Background The risk of sudden death from cardiac causes in thegeneral population peaks from 6 a.m. to noon and has a nadirfrom midnight to 6 a.m. Obstructive sleep apnea is highly prevalentand associated with neurohormonal and electrophysiological abnormalitiesthat may increase the risk of sudden death from cardiac causes,especially during sleep.
Methods We reviewed polysomnograms and the death certificatesof 112 Minnesota residents who had undergone polysomnographyand had died suddenly from cardiac causes between July 1987and July 2003. For four intervals of the day, we compared therates of sudden death from cardiac causes among people withobstructive sleep apnea and the following: the rates among peoplewithout obstructive sleep apnea, the rates in the general population,and the expectations according to chance. For each interval,we assessed the median apnea–hypopnea index and the relativerisk of sudden death from cardiac causes. We similarly analyzedsudden death from cardiac causes during three time intervalsthat correlate with usual sleep–wake cycles.
Results From midnight to 6 a.m., sudden death from cardiac causesoccurred in 46 percent of people with obstructive sleep apnea,as compared with 21 percent of people without obstructive sleepapnea (P=0.01), 16 percent of the general population (P<0.001),and the 25 percent expected by chance (P<0.001). People withsudden death from cardiac causes from midnight to 6 a.m. hada significantly higher apnea–hypopnea index than thosewith sudden death from cardiac causes during other intervals,and the apnea–hypopnea index correlated directly withthe relative risk of sudden death from cardiac causes from midnightto 6 a.m. For people with obstructive sleep apnea, the relativerisk of sudden death from cardiac causes from midnight to 6a.m. was 2.57 (95 percent confidence interval, 1.87 to 3.52).The analysis of usual sleep–wake cycles showed similarresults.
Conclusions People with obstructive sleep apnea have a peakin sudden death from cardiac causes during the sleeping hours,which contrasts strikingly with the nadir of sudden death fromcardiac causes during this period in people without obstructivesleep apnea and in the general population.
Source Information
From the Divisions of Cardiovascular Diseases (A.S.G., V.K.S.), Pulmonary and Critical Care Medicine (E.J.O.), and Hypertension (V.K.S.), Department of Internal Medicine (A.S.G., D.E.H., E.J.O., V.K.S.), Mayo Clinic College of Medicine, Rochester, Minn.
Address reprint requests to Dr. Somers at the Division of Cardiovascular Diseases, Mayo Clinic College of Medicine, 200 First St. SW, Rochester, MN 55905, or at somers.virend{at}mayo.edu.
Monahan, K., Storfer-Isser, A., Mehra, R., Shahar, E., Mittleman, M., Rottman, J., Punjabi, N., Sanders, M., Quan, S. F., Resnick, H., Redline, S.
(2009). Triggering of nocturnal arrhythmias by sleep-disordered breathing events.. J Am Coll Cardiol
54: 1797-1804
[Abstract][Full Text]
Wilcox, I., Semsarian, C.
(2009). Obstructive sleep apnea a respiratory syndrome with protean cardiovascular manifestations.. J Am Coll Cardiol
54: 1810-1812
[Full Text]
Takasugi, N., Nishigaki, K., Kubota, T., Tsuchiya, K., Natsuyama, K., Takasugi, M., Nawa, T., Ojio, S., Aoyama, T., Kawasaki, M., Takemura, G., Minatoguchi, S.
(2009). Sleep apnoea induces cardiac electrical instability assessed by T-wave alternans in patients with congestive heart failure. Eur J Heart Fail
11: 1063-1070
[Abstract][Full Text]
READING, S. R., CROWSON, C. S., RODEHEFFER, R. J., FITZ-GIBBON, P. D., MARADIT-KREMERS, H., GABRIEL, S. E.
(2009). Do Rheumatoid Arthritis Patients Have a Higher Risk for Sleep Apnea?. The Journal of Rheumatology
36: 1869-1872
[Abstract][Full Text]
Verrier, R. L., Josephson, M. E.
(2009). Impact of Sleep on Arrhythmogenesis. Circ Arrhythm Electrophysiol
2: 450-459
[Full Text]
Tamisier, R., Gilmartin, G. S., Launois, S. H., Pepin, J. L., Nespoulet, H., Thomas, R., Levy, P., Weiss, J. W.
(2009). A new model of chronic intermittent hypoxia in humans: effect on ventilation, sleep, and blood pressure. J. Appl. Physiol.
107: 17-24
[Abstract][Full Text]
Lee, E. J., Woodske, M. E., Zou, B., O'Donnell, C. P.
(2009). Dynamic arterial blood gas analysis in conscious, unrestrained C57BL/6J mice during exposure to intermittent hypoxia. J. Appl. Physiol.
107: 290-294
[Abstract][Full Text]
Mehra, R., Stone, K. L., Varosy, P. D., Hoffman, A. R., Marcus, G. M., Blackwell, T., Ibrahim, O. A., Salem, R., Redline, S.
(2009). Nocturnal Arrhythmias Across a Spectrum of Obstructive and Central Sleep-Disordered Breathing in Older Men: Outcomes of Sleep Disorders in Older Men (MrOS Sleep) Study. Arch Intern Med
169: 1147-1155
[Abstract][Full Text]
Yaggi, H. K.
(2009). Sleep and the Cardiovascular System. ACCP Sleep Med Brd Rev
4: 123-132
[Full Text]
Kohler, M., Pepperell, J. C. T., Casadei, B., Craig, S., Crosthwaite, N., Stradling, J. R., Davies, R. J. O.
(2008). CPAP and measures of cardiovascular risk in males with OSAS. Eur Respir J
32: 1488-1496
[Abstract][Full Text]
Moss, M.
(2008). Clinical Year in Review I: Lung Cancer, Pleural Disease, Exercise Testing and Pulmonary Rehabilitation, and Sleep Medicine. Proc Am Thorac Soc
5: 739-744
[Full Text]
Somers, V. K., White, D. P., Amin, R., Abraham, W. T., Costa, F., Culebras, A., Daniels, S., Floras, J. S., Hunt, C. E., Olson, L. J., Pickering, T. G., Russell, R., Woo, M., Young, T.
(2008). Sleep Apnea and Cardiovascular Disease: An American Heart Association/American College of Cardiology Foundation Scientific Statement From the American Heart Association Council for High Blood Pressure Research Professional Education Committee, Council on Clinical Cardiology, Stroke Council, and Council on Cardiovascular Nursing In Collaboration With the National Heart, Lung, and Blood Institute National Center on Sleep Disorders Research (National Institutes of Health). Circulation
118: 1080-1111
[Full Text]
Somers, V. K., White, D. P., Amin, R., Abraham, W. T., Costa, F., Culebras, A., Daniels, S., Floras, J. S., Hunt, C. E., Olson, L. J., Pickering, T. G., Russell, R., Woo, M., Young, T.
(2008). Sleep Apnea and Cardiovascular Disease: An American Heart Association/American College of Cardiology Foundation Scientific Statement From the American Heart Association Council for High Blood Pressure Research Professional Education Committee, Council on Clinical Cardiology, Stroke Council, and Council on Cardiovascular Nursing In Collaboration With the National Heart, Lung, and Blood Institute National Center on Sleep Disorders Research (National Institutes of Health). J Am Coll Cardiol
52: 686-717
[Full Text]
Sert Kuniyoshi, F. H., Garcia-Touchard, A., Gami, A. S., Romero-Corral, A., van der Walt, C., Pusalavidyasagar, S., Kara, T., Caples, S. M., Pressman, G. S., Vasquez, E. C., Lopez-Jimenez, F., Somers, V. K.
(2008). Day-Night Variation of Acute Myocardial Infarction in Obstructive Sleep Apnea. J Am Coll Cardiol
52: 343-346
[Abstract][Full Text]
Faure, P., Tamisier, R., Baguet, J-P., Favier, A., Halimi, S., Levy, P., Pepin, J-L.
(2008). Impairment of serum albumin antioxidant properties in obstructive sleep apnoea syndrome. Eur Respir J
31: 1046-1053
[Abstract][Full Text]
Ritz, E., Wanner, C.
(2008). The Challenge of Sudden Death in Dialysis Patients. CJASN
3: 920-929
[Full Text]
Sorajja, D., Gami, A. S., Somers, V. K., Behrenbeck, T. R., Garcia-Touchard, A., Lopez-Jimenez, F.
(2008). Independent Association Between Obstructive Sleep Apnea and Subclinical Coronary Artery Disease. Chest
133: 927-933
[Abstract][Full Text]
Nakagawa, Y., Kishida, K., Kihara, S., Sonoda, M., Hirata, A., Yasui, A., Nishizawa, H., Nakamura, T., Yoshida, R., Shimomura, I., Funahashi, T.
(2008). Nocturnal reduction in circulating adiponectin concentrations related to hypoxic stress in severe obstructive sleep apnea-hypopnea syndrome. Am. J. Physiol. Endocrinol. Metab.
294: E778-E784
[Abstract][Full Text]
Lopez-Jimenez, F., Sert Kuniyoshi, F. H., Gami, A., Somers, V. K.
(2008). Obstructive Sleep Apnea: Implications for Cardiac and Vascular Disease. Chest
133: 793-804
[Full Text]
Punjabi, N. M.
(2008). The Epidemiology of Adult Obstructive Sleep Apnea. Proc Am Thorac Soc
5: 136-143
[Abstract][Full Text]
Sanders, M. H., Montserrat, J. M., Farre, R., Givelber, R. J.
(2008). Positive Pressure Therapy: A Perspective on Evidence-based Outcomes and Methods of Application. Proc Am Thorac Soc
5: 161-172
[Abstract][Full Text]
Golbin, J. M., Somers, V. K., Caples, S. M.
(2008). Obstructive Sleep Apnea, Cardiovascular Disease, and Pulmonary Hypertension. Proc Am Thorac Soc
5: 200-206
[Abstract][Full Text]
Sahlin, C., Sandberg, O., Gustafson, Y., Bucht, G., Carlberg, B., Stenlund, H., Franklin, K. A.
(2008). Obstructive Sleep Apnea Is a Risk Factor for Death in Patients With Stroke: A 10-Year Follow-up. Arch Intern Med
168: 297-301
[Abstract][Full Text]
Yokoe, T., Alonso, L. C., Romano, L. C., Rosa, T. C., O'Doherty, Robert. M., Garcia-Ocana, A., Minoguchi, K., O'Donnell, C. P.
(2008). Intermittent hypoxia reverses the diurnal glucose rhythm and causes pancreatic {beta}-cell replication in mice. J. Physiol.
586: 899-911
[Abstract][Full Text]
Amit Benjamin, J, Lewis, K E
(2008). Sleep-disordered breathing and cardiovascular disease. Postgrad. Med. J.
84: 15-22
[Abstract][Full Text]
Lavie, P.
(2007). Mortality in sleep apnoea syndrome: a review of the evidence. ERR
16: 203-210
[Abstract][Full Text]
Romero-Corral, A., Somers, V. K., Pellikka, P. A., Olson, E. J., Bailey, K. R., Korinek, J., Orban, M., Sierra-Johnson, J., Kato, M., Amin, R. S., Lopez-Jimenez, F.
(2007). Decreased Right and Left Ventricular Myocardial Performance in Obstructive Sleep Apnea. Chest
132: 1863-1870
[Abstract][Full Text]
Hernandez, L., Torrella, M., Roger, N., Llunell, A., Ballester, E., Quinto, L., Serrano, M., Masa, F., Montserrat, J. M.
(2007). Management of Sleep Apnea: Concordance Between Nonreference and Reference Centers. Chest
132: 1853-1857
[Abstract][Full Text]
Laitio, T., Jalonen, J., Kuusela, T., Scheinin, H.
(2007). The Role of Heart Rate Variability in Risk Stratification for Adverse Postoperative Cardiac Events. Anesth. Analg.
105: 1548-1560
[Abstract][Full Text]
Ahmed, M., Patel, N. P., Rosen, I.
(2007). Portable Monitors in the Diagnosis of Obstructive Sleep Apnea. Chest
132: 1672-1677
[Abstract][Full Text]
Cassar, A., Morgenthaler, T. I., Lennon, R. J., Rihal, C. S., Lerman, A.
(2007). Treatment of Obstructive Sleep Apnea Is Associated With Decreased Cardiac Death After Percutaneous Coronary Intervention. J Am Coll Cardiol
50: 1310-1314
[Abstract][Full Text]
Parati, G., Lombardi, C., Narkiewicz, K.
(2007). Sleep apnea: epidemiology, pathophysiology, and relation to cardiovascular risk. Am. J. Physiol. Regul. Integr. Comp. Physiol.
293: R1671-R1683
[Abstract][Full Text]
Bucca, C. B., Brussino, L., Battisti, A., Mutani, R., Rolla, G., Mangiardi, L., Cicolin, A.
(2007). Diuretics in Obstructive Sleep Apnea With Diastolic Heart Failure. Chest
132: 440-446
[Abstract][Full Text]
Oldenburg, O., Faber, L., Vogt, J., Dorszewski, A., Szabados, F., Horstkotte, D., Lamp, B.
(2007). Influence of cardiac resynchronisation therapy on different types of sleep disordered breathing. Eur J Heart Fail
9: 820-826
[Abstract][Full Text]
Javaheri, S., Shukla, R., Zeigler, H., Wexler, L.
(2007). Central Sleep Apnea, Right Ventricular Dysfunction, and Low Diastolic Blood Pressure Are Predictors of Mortality in Systolic Heart Failure. J Am Coll Cardiol
49: 2028-2034
[Abstract][Full Text]
Martinez-Garcia, M. A., Gomez-Aldaravi, R., Soler-Cataluna, J-J., Martinez, T. G., Bernacer-Alpera, B., Roman-Sanchez, P.
(2007). Positive effect of CPAP treatment on the control of difficult-to-treat hypertension. Eur Respir J
29: 951-957
[Abstract][Full Text]
Patruno, V., Aiolfi, S., Costantino, G., Murgia, R., Selmi, C., Malliani, A., Montano, N.
(2007). Fixed and Autoadjusting Continuous Positive Airway Pressure Treatments Are Not Similar in Reducing Cardiovascular Risk Factors in Patients With Obstructive Sleep Apnea. Chest
131: 1393-1399
[Abstract][Full Text]
Wang, H., Parker, J. D., Newton, G. E., Floras, J. S., Mak, S., Chiu, K.-L., Ruttanaumpawan, P., Tomlinson, G., Bradley, T. D.
(2007). Influence of Obstructive Sleep Apnea on Mortality in Patients With Heart Failure. J Am Coll Cardiol
49: 1625-1631
[Abstract][Full Text]
Oldenburg, O., Lamp, B., Faber, L., Teschler, H., Horstkotte, D., Topfer, V.
(2007). Sleep-disordered breathing in patients with symptomatic heart failure A contemporary study of prevalence in and characteristics of 700 patients. Eur J Heart Fail
9: 251-257
[Abstract][Full Text]
Nalivaiko, E., Catcheside, P. G., Adams, A., Jordan, A. S., Eckert, D. J., McEvoy, R. D.
(2007). Cardiac changes during arousals from non-REM sleep in healthy volunteers. Am. J. Physiol. Regul. Integr. Comp. Physiol.
292: R1320-R1327
[Abstract][Full Text]
McNicholas, W. T., Bonsignore, M. R., the Management Committee of EU COST ACTION B26,
(2007). Sleep apnoea as an independent risk factor for cardiovascular disease: current evidence, basic mechanisms and research priorities. Eur Respir J
29: 156-178
[Abstract][Full Text]
Polotsky, V. Y., O'Donnell, C. P.
(2007). Genomics of Sleep-disordered Breathing. Proc Am Thorac Soc
4: 121-126
[Abstract][Full Text]
Foster, G. E., Poulin, M. J., Hanly, P. J.
(2007). Sleep Apnoea & Hypertension: Physiological bases for a causal relation: Intermittent hypoxia and vascular function: implications for obstructive sleep apnoea. Exp Physiol
92: 51-65
[Abstract][Full Text]
Hui, D S, To, K W, Ko, F W, Fok, J P, Chan, M C, Ngai, J C, Tung, A H, Ho, C W, Tong, M W, Szeto, C-C, Yu, C-M
(2006). Nasal CPAP reduces systemic blood pressure in patients with obstructive sleep apnoea and mild sleepiness. Thorax
61: 1083-1090
[Abstract][Full Text]
Moss, M.
(2006). Clinical Year in Review III: Critical Care, Mechanical Ventilation, Sleep Medicine, and Lung Cancer. Proc Am Thorac Soc
3: 645-649
[Full Text]
Peker, Y., Carlson, J., Hedner, J.
(2006). Increased incidence of coronary artery disease in sleep apnoea: a long-term follow-up. Eur Respir J
28: 596-602
[Abstract][Full Text]
Sumi, K., Chin, K., Takahashi, K., Nakamura, T., Matsumoto, H., Niimi, A., Mishima, M.
(2006). Effect of nCPAP therapy on heart rate in patients with obstructive sleep apnoea-hypopnoea. QJM
99: 545-553
[Abstract][Full Text]
Datta, A., Tipton, M.
(2006). Respiratory responses to cold water immersion: neural pathways, interactions, and clinical consequences awake and asleep. J. Appl. Physiol.
100: 2057-2064
[Abstract][Full Text]
Iellamo, F., Montano, N.
(2006). Continuous Positive Airway Pressure Treatment: Good for Obstructive Sleep Apnea Syndrome, Maybe Not for Hypertension?. Chest
129: 1403-1405
[Full Text]
El Solh, A. A., Saliba, R., Bosinski, T., Grant, B. J. B., Berbary, E., Miller, N.
(2006). Allopurinol improves endothelial function in sleep apnoea: a randomised controlled study.. Eur Respir J
27: 997-1002
[Abstract][Full Text]
Sanner, B. M., Tepel, M.
(2006). Sleep is more than a break from life. Eur Heart J
27: 1016-1017
[Full Text]
Norman, D., Loredo, J. S., Nelesen, R. A., Ancoli-Israel, S., Mills, P. J., Ziegler, M. G., Dimsdale, J. E.
(2006). Effects of Continuous Positive Airway Pressure Versus Supplemental Oxygen on 24-Hour Ambulatory Blood Pressure. Hypertension
47: 840-845
[Abstract][Full Text]
Horner, R. L., Bradley, T. D.
(2006). Update in sleep and control of ventilation 2005.. Am. J. Respir. Crit. Care Med.
173: 827-832
[Full Text]
Mehra, R., Benjamin, E. J., Shahar, E., Gottlieb, D. J., Nawabit, R., Kirchner, H. L., Sahadevan, J., Redline, S.
(2006). Association of Nocturnal Arrhythmias with Sleep-disordered Breathing: The Sleep Heart Health Study. Am. J. Respir. Crit. Care Med.
173: 910-916
[Abstract][Full Text]
Shivalkar, B., Van De Heyning, C., Kerremans, M., Rinkevich, D., Verbraecken, J., De Backer, W., Vrints, C.
(2006). Obstructive Sleep Apnea Syndrome: More Insights on Structural and Functional Cardiac Alterations, and the Effects of Treatment With Continuous Positive Airway Pressure. J Am Coll Cardiol
47: 1433-1439
[Abstract][Full Text]
Bassetti, C. L., Milanova, M., Gugger, M.
(2006). Sleep-Disordered Breathing and Acute Ischemic Stroke: Diagnosis, Risk Factors, Treatment, Evolution, and Long-Term Clinical Outcome. Stroke
37: 967-972
[Abstract][Full Text]
Meadows, G. E., Kotajima, F., Vazir, A., Kostikas, K., Simonds, A. K., Morrell, M. J., Corfield, D. R.
(2005). Overnight Changes in the Cerebral Vascular Response to Isocapnic Hypoxia and Hypercapnia in Healthy Humans: Protection Against Stroke. Stroke
36: 2367-2372
[Abstract][Full Text]
Li, J., Thorne, L. N., Punjabi, N. M., Sun, C.-K., Schwartz, A. R., Smith, P. L., Marino, R. L., Rodriguez, A., Hubbard, W. C., O'Donnell, C. P., Polotsky, V. Y.
(2005). Intermittent Hypoxia Induces Hyperlipidemia in Lean Mice. Circ. Res.
97: 698-706
[Abstract][Full Text]
Bassetti, C. L.
(2005). Obstructive Sleep Apnea and Atherosclerosis: "Guilt by Association". Am. J. Respir. Crit. Care Med.
172: 518-519
[Full Text]
Ryan, C M, Usui, K, Floras, J S, Bradley, T D
(2005). Effect of continuous positive airway pressure on ventricular ectopy in heart failure patients with obstructive sleep apnoea. Thorax
60: 781-785
[Abstract][Full Text]
Klerman, E. B.
(2005). Clinical Aspects of Human Circadian Rhythms. J Biol Rhythms
20: 375-386
[Abstract]
(2005). Nighttime Sudden Death Among Patients with Obstructive Sleep Apnea. Journal Watch Cardiology
2005: 5-5
[Full Text]
Previous
