Scott Webb (Host): There are many health benefits to getting good sleep, but my guest is here today to share his thoughts and expertise on the benefits to our hearts and cardiovascular system when we get the recommended amount of uninterrupted sleep each night. And I'm joined today by Dr. Jeffrey Barasch. He's the Medical Director for the Center for Sleep Medicine, Medical Director for the Pulmonary Division, and Medical Director for the Pulmonary Rehabilitation Program with the Valley Medical Group.

 Welcome to Conversations Like No Other: Heart Care, presented by the Heart and Vascular Institute of Valley Health System in Paramus, New Jersey. Our podcast goes beyond broad everyday cardiac topics to discuss very real and very specific subjects that impact your heart health. We think you'll enjoy our fresh take. I'm Scott Webb. Thanks for listening.

Host: Doctor, it's nice to have you here today. We're going to talk about sleep and its impact on heart health, but thanks for joining me.

Dr. Jeffrey Barasch: Scott, thanks for having me and the opportunity to discuss sleep.

Host: Yeah, it's a pleasure to have you here. Sleep's one of those things that we all need, of course, and some folks struggle to get good sleep or the right sleep and all of that. But before we get there, maybe just give us an overview, a general sense, like why sleep is such a vital component of our overall health and, in particular, our heart health.

Dr. Jeffrey Barasch: So, that's a good question and it gets right to the heart of the matter. So, why is sleep important to health and cardiac health? Well, I've always been fascinated by sleep, maybe because sleep's always seems so mysterious, you know, what's going on when someone's unconscious for seven or eight hours, and yet it's so universal, every single person and nearly every animal too sleeps everyday.

Host: Right. We all do it. Yeah.

Dr. Jeffrey Barasch: So, humans sleep about a third of our lives. And this is actually more time than we spend doing any other activity in our entire lives. One of the earliest scientists to explore the function of sleep and why we sleep once said that if sleep weren't very important, it would be an awful waste of time. So, that's one clue that it's got to be important. But in fact, we now know that sleep is a basic biologic need like air or water or food. When we look at healthy lifestyles, the medical world has increasingly recognized now that sleep is a foundation to good health along with diet and exercise. Every organ, every cell in the body requires sleep to function properly, either to regenerate depleted energy supplies or repair from stress or clear toxins, or build up the immune system among other things.

In 2022, the American Heart Association recognized explicitly about sleep as a critical element of cardiovascular health. They stated clearly that adequate quantity and quality of sleep are essential for heart health and that sleep disorders will adversely affect the heart and can contribute to high blood pressure and diabetes and obesity, as well as being important to brain function and mental health.

So, let me briefly explain what happens during sleep with respect to the heart. During sleep, the external stresses and the internal excitement of the brain and the heart are all quieted down; for most of us, the only time during the day that this happens. So, this is especially true during the deepest what we call non-REM sleep. The sympathetic nervous system, which is the excitatory or arousing part of the nervous system and is associated with activity and with stress becomes quieter. At the same time, the parasympathetic nervous system-- this is like the yin and the yang-- so the parasympathetic nervous system is associated with slowing down and relaxing and mellowing, now that predominates during non-REM sleep.

Also, during sleep, there's lower levels of stress hormones like adrenaline, which stimulate the heart and tighten blood vessels so that blood pressure and heart rate fall. The average heart rate drops 20-30% and blood pressure drops by 10-20% compared to daytime. We refer to this as the nocturnal blood pressure dip. That's a normal phenomenon. During REM sleep, it's a little different. When we're dreaming, there's more fluctuations in blood pressure and heart rates. In that respect, it's a little bit more like wakefulness.

Now, unfortunately, something has changed in the modern world, in modern society, we've too often neglected the importance of sleep, right? It seems like we're not doing anything productive. We're not working, we're not producing, we're not even having fun.

Host: Right.

Dr. Jeffrey Barasch: So, people sometimes think of sleep as a waste of time, and they give it a low priority. Someone who did this a while back was Thomas Edison. He famously said, and this is almost a direct quote, that sleep is a criminal waste of time. Maybe that's why he was so determined to invent a light bulb, which has contributed to a lot of sleep loss nowadays.

So, sleep has started as a luxury rather than necessity. People sacrifice their sleep to do almost everything else, to work, to exercise, for recreation. And now, a lot of people often think of it associated with laziness and very low productivity. In fact, over the last 50 years, the average American sleeps about an hour less, and over the past a hundred years, about two hours less. And we can thank Edison for that, because the world used to be dark at night.

Host: Right.

Dr. Jeffrey Barasch: But associated with this decline in sleep has been an epidemic of obesity and chronic diseases, including the rise in heart disease, diabetes, stroke, and dementia. There is clearly a connection. Even shift work in which the timing of sleep is altered, like people working at night is associated with increased health problems. So in reality, in order to be healthy, especially cardiac health, sleep has to be given a priority. And adequate good quality sleep needs to be on a regular basis.

Host: Yeah. And, you know, when we think about sleep, in some cases, it's the sheer number of hours. Let's say, you know, folks need at least eight hours of sleep or with kids and my teenagers, you know, 10, 12 hours of sleep. So, there's perhaps good sleep and poor sleep, lack of sleep. There's a lot of sleep factors in there. Ultimately, when we think about bad sleep, poor sleep, lack of sleep, how does that impact the cardiovascular system?

Dr. Jeffrey Barasch: So, you are correct that the amount of sleep that people need does vary with age. Younger people need more sleep and it's often more than they think. I mean, infants need as much as 20 hours of sleep. Adolescents often do need 10 or more hours of sleep. But adults, generally, we're talking about in the eight or nine-hour range. Now, lack of sleep or poor quality sleep, unfortunately, is quite common, but it's been repeatedly shown to have a strong association with high blood pressure, diabetes, cardiovascular disease, and obesity.

The three most common sleep disorders are insufficient sleep, insomnia, and sleep apnea, and all of them were associated with increased heart disease. The CDC actually recognized lack of sleep about 10 years ago as a public health epidemic in their words, because one out of three Americans don't get the recommended amount of sleep. And with insufficient sleep, bad things happen. So if there's insufficient sleep, you have an increase in adrenaline, in cortisol, in blood pressure, in appetite, and in weight. People who sleep six hours or less more often have high blood pressure and diabetes, and obesity and inflammation. They have impaired performance in the daytime, and there's an effect on mental health and our overall mortality.

A study was done of over a hundred thousand people, and it showed that people getting five hours or less of sleep have double the risk of high blood pressure and diabetes, and a significantly increased likelihood of being obese. Adults with five hours or less have a two to three times higher risk of having coronary disease. Even those with only slightly less than normal, say five or six hours of sleep, have a higher risk of high blood pressure, diabetes, and obesity by about a third. So, when people have been tracked who weren't obese over several years, those people who were getting less than seven hours were over 50% more likely to become obese and 20-30% more likely to get high blood pressure and diabetes.

So, what happens, unfortunately, is when people are sleep-deprived, there are changes in hormones, which are regulated by sleep. So, one of them is a hormone called ghrelin, which makes you hungry. And another one is leptin, which makes you feel full. And this occurs throughout the day. So, the result is that when people sleep less, they're more hungry, especially at night, and they eat more; and then, therefore, they gain weight.

So, insomnia is a little bit different than sleep deprivation. Insomnia is difficulty falling asleep or waking during the night or too early in spite of adequate opportunity. When we say sleep insufficiency where somebody isn't giving themselves the opportunity to sleep, but with insomnia, there's the opportunity, but the inability to sleep, and that is also associated with heart disease and diabetes. People with insomnia are much more likely to have heart attacks and strokes or gain weight. So, people with insomnia have a 45% higher risk of cardiovascular disease and a three-fold risk of developing high blood pressure. Now, this may be related to the higher levels of the stress hormones like cortisol, which are seen in people with insomnia. Alarmingly, people with insomnia have over 50% higher risk of having a stroke within a four or five-year time span.

Now, interestingly, insomnia is not all one thing. So, one way of looking at insomnia, when people say have a sleep study, they can actually be separated into two groups. There are those who have reduced objective sleep time, they're actually sleeping less, and there are those who actually are sleeping an adequate or normal amount of sleep, just their perception is that they're not sleeping enough. We refer to that as sleep state misperception, because they subjectively feel they're not sleeping when they actually are.

So, it is just the people with the reduced objective sleep time that have a significantly higher risk of high blood pressure and cardiovascular disease. In a massive study, over a million people across six countries, those who had insomnia with less than five hours of sleep were 70% more likely to have a heart attack and had a 33% increased risk in cardiovascular mortality.

Host: Yeah, it's a lot to take in. But obviously, a lot of physical, psychological, mental benefits to getting sleep. And I want to drill down a little bit more into sleep apnea and conditions like high blood pressure, arrhythmias, heart failure. What's the link between, you know, sleep apnea and those other conditions, if you will?

Dr. Jeffrey Barasch: Right. That's a great question, but let me start with a hypothetical analogy. So, imagine you have a recurrent dream of someone chasing you and then choking you. And while sleeping, you experience this fight or flight response, and you wake up with sweating and your heart racing and your blood pressure soaring. Imagine that happens, not once, but dozens of times a night, every night. Now, imagine that's not a dream, but real. That is what happens with sleep apnea. When someone has sleep apnea, there are repeated episodes of stopping breathing during sleep, which we call an apnea, if you stop breathing for 10 seconds or more. And it occurs because there's a loss of muscle tone in the throat muscles so that the throat narrows and collapses, and the air passage in the neck is obliterated. With every episode of an apnea, there's a drop in the oxygen level in the bloodstream, because you're not breathing, often with a rise in carbon dioxide until breathing resumes. That triggers a surge of adrenaline. That's our principal stress hormone, just like the fight or flight response, and that causes an acceleration in heart rate and a rise in blood pressure.

And then, apnea causes an arousal, a brief awakening from sleep, which enables you to resume breathing and the apnea ends. It allows the oxygen level to come back to normal, and sleep quickly returns until another episode occurs very soon. So, this happens in people with sleep apnea, not once or twice during the night, but dozens or even hundreds of times. It severely disrupts sleep when people are supposed to be getting good rest. So, many times people are unaware this is happening because they're asleep.

Scott Webb: Sure.

Dr. Jeffrey Barasch: And this is when the cardiovascular system is supposed to be getting good rest. So now, the drops in oxygen level combined with those surges of adrenaline, they occur at the same time. So, that's extremely stressful to the cardiovascular system. It's a little bit like trying to drive a car up a steep hill with very little gas. The evidence is suggesting that the low oxygen levels are mostly responsible for the cardiac problems, while the brief arousal from sleep with disruption and fragmenting sleep are what lead to daytime sleepiness or fatigue.

So, what goes beyond that, we've discovered that there are both acute effects, meaning the stress to the heart that's immediate, and that can trigger an adverse event, like an arrhythmia or a heart attack or a stroke. And then, there are more chronic effects because this is occurring night after night, repeated drops, hour after hour, night after night, repeated surges of adrenaline, repeated drops in oxygen level, and that has led to permanent changes in the heart, including damage to the nerves that control the electrical system and the communication channels called connections between heart muscle cells, which enable them to coordinate their beating of the heart. And all of this makes the heart more vulnerable to have irregular rhythms.

Beyond that, there's increased inflammation and clotting factors, which can lead to thrombosis or clots in the coronary arteries. In addition, there's changes in the lining of the blood vessels, which makes the arteries stiffer and makes sustained high blood pressure happen even during awake. And these are just some of the cardiac effects. So, the drops in oxygen level also cause a release of what's called free radicals. These are unstable oxygen molecules that pour into the bloodstream, and they're like wrecking balls, damaging cells, and contributing to disease and even to aging.

So normally, as I mentioned before, people have a progressive fall in blood pressure during the night, and blood pressure's the lowest in the morning. People with sleep apnea have a rise in blood pressure during the night. And the same time, there's adverse effects going on in the brain, which can lead to fogginess and effects on memory and concentration and alertness and reaction time, which leads to increased accidents. So as a result of all of this, people with sleep apnea more often have heart attacks, strokes, and arrhythmias, especially at night, but often can spill over in the day and often a lot earlier in life than might otherwise occur.

So just a few brief statistics, about 50% of people with sleep apnea have high blood pressure. And about 40-50% of people with high blood pressure have sleep apnea. And people who have resistant high blood pressure, meaning that it's difficult to treat, requiring two or more medicines to control. The incidence of sleep apnea is as much as 80% or 90% untreated. Sleep apnea doubles the risk of having a heart attack. And the risk of atrial fibrillation is four to six times higher in people with sleep apnea. And if someone has severe sleep apnea, they have a three times risk of having a stroke. There's also an association with heart failure with a two to threefold increased risk in people with untreated sleep apnea. An almost incredible two-thirds of people with heart failure have sleep apnea. And if you have heart failure, having sleep apnea is very bad for the heart, leading to worsening heart function and arrhythmias, and bad outcome. We also know that people with sleep apnea are hospitalized much more. They have more complications where they're in the hospital, they have longer hospital stays, and they're more frequently readmitted to the hospital.

Host: Yeah. And I had no idea-- this is why we have experts. I had no idea. Because in my mind, I was thinking, all right, well if someone has sleep apnea, yeah, they wake up a few times, they get a CPAP, they'll be fine. I had no idea that it could be dozens of times, hundreds of times a night. A much better sense of why there's so many health risks to untreated sleep apnea, heart risks, of course, which is why you're here today. What are some signs then, Doctor, that we might have sleep problems that are putting our heart at risk. Like, sure, if we're foggy the next day-- you know, if we didn't get good sleep or enough sleep, yeah, you might be foggy, you might nod off in the afternoon, you might just be sleepy or tired, if those are interchangeable. But how would you know if our hearts are also at risk?

Dr. Jeffrey Barasch: Sure. Well, with respect to what you mentioned a minute ago about the frequency, you know, we measure sleep apnea, not by how many times it happens at night, but how many times It happens per hour at night. And we consider someone to have sleep apnea if they have five episodes an hour, and that's the mildest. Severe sleep apnea would be 30 times an hour. But it's not uncommon for us to see someone with 60 or 80 or 90 times per hour that they're having these events.

Now, in answer to your question about how would someone know that their heart is at risk? So, there's a number of things. So first of all, as I mentioned before, if you're regularly getting less than seven hours due to work or lifestyle or insomnia, you are putting your heart at risk. In terms of diagnosis, having untreated sleep apnea, as we said, is a significant risk to your heart. It's estimated that 30 million Americans have sleep apnea and maybe close to a billion people worldwide. So, it's very common, but varying degrees of severity. So in the U.S., about 80% are undiagnosed. Not all people have the same degree of risk. So, how can we break that down?

Well, first of all, severe sleep apnea has the highest risk. And by that, we're talking about, as I said, the frequency, considering someone to have 30 episodes or more an hour would be severe. But even in that, the risk can vary. And so, people looked at, "Well, why would that be?" Some people can have shorter apnea, some people have longer ones. The longer the apnea, the lower the oxygen levels and the greater risk. So, a new measurement was recently developed from data that's collected during a sleep study that we call the hypoxic burden. And what this is is a cumulative frequency, depth and duration of the low oxygen levels. We call it the area under the curve. And it gives weight to how often the oxygen level drops, how low it goes, and how long it stays low. It turns out that this index we call the hypoxic burden, the greater it is, the greater the cardiovascular risk, and it seems to correlate, better than a lot of the other indices that we've used.

Now, those with sleep apnea who also have comorbidities, meaning they already have high blood pressure, obesity, diabetes or heart disease, they're also at much higher risk, especially if they have coronary disease or heart failure. In terms of symptoms, those people who have sleep apnea, who have daytime sleepiness seem to have a higher cardiovascular risk. But another group that's been recognized recently that's extremely high risk is those people who have sleep apnea, who also have insomnia. We call this COMISA. It's a newly kind of designated term, stands for co-morbid obesity and insomnia. These people seem to be at extremely high risk for cardiovascular disease and early mortality.

We actually didn't recognize until recently how common it is for someone to have both sleep apnea and insomnia. It stands to reason they're both common. And so, there's going to be people with both, but it turns out as much as 30-50% of people with sleep apnea also have insomnia. And 40-50% of people with insomnia have both conditions. And in those people who have both, there's a 50-70% increased cardiovascular mortality over 10 to 20 years.

Host: I can't even imagine. I don't want one of these. But to have insomnia and sleep apnea together, I mean, just doubling down and all the more reason to try to get a handle on this and to try to make changes if necessary. But I want to get a sense from you, you know, once you make a diagnosis, what are our treatment options? How do you help folks get to sleep, stay asleep, all that good stuff?

Dr. Jeffrey Barasch: Well, fortunately, we have more successful treatments than ever before for sleep apnea, as well as for other conditions like insomnia. So in people with mild sleep apnea, there are several simple devices like a nasal valve or an oral appliance, or even exercises, so using electric current to strengthen the tongue muscle.

In severe sleep apnea, the principal treatment is something called CPAP, which is a system that uses gentle air pressure to keep the upper airway open during sleep. And this treatment's been around for almost 50 years now, and it's improved a lot over recent years. A lot of people have gotten impression of it from the older types. But there are newer types of machines that are small and quiet and deliver the pressure more gently, and a myriad of new types of masks or interfaces to give the impression that make it a lot more comfortable and palatable.

For people who don't tolerate or benefit from other treatments, then there's surgery, or there is a device that can be implanted electrically that stimulates the airway in the throat to keep it open. In the near future, there'll be medications. There are several promising clinical trials underway that are a couple years away from being able to treat sleep apnea with medications.

Now, there's a lot of data that treating sleep apnea is beneficial to the heart. So, people with sleep apnea who have high blood pressure often see an improvement in their blood pressure within a few months. In people with heart failure, CPAP improves heart function and the heart's performance.

Now, a very, very important landmark study was just published this year that combined data from multiple studies of over a million people who were followed for five years, and it showed that the risk of dying from cardiovascular disease was over 50% less in people who were treated with CPAP, and the risk of dying from any cause was almost 40% lower. But also, the amount of usage made a difference. They showed that with every additional hour of use of CPAP per night improved the odds of survival over five years.

Now in terms of insomnia, we also have improved our treatment. The preferred approach is what we call cognitive behavioral therapy, which involves optimizing people's sleep patterns. So, it includes things like waking up the same time every day, avoiding stimulation before bed, like physical activity or mental stimulation or light, avoiding spending excessive time in bed when not sleeping, and being very active in the day with adequate natural light.

Host: Not having coffee at 10 o'clock at night.

Dr. Jeffrey Barasch: Right. So, there's a chemical stimulation, coffee or alcohol could be detrimental to sleep.

Scott Webb: Doctor, you gave us a sense of how you can help us. How do we help ourselves? I'm assuming, you know, quit smoking, you know, some of the greatest hits. But in general, what could we do to help ourselves to improve our sleep and protect our hearts?

Dr. Jeffrey Barasch: So first of all, getting an adequate amount of quality sleep on a regular basis is cornerstone. But with respect to sleep apnea, it's clear that weight has a large impact. So, you know, weight gain makes it worse. Weight loss leads to improvement. And it doesn't matter how someone loses the weight, whether it's with dieting or exercise or weight loss medications or surgery. As long as the weight comes down, sleep apnea will improve.

Host: Yeah, however you get there.

Dr. Jeffrey Barasch: Now, weight's not the underlying cause of sleep apnea. There appears to be a genetic component. So, weight loss doesn't always cure it. And it's only beneficial to the extent someone's overweight. There's no benefit to going underweight.

Alcohol close to bedtime will not only make sleep apnea worse, but also disrupts the sleep even if you don't have sleep apnea. Muscle relaxants like alprazolam make sleep apnea worse if it's taken close to bedtime. You mentioned cigarette smoking. That does worsen sleep apnea. Body position makes a difference. We tell people in most people it's better if you're sleeping on your side than on your back. So, we encourage people to do things. There's some devices that can promote remaining on your side. Something's very simple, like a t-shirt that has a pocket in the back or something soft and lumpy. And finally, nasal congestion. If the nose is stuffed, it makes sleep apnea worse. Keeping the nose clear can help people sleep better if they have sleep apnea.

Host: Well, thankfully, I'm a lifelong side sleeper, Doc.

Dr. Jeffrey Barasch: That's better.

Host: I got that working for me. I can't sleep on my back to save my life. This has been so good, so educational today. I want to finish up and talk about, you know, how much sleep is enough sleep, how do we get the right kind of sleep, maybe what factor sleep hygiene plays in all of this. Finish up by just giving us a sense, like how much do we need to sleep, how good does the sleep need to be? And ultimately, what are the benefits?

Dr. Jeffrey Barasch: So, the optimal amount of sleep has pretty much been settled now that it's in the seven to nine-hour Both less than seven hours more than eight and a half hours regularly is associated with increased heart disease and mortality. Why would more sleep? It may be that because sleeping more than seven to nine hours, which is the biologically needed amount, maybe an indication of sleepiness, and that there's a sleep disorder, like sleep apnea. But oversleeping also seems to cause inflammation and atherosclerosis, and stiffening of the arteries. So, it's not good to oversleep either.

In terms of quality, there's research that showed that disrupted sleep leads to inflammation, which causes atherosclerosis and leads to high blood pressure, heart attacks, and strokes also. And this has been shown even with irregular sleep duration. So for some people who sleep, you know, more one day and less the next, if the amount of sleep varies by two hours or more a night, that can double the risk of developing cardiovascular disease.

So, to be adequately rested and healthy, three factors are important to keep in mind. Quantity, meaning seven to eight and a half hours. Quality, meaning no disruptions or sleep disorders or insomnia. And also, timing, by timing we mean sleeping on a regular schedule in accordance with someone's natural biological clock. So, the best way to protect the heart is to pay attention to all three: sleep, quantity, quality, and timing.

Host: Yeah. Well, that's perfect. I know that I've benefited from your expertise today. I'm sure listeners have as well. As you say, there's a lot of folks suffering out there. There's a lot of sleepy folks, tired folks, people with undiagnosed sleep apnea and perhaps other sleep conditions, insomnia, whatever it might be. So, I really appreciate your time, your expertise today. It's nice to know that there are some things we can do to help ourselves. You help us, we help ourselves, and hopefully we all get a good night's sleep, right?

Dr. Jeffrey Barasch: Great. That's right. Thanks very much.

Host: And thank you for joining us for this episode of Conversations like No Other: Heart Care. We hope Dr. Jeffrey Barasch's insights have helped you to better understand the powerful connection between sleep and heart health. And remember getting quality rest is more than just recharging, it's a key part of protecting your heart.

If you're experiencing sleep issues or have concerns about your heart, don't hesitate to speak with your doctor. For more information and resources, visit valleyhealth.com/heart. And as always, be sure to subscribe and share this episode, and take good care.