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citation_author=Peter, RS; citation_author=Mayer, B; citation_author=Concin, H; citation_author=Nagel, G.; citation_publication_date=2015; citation_journal_title=Int J Obes; citation_volume=39; citation_firstpage=530; citation_doi=10.1038/ijo.2014.168"> <meta name="citation_reference" content="citation_title=Sleep before and after retirement; citation_author=Myllyntausta, S; citation_author=Stenholm, S.; citation_publication_date=2018; citation_journal_title=Curr Sleep Med Rep; citation_volume=4; citation_firstpage=278; citation_doi=10.1007/s40675-018-0132-5"> <meta name="citation_abstract" content="Background:Excess sleep is associated with higher risk of stroke, but whether the risk is modified by age and if it remains elevated after accounting for the competing risk of death is not well understood.Methods:We used nine years of the Canadian Community Health Survey between 2000 to 2016 to obtain self-reported sleep duration and created a cohort of individuals without prior stroke, heart disease, or cancer. We linked to hospital records to determine subsequent admissions or emergency department visits for acute stroke until December 31, 2017. We used Cox proportional hazard models to determine the association between sleep duration and risk of stroke, assessing for modification by age and sex and adjusting for demographic, vascular, and social factors. We obtained cumulative incidence of stroke accounting for the competing risk of death.Results:There were 82,795 individuals in our cohort who met inclusion criteria and had self-reported sleep duration, with 1705 stroke events in follow-up. There was an association between excess sleep (≥10 h/night) and risk of stroke in those &lt;70 years (fully adjusted hazard ratio 2.29, 95% CI 1.04–5.06), but not ≥70 years of age, with a similar association after accounting for the competing risk of death.Conclusion:Sleep duration ≥10 h/night is associated with increased risk of stroke in those &lt;70 years of age. The findings support current guidelines for 7–9 h of sleep per night. Further research is needed to elucidate the relationship between sleep and cerebrovascular disease."> <meta name="citation_abstract" lang="fr" content="Résumé :Association entre des durées prolongées de sommeil et le risque d’AVC : une étude basée sur la population.Contexte :On le sait, les excès de sommeil sont associés à un risque accru d’AVC. Cela dit, on n’est pas encore certains si un tel risque peut évoluer en fonction de l’âge et s’il demeure élevé lorsqu’on tient compte du risque concurrent de décès. Méthodes :De 2000 à 2016, nous avons fait appel à neuf cycles de collecte de l’Enquête sur la santé dans les collectivités canadiennes pour obtenir des données portant sur la durée de sommeil déclarée par des patients. Cela nous a permis de constituer une cohorte de sujets sans antécédent d’AVC, de maladie cardiaque ou de cancer. Nous avons ensuite établi un lien avec des dossiers hospitaliers pour déterminer les admissions ultérieures ou les visites aux urgences pour un AVC aigu, et ce, jusqu’au 31 décembre 2017. À noter que nous avons utilisé des modèles à risque proportionnel de Cox afin de déterminer l’association entre la durée du sommeil et le risque d’AVC. À cet égard, nous avons évalué les modifications du risque en lien avec l’âge et le sexe et avons ajusté les facteurs démographiques, vasculaires et sociaux. Enfin, nous avons obtenu l’incidence cumulative de l’AVC en tenant compte du risque concurrent de décès.Résultats :Notre cohorte a compté 82 790 personnes répondant à nos critères d’inclusion et ayant signalé elles-mêmes la durée de leur sommeil. Au total, 1705 cas d’AVC ont été signalés lors d’un suivi. Une association entre une durée prolongée de sommeil (≥10 heures) et un risque d’AVC a été notée chez des personnes âgées de moins de 70 ans (rapport de risque entièrement ajusté = 2,29 ; IC 95 % 1,04–5,06) mais non pas chez celles âgées de 70 ans ou plus, une telle association s’étant avérée similaire même en tenant compte du risque concurrent de décès.Conclusion :Une durée de sommeil prolongée (≥10 heures) est donc associée à un risque accru d’AVC chez les personnes âgées de moins de 70 ans. Ces résultats vont dans le sens des recommandations actuelles qui préconisent de 7 à 9 heures de sommeil par nuit. Chose certaine, des recherches supplémentaires sont nécessaires pour élucider la relation qui existe entre le sommeil et les maladies cérébrovasculaires."> <meta name="citation_doi" content="10.1017/cjn.2021.242"> <link rel="alternate" href="/core/journals/canadian-journal-of-neurological-sciences/article/association-between-excess-sleep-duration-and-risk-of-stroke-a-populationbased-study/F26C6DAE19F920794075859D10082AB1" hreflang="en" /> <link rel="icon" href="/core/cambridge-core/public/images/favicon.ico" type="image/x-icon"/> <link rel="shortcut icon" href="/core/cambridge-core/public/images/favicon.ico" type="image/x-icon"/> <link href='//fonts.googleapis.com/css?family=Noto+Sans:400,700,400italic,700italic' rel='stylesheet' type='text/css'>  <link rel="stylesheet" href="/core/cambridge-core/public/css/app.css?version=v7.401.0"/> <link rel="dns-prefetch" href="https://usage.prod.aop.cambridge.org/v1/events"> <link rel="stylesheet" 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data-v-3692cf84><span data-v-63dfaf6e>Canadian Journal of Neurological Sciences</span> </a></li><li class="page-breadcrumbs__item" data-v-3692cf84><span aria-hidden="true" class="breadcrumbs-wrapper__arrow" data-v-3692cf84>></span><a href="/core/journals/canadian-journal-of-neurological-sciences/issue/CF63E659BE79CAA55AD3BDA720EEB698" class="app-link app-link__text app-link--accent" data-v-63dfaf6e data-v-3692cf84><span data-v-63dfaf6e>Volume 50 Issue 1</span> </a></li><li class="page-breadcrumbs__item" data-v-3692cf84><span aria-hidden="true" class="breadcrumbs-wrapper__arrow" data-v-3692cf84>></span><span data-v-3692cf84>Association Between Excess Sleep Duration and Risk...</span></li></ul></div></div> <div class="language" data-v-3692cf84><ul class="language-switch" data-v-6b1118dd data-v-3692cf84><li aria-label="English" data-v-6b1118dd><span class="language-option current divider" data-v-6b1118dd>English</span></li><li aria-label="Français" data-v-6b1118dd><span role="button" tabindex="0" href="#" lang="fr" class="language-option" data-v-6b1118dd> Français </span></li></ul></div></div></div></div> <div class="container container__modified" data-v-01274b1d>  <div class="row" data-v-01274b1d><div role="complementary" aria-label="table of content" class="column__left" data-v-01274b1d><div class="col journal-container row" data-v-146270e8 data-v-01274b1d><img src="https://static.cambridge.org/covers/CJN_0_0_0/canadian-journal-of-neurological-sciences.jpg" alt="" class="journal__image" data-v-146270e8> <a href="/core/journals/canadian-journal-of-neurological-sciences" class="app-link journal__title app-link__text app-link--underlined" data-v-63dfaf6e data-v-146270e8><span class="text" data-v-63dfaf6e>Canadian Journal of Neurological Sciences </span> </a> <hr aria-hidden="true" class="separator default" data-v-7036083a data-v-146270e8></div>  <div id="toc" class="table-of-content" data-v-01274b1d><h2>Article contents</h2> <div id="toc-list-wrapper" class="table-of-content__wrapper"><ul id="toc-list" class="list"><li class="list__item"><a href="#sec0" class="list__item__link"><span class="toc-title">Abstract:</span></a></li> <li class="list__item"><a href="#as1" class="list__item__link"> <span><div class="toc-title">Background:</div></span></a></li><li class="list__item"><a href="#as2" class="list__item__link"> <span><div class="toc-title">Methods:</div></span></a></li><li class="list__item"><a href="#as3" class="list__item__link"> <span><div class="toc-title">Results:</div></span></a></li><li class="list__item"><a href="#as4" class="list__item__link"> <span><div class="toc-title">Conclusion:</div></span></a></li><li class="list__item"><a href="#s1" class="list__item__link"> <span><div class="toc-title">Introduction</div></span></a></li><li class="list__item"><a href="#s2" class="list__item__link"> <span><div class="toc-title">Methods</div></span></a></li><li class="list__item"><a href="#s3" class="list__item__link"> <span><div class="toc-title">Results</div></span></a></li><li class="list__item"><a href="#s4" class="list__item__link"> <span><div class="toc-title">Discussion</div></span></a></li><li class="list__item"><a href="#s8" class="list__item__link"> <span><div class="toc-title">Supplementary Material</div></span></a></li><li class="list__item"><a href="#s5" class="list__item__link"> <span><div class="toc-title">Funding</div></span></a></li><li class="list__item"><a href="#s6" class="list__item__link"> <span><div class="toc-title">Disclosures</div></span></a></li><li class="list__item"><a href="#s7" class="list__item__link"> <span><div class="toc-title">Statement of Authorship</div></span></a></li>  <li class="list__item"><a href="#references-list" class="list__item__link"><span class="toc-title">References</span></a></li></ul></div></div></div> <div class="column__main" data-v-01274b1d><div class="row" data-v-01274b1d><div class="column__main__left" data-v-01274b1d><div id="maincontent" class="col" data-v-862424e6 data-v-01274b1d> <hgroup data-v-862424e6><h1 data-v-862424e6>Association Between Excess Sleep Duration and Risk of Stroke: A Population-Based Study</h1> </hgroup>    <div class="row part-of" data-v-862424e6><span class="part-of__label" data-v-862424e6> Part of: </span> <a href="/core/product/identifier/DFF7E9D6-32B8-43DD-A093-075255FB2ABF/type/BESPOKE_COLLECTION" class="part-of__collection" data-v-f0b31360 data-v-862424e6> CJNS Editor’s Choice Articles </a></div> <div class="row published-date" data-v-862424e6><p data-v-862424e6> Published online by Cambridge University Press: <strong data-v-862424e6>21 October 2021</strong></p></div>   <div class="contributors-details" data-v-99f6eb26 data-v-862424e6><div class="row contributors" data-v-99f6eb26><div class="col" data-v-99f6eb26><div class="row contributor-type" data-v-792406ce data-v-99f6eb26> <div class="contributor-type__contributor" data-v-792406ce><a href="/core/search?filters%5BauthorTerms%5D=Raed%20A.%20Joundi&eventCode=SE-AU" class="app-link app-link__text app-link--accent" data-v-63dfaf6e data-v-792406ce><span data-v-63dfaf6e>Raed A. Joundi</span> </a> <a target="_blank" href="https://orcid.org/0000-0001-9554-0701" data-test-orcid="Raed A. Joundi" class="app-link contributor-type__contributor__orcid app-link__icon app-link--" data-v-63dfaf6e data-v-792406ce><img src="data:image/svg+xml;base64,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" alt="Open the ORCID record for Raed A. Joundi" class="app-icon icon orcid" data-v-d2c09870 data-v-63dfaf6e> <span class="sr-only" data-v-63dfaf6e>[Opens in a new window]</span></a> <span data-v-792406ce>,</span></div><div class="contributor-type__contributor" data-v-792406ce><a href="/core/search?filters%5BauthorTerms%5D=Scott%20B.%20Patten&eventCode=SE-AU" class="app-link app-link__text app-link--accent" data-v-63dfaf6e data-v-792406ce><span data-v-63dfaf6e>Scott B. Patten</span> </a>  <span data-v-792406ce>,</span></div><div class="contributor-type__contributor" data-v-792406ce><a href="/core/search?filters%5BauthorTerms%5D=Jeanne%20V.A.%20Williams&eventCode=SE-AU" class="app-link app-link__text app-link--accent" data-v-63dfaf6e data-v-792406ce><span data-v-63dfaf6e>Jeanne V.A. Williams</span> </a>  <span data-v-792406ce> and</span></div><div class="contributor-type__contributor" data-v-792406ce><a href="/core/search?filters%5BauthorTerms%5D=Eric%20E.%20Smith&eventCode=SE-AU" class="app-link app-link__text app-link--accent" data-v-63dfaf6e data-v-792406ce><span data-v-63dfaf6e>Eric E. Smith</span> </a> <a target="_blank" href="https://orcid.org/0000-0003-3956-1668" data-test-orcid="Eric E. Smith" class="app-link contributor-type__contributor__orcid app-link__icon app-link--" data-v-63dfaf6e data-v-792406ce><img src="data:image/svg+xml;base64,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" alt="Open the ORCID record for Eric E. Smith" class="app-icon icon orcid" data-v-d2c09870 data-v-63dfaf6e> <span class="sr-only" data-v-63dfaf6e>[Opens in a new window]</span></a> <span data-v-792406ce></span></div> </div> </div> <div class="col-2 collapse-link" data-v-99f6eb26><a href="#authors-details" data-toggle="collapse" aria-expanded="false" aria-controls="authors-details" class="app-link collapsed app-link__text-icon app-link--secondary reverse" data-v-63dfaf6e data-v-99f6eb26><img src="data:image/svg+xml;base64,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" alt="" class="app-icon icon arrow-down" data-v-d2c09870 data-v-63dfaf6e><span class="text" data-v-63dfaf6e>Show author details </span> </a></div></div> <hr aria-hidden="true" class="separator default" data-v-7036083a data-v-99f6eb26> <dl id="authors-details" class="authors-details collapse" data-v-2edb8da6 data-v-99f6eb26><div data-test-author="Raed A. Joundi" class="row author" data-v-2edb8da6><dt class="col-12 col-sm-2 title" data-v-2edb8da6>Raed A. Joundi*</dt> <dd class="col content d-inline d-sm-flex" data-v-2edb8da6><span class="content__title" data-v-2edb8da6>Affiliation:</span> <div class="d-sm-flex flex-column flex-sm-1 d-inline" data-v-2edb8da6><span data-v-2edb8da6><span data-v-2edb8da6>Division of Neurology, Hamilton Health Sciences, McMaster University & Population Health Research Institute, Hamilton, ON, Canada</span> </span><span data-v-2edb8da6><span data-v-2edb8da6>Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada</span> </span><span data-v-2edb8da6><span data-v-2edb8da6>Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada</span> </span></div></dd></div><div data-test-author="Scott B. Patten" class="row author" data-v-2edb8da6><dt class="col-12 col-sm-2 title" data-v-2edb8da6>Scott B. Patten</dt> <dd class="col content d-inline d-sm-flex" data-v-2edb8da6><span class="content__title" data-v-2edb8da6>Affiliation:</span> <div class="d-sm-flex flex-column flex-sm-1 d-inline" data-v-2edb8da6><span data-v-2edb8da6><span data-v-2edb8da6>Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada</span> </span></div></dd></div><div data-test-author="Jeanne V.A. Williams" class="row author" data-v-2edb8da6><dt class="col-12 col-sm-2 title" data-v-2edb8da6>Jeanne V.A. Williams</dt> <dd class="col content d-inline d-sm-flex" data-v-2edb8da6><span class="content__title" data-v-2edb8da6>Affiliation:</span> <div class="d-sm-flex flex-column flex-sm-1 d-inline" data-v-2edb8da6><span data-v-2edb8da6><span data-v-2edb8da6>Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada</span> </span></div></dd></div><div data-test-author="Eric E. Smith" class="row author" data-v-2edb8da6><dt class="col-12 col-sm-2 title" data-v-2edb8da6>Eric E. Smith</dt> <dd class="col content d-inline d-sm-flex" data-v-2edb8da6><span class="content__title" data-v-2edb8da6>Affiliation:</span> <div class="d-sm-flex flex-column flex-sm-1 d-inline" data-v-2edb8da6><span data-v-2edb8da6><span data-v-2edb8da6>Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada</span> </span><span data-v-2edb8da6><span data-v-2edb8da6>Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada</span> </span></div></dd></div> <div class="row" data-v-2edb8da6><dt class="col-sm-2 col-12 title" data-v-2edb8da6> * </dt> <dd class="col content" data-v-2edb8da6><div class="row" data-v-2edb8da6><div class="d-sm-flex d-inline flex-sm-1 flex-sm-wrap" data-v-2edb8da6><div class="d-inline" data-v-2edb8da6><span data-v-2edb8da6><div class="corresp"><span class="bold">Corresponding author:</span> Raed A. Joundi, Hamilton General Hospital, 237 Barton St. East, Hamilton, Ontario, Canada, L8L 2X2, Email: <a href="mailto:joundir@mcmaster.ca">joundir@mcmaster.ca</a></div></span></div></div></div></dd></div> <hr aria-hidden="true" class="separator default" data-v-7036083a data-v-2edb8da6></dl></div></div> <div id="app-tabs" class="tabs" data-v-1d90c6ce data-v-01274b1d><div id="app-tabs-wrapper" class="tabs__wrapper" data-v-1d90c6ce><div role="navigation" aria-label="tab navigation" class="container" data-v-1d90c6ce><a data-toggle="collapse" href="#appTabs" role="button" aria-expanded="false" aria-controls="appTabs" class="tabs__collapse collapsed d-sm-none d-print-none" data-v-1d90c6ce><span data-v-1d90c6ce></span> <span class="tabs-arrow-up" data-v-1d90c6ce></span> <span class="tabs-arrow-down" data-v-1d90c6ce></span></a> <ul id="appTabs" role="tablist" class="nav nav-tabs tabs__list collapse show" data-v-1d90c6ce><li role="none" class="tabs__tab" data-v-1d90c6ce><a aria-selected="true" 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class="list__item"><a href="#s4" class="list__item__link"> <span>Discussion</span></a></li><li class="list__item"><a href="#s8" class="list__item__link"> <span>Supplementary Material</span></a></li><li class="list__item"><a href="#s5" class="list__item__link"> <span>Funding</span></a></li><li class="list__item"><a href="#s6" class="list__item__link"> <span>Disclosures</span></a></li><li class="list__item"><a href="#s7" class="list__item__link"> <span>Statement of Authorship</span></a></li>  <li class="list__item"><a href="#references-list" class="list__item__link"><span class="toc-title">References</span></a></li></ul></div> <div class="action-bar" data-v-43a4d572><div class="row items"> <div class="app-dropdown d-print-none" data-v-fab090b8 data-v-113567da data-v-43a4d572><button aria-expanded="false" data-test-id="buttonSavePDFOptions" id="save-pdf-dropdown" class="app-button dropdown-menu-button app-button__text-icon app-button--secondary" data-v-2a038744 data-v-fab090b8><img 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target="_blank" href="https://s100.copyright.com/AppDispatchServlet?publisherName=CUP&publication=CJN&title=Association%20Between%20Excess%20Sleep%20Duration%20and%20Risk%20of%20Stroke%3A%20A%20Population-Based%20Study&publicationDate=21%20October%202021&author=Raed%20A.%20Joundi%2C%20Scott%20B.%20Patten%2C%20Jeanne%20V.A.%20Williams%2C%20Eric%20E.%20Smith©right=%C2%A9%20The%20Author(s)%2C%202021.%20Published%20by%20Cambridge%20University%20Press%20on%20behalf%20of%20Canadian%20Neurological%20Sciences%20Federation&contentID=10.1017%2Fcjn.2021.242&startPage=17&endPage=22&orderBeanReset=True&volumeNum=50&issueNum=1&oa=" data-test-id="buttonRightLink" class="app-link rights-link d-print-none app-link__text-icon app-link--accent" data-v-63dfaf6e data-v-92ee52a2 data-v-43a4d572><img src="/core/page-component/img/rights-icon.d4a677c.svg" alt="" class="app-icon icon rights" data-v-d2c09870 data-v-63dfaf6e><span class="text" data-v-63dfaf6e>Rights & Permissions </span> <span class="sr-only" data-v-63dfaf6e>[Opens in a new window]</span></a></div> <hr aria-hidden="true" class="separator default" data-v-7036083a></div> <div class="share-modal-overlay" style="display:none;" data-v-43a4d572></div> <div data-spy="scroll" data-target="#toc" class="scrollspy-content" data-v-43a4d572> <div id="sec0" class="col article-abstract sec" data-v-2fa8b348 data-v-43a4d572><div class="abstract-text-container" data-v-2fa8b348><div lang="en"><h2>Abstract:</h2>  <div class="abstract-content"><div class="abstract" data-abstract-type="normal"><div class="sec"><span class="bold">Background:</span><p>Excess sleep is associated with higher risk of stroke, but whether the risk is modified by age and if it remains elevated after accounting for the competing risk of death is not well understood.</p></div><div class="sec"><span class="bold">Methods:</span><p>We used nine years of the Canadian Community Health Survey between 2000 to 2016 to obtain self-reported sleep duration and created a cohort of individuals without prior stroke, heart disease, or cancer. We linked to hospital records to determine subsequent admissions or emergency department visits for acute stroke until December 31, 2017. We used Cox proportional hazard models to determine the association between sleep duration and risk of stroke, assessing for modification by age and sex and adjusting for demographic, vascular, and social factors. We obtained cumulative incidence of stroke accounting for the competing risk of death.</p></div><div class="sec"><span class="bold">Results:</span><p>There were 82,795 individuals in our cohort who met inclusion criteria and had self-reported sleep duration, with 1705 stroke events in follow-up. There was an association between excess sleep (≥10 h/night) and risk of stroke in those <70 years (fully adjusted hazard ratio 2.29, 95% CI 1.04–5.06), but not ≥70 years of age, with a similar association after accounting for the competing risk of death.</p></div><div class="sec"><span class="bold">Conclusion:</span><p>Sleep duration ≥10 h/night is associated with increased risk of stroke in those <70 years of age. The findings support current guidelines for 7–9 h of sleep per night. Further research is needed to elucidate the relationship between sleep and cerebrovascular disease.</p></div></div></div> <hr aria-hidden="true" class="abstract-divider separator default" data-v-7036083a></div><div lang="fr"><h2>Résumé :</h2>  <div class="abstract-content"><div class="abstract" data-abstract-type="translated"><title>Résumé :</title><p><span class='bold'>Association entre des durées prolongées de sommeil et le risque d’AVC : une étude basée sur la population.</span></p><title>Contexte :</title><p>On le sait, les excès de sommeil sont associés à un risque accru d’AVC. Cela dit, on n’est pas encore certains si un tel risque peut évoluer en fonction de l’âge et s’il demeure élevé lorsqu’on tient compte du risque concurrent de décès.</p> <title>Méthodes :</title><p>De 2000 à 2016, nous avons fait appel à neuf cycles de collecte de l’Enquête sur la santé dans les collectivités canadiennes pour obtenir des données portant sur la durée de sommeil déclarée par des patients. Cela nous a permis de constituer une cohorte de sujets sans antécédent d’AVC, de maladie cardiaque ou de cancer. Nous avons ensuite établi un lien avec des dossiers hospitaliers pour déterminer les admissions ultérieures ou les visites aux urgences pour un AVC aigu, et ce, jusqu’au 31 décembre 2017. À noter que nous avons utilisé des modèles à risque proportionnel de Cox afin de déterminer l’association entre la durée du sommeil et le risque d’AVC. À cet égard, nous avons évalué les modifications du risque en lien avec l’âge et le sexe et avons ajusté les facteurs démographiques, vasculaires et sociaux. Enfin, nous avons obtenu l’incidence cumulative de l’AVC en tenant compte du risque concurrent de décès.</p><title>Résultats :</title><p>Notre cohorte a compté 82 790 personnes répondant à nos critères d’inclusion et ayant signalé elles-mêmes la durée de leur sommeil. Au total, 1705 cas d’AVC ont été signalés lors d’un suivi. Une association entre une durée prolongée de sommeil (≥10 heures) et un risque d’AVC a été notée chez des personnes âgées de moins de 70 ans (rapport de risque entièrement ajusté = 2,29 ; IC 95 % 1,04–5,06) mais non pas chez celles âgées de 70 ans ou plus, une telle association s’étant avérée similaire même en tenant compte du risque concurrent de décès.</p><title>Conclusion :</title><p>Une durée de sommeil prolongée (≥10 heures) est donc associée à un risque accru d’AVC chez les personnes âgées de moins de 70 ans. Ces résultats vont dans le sens des recommandations actuelles qui préconisent de 7 à 9 heures de sommeil par nuit. Chose certaine, des recherches supplémentaires sont nécessaires pour élucider la relation qui existe entre le sommeil et les maladies cérébrovasculaires.</p></div></div> <hr aria-hidden="true" class="abstract-divider separator default" data-v-7036083a></div></div>   </div>  <div class="keywords" data-v-86c27100 data-v-43a4d572><h2 data-v-86c27100>Keywords</h2> <div class="row keywords__pills" data-v-86c27100><a href="/core/search?filters[keywords]=Stroke" data-v-f0b31360 data-v-86c27100><span data-v-f0b31360 data-v-86c27100>Stroke</span></a><a href="/core/search?filters[keywords]=Sleep" data-v-f0b31360 data-v-86c27100><span data-v-f0b31360 data-v-86c27100>Sleep</span></a><a href="/core/search?filters[keywords]=Epidemiology" data-v-f0b31360 data-v-86c27100><span data-v-f0b31360 data-v-86c27100>Epidemiology</span></a></div> <hr aria-hidden="true" class="separator default" data-v-7036083a data-v-86c27100></div>  <dl class="article-details" data-v-6e32a161 data-v-43a4d572><div class="row" data-v-6e32a161><dt class="col-12 col-sm-3 col-md-2_5 title" data-v-6e32a161> Type </dt> <dd class="col content" data-v-6e32a161>Original Article</dd></div> <div class="row" data-v-6e32a161><dt class="col-12 col-sm-3 col-md-2_5 title" data-v-6e32a161> Information </dt> <dd class="col content" data-v-6e32a161><div class="content__journal" data-v-6e32a161><a href="/core/journals/canadian-journal-of-neurological-sciences" class="app-link app-link__text app-link--underlined" data-v-63dfaf6e data-v-6e32a161><span class="text" data-v-63dfaf6e>Canadian Journal of Neurological Sciences </span> </a> <span data-v-6e32a161> , <a href="/core/journals/canadian-journal-of-neurological-sciences/volume/FF589D1CDFAEF2CE394E9B34F4E3B899" class="app-link app-link__text app-link--underlined" data-v-63dfaf6e data-v-6e32a161><span class="text" data-v-63dfaf6e>Volume 50 </span> </a></span> <span data-v-6e32a161> , <a href="/core/journals/canadian-journal-of-neurological-sciences/issue/CF63E659BE79CAA55AD3BDA720EEB698" class="app-link app-link__text app-link--underlined" data-v-63dfaf6e data-v-6e32a161><span class="text" data-v-63dfaf6e>Issue 1 </span> </a></span> <span data-v-6e32a161>, January 2023</span>  <span data-v-6e32a161>, pp. 17 - 22</span> </div> <div class="doi-data" data-v-6e32a161><div data-v-6e32a161>DOI: <a target="_blank" href="https://doi.org/10.1017/cjn.2021.242" class="app-link app-link__text app-link--accent" data-v-63dfaf6e data-v-6e32a161><span class="text" data-v-63dfaf6e>https://doi.org/10.1017/cjn.2021.242 </span> <span class="sr-only" data-v-63dfaf6e>[Opens in a new window]</span></a></div> </div>  </dd></div>   <div class="row" data-v-6e32a161><dt class="col-12 col-sm-3 col-md-2_5 title" data-v-6e32a161> Copyright </dt> <dd class="col content" data-v-6e32a161><div data-v-6e32a161> © The Author(s), 2021. Published by Cambridge University Press on behalf of Canadian Neurological Sciences Federation </div></dd></div></dl>  <div id="content-container" class="content-container" data-v-43a4d572><div class="content-box"><div class="article research-article NLM"> <div class="body"> <div class="sec intro" data-magellan-destination="s1" id="s1"> <h2 class="A"> Introduction</h2> <p class="p"> Divergence from the recommended 7–9 h of sleep duration has been associated with cardiovascular disease and mortality, with the suggestion of a J-shaped relationship.<sup class="sup"> <a class="xref bibr" href="#r1"><span class="show-for-sr">Reference Yazdanpanah, Homayounfar, Khademi, Zarei, Shahidi and Farjam</span>1</a>–<a class="xref bibr" href="#r4"><span class="show-for-sr">Reference Lao, Liu and Deng</span>4</a> </sup> Recently, an association between abnormal sleep duration and stroke incidence has been reported, especially excess sleep >9 h.<sup class="sup"> <a class="xref bibr" href="#r5"><span class="show-for-sr">Reference Chen, Brunner and Ren</span>5</a>–<a class="xref bibr" href="#r9"><span class="show-for-sr">Reference Titova, Michaëlsson and Larsson</span>9</a> </sup> </p> <p class="p"> However, the results are inconsistent, with some studies and meta-analyses reporting no association between sleep duration and stroke risk.<sup class="sup"> <a class="xref bibr" href="#r10"><span class="show-for-sr">Reference Amagai, Ishikawa, Gotoh, Kayaba, Nakamura and Kajii</span>10</a>,<a class="xref bibr" href="#r11"><span class="show-for-sr">Reference Westerlund, Bellocco, Sundström, Adami, Åkerstedt and Trolle Lagerros</span>11</a> </sup> In addition, older individuals have lower recommended and self-reported sleep duration,<sup class="sup"> <a class="xref bibr" href="#r12"><span class="show-for-sr">Reference Chaput, Dutil and Sampasa-Kanyinga</span>12</a> </sup> and whether age modifies the association of abnormal sleep duration with stroke is not well understood despite the potential importance of age for the targeting of preventive efforts. Lastly, sleep duration is also associated with all-cause mortality,<sup class="sup"> <a class="xref bibr" href="#r13"><span class="show-for-sr">Reference Cappuccio, D’Elia, Strazzullo and Miller</span>13</a>,<a class="xref bibr" href="#r14"><span class="show-for-sr">Reference Gallicchio and Kalesan</span>14</a> </sup> which may bias estimates of stroke risk.</p> <p class="p"> We sought to determine the association between sleep duration and stroke risk in a large Canadian population-based cohort, evaluate differences with age, and account for the competing risk of death.</p> </div> <div class="sec methods" data-magellan-destination="s2" id="s2"> <h2 class="A"> Methods</h2> <div class="sec" data-magellan-destination="s2-1" id="s2-1"> <h3 class="B"> Study Sample – Canadian Community Health Survey</h3> <p class="p"> The Canadian Community Health Survey (CCHS) is an annual cross-sectional survey, representing 97% of the Canadian household population aged 12 years and older.<sup class="sup"> <a class="xref bibr" href="#r15">15</a> </sup> The CCHS collects information about health status, health determinants, and health care utilization of the household population. The 3% of the general population that is excluded from the survey target population includes those living on Indigenous reserves, those living in foster care, full-time members of the Canadian Armed Forced, the institutionalized population, and the remote Région du Nunavik and Région des Terres-Cries-de-la-Baie-James.</p> </div> <div class="sec" data-magellan-destination="s2-2" id="s2-2"> <h3 class="B"> Administrative Linkages</h3> <p class="p"> Linkages were performed by Statistics Canada and included the Canadian Institutes of Health Discharge Abstract Database (CIHI-DAD) for hospitalizations, the National Ambulatory Care Reporting System (NACRS) for emergency department visits, and the Canadian Vital Statistics Database (CVSD) for deaths.<sup class="sup"> <a class="xref bibr" href="#r16">16</a>,<a class="xref bibr" href="#r17"><span class="show-for-sr">Reference Sanmartin, Decady and Trudeau</span>17</a> </sup> The linkage subsample contained 85% of total CCHS respondents who agreed to have their responses linked to administrative records. We used CIHI-DAD, NACRS, and CVSD to determine stroke events and deaths after the survey response until December 31, 2017. All participants had a minimum of 1 year of full follow-up for events and were censored if alive on December 31, 2017.</p> </div> <div class="sec" data-magellan-destination="s2-3" id="s2-3"> <h3 class="B"> Cohort</h3> <p class="p"> We used CCHS years 2000, 2007, 2008, and 2011–2016 to capture data on sleep duration and other baseline covariates. Sleep duration was an optional module in all years except 2000, meaning that it could be selected by some but not all provinces and territories. We excluded those under the age of 40 and those with a history of heart disease (self-report), cancer (self-report), or prior stroke (either administrative data diagnosis or self-report).</p> </div> <div class="sec" data-magellan-destination="s2-4" id="s2-4"> <h3 class="B"> Exposure</h3> <p class="p"> Our main exposure was self-reported sleep duration. Participants were asked the number of hours spent sleeping per night. Time spent in daytime napping was not captured. We categorized sleep duration as <4 h, 4–6 h, 7–9 h, and ≥10 h/day, with excess sleep duration defined as ≥10 h/day, as the Canadian guidelines recommend 7–9 h of sleep per night for individuals <65 years of age.<sup class="sup"> <a class="xref bibr" href="#r18"><span class="show-for-sr">Reference Ross, Chaput and Giangregorio</span>18</a> </sup> </p> </div> <div class="sec" data-magellan-destination="s2-5" id="s2-5"> <h3 class="B"> Covariates</h3> <p class="p"> Covariates were obtained from the CCHS, including age, sex, rural residence, and self-report of ethnicity, education level, total household income, marital status, body mass index, current smoking status, hypertension, diabetes, heart disease, cancer, arthritis, chronic obstructive pulmonary disease (COPD), migraine, and asthma. Categorization of the variables can be seen in Table <a class="xref table" href="#tbl1">1</a>. Due to known biases in self-report of body mass index, we employed a correction developed by the CCHS.<sup class="sup"> <a class="xref bibr" href="#r19"><span class="show-for-sr">Reference Shields, Gorber, Janssen and Tremblay</span>19</a> </sup> </p> <p class="p"> </p><div class="table-wrap" data-magellan-destination="tbl1" id="tbl1"> <div class="caption"> <p class="p"><span class="label">Table 1:</span> Weighted percentage of baseline characteristics</p> </div> <span> <div class="figure-thumb"><img src="data:image/gif;base64,R0lGODlhAQABAIAAAMLCwgAAACH5BAAAAAAALAAAAAABAAEAAAICRAEAOw==" data-src="https://static.cambridge.org/binary/version/id/urn:cambridge.org:id:binary:20230208102951209-0964:S0317167121002420:S0317167121002420_tab1.png?pub-status=live" class="aop-lazy-load-image" width="519" height="1377" data-original-image="/binary/version/id/urn:cambridge.org:id:binary:20230208102951209-0964:S0317167121002420:S0317167121002420_tab1.png" data-zoomable="true"></div> </span> </div> </div> <div class="sec" data-magellan-destination="s2-6" id="s2-6"> <h3 class="B"> Outcome</h3> <p class="p"> Our primary outcome was acute stroke (ischemic stroke or intracerebral hemorrhage [ICH]) at any time in follow-up, using <em class="italic">International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Canada</em> (ICD-10-CA) codes (ischemic stroke: I63.x, I64.x, H34.1; ICH: I61.x) and ICD-9 codes (ischemic stroke: 434.01, 434.11, 434.91, 436; ICH: 431). Our secondary outcome was death during follow-up.</p> </div> <div class="sec" data-magellan-destination="s2-7" id="s2-7"> <h3 class="B"> Analysis</h3> <p class="p"> We first used Cox proportional regression models to obtain the hazard of stroke by category of sleep duration, censoring people at death or end of follow-up. We assessed for the presence of modification of the sleep duration-stroke association by age (<70 years and ≥70 years) and sex. As there was evidence of modification by age but not sex, we created age-specific stratified models.</p> <p class="p"> In our simple model, we adjusted for sex only. In our vascular model, we adjusted for sex, body mass index, hypertension, diabetes, and smoking. In our full model, we adjusted for the above in addition to income quartile, rural residence, alcohol consumption, education, ethnicity, marital status, and other comorbidities (migraine, arthritis, COPD, and asthma). We evaluated the proportional hazards assumption by assessing the significance (<em class="italic">p</em> < 0.05) of an interaction term of sleep duration category and follow-up time.</p> <p class="p"> We conducted three sensitivity analyses. First, we additionally adjusted for symptoms of depression (2 or more weeks of feeling sad, blue, or depressed in the past 12 months) in the sub-set of individuals in which this variable was available. Second, we changed the upper category of sleep duration to ≥9 h. Third, we evaluated the risk of ischemic stroke only; there were insufficient events for an analysis of ICH only.</p> <p class="p"> Lastly, we conducted competing risk regression to confirm that the risk of stroke was elevated while accounting for the competing risk of death. We obtained subdistribution hazard ratios and generated cumulative incidence functions for the risk of stroke over follow-up time. We adjusted for the same factors as in previous models.</p> <p class="p"> Analyses were done in the Prairie Regional Data Centre at the University of Calgary using Stata 16.0 (College Station, TX, USA). Threshold of significance for <em class="italic">p</em>-values was <0.05. Under Tri-Council guidelines, this analysis did not require approval by a research ethics board.</p> </div> </div> <div class="sec results" data-magellan-destination="s3" id="s3"> <h2 class="A"> Results</h2> <p class="p"> Our total cohort comprised 82,795 people with self-reported sleep duration and without prior heart disease, cancer, or stroke. During a median follow-up time of 9.1 years (interquartile range [IQR] 3.2–16.6 years), there was a total of 1705 stroke events (88.3% ischemic). Among those with incident stroke, the median time from survey response until stroke was 7.5 years (IQR 3.8–12.3).</p> <p class="p"> Baseline characteristics of the cohort weighted to the Canadian population are shown in Table <a class="xref table" href="#tbl1">1</a>. The proportion of individuals <70 years was 86% and the proportion of females was 53.2%. The majority of people had 7–9 h of sleep duration (55.8%), with a small proportion having ≥10 h of sleep duration (1.2%).</p> <p class="p"> Weighted percentages of stroke events in follow-up are shown in Supplemental Table <a class="uri" href="https://doi.org/10.1017/cjn.2021.242">1</a> and stratified by subgroup. The greatest increases in stroke rate occurred when comparing 7–9 h of sleep with ≥10 h of sleep in those <70 years of age (1.5% to 5.9%) and in females (2.0% to 6.9%; Supplementary Table <a class="uri" href="https://doi.org/10.1017/cjn.2021.242">1</a>).</p> <p class="p"> In the simple Cox regression model, there was a significant interaction between sleep duration ≥10 h and age (<em class="italic">p</em> = 0.030), but not sex (<em class="italic">p</em> = 0.27). There was no evidence of violation of the proportional hazards assumption.</p> <p class="p"> Among individuals <70, excess sleep was associated with higher long-term risk of stroke in the simple model (adjusted hazard ratio [aHR] 3.15, 95% CI 1.74–5.73), vascular model (aHR 2.77, 95% CI 1.35–5.70), and full model (aHR 2.26, 95% CI 1.02–5.00; Figure <a class="xref fig" href="#f1">1</a>A–C). There was no association between excess sleep and risk of stroke in those ≥70 years (Figure <a class="xref fig" href="#f1">1</a>). The results were consistent in a sensitivity analysis adjusting for symptoms of depression. The association did not persist when the highest category of sleep duration was changed to ≥9 h (Supplementary Table <a class="uri" href="https://doi.org/10.1017/cjn.2021.242">2</a>). When analyzing ischemic stroke only, there was a higher risk in the simple and vascular models, but the association was attenuated in the full model (Supplementary Table <a class="uri" href="https://doi.org/10.1017/cjn.2021.242">3</a>).</p> <p class="p"> </p><section><div class="fig" data-magellan-destination="f1" id="f1"> <div class="figure-thumb"><img src="data:image/gif;base64,R0lGODlhAQABAIAAAMLCwgAAACH5BAAAAAAALAAAAAABAAEAAAICRAEAOw==" data-src="https://static.cambridge.org/binary/version/id/urn:cambridge.org:id:binary:20230208102951209-0964:S0317167121002420:S0317167121002420_fig1.png?pub-status=live" class="aop-lazy-load-image" width="2750" height="2550" data-original-image="/binary/version/id/urn:cambridge.org:id:binary:20230208102951209-0964:S0317167121002420:S0317167121002420_fig1.png" data-zoomable="true"></div> <div class="caption"><p class="p"> </p><p class="p"><span class="label">Figure 1:</span> Association between categories of sleep duration and risk of stroke, stratified by age. Hazard ratios with 95% CIs are from Cox regression models (A, simple model; B, vascular model; C, full model), and subdistribution hazard ratios are from competing risk analysis (D, full model). There is a higher hazard of stroke in those <70 years old who report 10+ hours of sleep per night.</p> </div></div></section> <p class="p"> After accounting for the competing risk of death, there remained a significantly elevated risk and higher cumulative incidence of stroke in those with excess sleep and age <70 years (Figure <a class="xref fig" href="#f1">1</a>D and Figure <a class="xref fig" href="#f2">2</a>).</p> <p class="p"> </p><section><div class="fig" data-magellan-destination="f2" id="f2"> <div class="figure-thumb"><img src="data:image/gif;base64,R0lGODlhAQABAIAAAMLCwgAAACH5BAAAAAAALAAAAAABAAEAAAICRAEAOw==" data-src="https://static.cambridge.org/binary/version/id/urn:cambridge.org:id:binary:20230208102951209-0964:S0317167121002420:S0317167121002420_fig2.png?pub-status=live" class="aop-lazy-load-image" width="2066" height="773" data-original-image="/binary/version/id/urn:cambridge.org:id:binary:20230208102951209-0964:S0317167121002420:S0317167121002420_fig2.png" data-zoomable="true"></div> <div class="caption"><p class="p"> </p><p class="p"><span class="label">Figure 2:</span> Cumulative incidence functions over years of follow-up for categories of sleep duration, stratified by age. Those ≥70 years have lower maximal follow-up time due to higher mortality. The greatest elevation in cumulative incidence of stroke occurs in individuals <70 years who report 10+ hours of sleep per night. Estimates obtained from fully adjusted competing risk regression models.</p> </div></div></section> </div> <div class="sec discussion" data-magellan-destination="s4" id="s4"> <h2 class="A"> Discussion</h2> <p class="p"> We demonstrate that excess sleep duration ≥10 h is associated with increased long-term risk of stroke among individuals younger than 70 years old, and this risk remains elevated after accounting for the competing risk of death.</p> <p class="p"> Our results are consistent with prior studies showing an increased risk of stroke with excess sleep time.<sup class="sup"> <a class="xref bibr" href="#r5"><span class="show-for-sr">Reference Chen, Brunner and Ren</span>5</a>–<a class="xref bibr" href="#r8"><span class="show-for-sr">Reference Helbig, Stöckl, Heier, Ladwig and Meisinger</span>8</a>,<a class="xref bibr" href="#r20"><span class="show-for-sr">Reference Song, Howard and Howard</span>20</a>,<a class="xref bibr" href="#r21"><span class="show-for-sr">Reference Leng, Cappuccio and Wainwright</span>21</a> </sup> Some studies have suggested a J-shaped relationship, with low amounts of sleep also increasing risk.<sup class="sup"> <a class="xref bibr" href="#r22"><span class="show-for-sr">Reference Li, Wang and Cao</span>22</a> </sup> While the point estimate of stroke risk for the category of <4 h sleep was elevated among individuals <70, it did not reach significance in our study. The mechanism of stroke with excess sleep and stroke is unknown. Long duration of sleep is associated with inflammatory biomarkers,<sup class="sup"> <a class="xref bibr" href="#r23"><span class="show-for-sr">Reference Patel, Zhu and Storfer-Isser</span>23</a>,<a class="xref bibr" href="#r24"><span class="show-for-sr">Reference Dowd, Goldman and Weinstein</span>24</a> </sup> vascular risk factors,<sup class="sup"> <a class="xref bibr" href="#r25"><span class="show-for-sr">Reference Yang, Yang and He</span>25</a>–<a class="xref bibr" href="#r27"><span class="show-for-sr">Reference Grandner, Mullington, Hashmi, Redeker, Watson and Morgenthaler</span>27</a> </sup> carotid intimal thickness,<sup class="sup"> <a class="xref bibr" href="#r28"><span class="show-for-sr">Reference Abe, Aoki, Yata and Okada</span>28</a> </sup> and white matter hyperintensities.<sup class="sup"> <a class="xref bibr" href="#r29"><span class="show-for-sr">Reference Ramos, Dong and Rundek</span>29</a> </sup> In addition, excess sleeping may be a surrogate for higher sedentary time, depression, sleep apnea, or low socioeconomic status, all of which have been linked to stroke and cardiovascular risk.<sup class="sup"> <a class="xref bibr" href="#r30"><span class="show-for-sr">Reference Dong, Zhang, Tong and Qin</span>30</a>–<a class="xref bibr" href="#r33"><span class="show-for-sr">Reference Biswas, Oh and Faulkner</span>33</a> </sup> Our findings are consistent with guidelines recommending 7–9 h of sleep per night to promote optimal health.<sup class="sup"> <a class="xref bibr" href="#r18"><span class="show-for-sr">Reference Ross, Chaput and Giangregorio</span>18</a>,<a class="xref bibr" href="#r34"><span class="show-for-sr">Reference Chaput, Dutil and Featherstone</span>34</a> </sup> </p> <p class="p"> The reason for the observed age modification is unclear. Multiple studies have reported associations between sleep and hypertension that are attenuated in the elderly.<sup class="sup"> <a class="xref bibr" href="#r35"><span class="show-for-sr">Reference van den Berg, Tulen and Neven</span>35</a>–<a class="xref bibr" href="#r37"><span class="show-for-sr">Reference Kim and Jo</span>37</a> </sup> Similarly, among individuals <65 years, both short and long duration sleep was associated with excess mortality, but not in individuals 65 years and older.<sup class="sup"> <a class="xref bibr" href="#r38"><span class="show-for-sr">Reference Åkerstedt, Ghilotti, Grotta, Bellavia, Lagerros and Bellocco</span>38</a> </sup> These finding are also in line with prior studies showing the associations between vascular risk factors such as obesity or diabetes and adverse outcomes are also greater at younger age.<sup class="sup"> <a class="xref bibr" href="#r39"><span class="show-for-sr">Reference Rawshani, Rawshani and Franzén</span>39</a>,<a class="xref bibr" href="#r40"><span class="show-for-sr">Reference Peter, Mayer, Concin and Nagel</span>40</a> </sup> Total sleep duration is significantly shorter in elderly, and the overall dynamics and homeostasis of sleep differ compared to middle-aged and younger subjects.<sup class="sup"> <a class="xref bibr" href="#r41"><span class="show-for-sr">Reference Campbell and Murphy</span>41</a> </sup> Retirement also improves sleep quality, which may mitigate the impact of excess sleep duration.<sup class="sup"> <a class="xref bibr" href="#r42"><span class="show-for-sr">Reference Myllyntausta and Stenholm</span>42</a> </sup> However, our results are in contrast to two studies from China showing the association of excess sleep and stroke was stronger at older age,<sup class="sup"> <a class="xref bibr" href="#r6"><span class="show-for-sr">Reference Zhou, Yu and Yang</span>6</a>,<a class="xref bibr" href="#r21"><span class="show-for-sr">Reference Leng, Cappuccio and Wainwright</span>21</a> </sup> and may be due to variability in the population studied, amount of follow-up, or other study differences. We had a smaller number of individuals who were ≥70 years old and shorter follow-up time due to higher mortality, which may have limited our ability to detect an association in this age group.</p> <p class="p"> There were some limitations to this study. First, we relied on self-reported sleep duration in the CCHS. Self-reported sleep duration overestimates sleep duration compared to objective measurements; therefore, the true threshold for increased risk may be lower than reported here.<sup class="sup"> <a class="xref bibr" href="#r43"><span class="show-for-sr">Reference Jackson, Patel, Jackson, Lutsey and Redline</span>43</a> </sup> Second, we relied on administrative data to measure stroke events, although the codes used have high validity in Canada.<sup class="sup"> <a class="xref bibr" href="#r44"><span class="show-for-sr">Reference Porter, Mondor, Kapral, Fang and Hall</span>44</a> </sup> Third, we had no assessment of sleep quality, sleep apnea, or mid-day napping. Lastly, there is the potential for residual confounding from many vascular and socioeconomic factors which may be related to both sleep duration and stroke risk.</p> <p class="p"> In conclusion, excess sleep duration ≥10 h was associated with elevated stroke risk in those <70 years of age. The results support current guidelines for 7–9 h of sleep per night and suggest the need for further research on determining mechanisms of sleep-related cardio- and cerebrovascular disease.</p> </div> </div> <div class="back"> <div class="sec other" data-magellan-destination="s8" id="s8"> <h2 class="A"> Supplementary Material</h2> <p class="p"> To view supplementary material for this article, please visit <a class="uri" href="https://doi.org/10.1017/cjn.2021.242">https://doi.org/10.1017/cjn.2021.242</a> </p> </div> <div class="ack"> <h2 class="A"> Acknowledgements</h2> <p class="p"> The analysis was conducted at the Prairie Regional Research Data Centre (RDC), which is part of the Canadian Research Data Centre Network. The services and activities provided by the Canadian Research Data Centre Network are made possible by the financial or in-kind support of the Social Sciences and Humanities Research Council, the Canadian Institutes of Health Research, the Canadian Foundation for Innovation, Statistics Canada, and participating universities whose support is gratefully acknowledged. The views expressed in this article do not necessarily represent those of the Canadian Research Data Centre Network or that of its partners. We thank Stephanie Cantlay for her assistance in the Prairie RDC.</p> </div> <div class="sec other" data-magellan-destination="s5" id="s5"> <h2 class="A"> Funding</h2> <p class="p"> RAJ is supported by a Fellowship Grant from the Canadian Institutes of Health Research (Funding reference number MFE-164702).</p> </div> <div class="sec coi-statement" data-magellan-destination="s6" id="s6"> <h2 class="A"> Disclosures</h2> <p class="p"> EES reports royalties from UpToDate, consulting fees from Alnylam, Biogen, and Javelin. The other authors report no disclosures.</p> </div> <div class="sec other" data-magellan-destination="s7" id="s7"> <h2 class="A"> Statement of Authorship</h2> <p class="p"> RJ was involved with conception, data analysis and interpretation, and drafting the article; SP, JW, and ES were involved with interpretation of results and critical revision of the article.</p> </div> </div> </div></div>   <hr aria-hidden="true" class="list-divider separator default" data-v-7036083a> <div id="references-list" class="circle-list"><h2>References</h2> <div id="ref1" aria-flowto="reference-1-content reference-1-button" class="circle-list__item"> <div class="circle-list__item__indicator"></div> <div aria-hidden="true" data-test-hidden="false" class="circle-list__item__number"> 1 </div> <div class="circle-list__item__grouped"><div id="reference-1-content" class="circle-list__item__grouped__content"><span class="string-name"><span class="surname">Yazdanpanah</span>, <span 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data-v-241a4b23><div class="figures__item__image-box" data-v-241a4b23><button class="figures__ref" data-v-241a4b23> View in content </button> <img src="data:image/gif;base64,R0lGODlhAQABAIAAAMLCwgAAACH5BAAAAAAALAAAAAABAAEAAAICRAEAOw==" alt="Figure 0" data-zoomable="true" data-src="https://static.cambridge.org/binary/version/id/urn:cambridge.org:id:binary:20230208102951209-0964:S0317167121002420:S0317167121002420_tab1.png" data-enlarged-image="https://static.cambridge.org/binary/version/id/urn:cambridge.org:id:binary:20230208102951209-0964:S0317167121002420:S0317167121002420_tab1.png" class="graphic" data-v-241a4b23></div> <div data-v-241a4b23><div class="caption" data-v-241a4b23><p data-v-241a4b23><span class="label" data-v-241a4b23>Table 1:</span> <span data-v-241a4b23><span class="p">Weighted percentage of baseline characteristics</span></span></p></div> </div></div> <hr aria-hidden="true" class="separator dashed" data-v-7036083a data-v-241a4b23></div><div data-v-241a4b23><div class="figures__item" data-v-241a4b23><div class="figures__item__image-box" data-v-241a4b23><button class="figures__ref" data-v-241a4b23> View in content </button> <img src="data:image/gif;base64,R0lGODlhAQABAIAAAMLCwgAAACH5BAAAAAAALAAAAAABAAEAAAICRAEAOw==" alt="Figure 1" data-zoomable="true" data-src="https://static.cambridge.org/binary/version/id/urn:cambridge.org:id:binary-alt:20230208103335-00711-mediumThumb-S0317167121002420_fig1.jpg" data-enlarged-image="https://static.cambridge.org/binary/version/id/urn:cambridge.org:id:binary-alt:20230208103335-22053-optimisedImage-S0317167121002420_fig1.jpg" class="graphic" data-v-241a4b23></div> <div data-v-241a4b23><div class="caption" data-v-241a4b23><p data-v-241a4b23><span class="label" data-v-241a4b23>Figure 1:</span> <span data-v-241a4b23><span class="p">Association between categories of sleep duration and risk of stroke, stratified by age. Hazard ratios with 95% CIs are from Cox regression models (A, simple model; B, vascular model; C, full model), and subdistribution hazard ratios are from competing risk analysis (D, full model). There is a higher hazard of stroke in those <70 years old who report 10+ hours of sleep per night.</span></span></p></div> </div></div> <hr aria-hidden="true" class="separator dashed" data-v-7036083a data-v-241a4b23></div><div data-v-241a4b23><div class="figures__item" data-v-241a4b23><div class="figures__item__image-box" data-v-241a4b23><button class="figures__ref" data-v-241a4b23> View in content </button> <img src="data:image/gif;base64,R0lGODlhAQABAIAAAMLCwgAAACH5BAAAAAAALAAAAAABAAEAAAICRAEAOw==" alt="Figure 2" data-zoomable="true" data-src="https://static.cambridge.org/binary/version/id/urn:cambridge.org:id:binary-alt:20230208103335-88233-mediumThumb-S0317167121002420_fig2.jpg" data-enlarged-image="https://static.cambridge.org/binary/version/id/urn:cambridge.org:id:binary-alt:20230208103335-85346-optimisedImage-S0317167121002420_fig2.jpg" class="graphic" data-v-241a4b23></div> <div data-v-241a4b23><div class="caption" data-v-241a4b23><p data-v-241a4b23><span class="label" data-v-241a4b23>Figure 2:</span> <span data-v-241a4b23><span class="p">Cumulative incidence functions over years of follow-up for categories of sleep duration, stratified by age. Those ≥70 years have lower maximal follow-up time due to higher mortality. The greatest elevation in cumulative incidence of stroke occurs in individuals <70 years who report 10+ hours of sleep per night. Estimates obtained from fully adjusted competing risk regression models.</span></span></p></div> </div></div> </div></div> <div id="supplementary-materials-tab" class="supplementary-materials tab-pane"><div class="materials-table"><div class="materials-table__item"><div class="materials-table__row"><img src="data:image/svg+xml;base64,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" alt="Supplementary material: File" class="app-icon materials-table__row__left-elem file" data-v-d2c09870> <div class="materials-table__row__main-elem"><h3 class="materials-table__row__title">Joundi et al. supplementary material</h3> <div class="materials-table__row__description"><p>Joundi et al. supplementary material 1</p></div></div> <a href="https://static.cambridge.org/content/id/urn:cambridge.org:id:article:S0317167121002420/resource/name/S0317167121002420sup001.docx" download="" class="app-link clickable-button materials-table__row__right-elem materials-table__row__download-button app-link__icon app-link--" data-v-63dfaf6e><img 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class=\"bold\"\u003ECorresponding author:\u003C\u002Fspan\u003E Raed A. Joundi, Hamilton General Hospital, 237 Barton St. East, Hamilton, Ontario, Canada, L8L 2X2, Email: \u003Ca href=\"mailto:joundir@mcmaster.ca\"\u003Ejoundir@mcmaster.ca\u003C\u002Fa\u003E\u003C\u002Fdiv\u003E",isAnonymous:a,fullName:"Raed A. Joundi",searchUrl:"\u002Fcore\u002Fsearch?filters%5BauthorTerms%5D=Raed%20A.%20Joundi&eventCode=SE-AU",orcidUrl:"https:\u002F\u002Forcid.org\u002F0000-0001-9554-0701"},{givenNames:"Scott B.",surname:"Patten",nameStyle:e,affiliations:[{text:r}],isCorresponding:a,notes:b,isAnonymous:a,fullName:"Scott B. Patten",searchUrl:"\u002Fcore\u002Fsearch?filters%5BauthorTerms%5D=Scott%20B.%20Patten&eventCode=SE-AU",orcidUrl:e},{givenNames:"Jeanne V.A.",surname:"Williams",nameStyle:e,affiliations:[{text:r}],isCorresponding:a,notes:b,isAnonymous:a,fullName:"Jeanne V.A. 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Smith",searchUrl:"\u002Fcore\u002Fsearch?filters%5BauthorTerms%5D=Eric%20E.%20Smith&eventCode=SE-AU",orcidUrl:"https:\u002F\u002Forcid.org\u002F0000-0003-3956-1668"}]},translators:{contributors:[],label:"Translated by"}},collections:[{link:"\u002Fcore\u002Fproduct\u002Fidentifier\u002FDFF7E9D6-32B8-43DD-A093-075255FB2ABF\u002Ftype\u002FBESPOKE_COLLECTION",id:"DFF7E9D6-32B8-43DD-A093-075255FB2ABF",title:"CJNS Editor’s Choice Articles"}],publishedDate:"21 October 2021",keywords:[{url:"\u002Fcore\u002Fsearch?filters[keywords]=Stroke",name:j},{url:"\u002Fcore\u002Fsearch?filters[keywords]=Sleep",name:i},{url:"\u002Fcore\u002Fsearch?filters[keywords]=Epidemiology",name:"Epidemiology"}],openPracticeBadges:[],doi:{url:"https:\u002F\u002Fdoi.org\u002F10.1017\u002Fcjn.2021.242",value:"10.1017\u002Fcjn.2021.242"},copyright:{statement:["© The Author(s), 2021. Published by Cambridge University Press on behalf of Canadian Neurological Sciences Federation"],holder:["The Author(s)"],year:[2021]},creativeCommons:e,acceptedManuscript:a,type:"research-article",pageRange:{range:"17 - 22",firstPage:P,lastPage:F},typeDescription:"Original Article",resultTypes:[],commentsCount:Q,topicsAndSubtopics:e},journal:{id:R,title:s,titleSlug:S,mnemonic:"CJN",titleHistory:[],isFirstView:a,journalSlug:S,isCompanion:a,parentCompanionJournalName:s,associatedParentCollection:e,paymentInfo:{prices:{"£":{price:26,sku:t,skuNew:n,currency:"£"},"€":{price:31,sku:t,skuNew:n,currency:"€"},US$:{price:36,sku:t,skuNew:n,currency:"US$"},AU$:{price:51,sku:t,skuNew:n,currency:"AU$"}}},url:T,firstViewUrl:"\u002Fcore\u002Fjournals\u002Fcanadian-journal-of-neurological-sciences\u002Ffirstview",coverUrl:"https:\u002F\u002Fstatic.cambridge.org\u002Fcovers\u002FCJN_0_0_0\u002Fcanadian-journal-of-neurological-sciences.jpg",submitMaterialsUrl:"\u002Fcore\u002Fjournals\u002Fcanadian-journal-of-neurological-sciences\u002Finformation\u002Fauthor-instructions\u002Fsubmitting-your-materials",hasHistory:a,latestTitle:s,latestId:R,hasPastTitle:a,issue:{id:"CF63E659BE79CAA55AD3BDA720EEB698",number:U,title:"Issue 1",publishedDate:"January 2023",printPublishTimestamp:1672531200000,url:V},volume:{id:"FF589D1CDFAEF2CE394E9B34F4E3B899",number:W,title:"Volume 50",publishedDate:"November 2023",printPublishTimestamp:1698796800000,url:"\u002Fcore\u002Fjournals\u002Fcanadian-journal-of-neurological-sciences\u002Fvolume\u002FFF589D1CDFAEF2CE394E9B34F4E3B899"}},abstract:{textAbstracts:[{title:"Abstract:",content:"\u003Cdiv class=\"abstract\" data-abstract-type=\"normal\"\u003E\u003Cdiv class=\"sec\"\u003E\u003Cspan class=\"bold\"\u003EBackground:\u003C\u002Fspan\u003E\u003Cp\u003EExcess sleep is associated with higher risk of stroke, but whether the risk is modified by age and if it remains elevated after accounting for the competing risk of death is not well understood.\u003C\u002Fp\u003E\u003C\u002Fdiv\u003E\u003Cdiv class=\"sec\"\u003E\u003Cspan class=\"bold\"\u003EMethods:\u003C\u002Fspan\u003E\u003Cp\u003EWe used nine years of the Canadian Community Health Survey between 2000 to 2016 to obtain self-reported sleep duration and created a cohort of individuals without prior stroke, heart disease, or cancer. We linked to hospital records to determine subsequent admissions or emergency department visits for acute stroke until December 31, 2017. We used Cox proportional hazard models to determine the association between sleep duration and risk of stroke, assessing for modification by age and sex and adjusting for demographic, vascular, and social factors. We obtained cumulative incidence of stroke accounting for the competing risk of death.\u003C\u002Fp\u003E\u003C\u002Fdiv\u003E\u003Cdiv class=\"sec\"\u003E\u003Cspan class=\"bold\"\u003EResults:\u003C\u002Fspan\u003E\u003Cp\u003EThere were 82,795 individuals in our cohort who met inclusion criteria and had self-reported sleep duration, with 1705 stroke events in follow-up. There was an association between excess sleep (≥10 h\u002Fnight) and risk of stroke in those <70 years (fully adjusted hazard ratio 2.29, 95% CI 1.04–5.06), but not ≥70 years of age, with a similar association after accounting for the competing risk of death.\u003C\u002Fp\u003E\u003C\u002Fdiv\u003E\u003Cdiv class=\"sec\"\u003E\u003Cspan class=\"bold\"\u003EConclusion:\u003C\u002Fspan\u003E\u003Cp\u003ESleep duration ≥10 h\u002Fnight is associated with increased risk of stroke in those <70 years of age. The findings support current guidelines for 7–9 h of sleep per night. Further research is needed to elucidate the relationship between sleep and cerebrovascular disease.\u003C\u002Fp\u003E\u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E",lang:X},{title:"Résumé :",content:"\u003Cdiv class=\"abstract\" data-abstract-type=\"translated\"\u003E\u003Ctitle\u003ERésumé :\u003C\u002Ftitle\u003E\u003Cp\u003E\u003Cspan class='bold'\u003EAssociation entre des durées prolongées de sommeil et le risque d’AVC : une étude basée sur la population.\u003C\u002Fspan\u003E\u003C\u002Fp\u003E\u003Ctitle\u003EContexte :\u003C\u002Ftitle\u003E\u003Cp\u003EOn le sait, les excès de sommeil sont associés à un risque accru d’AVC. Cela dit, on n’est pas encore certains si un tel risque peut évoluer en fonction de l’âge et s’il demeure élevé lorsqu’on tient compte du risque concurrent de décès.\u003C\u002Fp\u003E \u003Ctitle\u003EMéthodes :\u003C\u002Ftitle\u003E\u003Cp\u003EDe 2000 à 2016, nous avons fait appel à neuf cycles de collecte de l’Enquête sur la santé dans les collectivités canadiennes pour obtenir des données portant sur la durée de sommeil déclarée par des patients. Cela nous a permis de constituer une cohorte de sujets sans antécédent d’AVC, de maladie cardiaque ou de cancer. Nous avons ensuite établi un lien avec des dossiers hospitaliers pour déterminer les admissions ultérieures ou les visites aux urgences pour un AVC aigu, et ce, jusqu’au 31 décembre 2017. À noter que nous avons utilisé des modèles à risque proportionnel de Cox afin de déterminer l’association entre la durée du sommeil et le risque d’AVC. À cet égard, nous avons évalué les modifications du risque en lien avec l’âge et le sexe et avons ajusté les facteurs démographiques, vasculaires et sociaux. Enfin, nous avons obtenu l’incidence cumulative de l’AVC en tenant compte du risque concurrent de décès.\u003C\u002Fp\u003E\u003Ctitle\u003ERésultats :\u003C\u002Ftitle\u003E\u003Cp\u003ENotre cohorte a compté 82 790 personnes répondant à nos critères d’inclusion et ayant signalé elles-mêmes la durée de leur sommeil. Au total, 1705 cas d’AVC ont été signalés lors d’un suivi. Une association entre une durée prolongée de sommeil (≥10 heures) et un risque d’AVC a été notée chez des personnes âgées de moins de 70 ans (rapport de risque entièrement ajusté = 2,29 ; IC 95 % 1,04–5,06) mais non pas chez celles âgées de 70 ans ou plus, une telle association s’étant avérée similaire même en tenant compte du risque concurrent de décès.\u003C\u002Fp\u003E\u003Ctitle\u003EConclusion :\u003C\u002Ftitle\u003E\u003Cp\u003EUne durée de sommeil prolongée (≥10 heures) est donc associée à un risque accru d’AVC chez les personnes âgées de moins de 70 ans. Ces résultats vont dans le sens des recommandations actuelles qui préconisent de 7 à 9 heures de sommeil par nuit. Chose certaine, des recherches supplémentaires sont nécessaires pour élucider la relation qui existe entre le sommeil et les maladies cérébrovasculaires.\u003C\u002Fp\u003E\u003C\u002Fdiv\u003E",lang:"fr"}]},content:{html:"\u003Cdiv class=\"article research-article NLM\"\u003E\n\n\u003Cdiv class=\"body\"\u003E\n\u003Cdiv class=\"sec intro\" data-magellan-destination=\"s1\" id=\"s1\"\u003E\n\u003Ch2 class=\"A\"\u003E Introduction\u003C\u002Fh2\u003E\n\u003Cp class=\"p\"\u003E Divergence from the recommended 7–9 h of sleep duration has been associated with cardiovascular disease and mortality, with the suggestion of a J-shaped relationship.\u003Csup class=\"sup\"\u003E\n\u003Ca class=\"xref bibr\" href=\"#r1\"\u003E\u003Cspan class=\"show-for-sr\"\u003EReference Yazdanpanah, Homayounfar, Khademi, Zarei, Shahidi and Farjam\u003C\u002Fspan\u003E1\u003C\u002Fa\u003E–\u003Ca class=\"xref bibr\" href=\"#r4\"\u003E\u003Cspan class=\"show-for-sr\"\u003EReference Lao, Liu and Deng\u003C\u002Fspan\u003E4\u003C\u002Fa\u003E\n\u003C\u002Fsup\u003E Recently, an association between abnormal sleep duration and stroke incidence has been reported, especially excess sleep >9 h.\u003Csup class=\"sup\"\u003E\n\u003Ca class=\"xref bibr\" href=\"#r5\"\u003E\u003Cspan class=\"show-for-sr\"\u003EReference Chen, Brunner and Ren\u003C\u002Fspan\u003E5\u003C\u002Fa\u003E–\u003Ca class=\"xref bibr\" href=\"#r9\"\u003E\u003Cspan class=\"show-for-sr\"\u003EReference Titova, Michaëlsson and Larsson\u003C\u002Fspan\u003E9\u003C\u002Fa\u003E\n\u003C\u002Fsup\u003E\n\u003C\u002Fp\u003E\n\u003Cp class=\"p\"\u003E However, the results are inconsistent, with some studies and meta-analyses reporting no association between sleep duration and stroke risk.\u003Csup class=\"sup\"\u003E\n\u003Ca class=\"xref bibr\" href=\"#r10\"\u003E\u003Cspan class=\"show-for-sr\"\u003EReference Amagai, Ishikawa, Gotoh, Kayaba, Nakamura and Kajii\u003C\u002Fspan\u003E10\u003C\u002Fa\u003E,\u003Ca class=\"xref bibr\" href=\"#r11\"\u003E\u003Cspan class=\"show-for-sr\"\u003EReference Westerlund, Bellocco, Sundström, Adami, Åkerstedt and Trolle Lagerros\u003C\u002Fspan\u003E11\u003C\u002Fa\u003E\n\u003C\u002Fsup\u003E In addition, older individuals have lower recommended and self-reported sleep duration,\u003Csup class=\"sup\"\u003E\n\u003Ca class=\"xref bibr\" href=\"#r12\"\u003E\u003Cspan class=\"show-for-sr\"\u003EReference Chaput, Dutil and Sampasa-Kanyinga\u003C\u002Fspan\u003E12\u003C\u002Fa\u003E\n\u003C\u002Fsup\u003E and whether age modifies the association of abnormal sleep duration with stroke is not well understood despite the potential importance of age for the targeting of preventive efforts. Lastly, sleep duration is also associated with all-cause mortality,\u003Csup class=\"sup\"\u003E\n\u003Ca class=\"xref bibr\" href=\"#r13\"\u003E\u003Cspan class=\"show-for-sr\"\u003EReference Cappuccio, D’Elia, Strazzullo and Miller\u003C\u002Fspan\u003E13\u003C\u002Fa\u003E,\u003Ca class=\"xref bibr\" href=\"#r14\"\u003E\u003Cspan class=\"show-for-sr\"\u003EReference Gallicchio and Kalesan\u003C\u002Fspan\u003E14\u003C\u002Fa\u003E\n\u003C\u002Fsup\u003E which may bias estimates of stroke risk.\u003C\u002Fp\u003E\n\u003Cp class=\"p\"\u003E We sought to determine the association between sleep duration and stroke risk in a large Canadian population-based cohort, evaluate differences with age, and account for the competing risk of death.\u003C\u002Fp\u003E\n\u003C\u002Fdiv\u003E\n\u003Cdiv class=\"sec methods\" data-magellan-destination=\"s2\" id=\"s2\"\u003E\n\u003Ch2 class=\"A\"\u003E Methods\u003C\u002Fh2\u003E\n\u003Cdiv class=\"sec\" data-magellan-destination=\"s2-1\" id=\"s2-1\"\u003E\n\u003Ch3 class=\"B\"\u003E Study Sample – Canadian Community Health Survey\u003C\u002Fh3\u003E\n\u003Cp class=\"p\"\u003E The Canadian Community Health Survey (CCHS) is an annual cross-sectional survey, representing 97% of the Canadian household population aged 12 years and older.\u003Csup class=\"sup\"\u003E\n\u003Ca class=\"xref bibr\" href=\"#r15\"\u003E15\u003C\u002Fa\u003E\n\u003C\u002Fsup\u003E The CCHS collects information about health status, health determinants, and health care utilization of the household population. The 3% of the general population that is excluded from the survey target population includes those living on Indigenous reserves, those living in foster care, full-time members of the Canadian Armed Forced, the institutionalized population, and the remote Région du Nunavik and Région des Terres-Cries-de-la-Baie-James.\u003C\u002Fp\u003E\n\u003C\u002Fdiv\u003E\n\u003Cdiv class=\"sec\" data-magellan-destination=\"s2-2\" id=\"s2-2\"\u003E\n\u003Ch3 class=\"B\"\u003E Administrative Linkages\u003C\u002Fh3\u003E\n\u003Cp class=\"p\"\u003E Linkages were performed by Statistics Canada and included the Canadian Institutes of Health Discharge Abstract Database (CIHI-DAD) for hospitalizations, the National Ambulatory Care Reporting System (NACRS) for emergency department visits, and the Canadian Vital Statistics Database (CVSD) for deaths.\u003Csup class=\"sup\"\u003E\n\u003Ca class=\"xref bibr\" href=\"#r16\"\u003E16\u003C\u002Fa\u003E,\u003Ca class=\"xref bibr\" href=\"#r17\"\u003E\u003Cspan class=\"show-for-sr\"\u003EReference Sanmartin, Decady and Trudeau\u003C\u002Fspan\u003E17\u003C\u002Fa\u003E\n\u003C\u002Fsup\u003E The linkage subsample contained 85% of total CCHS respondents who agreed to have their responses linked to administrative records. We used CIHI-DAD, NACRS, and CVSD to determine stroke events and deaths after the survey response until December 31, 2017. All participants had a minimum of 1 year of full follow-up for events and were censored if alive on December 31, 2017.\u003C\u002Fp\u003E\n\u003C\u002Fdiv\u003E\n\u003Cdiv class=\"sec\" data-magellan-destination=\"s2-3\" id=\"s2-3\"\u003E\n\u003Ch3 class=\"B\"\u003E Cohort\u003C\u002Fh3\u003E\n\u003Cp class=\"p\"\u003E We used CCHS years 2000, 2007, 2008, and 2011–2016 to capture data on sleep duration and other baseline covariates. Sleep duration was an optional module in all years except 2000, meaning that it could be selected by some but not all provinces and territories. We excluded those under the age of 40 and those with a history of heart disease (self-report), cancer (self-report), or prior stroke (either administrative data diagnosis or self-report).\u003C\u002Fp\u003E\n\u003C\u002Fdiv\u003E\n\u003Cdiv class=\"sec\" data-magellan-destination=\"s2-4\" id=\"s2-4\"\u003E\n\u003Ch3 class=\"B\"\u003E Exposure\u003C\u002Fh3\u003E\n\u003Cp class=\"p\"\u003E Our main exposure was self-reported sleep duration. Participants were asked the number of hours spent sleeping per night. Time spent in daytime napping was not captured. We categorized sleep duration as <4 h, 4–6 h, 7–9 h, and ≥10 h\u002Fday, with excess sleep duration defined as ≥10 h\u002Fday, as the Canadian guidelines recommend 7–9 h of sleep per night for individuals <65 years of age.\u003Csup class=\"sup\"\u003E\n\u003Ca class=\"xref bibr\" href=\"#r18\"\u003E\u003Cspan class=\"show-for-sr\"\u003EReference Ross, Chaput and Giangregorio\u003C\u002Fspan\u003E18\u003C\u002Fa\u003E\n\u003C\u002Fsup\u003E\n\u003C\u002Fp\u003E\n\u003C\u002Fdiv\u003E\n\u003Cdiv class=\"sec\" data-magellan-destination=\"s2-5\" id=\"s2-5\"\u003E\n\u003Ch3 class=\"B\"\u003E Covariates\u003C\u002Fh3\u003E\n\u003Cp class=\"p\"\u003E Covariates were obtained from the CCHS, including age, sex, rural residence, and self-report of ethnicity, education level, total household income, marital status, body mass index, current smoking status, hypertension, diabetes, heart disease, cancer, arthritis, chronic obstructive pulmonary disease (COPD), migraine, and asthma. Categorization of the variables can be seen in Table \u003Ca class=\"xref table\" href=\"#tbl1\"\u003E1\u003C\u002Fa\u003E. Due to known biases in self-report of body mass index, we employed a correction developed by the CCHS.\u003Csup class=\"sup\"\u003E\n\u003Ca class=\"xref bibr\" href=\"#r19\"\u003E\u003Cspan class=\"show-for-sr\"\u003EReference Shields, Gorber, Janssen and Tremblay\u003C\u002Fspan\u003E19\u003C\u002Fa\u003E\n\u003C\u002Fsup\u003E\n\u003C\u002Fp\u003E\n\u003Cp class=\"p\"\u003E \n\u003C\u002Fp\u003E\u003Cdiv class=\"table-wrap\" data-magellan-destination=\"tbl1\" id=\"tbl1\"\u003E\n\n\u003Cdiv class=\"caption\"\u003E\n\u003Cp class=\"p\"\u003E\u003Cspan class=\"label\"\u003ETable 1:\u003C\u002Fspan\u003E Weighted percentage of baseline characteristics\u003C\u002Fp\u003E\n\u003C\u002Fdiv\u003E\n\u003Cspan\u003E\n\n\u003Cdiv class=\"figure-thumb\"\u003E\u003Cimg src=\"data:image\u002Fgif;base64,R0lGODlhAQABAIAAAMLCwgAAACH5BAAAAAAALAAAAAABAAEAAAICRAEAOw==\" data-src=\"https:\u002F\u002Fstatic.cambridge.org\u002Fbinary\u002Fversion\u002Fid\u002Furn:cambridge.org:id:binary:20230208102951209-0964:S0317167121002420:S0317167121002420_tab1.png?pub-status=live\" class=\"aop-lazy-load-image\" width=\"519\" height=\"1377\" data-original-image=\"\u002Fbinary\u002Fversion\u002Fid\u002Furn:cambridge.org:id:binary:20230208102951209-0964:S0317167121002420:S0317167121002420_tab1.png\" data-zoomable=\"true\"\u003E\u003C\u002Fdiv\u003E\n\u003C\u002Fspan\u003E\n\u003C\u002Fdiv\u003E\n\n\u003C\u002Fdiv\u003E\n\u003Cdiv class=\"sec\" data-magellan-destination=\"s2-6\" id=\"s2-6\"\u003E\n\u003Ch3 class=\"B\"\u003E Outcome\u003C\u002Fh3\u003E\n\u003Cp class=\"p\"\u003E Our primary outcome was acute stroke (ischemic stroke or intracerebral hemorrhage [ICH]) at any time in follow-up, using \u003Cem class=\"italic\"\u003EInternational Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Canada\u003C\u002Fem\u003E (ICD-10-CA) codes (ischemic stroke: I63.x, I64.x, H34.1; ICH: I61.x) and ICD-9 codes (ischemic stroke: 434.01, 434.11, 434.91, 436; ICH: 431). Our secondary outcome was death during follow-up.\u003C\u002Fp\u003E\n\u003C\u002Fdiv\u003E\n\u003Cdiv class=\"sec\" data-magellan-destination=\"s2-7\" id=\"s2-7\"\u003E\n\u003Ch3 class=\"B\"\u003E Analysis\u003C\u002Fh3\u003E\n\u003Cp class=\"p\"\u003E We first used Cox proportional regression models to obtain the hazard of stroke by category of sleep duration, censoring people at death or end of follow-up. We assessed for the presence of modification of the sleep duration-stroke association by age (<70 years and ≥70 years) and sex. As there was evidence of modification by age but not sex, we created age-specific stratified models.\u003C\u002Fp\u003E\n\u003Cp class=\"p\"\u003E In our simple model, we adjusted for sex only. In our vascular model, we adjusted for sex, body mass index, hypertension, diabetes, and smoking. In our full model, we adjusted for the above in addition to income quartile, rural residence, alcohol consumption, education, ethnicity, marital status, and other comorbidities (migraine, arthritis, COPD, and asthma). We evaluated the proportional hazards assumption by assessing the significance (\u003Cem class=\"italic\"\u003Ep\u003C\u002Fem\u003E < 0.05) of an interaction term of sleep duration category and follow-up time.\u003C\u002Fp\u003E\n\u003Cp class=\"p\"\u003E We conducted three sensitivity analyses. First, we additionally adjusted for symptoms of depression (2 or more weeks of feeling sad, blue, or depressed in the past 12 months) in the sub-set of individuals in which this variable was available. Second, we changed the upper category of sleep duration to ≥9 h. Third, we evaluated the risk of ischemic stroke only; there were insufficient events for an analysis of ICH only.\u003C\u002Fp\u003E\n\u003Cp class=\"p\"\u003E Lastly, we conducted competing risk regression to confirm that the risk of stroke was elevated while accounting for the competing risk of death. We obtained subdistribution hazard ratios and generated cumulative incidence functions for the risk of stroke over follow-up time. We adjusted for the same factors as in previous models.\u003C\u002Fp\u003E\n\u003Cp class=\"p\"\u003E Analyses were done in the Prairie Regional Data Centre at the University of Calgary using Stata 16.0 (College Station, TX, USA). Threshold of significance for \u003Cem class=\"italic\"\u003Ep\u003C\u002Fem\u003E-values was <0.05. Under Tri-Council guidelines, this analysis did not require approval by a research ethics board.\u003C\u002Fp\u003E\n\u003C\u002Fdiv\u003E\n\u003C\u002Fdiv\u003E\n\u003Cdiv class=\"sec results\" data-magellan-destination=\"s3\" id=\"s3\"\u003E\n\u003Ch2 class=\"A\"\u003E Results\u003C\u002Fh2\u003E\n\u003Cp class=\"p\"\u003E Our total cohort comprised 82,795 people with self-reported sleep duration and without prior heart disease, cancer, or stroke. During a median follow-up time of 9.1 years (interquartile range [IQR] 3.2–16.6 years), there was a total of 1705 stroke events (88.3% ischemic). Among those with incident stroke, the median time from survey response until stroke was 7.5 years (IQR 3.8–12.3).\u003C\u002Fp\u003E\n\u003Cp class=\"p\"\u003E Baseline characteristics of the cohort weighted to the Canadian population are shown in Table \u003Ca class=\"xref table\" href=\"#tbl1\"\u003E1\u003C\u002Fa\u003E. The proportion of individuals <70 years was 86% and the proportion of females was 53.2%. The majority of people had 7–9 h of sleep duration (55.8%), with a small proportion having ≥10 h of sleep duration (1.2%).\u003C\u002Fp\u003E\n\u003Cp class=\"p\"\u003E Weighted percentages of stroke events in follow-up are shown in Supplemental Table \u003Ca class=\"uri\" href=\"https:\u002F\u002Fdoi.org\u002F10.1017\u002Fcjn.2021.242\"\u003E1\u003C\u002Fa\u003E and stratified by subgroup. The greatest increases in stroke rate occurred when comparing 7–9 h of sleep with ≥10 h of sleep in those <70 years of age (1.5% to 5.9%) and in females (2.0% to 6.9%; Supplementary Table \u003Ca class=\"uri\" href=\"https:\u002F\u002Fdoi.org\u002F10.1017\u002Fcjn.2021.242\"\u003E1\u003C\u002Fa\u003E).\u003C\u002Fp\u003E\n\u003Cp class=\"p\"\u003E In the simple Cox regression model, there was a significant interaction between sleep duration ≥10 h and age (\u003Cem class=\"italic\"\u003Ep\u003C\u002Fem\u003E = 0.030), but not sex (\u003Cem class=\"italic\"\u003Ep\u003C\u002Fem\u003E = 0.27). There was no evidence of violation of the proportional hazards assumption.\u003C\u002Fp\u003E\n\u003Cp class=\"p\"\u003E Among individuals <70, excess sleep was associated with higher long-term risk of stroke in the simple model (adjusted hazard ratio [aHR] 3.15, 95% CI 1.74–5.73), vascular model (aHR 2.77, 95% CI 1.35–5.70), and full model (aHR 2.26, 95% CI 1.02–5.00; Figure \u003Ca class=\"xref fig\" href=\"#f1\"\u003E1\u003C\u002Fa\u003EA–C). There was no association between excess sleep and risk of stroke in those ≥70 years (Figure \u003Ca class=\"xref fig\" href=\"#f1\"\u003E1\u003C\u002Fa\u003E). The results were consistent in a sensitivity analysis adjusting for symptoms of depression. The association did not persist when the highest category of sleep duration was changed to ≥9 h (Supplementary Table \u003Ca class=\"uri\" href=\"https:\u002F\u002Fdoi.org\u002F10.1017\u002Fcjn.2021.242\"\u003E2\u003C\u002Fa\u003E). When analyzing ischemic stroke only, there was a higher risk in the simple and vascular models, but the association was attenuated in the full model (Supplementary Table \u003Ca class=\"uri\" href=\"https:\u002F\u002Fdoi.org\u002F10.1017\u002Fcjn.2021.242\"\u003E3\u003C\u002Fa\u003E).\u003C\u002Fp\u003E\n\u003Cp class=\"p\"\u003E \n\u003C\u002Fp\u003E\u003Csection\u003E\u003Cdiv class=\"fig\" data-magellan-destination=\"f1\" id=\"f1\"\u003E\n\n\n\u003Cdiv class=\"figure-thumb\"\u003E\u003Cimg src=\"data:image\u002Fgif;base64,R0lGODlhAQABAIAAAMLCwgAAACH5BAAAAAAALAAAAAABAAEAAAICRAEAOw==\" data-src=\"https:\u002F\u002Fstatic.cambridge.org\u002Fbinary\u002Fversion\u002Fid\u002Furn:cambridge.org:id:binary:20230208102951209-0964:S0317167121002420:S0317167121002420_fig1.png?pub-status=live\" class=\"aop-lazy-load-image\" width=\"2750\" height=\"2550\" data-original-image=\"\u002Fbinary\u002Fversion\u002Fid\u002Furn:cambridge.org:id:binary:20230208102951209-0964:S0317167121002420:S0317167121002420_fig1.png\" data-zoomable=\"true\"\u003E\u003C\u002Fdiv\u003E\n\u003Cdiv class=\"caption\"\u003E\u003Cp class=\"p\"\u003E \n\u003C\u002Fp\u003E\u003Cp class=\"p\"\u003E\u003Cspan class=\"label\"\u003EFigure 1:\u003C\u002Fspan\u003E Association between categories of sleep duration and risk of stroke, stratified by age. Hazard ratios with 95% CIs are from Cox regression models (A, simple model; B, vascular model; C, full model), and subdistribution hazard ratios are from competing risk analysis (D, full model). There is a higher hazard of stroke in those <70 years old who report 10+ hours of sleep per night.\u003C\u002Fp\u003E\n\u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E\u003C\u002Fsection\u003E\n\n\u003Cp class=\"p\"\u003E After accounting for the competing risk of death, there remained a significantly elevated risk and higher cumulative incidence of stroke in those with excess sleep and age <70 years (Figure \u003Ca class=\"xref fig\" href=\"#f1\"\u003E1\u003C\u002Fa\u003ED and Figure \u003Ca class=\"xref fig\" href=\"#f2\"\u003E2\u003C\u002Fa\u003E).\u003C\u002Fp\u003E\n\u003Cp class=\"p\"\u003E \n\u003C\u002Fp\u003E\u003Csection\u003E\u003Cdiv class=\"fig\" data-magellan-destination=\"f2\" id=\"f2\"\u003E\n\n\n\u003Cdiv class=\"figure-thumb\"\u003E\u003Cimg src=\"data:image\u002Fgif;base64,R0lGODlhAQABAIAAAMLCwgAAACH5BAAAAAAALAAAAAABAAEAAAICRAEAOw==\" data-src=\"https:\u002F\u002Fstatic.cambridge.org\u002Fbinary\u002Fversion\u002Fid\u002Furn:cambridge.org:id:binary:20230208102951209-0964:S0317167121002420:S0317167121002420_fig2.png?pub-status=live\" class=\"aop-lazy-load-image\" width=\"2066\" height=\"773\" data-original-image=\"\u002Fbinary\u002Fversion\u002Fid\u002Furn:cambridge.org:id:binary:20230208102951209-0964:S0317167121002420:S0317167121002420_fig2.png\" data-zoomable=\"true\"\u003E\u003C\u002Fdiv\u003E\n\u003Cdiv class=\"caption\"\u003E\u003Cp class=\"p\"\u003E \n\u003C\u002Fp\u003E\u003Cp class=\"p\"\u003E\u003Cspan class=\"label\"\u003EFigure 2:\u003C\u002Fspan\u003E Cumulative incidence functions over years of follow-up for categories of sleep duration, stratified by age. Those ≥70 years have lower maximal follow-up time due to higher mortality. The greatest elevation in cumulative incidence of stroke occurs in individuals <70 years who report 10+ hours of sleep per night. Estimates obtained from fully adjusted competing risk regression models.\u003C\u002Fp\u003E\n\u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E\u003C\u002Fsection\u003E\n\n\u003C\u002Fdiv\u003E\n\u003Cdiv class=\"sec discussion\" data-magellan-destination=\"s4\" id=\"s4\"\u003E\n\u003Ch2 class=\"A\"\u003E Discussion\u003C\u002Fh2\u003E\n\u003Cp class=\"p\"\u003E We demonstrate that excess sleep duration ≥10 h is associated with increased long-term risk of stroke among individuals younger than 70 years old, and this risk remains elevated after accounting for the competing risk of death.\u003C\u002Fp\u003E\n\u003Cp class=\"p\"\u003E Our results are consistent with prior studies showing an increased risk of stroke with excess sleep time.\u003Csup class=\"sup\"\u003E\n\u003Ca class=\"xref bibr\" href=\"#r5\"\u003E\u003Cspan class=\"show-for-sr\"\u003EReference Chen, Brunner and Ren\u003C\u002Fspan\u003E5\u003C\u002Fa\u003E–\u003Ca class=\"xref bibr\" href=\"#r8\"\u003E\u003Cspan class=\"show-for-sr\"\u003EReference Helbig, Stöckl, Heier, Ladwig and Meisinger\u003C\u002Fspan\u003E8\u003C\u002Fa\u003E,\u003Ca class=\"xref bibr\" href=\"#r20\"\u003E\u003Cspan class=\"show-for-sr\"\u003EReference Song, Howard and Howard\u003C\u002Fspan\u003E20\u003C\u002Fa\u003E,\u003Ca class=\"xref bibr\" href=\"#r21\"\u003E\u003Cspan class=\"show-for-sr\"\u003EReference Leng, Cappuccio and Wainwright\u003C\u002Fspan\u003E21\u003C\u002Fa\u003E\n\u003C\u002Fsup\u003E Some studies have suggested a J-shaped relationship, with low amounts of sleep also increasing risk.\u003Csup class=\"sup\"\u003E\n\u003Ca class=\"xref bibr\" href=\"#r22\"\u003E\u003Cspan class=\"show-for-sr\"\u003EReference Li, Wang and Cao\u003C\u002Fspan\u003E22\u003C\u002Fa\u003E\n\u003C\u002Fsup\u003E While the point estimate of stroke risk for the category of <4 h sleep was elevated among individuals <70, it did not reach significance in our study. The mechanism of stroke with excess sleep and stroke is unknown. Long duration of sleep is associated with inflammatory biomarkers,\u003Csup class=\"sup\"\u003E\n\u003Ca class=\"xref bibr\" href=\"#r23\"\u003E\u003Cspan class=\"show-for-sr\"\u003EReference Patel, Zhu and Storfer-Isser\u003C\u002Fspan\u003E23\u003C\u002Fa\u003E,\u003Ca class=\"xref bibr\" href=\"#r24\"\u003E\u003Cspan class=\"show-for-sr\"\u003EReference Dowd, Goldman and Weinstein\u003C\u002Fspan\u003E24\u003C\u002Fa\u003E\n\u003C\u002Fsup\u003E vascular risk factors,\u003Csup class=\"sup\"\u003E\n\u003Ca class=\"xref bibr\" href=\"#r25\"\u003E\u003Cspan class=\"show-for-sr\"\u003EReference Yang, Yang and He\u003C\u002Fspan\u003E25\u003C\u002Fa\u003E–\u003Ca class=\"xref bibr\" href=\"#r27\"\u003E\u003Cspan class=\"show-for-sr\"\u003EReference Grandner, Mullington, Hashmi, Redeker, Watson and Morgenthaler\u003C\u002Fspan\u003E27\u003C\u002Fa\u003E\n\u003C\u002Fsup\u003E carotid intimal thickness,\u003Csup class=\"sup\"\u003E\n\u003Ca class=\"xref bibr\" href=\"#r28\"\u003E\u003Cspan class=\"show-for-sr\"\u003EReference Abe, Aoki, Yata and Okada\u003C\u002Fspan\u003E28\u003C\u002Fa\u003E\n\u003C\u002Fsup\u003E and white matter hyperintensities.\u003Csup class=\"sup\"\u003E\n\u003Ca class=\"xref bibr\" href=\"#r29\"\u003E\u003Cspan class=\"show-for-sr\"\u003EReference Ramos, Dong and Rundek\u003C\u002Fspan\u003E29\u003C\u002Fa\u003E\n\u003C\u002Fsup\u003E In addition, excess sleeping may be a surrogate for higher sedentary time, depression, sleep apnea, or low socioeconomic status, all of which have been linked to stroke and cardiovascular risk.\u003Csup class=\"sup\"\u003E\n\u003Ca class=\"xref bibr\" href=\"#r30\"\u003E\u003Cspan class=\"show-for-sr\"\u003EReference Dong, Zhang, Tong and Qin\u003C\u002Fspan\u003E30\u003C\u002Fa\u003E–\u003Ca class=\"xref bibr\" href=\"#r33\"\u003E\u003Cspan class=\"show-for-sr\"\u003EReference Biswas, Oh and Faulkner\u003C\u002Fspan\u003E33\u003C\u002Fa\u003E\n\u003C\u002Fsup\u003E Our findings are consistent with guidelines recommending 7–9 h of sleep per night to promote optimal health.\u003Csup class=\"sup\"\u003E\n\u003Ca class=\"xref bibr\" href=\"#r18\"\u003E\u003Cspan class=\"show-for-sr\"\u003EReference Ross, Chaput and Giangregorio\u003C\u002Fspan\u003E18\u003C\u002Fa\u003E,\u003Ca class=\"xref bibr\" href=\"#r34\"\u003E\u003Cspan class=\"show-for-sr\"\u003EReference Chaput, Dutil and Featherstone\u003C\u002Fspan\u003E34\u003C\u002Fa\u003E\n\u003C\u002Fsup\u003E \n\u003C\u002Fp\u003E\n\u003Cp class=\"p\"\u003E The reason for the observed age modification is unclear. Multiple studies have reported associations between sleep and hypertension that are attenuated in the elderly.\u003Csup class=\"sup\"\u003E\n\u003Ca class=\"xref bibr\" href=\"#r35\"\u003E\u003Cspan class=\"show-for-sr\"\u003EReference van den Berg, Tulen and Neven\u003C\u002Fspan\u003E35\u003C\u002Fa\u003E–\u003Ca class=\"xref bibr\" href=\"#r37\"\u003E\u003Cspan class=\"show-for-sr\"\u003EReference Kim and Jo\u003C\u002Fspan\u003E37\u003C\u002Fa\u003E\n\u003C\u002Fsup\u003E Similarly, among individuals <65 years, both short and long duration sleep was associated with excess mortality, but not in individuals 65 years and older.\u003Csup class=\"sup\"\u003E\n\u003Ca class=\"xref bibr\" href=\"#r38\"\u003E\u003Cspan class=\"show-for-sr\"\u003EReference Åkerstedt, Ghilotti, Grotta, Bellavia, Lagerros and Bellocco\u003C\u002Fspan\u003E38\u003C\u002Fa\u003E\n\u003C\u002Fsup\u003E These finding are also in line with prior studies showing the associations between vascular risk factors such as obesity or diabetes and adverse outcomes are also greater at younger age.\u003Csup class=\"sup\"\u003E\n\u003Ca class=\"xref bibr\" href=\"#r39\"\u003E\u003Cspan class=\"show-for-sr\"\u003EReference Rawshani, Rawshani and Franzén\u003C\u002Fspan\u003E39\u003C\u002Fa\u003E,\u003Ca class=\"xref bibr\" href=\"#r40\"\u003E\u003Cspan class=\"show-for-sr\"\u003EReference Peter, Mayer, Concin and Nagel\u003C\u002Fspan\u003E40\u003C\u002Fa\u003E\n\u003C\u002Fsup\u003E Total sleep duration is significantly shorter in elderly, and the overall dynamics and homeostasis of sleep differ compared to middle-aged and younger subjects.\u003Csup class=\"sup\"\u003E\n\u003Ca class=\"xref bibr\" href=\"#r41\"\u003E\u003Cspan class=\"show-for-sr\"\u003EReference Campbell and Murphy\u003C\u002Fspan\u003E41\u003C\u002Fa\u003E\n\u003C\u002Fsup\u003E Retirement also improves sleep quality, which may mitigate the impact of excess sleep duration.\u003Csup class=\"sup\"\u003E\n\u003Ca class=\"xref bibr\" href=\"#r42\"\u003E\u003Cspan class=\"show-for-sr\"\u003EReference Myllyntausta and Stenholm\u003C\u002Fspan\u003E42\u003C\u002Fa\u003E\n\u003C\u002Fsup\u003E However, our results are in contrast to two studies from China showing the association of excess sleep and stroke was stronger at older age,\u003Csup class=\"sup\"\u003E\n\u003Ca class=\"xref bibr\" href=\"#r6\"\u003E\u003Cspan class=\"show-for-sr\"\u003EReference Zhou, Yu and Yang\u003C\u002Fspan\u003E6\u003C\u002Fa\u003E,\u003Ca class=\"xref bibr\" href=\"#r21\"\u003E\u003Cspan class=\"show-for-sr\"\u003EReference Leng, Cappuccio and Wainwright\u003C\u002Fspan\u003E21\u003C\u002Fa\u003E\n\u003C\u002Fsup\u003E and may be due to variability in the population studied, amount of follow-up, or other study differences. We had a smaller number of individuals who were ≥70 years old and shorter follow-up time due to higher mortality, which may have limited our ability to detect an association in this age group.\u003C\u002Fp\u003E\n\u003Cp class=\"p\"\u003E There were some limitations to this study. First, we relied on self-reported sleep duration in the CCHS. Self-reported sleep duration overestimates sleep duration compared to objective measurements; therefore, the true threshold for increased risk may be lower than reported here.\u003Csup class=\"sup\"\u003E\n\u003Ca class=\"xref bibr\" href=\"#r43\"\u003E\u003Cspan class=\"show-for-sr\"\u003EReference Jackson, Patel, Jackson, Lutsey and Redline\u003C\u002Fspan\u003E43\u003C\u002Fa\u003E\n\u003C\u002Fsup\u003E Second, we relied on administrative data to measure stroke events, although the codes used have high validity in Canada.\u003Csup class=\"sup\"\u003E\n\u003Ca class=\"xref bibr\" href=\"#r44\"\u003E\u003Cspan class=\"show-for-sr\"\u003EReference Porter, Mondor, Kapral, Fang and Hall\u003C\u002Fspan\u003E44\u003C\u002Fa\u003E\n\u003C\u002Fsup\u003E Third, we had no assessment of sleep quality, sleep apnea, or mid-day napping. Lastly, there is the potential for residual confounding from many vascular and socioeconomic factors which may be related to both sleep duration and stroke risk.\u003C\u002Fp\u003E\n\u003Cp class=\"p\"\u003E In conclusion, excess sleep duration ≥10 h was associated with elevated stroke risk in those <70 years of age. The results support current guidelines for 7–9 h of sleep per night and suggest the need for further research on determining mechanisms of sleep-related cardio- and cerebrovascular disease.\u003C\u002Fp\u003E\n\u003C\u002Fdiv\u003E\n\u003C\u002Fdiv\u003E\n\u003Cdiv class=\"back\"\u003E\n\u003Cdiv class=\"sec other\" data-magellan-destination=\"s8\" id=\"s8\"\u003E\n\u003Ch2 class=\"A\"\u003E Supplementary Material\u003C\u002Fh2\u003E\n\u003Cp class=\"p\"\u003E To view supplementary material for this article, please visit \u003Ca class=\"uri\" href=\"https:\u002F\u002Fdoi.org\u002F10.1017\u002Fcjn.2021.242\"\u003Ehttps:\u002F\u002Fdoi.org\u002F10.1017\u002Fcjn.2021.242\u003C\u002Fa\u003E\n\u003C\u002Fp\u003E\n\u003C\u002Fdiv\u003E\n\u003Cdiv class=\"ack\"\u003E\n\u003Ch2 class=\"A\"\u003E Acknowledgements\u003C\u002Fh2\u003E\n\u003Cp class=\"p\"\u003E The analysis was conducted at the Prairie Regional Research Data Centre (RDC), which is part of the Canadian Research Data Centre Network. The services and activities provided by the Canadian Research Data Centre Network are made possible by the financial or in-kind support of the Social Sciences and Humanities Research Council, the Canadian Institutes of Health Research, the Canadian Foundation for Innovation, Statistics Canada, and participating universities whose support is gratefully acknowledged. The views expressed in this article do not necessarily represent those of the Canadian Research Data Centre Network or that of its partners. We thank Stephanie Cantlay for her assistance in the Prairie RDC.\u003C\u002Fp\u003E\n\u003C\u002Fdiv\u003E\n\u003Cdiv class=\"sec other\" data-magellan-destination=\"s5\" id=\"s5\"\u003E\n\u003Ch2 class=\"A\"\u003E Funding\u003C\u002Fh2\u003E\n\u003Cp class=\"p\"\u003E RAJ is supported by a Fellowship Grant from the Canadian Institutes of Health Research (Funding reference number MFE-164702).\u003C\u002Fp\u003E\n\u003C\u002Fdiv\u003E\n\u003Cdiv class=\"sec coi-statement\" data-magellan-destination=\"s6\" id=\"s6\"\u003E\n\u003Ch2 class=\"A\"\u003E Disclosures\u003C\u002Fh2\u003E\n\u003Cp class=\"p\"\u003E EES reports royalties from UpToDate, consulting fees from Alnylam, Biogen, and Javelin. The other authors report no disclosures.\u003C\u002Fp\u003E\n\u003C\u002Fdiv\u003E\n\u003Cdiv class=\"sec other\" data-magellan-destination=\"s7\" id=\"s7\"\u003E\n\u003Ch2 class=\"A\"\u003E Statement of Authorship\u003C\u002Fh2\u003E\n\u003Cp class=\"p\"\u003E RJ was involved with conception, data analysis and interpretation, and drafting the article; SP, JW, and ES were involved with interpretation of results and critical revision of the article.\u003C\u002Fp\u003E\n\u003C\u002Fdiv\u003E\n\n\u003C\u002Fdiv\u003E\n\u003C\u002Fdiv\u003E",tableOfContent:[{level:h,current:a,title:"\u003Cdiv class=\"toc-title\"\u003EBackground:\u003C\u002Fdiv\u003E",url:"as1"},{level:h,current:a,title:"\u003Cdiv class=\"toc-title\"\u003EMethods:\u003C\u002Fdiv\u003E",url:"as2"},{level:h,current:a,title:"\u003Cdiv class=\"toc-title\"\u003EResults:\u003C\u002Fdiv\u003E",url:"as3"},{level:h,current:a,title:"\u003Cdiv class=\"toc-title\"\u003EConclusion:\u003C\u002Fdiv\u003E",url:"as4"},{level:h,current:a,title:"\u003Cdiv class=\"toc-title\"\u003EIntroduction\u003C\u002Fdiv\u003E",url:"s1"},{level:h,current:a,title:"\u003Cdiv class=\"toc-title\"\u003EMethods\u003C\u002Fdiv\u003E",url:"s2"},{level:h,current:a,title:"\u003Cdiv class=\"toc-title\"\u003EResults\u003C\u002Fdiv\u003E",url:"s3"},{level:h,current:a,title:"\u003Cdiv class=\"toc-title\"\u003EDiscussion\u003C\u002Fdiv\u003E",url:"s4"},{level:h,current:a,title:"\u003Cdiv class=\"toc-title\"\u003ESupplementary Material\u003C\u002Fdiv\u003E",url:"s8"},{level:h,current:a,title:"\u003Cdiv class=\"toc-title\"\u003EFunding\u003C\u002Fdiv\u003E",url:"s5"},{level:h,current:a,title:"\u003Cdiv class=\"toc-title\"\u003EDisclosures\u003C\u002Fdiv\u003E",url:"s6"},{level:h,current:a,title:"\u003Cdiv class=\"toc-title\"\u003EStatement of Authorship\u003C\u002Fdiv\u003E",url:"s7"}],footnotes:[],fulltextNotes:[],references:[{id:"ref1",displayNumber:U,existInContent:a,content:"\u003Cspan class=\"string-name\"\u003E\u003Cspan class=\"surname\"\u003EYazdanpanah\u003C\u002Fspan\u003E, \u003Cspan class=\"given-names\"\u003EMH\u003C\u002Fspan\u003E\u003C\u002Fspan\u003E, \u003Cspan class=\"string-name\"\u003E\u003Cspan class=\"surname\"\u003EHomayounfar\u003C\u002Fspan\u003E, \u003Cspan class=\"given-names\"\u003ER\u003C\u002Fspan\u003E\u003C\u002Fspan\u003E, \u003Cspan class=\"string-name\"\u003E\u003Cspan class=\"surname\"\u003EKhademi\u003C\u002Fspan\u003E, \u003Cspan class=\"given-names\"\u003EA\u003C\u002Fspan\u003E\u003C\u002Fspan\u003E, \u003Cspan class=\"string-name\"\u003E\u003Cspan class=\"surname\"\u003EZarei\u003C\u002Fspan\u003E, \u003Cspan class=\"given-names\"\u003EF\u003C\u002Fspan\u003E\u003C\u002Fspan\u003E, \u003Cspan class=\"string-name\"\u003E\u003Cspan class=\"surname\"\u003EShahidi\u003C\u002Fspan\u003E, \u003Cspan class=\"given-names\"\u003EA\u003C\u002Fspan\u003E\u003C\u002Fspan\u003E, \u003Cspan class=\"string-name\"\u003E\u003Cspan class=\"surname\"\u003EFarjam\u003C\u002Fspan\u003E, \u003Cspan class=\"given-names\"\u003EM.\u003C\u002Fspan\u003E\u003C\u002Fspan\u003E \u003Cspan class=\"article-title\"\u003EShort sleep is associated with higher prevalence and increased predicted risk of cardiovascular diseases in an Iranian population: Fasa PERSIAN cohort study\u003C\u002Fspan\u003E. \u003Cspan class=\"source\"\u003ESci Rep\u003C\u002Fspan\u003E. \u003Cspan class=\"year\"\u003E2020\u003C\u002Fspan\u003E;\u003Cspan class=\"volume\"\u003E10\u003C\u002Fspan\u003E:\u003Cspan class=\"fpage\"\u003E4608\u003C\u002Fspan\u003E.\u003Ca class='ref-link' target='_blank' aria-label='Google Scholar link for Short sleep is associated with higher prevalence and increased predicted risk of cardiovascular diseases in an Iranian population: Fasa PERSIAN cohort study' 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Scholar\u003C\u002Fa\u003E",item:[{googleScholarLink:"https:\u002F\u002Fscholar.google.com\u002Fscholar_lookup?title=Short+sleep+is+associated+with+higher+prevalence+and+increased+predicted+risk+of+cardiovascular+diseases+in+an+Iranian+population%3A+Fasa+PERSIAN+cohort+study&author=Yazdanpanah+MH&author=Homayounfar+R&author=Khademi+A&author=Zarei+F&author=Shahidi+A&author=Farjam+M.&publication+year=2020&journal=Sci+Rep&volume=10",openUrlParams:{genre:g,atitle:Y,jtitle:Z,title:Z,volume:o,artnum:"63e37a189efe210001b85176",spage:"4608",epage:e,date:p,sid:f,aulast:b,aufirst:b,doi:e,au:b},innerRefId:"r1",title:Y,doi:e,crossRefLink:b,pubMedLink:b}]},{id:"ref2",displayNumber:"2",existInContent:a,content:"\u003Cspan class=\"string-name\"\u003E\u003Cspan class=\"surname\"\u003EHoevenaar-Blom\u003C\u002Fspan\u003E, \u003Cspan class=\"given-names\"\u003EMP\u003C\u002Fspan\u003E\u003C\u002Fspan\u003E, \u003Cspan class=\"string-name\"\u003E\u003Cspan 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class=\"string-name\"\u003E\u003Cspan class=\"surname\"\u003EPorter\u003C\u002Fspan\u003E, \u003Cspan class=\"given-names\"\u003EJ\u003C\u002Fspan\u003E\u003C\u002Fspan\u003E, \u003Cspan class=\"string-name\"\u003E\u003Cspan class=\"surname\"\u003EMondor\u003C\u002Fspan\u003E, \u003Cspan class=\"given-names\"\u003EL\u003C\u002Fspan\u003E\u003C\u002Fspan\u003E, \u003Cspan class=\"string-name\"\u003E\u003Cspan class=\"surname\"\u003EKapral\u003C\u002Fspan\u003E, \u003Cspan class=\"given-names\"\u003EMK\u003C\u002Fspan\u003E\u003C\u002Fspan\u003E, \u003Cspan class=\"string-name\"\u003E\u003Cspan class=\"surname\"\u003EFang\u003C\u002Fspan\u003E, \u003Cspan class=\"given-names\"\u003EJ\u003C\u002Fspan\u003E\u003C\u002Fspan\u003E, \u003Cspan class=\"string-name\"\u003E\u003Cspan class=\"surname\"\u003EHall\u003C\u002Fspan\u003E, \u003Cspan class=\"given-names\"\u003ERE.\u003C\u002Fspan\u003E\u003C\u002Fspan\u003E \u003Cspan class=\"article-title\"\u003EHow reliable are administrative data 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characteristics\u003C\u002Fspan\u003E",thumbnailSrc:ce,enlargedSrc:ce,attrib:[]},{contentId:"f1",label:"Figure 1:",description:"\u003Cspan class=\"p\"\u003EAssociation between categories of sleep duration and risk of stroke, stratified by age. Hazard ratios with 95% CIs are from Cox regression models (A, simple model; B, vascular model; C, full model), and subdistribution hazard ratios are from competing risk analysis (D, full model). There is a higher hazard of stroke in those <70 years old who report 10+ hours of sleep per night.\u003C\u002Fspan\u003E",thumbnailSrc:"https:\u002F\u002Fstatic.cambridge.org\u002Fbinary\u002Fversion\u002Fid\u002Furn:cambridge.org:id:binary-alt:20230208103335-00711-mediumThumb-S0317167121002420_fig1.jpg",enlargedSrc:"https:\u002F\u002Fstatic.cambridge.org\u002Fbinary\u002Fversion\u002Fid\u002Furn:cambridge.org:id:binary-alt:20230208103335-22053-optimisedImage-S0317167121002420_fig1.jpg",attrib:[]},{contentId:"f2",label:"Figure 2:",description:"\u003Cspan class=\"p\"\u003ECumulative incidence functions over years of follow-up for categories of sleep duration, stratified by age. Those ≥70 years have lower maximal follow-up time due to higher mortality. The greatest elevation in cumulative incidence of stroke occurs in individuals <70 years who report 10+ hours of sleep per night. Estimates obtained from fully adjusted competing risk regression models.\u003C\u002Fspan\u003E",thumbnailSrc:"https:\u002F\u002Fstatic.cambridge.org\u002Fbinary\u002Fversion\u002Fid\u002Furn:cambridge.org:id:binary-alt:20230208103335-88233-mediumThumb-S0317167121002420_fig2.jpg",enlargedSrc:"https:\u002F\u002Fstatic.cambridge.org\u002Fbinary\u002Fversion\u002Fid\u002Furn:cambridge.org:id:binary-alt:20230208103335-85346-optimisedImage-S0317167121002420_fig2.jpg",attrib:[]}]},pdf:{standardResolution:{fileUrl:"\u002Fcore\u002Fservices\u002Faop-cambridge-core\u002Fcontent\u002Fview\u002FF26C6DAE19F920794075859D10082AB1\u002FS0317167121002420a.pdf\u002Fassociation-between-excess-sleep-duration-and-risk-of-stroke-a-population-based-study.pdf",fileSizeInMb:.41,articleTitle:E,slugTitle:"association-between-excess-sleep-duration-and-risk-of-stroke-a-population-based-study"},highResolution:e,media:e},classification:[],supplementaryMaterials:[{title:cf,description:"\u003Cp\u003EJoundi et al. 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Sleep Res","S0317167121002420","10","2020","32","Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada","Canadian Journal of Neurological Sciences","article_cjn_ind_pur","2011","J Clin Sleep Med","39","2015","Eur J Epidemiol","Health Rep","2016","Appl Physiol Nutr Metab","N Engl J Med","Am J Hypertens","Association Between Excess Sleep Duration and Risk of Stroke: A Population-Based Study","22","14","2010","18","27","45","2007","23","43","Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada","17",0,"A15C3D1075D5ECE8B8BA8069337C929A","canadian-journal-of-neurological-sciences","\u002Fcore\u002Fjournals\u002Fcanadian-journal-of-neurological-sciences","1","\u002Fcore\u002Fjournals\u002Fcanadian-journal-of-neurological-sciences\u002Fissue\u002FCF63E659BE79CAA55AD3BDA720EEB698","50","en","Short sleep is associated with higher prevalence and increased predicted risk of cardiovascular diseases in an Iranian population: Fasa PERSIAN cohort study","Sci Rep","Sleep duration and sleep quality in relation to 12-year cardiovascular disease incidence: the MORGEN study","34","Self-reported sleep duration and quality and cardiovascular disease and mortality: a dose-response meta-analysis","J Am Heart Assoc","7","10.1161\u002FJAHA.118.008552","4","Sleep quality, sleep duration, and the risk of coronary heart disease: a prospective cohort study with 60,586 adults","10.5664\u002Fjcsm.6894","Sleep duration and risk of ischemic stroke in postmenopausal women","10.1161\u002FSTROKEAHA.108.521773","6","Sleep duration, midday napping, and sleep quality and incident stroke: the Dongfeng-Tongji cohort","10.1212\u002FWNL.0000000000008739","Sleep duration and risk of incident stroke by age, sex, and race: the REGARDS study","10.1212\u002FWNL.0000000000006424","Symptoms of insomnia and sleep duration and their association with incident strokes: findings from the population-based MONICA\u002FKORA Augsburg cohort study","PloS One","Sleep duration and stroke","10.1161\u002FSTROKEAHA.120.029902","Sleep duration and incidence of cardiovascular events in a Japanese population: the Jichi Medical School cohort study","J Epidemiol","20","106","10.2188\u002Fjea.JE20090053","Sleep characteristics and cardiovascular events in a large Swedish cohort","28","2013","10.1007\u002Fs10654-013-9802-2","Sleeping hours: what is the ideal number and how does age impact this?","Nat Sci Sleep","10.2147\u002FNSS.S163071","Sleep duration and all-cause mortality: a systematic review and meta-analysis of prospective studies","33","585","10.1093\u002Fsleep\u002F33.5.585","Sleep duration and mortality: a systematic review and meta-analysis","2009","10.1111\u002Fj.1365-2869.2008.00732.x","15","unknown","Canadian Community Health Survey - Annual Component (CCHS)","16","Canadian Population Health Survey data (CCHS Annual and Focus Content) integrated with mortality, hospitalization, historical postal codes, cancer, tax data and Census","Linking the Canadian Community Health Survey and the Canadian Mortality Database: an enhanced data source for the study of mortality","Canadian 24-hour movement guidelines for adults aged 18-64 years and adults aged 65 years or older: an integration of physical activity, sedentary behaviour, and sleep","10.1139\u002Fapnm-2020-0467","Bias in self-reported estimates of obesity in Canadian health surveys: an update on correction equations for adults","35","Sleep does not benefit probabilistic motor sequence learning","J Neurosci","21","Sleep duration and risk of fatal and nonfatal stroke: a prospective study and meta-analysis","10.1212\u002FWNL.0000000000001371","Sleep duration and risk of stroke events and stroke mortality: a systematic review and meta-analysis of prospective cohort studies","Int J Cardiol","10.1016\u002Fj.ijcard.2016.08.302","Sleep duration and biomarkers of inflammation","10.1093\u002Fsleep\u002F32.2.200","24","Sleep duration, sleep quality, and biomarkers of inflammation in a Taiwanese population","Ann Epidemiol","10.1016\u002Fj.annepidem.2011.07.004","Longer sleep duration and midday napping are associated with a higher risk of CHD incidence in middle-aged and older Chinese: the Dongfeng-Tongji cohort study","26","Sleep duration and abnormal serum lipids: the China Health and Nutrition Survey","Sleep Med","2014","10.1016\u002Fj.sleep.2014.02.006","Sleep duration and hypertension: analysis of \u003E 700,000 adults by age and sex","10.5664\u002Fjcsm.7176","Sleep duration is significantly associated with carotid artery atherosclerosis incidence in a Japanese population","Atherosclerosis","10.1016\u002Fj.atherosclerosis.2011.02.029","Sleep duration is associated with white matter hyperintensity volume in older adults: the Northern Manhattan study","10.1111\u002Fjsr.12177","Depression and risk of stroke","37","2012","10.1161\u002FSTROKEAHA.111.630871","Obstructive sleep apnea as a risk factor for stroke and death","10.1056\u002FNEJMoa043104","Socioeconomic status and stroke","10.1161\u002FSTROKEAHA.111.639732","Sedentary time and its association with risk for disease incidence, mortality, and hospitalization in adults: a systematic review and meta-analysis","Ann Intern Med","10.7326\u002FM14-1651","Sleep duration and health in adults: an overview of systematic reviews","10.1139\u002Fapnm-2020-0034","Sleep duration and hypertension are not associated in the elderly","Hypertension","10.1161\u002FHYPERTENSIONAHA.107.092585","Sleep duration and risk for hypertension in women: results from the nurses’ health study","10.1093\u002Fajh\u002Fhpt044","Age-dependent association between sleep duration and hypertension in the adult Korean population","10.1038\u002Fajh.2010.166","Sleep duration, mortality and the influence of age","10.1007\u002Fs10654-017-0297-0","Risk factors, mortality, and cardiovascular outcomes in patients with type 2 diabetes","10.1056\u002FNEJMoa1800256","The effect of age on the shape of the BMI-mortality relation and BMI associated with minimum all-cause mortality in a large Austrian cohort","Int J Obes","10.1038\u002Fijo.2014.168","41","The nature of spontaneous sleep across adulthood","10.1111\u002Fj.1365-2869.2007.00567.x","Sleep before and after retirement","Curr Sleep Med Rep","10.1007\u002Fs40675-018-0132-5","Agreement between self-reported and objectively measured sleep duration among white, black, Hispanic, and Chinese adults in the United States: multi-ethnic study of atherosclerosis","10.1093\u002Fsleep\u002Fzsy057","How reliable are administrative data for capturing stroke patients and their care","Cerebrovasc Dis Extra","10.1159\u002F000449288","https:\u002F\u002Fstatic.cambridge.org\u002Fbinary\u002Fversion\u002Fid\u002Furn:cambridge.org:id:binary:20230208102951209-0964:S0317167121002420:S0317167121002420_tab1.png","Joundi et al. supplementary material",6,"application\u002Fvnd.openxmlformats-officedocument.wordprocessingml.document"));</script><script src="/core/page-component/06cd607.js" defer></script><script src="/core/page-component/20147ec.js" defer></script><script src="/core/page-component/66884fb.js" defer></script><script src="/core/page-component/6f4302c.js" defer></script> </div> </div> <div id="article-new-home-productCitations" class="product-citations-modal reveal-modal medium" data-reveal role="dialog" aria-labelledby="article-new-home-citedByModalHeader"> <div class="header"> <div class="heading_07 margin-bottom" id="article-new-home-citedByModalHeader">Cited by</div> </div> <div class="citation-content"> <div class="row collapse header margin-top productCitations-content"> <ul class="small-12 small-centered columns citations"> <li class="fade-in section-container active"> <a href="#" class="section-button" data-id="article-new-home-crossref-citations"> <div class="circular medium citation"> 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