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Originally Published 16 November 2020
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Adherence to a Healthy Sleep Pattern and Incident Heart Failure: A Prospective Study of 408 802 UK Biobank Participants

Heart failure affects >26 million people worldwide and is increasing alarmingly.1 Emerging evidence has implicated various sleep problems in the development of heart failure.2 Sleep behaviors are multifaceted, and individual sleep behaviors usually correlate with each other in a compensatory fashion.3,4 However, the majority of previous studies did not consider the complex nature of the overall sleep pattern. We recently generated and validated a healthy sleep pattern that incorporated 5 different sleep behaviors, which was associated with a lower risk of coronary heart disease in 2 independent cohorts.5 In the current study, we prospectively investigated the relationship between this healthy sleep pattern and the risk of heart failure.
The UK Biobank is a prospective cohort of 502 505 participants aged 37 to 73 years at the time of recruitment (2006–2010). We excluded participants with heart failure (N=2418) and those with missing information on the sleep behaviors (N=91 810) at baseline, leaving a total of 408 802 participants for the current analysis. All participants provided written informed consent. The study was approved by the National Health Service National Research Ethics Service and the Institutional Review Board of Tulane University.
Sleep behaviors were collected through a touchscreen questionnaire. A healthy sleep score was created by combining chronotype, sleep duration, insomnia, snoring, and excessive daytime sleepiness.5 Sleep duration was categorized into 3 groups: short (<7 h/d), recommended (7–8 h/d), and prolonged (>8 h/d). Healthy sleep factors were defined as early chronotype (“morning” person or “morning” than “evening” person); sleep 7 to 8 h/d; reported never/rarely or sometimes insomnia symptoms; no snoring; and no excessive daytime sleepiness (“never/rarely” or “sometimes”). Each sleep factor was coded 1 if meeting the healthy criterion and 0 if not. The healthy sleep score was obtained by summing up the 5 individual sleep factors. A higher score indicated a healthier sleep pattern.
Incidence of heart failure was collected until April 1, 2019, and defined based on International Classification of Diseases, Tenth Edition (I11.0, I13.0, I13.2, I50.X), hospital procedure codes, and self-reported information confirmed by nurses.
Among the 408 802 study participants, a total of 5221 cases of heart failure were recorded during a median follow-up of 10.1 years. The association between the healthy sleep score and heart failure incidence was estimated by Fine-Gray subdistribution hazard models, accounting for competing risk of mortality.
The healthy sleep score was inversely associated with the incidence of heart failure across all 3 models. The hazard ratio (95% CI) for heart failure was 0.85 (95% CI, 0.83–0.87) for a 1-point increase in the healthy sleep score (Table, model 2). The association did not appreciably change with additional adjustment for prevalent diabetes, hypertension, medication use, and genetic variations (Table, model 3; hazard ratio [95% CI], 0.87 [95% CI, 0.84–0.90]). Compared with participants with a healthy sleep score of 0 to 1, the hazard ratio (95% CI) for heart failure was 0.58 (95% CI, 0.49–0.70) for those with a healthy sleep score of 5 in model 3. The restricted cubic spline analysis showed a linear relationship between the healthy sleep score and incidence of heart failure (data not shown). When analyzing each binary (low-risk versus high-risk) component of the healthy sleep pattern and the risk of heart failure, early chronotype, sleeping 7 to 8 h/d, no frequent insomnia, and no frequent daytime sleepiness were each independently associated with 8%, 12%, 17%, and 34% lower risk of heart failure, respectively, in the multivariable-adjusted model (Table). The sensitivity analysis excluding patients who developed heart failure within 2 years of follow-up yielded similar results, providing evidence against reverse causation (data not shown).
Table 1. Hazard Ratios of Heart Failure by Healthy Sleep Score and Its Individual Component Among 408 802 UK Biobank Participants
Healthy sleepModel 1Model 2Model 3
HR (95% CI)P valueHR (95% CI)P valueHR (95% CI)P value
Healthy sleep score0.81 (0.78–0.83)<0.0010.85 (0.83–0.87)<0.0010.87 (0.84–0.90)<0.001
 0–1RefRefRef
 20.72 (0.61–0.85)<0.0010.77 (0.65–0.92)0.0030.85 (0.71–1.01)0.07
 30.56 (0.48–0.65)<0.0010.63 (0.54–0.74)<0.0010.72 (0.61–0.84)<0.001
 40.45 (0.38–0.53)<0.0010.53 (0.46–0.63)<0.0010.62 (0.53–0.73)<0.001
 50.40 (0.34–0.47)<0.0010.49 (0.41–0.58)<0.0010.58 (0.49–0.70)<0.001
Individual component*
 Early chronotype0.90 (0.85–0.97)0.0020.92 (0.84–0.99)0.030.92 (0.84–0.99)0.04
 Sleep 7–8 h/d0.76 (0.71–0.81)<0.0010.86 (0.79–0.94)<0.0010.88 (0.81–0.96)0.002
 No frequent insomnia0.77 (0.72–0.82)<0.0010.80 (0.74–0.87)<0.0010.83 (0.76–0.91)<0.001
 No self-report snoring0.92 (0.86–0.98)0.0090.91 (0.84–0.98)0.020.97 (0.89–1.05)0.44
 No frequent daytime sleepiness0.56 (0.49–0.64)<0.0010.62 (0.52–0.73)<0.0010.66 (0.55–0.78)<0.001
Model 1: adjusted for age, ethnicity, and sex.
Model 2: model 1+ Townsend deprivation index, center, alcohol intake, smoking status, physical activity, sedentary hour, healthy diet score, average household income, and education.
Model 3: Model 2+ diabetes (y/n), hypertension (y/n), medications for antihypertension, cholesterol lowering, and insulin, first 10 genetic principal components, and genetic risk score of heart failure. HR indicates hazard ratio; Ref, reference; and y/n, yes/no.
*
Each individual component was modeled as binary variable: met or did not meet the healthy criterion. All 5 individual components were included in the model simultaneously.
Our study is the first prospective investigation on the relation between adherence to an overall healthy sleep pattern and the risk of heart failure. Sleep behaviors are intercorrelated, and the human body regulates sleep in a holistic way to maintain an overall constancy of sleep intensity, quality, and duration. Thus, our study extends the previous findings on individual sleep behaviors by jointly evaluating multiple sleep behaviors. In addition, the healthy sleep pattern included not only the sleep behaviors during nighttime but also the chronotype and daytime sleepiness. Several potential limitations should be acknowledged. First, sleep behaviors were self-reported; thus, recall bias and misclassifications were inevitable. Second, the information on changes in sleeping behaviors during the follow-up was not available. Third, the observational nature of the study precludes causal inference. Fourth, although we have carefully controlled potential confounders in the analysis, unmeasured or unknown residual confounding might be possible.
In summary, our results provide new evidence to indicate that adherence to the healthy sleep pattern is associated with a lower risk of heart failure, independent of the conventional risk factors. Our findings highlight the potential importance of overall sleep behaviors in the prevention of heart failure.

Acknowledgments

The authors appreciate the participants in UK Biobank for their participation and contribution to the research. The study has been conducted using the UK Biobank Resource under Application 29256.

References

1.
Savarese G, Lund LH. Global public health burden of heart failure. Card Fail Rev. 2017;3:7–11. doi: 10.15420/cfr.2016:25:2
2.
Qi L. MicroRNAs and other mechanisms underlying the relation between sleep patterns and cardiovascular disease. Eur Heart J. 2020;41:2502. doi: 10.1093/eurheartj/ehaa349
3.
Porkka-Heiskanen T. Sleep homeostasis. Curr Opin Neurobiol. 2013;23:799–805. doi: 10.1016/j.conb.2013.02.010
4.
Vyazovskiy VV, Walton ME, Peirson SN, Bannerman DM. Sleep homeostasis, habits and habituation. Curr Opin Neurobiol. 2017;44:202–211. doi: 10.1016/j.conb.2017.05.002
5.
Fan M, Sun D, Zhou T, Heianza Y, Lv J, Li L, Qi L. Sleep patterns, genetic susceptibility, and incident cardiovascular disease: a prospective study of 385 292 UK biobank participants. Eur Heart J. 2020;41:1182–1189. doi: 10.1093/eurheartj/ehz849

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Published online: 16 November 2020
Published in print: 5 January 2021

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Keywords

  1. cardiovascular
  2. healthy sleep pattern
  3. heart failure

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Xiang Li, PhD
Department of Epidemiology, School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA(X.L., Q.X., M.W., T.Z., H.M., Y.H., L.Q.).
Qiaochu Xue, MPH
Department of Epidemiology, School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA(X.L., Q.X., M.W., T.Z., H.M., Y.H., L.Q.).
Mengying Wang, MPH
Department of Epidemiology, School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA(X.L., Q.X., M.W., T.Z., H.M., Y.H., L.Q.).
Tao Zhou, PhD
Department of Epidemiology, School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA(X.L., Q.X., M.W., T.Z., H.M., Y.H., L.Q.).
Hao Ma, PhD
Department of Epidemiology, School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA(X.L., Q.X., M.W., T.Z., H.M., Y.H., L.Q.).
Yoriko Heianza, PhD
Department of Epidemiology, School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA(X.L., Q.X., M.W., T.Z., H.M., Y.H., L.Q.).
Department of Epidemiology, School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA(X.L., Q.X., M.W., T.Z., H.M., Y.H., L.Q.).
Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA (L.Q.).
Channing Division of Network Medicine, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA(L.Q.).

Notes

Data sharing: Requests to access the dataset from qualified researchers trained in human subject confidentiality protocols may be sent to UK Biobank (https://www.ukbiobank.ac.uk/researchers/).
Lu Qi, MD, PhD, Department of Epidemiology, School of Public Health and Tropical Medicine, Tulane University, 1440 Canal Street, Suite 1724, New Orleans, LA 70112. Email [email protected]

Disclosures

None.

Sources of Funding

The study was supported by grants from the National Heart, Lung, and Blood Institute (HL071981, HL034594, HL126024), the National Institute of Diabetes and Digestive and Kidney Diseases (DK091718, DK100383, DK078616), the Boston Obesity Nutrition Research Center (DK46200), and United States–Israel Binational Science Foundation Grant2011036. Dr Qi was a recipient of the American Heart Association Scientist Development Award (0730094 N). Dr Li was the recipient of the American Heart Association Predoctoral Fellowship Award (19PRE34380036).

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  1. Implications of Long Sleep Duration on Cardiovascular Health: A Systematic Review, Cureus, (2025).https://doi.org/10.7759/cureus.77738
    Crossref
  2. Sleep patterns and cardiovascular disease risk in US participants: a comprehensive analysis, Frontiers in Neuroscience, 18, (2025).https://doi.org/10.3389/fnins.2024.1447543
    Crossref
  3. Association of healthy sleep patterns with incident sepsis: a large population-based prospective cohort study, Critical Care, 29, 1, (2025).https://doi.org/10.1186/s13054-025-05287-w
    Crossref
  4. Association of Sleep Traits With Venous Thromboembolism: Prospective Cohort and Mendelian Randomization Studies, American Journal of Hematology, (2025).https://doi.org/10.1002/ajh.27620
    Crossref
  5. Dietary N-6 Polyunsaturated Fatty Acid Intake and Brain Health in Middle-Aged and Elderly Adults, Nutrients, 16, 24, (4272), (2024).https://doi.org/10.3390/nu16244272
    Crossref
  6. Healthy Lifestyle Behaviors Attenuate the Effect of Poor Sleep Patterns on Chronic Kidney Disease Risk: A Prospective Study from the UK Biobank, Nutrients, 16, 23, (4238), (2024).https://doi.org/10.3390/nu16234238
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  7. Plasma Polyunsaturated Fatty Acid Levels and Mental Health in Middle-Aged and Elderly Adults, Nutrients, 16, 23, (4065), (2024).https://doi.org/10.3390/nu16234065
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  8. Chronic Low-Grade Inflammation and Brain Structure in the Middle-Aged and Elderly Adults, Nutrients, 16, 14, (2313), (2024).https://doi.org/10.3390/nu16142313
    Crossref
  9. The Swiss Sleep House Bern—A New Approach to Sleep Medicine, Clinical and Translational Neuroscience, 8, 1, (14), (2024).https://doi.org/10.3390/ctn8010014
    Crossref
  10. Genetic associations between Rapid Eye Movement (REM) sleep behavior disorder and cardiovascular diseases, PLOS ONE, 19, 5, (e0301112), (2024).https://doi.org/10.1371/journal.pone.0301112
    Crossref
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