Top Things to Know: Multidimensional Sleep Health: Definitions and Implications for Cardiometabolic Health
Published: April 14, 2025
Prepared by Brooke Aggarwal, EdD, MS, FAHA, Columbia University Department of Medicine
- Sleep health is associated with heart disease and stroke, cardiovascular mortality, and related cardiometabolic risk factors including blood pressure, lipids, inflammation, obesity, physical inactivity, and poor diet. This evidence led to the inclusion of sleep duration as an eighth metric of overall cardiovascular health in the American Heart Association’s Life’s Essential 8.
- Sleep health is a positive, multi-faceted model that goes beyond the absence of known sleep disorders or short sleep duration. Common sleep dimensions included as components of multidimensional sleep health include regularity/rhythmicity, satisfaction/quality, alertness/sleepiness, timing, efficiency, duration, disturbed sleep, and sleep architecture.
- Sleep health is best assessed by combining multiple methods rather than a single measure; these include polysomnography (the gold standard for sleep apnea and sleep architecture), wearable devices, objective measures of alertness, sleep diaries, and validated questionnaires.
- Sleep health disparities exist among different racial and ethnic groups and socioeconomic positions. A social-ecological model helps to explain sleep health by showing that individual-level factors, social-level factors, and societal-level factors all influence sleep patterns.
- Meta-analyses have found associations between short sleep (<7 hours) and metabolic syndrome, atrial fibrillation, stroke, and non-dipping blood pressure; and between long sleep (>9 hours) and metabolic syndrome, arterial stiffness, stroke, and all-cause and cardiovascular mortality. Cardiovascular disease risk appears lowest among adults with approximately 7.5 hours of nightly sleep, though with wide confidence intervals.
- Meta-analyses and systematic reviews have demonstrated that sleep continuity disturbances, such as insomnia symptoms, have been associated with hypertension, arterial stiffness, coronary heart disease, non-dipping blood pressure, and endothelial dysfunction.
- Later sleep timing, such as having a later bedtime, has been associated with higher adiposity, including general and abdominal obesity, and incident myocardial infarction. Higher sleep irregularity (e.g., irregular bed-wake times and/or irregular duration) has been associated with nearly 2-fold increased risk of cardiovascular mortality, while greater sleep consistency of sleep-wake timing has been associated with 22%-57% lower risk of cardiovascular mortality.
- Excessive daytime sleepiness is associated with increased risk of cardiovascular disease, coronary heart disease, and all-cause and cardiovascular mortality, with an existing bidirectional relationship between sleepiness and cardiometabolic risk factors.
- More research is needed using standardized measurements and definitions, along with studies showing how various combinations of sleep dimensions may increase cardiovascular risks. There is also a need for causal and mechanistic evidence that improving sleep health leads to better cardiometabolic health, to guide public health recommendations.
- Clinicians are encouraged to use the multidimensional framework of sleep health described in this paper and to ask patients about sleep more comprehensively using open-ended questions. Simple tools such as the RU_SATED questionnaire can be used to help provide better personalized guidance.
Citation
St-Onge M-P, Aggarwal B, Fernandez-Mendoza J, Johnson D, Kline CE, Knutson KL, Redeker N, Grandner MA; on behalf of the American Heart Association Council on Lifestyle and Cardiometabolic Health; Council on Cardiovascular and Stroke Nursing; Council on Clinical Cardiology; and Council on Quality of Care and Outcomes Research. Multidimensional sleep health: definitions and implications for cardiometabolic health: a scientific statement from the American Heart Association. Circ Cardiovasc Qual Outcomes. Published online April 14, 2025. doi: 10.1161/HCQ.0000000000000139