©AP

Short sleep time – a modifiable risk factor for prehypertension and hypertension

Aleksander PrejbiszDepartment of Hypertension

Institute of Cardiology

Warsaw, Poland

Venice, 23rd February 2018

©AP

©APCirculation, November 2011

©AP

Normal hypnogram

W

1

REM

2

3

4

0 1 2 3 4 5 6 7 8 heures

©AP

W

1

REM

2

3

4

0 1 2 3 4 5 6 7 8 heures

Sleep fragmentation

quality of sleep

©AP

W

1

REM

2

3

4

0 1 2 3 4 5 6 7 8 heures

Shortening of the sleep time

sleep time

©AP

SLEEP

DISORDERS

Consequences of Sleep Disruption. Muncey, Aaron R., MD, Murray and Nadel's Textbook of Respiratory Medicine, 87, 1547-1551.e

sleep quality sleep quantity

©APAJ©AP

Short sleep time– a modifiable riskfactor forprehypertensionand hypertension

Obstructive sleep apnea

Insomnia

Short sleep time

Shift-work

©APAJ©AP

Short sleep time– a modifiable riskfactor forprehypertensionand hypertension

Obstructive sleep apnea

Insomnia

Short sleep time

Shift-work

©AP

Sleep timeIntermittent hypoxia

Sleep apnea Short sleep time Insomnia

after Pepin JL i wsp. 2010 modified

Sleep disorders and hypertension

Microarousals↓ sleep quality

Sympathetic activity

Endothelial dysfunction

Inflammation Oxidative

stressAcute

symp. surges

Night-time hypertension

Daytime hypertension

©AP

AHI 113 / h

T< 90% - 57,3%

min SaO2 – 46%, śr SaO2 – 85%

Polysomnography – obstructive sleep apnea

©APAJ©AP

Short sleep time– a modifiable riskfactor forprehypertensionand hypertension

Obstructive sleep apnea

Insomnia

Short sleep time

Shift-work

©AP

Insomnia – subjective patent’s feeling that

that the quality of sleep is inadequate

or that the sleep is not refreshing

Insomnia is associated with negative impact on daytime activities

(Zorick, 1989)

„O sleep, O gentle sleep,Nature's soft nurse, how have I frighted thee,That thou no more wilt weigh my eyelids downAnd steep my sense in forgetfulness?”William ShakespeareHenry IV, Part I

Insomnia

©AP

▪ Population sample – 1206 subjects

▪ Athens Insomnia Scale

▪ Frequency of insomnia: 30.7 %

Frequency of insomnia – population of one Warsaw’s district

POL-MONICA BIS 2001

Piwoński J et al. 2003

©AP

-20

-18

-16

-14

-12

-10

-8

-6

-4

-2

0

Systolic BP Diastolic BP

%

With insomnia Bez bezsenności

P<0,01

P<0,01

Prejbisz A, Kabat M, Januszewicz A et al. Blood Pressure 2006

Untreated hypertensive subjects – night-time blood pressure decline

– patients with insomnia vs those without insomnia

©AP

Anxiety

disorders

Primary

insomnia

INSOMNIA

Depression

Chronic

somatic

diseases

Secondary

©APVgontzas AN et al. Sleep 2009

Insomnia with objective short sleep durationis associated with a high risk for hypertension

©APGangwisch JE et al. Am J Hypertens 2009

Insomnia and sleep durationas mediators of relationship between depressionand hypertension incidence

©APLa Y et al. Hypertension. 2015;65:644-650

Insomnia with physiological hyperarousalis associated with hypertension

©APNadciśnienie Tętnicze 2014, tom 18, nr 4, strony: 182–193

YES

YES

NO

NO

Insomnia

Hypertension

Wak

e t

ime

aft

er

sle

ep

on

set

(%)

Relationship between insomnia and sleep quality and structure in patients with hypertension

©AP

Sofietal.EurJPrevCardiol.2014Jan;21(1):57-64

13studies122501subjectfreeofCVDFollow-up3-20years

©APAmerican Journal of Hypertension 30(3) March 2017 319

Sleep to Lower Elevated Blood Pressure: A Randomized Controlled Trial (SLEPT)

web-delivered sleep intervention (sleep–hygiene education, stimulus control, and cognitive behavioral therapy)8 weeks follow-up

©APAJ©AP

Short sleep time– a modifiable riskfactor forprehypertensionand hypertension

Obstructive sleep apnea

Insomnia

Short sleep time

Shift-work

©AP

0

1

2

3

4

5

6

7

8

9

1910 1975 2005

9

7.56.8

SLEE

P D

UR

ATI

ON

(H

)

National Sleep Fundation. Sleep in America Poll "05

Mean sleep duration- USA 1910 2005

-2h

©APCirculation 2008

Obniżonym wskaźnikem skuteczności snu

Adolescents – age 13 – 16 years (n=238)Relationship between prehypertension and:

Krótkim czasem snu (≤6,5h)

Low sleep efficiency

Short sleep time (≤6,5h)

Sleep quality and elevated BP in adoescents

©AP

Relationship between short sleep time and HT – meta-analysis

Sleep Medicine 14 (2013) 324–332

Epidemiological evidence for the link between sleep duration and high BP

©APJ Am Heart Assoc. 2017;6:e005947. DOI: 10.1161/JAHA.117.005947

Sleep duration – relation with CVD morbidity and mortality- meta-analysis – 57 studies

7 hours 7 hours

©APFernandez-Mendoza J i wsp. Journal of Hypertension 2017

Sleep duration modifiesthe relationship between HT and mortality

©APSchmid, Sebastian M, MD, Lancet Diabetes & Endocrinology, The, Volume 3, Issue 1, 52-62

©APAJ©AP

Short sleep time– a modifiable riskfactor forprehypertensionand hypertension

Obstructive sleep apnea

Insomnia

Short sleep time

Shift-work

POL-FOKUS study

©AP

Pol-Fokus Study

Sleep disorders in hypertensive subjects

ESH 2017

High risk of OSA

• STOP-Bang questionnaire

Insomnia

• Athens Insomnia Scale ≥8 points

Short sleep duration

• Mean <6 hours – last 6 months

©AP

Pol-Fokus Study

Prevalence of sleep disorders in patients with resistant HT

ESH 2017

31.1%

43.7%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

40.0%

45.0%

50.0%

RHT (-) RHT (+)

OSA

32.7%

41.2%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

40.0%

45.0%

RHT (-) RHT (+)

INSOMNIA

11.3%

17.1%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

14.0%

16.0%

18.0%

RHT (-) RHT (+)

SHORT SLEEP TIME

©AP

Pol-Fokus Study

Factors related with resistant HT

ESH 2017

High risk of OSA 1.38

Insomnia 1.32

©APAJ©AP

Short sleep time– a modifiable riskfactor forprehypertensionand hypertension

Obstructive sleep apnea

Insomnia

Short sleep time

Shift-work

©AP

Shift-work and risk of HT

2010, 2013

©APJ Hypertens 2005; 23:2173-2178

Progression of hypertension- relation to shift-work

6495 men with mild HT – steel factoryFollow-up 1991 - 2001

©APJ Hypertens 2017; 35:1929-1937

Relationship between shift-workand nighttime work and HT

Cohort studies

Shfit-work > Nighttime work

Cross-sectional studies

©APAJ©AP

Short sleep time– a modifiable riskfactor forprehypertensionand hypertension

Obstructive sleep apnea

Insomnia

Short sleep time

Shift-work

medice, cura te ipsum ……

©APN Engl J Med 2004;351:1829-37.

85h/week 65h/week

Eliminating interns’ extended work shifts increasedsleep and decreased attentional failures during night work hours

©APN Engl J Med 2004;351:1829-37.

Eliminating interns’ extended work shifts increasedsleep and decreased attentional failures during night work hours

Sleep duration and work durationSleep duration

„Attentional Failures”

©APEuropean Heart Journal (2009) 30, 2606–2613

Arrhytmias- frequency during night-time shifts

0,5 vs 0,0

©AP

High risk of near-crash driving events followingnight-shift work

Lee i wsp. PNAS 2016

Postsleep drive

Postnight-shift drive

Postsleep drive

Postnight-shift drive

Postsleep drive

Postnight-shift drive

©AP

Der Bach singt voller Wohllaut durch das Dunkel.Die Blumen blassen im Dämmerschein.Die Erde atmet voll von Ruh' und Schlaf.Alle Sehnsucht will nun träumen,Die müden Menschen geh'n heimwärts,Um im Schlaf vergess'nes GlückUnd Jugend neu zu lernen!Die Vögel hocken still in ihren Zweigen.Die Welt schläft ein