LONG SLEEP DURATION AND RISK OF INCREASED ARTERIAL STIFFNESS IN MALES

http://dx.doi.org/10.5665/sleep.3920

Long Sleep Duration Associated With a Higher Risk of Increased Arterial

Stiffness in Males

Tsai-Chen Tsai, MD1; Jin-Shang Wu, MD, MS1,2; Yi-Ching Yang, MD, MPH1,2; Ying-Hsiang Huang, MD, MPH1; Feng-Hwa Lu, MD, MS1,2; Chih-Jen Chang, MD1,2
Department of Family Medicine, National Cheng Kung University Hospital, Tainan, Taiwan, ROC; 2Department of Family Medicine, College of
Medicine, National Cheng Kung University, Tainan, Taiwan, ROC

Study Objectives: We aimed to examine the association between sleep duration and arterial stiffness among adults of different ages, because to
date there has been only one study on this relationship, which was confined to middle-aged civil servants.
Design: Cross-sectional study.
Setting: A health examination center in National Cheng Kung University Hospital, Taiwan.
Participants: A total of 3,508 subjects, age 2087 y, were enrolled after excluding those with a history of cerebrovascular events, coronary artery
disease, peripheral artery disease, and taking lipid-lowering drugs, antihypertensives, hypoglycemic agents, and anti-inflammatory drugs, from
October 2006 to August 2009.
Interventions: N/A.
Measurements and Results: Sleep duration was classified into three groups: short (< 6 h), normal (68 h) and long (> 8 h). Arterial stiffness
was measured by brachial-ankle pulse-wave velocity (baPWV), and increased arterial stiffness was defined as baPWV 1400 cm/sec. The sleep
duration was different for subjects with and without increased arterial stiffness in males, but not in females. In the multivariate analysis for males,
long sleepers (odds ratio [OR] 1.75, P = 0.034) but not short sleepers (OR 0.98, P = 0.92) had a higher risk of increased arterial stiffness. In addition,
age, estimated glomerular filtration rate, hypertension, diabetes, total cholesterol/high-density lipoprotein cholesterol ratio, cigarette smoking, and
exercise were also independently associated factors. However, in females, neither short nor long sleep duration was associated with increased
arterial stiffness.
Conclusions: Long sleep duration was associated with a higher risk of increased arterial stiffness in males. Short sleepers did not exhibit a
significant risk of increased arterial stiffness in either sex.
Keywords: arterial stiffness, brachial-ankle pulse-wave velocity, cardiovascular disease, sleep duration
Citation: Tsai TC, Wu JS, Yang YC, Huang YH, Lu FH, Chang CJ. Long sleep duration associated with a higher risk of increased arterial stiffness
in males. SLEEP 2014;37(8):1315-1320.

INTRODUCTION
Epidemiological studies show that both short and long sleep
duration are associated with increased risk of obesity, diabetes,
hypertension, cardiovascular disease, and all-cause mortality.13
The mechanism of the association between sleep duration and
cardiovascular disease remains unclear, although previous
studies show that changes in sleep duration are associated with
metabolic alteration,4 increased sympathetic nervous activity,5
and inflammatory pathways.6,7 Because increased arterial
stiffness is also a predictor of fatal and nonfatal cardiovascular events and all-cause mortality,811 it can be seen as a link
between sleep duration and cardiovascular outcomes.
Arterial stiffness is associated with atherosclerosis at various
sites in the vascular tree.1214 Arterial stiffness is mainly caused
by stimulation of an inflammatory process, overproduction
of abnormal collagen, and decreased quantities of normal
elastin.15 Of the several noninvasive methods available to
assess arterial stiffness, pulse-wave velocity (PWV) is the most

A commentary on this article appears in this issue on page 1279.

Submitted for publication November, 2013
Submitted in final revised form January, 2014
Accepted for publication January, 2014
Address correspondence to: Chih-Jen Chang, Department of Family
Medicine, National Cheng Kung University Hospital, 138, Sheng Li Road,
Tainan, 70403, Taiwan, ROC; Tel: +886-6-2353535 ext 5355; Fax: +8866-2386650; E-mail: em75210@mail.ncku.edu.tw
SLEEP, Vol. 37, No. 8, 2014

validated and reproducible.16,17 Although the gold standard is

measuring central arterial stiffness via carotid-femoral PWV
(cfPWV), this requires persistent lateral rotation of the patients
neck and exposure of the inguinal region. In contrast, brachialankle PWV (baPWV) is more convenient to measure, because
a pressure cuff only needs to be wrapped over the limbs while
the subject is in a supine position. Studies also indicate that
baPWV has a similar degree of association with cardiovascular
risk factors and clinical events as cfPWV.10,1822
To date, few studies have examined the relationship between
sleep duration and arterial stiffness. Only one cross-sectional
Japanese study revealed a positive association between longer
sleep duration and increased arterial stiffness, as measured
by baPWV, in males, but not females.23 However, their study
subjects were confined to middle-aged (3562 y) civil servants,
without consideration of younger and older subjects. The aim
of this study is thus to examine the association between arterial
stiffness and sleep duration in a Taiwanese population.
METHODS
The baseline data, including 7,565 adult examinees, were
collected from a health examination center in National Cheng
Kung University Hospital, a tertiary medical center in Tainan,
Taiwan, from October 2006 to August 2009. All subjects
completed a structured questionnaire, which included items to
collect their demographic information, medical history, medication history, lifestyle habits (cigarette smoking, alcohol
drinking, and regular exercise), and self-reported sleep duration and snoring frequency. After exclusion of individuals with

1315

Sleep Duration and Arterial StiffnessTsai et al.

a history of cerebrovascular events, coronary artery disease,

peripheral artery disease with an ankle-brachial index (ABI)
less than 0.9, those taking lipid-lowering drugs, antihypertensive drugs, hypoglycemic agents, or anti-inflammatory drugs,
and incomplete data, a total of 3,508 subjects were enrolled for
the final analysis.
Cigarette smoking was classied as current smoker (at least
one pack per month for at least the previous 6 mo) and noncurrent smoker. Alcohol drinking was classified as current drinker
(at least once per week for at least the previous 6 mo) and
noncurrent drinker. Regular exercise was defined as vigorous
exercise at least three times per week. Sleep duration was
assessed by the following question in the self-reported questionnaire: On average, how many hours and minutes do you
sleep per night? We further classified sleep duration into three
groups: short (< 6 h), normal (68 h), and long (> 8 h).24
Anthropometric measurements included body weight
(minimal unit of measurement: 0.1 kg) and height (minimal
unit of measurement: 0.1 cm). Body mass index (BMI) was
calculated as weight (kg)/height (m2). Blood pressure (BP) was
measured in a supine position with a BP monitor (1846SX;
Johnson and Johnson, assembled in Mexico) after at least 15
min of rest. Hypertension was defined as systolic BP greater
than 140 mmHg or diastolic BP greater than 90 mmHg.
After 10 h of overnight fasting, all subjects underwent the
following blood tests: fasting plasma glucose, hemoglobin
(Hb)A1C, 2-h postload plasma glucose, total cholesterol (TC),
high-density lipoprotein cholesterol (HDL-C), triglyceride, and
creatinine. Diabetes mellitus was defined as a fasting glucose
level of 126 mg/dL or more, or a 2-h postload glucose level
of 200 mg/dL or more, or HbA1C more than or equal to 6.5%.
Estimated glomerular filtration rate (eGFR) was calculated
using the Modification of Diet in Renal Disease (MDRD)
formula. An increased atherosclerosis risk was defined as a TC/
HDL-C ratio of more than 5.
Arterial stiffness was measured by baPWV, using a noninvasive vascular screening device (BP-203RPE II; Colin Medical
Technology, Komaki, Japan) with four pneumatic pressure cuffs
over bilateral brachial arteries and tibial arteries, after 5 min of
rest in the supine position. Heart rate and ABI were measured
concurrently with PWV measurement. The baPWV value was
calculated as the distance traveled by the pulse wave divided by
the time taken to travel this distance. Increased arterial stiffness
was defined as baPWV 1400 cm/sec.
Statistical Analysis
All statistical analyses were performed using the 17th version
of the SPSS (Chicago, IL) software. The subjects were classified
into those with and without increased arterial stiffness. Clinical
characteristics in the study are presented as means standard
deviation (SD) or percentage. 2 tests were used to compare the
categorical variables between groups. In addition, the comparisons of the continuous variables were analyzed using Students
t-test between groups. Analysis of covariance (ANCOVA)
was used to compare the baPWV values among subjects with
different sleep durations by sex. Finally, we used multiple
logistic regressions to explore the relationship between sleep
duration and arterial stiffness. Statistical significance was
defined as P < 0.05.
SLEEP, Vol. 37, No. 8, 2014

RESULTS
Table 1 shows the comparisons of clinical characteristics
between subjects with and without increased baPWV by sex. In
both sexes, subjects with increased arterial stiffness were older;
had a higher systolic and diastolic blood pressure, fasting plasma
glucose, total cholesterol, TC/HDL-C ratio, and prevalences of
hypertension and diabetes mellitus; and lower eGFR than those
without increased arterial stiffness. In addition, BMI, triglycerides, HDL-C, and alcohol drinking were signicantly different
between female subjects with and without increased arterial stiffness. However, the sleep duration was different between subjects
with and without increased arterial stiffness in males only.
In males, based on ANCOVA, Figure 1 showed that long
sleepers had a higher baPWV value than normal sleepers
(adjusted mean: 1413.6 17.8 versus 1348.9 4.2 cm/
sec, P < 0.001). There was no significant difference in
baPWV between short and normal sleepers (adjusted mean:
1342.2 10.3 versus 1348.9 4.2 cm/sec, P = 0.547). As for
females, the baPWV values in normal, short, and long sleepers
were 1266.0 5.1, 1275.0 11.8, and 1297.3 19.7cm/sec,
respectively. There were no significant differences in baPWV
among these three groups.
The results of the multiple logistic regression analysis on
the relationship between sleep duration and baPWV in males
and females are summarized in Table 2. In males, long sleepers
(OR = 1.75, 95% confidence interval [CI] = 1.042.94), but not
short sleepers (OR = 0.98, 95% CI = 0.721.35), had a higher
risk of increased arterial stiffness after adjusting for other variables. In addition, age of 4059 y versus younger than 40 y, age
60 y or older versus younger than 40 y, lower eGFR, hypertension, diabetes, TC/HDL-C ratio > 5, and cigarette smoking
were independently associated with increased arterial stiffness,
and regular exercise had an inverted relationship. In females,
although age 4059 y versus younger than 40 y, age 60 y or
older versus younger than 40 y, BMI, hypertension and TC/
HDL-C ratio were the independently associated factors, both
short and long sleep duration were not related to increased arterial stiffness.
DISCUSSION
Our results revealed that long sleep duration is associated with a higher risk of increased arterial stiffness in males,
whereas no significant association was found for short sleepers
of either sex, after adjusting for the potential confounding
factors in a Taiwanese population. To the best of our knowledge,
there has only been one cross-sectional study on the relationship between sleep duration and arterial stiffness as measured
by baPWV.23 However, the study subjects in that study were
mainly males, and confined to middle-aged Japanese civil
servants. In addition, subjects with medications that would
influence arterial stiffness were not excluded. In contrast, our
study excluded subjects taking lipid-lowering drugs, antihypertensive agents, hypoglycemic agents, and anti-inflammatory
drugs because previous research showed that arterial stiffness is
mainly caused by an inflammatory process,15 and that a variety
of pharmacological treatments are associated with changes in
arterial stiffness.25
The results of the logistic regression analyses carried out in
this work showed that only long sleep duration was associated

1316

Sleep Duration and Arterial StiffnessTsai et al.

Table 1Clinical characteristics of study subjects with and without increased arterial stiffness by sex
baPWV in Males

Age (y)
Age group (y)
< 40
4059
60
Body mass index (kg/m2)
Systolic blood pressure (mmHg)
Diastolic blood pressure (mmHg)
Creatinine (mg/dL)
eGFR (ml/min/1.73 m2)
Fasting plasma glucose (mg/dL)
Total cholesterol (mg/dL)
Triglyceride (mg/dL)
HDL-C (mg/dL)
TC/HDL-C > 5
Sleep duration (hours)
<6
68
>8
Snoring 3/w
Hypertension
Diabetes mellitus
Smoking
Alcohol drinking
Regular exercise 3/w

P value

< 1400cm/s
(n = 1,418)
42.3 9.6

1400 cm/s
(n = 677)
52.7 11.1

547 (38.6)
823 (58.0)
48 (3.4)
24.7 3.3
115.9 10.3
69.7 8.3
0.96 0.12
93.3 15.1
88.6 18.8
195.1 35.8
136.5 94.3
47.0 11.5
377 (26.6)

75 (11.1)
433 (64.0)
169 (25.0)
24.8 3.1
130.1 15.5
79.6 10.4
0.99 0.35
88.1 16.0
94.9 24.6
204.3 36.6
144.1 93.0
47.0 12.1
227 (33.5)

188 (13.3)
1184 (83.5)
46 (3.2)
352 (24.6)
60 (4.2)
54 (3.8)
325 (22.9)
365 (25.7)
209 (14.7)

94 (13.9)
532 (78.6)
51 (7.5)
175 (24.4)
213 (31.5)
88 (13.0)
172 (25.4)
175 (25.8)
84 (12.4)

< 0.001
< 0.001

0.216
< 0.001
< 0.001
0.009
< 0.001
< 0.001
< 0.001
0.085
0.957
0.001
< 0.001

0.978
< 0.001
< 0.001
0.211
0.958
0.150

baPWV in Females
< 1400cm/s
(n = 1,094)
42.3 9.7

1400 cm/s
(n = 319)
55.9 9.4

423 (38.7)
635 (58.0)
36 (3.3)
22.2 3.3
106.1 11.0
61.7 8.0
0.69 0.19
102.4 18.3
85.1 12.3
189.9 34.3
89.5 53.4
60.1 14.3
53 (4.8)

12 (3.8)
208 (65.2)
99 (31.0)
23.8 3.3
128.6 16.5
73.9 10.0
0.73 0.38
94.6 20.0
93.6 27.4
206.8 41.3
124.3 84.6
57.3 14.6
48 (15.0)

165 (15.1)
876 (80.1)
53 (4.8)
102 (9.3)
16 (1.5)
29 (2.7)
35 (3.2)
53 (4.8)
99 (9.0)

45 (14.1)
250 (74.4)
24 (7.5)
39 (11.5)
96 (30.1)
39 (12.2)
4 (1.3)
4 (1.3)
33 (10.3)

P value

< 0.001
< 0.001

< 0.001
< 0.001
< 0.001
0.150
< 0.001
< 0.001
< 0.001
< 0.001
0.002
< 0.001
0.174

0.354
< 0.001
< 0.001
0.062
0.004
0.484

Data are expressed as means standard deviation or numbers (percentage). baPWV, brachial-ankle pulse-wave velocity; eGFR, estimated glomerular
filtration rate; HDL-C, high-density lipoprotein-cholesterol; TC, total cholesterol.

with a higher risk of increased arterial stiffness in male, but not

in females. This is consistent with the study results from Yoshioka et al., who found that, compared with a reference group
that reported an average of 7 h of sleep, long sleep duration
was significantly associated with higher baPWV.23 The underlying mechanisms between long sleep duration and arterial
stiffness are not clear, but the relationship may be related to the
following factors: sleep fragmentation, fatigue, immune function, photoperiodic abnormalities, lack of challenge, depression,
and underlying disease processes such as sleep apnea, heart
disease, and failing health,24 which might suggest that long
sleep is more strongly associated with cardiovascular outcomes
and all-cause mortality than short sleep.1,3,26 In addition, inflammatory pathways may be another mechanism for the positive
relationship between long sleep duration and increased arterial
stiffness. Because Asian long sleepers had a higher inflammation status than short sleepers,27,28 the inflammatory process will
cause dysregulation of collagen and elastin fibers of the vascular
wall, leading to arterial stiffness.15 Furthermore, long sleepers
reported difficulty falling asleep, awakening during the night,
awakening too early, awakening unrefreshed, daytime sleepiness,29 and greater insomnia and sleeping pill use30 than normal
sleepers. Thus, long sleep duration may be related to poor sleep
SLEEP, Vol. 37, No. 8, 2014

quality, and poor sleep quality was found to be associated

with insulin resistance,31 alteration of hypothalamic-pituitaryadrenal system activity,32 increased sympathetic activity,33 and
endothelial function impairment.34,35 This may partially explain
the association between long sleep duration and increased
arterial stiffness. Further research is needed to explore their
mechanism.
With regard to sex differences in the risk of increased arterial
stiffness, earlier studies revealed a linear relationship between
CRP and PWV among late perimenopausal or postmenopausal
women,36 and that the values of central pulse pressure and PWV
were lower in hormone therapy users.37,38 These findings show
that the female hormone may be a protective factor for arterial
stiffness, and thus may account for the sex advantage found
among females in this context.
Both structural and functional changes in the arteries occur
with the aging process. Sympathetic nerve activity elevation,39
endothelial dysfunction,40 and proinflammatory status41 induce
vasoconstriction, smooth muscle cell hypertrophy, and elastin
fragmentation with collagen synthesis, and then may lead to
increased arterial stiffness with aging.42
Our study showed that hypertension and a TC/HDL-C ratio
greater than 5 were independently associated factors of increased

1317

Sleep Duration and Arterial StiffnessTsai et al.

baPWV (cm/s)

baPWV (cm/s)

arterial stiffness, consistent with previous findings.4345 Higher

blood pressure increases the shearing stress of the artery, which
Male Female
induces arterial stiffening through endothelial dysfunction,43
P < 0.001
alterations in the extracellular matrix,44 and activation of the
1440
renin-angiotensin-aldosterone system.45 According to previous
1420
studies, the TC/HDL-C ratio is a superior measure of risk for
1400
P = 0.547
coronary heart disease compared with either TC or low-density
1380
lipoprotein cholesterol (LDL-C) levels.46,47 In addition, the
1360
cutoff point of five shows higher specificity and accuracy in
1340
Chinese populations when compared with using a LDL-C level
1320
of 130 mg/dL as the cutoff point.48 Dyslipidemia also has been
1300
shown to have a harmful effect on arterial stiffness through the
1280
mechanisms of endothelial dysfunction, reduced nitric oxide
<6
6-8
>8
bioavailability, and the inflammatory process.49
Sleep Duration (hours)
Diabetes was found to be associated with increased arterial
stiffness,5052 and the mechanism underlying this may be related
P = 0.124
to the inflammatory process and increased oxidative stress.50 In
1330
addition, advanced glycation end-products link with collagen
1320
in the vascular wall, resulting in irreversible cross-links, which
1310
P = 0.483
1300
are stiffer and less susceptible to hydrolytic turnover, and this
1290
leads to an increase in arterial stiffness.53 The only significant
1280
association found between diabetes and increased arterial
1270
stiffness in the current study was among males. This may be
1260
related to the lower statistical power with regard to the females
1250
data, because there was a lower prevalence of diabetes among
1240
women (4.8%) than men (6.8%) in this work.
1230
<6
6-8
>8
Our results showed that a higher BMI was positively related
Sleep Duration (hours)
to increased arterial stiffness in females only. The relationship between BMI and arterial stiffness remains unclear. Some
Figure 1Comparisons of brachial-ankle pulse-wave velocity
studies show a positive association between BMI and aortic
(baPWV) among subjects with different sleep durations by sex based
PWV,54,55 whereas others find an inverse association between
on analysis of covariance.
BMI and baPWV in both sexes.56,57 Moreover, Rodrigues et al.
found that BMI is not independently associated with increased
aortic stiffness.58 The effects of BMI
on arterial stiffness might be mediated by the intermediate parameters of
Table 2The adjusted odds ratios and 95% confidence intervals of multiple logistic regression analysis for
cardiovascular risk factors. There was
the relationship between sleep duration and increased arterial stiffness by sex
a high correlation between BMI and
Male
Female
TC/HDL-C ratio (r = 0.458) in current
OR (95% CI)
P value
OR (95% CI)
P value
study. In addition, the high correlation
Age group (y)
coefficient exists between baPWV
4059 vs. < 40
3.65 (2.704.92)
< 0.001
7.78 (4.2114.37) < 0.001
and the following variables: age
60 vs. < 40
21.67 (13.8533.91) < 0.001
48.08 (23.1699.85) < 0.001
(r = 0.592) and systolic (r = 0.668) and
0.98 (0.941.02)
0.237
1.06 (1.011.16)
0.011
Body mass index (kg/m2)
diastolic blood pressures (r = 0.598).
0.99 (0.981.00)
0.040
0.99 (0.991.00)
0.204
eGFR (mL/min/1.73 m2)
The effect of BMI on arterial stiffness
Hypertension (yes vs. no)
10.40 (7.3914.64) < 0.001
14.84 (8.2026.87) < 0.001
might be caused by high collinearity
Diabetes mellitus (yes vs. no)
2.36 (1.553.58)
< 0.001
1.10 (0.562.15)
0.781
and mediated by age, blood pressure,
and TC/HDL-C ratio. This may be a
TC/HDL-C > 5 (yes vs. no)
1.39 (1.081.77)
0.009
2.12 (1.273.55)
0.004
partial explanation for the inconsisSleep duration (h)
tent results in these earlier studies.
< 6 vs. 68
0.98 (0.721.35)
0.920
0.86 (0.561.31)
0.476
Our study showed an inverse asso> 8 vs. 68
1.75 (1.042.94)
0.034
1.02 (0.482.15)
0.963
ciation between eGFR and increased
Smoking (yes vs. no)
1.44 (1.111.87)
0.007
0.45 (0.131.62)
0.224
arterial stiffness in males. Chronic
Alcohol drinking (yes vs. no)
0.95 (0.741.23)
0.700
0.40 (0.131.17)
0.092
kidney disease is associated with
Regular exercise (yes vs. no)
0.69 (0.500.95)
0.025
1.09 (0.681.77)
0.717
increased arterial stiffness through the
Snoring 3/week (yes vs. no) 0.95 (0.731.22)
0.670
0.89 (0.521.52)
0.676
mechanism of endothelial dysfunction,
chronic inflammation and
CI, confidence interval; eGFR, estimated glomerular filtration rate, HDL-C, high-density lipoproteinvascular
calcification, and activation
cholesterol; OR, odds ratio; TC, total cholesterol.
of the renin-angiotensin-aldosterone
SLEEP, Vol. 37, No. 8, 2014

1318

Sleep Duration and Arterial StiffnessTsai et al.

system.59,60 As for the influence of lifestyle status on arterial

stiffness, smoking has been shown to be positively related to
increased arterial stiffness,61 whereas regular aerobic exercise
is associated with reduced arterial stiffness.62 In our study, there
was only a significant association between lifestyle status and
increased arterial stiffness in males. This may be explained by
the lower number of female subjects who smoked and who
exercised less regularly than male subjects.
This study has several limitations, as follows. First, the
cross-sectional design of this work means that it is not possible
to establish a causal relationship between sleep duration and
arterial stiffness. Second, self-reported sleep duration may have
subjective errors, although Lauderdale et al. found that subjective estimates of sleep duration correlated highly with polysomnographic assessments.63 Third, we measured only the quantity
but not the quality of sleep, although poor sleep quality scores
on the Pittsburgh Sleep Quality Index have been found to be
signicantly related to various cardiovascular risk factors, such
as diabetes and hypertension.64,65 Fourth, subjects with obstructive sleep apnea syndrome were not excluded in our study, and
this condition has been found to be associated with increased
arterial stiffness.66 Although we adjusted for the multiple
confounding variables and snoring frequency, the effect of
obstructive sleep apnea may not have been fully controlled for.
In conclusion, long sleep duration was associated with a higher
risk of increased arterial stiffness in males. Short sleepers did not
exhibit a significant risk of increased arterial stiffness in either
sex. In addition to cardiovascular risk factors and lifestyle, the
results of this study show that sleep duration cannot be ignored
when considering the prevention of cardiovascular disease.
ABBREVIATIONS
ABI, ankle-brachial index
baPWV, brachial-ankle PWV
BMI, body mass index
BP, blood pressure
cfPWV, carotid-femoral PWV
eGFR, estimated glomerular filtration rate
HDL-C, high density lipoprotein cholesterol
LDL-C, low density lipoprotein cholesterol
MDRD, Modification of Diet in Renal Disease
PWV, pulse-wave velocity
TC, total cholesterol
DISCLOSURE STATEMENT
This was not an industry supported study. This work was
supported by the Department of Family Medicine, National
Cheng-Kung University Hospital [Grant number NCKUHFM101-002]. The authors have indicated no financial conflicts of
interest.
REFERENCES

1. Gallicchio L, Kalesan B. Sleep duration and mortality: a systematic

review and meta-analysis. J Sleep Res 2009;18:14858.
2. Buxton OM, Marcelli E. Short and long sleep are positively associated
with obesity, diabetes, hypertension, and cardiovascular disease among
adults in the United States. Soc Sci Med 2010;71:102736.
3. Cappuccio FP, Cooper D, DElia L, Strazzullo P, Miller MA. Sleep
duration predicts cardiovascular outcomes: a systematic review and metaanalysis of prospective studies. Eur Heart J 2011;32:148492.

SLEEP, Vol. 37, No. 8, 2014

1319

4. Schmid SM, Schultes B. Disturbed sleep as risk factor for metabolic

syndrome. Internist (Berl) 2011;52:3838.
5. Nilsson PM, Nilsson JA, Hedblad B, Berglund G. Sleep disturbance
in association with elevated pulse rate for prediction of mortality
consequences of mental strain? J Intern Med 2001;250:5219.
6. Meier-Ewert HK, Ridker PM, Rifai N, et al. Effect of sleep loss on
C-reactive protein, an inflammatory marker of cardiovascular risk. J Am
Coll Cardiol 2004;43:67883.
7. Vgontzas AN, Zoumakis E, Bixler EO, et al. Adverse effects of modest
sleep restriction on sleepiness, performance, and inflammatory cytokines.
J Clin Endocrinol Metab 2004;89:211926.
8. Vlachopoulos C, Aznaouridis K, Stefanadis C. Prediction of cardiovascular
events and all-cause mortality with arterial stiffness: a systematic review
and meta-analysis. J Am Coll Cardiol 2010;55:131827.
9. Mitchell GF, Hwang SJ, Vasan RS, et al. Arterial stiffness and
cardiovascular events: the Framingham Heart Study. Circulation
2010;121:50511.
10. Meguro T, Nagatomo Y, Nagae A, et al. Elevated arterial stiffness
evaluated by brachial-ankle pulse wave velocity is deleterious for the
prognosis of patients with heart failure. Circ J 2009;73:67380.
11. Xiong Z, Zhu C, Zheng Z, et al. Relationship between arterial stiffness
assessed by brachial-ankle pulse wave velocity and coronary artery
disease severity assessed by the SYNTAX Score. J Atheroscler Thromb
2012:19:9706.
12. van Popele NM, Grobbee DE, Bots ML, et al. Association between
arterial stiffness and atherosclerosis: the Rotterdam Study. Stroke
2001;32:45460.
13. van Popele NM, Mattace-Raso FU, Vliegenthart R, et al. Aortic stiffness
is associated with atherosclerosis of the coronary arteries in older adults:
the Rotterdam Study. J Hypertens 2006;24:23716.
14. Kim J, Cha MJ, Lee DH, et al. The association between cerebral
atherosclerosis and arterial stiffness in acute ischemic stroke.
Atherosclerosis 2011;219:88791.
15. Zieman SJ, Melenovsky V, Kass DA. Mechanisms, pathophysiology,
and therapy of arterial stiffness. Arterioscler Thromb Vasc Biol
2005;25:93243.
16. Drager LF, Lorenzi-Filho G. Arterial stiffness: a long sleeper issue? Sleep
2011;34:16234.
17. Cavalcante JL, Lima JA, Redheuil A, Al-Mallah MH. Aortic stiffness:
current understanding and future directions. J Am Coll Cardiol
2011;57:151122.
18. Tanaka H, Munakata M, Kawano Y, et al. Comparison between carotidfemoral and brachial-ankle pulse wave velocity as measures of arterial
stiffness. J Hypertens 2009;27:20227.
19. Komatsubara I, Inoue S, Koumoto R, et al. Significant relationship
between changes in brachial-ankle pulse wave velocity relative to
blood pressure elevation and coronary artery disease. Coron Artery Dis
2010;21:40713.
20. Tsuchikura S, Shoji T, Kimoto E, et al. Brachial-ankle pulse wave
velocity as an index of central arterial stiffness. J Atheroscler Thromb
2010;17:65865.
21. Zheng YY, Ma YT, Xie X, et al. Association of ankle-brachial index and
pulse wave velocity with stroke in Han, Uighur, and Kazakh population
of Xinjiang. Zhonghua Liu Xing Bing Xue Za Zhi 2010;31:12558.
22. Nam HJ, Jung IH, Kim J, et al. Association between brachial-ankle pulse
wave velocity and occult coronary artery disease detected by multidetector computed tomography. Int J Cardiol 2012;157:22732.
23. Yoshioka E, Saijo Y, Kita T, et al. Relation between self-reported sleep
duration and arterial stiffness: a cross-sectional study of middle-aged
Japanese civil servants. Sleep 2011;34:16816.
24. Grandner MA, Drummond SP. Who are the long sleepers? Towards
an understanding of the mortality relationship. Sleep Med Rev
2007;11:34160.
25. Laurent S, Cockcroft J, Van Bortel L, et al. Expert consensus document
on arterial stiffness: methodological issues and clinical applications. Eur
Heart J 2006;27:2588605.
26. Cappuccio FP, DElia L, Strazzullo P, Miller MA. Sleep duration and
all-cause mortality: a systematic review and meta-analysis of prospective
studies. Sleep 2010;33:58592.
27. Dowd JB, Goldman N, Weinstein M. Sleep duration, sleep quality, and
biomarkers of inflammation in a Taiwanese population. Ann Epidemiol
2011;21:799806.

Sleep Duration and Arterial StiffnessTsai et al.

28. Grandner MA, Buxton OM, Jackson N, Sands-Lincoln M, Pandey A,

Jean-Louis G. Extreme sleep durations and increased C-reactive protein:
effects of sex and ethnoracial group. Sleep 2013;36:76979E.
29. Grandner MA, Kripke DF. Self-reported sleep complaints with long
and short sleep: a nationally representative sample. Psychosom Med
2004;66:23941.
30. Kripke DF, Garfinkel L, Wingard DL, Klauber MR, Marler MR. Mortality
associated with sleep duration and insomnia. Arch Gen Psychiatry
2002;59:1316.
31. Knutson KL, Van Cauter E, Zee P, Liu K, Lauderdale DS. Crosssectional associations between measures of sleep and markers of glucose
metabolism among subjects with and without diabetes: the Coronary
Artery Risk Development in Young Adults (CARDIA) Sleep Study.
Diabetes Care 2011;34:11716.
32. Goodin BR, Smith MT, Quinn NB, King CD, McGuire L. Poor sleep
quality and exaggerated salivary cortisol reactivity to the cold pressor
task predict greater acute pain severity in a non-clinical sample. Biol
Psychol 2012;91:3641.
33. Zhang J, Ma RC, Kong AP, et al. Relationship of sleep quantity and
quality with 24-hour urinary catecholamines and salivary awakening
cortisol in healthy middle-aged adults. Sleep 2011;34:22533.
34. Behl M, Bliwise D, Veledar E, et al. Vascular endothelial function and
self-reported sleep. Am J Med Sci 2014;347:4258.
35. Cooper DC, Ziegler MG, Milic MS, et al. Endothelial function and sleep:
associations of flow-mediated dilation with perceived sleep quality and
rapid eye movement (REM) sleep. J Sleep Res 2014;23:8493.
36. Woodard GA, Mehta VG, Mackey RH, et al. C-reactive protein is
associated with aortic stiffness in a cohort of African American and white
women transitioning through menopause. Menopause 2011;18:12917.
37. Miura S, Tanaka E, Mori A, et al. Hormone replacement therapy improves
arterial stiffness in normotensive postmenopausal women. Maturitas
2003;45:2938.
38. Gompel A, Boutouyrie P, Joannides R, et al. Association of menopause
and hormone replacement therapy with large artery remodeling. Fertil
Steril 2011;96:144550.
39. Dinenno FA, Jones PP, Seals DR, Tanaka H. Age-associated arterial
wall thickening is related to elevations in sympathetic activity in healthy
humans. Am J Physiol Heart Circ Physiol 2000;278:H120510.
40. Donato AJ, Gano LB, Eskurza I, et al. Vascular endothelial dysfunction
with aging: endothelin-1 and endothelial nitric oxide synthase. Am J
Physiol Heart Circ Physiol 2009;297:H42532.
41. Wang M, Zhang J, Jiang LQ, et al. Proinflammatory profile within the
grossly normal aged human aortic wall. Hypertension 2007;50:21927.
42. Mirea O, Donoiu I, Plesea IE. Arterial aging: a brief review. Rom J
Morphol Embryol 2012;53:4737.
43. Landmesser U, Drexler H. Endothelial function and hypertension. Curr
Opin Cardiol 2007;22:31620.
44. Castro MM, Tanus-Santos JE. Inhibition of matrix metalloproteinases
(MMPs) as a potential strategy to ameliorate hypertension-induced
cardiovascular alterations. Curr Drug Targets 2013;14:33543.
45. Mahmud A, Feely J. Arterial stiffness and the renin-angiotensinaldosterone system. J Renin Angiotensin Aldosterone Syst 2004;5:1028.
46. Kinosian B, Glick H, Garland G. Cholesterol and coronary heart disease:
predicting risks by levels and ratios. Ann Intern Med 1994;121:6417.
47. Kinosian B, Glick H, Preiss L, Puder KL. Cholesterol and coronary heart
disease: predicting risks in men by changes in levels and ratios. J Investig
Med 1995;43:44350.

SLEEP, Vol. 37, No. 8, 2014

1320

48. Wang TD, Chen WJ, Chien KL, et al. Efficacy of cholesterol levels and
ratios in predicting future coronary heart disease in a Chinese population.
Am J Cardiol 2001;88:73743.
49. Wilkinson I, Cockcroft JR. Cholesterol, lipids and arterial stiffness. Adv
Cardiol 2007;44:26177.
50. Mazzone T, Chait A, Plutzky J. Cardiovascular disease risk in
type 2 diabetes mellitus: insights from mechanistic studies. Lancet
2008;371:18009.
51. Li CH, Wu JS, Yang YC, Shih CC, Lu FH, Chang CJ. Increased arterial
stiffness in subjects with impaired glucose tolerance and newly diagnosed
diabetes but not isolated impaired fasting glucose. J Clin Endocrinol
Metab 2012;97:E65862.
52. Stehouwer CD, Henry RM, Ferreira I. Arterial stiffness in diabetes and the
metabolic syndrome: a pathway to cardiovascular disease. Diabetologia
2008;51:52739.
53. Lee AT, Cerami A. Role of glycation in aging. Ann N Y Acad Sci
1992;663:6370.
54. Wildman RP, Mackey RH, Bostom A, Thompson T, Sutton-Tyrrell K.
Measures of obesity are associated with vascular stiffness in young and
older adults. Hypertension 2003;42:46873.
55. Tuttolomondo A, Di Raimondo D, Di Sciacca R, et al. Arterial stiffness
and ischemic stroke in subjects with and without metabolic syndrome.
Atherosclerosis 2012;225:2169.
56. Tomiyama H, Yamashina A, Arai T, et al. Influences of age and gender on
results of noninvasive brachial-ankle pulse wave velocity measurementa
survey of 12517 subjects. Atherosclerosis 2003;166:3039.
57. Budimir D, Jeroncic A, Gunjaca G, Rudan I, Polasek O, Boban M. Sexspecific association of anthropometric measures of body composition
with arterial stiffness in a healthy population. Med Sci Monit
2012;18:CR6571.
58. Rodrigues SL, Baldo MP, Lani L, Nogueira L, Mill JG, Sa Cunha R. Body
mass index is not independently associated with increased aortic stiffness
in a Brazilian population. Am J Hypertens 2012;25:10649.
59. Briet M, Burns KD. Chronic kidney disease and vascular remodelling:
molecular mechanisms and clinical implications. Clin Sci (Lond)
2012;123:399416.
60. Moody WE, Edwards NC, Chue CD, Ferro CJ, Townend JN. Arterial
disease in chronic kidney disease. Heart 2013;99:36572.
61. Doonan RJ, Hausvater A, Scallan C, Mikhailidis DP, Pilote L,
Daskalopoulou SS. The effect of smoking on arterial stiffness. Hypertens
Res 2010;33:398410.
62. Tanaka H, Safar ME. Influence of lifestyle modification on arterial
stiffness and wave reflections. Am J Hypertens 2005;18:13744.
63. Lauderdale DS, Knutson KL, Yan LL, Liu K, Rathouz PJ. Self-reported
and measured sleep duration: how similar are they? Epidemiology
2008;19:83845.
64. Fiorentini A, Valente R, Perciaccante A, Tubani L. Sleeps quality
disorders in patients with hypertension and type 2 diabetes mellitus. Int J
Cardiol 2007;114:E502.
65. Bruno RM, Palagini L, Gemignani A, et al. Poor sleep quality and
resistant hypertension. Sleep Med 2013;14:115763.
66. Phillips CL, Butlin M, Wong KK, Avolio AP. Is obstructive sleep apnoea
causally related to arterial stiffness? A critical review of the experimental
evidence. Sleep Med Rev 2013;17:718.

Sleep Duration and Arterial StiffnessTsai et al.