In the JournalsPerspective

Less than 6 hours of sleep per night increases atherosclerosis risk

Deepak L. Bhatt
Deepak L. Bhatt

Elevated risk for subclinical multiterritory atherosclerosis occurred in patients with short sleep time or fragmented sleeping, according to findings in the Journal of the American College of Cardiology.

The researchers sought to evaluate the association of actigraphy-measured sleep parameters with subclinical atherosclerosis in an asymptomatic middle-aged population. Interactions among sleep, conventional risk factors, psychosocial factors, dietary habits and inflammation were also studied.

Sleep and CV risk

“Sleep deficiency is highly prevalent in Western societies, and epidemiological studies suggest that not only short but also long sleep duration is related to an increased cardiovascular risk,” Fernando Dominguez, MD, PhD, of the Spanish National Center for Cardiovascular Research in Madrid, and colleagues wrote.

The 7-day actigraphic recording was performed on 3,974 participants (mean age, 46 years; 62.6% men) from the PESA study, with four defined groups: less than 6 hours of sleep, 6 to 7 hours of sleep, 7 to 8 hours of sleep (the reference group) and more than 8 hours of sleep.

Dominguez and colleagues performed carotid and femoral 3D vascular ultrasound and cardiac CTA to quantify noncoronary atherosclerosis and coronary calcification.

After adjustment for conventional risk factors, very short sleep duration was associated with higher atherosclerotic burden with 3D vascular ultrasound (OR = 1.27; 95% CI, 1.06-1.52) compared with the reference group, researchers wrote.

Dominguez and colleagues identified that participants in the highest quintile of sleep fragmentation had a higher prevalence of multiple affected noncoronary territories (OR = 1.34; 95% CI, 1.09-1.64) compared with those in the lowest quintile.

The researchers identified no differences in coronary artery calcification scores among the four sleeping groups.

“Overall, our findings support the potential role of healthy sleeping in protecting against atherosclerosis. Thus, recommending a good sleep hygiene should be part of the lifestyle modifications provided in our daily clinical practice,” Dominguez and colleagues wrote.

Pillar of health

In a related editorial, Daniel J. Gottlieb, MD, MPH, director of the Sleep Disorders Center at the VA Boston Healthcare System, associate physician in the division of sleep and circadian disorders, departments of medicine and neurology, Brigham and Women’s Hospital and associate professor of medicine at Harvard Medical School, and Deepak L. Bhatt, MD, MPH, executive director of interventional cardiology programs at Brigham and Women’s Hospital, professor of medicine at Harvard Medical School and Cardiology Today’s Intervention Chief Medical Editor, wrote: “The potentially enormous impact of sleep deprivation and disruption on population health, reinforced by the present study, is ample justification for such trials, which are needed to place sleep with confidence alongside diet and exercise as a key pillar of a healthy lifestyle.” – by Earl Holland Jr.

Disclosures: Dominguez reports no relevant financial disclosures. Bhatt reports he has financial ties with numerous pharmaceutical and device companies. Gottlieb reports he is a consultant for Advance Medical and T. Leland Seeger and Associates and has received research funding from ResMed Corp. Please see the study for all other authors’ relevant financial disclosures.

Deepak L. Bhatt
Deepak L. Bhatt

Elevated risk for subclinical multiterritory atherosclerosis occurred in patients with short sleep time or fragmented sleeping, according to findings in the Journal of the American College of Cardiology.

The researchers sought to evaluate the association of actigraphy-measured sleep parameters with subclinical atherosclerosis in an asymptomatic middle-aged population. Interactions among sleep, conventional risk factors, psychosocial factors, dietary habits and inflammation were also studied.

Sleep and CV risk

“Sleep deficiency is highly prevalent in Western societies, and epidemiological studies suggest that not only short but also long sleep duration is related to an increased cardiovascular risk,” Fernando Dominguez, MD, PhD, of the Spanish National Center for Cardiovascular Research in Madrid, and colleagues wrote.

The 7-day actigraphic recording was performed on 3,974 participants (mean age, 46 years; 62.6% men) from the PESA study, with four defined groups: less than 6 hours of sleep, 6 to 7 hours of sleep, 7 to 8 hours of sleep (the reference group) and more than 8 hours of sleep.

Dominguez and colleagues performed carotid and femoral 3D vascular ultrasound and cardiac CTA to quantify noncoronary atherosclerosis and coronary calcification.

After adjustment for conventional risk factors, very short sleep duration was associated with higher atherosclerotic burden with 3D vascular ultrasound (OR = 1.27; 95% CI, 1.06-1.52) compared with the reference group, researchers wrote.

Dominguez and colleagues identified that participants in the highest quintile of sleep fragmentation had a higher prevalence of multiple affected noncoronary territories (OR = 1.34; 95% CI, 1.09-1.64) compared with those in the lowest quintile.

The researchers identified no differences in coronary artery calcification scores among the four sleeping groups.

“Overall, our findings support the potential role of healthy sleeping in protecting against atherosclerosis. Thus, recommending a good sleep hygiene should be part of the lifestyle modifications provided in our daily clinical practice,” Dominguez and colleagues wrote.

Pillar of health

In a related editorial, Daniel J. Gottlieb, MD, MPH, director of the Sleep Disorders Center at the VA Boston Healthcare System, associate physician in the division of sleep and circadian disorders, departments of medicine and neurology, Brigham and Women’s Hospital and associate professor of medicine at Harvard Medical School, and Deepak L. Bhatt, MD, MPH, executive director of interventional cardiology programs at Brigham and Women’s Hospital, professor of medicine at Harvard Medical School and Cardiology Today’s Intervention Chief Medical Editor, wrote: “The potentially enormous impact of sleep deprivation and disruption on population health, reinforced by the present study, is ample justification for such trials, which are needed to place sleep with confidence alongside diet and exercise as a key pillar of a healthy lifestyle.” – by Earl Holland Jr.

Disclosures: Dominguez reports no relevant financial disclosures. Bhatt reports he has financial ties with numerous pharmaceutical and device companies. Gottlieb reports he is a consultant for Advance Medical and T. Leland Seeger and Associates and has received research funding from ResMed Corp. Please see the study for all other authors’ relevant financial disclosures.

    Perspective
    Rami Khayat

    Rami Khayat

    The relationship between sleep restriction and poor CV outcomes has been recognized for some time. The American Heart Association issued a scientific statement in 2016 (St-Onge MP, et al. Circulation. 2016;doi:10.1161/CIR.0000000000000444) recognizing the relationship between short sleep duration and cardiometabolic risk and disease. The AHA reviewed several studies demonstrating independent association between short sleep duration and diabetes, CHD and stroke. Additionally, the relation between short sleep duration and weight gain and obesity has been recognized from experimental and epidemiological studies.

    This study made several important contributions. One was the objective measurement of sleep duration using actigraphy. Another was that the design included a method, albeit limited, to exclude individuals with obstructive sleep apnea.

    Thus far, most studies evaluating the relation between sleep restriction and cardiometabolic disease have shown independent association but not causation. This study takes the relation a step further and contributes to the evidence of strong association. However, the study does not establish that sleep restriction is a cause of subsequent development of CVD. Sleep restriction may be a marker of disease that just correlates with subsequent development of cardiometabolic disease rather than a cause of it.

    Even with these limitations, the study supports incorporation of sleep duration in health screening as a marker of CV risk. To date, there is no universally successful intervention for sleep expansion. The study lends strong support to an approach of incorporating sleep questionnaire in health screening. Attention will have to be paid to address causes of sleep restriction such as social, behavioral, or medical disorders.

    The cardiologist should incorporate questions about sleep duration in their intake. The general practitioners and cardiologists should include questions about sleep duration as well as sleep disorders in their health screening. This may be particularly important in patients who are on the metabolic syndrome spectrum and those who are being evaluated for CHD, dyslipidemia and atherosclerosis. 

    It is reasonable also to include sleep hygiene and sleep expansion education in general cardiac rehabilitation and cardiology subspecialty clinic educational materials and interventions.

    • Rami Khayat, MD
    • Professor of Medicine
      Director, Sleep Heart Program
      Ohio State University Wexner Medical Center

    Disclosures: Khayat reports no relevant financial disclosures.