@article {714, title = {Short-term variability of respiration and sleep during unattended nonlaboratory polysomnography--the Sleep Heart Health Study. [corrected].}, journal = {Sleep}, volume = {25}, year = {2002}, month = {2002 Dec}, pages = {843-9}, abstract = {

STUDY OBJECTIVES: To determine the short-term variability of indices of disturbed respiration and sleep during 2 nights of unattended nonlaboratory polysomnography conducted several months apart.

DESIGN: Participants were randomly selected using a block design with stratification on preliminary estimates of 2 criteria: respiratory disturbance index [RDI3\% (apnea or hypopnea events associated with > or = 3\% O2 desaturation): < 15/hour total sleep time, > or = 15/hour total sleep time] and sleep efficiency (SEff: < 85\% and > or = 85\%). The RDI and sleep data from initial and repeated polysomnography were compared.

SETTING: NA.

PARTICIPANTS: A subset of 99 participants in the Sleep Heart Health Study who agreed to have a repeat polysomnogram within 4 months of their original study.

INTERVENTIONS: NA.

MEASUREMENTS AND RESULTS: Acceptable repeat polysomnograms were obtained in 91 subjects (mean study interval: 77 +/- 18 [sd] days; range: 31-112 days). There was no significant bias in RDI between study nights using several different RDI definitions including RDI3\% and RDI4\% (apnea or hypopnea events associated with > or = 4\% O2 desaturation). Variability between studies estimated using intraclass correlations (ICC) ranged from 0.77 to 0.81. For subjects with a RDI3\% < 15, variability increased as a function of increasing RDI, but for those with a RDI3\% > or = 15, variability was constant. Body mass index, SEff, gender, or age did not directly predict RDI variability. Using RDI4\% cutpoints of < or = 5, < or = 10 and < or = 15 events per hour of sleep demonstrated that 79.1\%, 85.7\%, and 87.9\% of subjects, respectively, had the same classification of SDB status on both nights of study. There also was no significant bias in sleep staging, sleep efficiency, or arousal index between studies. However, variability was greater with ICC values ranging from 0.37 (\% time in REM) to 0.76 (arousal index).

CONCLUSION: In the Sleep Heart Health Study, accurate estimates of the severity of sleep-disordered breathing and the quality of sleep were obtained from a single night of unattended nonlaboratory polysomnography. These findings may be applicable to other large epidemiologic studies provided that similar recording techniques and quality-assurance procedures are followed.

}, keywords = {Adult, Aged, Aged, 80 and over, Apnea, Arousal, Body Mass Index, Circadian Rhythm, Electrocardiography, Electromyography, Electrooculography, Female, Humans, Male, Middle Aged, Oxygen Consumption, Polysomnography, Respiration, Sleep Apnea Syndromes, Sleep Stages, Time Factors}, issn = {0161-8105}, author = {Quan, Stuart F and Griswold, Michael E and Iber, Conrad and Nieto, F Javier and Rapoport, David M and Redline, Susan and Sanders, Mark and Young, Terry} } @article {736, title = {Recruitment of healthy adults into a study of overnight sleep monitoring in the home: experience of the Sleep Heart Health Study.}, journal = {Sleep Breath}, volume = {7}, year = {2003}, month = {2003 Mar}, pages = {13-24}, abstract = {

The Sleep Heart Health Study (SHHS) is a prospective cohort study using participants from several ongoing cardiovascular and respiratory disease research projects to investigate the relationship between sleep-disordered breathing and cardiovascular disease. This study design required unusual and different recruiting techniques to meet the study{\textquoteright}s enrollment goal of between 6000 and 6600 participants. Individuals were recruited to undergo an overnight home polysomnogram, completion of several questionnaires, and collection of a small amount of physical examination data. This article describes the methods used to recruit these participants and how these procedures influenced the final participation rate and the representativeness of SHHS to its parent cohorts. Of 30,773 people eligible for recruitment into SHHS, attempts were made to enroll 11,145 (36\%). Of those contacted, 6441 ultimately agreed to participate (58\%). Recruitment rates (38 to 91\%) varied among sites. SHHS participants were slightly younger (63.0 vs. 65.0 years, p < 0.001), had more years of education (14.1 vs. 13.7, p < 0.001), more likely to snore (34\% vs. 23\%, p < 0.001), had higher Epworth sleepiness scores (7.7 vs. 6.5, p < 0.001), slightly higher higher systolic and diastolic blood pressures (127.6/73.9 vs. 127.2/72.1, p < 0.001 for diastolic only), and a slightly higher body mass index (BMI) (28.5 vs. 27.5, p < 0.001). We conclude that it is feasible to recruit existing participants from one large-scale epidemiologic study into another with a high degree of success. However, the characteristics of the new cohort may vary in several respects from their original cohorts and therefore interpretation of study results will have to consider these differences.

}, keywords = {Adult, Body Mass Index, Cardiovascular Diseases, Catchment Area, Health, Circadian Rhythm, Cohort Studies, Disorders of Excessive Somnolence, Health Status, Home Care Services, Humans, Hypertension, Patient Selection, Polysomnography, Prospective Studies, Severity of Illness Index, Sleep Apnea Syndromes, Surveys and Questionnaires, United States}, issn = {1520-9512}, doi = {10.1007/s11325-003-0013-z}, author = {Lind, Bonnie K and Goodwin, James L and Hill, Joel G and Ali, Tauqeer and Redline, Susan and Quan, Stuart F} } @article {768, title = {The effects of age, sex, ethnicity, and sleep-disordered breathing on sleep architecture.}, journal = {Arch Intern Med}, volume = {164}, year = {2004}, month = {2004 Feb 23}, pages = {406-18}, abstract = {

BACKGROUND: Polysomnography is used to assess sleep quality and to gauge the functional effect of sleep disorders. Few population-based data are available to estimate the variation in sleep architecture across the population and the extent to which sleep-disordered breathing (SDB), a common health condition, contributes to poor sleep independent of other factors. The objective of this study was to describe the population variability in sleep quality and to quantify the independent associations with SDB.

METHODS: Cross-sectional analyses were performed on data from 2685 participants, aged 37 to 92 years, in a community-based multicenter cohort study. Dependent measures included the percentage time in each sleep stage, the arousal index, and sleep efficiency. Independent measures were age, sex, ethnicity, comorbidity status, and the respiratory disturbance index.

RESULTS: Lighter sleep was found in men relative to women and in American Indians and blacks relative to other ethnic groups. Increasing age was associated with impaired sleep in men, with less consistent associations in women. Notably, women had, on average, 106\% more slow wave sleep. Sleep-disordered breathing was associated with poorer sleep; however, these associations were generally smaller than associations with sex, ethnicity, and age. Current smokers had lighter sleep than ex-smokers or never smokers. Obesity had little effect on sleep.

CONCLUSIONS: Sleep architecture varies with sex, age, ethnicity, and SDB. Individual assessment of the effect of SDB on sleep quality needs to account for other host characteristics. Men, but not women, show evidence of poorer sleep with aging, suggesting important sex differences in sleep physiology.

}, keywords = {Adult, Age Factors, Aged, Aged, 80 and over, Body Mass Index, Comorbidity, Female, Humans, Male, Middle Aged, Multivariate Analysis, Sex Factors, Sleep, Sleep Apnea Syndromes}, issn = {0003-9926}, doi = {10.1001/archinte.164.4.406}, author = {Redline, Susan and Kirchner, H Lester and Quan, Stuart F and Gottlieb, Daniel J and Kapur, Vishesh and Newman, Anne} } @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 {833, title = {Factors associated with incidence and persistence of symptoms of disturbed sleep in an elderly cohort: the Cardiovascular Health Study.}, journal = {Am J Med Sci}, volume = {329}, year = {2005}, month = {2005 Apr}, pages = {163-72}, abstract = {

BACKGROUND: There are limited data pertaining to the factors influencing the incidence and persistence of sleep symptoms in the elderly. The purpose of this study was to determine the incidence and nonremission rates of the following sleep symptoms: trouble falling asleep (TFA), frequent awakenings (FA), and excessive daytime sleepiness (EDS) in the Cardiovascular Health Study (CHS), a prospective multicenter study of cardiovascular disease in a large cohort of elderly adults. Factors influencing these rates were assessed as well.

METHODS: 4467 participants in CHS were surveyed for the presence of TFA, FA, and EDS as well as other health problems at their baseline examination and at a follow-up examination 1 to 4 years later.

RESULTS: Annualized incidence and nonremission rates were the following: TFA (2.8\% and 15.4\%), FA (12.3\% and 22.7\%), and EDS (4.4\% and 13.4\%). Women were more likely to have incident and persistent TFA. Depression was the primary factor predicting the incidence of all three sleep symptoms. However, other health conditions, including respiratory symptoms and cardiovascular disease, and limitation in activities of daily living were important as well. Depression also was the most important factor associated with persistence of these sleep symptoms. The role of other health conditions in determining nonremission was much more limited.

CONCLUSIONS: Incidence of sleep disturbances in the elderly is related to depression, health conditions, and physical functioning. However, persistence of sleep disturbances is best predicted by the presence of depression.

}, keywords = {Aged, Cardiovascular Diseases, Cohort Studies, Depression, Female, Health Status, Humans, Incidence, Logistic Models, Male, Odds Ratio, Prevalence, Risk Factors, Sex Factors, Sleep Initiation and Maintenance Disorders, Surveys and Questionnaires}, issn = {0002-9629}, doi = {10.1097/00000441-200504000-00001}, author = {Quan, Stuart F and Katz, Ronit and Olson, Jean and Bonekat, William and Enright, Paul L and Young, Terry and Newman, Anne} } @article {857, title = {Haptoglobin phenotype, sleep-disordered breathing, and the prevalence of cardiovascular disease: the Sleep Heart Health Study.}, journal = {Sleep}, volume = {28}, year = {2005}, month = {2005 Feb}, pages = {207-13}, abstract = {

BACKGROUND: Diabetes is an independent risk factor for cardiovascular disease, and there is growing evidence that sleep-disordered breathing also may increase the risk of cardiovascular disease. The mechanism responsible for increased susceptibility of people with diabetes to cardiovascular disease is thought to share several features with sleep-disordered breathing, notably increased oxidative stress. We recently demonstrated that a particular haptoglobin phenotype that is associated with differential antioxidant activity is an independent risk factor for cardiovascular disease in individuals with diabetes. We therefore sought to determine whether sleep-disordered breathing and cardiovascular disease are more strongly associated among people with the unfavorable haptoglobin phenotype.

METHODS: We tested this hypothesis in 2612 middle-aged and older participants from the Sleep Heart Health Study. Haptoglobin phenotyping was performed by gel electrophoresis. Respiratory disturbance index was assessed by standard methods. Logistic regression analysis was performed to estimate the association between haptoglobin phenotype and cardiovascular disease, adjusting for known cardiovascular risk factors (age, sex, diabetes, smoking, lipid levels, and hypertension). Possible modification by haptoglobin phenotype of the association of sleep-disordered breathing with cardiovascular disease prevalence was explored by examining interaction terms.

RESULTS: We found no significant association between haptoglobin phenotype and prevalent cardiovascular disease in this cohort, nor were significant interactions found between haptoglobin phenotype and sleep-disordered breathing on the prevalence of cardiovascular disease.

CONCLUSIONS: Sleep-disordered breathing did not appear to interact with haptoglobin phenotype in modifying the association with prevalent cardiovascular disease in the Sleep Heart Health Study. These findings could be due to the absence of association or to survivor bias in these cross-sectional analyses.

}, keywords = {Aged, Angioplasty, Balloon, Coronary, Coronary Artery Bypass, Cross-Sectional Studies, Female, Haptoglobins, Humans, Male, Middle Aged, Myocardial Infarction, Oxidative Stress, Phenotype, Polysomnography, Prevalence, Sleep Apnea Syndromes}, issn = {0161-8105}, doi = {10.1093/sleep/28.2.207}, author = {Levy, Andrew P and Zhang, Lin and Miller-Lotan, Rachel and Redline, Susan and O{\textquoteright}Connor, George T and Quan, Stuart F and Resnick, Helaine E} } @article {839, title = {Predictors of heartburn during sleep in a large prospective cohort study.}, journal = {Chest}, volume = {127}, year = {2005}, month = {2005 May}, pages = {1658-66}, abstract = {

BACKGROUND AND AIMS: Nocturnal gastroesophageal reflux, which may result in nocturnal heartburn, has been demonstrated to be associated with a more severe form of gastroesophageal reflux disease (GERD). The aim of this study was to determine the clinical predictors of heartburn during sleep in a large prospective cohort study.

METHODS: Study subjects were members of the parent cohorts from which the Sleep Heart Health Study (SHHS) recruited participants. SHHS is a multicenter, longitudinal, cohort study of the cardiovascular consequences of sleep-disordered breathing. As part of the recruitment process, parent cohort members completed a questionnaire that permitted an assessment of the relationships between heartburn during sleep, and patient demographics, sleep abnormalities, medical history, and social habits in nine community-based parent cohorts across the United States. All variables, significant at the p < 0.05 level, were included as independent variables in multivariate logistic regression models with heartburn during sleep status included as the dependent variable

RESULTS: A total of 15,314 subjects completed the questions about heartburn during sleep, and of these, 3,806 subjects (24.9\%) reported having this symptom. In four increasingly comprehensive multivariate models, increased body mass index (BMI), carbonated soft drink consumption, snoring and daytime sleepiness (Epworth sleepiness scale score), insomnia, hypertension, asthma, and usage of benzodiazepines were strong predictors of heartburn during sleep. In contrast, college education decreased the risk of reporting heartburn during sleep.

CONCLUSIONS: Heartburn during sleep is very common in the general population. Reports of this type of symptom of GERD are strongly associated with increased BMI, carbonated soft drink consumption, snoring and daytime sleepiness, insomnia, hypertension, asthma, and usage of benzodiazepines. Overall, heartburn during sleep may be associated with sleep complaints and excessive daytime sleepiness.

}, keywords = {Aged, Body Mass Index, Carbonated Beverages, Cohort Studies, Educational Status, Female, Gastroesophageal Reflux, Heartburn, Humans, Male, Middle Aged, Multivariate Analysis, Prospective Studies, Sleep, Surveys and Questionnaires}, issn = {0012-3692}, doi = {10.1378/chest.127.5.1658}, author = {Fass, Ronnie and Quan, Stuart F and O{\textquoteright}Connor, George T and Ervin, Ann and Iber, Conrad} } @article {902, title = {Obstructive sleep apnea-hypopnea and neurocognitive functioning in the Sleep Heart Health Study.}, journal = {Sleep Med}, volume = {7}, year = {2006}, month = {2006 Sep}, pages = {498-507}, abstract = {

BACKGROUND AND PURPOSE: Obstructive sleep apnea-hypopnea (OSAH) is associated with sleep fragmentation and nocturnal hypoxemia. In clinical samples, patients with OSAH frequently are found to have deficits in neuropsychological function. However, the nature and severity of these abnormalities in non-clinical populations is less well defined.

PATIENTS AND METHODS: One hundred and forty-one participants from the Tucson, AZ and New York, NY field centers of the Sleep Heart Health Study completed a battery of neuropsychological tests for 9-40 months (mean=24 months, SD=7 months) after an unattended home polysomnogram. Sixty-seven participants had OSAH (AHI>10) and 74 did not have OSAH (control (CTL), apnea-hypopnea index (AHI)<5). In addition to the individual tests, composite variables representing attention, executive function, MotorSpeed and processing speed were constructed from the neuropsychological test battery.

RESULTS: There were no significant differences in any individual neuropsychological test or composite variable between the OSAH and CTL groups. However, when time spent with O(2) saturations less than 85\% was dichotomized into those participants in the top quartile of the distribution and those in the lower three quartiles, motor speed was significantly impaired in those who were more hypoxemic. In addition, poorer motor speed (model adjusted R(2)=0.242, P<0.001) and processing speed performance (model adjusted R(2)=0.122, P<0.001) were associated with more severe oxygen desaturation even after controlling for degree of daytime sleepiness, age, gender and educational level.

CONCLUSIONS: Mild to moderate OSAH has little impact on the selected measures of attention, executive function, motor speed and processing speed. However, hypoxemia adversely affects both motor and processing speed. These results suggest that in middle-aged to elderly adults the neuropsychological effects of clinically unrecognized mild to moderate OSAH are neither global nor large.

}, keywords = {Brain, Cognition Disorders, Continuous Positive Airway Pressure, Demography, Disorders of Excessive Somnolence, Electromyography, Electrooculography, Female, Health Status, Humans, Hypoxia, Male, Middle Aged, Neuropsychological Tests, Oxygen, Polysomnography, Severity of Illness Index, Sleep Apnea, Obstructive, Surveys and Questionnaires}, issn = {1389-9457}, doi = {10.1016/j.sleep.2006.02.005}, author = {Quan, Stuart F and Wright, Ron and Baldwin, Carol M and Kaemingk, Kristine L and Goodwin, James L and Kuo, Tracy F and Kaszniak, Alfred and Boland, Lori L and Caccappolo, Elise and Bootzin, Richard R} } @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 {996, title = {Relationship between reported and measured sleep times: the sleep heart health study (SHHS).}, journal = {J Clin Sleep Med}, volume = {3}, year = {2007}, month = {2007 Oct 15}, pages = {622-30}, abstract = {

STUDY OBJECTIVE: Subjective and objective assessments of sleep may be discrepant due to sleep misperception and measurement effects, the latter of which may change the quality and quantity of a person{\textquoteright}s usual sleep. This study compared sleep times from polysomnography (PSG) with self-reports of habitual sleep and sleep estimated on the morning after a PSG in adults.

DESIGN: Total sleep time and sleep onset latency obtained from unattended home PSGs were compared to sleep times obtained from a questionnaire completed before the PSG and a Morning Survey completed the morning after the PSG.

PARTICIPANTS: A total of 2,113 subjects who were > or = 40 years of age were included in this analysis.

MEASURES AND RESULTS: Subjects were 53\% female, 75\% Caucasian, and 38\% obese. The mean habitual sleep time (HABTST), morning estimated sleep time (AMTST), and PSG total sleep times (PSGTST) were 422 min, 379 min, and 363 min, respectively. The mean habitual sleep onset latency, morning estimated sleep onset latency, and PSG sleep onset latency were 17.0 min, 21.8 min, and 16.9 min, respectively. Models adjusting for related demographic factors showed that HABTST and AMTST differ significantly from PSGTST by 61 and 18 minutes, respectively. Obese and higher educated people reported less sleep time than their counterparts. Similarly, small but significant differences were seen for sleep latency.

CONCLUSIONS: In a community population, self-reported total sleep times and sleep latencies are overestimated even on the morning following overnight PSG.

}, keywords = {Adult, Attitude to Health, Female, Health Status, Humans, Male, Middle Aged, Polysomnography, Psychometrics, Sleep Initiation and Maintenance Disorders, Sleep Stages, Surveys and Questionnaires, Time Factors, Wakefulness}, issn = {1550-9389}, author = {Silva, Graciela E and Goodwin, James L and Sherrill, Duane L and Arnold, Jean L and Bootzin, Richard R and Smith, Terry and Walsleben, Joyce A and Baldwin, Carol M and Quan, Stuart F} } @article {1059, title = {Effect of sleep disordered breathing on the sleep of bed partners in the Sleep Heart Health Study.}, journal = {Sleep}, volume = {31}, year = {2008}, month = {2008 Oct}, pages = {1449-56}, abstract = {

OBJECTIVE: To study the sleep quality of bed partners of persons with sleep disordered breathing in a non-clinical population based sample in a home environment.

DESIGN: Cross-sectional study in a community sample.

METHODS: 110 pairs of subjects living in the same household from the Tucson, Minnesota, and Pittsburgh sites of the Sleep Heart Health Study (SHHS) were included if both partners had an in-home, unattended polysomnogram (PSG) performed as a part of SHHS exam cycle 2. Sleep disordered breathing (SDB) was considered present if the respiratory disturbance index (RDI) was > or =10 events/h and no SDB if RDI was <5 events/h. Pairs were classified according to their SDB status and assigned to one of 3 groups: 1) NoSDB-NoSDB (n = 46), 2) NoSDB-SDB (n = 42), and 3) SDB-SDB (n = 22).

RESULTS: There were no differences between the NoSDB-NoSDB and the SDB-SDB partners in their demographic, PSG, or quality of life variables. However, within the NoSDB-SDB group, NoSDB in comparison to their SDB partners weighed less (mean BMI: 26 vs. 29 kg/m2, P < 0.0003), had decreased stage 2\% (55 vs. 64, P < 0.0001), increased stage 3 and 4\% (21 vs. 11, P <0.0005) and a lower arousal index (13.8 vs. 20 events/h, P < 0.0001). When comparing the NoSDB subjects from the NoSDB-SDB group to subjects in the NoSDB-NoSDB group and to subjects in the SDB-SDB group, significant differences were seen for RDI and BMI but not for any other parameter.

CONCLUSION: In a non-clinical population based sample, the sleep quality of bed partners of SDB subjects without SDB is better than their SDB bed partner. However, their sleep quality was not different in comparison to the sleep of those without SDB who also had a bed partner without SDB.

}, keywords = {Aged, Arousal, Cohort Studies, Female, Humans, Male, Middle Aged, Polysomnography, Quality of Life, Sleep Apnea, Obstructive, Snoring, Spouses}, issn = {0161-8105}, author = {Sharief, Imran and Silva, Graciela E and Goodwin, James L and Quan, Stuart F} } @article {1125, title = {Longitudinal evaluation of sleep-disordered breathing and sleep symptoms with change in quality of life: the Sleep Heart Health Study (SHHS).}, journal = {Sleep}, volume = {32}, year = {2009}, month = {2009 Aug}, pages = {1049-57}, abstract = {

STUDY OBJECTIVES: Findings from population studies evaluating the progression and incidence of sleep disordered breathing have shown evidence of a longitudinal increase in the severity of sleep disordered breathing. The present study evaluates the association among changes in sleep disordered breathing, sleep symptoms, and quality of life over time.

DESIGN: Prospective cohort study. Data were from the Sleep Heart Health Study.

SETTING: Multicenter study.

PARTICIPANTS: Three thousand seventy-eight subjects aged 40 years and older from the baseline and follow-up examination cycles were included.

MEASUREMENTS: The primary outcomes were changes in the Physical Component Summary and Mental Component Summary scales obtained from the Medical Outcomes Study Short-Form Health Survey. The primary exposure was change in the respiratory disturbance index obtained from unattended overnight polysomnograms performed approximately 5 years apart. Other covariates included measures of excessive daytime sleepiness and difficulty initiating and maintaining sleep.

RESULTS: Mean respiratory disturbance index increased from 8.1 +/- 11 SD at baseline to 10.9 +/- 14 (P < 0.0001) at follow-up. The mean Physical Component Summary and Mental Component Summary scores were 48.5 and 54.1 at baseline and 46.3 and 54.8 at follow-up. No associations between change in respiratory disturbance index and changes in Physical Component Summary or Mental Component Summary scores were seen. However, worsening of difficulty initiating and maintaining sleep and excessive daytime sleepiness were significantly associated with lower quality of life.

CONCLUSIONS: A slight increase in severity of sleep disordered breathing was seen over 5 years; this was not associated with worsening of quality of life. However, subjective symptoms of quality of sleep and daytime sleepiness were associated with declining quality of life.

}, keywords = {Aged, Attitude to Health, Cohort Studies, Comorbidity, Disease Progression, Disorders of Excessive Somnolence, Female, Humans, Longitudinal Studies, Male, Middle Aged, Polysomnography, Quality of Life, Sleep Apnea, Obstructive, Sleep Initiation and Maintenance Disorders}, issn = {0161-8105}, author = {Silva, Graciela E and An, Ming-Wen and Goodwin, James L and Shahar, Eyal and Redline, Susan and Resnick, Helaine and Baldwin, Carol M and Quan, Stuart F} } @article {1083, title = {Prospective study of sleep-disordered breathing and hypertension: the Sleep Heart Health Study.}, journal = {Am J Respir Crit Care Med}, volume = {179}, year = {2009}, month = {2009 Jun 15}, pages = {1159-64}, abstract = {

RATIONALE: Cross-sectional epidemiologic studies show an association between sleep-disordered breathing and hypertension, but only one cohort study has examined sleep-disordered breathing as a risk factor for incident hypertension.

OBJECTIVES: To examine whether sleep-disordered breathing increases the risk of incident hypertension among persons 40 years of age and older.

METHODS: In a prospective cohort study, we analyzed data from 2,470 participants who at baseline did not have hypertension, defined as blood pressure of at least 140/90 mm Hg or taking antihypertensive medication. The apnea-hypopnea index (AHI), the number of apneas plus hypopneas per hour of sleep, was measured by overnight in-home polysomnography. We estimated odds ratios for developing hypertension during 5 years of follow-up according to baseline AHI.

MEASUREMENTS AND MAIN RESULTS: The odds ratios for incident hypertension increased with increasing baseline AHI; however, this relationship was attenuated and not statistically significant after adjustment for baseline body-mass index. Although not statistically significant, the observed association between a baseline AHI greater than 30 and future hypertension (odds ratio, 1.51; 95\% confidence interval, 0.93-2.47) does not exclude the possibility of a modest association.

CONCLUSIONS: Among middle-aged and older persons without hypertension, much of the relationship between AHI and risk of incident hypertension was accounted for by obesity. After adjustment for body mass index, the AHI was not a significant predictor of future hypertension, although a modest influence of an AHI greater than 30 on hypertension could not be excluded.

}, keywords = {Adult, Blood Pressure, Confidence Intervals, Cross-Sectional Studies, Female, Follow-Up Studies, Humans, Hypertension, Incidence, Male, Middle Aged, Odds Ratio, Polysomnography, Prognosis, Prospective Studies, Risk Factors, Sleep Apnea Syndromes, Time Factors, United States}, issn = {1535-4970}, doi = {10.1164/rccm.200712-1809OC}, author = {O{\textquoteright}Connor, George T and Caffo, Brian and Newman, Anne B and Quan, Stuart F and Rapoport, David M and Redline, Susan and Resnick, Helaine E and Samet, Jonathan and Shahar, Eyal} } @article {1215, title = {Prospective study of obstructive sleep apnea and incident coronary heart disease and heart failure: the sleep heart health study.}, journal = {Circulation}, volume = {122}, year = {2010}, month = {2010 Jul 27}, pages = {352-60}, abstract = {

BACKGROUND: Clinic-based observational studies in men have reported that obstructive sleep apnea is associated with an increased incidence of coronary heart disease. The objective of this study was to assess the relation of obstructive sleep apnea to incident coronary heart disease and heart failure in a general community sample of adult men and women.

METHODS AND RESULTS: A total of 1927 men and 2495 women > or =40 years of age and free of coronary heart disease and heart failure at the time of baseline polysomnography were followed up for a median of 8.7 years in this prospective longitudinal epidemiological study. After adjustment for multiple risk factors, obstructive sleep apnea was a significant predictor of incident coronary heart disease (myocardial infarction, revascularization procedure, or coronary heart disease death) only in men < or =70 years of age (adjusted hazard ratio 1.10 [95\% confidence interval 1.00 to 1.21] per 10-unit increase in apnea-hypopnea index [AHI]) but not in older men or in women of any age. Among men 40 to 70 years old, those with AHI > or =30 were 68\% more likely to develop coronary heart disease than those with AHI <5. Obstructive sleep apnea predicted incident heart failure in men but not in women (adjusted hazard ratio 1.13 [95\% confidence interval 1.02 to 1.26] per 10-unit increase in AHI). Men with AHI > or =30 were 58\% more likely to develop heart failure than those with AHI <5.

CONCLUSIONS: Obstructive sleep apnea is associated with an increased risk of incident heart failure in community-dwelling middle-aged and older men; its association with incident coronary heart disease in this sample is equivocal.

}, keywords = {Adult, Aged, Coronary Disease, Female, Heart Failure, Humans, Longitudinal Studies, Male, Middle Aged, Polysomnography, Proportional Hazards Models, Prospective Studies, Sleep Apnea, Obstructive, Survival Analysis}, issn = {1524-4539}, doi = {10.1161/CIRCULATIONAHA.109.901801}, author = {Gottlieb, Daniel J and Yenokyan, Gayane and Newman, Anne B and O{\textquoteright}Connor, George T and Punjabi, Naresh M and Quan, Stuart F and Redline, Susan and Resnick, Helaine E and Tong, Elisa K and Diener-West, Marie and Shahar, Eyal} } @article {1278, title = {Association of incident cardiovascular disease with progression of sleep-disordered breathing.}, journal = {Circulation}, volume = {123}, year = {2011}, month = {2011 Mar 29}, pages = {1280-6}, abstract = {

BACKGROUND: Prospective data suggest that sleep-disordered breathing enhances risk for incident and recurrent cardiovascular disease (CVD). However, a reverse causal pathway whereby incident CVD causes or worsens sleep-disordered breathing has not been studied.

METHODS AND RESULTS: A total of 2721 Sleep Heart Health Study participants (mean age 62, standard deviation=10 years; 57\% women; 23\% minority) without CVD at baseline underwent 2 polysomnograms 5 years apart. Incident CVD events, including myocardial infarction, congestive heart failure, and stroke, were ascertained and adjudicated. The relation of incident CVD to change in apnea-hypopnea index between the 2 polysomnograms was tested with general linear models, with adjustment for age, sex, race, study center, history of diabetes mellitus, change in body mass index, change in neck circumference, percent sleep time spent in supine sleep, and time between the 2 polysomnograms. Incident CVD occurred in 95 participants between the first and second polysomnograms. Compared with participants without incident CVD, those with incident CVD experienced larger increases in apnea-hypopnea index between polysomnograms. The difference in adjusted mean apnea-hypopnea index change between subjects with and without incident CVD was 2.75 events per hour (95\% confidence interval, 0.26 to 5.24; P=0.032). This association persisted after subjects with central sleep apnea were excluded. Compared with participants without incident CVD, participants with incident CVD had greater increases in both mean obstructive and central apnea indices, by 1.75 events per hour (95\% confidence interval, 0.10 to 1.75; P=0.04) and by 1.07 events per hour (95\% confidence interval, 0.40 to 1.74; P=0.001), respectively.

CONCLUSIONS: In a diverse, community-based sample of middle-aged and older adults, incident CVD was associated with worsening sleep-disordered breathing over 5 years.

}, keywords = {Aged, Cardiovascular Diseases, Disease Progression, Female, Follow-Up Studies, Humans, Incidence, Male, Middle Aged, Polysomnography, Risk Factors, Sleep Apnea Syndromes}, issn = {1524-4539}, doi = {10.1161/CIRCULATIONAHA.110.974022}, author = {Chami, Hassan A and Resnick, Helaine E and Quan, Stuart F and Gottlieb, Daniel J} } @article {1342, title = {Identification of patients with sleep disordered breathing: comparing the four-variable screening tool, STOP, STOP-Bang, and Epworth Sleepiness Scales.}, journal = {J Clin Sleep Med}, volume = {7}, year = {2011}, month = {2011 Oct 15}, pages = {467-72}, abstract = {

STUDY OBJECTIVE: The Epworth Sleepiness Scale (ESS) has been used to detect patients with potential sleep disordered breathing (SDB). Recently, a 4-Variable screening tool was proposed to identify patients with SDB, in addition to the STOP and STOP-Bang questionnaires. This study evaluated the abilities of the 4-Variable screening tool, STOP, STOP-Bang, and ESS questionnaires in identifying subjects at risk for SDB.

METHODS: A total of 4,770 participants who completed polysomnograms in the baseline evaluation of the Sleep Heart Health Study (SHHS) were included. Subjects with RDIs >= 15 and >= 30 were considered to have moderate-to-severe or severe SDB, respectively. Variables were constructed to approximate those in the questionnaires. The risk of SDB was calculated by the 4-Variable screening tool according to Takegami et al. The STOP and STOP-Bang questionnaires were evaluated including variables for snoring, tiredness/sleepiness, observed apnea, blood pressure, body mass index, age, neck circumference, and gender. Sleepiness was evaluated using the ESS questionnaire and scores were dichotomized into < 11 and >= 11.

RESULTS: The STOP-Bang questionnaire had higher sensitivity to predict moderate-to-severe (87.0\%) and severe (70.4\%) SDB, while the 4-Variable screening tool had higher specificity to predict moderate-to-severe and severe SDB (93.2\% for both).

CONCLUSIONS: In community populations such as the SHHS, high specificities may be more useful in excluding low-risk patients, while avoiding false positives. However, sleep clinicians may prefer to use screening tools with high sensitivities, like the STOP-Bang, in order to avoid missing cases that may lead to adverse health consequences and increased healthcare costs.

}, keywords = {Blood Pressure, Body Mass Index, Cohort Studies, Female, Humans, Male, Mass Screening, Middle Aged, Polysomnography, Predictive Value of Tests, Prospective Studies, Risk, ROC Curve, Sensitivity and Specificity, Severity of Illness Index, Sleep Apnea Syndromes, Snoring, Surveys and Questionnaires}, issn = {1550-9397}, doi = {10.5664/JCSM.1308}, author = {Silva, Graciela E and Vana, Kimberly D and Goodwin, James L and Sherrill, Duane L and Quan, Stuart F} } @article {1566, title = {The Impact of Sleep-Disordered Breathing on Body Mass Index (BMI): The Sleep Heart Health Study (SHHS).}, journal = {Southwest J Pulm Crit Care}, volume = {3}, year = {2011}, month = {2011 Dec 08}, pages = {159-168}, abstract = {

INTRODUCTION: It is well known that obesity is a risk factor for sleep-disordered breathing (SDB). However, whether SDB predicts increase in BMI is not well defined. Data from the Sleep Heart Health Study (SHHS) were analyzed to determine whether SDB predicts longitudinal increase in BMI, adjusted for confounding factors. METHODS: A full-montage unattended home polysomnogram (PSG) and body anthropometric measurements were obtained approximately five years apart in 3001 participants. Apnea-hypopnea index (AHI) was categorized using clinical thresholds: < 5 (normal), >= 5 to <15 (mild sleep apnea), and >= 15 (moderate to severe sleep apnea). Linear regression was used to examine the association between the three AHI groups and increased BMI. The model included age, gender, race, baseline BMI, and change in AHI as covariates. RESULTS: Mean (SD) age was 62.2 years (10.14), 55.2\% were female and 76.1\% were Caucasian. Five-year increase in BMI was modest with a mean (SD) change of 0.53 (2.62) kg/m(2) (p=0.071). A multivariate regression model showed that subjects with a baseline AHI between 5-15 had a mean increase in BMI of 0.22 kg/m(2) (p=0.055) and those with baseline AHI >= 15 had a BMI increase of 0.51 kg/m(2) (p<0.001) compared to those with baseline AHI of <5. CONCLUSION: Our findings suggest that there is a positive association between severity of SDB and subsequent increased BMI over approximately 5 years. This observation may help explain why persons with SDB have difficulty losing weight.

}, issn = {2160-6773}, author = {Brown, Mark A and Goodwin, James L and Silva, Graciela E and Behari, Ajay and Newman, Anne B and Punjabi, Naresh M and Resnick, Helaine E and Robbins, John A and Quan, Stuart F} } @article {1558, title = {Nocturia, sleep-disordered breathing, and cardiovascular morbidity in a community-based cohort.}, journal = {PLoS One}, volume = {7}, year = {2012}, month = {2012}, pages = {e30969}, abstract = {

BACKGROUND: Nocturia has been independently associated with cardiovascular morbidity and all-cause mortality, but such studies did not adjust for sleep-disordered breathing (SDB), which may have mediated such a relationship. Our aims were to determine whether an association between nocturia and cardiovascular morbidity exists that is independent of SDB. We also determined whether nocturia is independently associated with SDB.

METHODOLOGY/PRINCIPAL FINDINGS: In order to accomplish these aims we performed a cross-sectional analysis of the Sleep Heart Health Study that contained information regarding SDB, nocturia, and cardiovascular morbidity in a middle-age to elderly community-based population. In 6342 participants (age 63{\textpm}11 [SD] years, 53\% women), after adjusting for known confounders such as age, body mass index, diuretic use, diabetes mellitus, alpha-blocker use, nocturia was independently associated with SDB (measured as Apnea Hypopnea index >15 per hour; OR 1.3; 95\%CI, 1.2-1.5). After adjusting for SDB and other known confounders, nocturia was independently associated with prevalent hypertension (OR 1.23; 95\%CI 1.08-1.40; P = 0.002), cardiovascular disease (OR 1.26; 95\%CI 1.05-1.52; P = 0.02) and stroke (OR 1.62; 95\%CI 1.14-2.30; P = 0.007). Moreover, nocturia was also associated with adverse objective alterations of sleep as measured by polysomnography and self-reported excessive daytime sleepiness (P<0.05).

CONCLUSIONS/SIGNIFICANCE: Nocturia is independently associated with sleep-disordered breathing. After adjusting for SDB, there remained an association between nocturia and cardiovascular morbidity. Such results support screening for SDB in patients with nocturia, but the mechanisms underlying the relationship between nocturia and cardiovascular morbidity requires further study. MeSH terms: Nocturia, sleep-disordered breathing, obstructive sleep apnea, sleep apnea, polysomnography, hypertension.

}, keywords = {Aged, Cardiovascular Diseases, Cross-Sectional Studies, Female, Humans, Male, Middle Aged, Nocturia, Polysomnography, Sleep Apnea Syndromes}, issn = {1932-6203}, doi = {10.1371/journal.pone.0030969}, author = {Parthasarathy, Sairam and Fitzgerald, MaryPat and Goodwin, James L and Unruh, Mark and Guerra, Stefano and Quan, Stuart F} }