Physicians' Academy for Cardiovascular Education

Objectively measured poor sleep efficiency associated with MACE and CVD mortality

Objective Sleep Efficiency Predicts Cardiovascular Disease in a Community Population: The Sleep Heart Health Study

Literature - Yan B, Yang J, Zhao B et al., - J Am Heart Assoc. 2021 Mar 15;e016201. doi: 10.1161/JAHA.120.016201.

Introduction and methods

Previous studies used questionnaires to evaluate the relationship between sleep quality and risk of CVD. These studies showed that sleep quality is associated with CVD, T2DM and metabolic syndrome [1-3]. However, there is little evidence about the link between objective sleep efficiency (SE), measured by polysomnography, and CVD. This study investigated the association between objective SE and CVD using data from the Sleep Heart Health Study (SHHS).

The SHHS is a community-based, prospective cohort study investigating the consequences of sleep-disordered breathing [4]. This analysis included data from 3810 participants (mean age 63.2±11.0 years, 2097 [55%] women). Participants underwent in-home overnight polysomnography. Participants with a history of HF, MI, stroke, revascularization, or whose sleep was affected by polysomnography were excluded. SE was defined as the ratio of total time sleeping/time spent in bed and was classified into 4 groups (≥90%, 85-89.9%, 80-84.9%,<80%). Wake after sleep onset (WASO) was defined as the total time spent awake after going to sleep and categorized into 4 quartiles (Q1: <29.5 minutes; Q2: 29.5-47.0 minutes; Q3: 47.5-78.0 minutes; Q4: >78 minutes). The apnea-hypopnea index (AHI) was defined as all apnea and hypopnea episodes per hour of sleep with at least a 4% drop in oxygen saturation. The primary outcome was first occurrence of MACE, defined as CV death, CHF, MI, and stroke. The secondary outcome was MACE plus revascularization. Mean follow-up was 10.9±2.8 years from baseline polysomnography.

Main results


This analysis showed that objectively measured sleep efficiency and wake after sleep onset were associated with risk of major adverse CV events and CVD mortality.


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