Associations of Sleep Patterns With Dynamic Trajectory of Cardiovascular Multimorbidity and Mortality: A Multistate Analysis of a Large Cohort

BACKGROUND: The purpose of this study was to explore the association of sleep patterns with the development of first cardiovascular diseases (FCVD), progression to cardiovascular multimorbidity (CVM), and subsequently to mortality. METHODS AND RESULTS: This prospective study included 381 179 participants without coronary heart disease, stroke, atrial fibrillation, or heart failure at baseline, and they were followed up until March 31, 2021. We generated sleep patterns by summing the scores for 5 sleep behaviors, whereby <7 or >8 hours/d of sleep, evening chronotype, frequent insomnia, snoring, and daytime dozing were defined as high -risk groups. We used a multistate model to estimate the impacts of sleep patterns on the dynamic progression of cardiovascular diseases. Over a median follow -up of 12.1 years, 41 910 participants developed FCVD, 7302 further developed CVM, and 20 707 died. We found that adverse sleep patterns were significantly associated with the transition from health to FCVD, from FCVD to CVM, and from health to death, with hazard ratio associated with 1-factor increase in sleep scores being 1.08 (95% CI, 1.07- 1.09), 1.04 (95% CI, 1.02- 1.06), and 1.04 (95% CI, 1.02- 1.05), respectively. When further dividing FCVD into coronary heart disease, stroke, atrial fibrillation, and heart failure, adverse sleep patterns showed a significant and persistent effect on the transition from health to each cardiovascular disease, and from heart failure or atrial fibrillation to CVM. CONCLUSIONS: Our study provides evidence that adverse sleep patterns might increase the risk for the progression from health to cardiovascular diseases and further to CVM. Our findings suggest that improving sleep behaviors might be helpful for the primary and secondary prevention of cardiovascular diseases.