@article {784, title = {Polysomnography performed in the unattended home versus the attended laboratory setting--Sleep Heart Health Study methodology.}, journal = {Sleep}, volume = {27}, year = {2004}, month = {2004 May 01}, pages = {536-40}, abstract = {

STUDY OBJECTIVE: To compare polysomnographic recordings obtained in the home and laboratory setting.

DESIGN AND SETTING: Multicenter study comparing unsupervised polysomnography performed in the participant{\textquoteright}s home with polysomnography supervised at an academic sleep disorders center, using a randomized sequence of study setting. Sleep Heart Health Study (SHHS) standardized polysomnographic recording and scoring techniques were used for both settings.

PARTICIPANTS: 64 of 76 non-SHHS participants recruited from 7 SHHS field sites who had both a laboratory and home polysomnogram meeting acceptable quality criteria.

MEASUREMENTS AND RESULTS: Median sleep duration was greater in the home than in the laboratory (375 vs 318 minutes, respectively, P < .0001) as was sleep efficiency (86\% vs 82\%, respectively, P < .0024). Very small, but significant increases in percentage of rapid eye movement sleep and decreases in stage 1 sleep were noted in the laboratory. Employing multiple definitions of respiratory disturbance index (RDI), median RDI was similar in both settings (for example, RDI with 3\% desaturation: home 12.4, range 0.6-67; laboratory 9.5, range 0.1-93.4, P = .41). Quartile analysis of laboratory RDI showed moderate agreement with home RDI measurements. Based on the mean of laboratory and home RDI and using a cutpoint of 20, there was a biphasic distribution, with the RDI 3\% above 20 being more common in the recordings performed in the laboratory than in the home and below 20 being more common in the recordings performed in the home than in the laboratory. These differences could not be attributed to quality of recording, age, sex, or body mass index.

CONCLUSIONS: Using SHHS methodology, median RDI was similar in the unattended home and attended laboratory setting with differences of small magnitude in some sleep parameters. Differences in RDI between settings resulted in a rate of disease misclassification that is similar to repeated studies in the same setting.

}, keywords = {Adult, Aged, Body Mass Index, Clinical Laboratory Techniques, Cohort Studies, Health Status, Home Care Services, Humans, Middle Aged, Polysomnography, Sleep Apnea Syndromes, Sleep, REM}, issn = {0161-8105}, doi = {10.1093/sleep/27.3.536}, author = {Iber, Conrad and Redline, Susan and Kaplan Gilpin, Adele M and Quan, Stuart F and Zhang, Lin and Gottlieb, Daniel J and Rapoport, David and Resnick, Helaine E and Sanders, Mark and Smith, Philip} } @article {800, title = {Sleep-disordered breathing, glucose intolerance, and insulin resistance: the Sleep Heart Health Study.}, journal = {Am J Epidemiol}, volume = {160}, year = {2004}, month = {2004 Sep 15}, pages = {521-30}, abstract = {

Clinic-based studies suggest that sleep-disordered breathing (SDB) is associated with glucose intolerance and insulin resistance. However, in the available studies, researchers have not rigorously controlled for confounding variables to assess the independent relation between SDB and impaired glucose metabolism. The objective of this study was to determine whether SDB was associated with glucose intolerance and insulin resistance among community-dwelling subjects (n=2,656) participating in the Sleep Heart Health Study (1994-1999). SDB was characterized with the respiratory disturbance index and measurements of oxygen saturation during sleep. Fasting and 2-hour glucose levels measured during an oral glucose tolerance test were used to assess glycemic status. Relative to subjects with a respiratory disturbance index of less than 5.0 events/hour (the reference category), subjects with mild SDB (5.0-14.9 events/hour) and moderate to severe SDB (> or =15 events/hour) had adjusted odds ratios of 1.27 (95\% confidence interval: 0.98, 1.64) and 1.46 (95\% confidence interval: 1.09, 1.97), respectively, for fasting glucose intolerance (p for trend < 0.01). Sleep-related hypoxemia was also associated with glucose intolerance independently of age, gender, body mass index, and waist circumference. The results of this study suggest that SDB is independently associated with glucose intolerance and insulin resistance and may lead to type 2 diabetes mellitus.

}, keywords = {Aged, Blood Gas Analysis, Body Constitution, Body Mass Index, Cohort Studies, Confounding Factors, Epidemiologic, Cross-Sectional Studies, Diabetes Mellitus, Type 2, Fasting, Female, Glucose Intolerance, Glucose Tolerance Test, Humans, Insulin Resistance, Linear Models, Male, Middle Aged, Multivariate Analysis, Oxyhemoglobins, Polysomnography, Research Design, Risk Factors, Severity of Illness Index, Sleep Apnea Syndromes}, issn = {0002-9262}, doi = {10.1093/aje/kwh261}, author = {Punjabi, Naresh M and Shahar, Eyal and Redline, Susan and Gottlieb, Daniel J and Givelber, Rachel and Resnick, Helaine E} } @article {858, title = {Sleepiness in patients with moderate to severe sleep-disordered breathing.}, journal = {Sleep}, volume = {28}, year = {2005}, month = {2005 Apr}, pages = {472-7}, abstract = {

BACKGROUND: Population-based studies suggest that complaints of sleepiness are absent in many individuals with sleep-disordered breathing. We investigated the prevalence of sleepiness as well as factors associated with sleepiness in individuals with moderate to severe sleep-disordered breathing (apnea-hypopnea index > or = 15).

DESIGN: Cross-sectional study.

SETTING: The Sleep Heart Health Study.

PARTICIPANTS: Sleep Heart Health Study participants (N = 6440).

MEASUREMENTS AND RESULTS: Sleepiness was defined as an Epworth Sleepiness Scale score >10 or a report of at least frequently feeling unrested or sleepy. Forty-six percent of participants with moderate to severe sleep-disordered breathing (n = 1149) reported sleepiness. Characteristics associated with sleepiness after adjustment for confounders included presence of respiratory disease, shorter self-reported weekday and weekend sleep, sleep durations, complaints of insufficient sleep, complaints of sleep maintenance insomnia, early morning awakening, habitual snoring, and complaints of awakening with leg cramps or leg jerks. Some respiratory polysomnography measures were associated with sleepiness, but sleep-stage percentages and measures of sleep disruption were not.

CONCLUSIONS: In this community-based cohort, subjective sleepiness is absent in many individuals with significant sleep-disordered breathing. Comorbid conditions, including respiratory disease, sleep restriction, insomnia, and nocturnal leg complaints, are important risk factors for sleepiness in individuals with moderate to severe sleep-disordered breathing.

}, keywords = {Aged, Body Mass Index, Cohort Studies, Cross-Sectional Studies, Disorders of Excessive Somnolence, Female, Humans, Male, Middle Aged, Oxygen, Polysomnography, Prevalence, Risk Factors, Severity of Illness Index, Sleep Apnea Syndromes, Sleep Arousal Disorders, Sleep Stages, Surveys and Questionnaires}, issn = {0161-8105}, doi = {10.1093/sleep/28.4.472}, author = {Kapur, Vishesh K and Baldwin, Carol M and Resnick, Helaine E and Gottlieb, Daniel J and Nieto, F Javier} } @article {915, title = {Association of usual sleep duration with hypertension: the Sleep Heart Health Study.}, journal = {Sleep}, volume = {29}, year = {2006}, month = {2006 Aug}, pages = {1009-14}, abstract = {

STUDY OBJECTIVES: Limited experimental data suggest that sleep restriction acutely elevates blood pressure; however, little is known about the relationship between usual sleep duration and hypertension. This study assesses the relationship between usual sleep duration and hypertension in a community-based cohort.

DESIGN: Cross-sectional observational study.

SETTING: The Sleep Heart Health Study, a community-based prospective study of the cardiovascular consequences of sleep-disordered breathing.

PARTICIPANTS: Two thousand eight hundred thirteen men and 3097 women, aged 40 to 100 years.

INTERVENTIONS: None.

MEASUREMENTS AND RESULTS: Usual weekday and weekend sleep durations were obtained by questionnaire, and their weighted average were categorized as less than 6, 6 to less than 7, 7 to less than 8, 8 to less than 9, and 9 or more hours per night. Hypertension was defined as a systolic blood pressure of 140 mm Hg or greater, a diastolic blood pressure of 90 mm Hg or greater, or use of medication to treat hypertension. The relationship between sleep duration and hypertension was examined using categorical logistic regression with adjustment for age, sex, race, apnea-hypopnea index, and body mass index. Compared to subjects sleeping 7 to less than 8 hours per night, those sleeping less than 6 and between 6 and 7 hours per night had adjusted odds ratios for hypertension of 1.66 (95\% confidence interval 1.35-2.04) and 1.19 (1.02-1.39), respectively, whereas those sleeping between 8 and 9 and 9 or more hours per night had adjusted odds ratios for hypertension of 1.19 (1.04-1.37) and 1.30 (1.04-1.62), respectively (p < .0001 for association of sleep duration with hypertension). These associations persisted when analyses were further adjusted for caffeine and alcohol consumption, current smoking, insomnia symptoms, depression symptoms, sleep efficiency, and prevalent diabetes mellitus or cardiovascular disease.

CONCLUSIONS: Usual sleep duration above or below the median of 7 to less than 8 hours per night is associated with an increased prevalence of hypertension, particularly at the extreme of less than 6 hours per night.

}, keywords = {Adult, Aged, Aged, 80 and over, Body Mass Index, Cohort Studies, Comorbidity, Cross-Sectional Studies, Female, Health Surveys, Humans, Hypertension, Male, Middle Aged, Odds Ratio, Prospective Studies, Sleep, Sleep Apnea, Obstructive, Sleep Deprivation, Statistics as Topic}, issn = {0161-8105}, doi = {10.1093/sleep/29.8.1009}, author = {Gottlieb, Daniel J and Redline, Susan and Nieto, F Javier and Baldwin, Carol M and Newman, Anne B and Resnick, Helaine E and Punjabi, Naresh M} } @article {937, title = {Association of physical activity with sleep-disordered breathing.}, journal = {Sleep Breath}, volume = {11}, year = {2007}, month = {2007 Sep}, pages = {149-57}, abstract = {

This study was performed to determine whether there is a protective association between participation in vigorous or vigorous/moderately vigorous physical activity and the prevalence of sleep-disordered breathing (SDB). Polysomnographic and questionnaire data from the baseline examination of 4,275 participants in the Sleep Heart Health Study (SHHS) were analyzed in relation to information on amount of physical activity and other potentially relevant factors collected from five SHHS parent cohorts (Atherosclerosis Risk in Communities Study, Cardiovascular Health Study, Framingham Heart Study, Strong Heart Study, and Tucson Epidemiologic Study of Airways Obstructive Diseases). Logistic regression models were fitted to determine if amount and strenuousness of physical activity was associated with the presence of SDB. At least 3 h per week of vigorous physical activity reduced the odds of SDB, defined as a respiratory disturbance index (RDI) of at least 15 apneas/hypopneas per hour (Adjusted OR, 0.68; 95\%CI, 0.51-0.91). A qualitatively similar but slightly weaker association was observed when SDB was defined as a RDI > or = 10 per hour (Adjusted OR, 0.81; 95\%CI, 0.64-1.02). These findings remained after adjustment for sleepiness and restricting analyses to participants with good health. Three or more hours of moderately vigorous or vigorous physical activity also appeared to confer some protection against SDB, but these associations were weaker. Gender- and obesity-stratified analyses suggested that the protective association between physical activity and SDB occurred primarily in men and those who were obese. A program of regular vigorous physical activity of at least 3 h per week may be a useful adjunctive treatment modality for SDB, but this association needs confirmation with a prospective clinical trial.

}, keywords = {Adult, Cardiac Rehabilitation, Cardiovascular Diseases, Cohort Studies, Exercise, Female, Humans, Longitudinal Studies, Male, Middle Aged, Obesity, Polysomnography, Pulmonary Disease, Chronic Obstructive, Pulmonary Ventilation, Risk Factors, Sex Factors, Sleep Apnea Syndromes, Sleep Apnea, Obstructive, Sleep Stages, Weight Loss}, issn = {1520-9512}, doi = {10.1007/s11325-006-0095-5}, author = {Quan, Stuart F and O{\textquoteright}Connor, George T and Quan, Jason S and Redline, Susan and Resnick, Helaine E and Shahar, Eyal and Siscovick, David and Sherrill, Duane L} } @article {1043, title = {Fasting glycemia in sleep disordered breathing: lowering the threshold on oxyhemoglobin desaturation.}, journal = {Sleep}, volume = {31}, year = {2008}, month = {2008 Jul}, pages = {1018-24}, abstract = {

STUDY OBJECTIVES: Commonly used definitions of sleep-disordered breathing (SDB) are based on identifying discrete events of breathing abnormalities during sleep that are accompanied by an oxyhemoglobin desaturation (delta SaO2) of at least 4\%. However, it is not known whether disordered breathing events with oxyhemoglobin desaturation less than 4\% are associated with clinical sequelae such as abnormalities in fasting glycemia.

DESIGN: Cross-sectional study.

SUBJECTS AND SETTING: Participants from the Sleep Heart Health Study (SHHS) with a fasting glucose measurement made within a year of the baseline polysomnogram.

MEASUREMENTS AND RESULTS: SDB severity was defined using the apnea-hypopnea index (AHI) and the hypopnea index (HI) by counting events with different levels of oxyhemoglobin desaturation (0.0\%-1.9\%, 2.0\%-2.9\%, 3.0\%-3.9\%, > or = 4.0\%). Fasting glucose levels were used to classify individuals into normal (<100 mg/dL), impaired (100-125 mg/dL), and diabetic (> or = 126 mg/dL) groups. Ordinal logistic regression was used to determine the adjusted relative odds of an abnormal glucose value across quartiles of the hypopnea index, independent of factors such as age, body mass index, waist circumference, and usual sleep duration. The prevalence of impaired and diabetic fasting glucose in the analytical sample was 32.9\% and 5.8\%, respectively. The covariate-adjusted relative odds of impaired or diabetic fasting glucose in the highest versus the lowest AHI quartile was 1.35 (95\% CI: 1.04-1.76) for events with a delta SaO2 > or = 4.0\%, 1.72 (95\% CI: 1.20-2.48) for events with a delta SaO2 between 3.0\%-3.9\%, 1.41 (95\% CI: 1.07-1.86) for events with a delta SaO2 between 2.0\%-2.9\%, and 1.07 (95\% CI: 0.84-1.37) for events with a delta SaO2 between 0.0\%-1.9\%. The corresponding odds ratios for the HI were 1.47 (95\% CI: 1.13-1.92), 2.25 (95\% CI: 1.59-3.19), 1.44 (95\% CI: 1.09-1.90), and 1.15 (95\% CI: 0.90-1.47), respectively.

CONCLUSIONS: The results of this study indicate that SDB events accompanied by oxyhemoglobin desaturation of between 2\% to 4\% are associated with fasting hyperglycemia. These findings suggest that milder degrees of SDB may predispose to adverse metabolic outcomes.

}, keywords = {Aged, Blood Glucose, Body Mass Index, Cohort Studies, Cross-Sectional Studies, Diabetes Mellitus, Type 2, Fasting, Female, Humans, Male, Middle Aged, Odds Ratio, Oxygen, Oxyhemoglobins, Polysomnography, Reference Values, Sleep Apnea, Obstructive}, issn = {0161-8105}, author = {Stamatakis, Katherine and Sanders, Mark H and Caffo, Brian and Resnick, Helaine E and Gottlieb, Dan J and Mehra, Reena and Punjabi, Naresh M} } @article {1018, title = {Sleep-disordered breathing and cardiovascular disease: an outcome-based definition of hypopneas.}, journal = {Am J Respir Crit Care Med}, volume = {177}, year = {2008}, month = {2008 May 15}, pages = {1150-5}, abstract = {

RATIONALE: Epidemiologic studies on the consequences of sleep-disordered breathing invariably use the apnea-hypopnea index as the primary measure of disease severity. Although hypopneas constitute a majority of disordered breathing events, significant controversy remains about the best criteria used to define these events.

OBJECTIVES: The current investigation sought to assess the most appropriate definition for hypopneas that would be best correlated with cardiovascular disease.

METHODS: A community sample of middle-aged and older adults was recruited as part of the Sleep Heart Health Study. Full-montage polysomnography was conducted and hypopneas were defined using different thresholds of oxyhemoglobin desaturation with and without arousals. Prevalent cardiovascular disease was assessed based on self-report. Logistic regression analysis was used to characterize the independent association between the hypopnea index and prevalent cardiovascular disease.

MEASUREMENTS AND MAIN RESULTS: Using a sample of 6,106 adults with complete data on cardiovascular disease status and polysomnography, the current study found that hypopneas associated with an oxyhemoglobin desaturation of 4\% or more were associated with prevalent cardiovascular disease independent of confounding covariates. The adjusted prevalent odds ratios for quartiles of the hypopnea index using a 4\% desaturation criterion were as follows: 1.00 (<1.10 events/h), 1.10 (1.01-3.20 events/h), 1.33 (3.21-7.69 events/h), and 1.41 (>7.69 events/h). Hypopnea measures based on less than 4\% oxyhemoglobin desaturation or presence of arousals showed no association with cardiovascular disease.

CONCLUSIONS: Hypopneas comprise a significant component of sleep-disordered breathing in the general community. By varying the criteria for defining hypopneas, this study demonstrates that hypopneas with a desaturation of at least 4\% are independently associated with cardiovascular disease. In contrast, no association was observed between cardiovascular disease and hypopneas associated with milder desaturations or arousals.

}, keywords = {Aged, Apnea, Cardiovascular Diseases, Cohort Studies, Female, Humans, Male, Middle Aged, Odds Ratio, Oxyhemoglobins, Polysomnography, Sleep Apnea Syndromes, Terminology as Topic}, issn = {1535-4970}, doi = {10.1164/rccm.200712-1884OC}, author = {Punjabi, Naresh M and Newman, Anne B and Young, Terry B and Resnick, Helaine E and Sanders, Mark H} } @article {1105, title = {Polysomnographic and health-related quality of life correlates of restless legs syndrome in the Sleep Heart Health Study.}, journal = {Sleep}, volume = {32}, year = {2009}, month = {2009 Jun}, pages = {772-8}, abstract = {

STUDY OBJECTIVES: Sleep disturbance is the primary clinical morbidity of restless legs syndrome (RLS). To date, sleep disturbance in RLS has been measured in (1) clinical samples with polysomnography (PSG) or (2) population-based samples by self-report. The objective of this study was to analyze sleep by PSG in a population-based sample with symptoms of RLS.

DESIGN: Cross-sectional observational study.

SETTING: Community-based.

PARTICIPANTS: 3433 older men and women.

INTERVENTIONS: None.

MEASUREMENTS AND RESULTS: RLS was evaluated using an 8-item self-administered questionnaire based on NIH diagnostic criteria and required symptoms occurring > or = five times per month and associated with at least moderate distress. Health-related quality of life (HRQOL) was determined using the SF-36. Unattended, in-home PSG was performed. Data were assessed using general linear models with adjustment for demographic, health-related variables, and apnea-hypopnea index (AHI). Subjects with RLS had longer adjusted mean sleep latency (39.8 vs 26.4 min, P < 0.0001) and higher arousal index (20.1 vs 18.0, P = 0.0145) than those without RLS. Sleep latency increased progressively as the frequency of RLS symptoms increased from 5-15 days per month to 6-7 days per week. No differences in sleep stage percentages were observed between participants with and without RLS. Subjects with RLS also reported poorer HRQOL in all physical domains as well as in the Mental Health and Vitality domains.

CONCLUSIONS: These novel PSG data from a nonclinical, community-based sample of individuals with RLS document sleep disturbance in the home even in individuals with intermittent symptoms.

}, keywords = {Adult, Aged, Cohort Studies, Comorbidity, Cross-Sectional Studies, Female, Humans, Male, Middle Aged, Polysomnography, Prospective Studies, Quality of Life, Restless Legs Syndrome, Sleep Initiation and Maintenance Disorders, Statistics as Topic}, issn = {0161-8105}, author = {Winkelman, John W and Redline, Susan and Baldwin, Carol M and Resnick, Helaine E and Newman, Anne B and Gottlieb, Daniel J} }