Skip to main content

Abstract

BACKGROUND:

Rates of poor sleep and hypertension are alarming worldwide. In this study, we investigate the association between sleeping difficulties and sleep duration with hypertension risk in women.

METHODS:

Sixty-six thousand one hundred twenty-two participants of the Nurses’ Health Study 2, who were free of hypertension at baseline (2001), were followed prospectively for 16 years and incident hypertension assessed every 2 years. Cox proportional hazards models were used to estimate hazard ratios (HRs) and 95% confidence intervals (95% CIs) for hypertension incidence associated with sleeping difficulties and sleep duration.

RESULTS:

During follow-up, we documented 25 987 incident cases of hypertension. After controlling for demographic and lifestyle risk factors, compared with women who slept 7 to 8 hours, women with shorter sleep duration had a significantly higher risk of hypertension (≤5 hours: HR, 1.10 [95% CI, 1.05–1.16]; 6 hours: HR, 1.07 [95% CI, 1.03–1.10]), whereas the risk for women with longer sleep duration was not statistically significant (9 hours: HR, 1.03 [95% CI, 0.97–1.10]; >9 hours: HR, 1.08 [95% CI, 0.94–1.23]). Compared with women rarely having difficulty falling or staying asleep, women sometimes or usually having these sleep difficulties had significantly higher risk of developing hypertension (HR, 1.14 [95% CI, 1.11–1.17] and 1.28 [95% CI, 1.22–1.35]; Ptrend<0.001). Early morning awakening was not associated with hypertension risk (Ptrend=0.722). There was no effect modification by night work or chronotype.

CONCLUSIONS:

Difficulty falling or staying asleep and short sleep duration were associated with higher risk of hypertension among women in our study. Screening for poor sleep could be useful in identifying people at higher risk for hypertension.

Graphical Abstract

NOVELTY AND RELEVANCE

What Is New?

Our study showed that there is a significant association between difficulty falling asleep or maintaining sleep and short sleep duration, with higher risk of hypertension.

What Is Relevant?

Sleeping difficulties or short sleep duration could be an indicator of higher risk of hypertension.

Clinical/Pathophysiological Implications?

Screening for poor sleep could be useful in identifying people at higher risk for hypertension.
Sleeping difficulties are skyrocketing in the United States. Insomnia in particular is a highly prevalent sleep disorder defined by chronic (>3 months) occurrence of 1 of 3 common sleeping difficulties including difficulty falling asleep, difficulty staying asleep, and early wakening in the morning.1 The American Academy of Sleep Medicine suggests that ≈30% of adults in the United States experience symptoms of insomnia,2 though even higher prevalence rates of up to 40% to 50% of insomnia in adults, particularly among women,3,4 have been reported. Additionally, the Centers for Disease Control and Prevention reported that >35% of Americans do not get enough sleep on a daily basis.5 According to recommendations by the American Academy of Sleep Medicine and the Sleep Research Society, adults need 7 to 9 hours of sleep over a 24-hour period.6
People with sleeping difficulties have a higher prevalence of a multitude of medical problems, particularly high blood pressure.7,8 Hypertension is one of the leading preventable targets in reducing cardiovascular mortality.9 An estimated 45% of all adults in the United States have hypertension,10 and about 8.5 million deaths per year around the world are associated with hypertension and prehypertensive conditions.11 A higher sleep efficiency has been associated with lower hypertension risk,12 and a healthy sleep pattern may lower the risk of cardiometabolic comorbidities in patients with hypertension.13
The evidence on the association of insomnia or sleep duration and hypertension risk is not consistent across different studies. While some studies found significant associations between insomnia,7,14–18 insomnia with physiological hyperarousal,19 insomnia with short sleep duration,20,21 difficulty in falling asleep,14,15,22–24 difficulty maintaining sleep,15,22–24 early morning awakening,15 short sleep duration,25–30 and long sleep duration28 with risk of hypertension, others did not find any significant associations31–34 or the findings were only significant for a specific age group or sex.26,29,35,36 The main limitations of these studies are their cross-sectional nature or short duration of follow-up, small sample size, and not being able to account for all related variables that might affect the findings. Moreover, studies are lacking on the sleep of health care providers, who are disproportionately burdened by long work hours and night shifts, and their associated risk of hypertension.
In this study, we used the data of a large prospective cohort study, the Nurses’ Health Study 2 (NHS2), with 16 years of follow-up to examine the association of sleep characteristics and their combination with incident hypertension. We also explored the effect of chronotype and shiftwork on this association. We hypothesized that sleeping difficulties and short sleep duration are each associated with higher risk of hypertension.

METHODS

Data Availability

Due to participant confidentiality and privacy concerns, the data are available upon reasonable written request. According to standard controlled access procedure, applications to use NHS2 resources will be reviewed by our External Collaborators Committee for scientific aims, evaluation of the fit of the data for the proposed methodology, and verification that the proposed use meets the guidelines of the Ethics and Governance Framework and the consent that was provided by the participants. Investigators wishing to use NHS2 data are asked to submit a brief description of the proposed project (go to https://www.nurseshealthstudy.org/researchers [contact email: [email protected]] for details). The data that support the findings of this study are available upon reasonable request (contact email: [email protected]).

Participants

The NHS2 cohort is an ongoing prospective study which began in 1989, enrolling 116 429 female registered nurses from the United States, between 25 and 42 years of age. Demographic data were collected at baseline, and information on diet, lifestyle, medical history, and incidence of diseases was collected and updated primarily via biennial questionnaires. The study was approved by the Institutional Review Boards of the Brigham and Women’s Hospital. Return of the questionnaire by the nurses implied their consent.

Measures

Sleep Duration and Sleeping Difficulties

Sleep duration was assessed first in 2001 and then again in 2009, by querying the average hours of sleep over a 24-hour period. The possible responses were <5, 5, 6, 7, 8, 9, and 10+ hours. We collapsed the responses to categories of (1) ≤5 hours, (2) 6 hours, (3) 7 to 8 hours, (4) 9 hours, or (5) >9 hours.
Sleeping difficulties were assessed in 2001, 2013, and 2017. In 2001, the participants were asked if they have difficulty falling or staying asleep. Possible responses were in 6 levels ranging from none of the time to all of the time. In 2013 and 2017, they were asked about difficulty falling asleep, difficulty staying asleep, and early morning awakening problems, using separate questions. The possible responses were (1) rarely or never, (2) sometimes, and (3) most of the time. We reclassified the responses of the 2001 questionnaire to align with the categories in 2013 and 2017.

Hypertension

We defined incident hypertension as the first self-report of a diagnosis of hypertension by a physician or the first self-report of antihypertensive medication use, which was assessed by the biennial questionnaires. In the questionnaires, they were asked about the medications they had been taking regularly within the past 2 years. Reports of using the following medications were considered as antihypertensive medication use: calcium channel blockers, β-blockers, thiazide diuretics, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, loop diuretics, potassium, or other antihypertensive medications. Information on incident hypertension was collected between June 1, 2001, through May 31, 2017, in our analyses. During this time, a 140/90 mm Hg (systolic and diastolic) blood pressure cutoff was still valid for the definition of stage 1 hypertension, since the latest guidelines of the American College of Cardiology and American Heart Association considering a 130/80 cutoff for stage 1 hypertension were only published in 2017.37,38

Covariates

Information on time-invariant factors including height, race and ethnicity, and maternal and paternal history of hypertension was assessed at baseline (1989). Additionally, since the women’s chronotype (originally assessed in 5 categories: definite or more likely morning type, definitive or more likely evening type, and neither, which we grouped into 3 categories of morning type, evening type, and neither) was only reported once (2009), it was considered as a time-invariant factor. Time-varying factors were updated throughout follow-up and included physical activity (originally calculated as a continuous variable; we grouped it into previously used categories39 of <3, 3 to <9, 9 to <18, 18 to <27, 27+ metabolic equivalent hours/week; assessed in 2001, 2005, 2009, and 2013), alcohol use (originally calculated as a continuous variable; we grouped it into previously used categories39 of 0, 1 to <5, 5 to <10, 10 to <20, and 20+ g/day; assessed in 1999, 2003, 2007, 2011, and 2015), smoking status (originally categorized into 15 groups; we regrouped it into previously used categories39 of never smokers, former smokers, or current smokers of 1–14, 15–24, or 25+ cigarettes/day; assessed biennially between 2001 and 2017), and menopausal status (originally categorized into 4 groups). We regrouped it into categories of premenopausal or postmenopausal (assessed biennially between 2001 and 2017), shiftwork history (we grouped it into categories of never, <5, 5 to <10, and 10+ years; assessed in 2001, 2005, 2009, 2011, and 2013), diagnosis of sleep apnea (2013 and 2017), diet quality based using Dietary Approaches to Stop Hypertension40,41 (assessed in 1999, 2003, 2007, and 2011), and body mass index (kg/m2; using updated weight, which was assessed biennially between 2001 and 2017).
Though we did not specifically assess benzodiazepine use in our study, we had information on whether a woman regularly used sleeping pills. Among the women rarely having difficulties falling or staying asleep, 1.2%, among those sometimes having sleep difficulties, 2.9%, and among those usually having sleep difficulties, 7.2% reported the use of sleeping pills. Additional adjustment for this covariable did not change our results, and we, therefore, did not retain it in our main models.

Study Population

Of the 116 683 participants in NHS2, 108 095 returned the 2001 (baseline for this study) questionnaire. Of these, participants with missing age information (n=268) and prevalent prior hypertension defined by either self-reported diagnosis of hypertension or use of antihypertensive medication (n=26 630) were excluded. Further, those with missing information on sleep difficulty (n=19 962) or sleep duration (n=15 075), after carrying forward/backward the values for 1 cycle to replace with missing values, were excluded. The remaining data set for analyses comprised 61 235 women for analyses related to sleep difficulties, 66 122 women for analyses related to sleep duration, and 56 439 women with information on both sleep difficulties and duration for stratified analyses.

Statistical Analysis

For time-varying categorical covariates, if values were missing during follow-up, responses were carried forward one cycle, and if still missing, a missing indicator was used. For sleep difficulty and sleep duration, if values were missing, responses were carried forward and backward 1 cycle, and if still missing, they were excluded when they were used in models as the exposure variable, and a missing indicator was used when they were used in models as the covariate. For time-varying continuous factors (body mass index and diet quality), in the cases of missing values, responses were carried forward 1 cycle, and if still missing, the mean of the sample was imputed. For sleep apnea, if values were missing, they were considered as having responded no. For chronotype, which was assessed only once, an indicator variable was created for missing values.
Cox proportional hazards models were used to estimate hazard ratios (HRs) and 95% confidence intervals (95% CI) for hypertension incidence. P values for trend in the association of sleeping difficulty and hypertension risk were calculated using modeling the sleep difficulty levels as a continuous variable. In addition to considering sleeping difficulties and duration in separate models, we considered the effects of sleep difficulty in different groups of sleep duration (up to 6 hours, 7–8 hours, and ≥9 hours). In secondary analyses, we stratified the participants’ data by chronotype and history of shiftwork. P<0.05 was considered as evidence of statistically significant difference, and all statistical tests were 2 sided. The analyses were performed using SAS (version 9.1; SAS Institute, Inc, Cary, NC).

RESULTS

During 16 years of follow-up (2001–2017), we documented 25 987 incident cases of hypertension. Table 1 presents the distribution of age and age-adjusted baseline characteristics of participants across categories of falling or staying asleep and sleep duration. Briefly, women with sleeping difficulties had higher body mass index, had lower physical activity and diet quality score, and were more likely to drink alcohol and smoke and be postmenopausal. Compared with women who slept 7 to 8 hours, women with shorter or longer sleep duration had higher body mass index, had lower diet quality score, and were more likely to smoke and be postmenopausal.
Table 1. Age and Age-Standardized Characteristics by Difficulty Falling or Staying Asleep (Among 61 235 Participants) and Sleep Duration (Among 66 122 Participants) in the Nurses’ Health Study 2 at Baseline in 2001*
CharacteristicDifficulty falling or staying asleepSleep duration
Rarely (n=42 453)Sometimes (n=15 544)Usually (n=3238)≤6 h (n=18 674)7 or 8 h (n=44 077)≥9 h (n=3371)
Age, y45.7 (4.7)46.4 (4.6)46.4 (4.5)46.1 (4.6)45.8 (4.7)45.5 (4.7)
Race, %      
 White94.894.994.792.295.795.4
 Black1.00.91.22.00.60.9
 Other4.24.24.15.83.83.7
Maternal hypertension, %27.127.828.928.926.826.6
Paternal hypertension, %27.928.727.929.527.826.1
Body mass index (kg/m2)25.6 (5.3)26 (5.5)26.4 (5.8)26.4 (5.9)25.5 (5.2)26.1 (5.8)
Total activity MET-h/wk22.6 (27.9)21.1 (27.2)19.4 (29.6)22.6 (31.6)21.9 (26.3)19.8 (28)
Diet quality score24.0 (5.1)23.6 (5.0)23.1 (5.1)23.4 (5.2)24.0 (5.0)23.7 (5.1)
Smoking status, %      
 Never67.564.860.464.466.865.9
 Past25.026.426.824.725.826.2
 Current7.48.812.810.97.47.8
Alcohol use, g/d3.9 (6.7)4.5 (7.6)4.4 (8.2)3.6 (6.7)4.2 (7.1)4.4 (8.0)
Postmenopausal, %22.624.929.925.122.323.5
DASH indicates Dietary Approaches to Stop Hypertension; and MET-h, metabolic equivalent task-hours.
*
Values are means (SDs) for continuous variables, percentages for categorical variables, and are standardized to the age distribution of the study population. Values of polytomous variables may not sum to 100% because of rounding or missing. Diet quality and body mass index are presented before mean imputation.
Value is not age adjusted.
Diet quality was based on DASH. A higher diet quality score indicates a higher quality diet.
Table 2 presents the association between difficulty falling or staying asleep and sleep duration with incidence of hypertension. In age-adjusted analyses, risk of incident hypertension was significantly increased among the women who reported difficulty falling or staying asleep, sometimes or usually (sometimes group: HR, 1.18 [95% CI, 1.15–1.22]; usually group: HR, 1.45 [95% CI, 1.38–1.52]), compared with women who rarely experienced sleeping difficulties (Table 2). In multivariable-adjusted models, these risks were attenuated but retained significance (sometimes group: HR, 1.14 [95% CI, 1.11–1.17]; usually group: HR, 1.28 [95% CI, 1.22–1.35]; Ptrend<0.001). Sleep apnea, alcohol use, heavy smoking, and history of paternal or maternal hypertension were the main confounders in the observed associations between difficulties sleeping and risk of hypertension. There was also a significant increase in risk of hypertension in women who reported short sleep duration (≤5 hours: HR, 1.10 [95% CI, 1.05–1.16]; 6 hours: HR, 1.07 [95% CI, 1.03–1.10]), when compared with women who slept 7 to 8 hours a day, whereas the risk was not statistically significantly increased among women who slept for longer hours (9 hours: HR, 1.03 [95% CI, 0.97–1.10]; >9 hours: HR, 1.08 [95% CI, 0.94–1.23]). In sensitivity analyses, using a stricter definition for hypertension (ie, based on self-reported diagnosis of hypertension and antihypertensive medication use), results remained virtually unchanged (Table 2). When stratifying the analysis of sleep difficulty into 3 groups of sleep duration (S1), we observed that estimates for sleeping difficulties were slightly higher in the group with sleep duration of ≥9 hours. For the stricter definition of hypertension (ie, based on self-reported diagnosis of hypertension and antihypertensive medication use), we did not observe any considerable difference between the groups.
Table 2. HRs and 95% CIs for the Association Between Difficulty Falling or Staying Asleep (Among 61 235 Participants) and Sleep Duration (Among 66 122 Participants) With Incidence of Hypertension in the Nurses’ Health Study 2 for Follow-Up Between 2001 and 2017, Using Different Definitions for Incidence of Hypertension
Sleep characteristicsCases, nModel 1*Model 2
HR (95% CI)HR (95% CI)
Based on self-report of diagnosis of hypertension or antihypertension medication use
Difficulty falling or staying asleep   
 Rarely15 052RefRef
 Sometimes76351.18 (1.15–1.22)1.14 (1.11–1.17)
 Usually18471.45 (1.38–1.52)1.28 (1.22–1.35)
 24 534 Ptrend <0.001
Sleep duration, h   
 ≤516061.36 (1.30–1.44)1.10 (1.05–1.16)
 663941.18 (1.15–1.21)1.07 (1.03–1.10)
 7 or 816 578RefRef
 911751.08 (1.02–1.15)1.03 (0.97–1.10)
 >92101.32 (1.15–1.51)1.08 (0.94–1.23)
 25 963  
Based on self-report of diagnosis of hypertension and antihypertension medication use
Difficulty falling or staying asleep   
 Rarely10 661RefRef
 Sometimes53461.17 (1.14–1.21)1.13 (1.09–1.17)
 Usually12981.42 (1.34–1.51)1.27 (1.19–1.35)
 17 305 Ptrend <0.001
Sleep duration, h   
 ≤511421.34 (1.26–1.42)1.08 (1.01–1.15)
 644881.17 (1.13–1.21)1.05 (1.01–1.08)
 7 or 811 577RefRef
 97941.04 (0.97–1.12)1.00 (0.93–1.08)
 >91351.17 (0.99–1.39)0.99 (0.83–1.18)
 18 136  
BMI indicates body mass index; DASH, Dietary Approaches to Stop Hypertension; HR, hazard ratio; MET-h, metabolic equivalent task-hours; and Ref, reference.
*
Model 1 was adjusted for age (continuous).
Model 2 was adjusted for age (continuous), race (White, Black, and other), BMI (continuous), diet quality based on DASH (continuous), physical activity (<3, 3 to <9, 9 to <18, 18 to <27, 27+ MET-h/wk), alcohol consumption (0, 1 to <5, 5 to <10, 10 to <20, 20+ g/d), smoking status (nonsmokers, former smokers, or current smokers of 1–14, 15–24, or 25+ cigarettes/d), maternal and paternal history of hypertension, sleep apnea, menopausal status (pre or post), night shift work (never, <5 y, between 5 and 10 y, >10 y), chronotype (morningness, eveningness, or neither), and sleep duration (for difficulty falling or staying asleep) or difficulty falling or staying asleep (for sleep duration).
We additionally assessed the individual associations between difficulty falling asleep, difficulty maintaining sleep, and early morning awakening without being able to fall back asleep and risk of hypertension (follow-up, 2013–2017; Table 3). Compared with women who usually slept well, women who reported difficulty in falling asleep (sometimes group: HR, 1.11 [95% CI, 1.04–1.20]; usually group: HR, 1.11 [95% CI, 0.99–1.25]; Ptrend=0.006) or difficulties maintaining sleep (sometimes group: HR, 1.13 [95% CI, 1.04–1.23]; usually group: HR, 1.21 [95% CI, 1.10–1.34]; Ptrend<0.001) had significantly higher risk of hypertension. In contrast, early morning awakening was not associated with a higher risk of hypertension (sometimes group: HR, 1.00 [95% CI, 0.93–1.07]; usually group: HR, 1.03 [95% CI, 0.92–1.16]; Ptrend=0.688).
Table 3. HRs and 95% CIs for the Association Between Difficulty Falling Asleep (Among 40 559 Participants), Difficulty Maintaining Sleep (Among 40 562 Participants), and Early Morning Awakening (Among 40 555 Participants) With Incidence of Hypertension in the Nurses’ Health Study 2 for Follow-Up Between 2013 and 2017
Sleep characteristicsCases, nModel 1*Model 2
HR (95% CI)HR (95% CI)
Difficulty falling asleep   
 Rarely2111RefRef
 Sometimes13761.17 (1.09–1.25)1.11 (1.04–1.20)
 Usually4101.30 (1.17–1.45)1.11 (0.99–1.25)
 3897 Ptrend = 0.006
Difficulty maintaining sleep   
 Rarely911RefRef
 Sometimes17731.15 (1.06–1.25)1.13 (1.04–1.23)
 Usually12101.31 (1.20–1.43)1.21 (1.10–1.34)
 3894 Ptrend <0.001
Early morning awakening   
 Rarely1745RefRef
 Sometimes16451.07 (1.00–1.14)1.00 (0.93–1.07)
 Usually5061.21 (1.10–1.34)1.03 (0.92–1.16)
 3896 Ptrend = 0.722
BMI indicates body mass index; DASH, Dietary Approaches to Stop Hypertension; HR, hazard ratio; MET-h, metabolic equivalent task-hours; and Ref, reference.
*
Adjusted for age (continuous).
Adjusted for age (continuous), race (White or other), height (continuous in inches), BMI (continuous in kg/m2), diet quality based on DASH (continuous), physical activity (<3, 3 to <9, 9 to <18, 18 to <27, 27+ MET-hr/wk), alcohol consumption (0, 1 to <5, 5 to <10, 10 to <20, 20+ g/d), smoking status (nonsmokers, former smokers, or current smokers of 1–14, 15–24, or 25+ cigarettes/d), maternal and paternal history of hypertension, sleep duration, sleep apnea, difficulty falling sleep (for difficulty maintaining sleep and early morning awakening), difficulty maintaining sleep (for difficulty falling sleep and early morning awakening), early morning awakening (for difficulty falling sleep and difficulty maintaining sleep), menopausal, night shift work.
In secondary analyses, we stratified participants based on their history of rotating night shift work (S2 and S3). We found a significant increasing trend in the risk of hypertension with sleep difficulty in all the stratified groups with no major difference in HRs between the groups. We also found no differences in the association between sleep duration and hypertension risk by night shift work status. Specifically, the risk of hypertension for women with short sleep duration (≤5 hours) who did not have a history of working rotating night shifts (multivariable HR, 1.14 [95% CI, 1.01–1.28]) or had a relatively shorter history of working rotating night shifts (between 0- and 5-year history of rotating night shifts: multivariable HR, 1.13 [95% CI, 1.04–1.22]) was similar to that of women with a longer history of rotating night shift work (between 5 and 10 years of rotating night shifts: multivariable HR, 1.15 [95% CI, 1.00–1.31]; 10+ years of rotating night shifts: multivariable HR, 1.09 [95% CI, 0.92–1.28]).
In additional analyses, we stratified participants based on their chronotype (S4 and S5). We found a significant increasing trend in risk of hypertension with sleep difficulty in all the stratified groups with no major difference in HRs between the groups. Also, the relationship between sleep duration and hypertension risk was not modified by chronotype (S5).

DISCUSSION

In this study, we evaluated the association of sleeping difficulties and average sleep duration with the risk of hypertension. We found a higher risk of hypertension in women who reported difficulty falling or staying asleep or have sleep duration of 6 hours or less. The relationship between sleeping difficulties and hypertension was similar in different groups of sleep duration. Neither history of night shiftwork nor chronotype appeared to modify these associations.
Prior studies have found that people with insomnia had higher prevalence of hypertension.7,14,16,42–44 While these previous studies have been limited by their cross-sectional nature7,14,16,43,44 and small sample sizes,7,14,16,42–44 to the best of our knowledge, our study is the largest prospective study to date with 16 years of follow-up and a large number of incident cases, and powerfully confirms these prior findings. Some potential mechanisms for the association of sleeping difficulties and hypertension are dysregulation of hypothalamic-pituitary-adrenal axis, sympathetic activation, and systematic inflammation, which in a chain of events would lead to increase in sodium retention, cardiac output, arterial stiffness, and cardiac output and, therefore, endothelial dysfunction and hypertension.8 The disruption in sleep/wake cycle can also influence the vascular tone rhythm and endothelial cell function.8
We further evaluated the association between difficulty falling asleep, difficulty maintaining sleep, and early morning awakening, separately, with the risk of hypertension and found that only difficulty falling asleep and maintaining sleep, but not early morning awakening, are statistically significantly associated with the hypertension risk. The interpretation of this finding is not straightforward because we do not have enough information regarding the underlying reason for each of these sleep difficulties for each participant. Further, we lack information on their 24-hour blood pressure pattern: in a regular 24-hour blood pressure pattern, there is a decrease during nocturnal sleep compared with diurnal wakefulness.45,46 Our hypothesis is that the difficulty in falling asleep and maintaining sleep usually occurs during the period at night where a drop in blood pressure would be expected, that is, preventing from the sleep time dipping in blood pressure pattern, while the early awakening usually occurs during a period where an increase in blood pressure is expected. However, this hypothesis should be tested in a study using 24- or 48-hour ambulatory blood pressure measurements.
Our result on a significant association of short sleep duration and risk of hypertension is consistent with previous smaller size prospective (shorter follow-up duration compared with our study)25–27,47 and cross-sectional studies.34 The potential mechanisms for the association of short sleep duration and hypertension may be the increased sympathetic nervous system activity,28,48,49 alteration in activity of the hypothalamic-pituitary-adrenal axis,28,50 invigoration of psychological and physical stressors,50 and elevated cortisol level28 by short sleep duration, which may cause hypertension.
Previous studies on short sleep duration and sleeping difficulties reported and elevated risk of hypertension among participants with insomnia symptoms and short sleep20,51 that we could not confirm in our data. Considering finer cutoff points for stratification (up to 5 hours, 6 hours, 7–8 hours, and ≥9 hours) did not change our conclusions, leaving the cross-sectional nature or the shorter follow-up as possible explanations for inconsistency with previous reports.
The strengths of this study include: (1) using data of a large prospective cohort study with close to ≈25 000 incident cases of hypertension, (2) 16 years of follow-up, and (3) availability of information on a large variety of potential confounding variables. Nevertheless, some limitations need to be mentioned: (1) our results are based on women and a limited number of non-White participants, which could limit generalizability; (2) we rely on self-reports of sleep difficulties, sleep apnea, and duration; however, prior studies in the Nurses’ Health Studies found that a single questionnaire-based report of sleep duration is highly correlated with the reports of daily diaries,52 and self-reports of sleep apnea in nurses reliably captured moderate-to-severe cases53; (3) we rely on self-reports of hypertension diagnosis and antihypertensive medication use as we lacked information about the measured values of blood pressure, However, previous studies have validated the self-reported diagnosis of hypertension in this cohort.54,55 Related to that, (4) our results are based on incidence cases until 2017 before the latest guideline of the American College of Cardiology and American Heart Association (2017) was published considering systolic blood pressure of 130 mm Hg and diastolic blood pressure of 80 mm Hg as cutoff for stage 1 hypertension.37,38 (5) Although adjustment for sleeping pill used in secondary analyses did not alter our results, possible underreporting of sleeping pill use is another potential limitation of our study. (6) Chronotype was only assessed once not allowing us to evaluate its stability over time in our sample. While there are reports that chronotype changes with menopause,56,57 several studies based on repeated measures found chronotype to be a stable, rather trait like construct.58,59

PERSPECTIVE

We found a significant association between difficulty falling asleep or maintaining sleep, and short sleep duration, with higher risk of hypertension. Large studies with male and female participants and detailed assessment of sleep are needed to study the effect of sleeping difficulties and sleep duration on more detailed (including nocturnal) blood pressure pattern. Increased efforts should be made to curb and screen for the negative health effects of sleeping difficulties in general and among health care providers in particular.

Acknowledgments

The authors are indebted to the thousands of participants in the Nurses’ Health Study 2 and thank the staff of the Nurses’ Health Study 2 for their valuable contributions. The authors assume full responsibility for analyses and interpretation of these data.

Footnote

Nonstandard Abbreviations and Acronyms

HR
hazard ratio
NHS2
Nurses’ Health Study 2

Supplemental Material

File (hyp_hype-2023-21350_supp2.docx)

REFERENCES

1.
Sleep-wake disorders. In: Diagnostic and Statistical Manual of Mental Disorders. 5th ed. American Psychiatric Association; 2013. doi: 10.1176/appi.books.9780890425787.x12_Sleep-Wake_Disorders
2.
Insomnia. The American Academy of Sleep Medicine. 2008. https://aasm.org/resources/factsheets/insomnia.pdf
3.
Schutte-Rodin SL, Broch L, Buysee D, Dorsey C, Sateia M. Clinical guideline for the evaluation and management of chronic insomnia in adults. J Clin Sleep Med. 2008;4:487–504. doi: 10.5664/jcsm.27286
4.
Dopheide J. Insomnia overview: epidemiology, pathophysiology, diagnosis and monitoring, and nonpharmacologic therapy. Am J Manag Care. 2020;26:S76–S84. doi: 10.37765/ajmc.2020.42769
5.
Short sleep duration among US adults. National Center for Chronic Disease Prevention and Health Promotion. 2017. https://www.cdc.gov/sleep/data_statistics.html
6.
Watson NF, Badr MS, Belenky G, Bliwise DL, Buxton OM, Buysse D, Dinges DF, Gangwisch J, Grandner MA, Kushida C, et al; Consensus Conference Panel. Joint consensus statement of the American Academy of Sleep Medicine and Sleep Research Society on the recommended amount of sleep for a healthy adult: methodology and discussion. Sleep. 2015;38:1161–1183. doi: 10.5665/sleep.4886
7.
Taylor DJ, Mallory LJ, Lichstein KL, Durrence HH, Riedel BW, Bush AJ. Comorbidity of chronic insomnia with medical problems. Sleep. 2007;30:213–218. doi: 10.1093/sleep/30.2.213
8.
Jarrin DC, Alvaro PK, Bouchard MA, Jarrin SD, Drake CL, Morin CM. Insomnia and hypertension: a systematic review. Sleep Med Rev. 2018;41:3–38. doi: 10.1016/j.smrv.2018.02.003
9.
Patel SA, Winkel M, Ali MK, Narayan KMV, Mehta NK. Cardiovascular mortality associated with 5 leading risk factors: national and state preventable fractions estimated from survey data. Ann Intern Med. 2015;163:245–253. doi: 10.7326/M14-1753
10.
Ostchega Y, Fryar CD, Nwankwo T, Nguyen DT. Hypertension prevalence among adults aged 18 and over: United States, 2017–2018. NCHS Data Brief. 2020;(364):1–8.
11.
Zhou B, Perel P, Mensah GA, Ezzati M. Global epidemiology, health burden and effective interventions for elevated blood pressure and hypertension. Nat Rev Cardiol. 2021;18:785–802. doi: 10.1038/s41569-021-00559-8
12.
Virani SS, Alonso A, Benjamin EJ, Bittencourt MS, Callaway CW, Carson AP, Chamberlain AM, Chang AR, Cheng S, Delling FN. Heart disease and stroke statistics—2020 update a report from the American Heart Association. Circulation. 2020;141:e139. doi: 10.1161/CIR.0000000000000757
13.
He L, Ma T, Li J, Luo Y, Zhang G, Cheng X, Bai Y. Adherence to a healthy sleep pattern and incidence of cardiometabolic multimorbidity among hypertensive patients: a prospective study of UK Biobank. Sleep. 2022;45:zsac141. doi: 10.1093/sleep/zsac141
14.
Martikainen K, Partinen M, Hasan J, Laippala P, Urponen H, Vuori I. The impact of somatic health problems on insomnia in middle age. Sleep Med. 2003;4:201–206. doi: 10.1016/s1389-9457(02)00194-6
15.
Gureje O, Kola L, Ademola A, Olley BO. Profile, comorbidity and impact of insomnia in the Ibadan study of ageing. Int J Geriatr Psychiatry. 2009;24:686–693. doi: 10.1002/gps.2180
16.
Benbir G, Demir AU, Aksu M, Ardic S, Firat H, Itil O, Ozgen F, Yilmaz H, Karadeniz D. Prevalence of insomnia and its clinical correlates in a general population in Turkey. Psychiatry Clin Neurosci. 2015;69:543–552. doi: 10.1111/pcn.12252
17.
Lin CL, Liu TC, Lin FH, Chung CH, Chien WC. Association between sleep disorders and hypertension in Taiwan: a nationwide population-based retrospective cohort study. J Hum Hypertens. 2017;31:220–224. doi: 10.1038/jhh.2016.55
18.
Wang C, Wang B, Liu D, Zhang Y, Zheng Y, Guo L, Li S, Zuo H. Self-reported sleep-disordered breathing and insomnia in association with hypertension: a community-based study in Eastern China. Blood Press Monit. 2022;27:320–326. doi: 10.1097/MBP.0000000000000609
19.
Li Y, Vgontzas AN, Fernandez-Mendoza J, Bixler EO, Sun Y, Zhou J, Ren R, Li T, Tang X. Insomnia with physiological hyperarousal is associated with hypertension. Hypertension. 2015;65:644–650. doi: 10.1161/HYPERTENSIONAHA.114.04604
20.
Vgontzas AN, Liao D, Bixler EO, Chrousos GP, Vela-Bueno A. Insomnia with objective short sleep duration is associated with a high risk for hypertension. Sleep. 2009;32:491–497. doi: 10.1093/sleep/32.4.491
21.
Fernandez-Mendoza J, Vgontzas AN, Liao D, Shaffer ML, Vela-Bueno A, Basta M, Bixler EO. Insomnia with objective short sleep duration and incident hypertension: the Penn State Cohort. Hypertension. 2012;60:929–935. doi: 10.1161/HYPERTENSIONAHA.112.193268
22.
Suka M, Yoshida K, Sugimori H. Persistent insomnia is a predictor of hypertension in Japanese male workers. J Occup Health. 2003;45:344–350. doi: 10.1539/joh.45.344
23.
Phillips B, Mannino D. Correlates of sleep complaints in adults: the ARIC study. J Clin Sleep Med. 2005;1:277–283.
24.
Phillips B, Mannino DM. Do insomnia complaints cause hypertension or cardiovascular disease? J Clin Sleep Med. 2007;3:489–494. doi: 10.5664/jcsm.26913
25.
Gangwisch JE, Heymsfield SB, Boden-Albala B, Buijs RM, Kreier F, Pickering TG, Rundle AG, Zammit GK, Malaspina D. Short sleep duration as a risk factor for hypertension: analyses of the first National Health and Nutrition Examination Survey. Hypertension. 2006;47:833–839. doi: 10.1161/01.HYP.0000217362.34748.e0
26.
Cappuccio FP, Stranges S, Kandala NB, Miller MA, Taggart FM, Kumari M, Ferrie JE, Shipley MJ, Brunner EJ, Marmot MG. Gender-specific associations of short sleep duration with prevalent and incident hypertension: the Whitehall II Study. Hypertension. 2007;50:693–700. doi: 10.1161/HYPERTENSIONAHA.107.095471
27.
Knutson KL, Van Cauter E, Rathouz PJ, Yan LL, Hulley SB, Liu K, Lauderdale DS. Association between sleep and blood pressure in midlife: the CARDIA sleep study. Arch Intern Med. 2009;169:1055–1061. doi: 10.1001/archinternmed.2009.119
28.
Gottlieb DJ, Redline S, Nieto FJ, Baldwin CM, Newman AB, Resnick HE, Punjabi NM. Association of usual sleep duration with hypertension: the Sleep Heart Health Study. Sleep. 2006;29:1009–1014. doi: 10.1093/sleep/29.8.1009
29.
Stranges S, Dorn JM, Cappuccio FP, Donahue RP, Rafalson LB, Hovey KM, Freudenheim JL, Kandala NB, Miller MA, Trevisan M. A population-based study of reduced sleep duration and hypertension: the strongest association may be in premenopausal women. J Hypertens. 2010;28:896–902. doi: 10.1097/HJH.0b013e328335d076
30.
Guo X, Zheng L, Wang J, Zhang X, Zhang X, Li J, Sun Y. Epidemiological evidence for the link between sleep duration and high blood pressure: a systematic review and meta-analysis. Sleep Med. 2013;14:324–332. doi: 10.1016/j.sleep.2012.12.001
31.
Troxel WM, Buysse DJ, Matthews KA, Kip KE, Strollo PJ, Hall M, Drumheller O, Reis SE. Sleep symptoms predict the development of the metabolic syndrome. Sleep. 2010;33:1633–1640. doi: 10.1093/sleep/33.12.1633
32.
Lopez-Garcia E, Faubel R, Guallar-Castillon P, Leon-Muñoz L, Banegas JR, Rodriguez-Artalejo F. Self-reported sleep duration and hypertension in older Spanish adults. J Am Geriatr Soc. 2009;57:663–668. doi: 10.1111/j.1532-5415.2009.02177.x
33.
van den Berg JF, Tulen JHM, Neven AK, Hofman A, Miedema HME, Witteman JCM, Tiemeier H, et al. Sleep duration and hypertension are not associated in the elderly. Hypertension. 2007;50:585–589. doi: 10.1161/HYPERTENSIONAHA.107.092585
34.
Kim J, Jo I. Age-dependent association between sleep duration and hypertension in the adult Korean population. Am J Hypertens. 2010;23:1286–1291. doi: 10.1038/ajh.2010.166
35.
Wang H, Zee P, Reid K, Chervin RD, Patwari PP, Wang B, Li Z, Tang G, Liu X, Yang J, et al. Gender-specific association of sleep duration with blood pressure in rural Chinese adults. Sleep Med. 2011;12:693–699. doi: 10.1016/j.sleep.2010.12.019
36.
Rod NH, Vahtera J, Westerlund H, Kivimaki M, Zins M, Goldberg M, Lange T. Sleep disturbances and cause-specific mortality: results from the GAZEL cohort study. Am J Epidemiol. 2011;173:300–309. doi: 10.1093/aje/kwq371
37.
Whelton PK, Carey RM, Aronow WS, Casey DE, Collins KJ, Dennison Himmelfarb C, DePalma SM, Gidding S, Jamerson KA, Jones DW, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association task force on clinical practice guidelines. J Am Coll Cardiol. 2018;71:e127–e248. doi: 10.1016/j.jacc.2017.11.006
38.
Whelton PK, Carey RM, Aronow WS, Casey DE, Collins KJ, Dennison Himmelfarb C, DePalma SM, Gidding S, Jamerson KA, Jones DW, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association task force on clinical Pr. Hypertension. 2018;71:e13–e115. doi: 10.1161/HYP.0000000000000065
39.
Lawn RB, Nishimi KM, Sumner JA, Chibnik LB, Roberts AL, Kubzansky LD, Rich-Edwards JW, Koenen KC, Thurston RC. Sexual violence and risk of hypertension in women in the Nurses’ Health Study II: a 7-year prospective analysis. J Am Heart Assoc. 2022;11:e023015. doi: 10.1161/JAHA.121.023015
40.
Schwingshackl L, Hoffmann G. Diet quality as assessed by the healthy eating index, the alternate healthy eating index, the dietary approaches to stop hypertension score, and health outcomes: a systematic review and meta-analysis of cohort studies. J Acad Nutr Diet. 2015;115:780–800.e5. doi: 10.1016/j.jand.2014.12.009
41.
Schwingshackl L, Bogensberger B, Hoffmann G. Diet quality as assessed by the healthy eating index, alternate healthy eating index, dietary approaches to stop hypertension score, and health outcomes: an updated systematic review and meta-analysis of cohort studies. J Acad Nutr Diet. 2018;118:74–100.e11. doi: 10.1016/j.jand.2017.08.024
42.
Chen HC, Su TP, Chou P. A nine-year follow-up study of sleep patterns and mortality in community-dwelling older adults in Taiwan. Sleep. 2013;36:1187–1198. doi: 10.5665/sleep.2884
43.
Wang Y, Jiang T, Wang X, Zhao J, Kang J, Chen M, Wang H, Niu L, Wang Y, Zhou Y, et al. Association between insomnia and metabolic syndrome in a Chinese Han population: a cross-sectional study. Sci Rep. 2017;7:10893. doi: 10.1038/s41598-017-11431-6
44.
Yardi N, Adsule S. A cross-sectional observational study to determine the prevalence of insomnia amongst Indian corporate employees. J Assoc Physicians India. 2015;63:20–25.
45.
Haghayegh S, Smolensky MH, Khoshnevis S, Hermida RC, Castriotta RJ, Diller KR. The circadian rhythm of thermoregulation modulates both the sleep/wake cycle and 24 h pattern of arterial blood pressure. Compr Physiol. 2021;11:1–14. doi: 10.1002/cphy.c210008
46.
Hower IM, Harper SA, Buford TW. Circadian rhythms, exercise, and cardiovascular health. J Circadian Rhythms. 2018;16:1–8. doi: 10.5334/jcr.164
47.
Wells JCK, Hallal PC, Reichert FF, Menezes AMB, Araújo CLP, Victora CG. Sleep patterns and television viewing in relation to obesity and blood pressure: evidence from an adolescent Brazilian birth cohort. Int J Obes (Lond). 2008;32:1042–1049. doi: 10.1038/ijo.2008.37
48.
Lusardi P, Zoppi A, Preti P, Pesce RM, Piazza E, Fogari R. Effects of insufficient sleep on blood pressure in hypertensive patients: a 24-h study. Am J Hypertens. 1999;12(1 pt 1):63–68. doi: 10.1016/s0895-7061(98)00200-3
49.
Tochikubo O, Ikeda A, Miyajima E, Ishii M. Effects of insufficient sleep on blood pressure monitored by a new multibiomedical recorder. Hypertension. 1996;27:1318–1324. doi: 10.1161/01.hyp.27.6.1318
50.
Wang Q, Xi B, Liu M, Zhang Y, Fu M. Short sleep duration is associated with hypertension risk among adults: a systematic review and meta-analysis. Hypertens Res. 2012;35:1012–1018. doi: 10.1038/hr.2012.91
51.
Fernandez-Mendoza J, Vgontzas AN, Liao D, Shaffer ML, Vela-Bueno A, Basta M, Bixler EO. Insomnia with objective short sleep duration and incident hypertension. Hypertension. 2012;60:929–935. doi: 10.1161/HYPERTENSIONAHA.112.193268
52.
Patel SR, Ayas NT, Malhotra MR, White DP, Schernhammer ES, Speizer FE, Stampfer MJ, Hu FB. A prospective study of sleep duration and mortality risk in women. Sleep. 2004;27:440–444. doi: 10.1093/sleep/27.3.440
53.
Huang T, Lin BM, Markt SC, Stampfer MJ, Laden F, Hu FB, Tworoger SS, Redline S. Sex differences in the associations of obstructive sleep apnoea with epidemiological factors. Eur Respir J. 2018;51:1702421. doi: 10.1183/13993003.02421-2017
54.
Chasan-Taber L, Willett WC, Manson JE, Spiegelman D, Hunter DJ, Curhan G, Colditz GA, Stampfer MJ. Prospective study of oral contraceptives and hypertension among women in the United States. Circulation. 1996;94:483–489. doi: 10.1161/01.cir.94.3.483
55.
Forman JP, Curhan GC, Taylor EN. Plasma 25-hydroxyvitamin D levels and risk of incident hypertension among young women. Hypertension. 2008;52:828–832. doi: 10.1161/HYPERTENSIONAHA.108.117630
56.
Gómez-Santos C, Saura CB, Lucas JAR, Castell P, Madrid JA, Garaulet M. Menopause status is associated with circadian- and sleep-related alterations. Menopause. 2016;23:682–690. doi: 10.1097/GME.0000000000000612
57.
Pengo MF, Won CH, Bourjeily G. Sleep in women across the life span. Chest. 2018;154:196–206. doi: 10.1016/j.chest.2018.04.005
58.
Maukonen M, Kanerva N, Partonen T, Männistö S. Chronotype and energy intake timing in relation to changes in anthropometrics: a 7-year follow-up study in adults. Chronobiol Int. 2019;36:27–41. doi: 10.1080/07420528.2018.1515772
59.
Druiven SJM, Hovenkamp-Hermelink JHM, Knapen SE, Kamphuis J, Haarman BCM, Penninx BWJH, Antypa N, Meesters Y, Schoevers RA, Riese H. Stability of chronotype over a 7-year follow=up period and its association with severity of depressive and anxiety symptoms. Depress Anxiety. 2020;37:466–474. doi: 10.1002/da.22995

eLetters(0)

eLetters should relate to an article recently published in the journal and are not a forum for providing unpublished data. Comments are reviewed for appropriate use of tone and language. Comments are not peer-reviewed. Acceptable comments are posted to the journal website only. Comments are not published in an issue and are not indexed in PubMed. Comments should be no longer than 500 words and will only be posted online. References are limited to 10. Authors of the article cited in the comment will be invited to reply, as appropriate.

Comments and feedback on AHA/ASA Scientific Statements and Guidelines should be directed to the AHA/ASA Manuscript Oversight Committee via its Correspondence page.

Information & Authors

Information

Published In

Go to Hypertension
Go to Hypertension
Hypertension
Pages: 2407 - 2414
PubMed: 37721046

Versions

You are viewing the most recent version of this article.

History

Received: 9 April 2023
Accepted: 1 September 2023
Published online: 18 September 2023
Published in print: November 2023

Permissions

Request permissions for this article.

Keywords

  1. blood pressure
  2. chronotype
  3. hypertension
  4. sleep duration
  5. sleep initiation and maintenance disorders

Subjects

Authors

Affiliations

Shahab Haghayegh
Channing Division of Network Medicine, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA (S.H., S.S., A.H.E., E.B.R., E.S.S.).
Channing Division of Network Medicine, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA (S.H., S.S., A.H.E., E.B.R., E.S.S.).
Rikuta Hamaya
Departments of Epidemiology (R.H., A.H.E., W.C.W., E.B.R., E.S.S.), Harvard T.H. Chan School of Public Health, Boston, MA.
A. Heather Eliassen
Channing Division of Network Medicine, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA (S.H., S.S., A.H.E., E.B.R., E.S.S.).
Departments of Epidemiology (R.H., A.H.E., W.C.W., E.B.R., E.S.S.), Harvard T.H. Chan School of Public Health, Boston, MA.
Nutrition (A.H.E., W.C.W., E.B.R.), Harvard T.H. Chan School of Public Health, Boston, MA.
Departments of Epidemiology (R.H., A.H.E., W.C.W., E.B.R., E.S.S.), Harvard T.H. Chan School of Public Health, Boston, MA.
Nutrition (A.H.E., W.C.W., E.B.R.), Harvard T.H. Chan School of Public Health, Boston, MA.
Channing Division of Network Medicine, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA (S.H., S.S., A.H.E., E.B.R., E.S.S.).
Departments of Epidemiology (R.H., A.H.E., W.C.W., E.B.R., E.S.S.), Harvard T.H. Chan School of Public Health, Boston, MA.
Nutrition (A.H.E., W.C.W., E.B.R.), Harvard T.H. Chan School of Public Health, Boston, MA.
Channing Division of Network Medicine, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA (S.H., S.S., A.H.E., E.B.R., E.S.S.).
Department of Epidemiology, Center for Public Health, Medical University of Vienna, Austria (E.S.S.).
Departments of Epidemiology (R.H., A.H.E., W.C.W., E.B.R., E.S.S.), Harvard T.H. Chan School of Public Health, Boston, MA.

Notes

For Sources of Funding and Disclosures, see page 2413.
Supplemental Material is available at Supplemental Material.
Correspondence to: Eva S. Schernhammer, Channing Division of Network Medicine, Department of Medicine, Brigham and Women’s Hospital, 181 Longwood Ave, 02115 Boston, MA. Email [email protected]

Disclosures

Disclosures None.

Sources of Funding

This study was supported by the National Institutes of Health (grant numbers UM1CA186107, U01 CA176726, P01CA87969, U01 HL145386, P30 ES000002, R01 CA163451, and R01 HD101101) and by funding from the European Research Council under the European Union’s Horizon 2020 research and innovation program (grant agreement numbers 101053225).

Metrics & Citations

Metrics

Citations

Download Citations

If you have the appropriate software installed, you can download article citation data to the citation manager of your choice. Select your manager software from the list below and click Download.

  1. Sleep as a possible mediator in the association of mental health parameters with cardiovascular health indices in women: exploratory analyses from the Heart SCORE Study, Menopause, 32, 2, (142-150), (2025).https://doi.org/10.1097/GME.0000000000002461
    Crossref
  2. An association between average daily sleep duration and gallstones in US adults, Scientific Reports, 15, 1, (2025).https://doi.org/10.1038/s41598-025-89157-z
    Crossref
  3. Association of residential greenness and sleep duration in adults: A prospective cohort study in China, Environmental Research, 268, (120767), (2025).https://doi.org/10.1016/j.envres.2025.120767
    Crossref
  4. The Association Between Sleep Duration and the Risk of Hypertension: A Systematic Review and Meta-analysis of Cohort Studies, Journal of General Internal Medicine, (2025).https://doi.org/10.1007/s11606-025-09398-6
    Crossref
  5. Associations between insomnia and cardiovascular diseases: a meta-review and meta-analysis of observational and Mendelian randomization studies, Journal of Clinical Sleep Medicine, 20, 12, (1975-1984), (2024).https://doi.org/10.5664/jcsm.11326
    Crossref
  6. Correlation between sleep duration and prevalence of hypertension: the China Health and Nutrition Survey, Brazilian Journal of Medical and Biological Research, 57, (2024).https://doi.org/10.1590/1414-431x2024e13868
    Crossref
  7. Sex differences in hypertension incidence and risk factors: a population-based cohort study in Southern Iran, BMC Public Health, 24, 1, (2024).https://doi.org/10.1186/s12889-024-21082-8
    Crossref
  8. Awakening to the Pertinence of Sleep for Hypertension, Hypertension, 81, 12, (2407-2409), (2024)./doi/10.1161/HYPERTENSIONAHA.124.21727
    Abstract
  9. Self‐reported sleep duration and quality and cardiovascular diseases among middle‐aged and older Chinese: A 7‐year longitudinal cohort study, The Journal of Clinical Hypertension, 26, 10, (1145-1154), (2024).https://doi.org/10.1111/jch.14883
    Crossref
  10. Sleep and hypertension – up to date 2024, Hypertension Research, 47, 12, (3356-3362), (2024).https://doi.org/10.1038/s41440-024-01845-x
    Crossref
  11. See more
Loading...

View Options

View options

PDF and All Supplements

Download PDF and All Supplements

PDF/EPUB

View PDF/EPUB
Login options

Check if you have access through your login credentials or your institution to get full access on this article.

Personal login Institutional Login
Purchase Options

Purchase this article to access the full text.

Purchase access to this article for 24 hours

Sleeping Difficulties, Sleep Duration, and Risk of Hypertension in Women
Hypertension
  • Vol. 80
  • No. 11

Purchase access to this journal for 24 hours

Hypertension
  • Vol. 80
  • No. 11
Restore your content access

Enter your email address to restore your content access:

Note: This functionality works only for purchases done as a guest. If you already have an account, log in to access the content to which you are entitled.

Figures

Tables

Media

Share

Share

Share article link

Share

Comment Response