Short sleep duration and incident coronary artery calcification
Open accessAbstract
CONTEXT: Coronary artery calcification is a subclinical predictor of coronary heart disease. Recent studies have found that sleep duration is correlated with established risk factors for calcification including glucose regulation, blood pressure, sex, age, education, and body mass index. OBJECTIVE: To determine whether objective and subjective measures of sleep duration and quality are associated with incidence of calcification over 5 years and whether calcification risk factors mediate the association. DESIGN, SETTING, AND PARTICIPANTS: Observational cohort of home monitoring in a healthy middle-aged population of 495 participants from the Coronary Artery Risk Development in Young Adults (CARDIA) cohort Chicago site (black and white men and women aged 35-47 years at year 15 of the study in 2000-2001 with follow-up data at year 20 in 2005-2006). Potential confounders (age, sex, race, education, apnea risk, smoking status) and mediators (lipids, blood pressure, body mass index, diabetes, inflammatory markers, alcohol consumption, depression, hostility, self-reported medical conditions) were measured at both baseline and follow-up. Sleep metrics (wrist actigraphy measured duration and fragmentation, daytime sleepiness, overall quality, self-reported duration) were examined for association with incident calcification. Participants had no detectable calcification at baseline. MAIN OUTCOME MEASURE: Coronary artery calcification was measured by computed tomography in 2000-2001 and 2005-2006 and incidence of new calcification over that time was the primary outcome. RESULTS: Five-year calcification incidence was 12.3% (n = 61). Longer measured sleep duration was significantly associated with reduced calcification incidence (adjusted odds ratio, 0.67 per hour [95% confidence interval, 0.49-0.91 per hour]; P = .01). No potential mediators appreciably altered the magnitude or significance of sleep (adjusted odds ratio estimates ranged from 0.64 to 0.68 per sleep hour; maximum P = .02). Alternative sleep metrics were not significantly associated with calcification. CONCLUSION: Longer measured sleep is associated with lower calcification incidence independent of examined potential mediators and confounders.
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TL;DR
In a CARDIA ancillary cohort of 494 middle-aged adults without baseline coronary artery calcification, longer actigraph-measured sleep duration was associated with lower five-year incidence of calcification. The association persisted after adjustment for confounders and potential mediators, while other sleep metrics were not significantly associated.
Key findings
- Five-year incident calcification was 12.3% (n=61). Each additional hour of actigraph-measured sleep was associated with lower adjusted odds of incident calcification (OR 0.67, 95% CI 0.49–0.91, p=.011); the unadjusted OR was 0.57 (95% CI 0.44–0.73).
- Adding potential mediators one at a time did not appreciably change the sleep estimate (adjusted ORs 0.64–0.68; maximum p=.020). Alternative sleep metrics—self-reported duration, daytime sleepiness, Pittsburgh Sleep Quality Index, and fragmentation—were not significantly associated with calcification.
- Sensitivity analyses were similar: with a >10 Agatston unit threshold, adjusted OR 0.63 (95% CI 0.44–0.90); with Poisson regression, RR per hour 0.75 (95% CI 0.60–0.93, p=.011). One additional hour of sleep was modeled as equivalent to a 16.5 mmHg decrease in systolic blood pressure.
- Stratified estimates suggested a stronger sleep effect in women (OR 0.48, 95% CI 0.27–0.85) than men (OR 0.76, 95% CI 0.52–1.10), but the interaction was not significant (p=.122); race interaction p=.916 and apnea-risk interaction p=.507.
Methods
- Observational cohort using the CARDIA Chicago ancillary sleep study, 2000–2006. Participants were 494 African American and white men and women aged 35–47 at baseline, with sleep, demographic, and calcification measurements and no detectable baseline calcification.
- Sleep was measured by wrist actigraphy (Actiwatch-16) over six nights in two waves, plus self-reported duration and questionnaires (Pittsburgh Sleep Quality Index, Epworth Sleepiness Scale, Berlin Questionnaire). Coronary artery calcification was measured by CT in 2000–2001 and 2005–2006; incident new calcification was the primary outcome.
- Logistic regression adjusted for age, sex-race group, education, smoking, and apnea risk. Potential mediators were added one at a time; sensitivity analyses used a >10 Agatston unit threshold and Poisson regression.
Limitations
- Stated: too few participants had baseline calcification to examine further calcification; the first sleep wave occurred more than halfway through follow-up, so calcification may have occurred before sleep measurement, though the authors saw no obvious reverse causation mechanism; actigraphy cannot measure sleep stages; lack of a clinical apnea diagnosis was called the study’s main limitation; the Berlin Questionnaire may leave residual confounding; early calcification is not a clinical outcome; few participants had more than eight hours of measured sleep, limiting detection of a U-shaped relationship; inflammatory markers were incomplete (fibrinogen and interleukin-6 only at follow-up) and cortisol profiles were not investigated.
- Stated: actigraphic fragmentation has not been widely used and its relation to other sleep-quality measures remains unclear; self-reported sleep is only weakly correlated with polysomnography total sleep time (r=0.16), whereas actigraphy is highly correlated (r>0.90).
- Evident from the text: the observational design cannot establish causality; the sample came from one CARDIA site (Chicago) and an ancillary study, which may limit generalizability; residual confounding by unmeasured factors remains possible despite adjustment.
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Claims the paper makes
0 of 39 cited sources checked · 0 supported · 0 flagged
- Findingown data
Sensitivity analysis with a higher cut-point for positive calcification (>10 Agatston units) gave similar results (adjusted OR = 0.63, 95% CI 0.44-0.90).
“Results for a sensitivity analysis with a higher cut-point for positive calcification (>10 Agatston units) were similar (adjusted OR =0.63, 95% CI 0.44–0.90).”
Quote in the paperNot a substantial claim - Findingown data
Unadjusted logistic regression yields a significant reduction in the odds of incident calcification with increasing measured sleep duration; unadjusted OR = 0.57 (95% CI 0.44-0.73) per hour.
“Unadjusted logistic regression yields a significant reduction in the odds of incident calcification with increasing measured sleep duration; the unadjusted odds ratio is 0.57 (95% CI 0.44–0.73) per hour.”
Quote in the paperSubstantial claim - Findingown data
In sex-stratified models, the measured sleep duration effect was stronger for women (N=291; OR=0.48, 95% CI 0.27-0.85) than for men (N=203; OR=0.76, 95% CI 0.52-1.10).
“Stratifying by sex suggested a stronger measured sleep duration effect for women (N=291; sleep OR=0.48, 95% CI 0.27–0.85) than for men (N=203; sleep OR=0.76, 95% CI.52–1.10)”
Quote in the paperNot a substantial claim - Findingown data
In race-stratified models, the measured sleep duration effect was OR=0.61 (95% CI 0.39-0.96) for whites (N=275) and OR=0.64 (95% CI 0.41-1.02) for blacks (N=219).
“In stratified regression models there was no suggestion that effects vary by race: OR=0.61, 95% CI 0.39–0.96 for whites (N=275) and OR=0.64, 95% CI 0.41–1.02 for blacks (N=219).”
Quote in the paperNot a substantial claim - Findingown data
The modeled effect of one additional hour of sleep on the odds of incident calcification was equal to the modeled effect of a 16.5 mmHg decrease in systolic blood pressure.
“The modeled effect of one additional hour of sleep on the odds of incident calcification was equal to the modeled effect of a 16.5 mmHg decrease in systolic blood pressure.”
Quote in the paperNot a substantial claim
- Findingown data
No potential mediators appreciably altered the magnitude or significance of the association between measured sleep duration and calcification (adjusted OR estimates ranged from 0.64 to 0.68 per sleep hour, maximum p-value=.020).
“No potential mediators appreciably altered the magnitude or significance of sleep (adjusted OR estimates ranged from 0.64 to 0.68 per sleep hour, maximum p-value=.020).”
- Also stated in: § Results · plain
“none of the potential mediators substantially changed the sleep coefficient (although many had main effects on calcification incidence), or caused the p-value for the coefficient for sleep to fall below 0.05; adjusted odds ratios for measured sleep ranged from 0.64 to 0.68, and the largest p-value for sleep hours was 0.020.”
Quote in the paperSubstantial claim - Also stated in: § Results · plain
- Findingown data
The study found no evidence of a U-shaped relationship between sleep duration and calcification.
“Contrary to others [43,44], we find no evidence of a U-shaped relationship.”
Quote in the paperSubstantial claim0 of 2 sources checked- cites [43] Gottlieb DJ Redline S Nieto FJ Association of usual sleep duration with hypertension: the Sleep Heart Health Study Sleep 2006 29 8 1009 14 16944668
Not checked in the free run.
- cites [44] Ayas NT White DP Manson JE Stampfer MJ Speizer FE Malhotra A Hu FB A prospective study of sleep duration and coronary heart disease in women Arch Intern Med 2003 Jan 27 163 2 205 9 12546611
Not checked in the free run.
- Findingown data
Additionally adjusting for key cardiovascular risk factors had little effect on the odds ratio for measured sleep.
“Additionally adjusting for key cardiovascular risk factors had little effect on the odds ratio for measured sleep.”
Quote in the paperSubstantial claim - Findingown data
Alternative sleep metrics were not significantly associated with calcification.
“Alternative sleep metrics were not significantly associated with calcification.”
- Also stated in: § Results · plain
“None of the alternate metrics was significantly associated with incident calcification (Table 3).”
Quote in the paperSubstantial claim - Also stated in: § Results · plain
- Findingown data
No interaction terms between sleep and other covariates were found to be significant.
“No interaction terms between sleep and other covariates were found to be significant.”
Quote in the paperNot a substantial claim - Findingown data
Longer measured sleep duration was associated with decreased adjusted odds of incident calcification (OR = 0.67 per hour, 95% CI 0.49-0.91), adjusting for age, sex, race, education, smoking and apnea risk.
“Longer measured sleep duration was significantly associated with decreased adjusted odds of calcification (OR = 0.67 per hour, p=.011; 95% CI 0.49–0.91).”
- Also stated in: § Results · plain
“Adjusting for age, sex, race, education, smoking and apnea risk, longer measured sleep duration was associated with reduced calcification incidence: an odds ratio of 0.67 (95% CI 0.49–0.91) per hour.”
Quote in the paperSubstantial claim - Also stated in: § Results · plain
- Findingown data
The interaction term between race and sleep was not significant (p=.916).
“In combined regression, the interaction term of race and sleep was not significant (p=.916).”
Quote in the paperNot a substantial claim - Findingown data
The sleep effect among those with low apnea risk is similar to the effect in the whole sample (OR=0.72, 95% CI 0.2-1.01).
“If we stratify by apnea risk, however, the sleep effect among those with low apnea risk is quite similar to the effect in the whole sample (0.72, 95% CI 0.2, 1.01)”
Quote in the paperSubstantial claim - Findingown data
The interaction term between sex and sleep was not significant (p=.122).
“however the interaction term in a combined model was not significant (p=.122).”
Quote in the paperNot a substantial claim - Findingown data
The interaction term between apnea risk and sleep was not significant (p=.507).
“but the interaction was not significant (p=.507).”
Quote in the paperNot a substantial claim - Findingown data
The proportion of persons developing calcification decreases monotonically as actigraphic sleep hours increases (unadjusted).
“Figure 2 displays the unadjusted relationship between actigraphic and self reported sleep hours and calcification incidence; the proportion of persons developing calcification decreases monotonically as actigraphic sleep hours increases.”
Quote in the paperNot a substantial claim - Findingown data
Five-year calcification incidence was 12.3% (n=61).
“Five-year calcification incidence was 12.3% (n=61).”
Quote in the paperNot a substantial claim - Findingown data
The prevalence of detectable calcification was low (40/535) at the baseline exam.
“The prevalence of detectable calcification was low (40/535) at the baseline exam.”
Quote in the paperSubstantial claim - Premisecitation
Actigraphy avoids potential biases in self-reported sleep duration caused by the perception of fatigue in states of poor health.
“Actigraphy avoids potential biases in self-reported sleep duration caused by the perception of fatigue in states of poor health [14].”
Quote in the paperSubstantial claim0 of 1 sources checked- cites [14] Knutson KL Turek FW The U-shaped association between sleep and health: the 2 peaks do not mean the same thing Sleep 2006 Jul 1 29 7 878 9 16895253
Not checked in the free run.
- Premisecitation
Sleep quantity and quality are correlates of sex, age, education, and obesity.
“sex, age, education [10], and obesity [11]”
Quote in the paperSubstantial claim0 of 2 sources checked- cites [10] Lauderdale D Knutson K Yan L Objectively measured sleep characteristics among early middle-aged adults: The CARDIA Study Am J Epidemiology 2006 164 1 5 16 16740591
Not checked in the free run.
- cites [11] Gangwisch JE Malaspina D Boden-Albala B Heymsfield S Inadequate sleep as a risk factor for obesity: analysis of the NHANES I Sleep 2005 28 1265 1272 16295214
Not checked in the free run.
- Premisecitation
Actigraphy-measured total sleep duration is highly correlated with polysomnography (r > 0.90 in healthy subjects).
“Wrist actigraphy has been validated against polysomnography, demonstrating a correlation over 0.9 in healthy subjects for total sleep duration [19].”
- Also stated in: § Discussion · plain
“actigraphy is highly correlated to polysomnography total sleep time (r > 0.90) [19,20]”
Quote in the paperSubstantial claim0 of 2 sources checked- cites [19] Tryon WW Issues of validity in actigraphic sleep assessment Sleep 2004 27 158 65 14998254
Not checked in the free run.
- cites [20] Ancoli-Israel S Cole R Alessi C Chambers M Moorcroft W Pollak CP The role of actigraphy in the study of sleep and circadian rhythms Sleep 2003 26 3 342 92 12749557
Not checked in the free run.
- Also stated in: § Discussion · plain
- Premisecitation
Coronary artery calcification is a subclinical predictor of future coronary heart disease events.
“Coronary artery calcification, the accumulation of calcified plaques visible by computed tomography [1], is a subclinical predictor of future coronary heart disease events [2, 3].”
Quote in the paperSubstantial claim0 of 2 sources checked- cites [2] Detrano R Guerci AD Carr JJ Coronary calcium as a predictor of coronary events in four racial or ethnic groups N Engl J Med 2008 358 1336 1345 18367736
Not checked in the free run.
- cites [3] Greenland P Bonow RO Brundage RH ACCF/AHA 2007 clinical expert consensus document on coronary artery calcium scoring by computed tomography in global cardiovascular risk assessment and in evaluation of patients with chest pain J Am Coll Cardiol 2007 49 378 402 17239724
Not checked in the free run.
- Premisecitation
Actigraphy-measured sleep has been shown to be relatively stable year-to-year in this cohort.
“Actigraphy measured sleep has been shown to be relatively stable year-to-year in this cohort [34]”
Quote in the paperSubstantial claim0 of 1 sources checked- cites [34] Knutson KL Rathouz PJ Yan LL Liu K Lauderdale DS Intra-individual daily and yearly variability in actigraphically recorded sleep measures: the CARDIA study Sleep 2007 Jun 1 30 6 793 6 17580601 PMC1978344
Not checked in the free run.
- Premisecitation
Self-reported sleep is only weakly correlated with total sleep time from polysomnography (r = 0.16).
“Previous data indicate that self reported sleep is only weakly correlated to total sleep time from polysomnography (r = 0.16) [12]”
Quote in the paperSubstantial claim0 of 1 sources checked- cites [12] Silva GE Goodwin JL Sherrill DL Arnold JL Bootzin RR Smith T Walsleben JA Baldwin CM Quan SF Relationship between reported and measured sleep times: the sleep heart health study (SHHS) J Clin Sleep Med 2007 Oct 15 3 6 622 30 17993045 PMC2045712
Not checked in the free run.
- Premisecitation
Some correlations between sleep and risk factors have only been documented in studies where sleep is measured by self-report, which may be biased or insufficiently accurate.
“However, some of these correlations have only been documented in studies where sleep is measured by self-report, which may be biased or insufficiently accurate [12,13,14].”
Quote in the paperSubstantial claim0 of 3 sources checked- cites [12] Silva GE Goodwin JL Sherrill DL Arnold JL Bootzin RR Smith T Walsleben JA Baldwin CM Quan SF Relationship between reported and measured sleep times: the sleep heart health study (SHHS) J Clin Sleep Med 2007 Oct 15 3 6 622 30 17993045 PMC2045712
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- cites [13] Lauderdale DS Knutson KL Yan LJ Liu K Rathouz PJ Self-reported and measured sleep duration: how similar are they? Epidemiology 2008 November 19 6 838 845 18854708 PMC2785092
Not checked in the free run.
- cites [14] Knutson KL Turek FW The U-shaped association between sleep and health: the 2 peaks do not mean the same thing Sleep 2006 Jul 1 29 7 878 9 16895253
Not checked in the free run.
- Study design and conductown data
There were a few significant differences between those with follow-up scans and those without.
“There were a few significant differences between those with follow-up scans and those without”
Quote in the paperNot a substantial claim - Study design and conductcitation
The study's sleep measurement avoided the potential problem that self-reports of long sleep are confounded by health factors.
“Also, our sleep measurement avoided the potential problem that self-reports of long sleep are confounded by health factors [14].”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [14] Knutson KL Turek FW The U-shaped association between sleep and health: the 2 peaks do not mean the same thing Sleep 2006 Jul 1 29 7 878 9 16895253
Not checked in the free run.
- Study design and conductown data
The study had too few participants with calcification at baseline to examine the rate of further calcification among them.
“First, too few participants had calcification at baseline for us to examine the rate of further calcification among them.”
Quote in the paperNot a substantial claim - Study design and conductcitation
By observing persons in early middle-age, the study reduced the possibility that unmeasured health problems confound the association.
“By observing persons in early middle-age we have reduced the possibility that unmeasured health problems confound the association [14].”
Quote in the paperSubstantial claim0 of 1 sources checked- cites [14] Knutson KL Turek FW The U-shaped association between sleep and health: the 2 peaks do not mean the same thing Sleep 2006 Jul 1 29 7 878 9 16895253
Not checked in the free run.
- Study design and conductcitation
The study lacked a clinical apnea diagnosis, which is its main limitation.
“Because of the well-established association between apnea and cardiac outcomes [35,36,37], our lack of a clinical apnea diagnosis is the study’s main limitation.”
Quote in the paperSubstantial claim0 of 3 sources checked- cites [35] Jung HH Han H Lee JH Sleep apnea, coronary artery disease, and antioxidant status in hemodialysis patients Am J Kidney Dis 2005 May 45 5 875 82 15861353
Not checked in the free run.
- cites [36] Marin JM Carrizo SJ Vicente E Augusti AG Long-term cardiovascular outcomes in men with obstructive sleep apnoea-hypopnoea with or without treatment with continuous positive airway pressure: an observational study Lancet 2000 365 1046 1053 15781100
Not checked in the free run.
- cites [37] Drager LF Bortolotto LA Lorenzi MC Figueiredo AC Krieger EM Lorenzi-Filho G Early signs of atherosclerosis in obstructive sleep apnea Am J Respir Crit Care Med 2005 172 613 618 15901608
Not checked in the free run.
- Interpretationown data
Omitting participants without follow-up data is unlikely to affect the conclusions.
“we do not see evidence that omitting them is likely to affect our conclusions.”
Quote in the paperSubstantial claim - Study design and conductown data
Measured sleep was very similar for those with and without outcome data (p=0.925).
“Measured sleep was very similar for those with and without outcome data (p=0.925).”
Quote in the paperNot a substantial claim - Interpretationown data
Residual apnea confounding is not likely to be responsible for the positive results.
“suggesting that residual apnea confounding is not likely to be responsible for our positive results.”
Quote in the paperSubstantial claim - Study design and conductown data
The mean measured and self-reported sleep levels were very similar between those with and without follow-up data.
“Importantly, the mean measured and self-reported sleep levels were very similar between those with and without follow-up data.”
Quote in the paperSubstantial claim - Interpretationown data
Longer measured sleep is associated with lower calcification incidence independently of examined potential mediators and confounders.
“Longer measured sleep is associated with lower calcification incidence independently of examined potential mediators and confounders.”
Quote in the paperSubstantial claim - Interpretationown data
The study found a robust and novel association between objectively measured sleep duration and five-year incidence of coronary artery calcification.
“We have found a robust and novel association between objectively measured sleep duration and five-year incidence of coronary artery calcification.”
Quote in the paperSubstantial claim - Interpretationown data
The lack of significant heterogeneity by race or sex strengthened the finding.
“the lack of significant heterogeneity by race or sex strengthened this finding.”
Quote in the paperSubstantial claim
- May combine two claims. 12
- Classified as probably not a substantial claim. 24
May combine two claims.
Findingown dataIn apnea-risk-stratified models, the measured sleep duration effect was OR=0.38 (95% CI 0.13-1.10) for high risk and OR=0.72 (95% CI 0.52-1.01) for low risk.
“Stratifying by apnea risk, there was a suggestion of a stronger effect for those at high risk (OR=0.38, 95% CI 0.13–1.10) compared to low risk (OR=0.72, 95% CI 0.52–1.01)”
Quote in the paperNot a substantial claimMay combine two claims.
Findingown dataUse of relative risk regression (Poisson regression) did not substantially change the result: RR for gain of 1 hour = 0.75, p=0.011, 95% CI 0.60-0.93.
“Use of relative risk regression (Poisson regression) did not substantially change the result: RR for gain of 1 hour = 0.75, p=0.011, 95% CI 0.60–0.93.”
Quote in the paperNot a substantial claimMay combine two claims.
Findingown dataPositive follow-up calcification occurred among less than one-fifth of the participants (101/535); among those the intensity was generally low (<20 AU in 59%).
“Positive follow-up calcification occurred among less than one-fifth of the participants (101/535); among those the intensity was generally low (<20 AU in 59%).”
Quote in the paperNot a substantial claimClassified as probably not a substantial claim.
Findingnone givenAmong sleep study participants, 535 have both baseline and follow-up scans.
“Among sleep study participants, 535 have both baseline and follow-up scans.”
Quote in the paperSubstantial claimProbably not a substantial claim: may not pass S3 (load-bearing).
PremisecitationCalcification is a potent risk factor for coronary events.
“is a potent risk factor for coronary events [2,3]”
Quote in the paperNot a substantial claim0 of 2 sources checked- cites [2] Detrano R Guerci AD Carr JJ Coronary calcium as a predictor of coronary events in four racial or ethnic groups N Engl J Med 2008 358 1336 1345 18367736
Not checked in the free run.
- cites [3] Greenland P Bonow RO Brundage RH ACCF/AHA 2007 clinical expert consensus document on coronary artery calcium scoring by computed tomography in global cardiovascular risk assessment and in evaluation of patients with chest pain J Am Coll Cardiol 2007 49 378 402 17239724
Not checked in the free run.
Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.
PremisecitationUnlike polysomnography, actigraphy does not appear to alter sleep behavior, as there is no first night effect.
“Unlike polysomnography, actigraphy does not appear to alter sleep behavior, as there is no “first night effect” [20].”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [20] Ancoli-Israel S Cole R Alessi C Chambers M Moorcroft W Pollak CP The role of actigraphy in the study of sleep and circadian rhythms Sleep 2003 26 3 342 92 12749557
Not checked in the free run.
May combine two claims.
PremisecitationSleep quantity and quality are correlates of glucose and appetite regulation, hypertension, and inflammation.
“Recent experimental and epidemiological data implicate sleep quantity and quality as correlates of several of these risk factors, including glucose and appetite regulation [7], hypertension [8], inflammation [9]”
Quote in the paperSubstantial claim0 of 3 sources checked- cites [7] Knutson KL Spiegel K Penev P Van Cauter E The metabolic consequences of sleep deprivation Sleep Med Rev 2007 Jun 11 3 163 78 17442599 PMC1991337
Not checked in the free run.
- cites [8] Gangwisch JE Heymsfield SB Boden-Albala B Short sleep duration as a risk factor for hypertension: analysis of the First National Health and Nutrition Examination Survey Hypertension 2006 47 833 9 16585410
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- cites [9] Zisapel N Sleep and sleep disturbances: biological basis and clinical implications Cell Mol Life Sci 2007 May 64 10 1174 86 17364142 PMC11136060
Not checked in the free run.
Probably not a substantial claim: may not pass S3 (load-bearing).
PremisecitationCalcification tends to increase over time.
“Calcification tends to increase over time [32]”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [32] Yoon HC Emerick AM Hill JA Gjertson DW Goldin JG Calcium begets calcium: progression of coronary artery calcification in symptomatic subjects Radiology 2002 224 236 241 12091689
Not checked in the free run.
Classified as probably not a substantial claim. May combine two claims.
PremisecitationRisk factors for calcification include male sex, older age, glucose intolerance, tobacco use, dyslipidemia, high blood pressure, obesity, raised inflammatory markers, and low educational attainment.
“Risk factors for calcification include established heart disease risk factors such as male sex, older age, glucose intolerance, tobacco use, dyslipidemia, high blood pressure, obesity, raised inflammatory markers, and low educational attainment [4,5,6].”
Quote in the paperSubstantial claim0 of 3 sources checked- cites [4] Kronmal RA McClelland RL Detrano R Shea S Lima JA Cushman M Bild DE Burke GL Risk Factors for the Progression of Coronary Artery Calcification in Asymptomatic Subjects: Results From the Multi-Ethnic Study of Atherosclerosis (MESA) Circulation 2007 115 2722 2730 17502571
Not checked in the free run.
- cites [5] Loria CM Liu K Lewis CE Hulley SB Sidney S Schreiner PJ Williams OD Bild DE Detrano R Early adult risk factor levels and subsequent coronary artery calcification: the CARDIA Study J Am Coll Cardiol 2007 May 22 49 20 2013 20 17512357
Not checked in the free run.
- cites [6] Yan LL Liu K Daviglus ML Education, 15-year risk factor progression, and coronary artery calcium in young adulthood and early middle age: the Coronary Artery Risk Development in Young Adults study JAMA 2006 295 1793 1800 16622141
Not checked in the free run.
May combine two claims.
PremisecitationThe Berlin Questionnaire has high sensitivity (0.86) and moderate specificity (0.77).
“The Berlin Questionnaire has been found to have high sensitivity (0.86) and moderate specificity (0.77) [23]”
Quote in the paperSubstantial claim0 of 1 sources checked- cites [23] Netzer N Stoohs R Netzer C Using the Berlin Questionnaire to identify patients at risk for the sleep apnea syndrome Ann Intern Med 1999 131 485 91 10507956
Not checked in the free run.
Probably not a substantial claim: may not pass S3 (load-bearing).
PremisecitationBlood pressure significantly predicts calcification incidence.
“and significantly predicts [4] calcification incidence”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [4] Kronmal RA McClelland RL Detrano R Shea S Lima JA Cushman M Bild DE Burke GL Risk Factors for the Progression of Coronary Artery Calcification in Asymptomatic Subjects: Results From the Multi-Ethnic Study of Atherosclerosis (MESA) Circulation 2007 115 2722 2730 17502571
Not checked in the free run.
Probably not a substantial claim: may not pass S3 (load-bearing).
PremisecitationSleep apnea has been linked to calcification in a clinical population.
“Sleep apnea has been linked to calcification in a clinical population [35]”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [35] Jung HH Han H Lee JH Sleep apnea, coronary artery disease, and antioxidant status in hemodialysis patients Am J Kidney Dis 2005 May 45 5 875 82 15861353
Not checked in the free run.
Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.
Study design and conductnone givenActigraphy is unable to measure potentially important dimensions of sleep such as sleep stages, which may underlie the apparent association between duration and calcification.
“Finally, actigraphy is unable to measure potentially important dimensions of sleep such as sleep stages, which may underlie the apparent association between duration and calcification.”
Quote in the paperNot a substantial claimProbably not a substantial claim: may not pass S3 (load-bearing).
PremisecitationSleep apnea has been linked to heart disease in population-based cohorts.
“as well as to heart disease in population-based cohorts [36,37]”
Quote in the paperNot a substantial claim0 of 2 sources checked- cites [36] Marin JM Carrizo SJ Vicente E Augusti AG Long-term cardiovascular outcomes in men with obstructive sleep apnoea-hypopnoea with or without treatment with continuous positive airway pressure: an observational study Lancet 2000 365 1046 1053 15781100
Not checked in the free run.
- cites [37] Drager LF Bortolotto LA Lorenzi MC Figueiredo AC Krieger EM Lorenzi-Filho G Early signs of atherosclerosis in obstructive sleep apnea Am J Respir Crit Care Med 2005 172 613 618 15901608
Not checked in the free run.
Probably not a substantial claim: may not pass S3 (load-bearing).
PremisecitationPrevious studies have established a relationship between self-reported sleep duration and coronary events.
“and coronary events [44]”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [44] Ayas NT White DP Manson JE Stampfer MJ Speizer FE Malhotra A Hu FB A prospective study of sleep duration and coronary heart disease in women Arch Intern Med 2003 Jan 27 163 2 205 9 12546611
Not checked in the free run.
Probably not a substantial claim: may not pass S3 (load-bearing).
Study design and conductown dataSleep study participation did not vary by self-perceptions of usual sleep hours (p=0.745).
“Sleep study participation did not vary by self-perceptions of usual sleep hours (p=0.745).”
Quote in the paperNot a substantial claimClassified as probably not a substantial claim.
Interpretationown dataSuch a U-shaped relationship might be impossible to find in this study population because so few had more than eight hours measured sleep.
“However, such a relationship might be impossible to find in this study population because so few had more than eight hours measured sleep.”
Quote in the paperSubstantial claimMay combine two claims.
InterpretationreasoningThe small effect of apnea risk on incidence in Table 2 is likely a result both of the inclusion of persons without apnea in the high-risk group and the large effect on baseline prevalence.
“The small effect of apnea risk on incidence in Table 2 is likely a result both of the inclusion of persons without apnea in the high-risk group and also the large effect on baseline prevalence”
Quote in the paperNot a substantial claimMay combine two claims.
InterpretationcitationThe Berlin Questionnaire high-risk group should include almost all persons with apnea and a moderate number without.
“meaning our high-risk group should include almost all of the persons with apnea and a moderate number without.”
Quote in the paperSubstantial claimProbably not a substantial claim: may not pass S3 (load-bearing).
PremisecitationBlood pressure declines during sleep.
“blood pressure declines during sleep [48]”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [48] Staessen J Bulpitt CJ O’Brien E Cox J Fagard R Stanton A Thijs L Van Hulle S Vyncke G Amery A The diurnal blood pressure profile. A population study Am J Hypertens 1992 Jun 5 6 Pt 1 386 92 1524764
Not checked in the free run.
Probably not a substantial claim: may not pass S3 (load-bearing).
Study design and conductnone givenThe first wave of sleep measures was taken more than halfway through the period between baseline and follow-up.
“Second, our first wave of sleep measures was taken more than halfway through the period between baseline and follow-up.”
Quote in the paperNot a substantial claimProbably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.
Study design and conductnone givenEarly calcification is not a clinical outcome and coronary events may not necessarily follow.
“However, early calcification is not a clinical outcome and coronary events may not necessarily follow.”
Quote in the paperNot a substantial claimProbably not a substantial claim: may not pass S3 (load-bearing).
PremisecitationPrevious studies have established a relationship between self-reported sleep duration and hypertension.
“previous studies have established a relationship between self-reported sleep duration and related outcomes, such as hypertension [8,43]”
Quote in the paperNot a substantial claim0 of 2 sources checked- cites [8] Gangwisch JE Heymsfield SB Boden-Albala B Short sleep duration as a risk factor for hypertension: analysis of the First National Health and Nutrition Examination Survey Hypertension 2006 47 833 9 16585410
Not checked in the free run.
- cites [43] Gottlieb DJ Redline S Nieto FJ Association of usual sleep duration with hypertension: the Sleep Heart Health Study Sleep 2006 29 8 1009 14 16944668
Not checked in the free run.
Classified as probably not a substantial claim.
Study design and conductnone givenThe main models were adjusted for age, sex-race group, educational attainment, smoking, and apnea risk.
“These models were all adjusted for key potential confounders: age, sex-race group, educational attainment, smoking, and apnea risk.”
Quote in the paperSubstantial claimClassified as probably not a substantial claim.
Study design and conductcitationAgatston scores were adjusted for between-center differences using a standard calcium phantom.
“Agatston scores [17] were adjusted for between-center differences using a standard calcium phantom scanned underneath each participant”
Quote in the paperSubstantial claim0 of 1 sources checked- cites [17] Agatston AS Janowitz WR Hildner FJ Zusmer NR Viamonte M Jr Detrano R Quantification of coronary artery calcium using ultrafast computed tomography J Am Coll Cardiol 1990 Mar 15 15 4 827 32 2407762
Not checked in the free run.
Probably not a substantial claim: may not pass S3 (load-bearing).
Study design and conductnone givenThe main analysis was repeated using relative risk (Poisson) regression in place of logistic regression.
“We also repeated the main analysis using relative risk (Poisson) regression in place of logistic regression.”
Quote in the paperNot a substantial claimProbably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.
Study design and conductnone givenRegression diagnostics were performed, and data points examined for excessive influence.
“Regression diagnostics were performed, and data points examined for excessive influence.”
Quote in the paperNot a substantial claimProbably not a substantial claim: may not pass S3 (load-bearing).
Study design and conductnone givenThe main analysis was repeated using only participants who reported fasting for eight hours prior to both clinical examinations.
“Additionally, we repeated the regression using only the participants who reported fasting for eight hours prior to both clinical examinations.”
Quote in the paperNot a substantial claimClassified as probably not a substantial claim.
Study design and conductnone givenScans were read centrally blinded to all participant characteristics.
“Scans were read centrally; each participant’s scans were read independently blinded to all participant characteristics.”
Quote in the paperSubstantial claimProbably not a substantial claim: may not pass S3 (load-bearing).
Study design and conductnone givenSensitivity analyses were conducted using an alternative threshold for calcification of >10 AU rather than >0 AU.
“Sensitivity analyses were conducted using an alternative threshold for calcification of >10 AU rather than >0 AU.”
Quote in the paperNot a substantial claimProbably not a substantial claim: may not pass S3 (load-bearing).
Study design and conductnone givenBiweekly calibrations were conducted using a standard torso insert to guard against between center and temporal variability.
“Biweekly calibrations were conducted using a standard torso insert to guard against between center and temporal variability.”
Quote in the paperNot a substantial claim
The paper relies on this without support.
No previous literature directly relates sleep and calcification.
“We have not been able to find previous literature directly relating sleep and calcification.”
The paper relies on this without support.
There is no reverse causation mechanism by which calcification affects sleep duration.
“While calcification may have occurred before sleep measurements, there is no obvious reverse causation mechanism.”
Claims other papers make about this one
Each is checked against this paper’s own text: does it say what the citing paper says it does?
Coronary artery calcification is a predictor of the development of coronary heart disease.
“which is a predictor of the development of coronary heart disease [210].”
From Association between sleep deficiency and cardiometabolic disease: implications for health disparities (2016) · cites this paper as [210]
Self-check
Percentages, sums and reported differences re-computed from the paper’s own numbers.
Each contradiction between two passages listed here was confirmed by an independent check.
Low-apnea-risk confidence interval has conflicting lower bounds
MinorThe Results give the low-apnea-risk sleep effect a 95% CI lower bound of 0.52, while the Discussion gives 0.2 for the same odds ratio and upper bound.
“compared to low risk (OR=0.72, 95% CI 0.52–1.01)”
“the sleep effect among those with low apnea risk is quite similar to the effect in the whole sample (0.72, 95% CI 0.2, 1.01)”
Mediators described as measured at both examinations were follow-up-only
MinorThe abstract says the mediators were measured at both baseline and follow-up, but the methods say interleukin-6 and fibrinogen were available only at follow-up.
“Potential confounders (age, sex, race, education, apnea risk, smoking status) and mediators (lipids, blood pressure, body mass index, diabetes, inflammatory markers, alcohol, depression, hostility, self reported medical conditions) were measured at both baseline and follow-up.”
“Interleukin-6 was measured by ultra-sensitive ELISA (R&D Systems, Minneapolis, MN) [29], and was only available at the follow-up examination. Plasma fibrinogen measurements were performed at the follow-up examination using an immunoassay.”
The citation lists haven’t been fetched yet
References 49 · Cited by 389
- Authors
- King, C. R., Knutson, K. L., Rathouz, P. J., Sidney, S., Liu, K., & Lauderdale, D. S.
- Affiliations
- University of Chicago (US)
- Kaiser Permanente (US)
- Northwestern University (US)
- Corresponding author
- Diane S. Lauderdale
- Venue
- JAMA
- Publisher
- American Medical Association (AMA)
- Published
- 2008-12-24
- Volume
- 300
- Issue
- 24
- Pages
- 2859
- ISSN
- 0002-9955 (ISSN-L)
- 0098-7484
- PMC
- PMC2661105
- OpenAlex
- W1553753314
- Semantic Scholar
- 4a2681860b2d9541e97d9d0cfc63f507793a2820
- Cited by
- 389
- References
- 49
- Citations by year
- 2026: 9 · 2025: 11 · 2024: 27 · 2023: 15 · 2022: 14 · 2021: 30 · 2020: 11 · 2019: 18 · 2018: 24 · 2017: 27 · 2016: 22 · 2015: 25 · 2014: 17 · 2013: 34 · 2012: 19
- FWCI
- 37.63
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Locations
- JAMA (publishedVersion)
- PubMed (publishedVersion)
- PubMed Central (acceptedVersion)
- Funders
- National Institutes of Health (n01hc95095-66-0-1, n01hc48050-59-0-1, n01hc48048-58-0-1, n01hc48047-55-0-1, n01hc48049-61-0-1)
- National Institute on Aging (P01AG011412, AG-11412)
- National Heart, Lung, and Blood Institute (N01HC48050, N01 HC 95095, N01 HC048048, N01-HC-048049, N01 HC095095, N01 HC048050, N01-HC48048, N01-HC-48-049, N01 HC048047, N01-HC-480-47)
- National Institute of General Medical Sciences (T32GM007281)
- Topics
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Sleep and related disorders
- Health Sciences › Medicine › Radiology, Nuclear Medicine and Imaging › Cardiac Imaging and Diagnostics
- Health Sciences › Medicine › Physiology › Obstructive Sleep Apnea Research
- Keywords
- sleep duration, coronary artery calcification, sleep quality, sleep fragmentation, daytime sleepiness, actigraphy, coronary heart disease risk, subclinical atherosclerosis, middle-aged adults
- MeSH terms
- Adult, Calcinosis, Coronary Artery Disease, Female, Follow-Up Studies, Humans, Male, Middle Aged, Monitoring, Physiologic, Risk Factors, Sleep, Tomography, X-Ray Computed, Cohort Studies
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Claims read by deepseek-v4.1-flash under definition version 3 (extract-v3) on 2026-10-10.
Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-10-10.
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