Multiple sleep-wake disturbances after stroke predict an increased risk of cardio-cerebrovascular events or death - a prospective cohort study.

Duss, Simone B; Bernasconi, Corrado; Steck, Anita; Brill, Anne-Kathrin; Manconi, Mauro; Dekkers, Martijn; Schmidt, Markus H; Bassetti, Claudio L. A. (2023). Multiple sleep-wake disturbances after stroke predict an increased risk of cardio-cerebrovascular events or death - a prospective cohort study. European journal of neurology, 30(6), pp. 1696-1705. Wiley 10.1111/ene.15784

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BACKGROUND

In the general population, sleep-wake disturbances (SWD) have been shown to increase the risk of cardio- and cerebrovascular events (CCE) including death. Systematic studies on the effect of SWD on the risk of CCE in patients with stroke are lacking.

METHODS

Patients with acute ischemic stroke or transient ischemic attack (TIA) were prospectively recruited. Four SWD were analyzed: 1) sleep-disordered breathing (SDB) with respirography, 2) insomnia (by insomnia severity index, ISI), 3) restless legs syndrome (RLS, by International RLS Study Group rating scale) and 4) self-estimated sleep duration at 1 and 3 months. A "sleep burden index" as the mean of z-transformed values from assessments of these four SWD was created. The occurrence of CCE was recorded over a follow-up of 3.2±0.3 years (mean±standard deviation).

RESULTS

We assessed 437 patients (87% ischemic stroke, 13% TIA, 64% males) with a mean age of 65.1±13.0 years. SDB (respiratory event index, REI≥5) was present in 66.2% thereof. Insomnia (ISI≥10), RLS and extreme sleep duration affected 26.2%, 6.4% and 13.7% of the patients 3-month post-stroke. Seventy out of the 437 (16%) had at least one CCE during the follow-up. The sleep burden index was associated with a higher risk for subsequent CCE including death (Odds Ratio = 1.80 per index unit, 95% CI: 1.19-2.72, p=0.0056).

CONCLUSION

The presence of multiple SWDs constitutes a risk for subsequent CCE (including death) within the first three years following stroke. Larger systematic studies should assess the sleep burden index' utility for patients' risk stratification in clinical practice.

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