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Eur Heart J. 2019 May 21;40(20):1620-1629. doi: 10.1093/eurheartj/ehy695.

Association of estimated sleep duration and naps with mortality and cardiovascular events: a study of 116 632 people from 21 countries.

Author information

Department of Medicine, Population Health Research Institute, McMaster University, 237 Barton Street East, Hamilton, Ontario, Canada.
Medical Research and Biometrics Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College, Chinese Academy of Medical Sciences, Room 101-106, Block A, Shilong West Road, Mentougou District, Beijing, China.
Department of Medicine, Faculty of Health Sciences, Simon Fraser University, 8888 University Drive, Burnaby, British Columbia, Canada.
Department of Cardiac Sciences, King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia.
Madras Diabetes Research Foundation, Dr Mohan's Diabetes Specialities Centre, No. 6B, Conran Smith Road, Gopalapuram, Chennai, India.
Department of Medicine, Faculté de pharmacie, Université Laval, Institut universitaire de cardiologie et de pneumologie de Québec, 2725 Chemin Sainte-Foy, Québec City, Québec, Canada.
Division of Occupational and Environmental Health, Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Ngan Shing Street, Sha Tin, Hong Kong SAR 96H2+9X, China.
Department of Molecular and Clinical Medicine, Sahlgrenska Academy, Sahlgrenska University Hospital, University of Gothenburg, Diagnosvägen 11, Gothenburg, Sweden.
Department of Community Medicine, School of Public Health, Post Graduate Institute of Medical Education & Research, Sector 12, Chandigarh, India.
Research Institute, FOSCAL, Department of Medicine, Medical School, UDES, Calle 158 #20-95, local 101-102, Floridablanca, Colombia.
Department of Medicine, UiTM Selayang, 40450 Shah Alam, Selangor Darul Ehsan, Malaysia, and UCSI University, 1, Jalan Puncak Menara Gading, Taman Connaught, Kuala Lumpur, Wilayah Persekutuan Kuala Lumpur, Malaysia.
Dubai Health Authority, Al Maktoum Bridge Street, Bur Dubai Area 4545, Dubai, United Arab Emirates.
Health Action by People, Thiruvananthapuram and Community Medicine, Department of Community Medicine, Amrita School of Medicine, Amrita Vishwa Vidyapeetham, AIMS Health Sciences Campus, AIMS Ponekkara P. O., Kochi, Kerala, India.
Department of Community Health, Faculty of Medicine, University Kebangsaan Malaysia, Bangi, Selangor, Malaysia.
Department of Medicine, Universidad de La Frontera, Francisco Salazar 1145, Temuco, Regiæn de la Araucanía, Chile.
Department of Medicine, UP College of Medicine, University of the Philippines Manila, Padre Faura Street, Ermita, Manila, Metro Manila, Philippines.
Africa Unit for Transdisciplinary Health Research, Department of Medicine, Faculty of Health Sciences, North-West University, Private Bag X2046 Mmabatho, South Africa.
Department of Medicine, Queen's University, Office of Global Health Research, 99 University Avenue, Kingston, Ontario, Canada.
Department of Medicine, University of the Western Cape, Robert Sobukwe Road, Bellville, Cape Town, South Africa.
School of Life Sciences, Independent University, Academic Building, Room 10002, Plot #16, Block B, Aftabuddin Ahmed Road, Bashundhara R/A, Dhaka-1229, Bangladesh.
ECLA Foundation, Paraguay 160, Rosario, Santa Fe, Argentina.
Department of Social Medicine, Medical University of Wrocław, Bujwida 44 Street, 50-345 Wrocław, Poland.
Hypertension Research Center, Cardiovascular Research Institute, Department of Medicine, Isfahan University of Medical Sciences, Hezar-Jerib Avenue, Isfahan 81746 73461, Iran.
Department of Clinical Research, EHCC, Jawahar Circle, Jaipur, India.
Departments of Neurology, Northwestern University Feinberg School of Medicine, Arthur J. Rubloff Building, 420 East Superior Street, Chicago, IL, USA.
Department of Cardiology, Turkiye Yuksek Ihtisas Education and Research Hospital, University of Saglik Bilimleri, Tıbbiye Cd No. 38, Selimiye Mahallesi, 34668 Üsküdar/İstanbul, Turkey.



To investigate the association of estimated total daily sleep duration and daytime nap duration with deaths and major cardiovascular events.


We estimated the durations of total daily sleep and daytime naps based on the amount of time in bed and self-reported napping time and examined the associations between them and the composite outcome of deaths and major cardiovascular events in 116 632 participants from seven regions. After a median follow-up of 7.8 years, we recorded 4381 deaths and 4365 major cardiovascular events. It showed both shorter (≤6 h/day) and longer (>8 h/day) estimated total sleep durations were associated with an increased risk of the composite outcome when adjusted for age and sex. After adjustment for demographic characteristics, lifestyle behaviours and health status, a J-shaped association was observed. Compared with sleeping 6-8 h/day, those who slept ≤6 h/day had a non-significant trend for increased risk of the composite outcome [hazard ratio (HR), 1.09; 95% confidence interval, 0.99-1.20]. As estimated sleep duration increased, we also noticed a significant trend for a greater risk of the composite outcome [HR of 1.05 (0.99-1.12), 1.17 (1.09-1.25), and 1.41 (1.30-1.53) for 8-9 h/day, 9-10 h/day, and >10 h/day, Ptrend < 0.0001, respectively]. The results were similar for each of all-cause mortality and major cardiovascular events. Daytime nap duration was associated with an increased risk of the composite events in those with over 6 h of nocturnal sleep duration, but not in shorter nocturnal sleepers (≤6 h).


Estimated total sleep duration of 6-8 h per day is associated with the lowest risk of deaths and major cardiovascular events. Daytime napping is associated with increased risks of major cardiovascular events and deaths in those with >6 h of nighttime sleep but not in those sleeping ≤6 h/night.


Cardiovascular diseases; Mortality; Naps; Sleep duration

[Available on 2020-05-21]

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