You are leaving Medscape Education
Cancel Continue
Log in to save activities Your saved activities will show here so that you can easily access them whenever you're ready. Log in here CME & Education Log in to keep track of your credits.
 

CME / ABIM MOC / CE

Can Disordered Sleep Increase Stroke Risk?

  • Authors: News Author: Kelli Whitlock Burton; CME Author: Laurie Barclay, MD
  • CME / ABIM MOC / CE Released: 5/12/2023
  • Valid for credit through: 5/12/2024, 11:59 PM EST
Start Activity

  • Credits Available

    Physicians - maximum of 0.25 AMA PRA Category 1 Credit(s)™

    ABIM Diplomates - maximum of 0.25 ABIM MOC points

    Nurses - 0.25 ANCC Contact Hour(s) (0 contact hours are in the area of pharmacology)

    Pharmacists - 0.25 Knowledge-based ACPE (0.025 CEUs)

    Physician Assistant - 0.25 AAPA hour(s) of Category I credit

    IPCE - 0.25 Interprofessional Continuing Education (IPCE) credit

    You Are Eligible For

    • Letter of Completion
    • ABIM MOC points

Target Audience and Goal Statement

This activity is intended for neurologists, family medicine/primary care clinicians, internists, public health and prevention officials, nurses, nurse practitioners, pharmacists, physician assistants, and other members of the healthcare team for patients with sleep disorders who may be at increased risk for stroke.

The goal of this activity is for members of the healthcare team to be better able to describe the association between a spectrum of sleep disturbance symptoms and risk for acute stroke in an international setting, according to the INTERSTROKE international case control study of patients presenting with first acute stroke and control participants matched by age and sex.

Upon completion of this activity, participants will:

  • Describe the association between a spectrum of sleep disturbance symptoms and risk for acute stroke in an international setting, according to the INTERSTROKE international case control study
  • Identify clinical and public health implications of the association between a spectrum of sleep disturbance symptoms and risk for acute stroke in an international setting, according to the INTERSTROKE international case-control study
  • Outline implications for the healthcare team


Disclosures

Medscape, LLC requires every individual in a position to control educational content to disclose all financial relationships with ineligible companies that have occurred within the past 24 months. Ineligible companies are organizations whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.

All relevant financial relationships for anyone with the ability to control the content of this educational activity are listed below and have been mitigated. Others involved in the planning of this activity have no relevant financial relationships.


News Author

  • Kelli Whitlock Burton

    Freelance writer, Medscape

    Disclosures

    Kelli Whitlock Burton has no relevant financial relationships.

CME Author

  • Laurie Barclay, MD

    Freelance writer and reviewer
    Medscape, LLC

    Disclosures

    Laurie Barclay, MD, has no relevant financial relationships.

Editor/Compliance Reviewer

  • Yaisanet Oyola, MD

    Associate Director, Accreditation and Compliance, Medscape, LLC

    Disclosures

    Yaisanet Oyola, MD, has no relevant financial relationships.

Nurse Planner

  • Stephanie Corder, ND, RN, CHCP

    Associate Director, Accreditation and Compliance, Medscape, LLC

    Disclosures

    Stephanie Corder, ND, RN, CHCP, has no relevant financial relationships.

Peer Reviewer

This activity has been peer reviewed and the reviewer has no relevant financial relationships.


Accreditation Statements

Medscape

Interprofessional Continuing Education

In support of improving patient care, Medscape, LLC is jointly accredited with commendation by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

IPCE

This activity was planned by and for the healthcare team, and learners will receive 0.25 Interprofessional Continuing Education (IPCE) credit for learning and change.

    For Physicians

  • Medscape, LLC designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™ . Physicians should claim only the credit commensurate with the extent of their participation in the activity.

    Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 0.25 MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program. Participants will earn MOC points equivalent to the amount of CME credits claimed for the activity. It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit.

    The European Union of Medical Specialists (UEMS)-European Accreditation Council for Continuing Medical Education (EACCME) has an agreement of mutual recognition of continuing medical education (CME) credit with the American Medical Association (AMA). European physicians interested in converting AMA PRA Category 1 credit™ into European CME credit (ECMEC) should contact the UEMS (www.uems.eu).

    College of Family Physicians of Canada Mainpro+® participants may claim certified credits for any AMA PRA Category 1 credit(s)™, up to a maximum of 50 credits per five-year cycle. Any additional credits are eligible as non-certified credits. College of Family Physicians of Canada (CFPC) members must log into Mainpro+® to claim this activity.

    Through an agreement between the Accreditation Council for Continuing Medical Education and the Royal College of Physicians and Surgeons of Canada, medical practitioners participating in the Royal College MOC Program may record completion of accredited activities registered under the ACCME’s “CME in Support of MOC” program in Section 3 of the Royal College’s MOC Program.

    Contact This Provider

    For Nurses

  • Awarded 0.25 contact hour(s) of nursing continuing professional development for RNs and APNs; 0.00 contact hours are in the area of pharmacology.

    Contact This Provider

    For Pharmacists

  • Medscape designates this continuing education activity for 0.25 contact hour(s) (0.025 CEUs) (Universal Activity Number: JA0007105-0000-23-158-H01-P).

    Contact This Provider

  • For Physician Assistants

    Medscape, LLC has been authorized by the American Academy of PAs (AAPA) to award AAPA Category 1 CME credit for activities planned in accordance with AAPA CME Criteria. This activity is designated for 0.25 AAPA Category 1 CME credits. Approval is valid until 05/12/2024. PAs should only claim credit commensurate with the extent of their participation.

For questions regarding the content of this activity, contact the accredited provider for this CME/CE activity noted above. For technical assistance, contact [email protected]


Instructions for Participation and Credit

There are no fees for participating in or receiving credit for this online educational activity. For information on applicability and acceptance of continuing education credit for this activity, please consult your professional licensing board.

This activity is designed to be completed within the time designated on the title page; physicians should claim only those credits that reflect the time actually spent in the activity. To successfully earn credit, participants must complete the activity online during the valid credit period that is noted on the title page. To receive AMA PRA Category 1 Credit™, you must receive a minimum score of 75% on the post-test.

Follow these steps to earn CME/CE credit*:

  1. Read the target audience, learning objectives, and author disclosures.
  2. Study the educational content online or printed out.
  3. Online, choose the best answer to each test question. To receive a certificate, you must receive a passing score as designated at the top of the test. We encourage you to complete the Activity Evaluation to provide feedback for future programming.

You may now view or print the certificate from your CME/CE Tracker. You may print the certificate but you cannot alter it. Credits will be tallied in your CME/CE Tracker and archived for 6 years; at any point within this time period you can print out the tally as well as the certificates from the CME/CE Tracker.

*The credit that you receive is based on your user profile.

CME / ABIM MOC / CE

Can Disordered Sleep Increase Stroke Risk?

Authors: News Author: Kelli Whitlock Burton; CME Author: Laurie Barclay, MDFaculty and Disclosures

CME / ABIM MOC / CE Released: 5/12/2023

Valid for credit through: 5/12/2024, 11:59 PM EST

processing....

Clinical Context

Good health requires adequate sleep. Impaired sleep may include mild deviations in duration; impairments in quality, initiation, maintenance; associated symptoms; and complex syndromes.

Most previous studies have incompletely measured all relevant sleep domains, hindering complete assessment of their independent contribution. Certain symptoms, including nocturnal awakening and snorting, are incompletely studied as potential independent risk factors.

Study Synopsis and Perspective

Disordered sleep is associated with a significantly increased risk for stroke, new research shows.

Results of a large international study show stroke risk was more than 3 times higher in persons who slept too little, more than twice as high in persons who sleep too much, and 2 to 3 times higher in persons with symptoms of severe obstructive sleep apnea (OSA).

The study also showed the greater the number of sleep disorder symptoms, the greater the stroke risk. The 11% of study participants with 5 or more symptoms of disordered sleep had a 5-fold increased risk for stroke.

Although the study data do not show a causal link between disordered sleep and stroke, the association between the two was strong.

"Given the association, sleep disturbance may represent a marker of somebody at increased risk of stroke and further interventional studies are required to see if management can reduce this risk," lead investigator Christine Mc Carthy, MD, PhD, a geriatric and stroke medicine physician and researcher with the University of Galway, Galway, Ireland, told Medscape Medical News. "In the interim, however, management of sleep disturbance may have a positive impact on a patient's quality of life."

The findings were published online April 5 in the journal Neurology.[1]

More Symptoms, More Risk

Previous research shows severe OSA doubles the risk for stroke and increases the chance of recurrent stroke. A 2019 study showed people with insomnia had a small increased risk of stroke[2].

"Both snoring and extremes of sleep duration have been previously associated with an increased risk of stroke in observational research, but less is known about other symptoms of sleep impairment, with less consistent findings," Mc Carthy said.

Prior studies also have come from a single geographic region, which Mc Carthy noted could limit their generalizability.

For this effort, investigators used data from 4496 participants in INTERSTROKE, an international case-control study of risk factors for a first acute stroke. About half of the participants had a history of stroke.

Using information collected from a survey of sleep habits, researchers found an elevated stroke risk in persons who received fewer than 5 hours of sleep per night (odds ratio [OR] 3.15 [95% CI:, 2.09, 4.76]) or more than 9 hours of sleep per night (OR 2.67 [95% CI: 1.89, 3.78]) compared with persons who slept 7 hours per night.

Participants who took unplanned naps or naps lasting an hour or more (OR 2.46 [95% CI: 1.69, 3.57]) and participants who reported poor quality sleep (OR 1.52 [95% CI: 1.32, 1.75]) also were at increased risk for stroke.

Symptoms of OSA were also strongly associated with increased stroke risk, including snoring (OR 1.91 [95% CI: 1.62, 2.24]), snorting (OR 2.64 [95% CI: 2.17, 3.2]), and breathing cessation (OR 2.87 [95% CI: 2.28, 2.6]).

Stroke risk increased as the number of sleep disturbance symptoms rose, with the greatest risk in the 11% of participants who had 5 or more symptoms (OR 5.38 [95% CI: 4.03, 7.18]).

"This study finds an association between a broad range of sleep impairment symptoms and stroke, and a graded association with increasing symptoms, in an international setting," Mc Carthy said.

Researchers are not sure what is driving the higher stroke risk among people with sleep disturbances.

Although the study did control for potential confounders, it was not designed to get at what is driving the association.

"Sleep disturbance may also have a bi-directional relationship with many stroke risk factors; for example, sleep disturbance may be a symptom of disease and exacerbate disease," McCarthy said. "Future interventional studies are required to determine the true direction of the relationship."

A Marker of Stroke Risk

Commenting on the findings for Medscape Medical News, Daniel Lackland, DrPH, professor of neurology at the Medical University of South Carolina in Charleston, South Carolina, said the findings provide additional evidence of the link between sleep and stroke risk.

"The results confirm sleep disorders as a potential marker and part of the risk profile," he said.

Collecting information about sleep using a validated assessment tool is an important piece of clinical care, Lackland said, especially among patients with other stroke risk factors.

One limitation of the study was that researchers collected data on sleep only at one point and did not follow participants over time to see if changes in sleep affected stroke risk.

"This is an important point and should be a focus for future studies, as it is critical in the design of interventions," Lackland said.

The INTERSTROKE study is funded by the Canadian Institutes of Health Research, Heart and Stroke Foundation of Canada, Canadian Stroke Network, Swedish Research Council, Swedish Heart and Lung Foundation, The Health & Medical Care Committee of the Regional Executive Board, Region Västra Götaland, AstraZeneca Pharmaceuticals LP; Boehringer Ingelheim (Canada); Pfizer Inc. (Canada); Merck, Sharp and Dohme GmBH; the Swedish Heart and Lung Foundation; UK Chest; and UK Heart and Stroke. Mc Carthy and Lackland report no relevant financial relationships.

Neurology. Published online April 5, 2023.[1]

Study Highlights

  • INTERSTROKE participants (N = 4496), including patients presenting with first acute stroke (1799 ischemic stroke; 439 intracerebral hemorrhage; 16.7% of the INTERSTROKE population) and control participants matched by age (± 5 years) and sex, completed a questionnaire regarding sleep symptoms in the previous month.
  • Conditional logistic regression estimated the association between sleep symptoms and acute stroke.
  • The primary model adjusted for age, occupation, marital status, and modified-Rankin Scale at baseline; subsequent models adjusted for behavioral/disease risk factors as potential mediators.
  • Factors significantly associated with increased odds for acute stroke in the primary model were short sleep (< 5 hours [OR 3.15 [95% CI: 2.09, 4.76]), long sleep (> 9 hours: OR 2.67 [95% CI: 1.89, 3.78]), impaired quality (OR 1.52 [95% CI: 1.32, 1.75]), difficulty falling asleep (OR 1.32 [95% CI: 1.13, 1.55]) or maintaining sleep (OR 1.33 [95% CI: 1.15, 1.53]), unplanned napping (OR 1.59 [95% CI: 1.31, 1.92]), prolonged napping (> 1 hour: OR 1.88 [95% CI: 1.49, 2.38]), snoring (OR 1.91 [95% CI: 1.62, 2.24]), snorting (OR 2.64 [95% CI: 2.17, 3.2]) and breathing cessation (OR 2.87 [95% CI: 2.28, 2.6]).
  • Derived OSA score of 2 to 3 (OR 2.67 [95% CI: 2.25, 3.15]) and cumulative sleep symptoms were also associated with significantly increased odds for acute stroke.
  • In the primary model, increasing numbers of symptoms were associated with graded increase in stroke risk (2-3: OR 1.63 [95% CI: 1.36, 1.96]; 4-5: OR 3.08 [95% CI: 2.49, 3.8]; > 5 [11% of participants]: OR 5.38 [95% CI: 4.03, 7.18]), with reference 0 to 1.
  • Findings were consistent for ischemic stroke (> 5: OR 5.06 [95% CI: 3.67, 6.97]) and ICH (> 5: OR 8.36 [95% CI: 4.05, 17.26]).
  • Except for difficulty falling asleep, maintaining sleep and unplanned napping, associations of other sleep symptoms with stroke risk maintained significance after extensive adjustment, with similar findings for stroke subtypes.
  • There was a significant interaction between sleep duration and snoring (P = .002) but no other individual sleep symptoms.
  • Estimates in the primary model were highest in snorers with short sleep duration (OR 4.04 [95% CI: 3.12, 5.25]) and lowest in nonsnorers with long sleep duration (OR 1.39 [95% CI: 1.13, 1.69]).
  • In the primary model, the association of short sleep duration with stroke was highest for South Asian ethnicity and South Asia, and nonsignificant for Chinese ethnicity and China (P interaction < .001 for both).
  • The investigators concluded that in their international cohort, sleep disturbance symptoms were common and associated with graded increased risk for stroke.
  • Individual and cumulative symptoms of sleep disturbance may be important independent modifiable risk factors for stroke and/or be markers of greater stroke risk.
  • The findings suggest a complex relationship of sleep impairment, intermediate cerebrovascular risk factors, and stroke risk.
  • Sleep disturbance may have a bidirectional relationship with various stroke risk factors and could be a symptom of disease and exacerbate disease.
  • The primary model, which did not include cerebrovascular risk factors, likely overestimated the independent association of sleep impairment and stroke risk, whereas the fully adjusted model including mediator variables likely underestimated the association.
  • The findings suggest that prolonged napping may be harmful or representative of an underlying condition that requires further workup, whereas a brief, planned nap is less likely to increase stroke risk.
  • Physicians should collect information about sleep using a validated assessment tool, as a marker of stroke risk, especially among patients with other stroke risk factors, and also to allow interventions to mitigate sleep symptoms and improve quality of life.
  • Study limitations include cross-sectional design precluding causal inferences, despite the strong associations, and inability to identify potential drivers of the association between sleep symptoms and stroke risk.
  • In the global effort to reduce stroke incidence, interventional studies in patients with high sleep disturbance burden, and in persons with individual sleep symptoms, should be considered a priority research target.
  • Future research should follow participants over time to determine if changes in sleep affect stroke risk, as such information is essential in the design of interventions.

Clinical Implications

  • Sleep disturbance symptoms are common and associated with greater increased risk for stroke.
  • Sleep symptoms may be markers of increased individual risk or represent independent risk factors.
  • Implications for the Healthcare Team: Clinicians should collect information about sleep using a validated assessment tool.

 

Earn Credit

  • Print