Altered heart rate variability is associated with all-cause mortality in patients with co-morbid insomnia and obstructive sleep apnea

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ID: 317730
2026
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Abstract
Abstract Study Objectives Data regarding the additive effect of co-morbid insomnia and obstructive sleep apnea (COMISA) on autonomic modulation is lacking, and an association between cardiac autonomic burden and all-cause mortality in COMISA remains underexplored. Methods 5225 participants from the Sleep Heart Health Study were included. COMISA was diagnosed if the criteria for insomnia (difficulties initiating sleep, maintaining sleep, and/or early morning awakenings 16-30 times/month and daytime impairment) and OSA (AHI ≥ 15 events/h) were met. Heart rate variability (HRV) measures were computed from ECG during wakefulness before sleep onset and sleep using linear and non-linear analysis. Analysis of covariance was used to compare HRV among groups. Cox regression analysis was performed to examine associations between HRV and all-cause mortality in COMISA. Results Of the 5225 participants, 2697 were controls without insomnia or OSA, 170 had only insomnia, 2221 had only OSA, and 137 had COMISA. 42 deaths occurred in COMISA (30.6%). By comparisons of HRV among these 4 groups, COMISA were associated with elevated autonomic burdens, showing decreased parasympathetic activity. In multivariable Cox models, higher deceleration capacity (DC) of heart rate per 1-SD increase was independently associated with a lower risk of all-cause mortality in COMISA during wakefulness (HR, 0.75; 95% CI, 0.57-0.98; p = 0.037) and sleep (HR, 0.68; 95% CI, 0.49-0.95; p = 0.024). Conclusions Autonomic dysfunction is highly burdensome with COMISA through decreased parasympathetic function, leading to increased mortality. Among HRV measures, DC demonstrated the strongest predictive value, indicating its potential utility for improving mortality risk identification and stratification of all-causal mortality in COMISA. Clinical Trial Information Data were derived from the Sleep Heart Health Study (SHHS), available at: https://clinicaltrials.gov/study/NCT00005275. Clinical trial identifier: NCT00005275.
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Authors Hua Qin, Fernando Vaquerizo-Villar, Jan W. Kantelhardt, Rundong Qin, Jan F. Kraemer, Niels Wessel, Ronny P. Bartsch, Aicko Y. Schumann, Nicolas Steenbergen, Fan Pan, Thomas Penzel, Xiaowen Zhang
Journal Sleep & breathing = Schlaf & Atmung
Year 2026
DOI
10.1093/sleep/zsag150
URL
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