline in muscle sympathetic activity • Slow HR and low BP • A very stable state

  9. Sleep and the Heart: REM • REM • Increased sympathetic activity • Variable heart rate and blood pressure • Sinus arrest at REM onset • An unstable state

  10. Recumbency • Lying down increases cardiac filling pressures • Increased sympathetic activation • Lying down increases upper airway edema in patients with CHF • Worsens pre-existing obstructive sleep apnea

  11. Overall Cardiovascular Response to Normal Sleep • Fall in epinephrine • Fall in heart rate • Fall in blood pressure (“morning dip”) • Fall in cortisol (until 5 a.m.) • HRV (LF/HF) falls • Sympathetic activity declines • Overall arrhythmogenicity falls

  12. Circadian Variation in Cardiovascular Events (Marler Stroke, 1989)

  13. Sleep and the Heart • Overview of sleep • Sleep duration and outcomes • Insomnia and the heart • What about napping?

  14. How Much Sleep is Enough?(Kripke D, Arch Gen Psych 2002n= 480, 841 men)

  15. Sleep Duration and Death (Patel SR, Sleep 2004, n=82,969)

  16. Sleep Duration and Coronary Heart Disease in Women (Ayas et al, 2003, n=71,617)

  17. OR for Hypertension by Sleep Duration in the SHHS (n=2,813; mean age, 63) (Gottlieb DJ, Sleep 2006) Adjusted for age, race, sex, AHI, and BMI

  18. Sleep Duration and Obesity (Taheri S, PLoS 2004, WSCS, n=1024))

  19. Sleep Duration and Hypertension(Gangwisch J, Am Heart J 2006)

  20. HR for Hypertension, Adjusted(Gangwisch J, Am Heart J 2006)

  21. Sleep Duration and Incident Coronary Artery Calcification (King R, JAMA, 2008, from the CARDIA Study)

  22. Results from the CARDIA Study • These participants were younger (mean age about 40 years) than most previous studies of sleep duration and outcomes. • One more hour of sleep reduced the estimated odds of calcification by 33%. • This relationship appeared linear, rather than U-shaped.

  23. BP Over 5 Years by Sleep Duration and Maintenance in the CARDIA Study (n = 505) Knutson K Arch Intern Med 2009 Adjusted for age, race, and sex , and excluding those hypertensive at baseline .

  24. Sleep Characteristics by Race and Gender (n=699) From the CARDIA Study(Lauderdale DS, Am J Epidemiol. 2006)

  25. Sleep Duration and Outcomes • Optimum sleep duration appears to be 7-8 hours. • Risk with short sleep greatest for younger people. • Risk for long sleep greatest for older people.

  26. Sleep and the Heart • Overview of sleep • Sleep duration and outcomes • Insomnia and the heart • What about napping?

  27. Insomnia and the Heart • Older studies suggest insomnia is associated with increased risk of coronary heart disease, hypertension, death, etc, etc. • Most studies of insomnia have not controlled for other important risk factors, notably depression. • Insomnia has a variable and subjective definition, which limits its reliability as a predictor of anything!

  28. Definition of Insomnia(NIH, 2005) • Difficulty falling asleep (DFA) • Difficulty maintaining sleep (DMS) • Waking up too early (WASO, EMA) • (Nonrestorative or poor-quality sleep) • May include daytime impact

  29. Epidemiology (NIH) Although chronic insomnia is considered to be common… Conclusive evidence from epidemiologic studies has been limited by their different definitions of chronic insomnia and by the lack of standardized…screening methods. Population-based studies suggest that about 30 percent of the general population has complaints of sleep disruption, while approximately 10 percent has associated symptoms of daytime functional impairment…

  30. Consequence of Insomnia? (NIH) “Insomnia usually appears in the presence of at least one other disorder. Particularly common comorbidities are major depression, generalized anxiety, substance abuse, attention deficit/hyperactivity in children, dementia, and a variety of physical problems. The research diagnostic criteria for insomnia recently developed by the American Academy of Sleep Medicine indeed share many of the criteria of major depressive disorder. Explaining this overlap requires a study that determines how often insomnia precedes the disorders with which it is associated and continues to exist after the other disorders are cured or go into temporary remission.”

  31. Methods: Population • The Atherosclerosis Risk in Communities (ARIC) participants • Multicenter cohort, aged 44-69 years • Examinations, interviews, questionnaires at intake (1987-1989) and approximately every 3 years afterward • We used data from 2nd visit as baseline, and survival at follow-up (mean, 6.3 + 1.1 years) as a dependent variable.

  32. Methods: Variables • Three sleep complaints were available as part of the Maastricht questionnaire: • “Do you often have trouble falling asleep?” (difficulty falling asleep, DFA) • “Do you wake up repeatedly during the night?” (sleep continuity disturbance, SCD) • “Do you ever wake up with a feeling of exhaustion and fatigue?” (nonrestorative sleep, NRS) • We defined insomnia as difficulty falling asleep or staying asleep, plus nonrestorative sleep.

  33. Methods: Analysis • We identified prevalence of and predicted death by • Insomnia • Hypnotic use • We used Cox proportional hazard regression models using the SUDAAN procedure SURVIVAL to account for differential follow-up • We also performed logistic regression analysis of the factors predicting insomnia. • We controlled for an extensive list of variables.

  34. Results: 13,564 Participants n (%) Age 45-49: 1477 (10.9) 50-54: 3670 (27.1) 55-59: 3515 (25.9) 60-65: 3181 (23.5) 65-69: 1720 (12.7) Sex: Female 7482 (55.2) Premenopausal: 774 (5.7) Race Black: 3213 (23.7) White: 10350 (76.3)

  35. Results: Participantsn (%) Education • < 12 Years: 2906 (21.4) • 12 Years: 4474 (33.0) • > 12 Years: 6183 (45.6) • Body Mass Index • < 20: 399 (2.9) • 20-24: 3833 (28.3) • 25-29: 5417 (39.9) • >30: 3914 (28.9)

  36. Results: Participants • Depression 30.5% • Cardiac Disease 12.5% • Abnormal Lung Function: 45.2% • Hypertension 35.4% • Diabetes 14.7%

  37. Results: Participants • Smoking Status % • Current Smoker 24.7 • Former Smoker 37.7 • Never Smoker 37.7 • Alcohol Intake % • Heavy 5.0 • Moderate 29.0 • Light 22.8 • Former 20.8 • Never 22.4

  38. Results: Participants • Hypnotic Use % • Barbiturates 0.3 • Antihistamines 0.8 • Benzodiazepines 1.1 • None 97.8

  39. Insomnia Complaints % • Difficulty falling asleep 21.5 • Waking up repeatedly 38.5 • Nonrestorative sleep 35.0 • All of the above 9.6 • Insomnia * 23.0 (DFA OR SCD PLUS NRS)

  40. Risk Factors for Insomnia OR (CI) • Female gender (vs. male) 1.78 (1.42,2.22) • Annual income: < $50,000 1.23 (1.09,1.40) • Depression 5.05 (4.60-5.55) • Heart disease 1.89 (1.67-2.14) • Severe airflow obstruction 1.61 (1.17-2.22) • Pulmonary symptoms 1.71 (1.50-1.95) • Restrictive lung disease 1.27 (1.10-1.47)

  41. Risk Factors for Death at 6 Years (N=709) • Age • Male gender • Less than high school education • BMI < 20 • Diabetes • Depression • Heart disease • Severe pulmonary disease or symptoms • Current or former cigarette smoking • Former or never alcohol use • ..but NOT insomnia

  42. Risk for Death • After controlling for covariates, insomnia was not associated with an increased risk of death at 6.3 year follow-up. • After controlling only for depression, insomnia was not associated with an increased risk of death. • Use of hypnotics was not associated with increased risk of death.

  43. Does Insomnia Kill? • Insomnia doesn’t kill, but many of the factors associated with it do. • Sleeping pills don’t appear to kill, either, though this data set did not include many who used sleeping pills.

  44. Do Insomnia Complaints Cause Hypertension or Cardiovascular Disease? (Phillips BA, Mannino DM, JCSM, 2005) • Endorsement of all three sleep complaints predicted a slightly increased risk of cardiovascular disease (OR 1.5, 1.1-2.0), but not of hypertension. • Endorsement of either DFA or SCA predicted slightly increased risk of hypertension (OR 1.2, 1.03-1.3) • Conclusions: The definition of insomnia affects its impact.

  45. The Cardiovascular Health Study (CHS) (Phillips Sleep 2009) • Hypothesis: Sleep complaints predict incident hypertension, particularly in African Americans. • Design: Secondary analysis of an existing dataset (the Cardiovascular Health Study, CHS) • Setting: Community-based study over a 6 year period of follow-up.

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