@article {1499, title = {The Sleep Heart Health Study: design, rationale, and methods.}, journal = {Sleep}, volume = {20}, year = {1997}, month = {1997 Dec}, pages = {1077-85}, abstract = {

The Sleep Heart Health Study (SHHS) is a prospective cohort study designed to investigate obstructive sleep apnea (OSA) and other sleep-disordered breathing (SDB) as risk factors for the development of cardiovascular disease. The study is designed to enroll 6,600 adult participants aged 40 years and older who will undergo a home polysomnogram to assess the presence of OSA and other SDB. Participants in SHHS have been recruited from cohort studies in progress. Therefore, SHHS adds the assessment of OSA to the protocols of these studies and will use already collected data on the principal risk factors for cardiovascular disease as well as follow-up and outcome information pertaining to cardiovascular disease. Parent cohort studies and recruitment targets for these cohorts are the following: Atherosclerosis Risk in Communities Study (1,750 participants), Cardiovascular Health Study (1,350 participants), Framingham Heart Study (1,000 participants), Strong Heart Study (600 participants), New York Hypertension Cohorts (1,000 participants), and Tucson Epidemiologic Study of Airways Obstructive Diseases and the Health and Environment Study (900 participants). As part of the parent study follow-up procedures, participants will be surveyed at periodic intervals for the incidence and recurrence of cardiovascular disease events. The study provides sufficient statistical power for assessing OSA and other SDB as risk factors for major cardiovascular events, including myocardial infarction and stroke.

}, keywords = {Adult, Aged, Aged, 80 and over, Arteriosclerosis, Cohort Studies, Coronary Disease, Female, Humans, Hypertension, Longitudinal Studies, Male, Middle Aged, Polysomnography, Positive-Pressure Respiration, Prospective Studies, Research Design, Sleep Apnea Syndromes}, issn = {0161-8105}, author = {Quan, S F and Howard, B V and Iber, C and Kiley, J P and Nieto, F J and O{\textquoteright}Connor, G T and Rapoport, D M and Redline, S and Robbins, J and Samet, J M and Wahl, P W} } @article {1523, title = {Relation of sleepiness to respiratory disturbance index: the Sleep Heart Health Study.}, journal = {Am J Respir Crit Care Med}, volume = {159}, year = {1999}, month = {1999 Feb}, pages = {502-7}, abstract = {

Obstructive sleep apnea syndrome is a well recognized cause of excessive sleepiness; however, the relation of sleepiness to mild sleep-disordered breathing (SDB), which affects as much as half the adult population, is uncertain. In order to explore this relation, we conducted a cross-sectional cohort study of community-dwelling adults participating in the Sleep Heart Health Study, a longitudinal study of the cardiovascular consequences of SDB. The study sample comprises 886 men and 938 women, with a mean age of 65 (SD 11) yr. Sleepiness was quantified using the Epworth Sleepiness Scale (ESS). Sleep-disordered breathing was quantified by the respiratory disturbance index (RDI), defined as the number of apneas plus hypopneas per hour of sleep, measured during in-home polysomnography. When RDI was categorized into four groups (< 5, 5 to < 15, 15 to < 30, >/= 30), a significantly progressive increase in mean ESS score was seen across all four levels of SDB, from 7.2 (4.3) in subjects with RDI < 5 to 9.3 (4.9) in subjects with RDI >/= 30 (p < 0.001). There was no significant modification of this effect by age, sex, body mass index, or evidence of chronic restriction of sleep time or periodic limb movement disorder. The percentage of subjects with excessive sleepiness, defined as an ESS score >/= 11, increased from 21\% in subjects with RDI < 5 to 35\% in those with RDI >/= 30 (p < 0. 001). We conclude that SDB is associated with excess sleepiness in community-dwelling, middle-aged and older adults, not limited to those with clinically apparent sleep apnea.

}, keywords = {Aged, Cardiovascular Diseases, Cross-Sectional Studies, Disorders of Excessive Somnolence, Female, Humans, Male, Middle Aged, Polysomnography, Respiration, Retrospective Studies, Severity of Illness Index, Sleep Apnea Syndromes, Surveys and Questionnaires}, issn = {1073-449X}, doi = {10.1164/ajrccm.159.2.9804051}, author = {Gottlieb, D J and Whitney, C W and Bonekat, W H and Iber, C and James, G D and Lebowitz, M and Nieto, F J and Rosenberg, C E} } @article {613, title = {Association of sleep-disordered breathing, sleep apnea, and hypertension in a large community-based study. Sleep Heart Health Study.}, journal = {JAMA}, volume = {283}, year = {2000}, month = {2000 Apr 12}, pages = {1829-36}, abstract = {

CONTEXT: Sleep-disordered breathing (SDB) and sleep apnea have been linked to hypertension in previous studies, but most of these studies used surrogate information to define SDB (eg, snoring) and were based on small clinic populations, or both.

OBJECTIVE: To assess the association between SDB and hypertension in a large cohort of middle-aged and older persons.

DESIGN AND SETTING: Cross-sectional analyses of participants in the Sleep Heart Health Study, a community-based multicenter study conducted between November 1995 and January 1998.

PARTICIPANTS: A total of 6132 subjects recruited from ongoing population-based studies (aged > or = 40 years; 52.8\% female).

MAIN OUTCOME MEASURES: Apnea-hypopnea index (AHI, the average number of apneas plus hypopneas per hour of sleep, with apnea defined as a cessation of airflow and hypopnea defined as a > or = 30\% reduction in airflow or thoracoabdominal excursion both of which are accompanied by a > or = 4\% drop in oxyhemoglobin saturation) [corrected], obtained by unattended home polysomnography. Other measures include arousal index; percentage of sleep time below 90\% oxygen saturation; history of snoring; and presence of hypertension, defined as resting blood pressure of at least 140/90 mm Hg or use of antihypertensive medication.

RESULTS: Mean systolic and diastolic blood pressure and prevalence of hypertension increased significantly with increasing SDB measures, although some of this association was explained by body mass index (BMI). After adjusting for demographics and anthropometric variables (including BMI, neck circumference, and waist-to-hip ratio), as well as for alcohol intake and smoking, the odds ratio for hypertension, comparing the highest category of AHI (> or = 30 per hour) with the lowest category (< 1.5 per hour), was 1.37 (95\% confidence interval [CI], 1.03-1.83; P for trend = .005). The corresponding estimate comparing the highest and lowest categories of percentage of sleep time below 90\% oxygen saturation (> or = 12\% vs < 0.05\%) was 1.46 (95\% CI, 1.12-1.88; P for trend <.001). In stratified analyses, associations of hypertension with either measure of SDB were seen in both sexes, older and younger ages, all ethnic groups, and among normal-weight and overweight individuals. Weaker and nonsignificant associations were observed for the arousal index or self-reported history of habitual snoring.

CONCLUSION: Our findings from the largest cross-sectional study to date indicate that SDB is associated with systemic hypertension in middle-aged and older individuals of different sexes and ethnic backgrounds.

}, keywords = {Adult, Aged, Cohort Studies, Cross-Sectional Studies, Female, Humans, Hypertension, Logistic Models, Male, Middle Aged, Obesity, Polysomnography, Sleep Apnea Syndromes, Snoring}, issn = {0098-7484}, doi = {10.1001/jama.283.14.1829}, author = {Nieto, F J and Young, T B and Lind, B K and Shahar, E and Samet, J M and Redline, S and D{\textquoteright}Agostino, R B and Newman, A B and Lebowitz, M D and Pickering, T G} } @article {633, title = {The association of sleep-disordered breathing and sleep symptoms with quality of life in the Sleep Heart Health Study.}, journal = {Sleep}, volume = {24}, year = {2001}, month = {2001 Feb 01}, pages = {96-105}, abstract = {

This study assessed the extent to which sleep-disordered breathing (SDB), difficulty initiating and maintaining sleep (DIMS), and excessive daytime sleepiness (EDS) were associated with impairment of quality of life (QoL) using the SF-36. Participants (n=5,816; mean age=63 years; 52.5\% women) were enrolled in the nation-wide population-based Sleep Heart Health Study (SHHS) implemented to investigate sleep-disordered breathing as a risk factor in the development of cardiovascular disease. Each transformed SF-36 scale was analyzed independently using multiple logistic regression analysis with sleep and other potential confounding variables (e.g., age, ethnicity) included as independent variables. Men (11.6\%) were significantly more likely to have SDB compared to women (5.6\%), while women (42.4\%) were significantly more likely to report DIMS than men (32.5\%). Vitality was the sole SF-36 scale to have a linear association with the clinical categories of SDB (mild, moderate, severe SDB). However, individuals with severe SDB indicated significantly poorer QoL on several SF-36 scales. Both DIMS and EDS were strongly associated with reduced QoL even after adjusting for confounding variables for both sexes. Findings suggest 1) mild to moderate SDB is associated with reduced vitality, while severe SDB is more broadly associated with poorer QoL, 2) subjective sleep symptoms are comprehensively associated with poorer QoL, and 3) SF-36 mean score profiles for SDB and sleep symptoms are equivalent to other chronic diseases in the U.S. general population.

}, keywords = {Adult, Cardiovascular Diseases, Chronic Disease, Circadian Rhythm, Disorders of Excessive Somnolence, Female, Health Status, Humans, Male, Middle Aged, Polysomnography, Population Surveillance, Prevalence, Quality of Life, Risk Factors, Severity of Illness Index, Sleep Apnea Syndromes, United States}, issn = {0161-8105}, doi = {10.1093/sleep/24.1.96}, author = {Baldwin, C M and Griffith, K A and Nieto, F J and O{\textquoteright}Connor, G T and Walsleben, J A and Redline, S} } @article {654, title = {Relation of sleep-disordered breathing to cardiovascular disease risk factors: the Sleep Heart Health Study.}, journal = {Am J Epidemiol}, volume = {154}, year = {2001}, month = {2001 Jul 01}, pages = {50-9}, abstract = {

Associations between sleep-disordered breathing and cardiovascular disease (CVD) may be mediated by higher cardiovascular risk factor levels in those with sleep-disordered breathing. The authors examined these relations in the Sleep Heart Health Study, a multiethnic cohort of 6,440 men and women over age 40 years conducted from October 1995 to February 1998 and characterized by home polysomnography. In 4,991 participants who were free of self-reported CVD at the time of the sleep study, moderate levels of sleep-disordered breathing were common, with a median Respiratory Disturbance Index (RDI) of 4.0 (interquartile range, 1.25-10.7). The level of RDI was associated cross-sectionally with age, body mass index, waist-to-hip ratio, hypertension, diabetes, and lipid levels. These relations were more pronounced in those under age 65 years than in those over age 65. Women under age 65 years with RDI in the higher quartiles were more obese than men with similar RDI. Although the pattern of associations was consistent with greater obesity in those with higher RDI, higher body mass index did not explain all of these associations. If sleep-disordered breathing is shown in future follow-up to increase the risk for incident CVD events, part of the risk is likely to be due to the higher cardiovascular risk factors in those with higher RDI.

}, keywords = {Adult, Aged, Analysis of Variance, Cardiovascular Diseases, Chi-Square Distribution, Cross-Sectional Studies, Female, Humans, Linear Models, Longitudinal Studies, Male, Middle Aged, Polysomnography, Risk Factors, Sleep Apnea Syndromes, United States}, issn = {0002-9262}, doi = {10.1093/aje/154.1.50}, author = {Newman, A B and Nieto, F J and Guidry, U and Lind, B K and Redline, S and Pickering, T G and Quan, S F} } @article {636, title = {Sleep-disordered breathing and cardiovascular disease: cross-sectional results of the Sleep Heart Health Study.}, journal = {Am J Respir Crit Care Med}, volume = {163}, year = {2001}, month = {2001 Jan}, pages = {19-25}, abstract = {

Disordered breathing during sleep is associated with acute, unfavorable effects on cardiovascular physiology, but few studies have examined its postulated association with cardiovascular disease (CVD). We examined the cross-sectional association between sleep- disordered breathing and self-reported CVD in 6,424 free-living individuals who underwent overnight, unattended polysomnography at home. Sleep-disordered breathing was quantified by the apnea-hypopnea index (AHI)-the average number of apneas and hypopneas per hour of sleep. Mild to moderate disordered breathing during sleep was highly prevalent in the sample (median AHI: 4.4; interquartile range: 1.3 to 11.0). A total of 1,023 participants (16\%) reported at least one manifestation of CVD (myocardial infarction, angina, coronary revascularization procedure, heart failure, or stroke). The multivariable-adjusted relative odds (95\% CI) of prevalent CVD for the second, third, and fourth quartiles of the AHI (versus the first) were 0.98 (0.77-1.24), 1.28 (1.02-1.61), and 1.42 (1.13-1.78), respectively. Sleep-disordered breathing was associated more strongly with self-reported heart failure and stroke than with self-reported coronary heart disease: the relative odds (95\% CI) of heart failure, stroke, and coronary heart disease (upper versus lower AHI quartile) were 2.38 (1.22-4.62), 1.58 (1.02- 2.46), and 1.27 (0.99-1.62), respectively. These findings are compatible with modest to moderate effects of sleep-disordered breathing on heterogeneous manifestations of CVD within a range of AHI values that are considered normal or only mildly elevated.

}, keywords = {Aged, Cardiovascular Diseases, Cohort Studies, Cross-Sectional Studies, Female, Humans, Male, Middle Aged, Sleep Apnea Syndromes}, issn = {1073-449X}, doi = {10.1164/ajrccm.163.1.2001008}, author = {Shahar, E and Whitney, C W and Redline, S and Lee, E T and Newman, A B and Nieto, F J and O{\textquoteright}Connor, G T and Boland, L L and Schwartz, J E and Samet, J M} }