At a Glance Commentary (191/200) Scientific Knowledge on the SubjectRecent studies that have assessed obstructive sleep apnea (OSA) over several consecutive nights indicate that OSA severity can vary markedly from night-to-night which may have important implications for diagnosis, management, and prevalence estimates. Prior to recent advances in non-invasive home sleep monitoring technology, it was not feasible to examine night-to-night variation in OSA severity and its potential impact on diagnostic classification and prevalence estimates over extended periods in the home setting at scale.
Study ObjectivesIncreased mortality has been reported in people with insomnia and in those with obstructive sleep apnoea (OSA). However, these conditions commonly co-occur and the combined effect of co-morbid insomnia and sleep apnoea (COMISA) on mortality risk is unknown. This study used Sleep Heart Health Study (SHHS) data to assess associations between COMISA and all-cause mortality risk.MethodsInsomnia was defined as difficulties falling asleep, maintaining sleep, and/or early morning awakenings from sleep ≥16 times a month and daytime impairment. OSA was defined as an apnoea-hypopnoea index ≥15 events/h sleep. COMISA was defined if both conditions were present. Multivariable adjusted Cox proportional hazard models were used to determine the association between COMISA and all-cause mortality (n=1210) over 15 years of follow-up.Results5236 participants were included. 2708 (52%) did not have insomnia/OSA (control), 170 (3%) had insomnia-alone, 2221 (42%) had OSA-alone, and 137 (3%) had COMISA. COMISA participants had a higher prevalence of hypertension (ORs [95%CI]; 2.00 [1.39, 2.90]) and cardiovascular disease compared to controls (1.70 [1.11, 2.61]). Insomnia-alone and OSA-alone were associated with higher risk of hypertension but not cardiovascular disease compared to controls. Compared to controls, COMISA was associated with a 47% (HR, 95% CI; 1.47 (1.06, 2.07)) increased risk of mortality. The association between COMISA and mortality was consistent across multiple definitions of OSA and insomnia.ConclusionsCo-morbid insomnia and sleep apnoea was associated with higher rates of hypertension and cardiovascular disease at baseline, and an increased risk of all-cause mortality compared to no insomnia/OSA.
Summary Insomnia and obstructive sleep apnea commonly co‐occur (co‐morbid insomnia and sleep apnea), and their co‐occurrence has been associated with worse cardiometabolic and mental health. However, it remains unknown if people with co‐morbid insomnia and sleep apnea are at a heightened risk of incident cardiovascular events. This study used longitudinal data from the Sleep Heart Health Study (N = 5803) to investigate potential associations between co‐morbid insomnia and sleep apnea and cardiovascular disease prevalence at baseline and cardiovascular event incidence over ~11 years follow‐up. Insomnia was defined as self‐reported difficulties initiating and/or maintaining sleep AND daytime impairment. Obstructive sleep apnea was defined as an apnea–hypopnea index ≥ 15 events per hr sleep. Co‐morbid insomnia and sleep apnea was defined if both conditions were present. Data from 4160 participants were used for this analysis. The prevalence of no insomnia/obstructive sleep apnea, insomnia only, obstructive sleep apnea only and co‐morbid insomnia and sleep apnea was 53.2%, 3.1%, 39.9% and 1.9%, respectively. Co‐morbid insomnia and sleep apnea was associated with a 75% (odd ratios [95% confidence interval]; 1.75 [1.14, 2.67]) increase in likelihood of having cardiovascular disease at baseline after adjusting for pre‐specified confounders. In the unadjusted model, co‐morbid insomnia and sleep apnea was associated with a twofold increase (hazard ratio, 95% confidence interval: 2.00 [1.33, 2.99]) in risk of cardiovascular event incidence. However, after adjusting for pre‐specified covariates, co‐morbid insomnia and sleep apnea was not significantly associated with incident cardiovascular events (hazard ratio 1.38 [0.92, 2.07]). Comparable findings were obtained when an alternative definition of insomnia (difficulties initiating and/or maintaining sleep without daytime impairment) was used.
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