Increased Mortality in Relation to Insomnia and Obstructive Sleep Apnea in Korean Patients Studied with Nocturnal Polysomnography

Abstract

Study Objectives: To elucidate the links between the two most prevalent sleep disorders, insomnia and obstructive sleep apnea (OSA), and mortality. Methods: We studied 4,225 subjects who were referred to the Center for Sleep and Chronobiology, Seoul National University Hospital, from January 1994 to December 2008. We divided the subjects into five groups: mild OSA (5 ≤ AHI < 15), moderate OSA (15 ≤ AHI < 30), severe OSA (AHI ≥ 30), insomnia, and a no-sleep-disorder group consisting of subjects without sleep disorders. Standardized mortality ratio (SMR), hazard ratio, and the survival rates of the five groups were calculated and evaluated. Results:The SMR of all-cause mortality was significantly higher in the severe OSA group than in the general population (1.52, 95% CI 1.23-1.85, p < 0.05). The SMR of cardiovascular mortality increased progressively with the severity of OSA (no-sleep-disorder: 0.09, mild: 0.40, moderate: 0.52, severe: 1.79, p < 0.05). Statistical analyses of the hazard ratios indicated that severe OSA is a risk factor for all-cause mortality (HR 3.50, 95% CI 1.03-11.91, p = 0.045) and cardiovascular mortality (HR 17.16, 95% CI 2.29-128.83, p = 0.006). Cardiovascular mortality was also significantly elevated in the insomnia group (HR 8.11, 95% CI 1.03-63.58, p = 0.046). Conclusions: Severe OSA was associated with increased all-cause mortality and cardiovascular mortality compared to the no-sleep-disorder group. Insomnia was associated with increased cardiovascular mortality compared to the no-sleep-disorder group. Keywords: insomnia, OSA, mortality Citation: Choi JW, Song JS, Lee YJ, Won TB, Jeong DU. Increased mortality in relation to insomnia and obstructive sleep apnea in Korean patients studied with nocturnal polysomnography. J Clin Sleep Med. 2017;13(1):49-56. I NTRO DUCTI O NSleep disorders have negative effects on physical and mental health.1-3 Two of the most common sleep disorders are insomnia and obstructive sleep apnea (OSA). The estimated prevalence of insomnia varies according to the criteria used for its definition, ranging from 14.7% for the RDC/ICSD-2 criteria to 22.1% for the DSM-IV-TR criteria. 4 The prevalence of insomnia in Korea is 22.8%. The prevalence is higher in women (25.3%) than in men (20.2%).5 OSA is the second most common sleep disorder with a prevalence of about 3% to 7% in men and 2% to 5% in women. 6 In Korea, an epidemiologic study found that the prevalence of OSA was 4.5% in men and 3.2% in women. Although the mechanistic basis for the association between insomnia and death is unclear, a growing number of studies have suggested that insomnia is related to inflammation, an increase in the activation of the hypothalamic-pituitary-adrenal (HPA) axis, and the sympathetic system, which, in turn, can lead to hypertension, increased heart rate, metabolic dysfunction, and possibly death. [8][9][10][11][12] Moreover, insomnia is comorbid with other psychiatric disorders such as mood disorder and anxiety disorder, which are both closely associated with risk factors for de...

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