Sleep duration-associated CV risk dependent on sex and race

Sleep duration and risk of incident stroke by age, sex, and race The REGARDS study

Literature - Petrov ME, Howard G, Grandner MA, Kleindorfer D et al. - Neurology 2018;00:e1-e8

Introduction and methods

Sleep duration may contribute to risk of stroke [1] and this relationship may be dependent on demographic factors, such as age, sex and race [2]. Previous data suggest that short sleep duration partially modifies the relationship between race (black vs. white adults) and incident stroke symptoms [3], and that short or long sleep duration may be related to excess risk of poor cardiometabolic risk status among black adults [4-9]. However, only few studies assessed race differences on the effect of sleep duration on risk of stroke. This study investigated the sleep duration-stroke relationship and determined whether age, sex, race and combinations of these factors modified this relationship.

The Reasons for Geographic and Racial Differences in Stroke REGARDS (REGARDS) study is a US-population based cohort investigating stroke incidence and mortality among 30,239 black and white participants aged ≥45 years. This subanalysis of the REGARDS study (n=16,733) included subjects that completed an ancillary sleep module and who were free of physician-diagnosed stroke and obstructive sleep apnea at the time of sleep module completion.

Habitual sleep duration was assessed based on questions regarding their habitual sleep duration on weekdays and weekends. Participants were categorized based on a weighted average of the duration on weekdays and weekends: <6 hours (short duration), 6.0 - 6.9, 7.0 - 8.9 (reference group) and ≥9 hours (long duration). Stroke events were identified every 6 months via telephone interview and medical records associated with these events were retrieved and physician-adjudicated.

Main results

  • There was no interaction between sleep duration and age (P=0.92) or sleep duration and sex in the demographic model (P=0.31).
  • After multivariable adjustment, an interaction was observed between sleep duration and race (P=0.018).
  • Short sleep duration was associated with reduced risk for stroke in black participants (HR: 0.48, 95%CI: 0.28–0.83, P<0.05) and with increased risk for stroke in white participants (HR: 1.64,95%CI: 1.09–2.45, P<0.05). This increased risk of stroke in white individuals was attenuated after adjustment for risk factors of stroke (HR: 1.40, 95%CI: 0.91–2.13).
  • After multivariable adjustment, there was an interaction between sleep duration and race–sex groups (P=0.028).
  • Short sleep duration was associated with decreased risk for stroke in black men (HR: 0.20, 95%CI: 0.06–0.66, P<0.05) and long sleep duration was associated with increased risk for stroke in white men (HR: 1.96, 95%CI: 1.25–3.09, P<0.05), which remained after adjustment for stroke risk factors and hypertension.
  • Interaction between sleep duration and race-sex group became non-significant (P=0.074) when participants at high risk for sleep-disordered breathing were omitted from analysis.


Short sleep duration (<6 hours) was associated with decreased risk of incident stroke in black men, whereas long sleep duration (≥9 hours) was associated with increased risk for stroke in white men, suggesting that short and long sleep duration may have differing consequences depending on race and sex. These data underscore the need for mechanistic, longitudinal research of the sleep duration-stroke relationship by demographic subgroups. Furthermore, it may be clinically advisable to assess and monitor middle-aged adult patient with long sleep duration, particularly white men, for CV risk.


1. Howard G, Cushman M, Kissela BM, et al. Traditional risk factors as the underlying cause of racial disparities in stroke: lessons from the half full (empty?) glass. Stroke 2011;42:3369–3375.

2. Leng Y, Cappuccio FP, Wainwright NW, et al. Sleep duration and risk of fatal and nonfatal stroke:a prospective study and meta-analysis. Neurology 2015;84:1072–1079.

3. Petrov ME, Letter AJ, Howard VJ, Kleindorfer D. Self-reported sleep duration in relation to incident stroke symptoms: nuances by body mass and race from the REGARDS study. J Stroke Cerebrovasc Dis 2014;23:e123–132.

4. Zizi F, Pandey A, Murrray-Bachmann R, et al. Race/ethnicity, sleep duration, and diabetes mellitus: analysis of the National Health Interview Survey. Am J Med 2012; 125:162–167.

5. Knutson KL, Van Cauter E, Rathouz PJ, et al. Association between sleep and blood pressureinmidlife:theCARDIAsleepstudy.ArchInternMed2009;169:1055–1061.

6. GrandnerMA,ChakravortyS,PerlisML,OliverL,GurubhagavatulaI.Habitualsleep duration associated with self-reported and objectively determined cardiometabolic risk factors. Sleep Med 2014;15:42–50.

7. Hill AN, Williams NJ, Salifu I, et al. The role of race/ethnicity and gender in the association between inadequate sleep and hypercholesterolemia. J Sleep Disord Ther 2015;4:194.

8. Ceïde ME, Pandey A, Ravenell J, Donat M, Ogedegbe G, Jean-Louis G. Associations of short sleep and shift work status with hypertension among black and white Americans. Int J Hypertens 2015;2015:697275.

9. Vishnu A, Shankar A, Kalidindi S. Examination of the association between insufficient sleep and cardiovascular disease and diabetes by race/ethnicity.IntJEndocrinol2011; 2011:789358.

Find this article online at Neurology

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