Including Sleep Health in Cardiovascular Health Scores Could Predict CVD Risk

An improved score to assess cardiovascular health (CVH) that included sleep health was more effective in predicting the risk of cardiovascular disease (CVD) in older adults in the United States, according to a new study published in Journal of the American Heart Association.

Health sleep is not included in the American College of Cardiology/American Heart Association (AHA) CVD prevention guidelines, even though sleep is regarded as 1 of the 3 pillars of health. The present study's researchers investigated whether adding healthy sleep to the AHA Life Simple 7 (LS7) test that assesses CVH was the best measure for predicting the risk of CVD.

The researchers used the Multi-Ethnic Study of Atherosclerosis (MESA) for data for this study. Patients enrolled in Exam 5, which took place from 2010 to 2012, participated in the sleep study that included single overnight polysomnography, 7-day wrist actigraphy, and validated questionnaires.

All participants had an actigraphy performed for 7 consecutive days that evaluated duration, efficiency, and regularity; a sleep duration of 7 to 9 hours was deemed sufficient. Overnight polysomnography was also conducted, insomnia was assessed with the Women’s Health Initiative Insomnia Rating Scale, and the Epworth Sleepiness Scale was used to measure daytime sleepiness.

Operationalizing the CVH scores was done by collecting information on CVH metrics. Participants who developed CVD at or before the sleep exam were classified as prevalent cases (n = 95) whereas patients who received a CVD diagnosis after the sleep exam were considered incident cases (n = 93). The mean follow-up was 4.4 years.

The mean (SD) age of the overall 1920 participants was 69 (9) years, 54% were female, 40% were White, 27% were Black, 23% were Hispanic, and 10% were Chinese. Seventy-three percent of the participants were overweight and 18% had diabetes. The mean LS7 score was 7.3, and the means of the CVH scores that included sleep ranged from 7.4 to 7.8.

The actigraphy found that 63% of participants slept for less than 7 hours and 30% slept for less than 6 hours. Thirty-nine percent and 25% of participants, respectively, had high night-to-night variability in sleep duration and sleep onset timing respectively; 14% and 36% had excessive daytime sleepiness and high insomnia symptoms, respectively.

Linear models found that longer sleep duration and higher sleep efficiency were associated with higher LS7 scores, while lower LS7 scores were associated with greater daytime sleepiness, high night-to-night variability in sleep duration and sleep timing, and moderate to severe obstructive sleep apnea (OSA). Logistic models found that short sleep (odds ratio [OR], 1.25; 95% CI, 1.01-1.55), high night-to-night variability in sleep duration (OR, 1.24; 95% CI, 1.02-1.51) and sleep timing (OR, 1.31; 95% CI, 1.04-1.64), and moderate to severe OSA (OR, 2.21; 95% CI, 1.78-2.73) were associated with greater odds of poor CVH.

Participants in the highest tertile of the LS7 score had 75% lower odds of CVD (OR, 0.25; 95% CI, 0.13-0.49) vs those in the lowest. Participants in the highest tertile of CVH score 1, including sleep duration, and CVH score 2 had 71% (OR, 0.29; 95% CI, 0.16-0.54) and 80% (OR, 0.20; 95% CI, 0.10-0.41) lower odds of prevalent CVD, respectively. Participants in the highest tertile of CVH score 3, which included studied sleep characteristics associated with CV risk, and CVH score 4, which studied sleep regularity and sleep characteristics as novel sleep-related risk factors, had 68% (OR, 0.32; 95% CI, 0.17-0.60) and 67% (OR, 0.33; 95% CI, 0.18-0.59) lower odds of CVD.

A Cox proportional hazards model found that participants in the highest tertile of CVH score 1 had a 43% lower risk of CVD (HR, 0.57; 95% CI, 0.33-0.97) compared with the lowest tertile. Participants in the highest tertile of CVH score 4 also had 47% lower risk of CVD (HR, 0.53; 95% CI, 0.32-0.89).

There were some limitations of this study: There were few cases of CVD in the follow-up period, and there was limited ability to properly test for subgroup differences in sex, race, and ethnicity. In addition, the full picture of an individual’s sleep health may not have been captured in the sleep health scores.

The researchers concluded that including sleep health in CVH scores could help to more accurately predict participants who could develop CVD in the future.

Reference

Makarem N, Castro-Diehl C, St-Onge MP, et al. Redefining cardiovascular health to include sleep: prospective associations with cardiovascular disease in the MESA Sleep Study. J Am Heart Assoc. Published online October 19, 2022. doi:10.1161/jaha.122.025252