Chest
Volume 152, Issue 2, August 2017, Pages 435-444
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Contemporary Reviews in Sleep Medicine
Insomnia and Risk of Cardiovascular Disease

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Insomnia is the most prevalent sleep disorder in the United States and has high comorbidity with a number of cardiovascular diseases (CVDs). In the past decade, a number of observational studies have demonstrated an association between insomnia and incident cardiovascular disease (CVD) morbidity and mortality, including hypertension (HTN), coronary heart disease (CHD), and heart failure (HF). Despite some inconsistencies in the literature, likely due to variations in how insomnia is defined and measured, the existing data suggest that insomnia, especially when accompanied by short sleep duration, is associated with increased risk for HTN, CHD and recurrent acute coronary syndrome, and HF. Purported mechanisms likely relate to dysregulation of the hypothalamic-pituitary axis, increased sympathetic nervous system activity, and increased inflammation. This paper reviews the most recent studies of insomnia and CVD and the potential pathophysiological mechanisms underlying this relationship and highlights the need for randomized trials to further elucidate the nature of the relationship between insomnia and CVD.

Section snippets

Defining and Measuring Insomnia

Several diagnostic systems have used varying definitions of insomnia, which may have contributed to inconsistencies in clinical practice and research. The current classification of insomnia in the newest editions of both the International Classification of Sleep Disorders, 3rd edition, and the Diagnostic and Statistical Manual of Mental Disorders, 5th edition, have attempted to clarify past nosologies by simplifying the insomnia criteria. The previous classification systems had differentiated

Insomnia and CVD Pathophysiology: Underlying Mechanisms

Although the pathogenesis of insomnia and CVD is not fully understood, there are multiple mechanisms underlying this relationship, including dysregulation of the hypothalamic-pituitary axis (HPA) axis,24, 35, 36, 37, 38 abnormal modulation of the autonomic nervous system, and increased sympathetic nervous system (SNS) activity,39 increased systemic inflammation,40, 41 and increased atherogenesis19, 42 (Fig 1). Chronic insomnia is considered a state of conditioned hyperarousal43 and thought to

Hypertension

Existing research mostly supports an association between insomnia and incident HTN.6, 7, 8, 9, 61 One of the largest prospective epidemiologic studies, from the Penn State cohort, followed 786 individuals with chronic insomnia who were free of baseline HTN for 7½ years. Participants were recruited from a random general community sample and underwent PSG at baseline. Chronic insomnia was defined as a complaint of insomnia for ≥ 1 year. After adjustment for numerous potential confounders, chronic

Coronary Heart Disease

A number of prospective observational studies have demonstrated that insomnia is associated with increased risk of CHD, recurrent ACS, and mortality.10, 11, 12, 13, 14, 15, 16 Further, there is a high prevalence of insomnia among patients with comorbid CHD: an astounding one third of patients presenting with initial ACS during and after hospitalization report insomnia.15

One of the first large prospective population studies associating insomnia with incident CHD was the Nord-Trondelag Health

Heart Failure

There is a high prevalence of insomniac symptoms among patients with HF, ranging from 23% to 73%. There are many reasons insomnia may be a result of HF, such as disease-related anxiety and depression, medications, and Cheyne-Stokes respiration. There are also longitudinal data from some,17, 65 although not all, studies66 that have reported insomnia to precede the onset of HF. In a middle-aged prospective cohort of 2,322 men, self-reported symptoms of insomnia predicted increased risk of

Insomnia and Overall CVD Risk and Mortality

Several studies have also reported that insomnia is associated with both CVD risk and CVD mortality. A systematic review and meta-analysis of prospective cohort studies showed that 122,501 subjects free of baseline CVD disease with insomnia (assessed using a questionnaire) had a 45% increased risk (95% CI, 1.29-1.62) of the development of or death from CVD during a 3- to 20-year follow-up.67 Another meta-analysis of 17 cohort studies with 311,260 subjects free of baseline CVD demonstrated a

Unanswered Questions

Variations in the measurement and definition of insomnia continue to be a research challenge despite attempts at expert consensus regarding the best means of identifying and defining insomnia for research purposes. There is a need to further clarify the roles of short sleep duration vs poor sleep quality on CVD and to better define subgroups at increased risk. Future research may benefit from attempting to dissect the distinct as well as overlapping influences of insomnia and short sleep

Acknowledgments

Financial/nonfinancial disclosures: None declared.

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    FUNDING/SUPPORT: This work was supported by National Institutes of Health Grant [NIH 5T32HL007901].

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