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ORIGINAL ARTICLE
Abstract
Elucidation of the association between short sleep duration and elevated blood pressure has implications for assessing and
managing hypertension in adults. Objective. To assess the relationship between sleep duration and blood pressure, and its role
in the etiology of hypertension. Methods. On a systematic search from MEDLINE, EMBASE, CINAHL, PEDro, PsychINFO
and grey literature were included articles with participants over 18 years, reported sleep duration, measured blood pressure or
diagnosed hypertension, and the relationship between sleep duration and blood pressure was analyzed. Results. Of 2522 articles
initially identified, 11 studies met the inclusion criteria. Sample sizes ranged from 505 to 8860 (aged 2098 years). Five studies (aged 5860 years) determined that sleep duration and blood pressure were unrelated. In younger adults, five studies
reported an association between short sleep duration and hypertension before adjustment for confounding variables; only
the findings from one study remained significant after adjustment. Two studies supported a sex association; women who sleep
less than 56 h nightly are at greater risk of developing hypertension. Conclusion. Sleep duration and blood pressure are
associated in both women and adults under 60 years. Controlled studies are needed to elucidate confounding factors and
the degree to which sleep profiles could augment diagnosis of hypertension and sleep recommendations to prevent or manage
hypertension.
Key Words: blood pressure, hypertension, sleep, sleep quality
Introduction
High blood pressure, estimated to cause 7.1 million
deaths worldwide annually (1), is a risk factor for ischemic heart disease, cerebrovascular disease, and cardiac
and renal failure (2). Over a quarter of the worlds adult
population was estimated to have hypertension in 2000;
this proportion is predicted to rise to 29% by 2025 (3).
In Canada, the 6-month healthcare cost for a single
patient with hypertension exceeds $3000, with drugs
accounting for more than 50% of the direct cost (4).
Although the need to integrate health promotion
and disease prevention strategies into biomedical care
is becoming better acknowledged in healthcare, some
authorities argue that a substantial gap persists between
knowledge and action (5). In line with this trend,
lifestyle factors and their modification are being
Correspondence: Selma Sousa Bruno, Department of Physical Therapy, Science Health Center, Federal University of Rio Grande of Norte, Natal, Brazil,
and Visiting Professor, Department of Physical Therapy, Faculty of Medicine, University of British Columbia, Canada. Tel: 55 (84) 3342 2000. Fax: (84)
3342 2001. E-mail: sbruno@ufrnet.br
(Received 13 March 2011; accepted 16 May 2011)
ISSN 0803-7051 print/ISSN 1651-1999 online 2012 Scandinavian Foundation for Cardiovascular Research
DOI: 10.3109/08037051.2011.596320
46
E. Dean et al.
American sleeps 6.7 h a night (7). Although the optimal amount of sleep that people need has been debated
(6), a growing body of evidence supports the key role
of sleep in overall health and wellbeing. Conversely,
suboptimal sleep has been associated with a myriad of
health issues including coronary heart disease (8),
immune dysfunction (9), type II diabetes (10,11),
obesity (12) and mood disorders (13).
Short-term sleep deprivation studies support that
reduced habitual sleep increases blood pressure
(14,15). Related to this body of evidence are the
results of several population-based studies that conclude sleep apnea is an independent risk factor for
hypertension (16,17), and a causal link has been proposed (18). This relationship remains to be firmly
established for the general population. If such a relationship exists, sleep prescription and sleep hygiene
counseling could be adopted as a practical, nonpharmaceutical and economical intervention to prevent or mitigate hypertension as well as promote
general health and wellbeing.
The primary purpose of this study was to conduct
a literature review to evaluate systematically the evidence
associating habitual sleep duration with blood pressure
in adults. If a firm association exists, our secondary purpose was to establish whether a direct relationship exists
between habitual short sleep duration and hypertension.
Methods
Search strategy
We performed a systematic search of MEDLINE
(1950 to present), EMBASE (1980 to present),
Duplicates removed (n = 6)
Full-text articles
reviewed (n = 19)
Articles excluded for not meeting inclusion criteria (n = 8):
Analyzed population with sleep-disordered breathing (n = 1)
Did not include participants habitual sleep duration (n = 2)
Did not analyze relationship between sleep and blood
pressure (n = 4)
Did not provide data or methods (n = 1)
Publications included
for systematic review
(n = 11)
Results
Study selection
A flow chart of the study search and selection process
appears in Figure 1. Our initial search strategy yielded
2522 articles from six resources: 990 from MEDLINE; 1038 from EMBASE; 141 from CINAHL; 138
from PsycINFO; 212 from grey literature sources; and
three from the Web of Science. After our stringent
selection process, 11 source studies resulted.
47
Study
2006
2007
2008
2006
2008
2008
2009
2008
2009
2008
2007
8
9
9
9
9
7
9
7
9
8
9
0
0
2
2
2
0
2
2
2
1
2
5
8
5
8
5
4
8
3
8
7
5
13
17
16
19
16
11
19
12
19
16
16
This review incorporates data from multiple countries, included both sexes (except one study) and most
had large sample sizes (Table II).
Measurement of habitual sleep and blood pressure
Table III compares studies with respect to measurement of habitual sleep and blood pressure measurement. All 11 source studies collected data on sleep
quantity from self-report through means of interview
or questionnaire. Two studies used wrist actigraphy
in addition to self-report to measure sleep (28,31).
Studies were inconsistent regarding attention to the
time of day for blood pressure measurement.
There were also marked inconsistencies across
studies regarding the qualifications and experience of
personnel taking blood pressure, the body position
and resting state of the subjects prior to taking blood
pressure, arm the blood pressure was taken, and
whether blood pressures were averaged (Table III).
Table III also shows detailed information on the
blood pressure and sleep data as well as hypertension
definitions. Hypertension was defined inconsistently
across the source studies.
Main findings
There was marked variability among the source studies in how they represented and reported their results
(Table IV). Studies generally compared sleep duration
with a reference group whose nightly sleep was
approximately 7 h, though the exact parameters
varied. Most studies adjusted their findings for multiple confounding variables. The significance of the
relationship between sleep duration and blood pressure often changed with adjustments suggesting a role
for mediating variables.
Age-related findings. Several studies exclusively analyzed older adults (22,28,32). Each of these studies
concluded that sleep duration is not associated with
prevalent hypertension in this population before or
Quality assessment
For the source studies, quality assessment scores derived
from the Downs and Black Quality Index appear in
Table I. The average score across all 11 studies is
15.82 2.79.
48
E. Dean et al.
Year
Bjorvatn
et al. (23)
2007
Cappuccio
et al. (30)
2007
Country
Study design
Study size
Subject age
Population source
Norway
Cross-sectional
8860
4045
UK
Cross-sectional
Longitudinal
(mean 5-year
follow-up)
Cross-sectional
3555
4222
20
Longitudinal
(810-year
follow-up)
4810
2574
USA
Cross-sectional
1214
3054
2008
Japan
Cross-sectional
4941
3660
2009
USA
Cross-sectional
578
3345
Choi et al.
(24)
2008
Korea
Gangwisch
et al. (29)
2006
USA
Hall et al.
(25)
2008
Kawada
et al. (26)
Knutson
et al. (31)
Longitudinal
(5-year
follow-up)
505 (535
for incident
hyper-tension
analysis)
1423
Lima-Costa
et al. (22)
2008
Brazil
Cross-sectional
Lopez-Garcia
et al. (32)
2009
Spain
Cross-sectional
3686
Longitudinal
(2-year
follow-up)
Comparative
cross-sectional
890
Stranges
et al. (27)
2008
UK; USA
2007
Netherlands
Cross-sectional
5058
6095
60
UK: 4569;
USA: 3579
5898
49
Study
BP measurement technique
Bjorvatn
et al. (23)
Cappuccio
et al. (30)
Choi et al.
(24)
Gangwisch
et al. (29)
Specific question
posed and/or
technique used to
analyze sleep data
Definition of htn or
high BP
Method of sleep
data collection
Averaged final 2 of
3 readings
Defined high BP as
SBP 140 mmHg
or DPB 90
mmHg
Self-report
via selfadministered
questionnaire
Averaged final 2 of
3 readings
Self-report
questionnaire
Average of 2
readings
Self-report
questionnaire
N/A
Measured 3 times
Defined htn as
SBP 140 mmHg
or DPB 90 mmHg,
or self-report of
physician diagnosis,
hospital record, or
reported cause of
death
Defined high BP as
SBP 130 mmHg,
or DBP 85 mmHg,
or use of
antihypertensive
medication
Self-report
questionnaire
How many
hours of sleep
do you usually
get a night (or
when you
usually sleep)?
Self-report
through
in-person
interview
conducted
by trained
interviewers
Calculation of BP
Hall et al.
(25)
Average of 2
readings
Kawada
et al. (26)
1. If initial reading
was under
130/85 mmHg,
then BP was not
re-measured; 2.
Measured twice
after 3 min
interval if initial
reading 130/85
mmHg; lowest
reading retained
Defined high BP as
SBP 130 mmHg
and/or 85 mmHg
Self-report
Sleep duration
calculated as
total time in bed
(from bedtime to
rise time) minus
self-reported
sleep latency;
Calculated sleep
during workweek
and during free
time
independently
How many
hours of sleep
do you have on
an average
week night?
(Continued)
50
E. Dean et al.
Definition of htn or
high BP
Method of sleep
data collection
Averaged final 2 of
3 readings
Self-report
during
clinical exam
and wrist
actigraphy
monitor
N/A
Average of 2 out of
3 readings
Self-report
LopezGarcia
et al. (32)
1. Measured 6 times at
level of heart in right arm
at 2 min intervals; 2.
Measured after 5 min
rest in seated position
using mercury
sphygmomanometer
Average of 6
readings
Stranges
et al. (27)
Averaged final 2 of
3 readings
1. Self-report
through
home based
personal
interview
at baseline;
2. Phone
interview at
follow-up
Self-report
questionnaire
Study
BP measurement technique
Calculation of BP
Knutson
et al. (31)
Lima-Costa
et al. (22)
Specific question
posed and/or
technique used to
analyze sleep data
1. Actigraphy for
three
consecutive days
on 2 occasions
approximately
1 year apart; 2.
Self-reported
questions about
sleep duration
and quality
during clinical
exam
1. During the
last month, in
the workdays
and without
considering the
weekends, at
what time did
you: lay down
to sleep; get
asleep; wake up;
leave the bed?;
2. Weekend
sleeping habits
determined by
use of similar
question to
above; 3. Usual
sleep duration
determined by
formula
How many hours
do you usually
sleep per day
(including sleep
at night and
during the
day)?
51
Study
BP measurement technique
Calculation of BP
Average of 2
readings
Definition of htn or
high BP
Defined htn as
SBP 160 mmHg, or
DBP 100 mmHg,
or current use of
antihypertensive
medication
Method of sleep
data collection
Self-report by
way of
in-person
home
interview,
and wrist
actigraphy
Specific question
posed and/or
technique used to
analyze sleep data
1. During the
past month, how
many hours of
actual sleep did
you get at
night?; 2. Wrist
actigraphy over
57 consecutive
nights;
actigraphy
algorithm used
on raw data
BP, blood pressure; SBP, systolic blood pressure; DBP, diastolic blood pressure.
52
E. Dean et al.
Table IV. Adjusted variables and main findings of the source studies.
First author, year
Study design
Sleep reference
(h/day)
Data analysis/adjusted
variables
Cross-sectional
77.99
Cappuccio et al.
(30)
Cross-sectional
7 8
Hierarchical linear
regression analysis: Step
1: unadjusted sleep
duration; Step 2: gender,
smoking, sleep duration
free time; Step 3: BMI;
Crude logistic regression
analyses using sleep
duration (workweek) as
the predictor for systolic
blood pressure (140
mmHg vs 140 mmHg)
and diastolic blood
pressure (90 mmHg vs
90 mmHg); Adjusted
logistic regression
analysis controlling for
gender, smoking, BMI
Reduced model: adjusted
for age and employment;
Fully adjusted: as above
plus alcohol consumption,
smoking, physical
activity, BMI,
cardiovascular disease
drugs, Short Form-36
mental and physical
health score, depression,
use of hypnotics
Longitudinal
(5-year
follow-up)
As above
Cross-sectional
Gangwisch et al.
(29)
Longitudinal
(810-year
follow-up)
78
Cross-sectional
78
Unadjusted
Main findings
Unadjusted, both SBP and DBP were
higher with shorter sleep durations;
Controlled, these associations were no
longer significant; Sleep duration
55.99 h and 66.99 h became
significantly negatively related to SPB;
SBP: no relationship between sleep
duration and SBP 140 mmHg;
DBP: 5 h significantly related to
DBP 90 mmHg; SBP: 55.99 h and
66.99 h associated with decreased
risk of high SBP; DBP: no duration
significantly related
(Continued)
53
Sleep reference
(h/day)
Data analysis/adjusted
variables
Kawada et al.
(26)
Cross-sectional
6 vs 6
Knutson et al.
(31)
Cross-sectional
Continuous
variable
Longitudinal (5
years)
Lima-Costa et al.
(22)
Cross-sectional
7 8
Lopez-Garcia
et al. (32)
Cross-sectional
Longitudinal
(2-year
follow-up)
Stranges et al.
(27)
Comparative
crosssectional
Cross-sectional
68
7- 8 for
self-report;
6- 7 for
actigraphy
group
Model 1: unadjusted;
Model 2: age, gender;
Model 3: 2 skin color,
diabetes mellitus,
depressive symptoms,
body mass index, and
hypnotic or sedative meds
Adjusted for age, sex, physical
activity, BMI, smoking,
alcohol consumption,
coffee, consumption,
education level, number of
social ties, perceived health,
depression, number of
chronic disease, arousal
from sleep at night,
anxiolytic intake
As above
Main findings
Sleeping 6 h not significantly
associated with high BP (OR 1.12
[0.901.31])
htn, hypertension; SBP, systolic blood pressure; DBP, diastolic blood pressure; OR, odds ratio; HR, hazard ratio; CI, confidence interval.
54
E. Dean et al.
55
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