Sleep is essential for optimal health,1 yet more than one-third of US adults report insufficient sleep2 and 50 to 70 million people in the United States experience 1 or several sleep disorders.3 Both short and long sleep (<7 or >7 hours per night, respectively) have been associated with a greater risk of all-cause mortality and cardiovascular disease (CVD).4 Evidence links hypertension, coronary heart disease, and cerebrovascular disease to both ends of the sleep duration continuum (<5–6 hours or >8–9 hours).5,6 In addition to sleep duration, irregular sleep timing is associated with cardiovascular events.7 Irregular sleep timing (differing bedtimes and rise times for 1 week)7 represents the potential for circadian misalignment. Evidence has emerged demonstrating increased CVD risk among shift workers,8 as well as rise in cardiac events after daylight saving time,9 and in individuals who have longer sleep times on weekends compared with weekdays (called social jetlag).10,11
Populations at Risk
Some populations may be at a greater risk for sleep-related CVD risk. Many factors, such as the social determinants of health and lifestyle behaviors, influence sleep. Hale and colleagues12 observed that living in disadvantaged neighborhoods was associated with poor sleep quality, sleep disruptions, and insufficient sleep. Individuals with lower income and education levels experience a shorter sleep duration,13 of which occupational characteristics may play a role.14 Living arrangements and family structure have also been noted to affect sleep. Living alone and living with high levels of environmental noise contribute to sleep deficits.12,15 Adults with children report shorter sleep than those without children living in the home.12
Lifestyle behaviors, such as smoking, alcohol consumption, and physical inactivity, also influence an individual's sleep. Those who smoke report shorter sleep durations than nonsmokers and experience more insomnia symptoms than light smokers or nonsmokers.16 Alcohol consumption in nonalcoholics may promote sleep during the first half of the sleep period but disrupts sleep during the second half, leading to impaired sleep homeostasis.17 Binge drinking further disrupts sleep homeostasis.17
Women may be at a greater risk for cardiovascular effects of sleep restriction than men. Covassin and colleagues18 reported that 9 consecutive nights of sleep restriction resulted in elevated ambulatory blood pressure, impaired endothelial function, and stimulated sympathetic response among healthy adults. Of note, elevated blood pressure occurred only in women.
The COVID-19 pandemic has altered lifestyles resulting in sleep disturbances. Sleep problems continue to be common during this pandemic, affecting roughly 40% of the general and healthcare populations.19 A longitudinal study demonstrated that midsleep times (the midpoint between bedtime and wake time), which are indicative of the circadian system, were delayed, whereas midsleep variability and resting heart rate decreased.20 Healthcare workers are the most vulnerable population in the fight against COVID-19 and its variants because they are on the front lines. Approximately 40% of physicians and 35% of nurses reported sleep disturbances,21 and 36% to 41% of nurses experienced insomnia symptoms.22 The Society of Behavioral Sleep Medicine has issued objectives and recommendations for managing sleep problems during a pandemic. These guidelines include many resources for clinicians.23
Healthy sleep requires adequate duration, regularity of timing, daytime alertness, absence of sleep disorders, and good subjective quality.1 Sleep is a potentially modifiable behavior that is critical to the promotion of health and reduction of cardiovascular risk. The American Academy of Sleep Medicine issued a position statement in June 2021. The Academy recommended that healthcare providers routinely assess sleep habits, sleep symptoms, and sleep patterns and timing during patient encounters. They recommend that sleep health be “targeted by public health and workplace interventions to improve health-related outcomes, and behaviors that help people attain healthy sleep.”24(p2) The Academy also places a major emphasis on sleep health education in schools, in community and healthcare settings, in the workplace, and in public health policy arenas. The evidence-based recommendations issued by the Academy provide a “call to action” for nurses and nursing underscoring the importance of quality and quantity of sleep across the life course of individuals. Cardiovascular nurses are well positioned in clinical and community-based settings to implement the recommendations and advocate for the promotion of sleep health for patients, healthcare providers, and the public.
1. Buysse DJ. Sleep health: can we define it? Does it matter?Sleep
2. Centers for Disease Control and Prevention. 1 in 3 adults don't get enough sleep. Centers for Disease Control and Prevention Web site. https://www.cdc.gov/media/releases/2016/p0215-enough-sleep.html
. Accessed October 24, 2021.
3. Colten HR, Altevogt BM. Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem
. Washington, DC: Institute of Medicine; 2006.
4. Yin J, Jin X, Shan Z, et al. Relationship of sleep duration with all-cause mortality and cardiovascular events: a systematic review and dose-response meta-analysis of prospective cohort studies. J Am Heart Assoc
5. Cappuccio FP, Cooper D, D'Elia L, Strazzullo P, Miller MA. Sleep duration predicts cardiovascular outcomes: a systematic review and meta-analysis of prospective studies. Eur Heart J
6. Covassin N, Singh P. Sleep duration and cardiovascular disease risk: epidemiologic and experimental evidence. Sleep Med Clin
7. Huang T, Mariani S, Redline S. Sleep irregularity and risk of cardiovascular events: the multi-ethnic study of atherosclerosis. J Am Coll Cardiol
8. Torquati L, Mielke GI, Brown WJ, Kolbe-Alexander T. Shift work and the risk of cardiovascular disease. A systematic review and meta-analysis including dose-response relationship. Scand J Work Environ Health
9. Sandhu A, Seth M, Gurm HS. Daylight savings time and myocardial infarction. Open Heart
10. Jansen EC, Dunietz GL, Chervin RD, et al. Adiposity in adolescents: the interplay of sleep duration and sleep variability. J Pediatr
11. Roenneberg T, Allebrandt KV, Merrow M, Vetter C. Social jetlag and obesity. Curr Biol
12. Hale L, Emanuele E, James S. Recent updates in the social and environmental determinants of sleep health. Curr Sleep Med Rep
13. Beydoun HA, Beydoun MA, Chen X, et al. Sex and age differences in the associations between sleep behaviors and all-cause mortality in older adults: results from the National Health and Nutrition Examination Surveys. Sleep Med
14. Ertel KA, Berkman LF, Buxton OM. Socioeconomic status, occupational characteristics, and sleep duration in African/Caribbean immigrants and US White health care workers. Sleep
15. Bjorøy I, Jørgensen VA, Pallesen S, Bjorvatn B. The prevalence of insomnia subtypes in relation to demographic characteristics, anxiety, depression, alcohol consumption and use of hypnotics. Front Psychol
16. Nuñez A, Rhee JU, Haynes P, et al. Smoke at night and sleep worse? The associations between cigarette smoking with insomnia severity and sleep duration. Sleep Health
17. Thakkar MM, Sharma R, Sahota P. Alcohol disrupts sleep homeostasis. Alcohol
18. Covassin N, Bukartyk J, Singh P, Calvin AD, St Louis EK, Somers VK. Effects of experimental sleep restriction on ambulatory and sleep blood pressure in healthy young adults: a randomized crossover study. Hypertension
19. Jahrami H, BaHammam AS, Bragazzi NL, Saif Z, Faris M, Vitiello MV. Sleep problems during the COVID-19 pandemic by population: a systematic review and meta-analysis. 2021;17(2):299–313.
20. Ong JL, Lau T, Karsikas M, Kinnunen H, Chee MWL. A longitudinal analysis of COVID-19 lockdown stringency on sleep and resting heart rate measures across 20 countries. Sci Rep
21. Salari N, Khazaie H, Hosseinian-Far A, et al. The prevalence of sleep disturbances among physicians and nurses facing the COVID-19 patients: a systematic review and meta-analysis. 2020;16(1):1–14.
22. Al Maqbali M, Al Sinani M, Al-Lenjawi B. Prevalence of stress, depression, anxiety and sleep disturbance among nurses during the COVID-19 pandemic: a systematic review and meta-analysis. J Psychosom Res
23. Crew EC, Baron KG, Grandner MA, et al. The Society of Behavioral Sleep Medicine (SBSM) COVID-19 task force: objectives and summary recommendations for managing sleep during a pandemic. Behav Sleep Med
24. Ramar K, Malhotra RK, Carden KA, et al. Sleep is essential to health: an American Academy of Sleep Medicine position statement. J Clin Sleep Med
. 2021. Jun 21. doi:10.5664/jcsm.9476. Online ahead of print.