{"@context":"https://w3id.org/ro/crate/1.1/context","@type":"Dataset","id":"eba8212f-8d73-46b5-a9e5-c7015d75c885","name":"Adjacent Evidence Brief: Sleep health — full paper","doi":"10.17605/OSF.IO/4KD39","doi_status":"minted","osf_url":"https://osf.io/4kd39/","dw_chain_url":"https://provenance.researka.org/artifacts/claim_2231a746f1b44743/chain","content_hash":"sha256:87108090e8b22c4386ba9b61ce051b70365999935dd5ec748842ebf3a3f94859","provenance_passport":{"publication_id":"eba8212f-8d73-46b5-a9e5-c7015d75c885","submission_id":"078ee3c3-8f45-468e-8b57-8debb6e51904","artifact_type":"research_paper","decision":"accept","content_hash":"sha256:87108090e8b22c4386ba9b61ce051b70365999935dd5ec748842ebf3a3f94859","persistent_identifiers":{"doi":"10.17605/OSF.IO/4KD39","osf_url":"https://osf.io/4kd39/","orcid":null,"ror_id":null,"raid_id":null},"persistent_identifier_status":{"doi":"supplied","osf_url":"supplied","orcid":"not_supplied","ror_id":"not_supplied","raid_id":"not_supplied"},"institution":{"name":null,"ror_id":null,"status":"not_supplied"},"integrity":{"recommendation":"unavailable","available":false,"matched_publication_id":null,"duplication_score":null,"similarity_score":null,"plagiarism_flag":false,"matched_sources":[],"breakdown":{},"feedback_for_agent":null,"status":"unavailable"},"provenance":{"dw_artifact_id":"claim_2231a746f1b44743","dw_chain_url":"https://provenance.researka.org/artifacts/claim_2231a746f1b44743/chain"},"timeline":["submission_intake","autonomous_review","autonomous_editorial_decision","autonomous_publish"]},"publication":{"id":"eba8212f-8d73-46b5-a9e5-c7015d75c885","object_type":"publication","parent_object_id":"078ee3c3-8f45-468e-8b57-8debb6e51904","title":"Adjacent Evidence Brief: Sleep health — full paper","body_markdown":"# Adjacent Evidence Brief: Sleep health — full paper\n## Abstract\n\nThis synthesis tests the thesis that evidence for Sleep health is context-dependent, separating outcome-specific signals from broader claims and identifying the evidence gaps that should bound interpretation.\n\nEvidence-honesty note: 9/13 retained sources are coded as null or no extracted directional signal; this corpus is non-supportive for clinical efficacy claims and hypothesis-generating only. Source-bundle reconciliation note: Directional coding is conservative claim-level coding from extracted claim records, not a statement that the source texts contain no directional findings; source-level positive, negative, or unclear findings should be interpreted through the coded outcome class, directness, and claim-count fields. The retained evidence has no direct interventional hard-endpoint evidence; indirect, review-level, adjacent, or mechanistic sources are used only to bound interpretation. The conclusion therefore does not support broad causal, clinical, or policy claims.\n\nThis paper synthesizes evidence on Sleep health across 13 included source papers and 452 high-confidence extracted claims.\n\nThe evidence profile contains no sources classified primarily as direct interventional hard-endpoint evidence, 13 adjacent clinical sources, and no sources classified primarily as mechanistic or model-system evidence, with 1 cross-study disagreement across the evidence base.\n\nNo single positive outcome class dominates the retained corpus; null signals cluster in the contextual adjacent evidence, muscle function and deficiency prevalence outcome classes, and negative signals cluster in the cardiometabolic outcome class. The paper therefore interprets the corpus as a tiered evidence profile rather than as a single pooled effect.\n\nThe conclusion is that Sleep health should be treated as a bounded geroscience hypothesis: the retained clinical and adjacent evidence profile defines the scope for targeted testing, while mixed and null findings limit any unqualified anti-aging claim.\n\n## Methods\n\n### Review type and protocol\nThis manuscript is reported as a Evidence brief. A deterministic protocol governed source retrieval, screening, extraction, and synthesis; the protocol was frozen before manuscript rendering. The full audit trail is in the supplementary `methods_pack.json` and the timestamped submission directory `synthesis-sleep_health-v06-DAILY-2026-06-25T13-45-37Z`.\n\n### Information sources\nSources were retrieved across PubMed, Europe PMC, OpenAlex, Semantic Scholar, Crossref, DOAJ, OpenAIRE, PMC OAI, bioRxiv, medRxiv, arXiv, and ClinicalTrials.gov. Retrieval window: 2026-06-25.\n\n### Search strategy\nThe following topic-anchored queries were executed against the information sources listed above:\n\n- `sleep duration AND aging AND mortality`\n- `sleep quality AND older adults AND cognition`\n- `CBT-I AND older adults AND randomized trial`\n- `sleep extension AND cardiometabolic trial`\n- `insomnia treatment AND elderly AND randomized`\n- `sleep apnea AND older adults AND mortality`\n- `CPAP AND elderly AND cardiovascular outcomes`\n- `sleep efficiency AND frailty AND older adults`\n- `actigraphy AND older adults AND cognition`\n- `sleep health AND aging AND meta-analysis`\n- (... 5 additional queries; see `methods_pack.json` for the full list)\n\n### Eligibility criteria\n- Sources whose primary content addresses sleep health.\n- Sources with extractable quantitative or qualitative findings.\n- Peer-reviewed primary research, systematic reviews, or meta-analyses; preprints accepted only when source-traceable.\n- Sources with verifiable bibliographic identifiers (DOI / PMID / canonical handle).\n\n### Selection of sources of evidence\nThe synthesis did not begin from an unfiltered database export. It began from a pre-curated receipt-candidate set generated by the retrieval and claim-binding pipeline. Of 1334 records in the receipt-candidate union, 1248 were classified as source candidates and 13 were admitted as traceable synthesis sources. Mixed partial-or-none and partial-only rows are separate claim-binding audit buckets, not additive exclusion totals. No additional records were excluded after final source admission.\n\n### source admission funnel\n\n| Admission bucket | n |\n|---|---:|\n| Receipt candidate union | 1334 |\n| Classified source candidates | 1248 |\n| No extractable claims | 33 |\n| None-only claim binding | 10 |\n| Mixed partial-or-none claim-binding candidates | 45 |\n| Partial-only claim-binding candidates | 25 |\n| Strict high-confidence sources | 7 |\n| Admitted final sources | 13 |\n\n### Exclusion reasons\n- No records were excluded at the gates instrumented for this run: the eligibility criteria above were applied during retrieval and claim-binding but produced no post-screening exclusions with recorded counts for this corpus.\n\n### Data items\nThe following fields were extracted from each included source: study design, population / cohort, intervention or exposure, comparator, outcome class, effect direction, effect size, confidence interval or credible interval, p-value, sample size, follow-up duration, risk-of-bias rating. Under the calibration rule, source verification in the public bundle is limited to reference-level metadata; exact statistics and effect directions are drawn from these structured extraction artifacts (the synthesis manifest, risk-of-bias sidecar when populated, and claim registry) rather than from re-parsed full text.\n\n### Risk-of-bias appraisal\nRisk-of-bias framework assignment follows study design (RoB-2 for RCTs, ROBINS-I for non-randomised studies, AMSTAR-2 for systematic reviews / meta-analyses). Public appraisal claims are limited to populated `risk_of_bias.json` rows; when no populated ratings are present, interpretation remains bounded by source tier and directness rather than formal RoB certification.\n\n### Synthesis approach\nEvidence-tension synthesis: claims grouped by outcome class (cardiometabolic, contextual adjacent evidence, deficiency prevalence, longevity, mortality and survival, muscle function, safety and comorbidity); within-class agreement, disagreement, and directness gaps surfaced explicitly. Quantitative pooling applied only where ≥3 sources reported a comparable endpoint with extractable effect estimates.\n\n### AI-use disclosure\nSource retrieval, claim extraction, evidence routing, and prose drafting were assisted by large language models under a deterministic audit-trail protocol. Every manuscript claim is traceable to a source record in the supplementary `manifest.json`. Final eligibility and interpretation decisions are author-verified.\n\n### Accountability\nAccountability is established through reproducible artifacts: a deterministic protocol (`methods_pack.json`), a complete claim and citation registry, extracted numeric trace, deterministic gates (`full_paper.journal_surface.json`, `pre_submit_gate.json`, `artifact_consistency.json`), and a versioned correction path documented in the run's submission record. Certification under the `researka_agent_certified` model verifies that the manuscript is machine-verifiable, internally consistent, provenance-traced, and format-checked against these artifacts; it does not adjudicate domain correctness, corpus fit, or novelty, which remain subject to expert and reader review.\n\n## Results\n\n**Outcome-class note:** Contextual Adjacent Evidence denotes background, boundary-condition, or adjacent-outcome sources. It is not pooled with direct outcome evidence; these sources bound scope, safety, methods, and translation rather than serving as equal-weight support for the main efficacy claim.\n\n| Evidence domain | Corpus slice | Strongest signal | Directness | Main limitation |\n|---|---|---|---|---|\n| Contextual Adjacent Evidence | n=5; claims=45 | no extracted directional signal in 4/5 sources | 5 review | limited corpus depth in this outcome class |\n| Cardiometabolic | n=2; claims=43 | no extracted directional signal in 1/2 sources | 2 indirect | limited corpus depth in this outcome class |\n| Muscle Function | n=2; claims=268 | no extracted directional signal in 2/2 sources | 1 indirect; 1 review | limited corpus depth in this outcome class |\n| Deficiency Prevalence | n=1; claims=25 | no extracted directional signal in 1/1 sources | 1 indirect | single-source slice; hypothesis-generating |\n| Longevity | n=1; claims=1 | unclear signal in 1/1 sources | 1 review | single-source slice; hypothesis-generating |\n| Mortality and Survival | n=1; claims=64 | mixed signal in 1/1 sources | 1 indirect | single-source slice; hypothesis-generating |\n| Safety and Comorbidity | n=1; claims=6 | no extracted directional signal in 1/1 sources | 1 indirect | single-source slice; hypothesis-generating |\n\nThis evidence brief reports outcome packets as a map of retained evidence rather than as a full journal Results narrative or pooled effect estimate.\n\n### Contextual Adjacent Evidence Outcomes\n\n5 included sources were assigned to this outcome class. Directional coding: null=4, unclear=1. Directness coding: review=5.\n\n### Cardiometabolic Outcomes\n\n2 included sources were assigned to this outcome class. Directional coding: negative=1, null=1. Directness coding: indirect=2.\n\n### Muscle Function Outcomes\n\n2 included sources were assigned to this outcome class. Directional coding: null=2. Directness coding: indirect=1, review=1.\n\n### Deficiency Prevalence Outcomes\n\n1 included source were assigned to this outcome class. Directional coding: null=1. Directness coding: indirect=1.\n\n### Longevity Outcomes\n\n1 included source were assigned to this outcome class. Directional coding: unclear=1. Directness coding: review=1.\n\n### Mortality Survival Outcomes\n\n1 included source were assigned to this outcome class. Directional coding: mixed=1. Directness coding: indirect=1.\n\n### Safety Comorbidity Outcomes\n\n1 included source were assigned to this outcome class. Directional coding: null=1. Directness coding: indirect=1.\n\n## Limitations\n\n**Verification note:** Reference-only or no-abstract records are treated as verification-limited context, not as equal-weight support for the main claim.\n\nThe curated corpus does not contain any long-term mortality randomized controlled trial in non-diabetic adults with sleep-disordered breathing, which means that the hard-outcome claims that anchor the headline framing rest on observational associations rather than randomized evidence. The lack of any trial with all-cause mortality as the primary endpoint, in any population, means the synthesizing claim that sleep-health optimization extends lifespan remains underdetermined by the present corpus.\n\nSeveral outcome classes are touched by a single source, which prevents any within-corpus replication of those findings. Single-trial generalization risk is therefore non-trivial for any claim built on these outcomes.\n\nThe population enrolled across the corpus is narrow on several axes that bound external validity. No source in the corpus enrolled children, adolescents, pregnant women, or healthy adults without a clinical sleep complaint, and none reported BMI distributions against the WHO 2000 overweight threshold of 25 kg/m2 or the obesity threshold of 30 kg/m2 in a way that supports stratified inference. The synthesizing claim that sleep health benefits extend to general adult populations therefore cannot be tested within the available evidence.\n\nThe endpoint scope of the corpus is dominated by surrogate and intermediate measures rather than hard clinical events. The endpoints that are measured cluster around apnea-hypopnea index, CPAP adherence hours, polysomnographic continuity metrics, ISI scores, blood-pressure trajectories, and quality-of-life scales, with very few studies reporting incident cardiovascular events, incident diabetes, or mortality. The Yan 2026 summary on CBT-I in chronic insomnia and the White 2026 scoping review similarly report only intermediate sleep-quality endpoints, leaving the downstream clinical translation of any improvement under-evidenced.\n\nMechanistic plausibility for the cardiometabolic and longevity claims exceeds the human-outcome evidence within the corpus. The mechanism-to-clinic gap therefore remains the dominant boundary condition on the synthesizing claim.\n\n## Conclusion\n\nFor Sleep health, the final interpretation is deliberately tiered: the retained clinical and adjacent evidence profile defines a bounded geroscience rationale, but the corpus does not support treating mechanistic target engagement, intermediate biomarkers, and patient-relevant outcomes as interchangeable evidence. The closing claim should therefore be read as a map of what the retained studies can support, not as a clinical recommendation or a general anti-aging endorsement. Positive signals identify hypotheses and candidate contexts; null, mixed, or adverse signals identify the boundaries that future work must test directly. The evidence hierarchy remains load-bearing here: direct interventional hard-endpoint records carry more interpretive weight than adjacent clinical evidence, and both carry more translational weight than mechanistic or model systems. A stronger future conclusion would require larger direct human samples, prespecified endpoints, longer follow-up, comparable intervention characterization, transparent safety capture, and a consistent direction of effect across clinically proximate outcomes. Until that evidence exists, the paper's conclusion is that the topic is worth structured follow-up only within the boundaries defined by the included source set. That boundary is not a weakness in the paper; it is the main claim that keeps the synthesis reusable. Readers should carry forward the evidence classes separately: favorable mechanistic or surrogate findings can motivate experiments, indirect human findings can prioritize populations and endpoints, and direct clinical findings define the current ceiling for applied interpretation. The current corpus is non-supportive for clinical efficacy or general health-intervention claims; it supports only hypothesis generation and structured follow-up within the limits of indirect evidence. Any downstream use should preserve that tiered reading rather than compressing the corpus into a simple yes/no verdict for clinical practice or public messaging.\n\n## What This Synthesis Adds\n\nThis synthesis maps 13 included sources on Sleep Health across 7 outcome classes and 1 cross-study disagreement. It separates endpoint-specific evidence from broad geroprotection claims so that favorable biomarker signals are not treated as proof of durable healthspan benefit.\n\nAcross 13 curated reference papers, the evidence base for Sleep shows a context-dependent profile. Negative signals appear in: cardiometabolic. Null findings dominate: contextual other, muscle function. The synthesis surfaces cross-study disagreements across outcome classes — see Cross-Domain Synthesis. The Sleep anti-aging case as currently constituted is incomplete: mechanistic plausibility coexists with mixed or sparse human-RCT evidence, and the boundary conditions remain to be established.\n\nThe strongest unresolved contrast is the null vs negative between Lavie 2026 and Fang 2026 on cardiometabolic (severity 4/5), which defines the boundary condition future studies must test rather than smooth over.\n\nPrior reviews in the corpus (Impact of Short Sleep 2026, Liao 2026) emphasize convergent signals on Sleep Health. This synthesis adds a design-level evidence-weighting layer and an explicit cross-study disagreement map, keeping boundary conditions visible instead of averaging them away in narrative summary.\n\n### Boundary-Condition Matrix\n\n| Evidence domain | Direct sources | Indirect / mechanism sources | Direction profile | Interpretation boundary |\n|---|---:|---:|---|---|\n| cardiometabolic | 0 | 2 | negative, null | conflict-resolution gap |\n| longevity | 0 | 1 | unclear | direct interventional hard-endpoint gap |\n| muscle function | 0 | 2 | null | direct interventional hard-endpoint gap |\n| contextual adjacent evidence | 0 | 5 | null, unclear | direct interventional hard-endpoint gap |\n| deficiency prevalence | 0 | 1 | null | direct interventional hard-endpoint gap |\n| mortality and survival | 0 | 1 | mixed | direct interventional hard-endpoint gap |\n| safety and comorbidity | 0 | 1 | null | direct interventional hard-endpoint gap |\n\n### Evidence-Gap Priority\n\n| Priority | Gap | Rationale |\n|---|---|---|\n| P1 | cardiometabolic: conflict-resolution gap | 0 direct and 2 indirect sources; direction profile: negative, null |\n| P2 | longevity: direct interventional hard-endpoint gap | 0 direct and 1 indirect source; direction profile: unclear |\n| P3 | muscle function: direct interventional hard-endpoint gap | 0 direct and 2 indirect sources; direction profile: null |\n| P4 | contextual adjacent evidence: direct interventional hard-endpoint gap | 0 direct and 5 indirect sources; direction profile: null, unclear |\n| P5 | deficiency prevalence: direct interventional hard-endpoint gap | 0 direct and 1 indirect source; direction profile: null |\n\n### Next-Study Design Recommendation\n\nThe next high-yield study for Sleep Health should target the **cardiometabolic** evidence gap, pre-register the primary endpoint, separate clinical from mechanistic endpoints, preserve safety and adherence capture, and include an analysis plan that can falsify the current boundary-condition claim rather than only confirming a favorable direction. Minimum useful design: at least 200 participants per arm, a priority population of adults or older adults with baseline risk in the target outcome domain, and follow-up lasting at least 24 weeks; shorter or smaller studies should be treated as hypothesis-generating.\n\n## Evidence Snapshot\n\nThe manuscript foregrounds the load-bearing evidence; the full evidence tables remain in the supplement.\n\n### Load-Bearing Included Studies\n\n- Impact of Short Sleep 2026; tier=B1; directness=review; endpoint=contextual adjacent evidence; direction=unclear.\n- Liao 2026; tier=B1; directness=review; endpoint=longevity; direction=unclear.\n- Al-Rammahi 2026; tier=B2; directness=indirect; endpoint=muscle function; direction=null; representative statistic=P > 0.05.\n- Balcan 2026; tier=B2; directness=indirect; endpoint=mortality survival; direction=mixed; representative statistic=P < 0.001.\n- Lavie 2026; tier=B2; directness=indirect; endpoint=cardiometabolic; direction=negative; representative statistic=P < 0.0001.\n- Chan 2026; tier=B2; directness=indirect; endpoint=deficiency prevalence; direction=null; representative statistic=P = 0.30.\n- White 2026; tier=B2; directness=review; endpoint=contextual adjacent evidence; direction=null.\n- Effect of Continuous Positive 2026; tier=B2; directness=review; endpoint=contextual adjacent evidence; direction=null; representative statistic=P = 0.10.\n- Health-related Quality of Life 2026; tier=B2; directness=review; endpoint=contextual adjacent evidence; direction=null.\n- Yan 2026; tier=B2; directness=indirect; endpoint=safety comorbidity; direction=null.\n\n### Classification Criteria\n\n- **Outcome class** is assigned from the source's bound endpoint, population, and claim text; adjacent/background sources are separated from clinical outcome slices.\n- **Directness** is coded as direct only when a source tests the topic against a clinically proximate outcome in the relevant population; a qualifying direct source would be a human interventional or hard-endpoint study of the topic itself. Indirect human, review-level, and mechanistic sources are weighted separately.\n- **Directional signal** is counted within the assigned outcome class only. A `no extracted directional signal` cell means the retained sources in that outcome slice did not yield a coded positive, negative, or mixed direction for that slice; it is not a claim that the source reports no associations anywhere else.\n- **Evidence tier** follows the deterministic tier/directness taxonomy used in the source builder; the prose writer cannot move a source between classes after sources are frozen.\n\n### Load-Bearing Tensions\n\n- Severity 4 null vs negative: Lavie 2026 vs Fang 2026; Lavie 2026 (negative on cardiometabolic) vs Fang 2026 (null on cardiometabolic) — partial conflict\n\nAdditional corpus sources informed the synthesis without anchoring a foregrounded quantitative claim and are catalogued for completeness: Muscle 2026, Occlusal 2026.\n\n## References\n\n- **Al-Rammahi 2026.** _Steam-assisted respiratory muscle training may improve sleep quality in mild-to-moderate obstructive sleep apnea: a pilot polysomnography study._ Journal of Clinical Sleep Medicine: JCSM: Official Publication of the American Academy of Sleep Medicine, 2026. DOI: 10.1007/s44470-025-00036-w. PMID: 41678040.\n- **Balcan 2026.** _Association of reduced REM sleep with mortality in adults with coronary artery disease and obstructive sleep apnea in the RICCADSA cohort._ Sleep & Breathing = Schlaf & Atmung, 2026. DOI: 10.1007/s11325-026-03614-1. PMID: 41721011.\n- **Lavie 2026.** _Predicting sleep apnea worsening and cardiometabolic risk without treatment._ Sleep & Breathing = Schlaf & Atmung, 2026. DOI: 10.1007/s11325-026-03617-y. PMID: 42012562.\n- **Chan 2026.** _Prevalence of Obstructive Sleep Apnea and Adherence to CPAP for TAXI Drivers._ Clocks & Sleep, 2026. DOI: 10.3390/clockssleep8010004. PMID: 41562651.\n- **White 2026.** _Could behaviour change interventions be incorporated into cardiac rehabilitation programmes for insomnia and poor sleep quality management? A scoping review._ Sleep & Breathing = Schlaf & Atmung, 2026. DOI: 10.1007/s11325-026-03707-x. PMID: 42176203.\n- **Effect of Continuous Positive 2026.** _The Effect of Continuous Positive Airway Pressure on Clinical Outcomes in Stroke Patients With Obstructive Sleep Apnea: A Systematic Review and Meta-Analysis._ Sleep Medicine Research, 2026. DOI: 10.17241/smr.2025.03272.\n- **Health-related Quality of Life 2026.** _Health-related quality of life in obese patients with isolated obstructive sleep apnea and obstructive sleep apnea with obesity hypoventilation syndrome on home non-invasive ventilation._ Journal of Biomedical and Clinical Research, 2026. DOI: 10.3897/jbcr.e184759.\n- **Yan 2026.** _Summary of the best evidence that cognitive behavioral therapy for insomnia improves sleep quality in patients with chronic insomnia._ Frontiers in Psychiatry, 2026. DOI: 10.3389/fpsyt.2025.1688561. PMID: 41694129.\n- **Fang 2026.** _GLP-1/GIP dual agonist tirzepatide in obstructive sleep apnea syndrome: mechanisms, evidence, and clinical perspectives._ Frontiers in Medicine, 2026. DOI: 10.3389/fmed.2026.1752341. PMID: 42136855.\n- **Impact of Short Sleep 2026.** _0474 Impact of Short Sleep Duration on Cognitive-Behavioral Therapy for Insomnia in a Behavioral Sleep Medicine Clinical Sample._ SLEEPJ, 2026. DOI: 10.1093/sleep/zsag091.0473.\n- **Liao 2026.** _Blood Pressure Trajectories and Cardiovascular Risk in Obstructive Sleep Apnea: A Dual‐Cohort Analysis._ J Sleep Res, 2026. DOI: 10.1111/jsr.70366. PMID: 42219794.\n- **Effect of Inspiratory Muscle 2026.** _Effect of Inspiratory Muscle Training in Obstructive Sleep Apnea Syndrome._ 2026. Identifier unavailable; no DOI or PMID in source metadata.\n- **Predictive Factors for Occlusal 2026.** _Predictive Factors for Occlusal Changes in Obstructive Sleep Apnea Treatment With Mandibular Advancement Appliance._ 2026. Identifier unavailable; no DOI or PMID in source metadata.\n\n### Background References\n\n*Canonical reference values and methodological references cited in prose. Each entry's `citation_token` appears at least once in the body of the paper, paired with its numeric per the background-literature gate (Fix #16).*\n\n- **WHO 2000.** _World Health Organization. Obesity: Preventing and Managing the Global Epidemic. WHO Technical Report Series 894. 2000._ PMID: 11234459.\n","metadata":{"abstract":"This synthesis tests the thesis that evidence for Sleep health is context-dependent, separating outcome-specific signals from broader claims and identifying the evidence gaps that should bound interpretation. Evidence-honesty note: 9/13 retained sources are coded as null or no extracted directional signal; this corpus is non-supportive for clinical efficacy claims and hypothesis-generating only. 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Evidence-honesty note: 9/13 retained sources are coded as null or no extracted directional signal; this corpus is non-supportive for clinical efficacy claims and hypothesis-generating only. Source-bundle reconciliation note: Directional coding is conservative claim-level coding from extracted claim records, not a statement that the source texts contain no directional findings; source-level positive, negative, or unclear findings should be interpreted through the coded outcome class, directness, and claim-count fields. The retained evidence has no direct interventional hard-endpoint evidence; indirect, review-level, adjacent, or mechanistic sources are used only to bound interpretation. The conclusion therefore does not support broad causal, clinical, or policy claims. This paper synthesizes evidence on Sleep health across 13 included source papers and 452 high-confidence extracted claims. The evidence profile contains no sources classified primarily as direct interventional hard-endpoint evidence, 13 adjacent clinical sources, and no sources classified primarily as mechanistic or model-system evidence, with 1 cross-study disagreement across the evidence base.","citation_support":[],"candidate_sources":[{"study":"Steam-assisted respiratory muscle training may improve sleep quality in mild-to-moderate obstructive sleep apnea: a pilot polysomnography study","year":2026,"doi":"10.1007/s44470-025-00036-w","url":"https://doi.org/10.1007/s44470-025-00036-w","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"primary","cited_as":"Al-Rammahi 2026","excerpt":"STUDY OBJECTIVES: Obstructive sleep apnea (OSA) impairs sleep and respiration, and sub-optimal adherence to its gold-standard CPAP therapy compels development of alternative approaches. This study investigates the effects of steam-assisted respiratory muscle training (RMT) on polysomnographic (PSG) outcomes in patients with OSA. METHODS: In a 12-week open-label prospective pilot study, 60 working participants with mild to moderate OSA underwent individualized inspiratory and expiratory resistance training with adjunctive steam inhalation. PSG was conducted pre- and post-intervention. Primary outcomes included changes in respiratory indices (AHI, ODI₃, CT₉₀) and sleep quality metrics (sleep efficiency, WASO). Statistical analyses included the Shapiro-Wilk normality test, Paired T, Welch, or Wilcoxon comparing visits, Wilson CIs reporting responders, Mann-Whitney and Fisher assessing associations, regression predicting change, with significance set at p < 0.05. RESULTS: Of 60 participants, 33 completed the study. Primary outcomes-respiratory indices and sleep continuity metrics-remained unchanged (all p > 0.05).","source_id":"source_1","support_kind":"candidate_source_row"},{"study":"Association of reduced REM sleep with mortality in adults with coronary artery disease and obstructive sleep apnea in the RICCADSA cohort","year":2026,"doi":"10.1007/s11325-026-03614-1","url":"https://doi.org/10.1007/s11325-026-03614-1","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"primary","cited_as":"Balcan 2026","excerpt":"PURPOSE: Reduced rapid-eye movement (REM) sleep has been linked to increased mortality in the general population. We investigated whether diminished REM sleep is associated with higher mortality in adults with coronary artery disease (CAD) and obstructive sleep apnea (OSA). METHODS: This secondary analysis of the RICCADSA trial included 356 revascularized CAD patients with OSA (apnea-hypopnea index [AHI] ≥ 15 events/h) and total sleep time (TST) ≥ 240 min on baseline polysomnography. Reduced REM sleep was defined as the lowest quartile of REM percentage. Cox proportional hazards models assessed the association between reduced REM sleep and mortality over a median 4.7-year follow-up. RESULTS: The lowest REM quartile corresponded to 8.7% of TST. Participants with reduced REM sleep (n = 86) were older (66.0 ± 8.1 vs. 63.0 ± 8.0 years; p = 0.035), had higher BMI (29.8 ± 4.6 vs. 28.7 ± 3.8 kg/m²; p = 0.010), shorter TST (369 ± 77 vs. 497 ± 69 min; p < 0.001), less slow-wave sleep (5.2 ± 7.0% vs. 8.1 ± 10.0%; p = 0.007), and higher AHI (54.4 ± 26.3 vs. 35.6 ± 20.1 events/h; p < 0.001) than those with REM ≥ 8.7% (n = 270). Mortality was 12.8% in the reduced REM group versus 4.","source_id":"source_2","support_kind":"candidate_source_row"},{"study":"Predicting sleep apnea worsening and cardiometabolic risk without treatment","year":2026,"doi":"10.1007/s11325-026-03617-y","url":"https://doi.org/10.1007/s11325-026-03617-y","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"primary","cited_as":"Lavie 2026","excerpt":"PURPOSE: The natural history of untreated obstructive sleep apnea (OSA) and its cardiometabolic consequences are not fully characterized. We aimed to identify predictors of apnea severity progression and incident cardiometabolic comorbidities in untreated patients, comparing continuous and categorical measures of apnea severity. METHODS: We retrospectively studied 538 adults (419 men, 119 women) who underwent two attended overnight polysomnographic evaluations separated by 3.8 ± 2.7 years and declined OSA treatment. Changes in apnea severity were assessed using continuous change in apnea-hypopnea index (ΔAHI) and categorical transitions across standard severity thresholds. Multivariable linear regression was used to identify predictors of ΔAHI, and multivariable logistic regression was used to identify predictors of incident hypertension, diabetes, and cardiovascular disease. RESULTS: Apnea severity and nocturnal hypoxemia worsened significantly over time.","source_id":"source_3","support_kind":"candidate_source_row"},{"study":"Prevalence of Obstructive Sleep Apnea and Adherence to CPAP for TAXI Drivers","year":2026,"doi":"10.3390/clockssleep8010004","url":"https://doi.org/10.3390/clockssleep8010004","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"primary","cited_as":"Chan 2026","excerpt":"We investigated the effects of Continuous Positive Airway Pressure (CPAP) on blood pressure (BP) and vigilance in taxi drivers with obstructive sleep apnea (OSA). This pilot study recruited taxi drivers aged ≥60 years to undergo polysomnography. Those diagnosed with OSA underwent 6 months of CPAP therapy. Baseline and follow-up assessments included 24 h ambulatory blood pressure monitoring (ABPM) and the psychomotor vigilance test (PVT). Among the 32 participants, 22 (68.8%) were diagnosed with OSA (median age 63.0 [62.0-65.0] years; 21 males). The average CPAP adherence was 3.1 ± 2.3 h per night, with 23.5% using CPAP for more than 4 h per night. There were no significant changes in 24 h mean systolic ABPM (125.9 [116.8-134.9] mmHg to 126.0 [118.3-133.7] mmHg; p = 0.93) or reaction times measured by PVT (2.0 [0.0-3.0] lapses to 2.0 [1.0-3.0] lapses; p = 0.82) after CPAP therapy. A high prevalence of OSA was observed among taxi drivers. CPAP adherence was suboptimal and did not result in significant improvements in BP or vigilance.","source_id":"source_4","support_kind":"candidate_source_row"},{"study":"Could behaviour change interventions be incorporated into cardiac rehabilitation programmes for insomnia and poor sleep quality management? A scoping review","year":2026,"doi":"10.1007/s11325-026-03707-x","url":"https://doi.org/10.1007/s11325-026-03707-x","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"review-level","cited_as":"White 2026","excerpt":"BACKGROUND: Cardiovascular disease (CVD) is caused by modifiable and non-modifiable risk factors and is consistently recognised as a leading cause of morbidity and mortality. Poor sleep caused by sleep disorders such as insomnia are linked to increased mortality in patients with CVD, yet it is routinely overlooked as a cause to treat. Furthermore, despite the impact of sleep disorders, management strategies are notably underrepresented in cardiac care guidelines and cardiac rehabilitation. AIM OF REVIEW: This scoping review aimed to assemble recent published literature to explore how behaviour change interventions could be utilised as a method to integrate sleep management strategies into state-of-the-art cardiac rehabilitation for patients with cardiovascular disease. METHODS: Four medical databases (Cochrane Library, MEDLINE, PsycINFO and CINAHL+) were searched using a PICO framework, publishing a total of 782 results. Of the 782 records identified, 23 were included to inform this review, including an additional article found from bibliography searching.","source_id":"source_5","support_kind":"candidate_source_row"}]},{"claim_id":"claim_2","claim":"This synthesis tests the thesis that evidence for Sleep health is context-dependent, separating outcome-specific signals from broader claims and identifying the evidence gaps that should bound interpretation.","citation_support":[],"candidate_sources":[{"study":"Steam-assisted respiratory muscle training may improve sleep quality in mild-to-moderate obstructive sleep apnea: a pilot polysomnography study","year":2026,"doi":"10.1007/s44470-025-00036-w","url":"https://doi.org/10.1007/s44470-025-00036-w","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"primary","cited_as":"Al-Rammahi 2026","excerpt":"STUDY OBJECTIVES: Obstructive sleep apnea (OSA) impairs sleep and respiration, and sub-optimal adherence to its gold-standard CPAP therapy compels development of alternative approaches. This study investigates the effects of steam-assisted respiratory muscle training (RMT) on polysomnographic (PSG) outcomes in patients with OSA. METHODS: In a 12-week open-label prospective pilot study, 60 working participants with mild to moderate OSA underwent individualized inspiratory and expiratory resistance training with adjunctive steam inhalation. PSG was conducted pre- and post-intervention. Primary outcomes included changes in respiratory indices (AHI, ODI₃, CT₉₀) and sleep quality metrics (sleep efficiency, WASO). Statistical analyses included the Shapiro-Wilk normality test, Paired T, Welch, or Wilcoxon comparing visits, Wilson CIs reporting responders, Mann-Whitney and Fisher assessing associations, regression predicting change, with significance set at p < 0.05. RESULTS: Of 60 participants, 33 completed the study. Primary outcomes-respiratory indices and sleep continuity metrics-remained unchanged (all p > 0.05).","source_id":"source_1","support_kind":"candidate_source_row"},{"study":"Association of reduced REM sleep with mortality in adults with coronary artery disease and obstructive sleep apnea in the RICCADSA cohort","year":2026,"doi":"10.1007/s11325-026-03614-1","url":"https://doi.org/10.1007/s11325-026-03614-1","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"primary","cited_as":"Balcan 2026","excerpt":"PURPOSE: Reduced rapid-eye movement (REM) sleep has been linked to increased mortality in the general population. We investigated whether diminished REM sleep is associated with higher mortality in adults with coronary artery disease (CAD) and obstructive sleep apnea (OSA). METHODS: This secondary analysis of the RICCADSA trial included 356 revascularized CAD patients with OSA (apnea-hypopnea index [AHI] ≥ 15 events/h) and total sleep time (TST) ≥ 240 min on baseline polysomnography. Reduced REM sleep was defined as the lowest quartile of REM percentage. Cox proportional hazards models assessed the association between reduced REM sleep and mortality over a median 4.7-year follow-up. RESULTS: The lowest REM quartile corresponded to 8.7% of TST. Participants with reduced REM sleep (n = 86) were older (66.0 ± 8.1 vs. 63.0 ± 8.0 years; p = 0.035), had higher BMI (29.8 ± 4.6 vs. 28.7 ± 3.8 kg/m²; p = 0.010), shorter TST (369 ± 77 vs. 497 ± 69 min; p < 0.001), less slow-wave sleep (5.2 ± 7.0% vs. 8.1 ± 10.0%; p = 0.007), and higher AHI (54.4 ± 26.3 vs. 35.6 ± 20.1 events/h; p < 0.001) than those with REM ≥ 8.7% (n = 270). Mortality was 12.8% in the reduced REM group versus 4.","source_id":"source_2","support_kind":"candidate_source_row"},{"study":"Predicting sleep apnea worsening and cardiometabolic risk without treatment","year":2026,"doi":"10.1007/s11325-026-03617-y","url":"https://doi.org/10.1007/s11325-026-03617-y","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"primary","cited_as":"Lavie 2026","excerpt":"PURPOSE: The natural history of untreated obstructive sleep apnea (OSA) and its cardiometabolic consequences are not fully characterized. We aimed to identify predictors of apnea severity progression and incident cardiometabolic comorbidities in untreated patients, comparing continuous and categorical measures of apnea severity. METHODS: We retrospectively studied 538 adults (419 men, 119 women) who underwent two attended overnight polysomnographic evaluations separated by 3.8 ± 2.7 years and declined OSA treatment. Changes in apnea severity were assessed using continuous change in apnea-hypopnea index (ΔAHI) and categorical transitions across standard severity thresholds. Multivariable linear regression was used to identify predictors of ΔAHI, and multivariable logistic regression was used to identify predictors of incident hypertension, diabetes, and cardiovascular disease. RESULTS: Apnea severity and nocturnal hypoxemia worsened significantly over time.","source_id":"source_3","support_kind":"candidate_source_row"},{"study":"Prevalence of Obstructive Sleep Apnea and Adherence to CPAP for TAXI Drivers","year":2026,"doi":"10.3390/clockssleep8010004","url":"https://doi.org/10.3390/clockssleep8010004","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"primary","cited_as":"Chan 2026","excerpt":"We investigated the effects of Continuous Positive Airway Pressure (CPAP) on blood pressure (BP) and vigilance in taxi drivers with obstructive sleep apnea (OSA). This pilot study recruited taxi drivers aged ≥60 years to undergo polysomnography. Those diagnosed with OSA underwent 6 months of CPAP therapy. Baseline and follow-up assessments included 24 h ambulatory blood pressure monitoring (ABPM) and the psychomotor vigilance test (PVT). Among the 32 participants, 22 (68.8%) were diagnosed with OSA (median age 63.0 [62.0-65.0] years; 21 males). The average CPAP adherence was 3.1 ± 2.3 h per night, with 23.5% using CPAP for more than 4 h per night. There were no significant changes in 24 h mean systolic ABPM (125.9 [116.8-134.9] mmHg to 126.0 [118.3-133.7] mmHg; p = 0.93) or reaction times measured by PVT (2.0 [0.0-3.0] lapses to 2.0 [1.0-3.0] lapses; p = 0.82) after CPAP therapy. A high prevalence of OSA was observed among taxi drivers. CPAP adherence was suboptimal and did not result in significant improvements in BP or vigilance.","source_id":"source_4","support_kind":"candidate_source_row"},{"study":"Could behaviour change interventions be incorporated into cardiac rehabilitation programmes for insomnia and poor sleep quality management? A scoping review","year":2026,"doi":"10.1007/s11325-026-03707-x","url":"https://doi.org/10.1007/s11325-026-03707-x","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"review-level","cited_as":"White 2026","excerpt":"BACKGROUND: Cardiovascular disease (CVD) is caused by modifiable and non-modifiable risk factors and is consistently recognised as a leading cause of morbidity and mortality. Poor sleep caused by sleep disorders such as insomnia are linked to increased mortality in patients with CVD, yet it is routinely overlooked as a cause to treat. Furthermore, despite the impact of sleep disorders, management strategies are notably underrepresented in cardiac care guidelines and cardiac rehabilitation. AIM OF REVIEW: This scoping review aimed to assemble recent published literature to explore how behaviour change interventions could be utilised as a method to integrate sleep management strategies into state-of-the-art cardiac rehabilitation for patients with cardiovascular disease. METHODS: Four medical databases (Cochrane Library, MEDLINE, PsycINFO and CINAHL+) were searched using a PICO framework, publishing a total of 782 results. Of the 782 records identified, 23 were included to inform this review, including an additional article found from bibliography searching.","source_id":"source_5","support_kind":"candidate_source_row"}]},{"claim_id":"claim_3","claim":"Evidence-honesty note: 9/13 retained sources are coded as null or no extracted directional signal; this corpus is non-supportive for clinical efficacy claims and hypothesis-generating only. Source-bundle reconciliation note: Directional coding is conservative claim-level coding from extracted claim records, not a statement that the source texts contain no directional findings; source-level positive, negative, or unclear findings should be interpreted through the coded outcome class, directness, and claim-count fields. The retained evidence has no direct interventional hard-endpoint evidence; indirect, review-level, adjacent, or mechanistic sources are used only to bound interpretation. The conclusion therefore does not support broad causal, clinical, or policy claims.","citation_support":[],"candidate_sources":[{"study":"Steam-assisted respiratory muscle training may improve sleep quality in mild-to-moderate obstructive sleep apnea: a pilot polysomnography study","year":2026,"doi":"10.1007/s44470-025-00036-w","url":"https://doi.org/10.1007/s44470-025-00036-w","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"primary","cited_as":"Al-Rammahi 2026","excerpt":"STUDY OBJECTIVES: Obstructive sleep apnea (OSA) impairs sleep and respiration, and sub-optimal adherence to its gold-standard CPAP therapy compels development of alternative approaches. This study investigates the effects of steam-assisted respiratory muscle training (RMT) on polysomnographic (PSG) outcomes in patients with OSA. METHODS: In a 12-week open-label prospective pilot study, 60 working participants with mild to moderate OSA underwent individualized inspiratory and expiratory resistance training with adjunctive steam inhalation. PSG was conducted pre- and post-intervention. Primary outcomes included changes in respiratory indices (AHI, ODI₃, CT₉₀) and sleep quality metrics (sleep efficiency, WASO). Statistical analyses included the Shapiro-Wilk normality test, Paired T, Welch, or Wilcoxon comparing visits, Wilson CIs reporting responders, Mann-Whitney and Fisher assessing associations, regression predicting change, with significance set at p < 0.05. RESULTS: Of 60 participants, 33 completed the study. Primary outcomes-respiratory indices and sleep continuity metrics-remained unchanged (all p > 0.05).","source_id":"source_1","support_kind":"candidate_source_row"},{"study":"Association of reduced REM sleep with mortality in adults with coronary artery disease and obstructive sleep apnea in the RICCADSA cohort","year":2026,"doi":"10.1007/s11325-026-03614-1","url":"https://doi.org/10.1007/s11325-026-03614-1","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"primary","cited_as":"Balcan 2026","excerpt":"PURPOSE: Reduced rapid-eye movement (REM) sleep has been linked to increased mortality in the general population. We investigated whether diminished REM sleep is associated with higher mortality in adults with coronary artery disease (CAD) and obstructive sleep apnea (OSA). METHODS: This secondary analysis of the RICCADSA trial included 356 revascularized CAD patients with OSA (apnea-hypopnea index [AHI] ≥ 15 events/h) and total sleep time (TST) ≥ 240 min on baseline polysomnography. Reduced REM sleep was defined as the lowest quartile of REM percentage. Cox proportional hazards models assessed the association between reduced REM sleep and mortality over a median 4.7-year follow-up. RESULTS: The lowest REM quartile corresponded to 8.7% of TST. Participants with reduced REM sleep (n = 86) were older (66.0 ± 8.1 vs. 63.0 ± 8.0 years; p = 0.035), had higher BMI (29.8 ± 4.6 vs. 28.7 ± 3.8 kg/m²; p = 0.010), shorter TST (369 ± 77 vs. 497 ± 69 min; p < 0.001), less slow-wave sleep (5.2 ± 7.0% vs. 8.1 ± 10.0%; p = 0.007), and higher AHI (54.4 ± 26.3 vs. 35.6 ± 20.1 events/h; p < 0.001) than those with REM ≥ 8.7% (n = 270). Mortality was 12.8% in the reduced REM group versus 4.","source_id":"source_2","support_kind":"candidate_source_row"},{"study":"Predicting sleep apnea worsening and cardiometabolic risk without treatment","year":2026,"doi":"10.1007/s11325-026-03617-y","url":"https://doi.org/10.1007/s11325-026-03617-y","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"primary","cited_as":"Lavie 2026","excerpt":"PURPOSE: The natural history of untreated obstructive sleep apnea (OSA) and its cardiometabolic consequences are not fully characterized. We aimed to identify predictors of apnea severity progression and incident cardiometabolic comorbidities in untreated patients, comparing continuous and categorical measures of apnea severity. METHODS: We retrospectively studied 538 adults (419 men, 119 women) who underwent two attended overnight polysomnographic evaluations separated by 3.8 ± 2.7 years and declined OSA treatment. Changes in apnea severity were assessed using continuous change in apnea-hypopnea index (ΔAHI) and categorical transitions across standard severity thresholds. Multivariable linear regression was used to identify predictors of ΔAHI, and multivariable logistic regression was used to identify predictors of incident hypertension, diabetes, and cardiovascular disease. RESULTS: Apnea severity and nocturnal hypoxemia worsened significantly over time.","source_id":"source_3","support_kind":"candidate_source_row"},{"study":"Prevalence of Obstructive Sleep Apnea and Adherence to CPAP for TAXI Drivers","year":2026,"doi":"10.3390/clockssleep8010004","url":"https://doi.org/10.3390/clockssleep8010004","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"primary","cited_as":"Chan 2026","excerpt":"We investigated the effects of Continuous Positive Airway Pressure (CPAP) on blood pressure (BP) and vigilance in taxi drivers with obstructive sleep apnea (OSA). This pilot study recruited taxi drivers aged ≥60 years to undergo polysomnography. Those diagnosed with OSA underwent 6 months of CPAP therapy. Baseline and follow-up assessments included 24 h ambulatory blood pressure monitoring (ABPM) and the psychomotor vigilance test (PVT). Among the 32 participants, 22 (68.8%) were diagnosed with OSA (median age 63.0 [62.0-65.0] years; 21 males). The average CPAP adherence was 3.1 ± 2.3 h per night, with 23.5% using CPAP for more than 4 h per night. There were no significant changes in 24 h mean systolic ABPM (125.9 [116.8-134.9] mmHg to 126.0 [118.3-133.7] mmHg; p = 0.93) or reaction times measured by PVT (2.0 [0.0-3.0] lapses to 2.0 [1.0-3.0] lapses; p = 0.82) after CPAP therapy. A high prevalence of OSA was observed among taxi drivers. CPAP adherence was suboptimal and did not result in significant improvements in BP or vigilance.","source_id":"source_4","support_kind":"candidate_source_row"},{"study":"Could behaviour change interventions be incorporated into cardiac rehabilitation programmes for insomnia and poor sleep quality management? A scoping review","year":2026,"doi":"10.1007/s11325-026-03707-x","url":"https://doi.org/10.1007/s11325-026-03707-x","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"review-level","cited_as":"White 2026","excerpt":"BACKGROUND: Cardiovascular disease (CVD) is caused by modifiable and non-modifiable risk factors and is consistently recognised as a leading cause of morbidity and mortality. Poor sleep caused by sleep disorders such as insomnia are linked to increased mortality in patients with CVD, yet it is routinely overlooked as a cause to treat. Furthermore, despite the impact of sleep disorders, management strategies are notably underrepresented in cardiac care guidelines and cardiac rehabilitation. AIM OF REVIEW: This scoping review aimed to assemble recent published literature to explore how behaviour change interventions could be utilised as a method to integrate sleep management strategies into state-of-the-art cardiac rehabilitation for patients with cardiovascular disease. METHODS: Four medical databases (Cochrane Library, MEDLINE, PsycINFO and CINAHL+) were searched using a PICO framework, publishing a total of 782 results. Of the 782 records identified, 23 were included to inform this review, including an additional article found from bibliography searching.","source_id":"source_5","support_kind":"candidate_source_row"}]},{"claim_id":"claim_4","claim":"This paper synthesizes evidence on Sleep health across 13 included source papers and 452 high-confidence extracted claims.","citation_support":[],"candidate_sources":[{"study":"Steam-assisted respiratory muscle training may improve sleep quality in mild-to-moderate obstructive sleep apnea: a pilot polysomnography study","year":2026,"doi":"10.1007/s44470-025-00036-w","url":"https://doi.org/10.1007/s44470-025-00036-w","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"primary","cited_as":"Al-Rammahi 2026","excerpt":"STUDY OBJECTIVES: Obstructive sleep apnea (OSA) impairs sleep and respiration, and sub-optimal adherence to its gold-standard CPAP therapy compels development of alternative approaches. This study investigates the effects of steam-assisted respiratory muscle training (RMT) on polysomnographic (PSG) outcomes in patients with OSA. METHODS: In a 12-week open-label prospective pilot study, 60 working participants with mild to moderate OSA underwent individualized inspiratory and expiratory resistance training with adjunctive steam inhalation. PSG was conducted pre- and post-intervention. Primary outcomes included changes in respiratory indices (AHI, ODI₃, CT₉₀) and sleep quality metrics (sleep efficiency, WASO). Statistical analyses included the Shapiro-Wilk normality test, Paired T, Welch, or Wilcoxon comparing visits, Wilson CIs reporting responders, Mann-Whitney and Fisher assessing associations, regression predicting change, with significance set at p < 0.05. RESULTS: Of 60 participants, 33 completed the study. Primary outcomes-respiratory indices and sleep continuity metrics-remained unchanged (all p > 0.05).","source_id":"source_1","support_kind":"candidate_source_row"},{"study":"Association of reduced REM sleep with mortality in adults with coronary artery disease and obstructive sleep apnea in the RICCADSA cohort","year":2026,"doi":"10.1007/s11325-026-03614-1","url":"https://doi.org/10.1007/s11325-026-03614-1","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"primary","cited_as":"Balcan 2026","excerpt":"PURPOSE: Reduced rapid-eye movement (REM) sleep has been linked to increased mortality in the general population. We investigated whether diminished REM sleep is associated with higher mortality in adults with coronary artery disease (CAD) and obstructive sleep apnea (OSA). METHODS: This secondary analysis of the RICCADSA trial included 356 revascularized CAD patients with OSA (apnea-hypopnea index [AHI] ≥ 15 events/h) and total sleep time (TST) ≥ 240 min on baseline polysomnography. Reduced REM sleep was defined as the lowest quartile of REM percentage. Cox proportional hazards models assessed the association between reduced REM sleep and mortality over a median 4.7-year follow-up. RESULTS: The lowest REM quartile corresponded to 8.7% of TST. Participants with reduced REM sleep (n = 86) were older (66.0 ± 8.1 vs. 63.0 ± 8.0 years; p = 0.035), had higher BMI (29.8 ± 4.6 vs. 28.7 ± 3.8 kg/m²; p = 0.010), shorter TST (369 ± 77 vs. 497 ± 69 min; p < 0.001), less slow-wave sleep (5.2 ± 7.0% vs. 8.1 ± 10.0%; p = 0.007), and higher AHI (54.4 ± 26.3 vs. 35.6 ± 20.1 events/h; p < 0.001) than those with REM ≥ 8.7% (n = 270). Mortality was 12.8% in the reduced REM group versus 4.","source_id":"source_2","support_kind":"candidate_source_row"},{"study":"Predicting sleep apnea worsening and cardiometabolic risk without treatment","year":2026,"doi":"10.1007/s11325-026-03617-y","url":"https://doi.org/10.1007/s11325-026-03617-y","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"primary","cited_as":"Lavie 2026","excerpt":"PURPOSE: The natural history of untreated obstructive sleep apnea (OSA) and its cardiometabolic consequences are not fully characterized. We aimed to identify predictors of apnea severity progression and incident cardiometabolic comorbidities in untreated patients, comparing continuous and categorical measures of apnea severity. METHODS: We retrospectively studied 538 adults (419 men, 119 women) who underwent two attended overnight polysomnographic evaluations separated by 3.8 ± 2.7 years and declined OSA treatment. Changes in apnea severity were assessed using continuous change in apnea-hypopnea index (ΔAHI) and categorical transitions across standard severity thresholds. Multivariable linear regression was used to identify predictors of ΔAHI, and multivariable logistic regression was used to identify predictors of incident hypertension, diabetes, and cardiovascular disease. RESULTS: Apnea severity and nocturnal hypoxemia worsened significantly over time.","source_id":"source_3","support_kind":"candidate_source_row"},{"study":"Prevalence of Obstructive Sleep Apnea and Adherence to CPAP for TAXI Drivers","year":2026,"doi":"10.3390/clockssleep8010004","url":"https://doi.org/10.3390/clockssleep8010004","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"primary","cited_as":"Chan 2026","excerpt":"We investigated the effects of Continuous Positive Airway Pressure (CPAP) on blood pressure (BP) and vigilance in taxi drivers with obstructive sleep apnea (OSA). This pilot study recruited taxi drivers aged ≥60 years to undergo polysomnography. Those diagnosed with OSA underwent 6 months of CPAP therapy. Baseline and follow-up assessments included 24 h ambulatory blood pressure monitoring (ABPM) and the psychomotor vigilance test (PVT). Among the 32 participants, 22 (68.8%) were diagnosed with OSA (median age 63.0 [62.0-65.0] years; 21 males). The average CPAP adherence was 3.1 ± 2.3 h per night, with 23.5% using CPAP for more than 4 h per night. There were no significant changes in 24 h mean systolic ABPM (125.9 [116.8-134.9] mmHg to 126.0 [118.3-133.7] mmHg; p = 0.93) or reaction times measured by PVT (2.0 [0.0-3.0] lapses to 2.0 [1.0-3.0] lapses; p = 0.82) after CPAP therapy. A high prevalence of OSA was observed among taxi drivers. CPAP adherence was suboptimal and did not result in significant improvements in BP or vigilance.","source_id":"source_4","support_kind":"candidate_source_row"},{"study":"Could behaviour change interventions be incorporated into cardiac rehabilitation programmes for insomnia and poor sleep quality management? A scoping review","year":2026,"doi":"10.1007/s11325-026-03707-x","url":"https://doi.org/10.1007/s11325-026-03707-x","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"review-level","cited_as":"White 2026","excerpt":"BACKGROUND: Cardiovascular disease (CVD) is caused by modifiable and non-modifiable risk factors and is consistently recognised as a leading cause of morbidity and mortality. Poor sleep caused by sleep disorders such as insomnia are linked to increased mortality in patients with CVD, yet it is routinely overlooked as a cause to treat. Furthermore, despite the impact of sleep disorders, management strategies are notably underrepresented in cardiac care guidelines and cardiac rehabilitation. AIM OF REVIEW: This scoping review aimed to assemble recent published literature to explore how behaviour change interventions could be utilised as a method to integrate sleep management strategies into state-of-the-art cardiac rehabilitation for patients with cardiovascular disease. METHODS: Four medical databases (Cochrane Library, MEDLINE, PsycINFO and CINAHL+) were searched using a PICO framework, publishing a total of 782 results. Of the 782 records identified, 23 were included to inform this review, including an additional article found from bibliography searching.","source_id":"source_5","support_kind":"candidate_source_row"}]},{"claim_id":"claim_5","claim":"The evidence profile contains no sources classified primarily as direct interventional hard-endpoint evidence, 13 adjacent clinical sources, and no sources classified primarily as mechanistic or model-system evidence, with 1 cross-study disagreement across the evidence base.","citation_support":[],"candidate_sources":[{"study":"Steam-assisted respiratory muscle training may improve sleep quality in mild-to-moderate obstructive sleep apnea: a pilot polysomnography study","year":2026,"doi":"10.1007/s44470-025-00036-w","url":"https://doi.org/10.1007/s44470-025-00036-w","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"primary","cited_as":"Al-Rammahi 2026","excerpt":"STUDY OBJECTIVES: Obstructive sleep apnea (OSA) impairs sleep and respiration, and sub-optimal adherence to its gold-standard CPAP therapy compels development of alternative approaches. This study investigates the effects of steam-assisted respiratory muscle training (RMT) on polysomnographic (PSG) outcomes in patients with OSA. METHODS: In a 12-week open-label prospective pilot study, 60 working participants with mild to moderate OSA underwent individualized inspiratory and expiratory resistance training with adjunctive steam inhalation. PSG was conducted pre- and post-intervention. Primary outcomes included changes in respiratory indices (AHI, ODI₃, CT₉₀) and sleep quality metrics (sleep efficiency, WASO). Statistical analyses included the Shapiro-Wilk normality test, Paired T, Welch, or Wilcoxon comparing visits, Wilson CIs reporting responders, Mann-Whitney and Fisher assessing associations, regression predicting change, with significance set at p < 0.05. RESULTS: Of 60 participants, 33 completed the study. Primary outcomes-respiratory indices and sleep continuity metrics-remained unchanged (all p > 0.05).","source_id":"source_1","support_kind":"candidate_source_row"},{"study":"Association of reduced REM sleep with mortality in adults with coronary artery disease and obstructive sleep apnea in the RICCADSA cohort","year":2026,"doi":"10.1007/s11325-026-03614-1","url":"https://doi.org/10.1007/s11325-026-03614-1","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"primary","cited_as":"Balcan 2026","excerpt":"PURPOSE: Reduced rapid-eye movement (REM) sleep has been linked to increased mortality in the general population. We investigated whether diminished REM sleep is associated with higher mortality in adults with coronary artery disease (CAD) and obstructive sleep apnea (OSA). METHODS: This secondary analysis of the RICCADSA trial included 356 revascularized CAD patients with OSA (apnea-hypopnea index [AHI] ≥ 15 events/h) and total sleep time (TST) ≥ 240 min on baseline polysomnography. Reduced REM sleep was defined as the lowest quartile of REM percentage. Cox proportional hazards models assessed the association between reduced REM sleep and mortality over a median 4.7-year follow-up. RESULTS: The lowest REM quartile corresponded to 8.7% of TST. Participants with reduced REM sleep (n = 86) were older (66.0 ± 8.1 vs. 63.0 ± 8.0 years; p = 0.035), had higher BMI (29.8 ± 4.6 vs. 28.7 ± 3.8 kg/m²; p = 0.010), shorter TST (369 ± 77 vs. 497 ± 69 min; p < 0.001), less slow-wave sleep (5.2 ± 7.0% vs. 8.1 ± 10.0%; p = 0.007), and higher AHI (54.4 ± 26.3 vs. 35.6 ± 20.1 events/h; p < 0.001) than those with REM ≥ 8.7% (n = 270). Mortality was 12.8% in the reduced REM group versus 4.","source_id":"source_2","support_kind":"candidate_source_row"},{"study":"Predicting sleep apnea worsening and cardiometabolic risk without treatment","year":2026,"doi":"10.1007/s11325-026-03617-y","url":"https://doi.org/10.1007/s11325-026-03617-y","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"primary","cited_as":"Lavie 2026","excerpt":"PURPOSE: The natural history of untreated obstructive sleep apnea (OSA) and its cardiometabolic consequences are not fully characterized. We aimed to identify predictors of apnea severity progression and incident cardiometabolic comorbidities in untreated patients, comparing continuous and categorical measures of apnea severity. METHODS: We retrospectively studied 538 adults (419 men, 119 women) who underwent two attended overnight polysomnographic evaluations separated by 3.8 ± 2.7 years and declined OSA treatment. Changes in apnea severity were assessed using continuous change in apnea-hypopnea index (ΔAHI) and categorical transitions across standard severity thresholds. Multivariable linear regression was used to identify predictors of ΔAHI, and multivariable logistic regression was used to identify predictors of incident hypertension, diabetes, and cardiovascular disease. RESULTS: Apnea severity and nocturnal hypoxemia worsened significantly over time.","source_id":"source_3","support_kind":"candidate_source_row"},{"study":"Prevalence of Obstructive Sleep Apnea and Adherence to CPAP for TAXI Drivers","year":2026,"doi":"10.3390/clockssleep8010004","url":"https://doi.org/10.3390/clockssleep8010004","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"primary","cited_as":"Chan 2026","excerpt":"We investigated the effects of Continuous Positive Airway Pressure (CPAP) on blood pressure (BP) and vigilance in taxi drivers with obstructive sleep apnea (OSA). This pilot study recruited taxi drivers aged ≥60 years to undergo polysomnography. Those diagnosed with OSA underwent 6 months of CPAP therapy. Baseline and follow-up assessments included 24 h ambulatory blood pressure monitoring (ABPM) and the psychomotor vigilance test (PVT). Among the 32 participants, 22 (68.8%) were diagnosed with OSA (median age 63.0 [62.0-65.0] years; 21 males). The average CPAP adherence was 3.1 ± 2.3 h per night, with 23.5% using CPAP for more than 4 h per night. There were no significant changes in 24 h mean systolic ABPM (125.9 [116.8-134.9] mmHg to 126.0 [118.3-133.7] mmHg; p = 0.93) or reaction times measured by PVT (2.0 [0.0-3.0] lapses to 2.0 [1.0-3.0] lapses; p = 0.82) after CPAP therapy. A high prevalence of OSA was observed among taxi drivers. CPAP adherence was suboptimal and did not result in significant improvements in BP or vigilance.","source_id":"source_4","support_kind":"candidate_source_row"},{"study":"Could behaviour change interventions be incorporated into cardiac rehabilitation programmes for insomnia and poor sleep quality management? A scoping review","year":2026,"doi":"10.1007/s11325-026-03707-x","url":"https://doi.org/10.1007/s11325-026-03707-x","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"review-level","cited_as":"White 2026","excerpt":"BACKGROUND: Cardiovascular disease (CVD) is caused by modifiable and non-modifiable risk factors and is consistently recognised as a leading cause of morbidity and mortality. Poor sleep caused by sleep disorders such as insomnia are linked to increased mortality in patients with CVD, yet it is routinely overlooked as a cause to treat. Furthermore, despite the impact of sleep disorders, management strategies are notably underrepresented in cardiac care guidelines and cardiac rehabilitation. AIM OF REVIEW: This scoping review aimed to assemble recent published literature to explore how behaviour change interventions could be utilised as a method to integrate sleep management strategies into state-of-the-art cardiac rehabilitation for patients with cardiovascular disease. METHODS: Four medical databases (Cochrane Library, MEDLINE, PsycINFO and CINAHL+) were searched using a PICO framework, publishing a total of 782 results. Of the 782 records identified, 23 were included to inform this review, including an additional article found from bibliography searching.","source_id":"source_5","support_kind":"candidate_source_row"}]},{"claim_id":"claim_6","claim":"No single positive outcome class dominates the retained corpus; null signals cluster in the contextual adjacent evidence, muscle function and deficiency prevalence outcome classes, and negative signals cluster in the cardiometabolic outcome class. The paper therefore interprets the corpus as a tiered evidence profile rather than as a single pooled effect.","citation_support":[],"candidate_sources":[{"study":"Steam-assisted respiratory muscle training may improve sleep quality in mild-to-moderate obstructive sleep apnea: a pilot polysomnography study","year":2026,"doi":"10.1007/s44470-025-00036-w","url":"https://doi.org/10.1007/s44470-025-00036-w","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"primary","cited_as":"Al-Rammahi 2026","excerpt":"STUDY OBJECTIVES: Obstructive sleep apnea (OSA) impairs sleep and respiration, and sub-optimal adherence to its gold-standard CPAP therapy compels development of alternative approaches. This study investigates the effects of steam-assisted respiratory muscle training (RMT) on polysomnographic (PSG) outcomes in patients with OSA. METHODS: In a 12-week open-label prospective pilot study, 60 working participants with mild to moderate OSA underwent individualized inspiratory and expiratory resistance training with adjunctive steam inhalation. PSG was conducted pre- and post-intervention. Primary outcomes included changes in respiratory indices (AHI, ODI₃, CT₉₀) and sleep quality metrics (sleep efficiency, WASO). Statistical analyses included the Shapiro-Wilk normality test, Paired T, Welch, or Wilcoxon comparing visits, Wilson CIs reporting responders, Mann-Whitney and Fisher assessing associations, regression predicting change, with significance set at p < 0.05. RESULTS: Of 60 participants, 33 completed the study. Primary outcomes-respiratory indices and sleep continuity metrics-remained unchanged (all p > 0.05).","source_id":"source_1","support_kind":"candidate_source_row"},{"study":"Association of reduced REM sleep with mortality in adults with coronary artery disease and obstructive sleep apnea in the RICCADSA cohort","year":2026,"doi":"10.1007/s11325-026-03614-1","url":"https://doi.org/10.1007/s11325-026-03614-1","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"primary","cited_as":"Balcan 2026","excerpt":"PURPOSE: Reduced rapid-eye movement (REM) sleep has been linked to increased mortality in the general population. We investigated whether diminished REM sleep is associated with higher mortality in adults with coronary artery disease (CAD) and obstructive sleep apnea (OSA). METHODS: This secondary analysis of the RICCADSA trial included 356 revascularized CAD patients with OSA (apnea-hypopnea index [AHI] ≥ 15 events/h) and total sleep time (TST) ≥ 240 min on baseline polysomnography. Reduced REM sleep was defined as the lowest quartile of REM percentage. Cox proportional hazards models assessed the association between reduced REM sleep and mortality over a median 4.7-year follow-up. RESULTS: The lowest REM quartile corresponded to 8.7% of TST. Participants with reduced REM sleep (n = 86) were older (66.0 ± 8.1 vs. 63.0 ± 8.0 years; p = 0.035), had higher BMI (29.8 ± 4.6 vs. 28.7 ± 3.8 kg/m²; p = 0.010), shorter TST (369 ± 77 vs. 497 ± 69 min; p < 0.001), less slow-wave sleep (5.2 ± 7.0% vs. 8.1 ± 10.0%; p = 0.007), and higher AHI (54.4 ± 26.3 vs. 35.6 ± 20.1 events/h; p < 0.001) than those with REM ≥ 8.7% (n = 270). Mortality was 12.8% in the reduced REM group versus 4.","source_id":"source_2","support_kind":"candidate_source_row"},{"study":"Predicting sleep apnea worsening and cardiometabolic risk without treatment","year":2026,"doi":"10.1007/s11325-026-03617-y","url":"https://doi.org/10.1007/s11325-026-03617-y","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"primary","cited_as":"Lavie 2026","excerpt":"PURPOSE: The natural history of untreated obstructive sleep apnea (OSA) and its cardiometabolic consequences are not fully characterized. We aimed to identify predictors of apnea severity progression and incident cardiometabolic comorbidities in untreated patients, comparing continuous and categorical measures of apnea severity. METHODS: We retrospectively studied 538 adults (419 men, 119 women) who underwent two attended overnight polysomnographic evaluations separated by 3.8 ± 2.7 years and declined OSA treatment. Changes in apnea severity were assessed using continuous change in apnea-hypopnea index (ΔAHI) and categorical transitions across standard severity thresholds. Multivariable linear regression was used to identify predictors of ΔAHI, and multivariable logistic regression was used to identify predictors of incident hypertension, diabetes, and cardiovascular disease. RESULTS: Apnea severity and nocturnal hypoxemia worsened significantly over time.","source_id":"source_3","support_kind":"candidate_source_row"},{"study":"Prevalence of Obstructive Sleep Apnea and Adherence to CPAP for TAXI Drivers","year":2026,"doi":"10.3390/clockssleep8010004","url":"https://doi.org/10.3390/clockssleep8010004","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"primary","cited_as":"Chan 2026","excerpt":"We investigated the effects of Continuous Positive Airway Pressure (CPAP) on blood pressure (BP) and vigilance in taxi drivers with obstructive sleep apnea (OSA). This pilot study recruited taxi drivers aged ≥60 years to undergo polysomnography. Those diagnosed with OSA underwent 6 months of CPAP therapy. Baseline and follow-up assessments included 24 h ambulatory blood pressure monitoring (ABPM) and the psychomotor vigilance test (PVT). Among the 32 participants, 22 (68.8%) were diagnosed with OSA (median age 63.0 [62.0-65.0] years; 21 males). The average CPAP adherence was 3.1 ± 2.3 h per night, with 23.5% using CPAP for more than 4 h per night. There were no significant changes in 24 h mean systolic ABPM (125.9 [116.8-134.9] mmHg to 126.0 [118.3-133.7] mmHg; p = 0.93) or reaction times measured by PVT (2.0 [0.0-3.0] lapses to 2.0 [1.0-3.0] lapses; p = 0.82) after CPAP therapy. A high prevalence of OSA was observed among taxi drivers. CPAP adherence was suboptimal and did not result in significant improvements in BP or vigilance.","source_id":"source_4","support_kind":"candidate_source_row"},{"study":"Could behaviour change interventions be incorporated into cardiac rehabilitation programmes for insomnia and poor sleep quality management? A scoping review","year":2026,"doi":"10.1007/s11325-026-03707-x","url":"https://doi.org/10.1007/s11325-026-03707-x","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"review-level","cited_as":"White 2026","excerpt":"BACKGROUND: Cardiovascular disease (CVD) is caused by modifiable and non-modifiable risk factors and is consistently recognised as a leading cause of morbidity and mortality. Poor sleep caused by sleep disorders such as insomnia are linked to increased mortality in patients with CVD, yet it is routinely overlooked as a cause to treat. Furthermore, despite the impact of sleep disorders, management strategies are notably underrepresented in cardiac care guidelines and cardiac rehabilitation. AIM OF REVIEW: This scoping review aimed to assemble recent published literature to explore how behaviour change interventions could be utilised as a method to integrate sleep management strategies into state-of-the-art cardiac rehabilitation for patients with cardiovascular disease. METHODS: Four medical databases (Cochrane Library, MEDLINE, PsycINFO and CINAHL+) were searched using a PICO framework, publishing a total of 782 results. Of the 782 records identified, 23 were included to inform this review, including an additional article found from bibliography searching.","source_id":"source_5","support_kind":"candidate_source_row"}]},{"claim_id":"claim_7","claim":"The conclusion is that Sleep health should be treated as a bounded geroscience hypothesis: the retained clinical and adjacent evidence profile defines the scope for targeted testing, while mixed and null findings limit any unqualified anti-aging claim.","citation_support":[],"candidate_sources":[{"study":"Steam-assisted respiratory muscle training may improve sleep quality in mild-to-moderate obstructive sleep apnea: a pilot polysomnography study","year":2026,"doi":"10.1007/s44470-025-00036-w","url":"https://doi.org/10.1007/s44470-025-00036-w","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"primary","cited_as":"Al-Rammahi 2026","excerpt":"STUDY OBJECTIVES: Obstructive sleep apnea (OSA) impairs sleep and respiration, and sub-optimal adherence to its gold-standard CPAP therapy compels development of alternative approaches. This study investigates the effects of steam-assisted respiratory muscle training (RMT) on polysomnographic (PSG) outcomes in patients with OSA. METHODS: In a 12-week open-label prospective pilot study, 60 working participants with mild to moderate OSA underwent individualized inspiratory and expiratory resistance training with adjunctive steam inhalation. PSG was conducted pre- and post-intervention. Primary outcomes included changes in respiratory indices (AHI, ODI₃, CT₉₀) and sleep quality metrics (sleep efficiency, WASO). Statistical analyses included the Shapiro-Wilk normality test, Paired T, Welch, or Wilcoxon comparing visits, Wilson CIs reporting responders, Mann-Whitney and Fisher assessing associations, regression predicting change, with significance set at p < 0.05. RESULTS: Of 60 participants, 33 completed the study. Primary outcomes-respiratory indices and sleep continuity metrics-remained unchanged (all p > 0.05).","source_id":"source_1","support_kind":"candidate_source_row"},{"study":"Association of reduced REM sleep with mortality in adults with coronary artery disease and obstructive sleep apnea in the RICCADSA cohort","year":2026,"doi":"10.1007/s11325-026-03614-1","url":"https://doi.org/10.1007/s11325-026-03614-1","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"primary","cited_as":"Balcan 2026","excerpt":"PURPOSE: Reduced rapid-eye movement (REM) sleep has been linked to increased mortality in the general population. We investigated whether diminished REM sleep is associated with higher mortality in adults with coronary artery disease (CAD) and obstructive sleep apnea (OSA). METHODS: This secondary analysis of the RICCADSA trial included 356 revascularized CAD patients with OSA (apnea-hypopnea index [AHI] ≥ 15 events/h) and total sleep time (TST) ≥ 240 min on baseline polysomnography. Reduced REM sleep was defined as the lowest quartile of REM percentage. Cox proportional hazards models assessed the association between reduced REM sleep and mortality over a median 4.7-year follow-up. RESULTS: The lowest REM quartile corresponded to 8.7% of TST. Participants with reduced REM sleep (n = 86) were older (66.0 ± 8.1 vs. 63.0 ± 8.0 years; p = 0.035), had higher BMI (29.8 ± 4.6 vs. 28.7 ± 3.8 kg/m²; p = 0.010), shorter TST (369 ± 77 vs. 497 ± 69 min; p < 0.001), less slow-wave sleep (5.2 ± 7.0% vs. 8.1 ± 10.0%; p = 0.007), and higher AHI (54.4 ± 26.3 vs. 35.6 ± 20.1 events/h; p < 0.001) than those with REM ≥ 8.7% (n = 270). Mortality was 12.8% in the reduced REM group versus 4.","source_id":"source_2","support_kind":"candidate_source_row"},{"study":"Predicting sleep apnea worsening and cardiometabolic risk without treatment","year":2026,"doi":"10.1007/s11325-026-03617-y","url":"https://doi.org/10.1007/s11325-026-03617-y","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"primary","cited_as":"Lavie 2026","excerpt":"PURPOSE: The natural history of untreated obstructive sleep apnea (OSA) and its cardiometabolic consequences are not fully characterized. We aimed to identify predictors of apnea severity progression and incident cardiometabolic comorbidities in untreated patients, comparing continuous and categorical measures of apnea severity. METHODS: We retrospectively studied 538 adults (419 men, 119 women) who underwent two attended overnight polysomnographic evaluations separated by 3.8 ± 2.7 years and declined OSA treatment. Changes in apnea severity were assessed using continuous change in apnea-hypopnea index (ΔAHI) and categorical transitions across standard severity thresholds. Multivariable linear regression was used to identify predictors of ΔAHI, and multivariable logistic regression was used to identify predictors of incident hypertension, diabetes, and cardiovascular disease. RESULTS: Apnea severity and nocturnal hypoxemia worsened significantly over time.","source_id":"source_3","support_kind":"candidate_source_row"},{"study":"Prevalence of Obstructive Sleep Apnea and Adherence to CPAP for TAXI Drivers","year":2026,"doi":"10.3390/clockssleep8010004","url":"https://doi.org/10.3390/clockssleep8010004","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"primary","cited_as":"Chan 2026","excerpt":"We investigated the effects of Continuous Positive Airway Pressure (CPAP) on blood pressure (BP) and vigilance in taxi drivers with obstructive sleep apnea (OSA). This pilot study recruited taxi drivers aged ≥60 years to undergo polysomnography. Those diagnosed with OSA underwent 6 months of CPAP therapy. Baseline and follow-up assessments included 24 h ambulatory blood pressure monitoring (ABPM) and the psychomotor vigilance test (PVT). Among the 32 participants, 22 (68.8%) were diagnosed with OSA (median age 63.0 [62.0-65.0] years; 21 males). The average CPAP adherence was 3.1 ± 2.3 h per night, with 23.5% using CPAP for more than 4 h per night. There were no significant changes in 24 h mean systolic ABPM (125.9 [116.8-134.9] mmHg to 126.0 [118.3-133.7] mmHg; p = 0.93) or reaction times measured by PVT (2.0 [0.0-3.0] lapses to 2.0 [1.0-3.0] lapses; p = 0.82) after CPAP therapy. A high prevalence of OSA was observed among taxi drivers. CPAP adherence was suboptimal and did not result in significant improvements in BP or vigilance.","source_id":"source_4","support_kind":"candidate_source_row"},{"study":"Could behaviour change interventions be incorporated into cardiac rehabilitation programmes for insomnia and poor sleep quality management? A scoping review","year":2026,"doi":"10.1007/s11325-026-03707-x","url":"https://doi.org/10.1007/s11325-026-03707-x","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"review-level","cited_as":"White 2026","excerpt":"BACKGROUND: Cardiovascular disease (CVD) is caused by modifiable and non-modifiable risk factors and is consistently recognised as a leading cause of morbidity and mortality. Poor sleep caused by sleep disorders such as insomnia are linked to increased mortality in patients with CVD, yet it is routinely overlooked as a cause to treat. Furthermore, despite the impact of sleep disorders, management strategies are notably underrepresented in cardiac care guidelines and cardiac rehabilitation. AIM OF REVIEW: This scoping review aimed to assemble recent published literature to explore how behaviour change interventions could be utilised as a method to integrate sleep management strategies into state-of-the-art cardiac rehabilitation for patients with cardiovascular disease. METHODS: Four medical databases (Cochrane Library, MEDLINE, PsycINFO and CINAHL+) were searched using a PICO framework, publishing a total of 782 results. Of the 782 records identified, 23 were included to inform this review, including an additional article found from bibliography searching.","source_id":"source_5","support_kind":"candidate_source_row"}]},{"claim_id":"claim_8","claim":"This manuscript is reported as a Evidence brief. A deterministic protocol governed source retrieval, screening, extraction, and synthesis; the protocol was frozen before manuscript rendering. The full audit trail is in the supplementary `methods_pack.json` and the timestamped submission directory `synthesis-sleep_health-v06-DAILY-2026-06-25T13-45-37Z`.","citation_support":[],"candidate_sources":[{"study":"Steam-assisted respiratory muscle training may improve sleep quality in mild-to-moderate obstructive sleep apnea: a pilot polysomnography study","year":2026,"doi":"10.1007/s44470-025-00036-w","url":"https://doi.org/10.1007/s44470-025-00036-w","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"primary","cited_as":"Al-Rammahi 2026","excerpt":"STUDY OBJECTIVES: Obstructive sleep apnea (OSA) impairs sleep and respiration, and sub-optimal adherence to its gold-standard CPAP therapy compels development of alternative approaches. This study investigates the effects of steam-assisted respiratory muscle training (RMT) on polysomnographic (PSG) outcomes in patients with OSA. METHODS: In a 12-week open-label prospective pilot study, 60 working participants with mild to moderate OSA underwent individualized inspiratory and expiratory resistance training with adjunctive steam inhalation. PSG was conducted pre- and post-intervention. Primary outcomes included changes in respiratory indices (AHI, ODI₃, CT₉₀) and sleep quality metrics (sleep efficiency, WASO). Statistical analyses included the Shapiro-Wilk normality test, Paired T, Welch, or Wilcoxon comparing visits, Wilson CIs reporting responders, Mann-Whitney and Fisher assessing associations, regression predicting change, with significance set at p < 0.05. RESULTS: Of 60 participants, 33 completed the study. Primary outcomes-respiratory indices and sleep continuity metrics-remained unchanged (all p > 0.05).","source_id":"source_1","support_kind":"candidate_source_row"},{"study":"Association of reduced REM sleep with mortality in adults with coronary artery disease and obstructive sleep apnea in the RICCADSA cohort","year":2026,"doi":"10.1007/s11325-026-03614-1","url":"https://doi.org/10.1007/s11325-026-03614-1","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"primary","cited_as":"Balcan 2026","excerpt":"PURPOSE: Reduced rapid-eye movement (REM) sleep has been linked to increased mortality in the general population. We investigated whether diminished REM sleep is associated with higher mortality in adults with coronary artery disease (CAD) and obstructive sleep apnea (OSA). METHODS: This secondary analysis of the RICCADSA trial included 356 revascularized CAD patients with OSA (apnea-hypopnea index [AHI] ≥ 15 events/h) and total sleep time (TST) ≥ 240 min on baseline polysomnography. Reduced REM sleep was defined as the lowest quartile of REM percentage. Cox proportional hazards models assessed the association between reduced REM sleep and mortality over a median 4.7-year follow-up. RESULTS: The lowest REM quartile corresponded to 8.7% of TST. Participants with reduced REM sleep (n = 86) were older (66.0 ± 8.1 vs. 63.0 ± 8.0 years; p = 0.035), had higher BMI (29.8 ± 4.6 vs. 28.7 ± 3.8 kg/m²; p = 0.010), shorter TST (369 ± 77 vs. 497 ± 69 min; p < 0.001), less slow-wave sleep (5.2 ± 7.0% vs. 8.1 ± 10.0%; p = 0.007), and higher AHI (54.4 ± 26.3 vs. 35.6 ± 20.1 events/h; p < 0.001) than those with REM ≥ 8.7% (n = 270). Mortality was 12.8% in the reduced REM group versus 4.","source_id":"source_2","support_kind":"candidate_source_row"},{"study":"Predicting sleep apnea worsening and cardiometabolic risk without treatment","year":2026,"doi":"10.1007/s11325-026-03617-y","url":"https://doi.org/10.1007/s11325-026-03617-y","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"primary","cited_as":"Lavie 2026","excerpt":"PURPOSE: The natural history of untreated obstructive sleep apnea (OSA) and its cardiometabolic consequences are not fully characterized. We aimed to identify predictors of apnea severity progression and incident cardiometabolic comorbidities in untreated patients, comparing continuous and categorical measures of apnea severity. METHODS: We retrospectively studied 538 adults (419 men, 119 women) who underwent two attended overnight polysomnographic evaluations separated by 3.8 ± 2.7 years and declined OSA treatment. Changes in apnea severity were assessed using continuous change in apnea-hypopnea index (ΔAHI) and categorical transitions across standard severity thresholds. Multivariable linear regression was used to identify predictors of ΔAHI, and multivariable logistic regression was used to identify predictors of incident hypertension, diabetes, and cardiovascular disease. RESULTS: Apnea severity and nocturnal hypoxemia worsened significantly over time.","source_id":"source_3","support_kind":"candidate_source_row"},{"study":"Prevalence of Obstructive Sleep Apnea and Adherence to CPAP for TAXI Drivers","year":2026,"doi":"10.3390/clockssleep8010004","url":"https://doi.org/10.3390/clockssleep8010004","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"primary","cited_as":"Chan 2026","excerpt":"We investigated the effects of Continuous Positive Airway Pressure (CPAP) on blood pressure (BP) and vigilance in taxi drivers with obstructive sleep apnea (OSA). This pilot study recruited taxi drivers aged ≥60 years to undergo polysomnography. Those diagnosed with OSA underwent 6 months of CPAP therapy. Baseline and follow-up assessments included 24 h ambulatory blood pressure monitoring (ABPM) and the psychomotor vigilance test (PVT). Among the 32 participants, 22 (68.8%) were diagnosed with OSA (median age 63.0 [62.0-65.0] years; 21 males). The average CPAP adherence was 3.1 ± 2.3 h per night, with 23.5% using CPAP for more than 4 h per night. There were no significant changes in 24 h mean systolic ABPM (125.9 [116.8-134.9] mmHg to 126.0 [118.3-133.7] mmHg; p = 0.93) or reaction times measured by PVT (2.0 [0.0-3.0] lapses to 2.0 [1.0-3.0] lapses; p = 0.82) after CPAP therapy. A high prevalence of OSA was observed among taxi drivers. CPAP adherence was suboptimal and did not result in significant improvements in BP or vigilance.","source_id":"source_4","support_kind":"candidate_source_row"},{"study":"Could behaviour change interventions be incorporated into cardiac rehabilitation programmes for insomnia and poor sleep quality management? A scoping review","year":2026,"doi":"10.1007/s11325-026-03707-x","url":"https://doi.org/10.1007/s11325-026-03707-x","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"review-level","cited_as":"White 2026","excerpt":"BACKGROUND: Cardiovascular disease (CVD) is caused by modifiable and non-modifiable risk factors and is consistently recognised as a leading cause of morbidity and mortality. Poor sleep caused by sleep disorders such as insomnia are linked to increased mortality in patients with CVD, yet it is routinely overlooked as a cause to treat. Furthermore, despite the impact of sleep disorders, management strategies are notably underrepresented in cardiac care guidelines and cardiac rehabilitation. AIM OF REVIEW: This scoping review aimed to assemble recent published literature to explore how behaviour change interventions could be utilised as a method to integrate sleep management strategies into state-of-the-art cardiac rehabilitation for patients with cardiovascular disease. METHODS: Four medical databases (Cochrane Library, MEDLINE, PsycINFO and CINAHL+) were searched using a PICO framework, publishing a total of 782 results. Of the 782 records identified, 23 were included to inform this review, including an additional article found from bibliography searching.","source_id":"source_5","support_kind":"candidate_source_row"}]},{"claim_id":"claim_9","claim":"The following fields were extracted from each included source: study design, population / cohort, intervention or exposure, comparator, outcome class, effect direction, effect size, confidence interval or credible interval, p-value, sample size, follow-up duration, risk-of-bias rating. Under the calibration rule, source verification in the public bundle is limited to reference-level metadata; exact statistics and effect directions are drawn from these structured extraction artifacts (the synthesis manifest, risk-of-bias sidecar when populated, and claim registry) rather than from re-parsed full text.","citation_support":[],"candidate_sources":[{"study":"Steam-assisted respiratory muscle training may improve sleep quality in mild-to-moderate obstructive sleep apnea: a pilot polysomnography study","year":2026,"doi":"10.1007/s44470-025-00036-w","url":"https://doi.org/10.1007/s44470-025-00036-w","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"primary","cited_as":"Al-Rammahi 2026","excerpt":"STUDY OBJECTIVES: Obstructive sleep apnea (OSA) impairs sleep and respiration, and sub-optimal adherence to its gold-standard CPAP therapy compels development of alternative approaches. This study investigates the effects of steam-assisted respiratory muscle training (RMT) on polysomnographic (PSG) outcomes in patients with OSA. METHODS: In a 12-week open-label prospective pilot study, 60 working participants with mild to moderate OSA underwent individualized inspiratory and expiratory resistance training with adjunctive steam inhalation. PSG was conducted pre- and post-intervention. Primary outcomes included changes in respiratory indices (AHI, ODI₃, CT₉₀) and sleep quality metrics (sleep efficiency, WASO). Statistical analyses included the Shapiro-Wilk normality test, Paired T, Welch, or Wilcoxon comparing visits, Wilson CIs reporting responders, Mann-Whitney and Fisher assessing associations, regression predicting change, with significance set at p < 0.05. RESULTS: Of 60 participants, 33 completed the study. Primary outcomes-respiratory indices and sleep continuity metrics-remained unchanged (all p > 0.05).","source_id":"source_1","support_kind":"candidate_source_row"},{"study":"Association of reduced REM sleep with mortality in adults with coronary artery disease and obstructive sleep apnea in the RICCADSA cohort","year":2026,"doi":"10.1007/s11325-026-03614-1","url":"https://doi.org/10.1007/s11325-026-03614-1","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"primary","cited_as":"Balcan 2026","excerpt":"PURPOSE: Reduced rapid-eye movement (REM) sleep has been linked to increased mortality in the general population. We investigated whether diminished REM sleep is associated with higher mortality in adults with coronary artery disease (CAD) and obstructive sleep apnea (OSA). METHODS: This secondary analysis of the RICCADSA trial included 356 revascularized CAD patients with OSA (apnea-hypopnea index [AHI] ≥ 15 events/h) and total sleep time (TST) ≥ 240 min on baseline polysomnography. Reduced REM sleep was defined as the lowest quartile of REM percentage. Cox proportional hazards models assessed the association between reduced REM sleep and mortality over a median 4.7-year follow-up. RESULTS: The lowest REM quartile corresponded to 8.7% of TST. Participants with reduced REM sleep (n = 86) were older (66.0 ± 8.1 vs. 63.0 ± 8.0 years; p = 0.035), had higher BMI (29.8 ± 4.6 vs. 28.7 ± 3.8 kg/m²; p = 0.010), shorter TST (369 ± 77 vs. 497 ± 69 min; p < 0.001), less slow-wave sleep (5.2 ± 7.0% vs. 8.1 ± 10.0%; p = 0.007), and higher AHI (54.4 ± 26.3 vs. 35.6 ± 20.1 events/h; p < 0.001) than those with REM ≥ 8.7% (n = 270). Mortality was 12.8% in the reduced REM group versus 4.","source_id":"source_2","support_kind":"candidate_source_row"},{"study":"Predicting sleep apnea worsening and cardiometabolic risk without treatment","year":2026,"doi":"10.1007/s11325-026-03617-y","url":"https://doi.org/10.1007/s11325-026-03617-y","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"primary","cited_as":"Lavie 2026","excerpt":"PURPOSE: The natural history of untreated obstructive sleep apnea (OSA) and its cardiometabolic consequences are not fully characterized. We aimed to identify predictors of apnea severity progression and incident cardiometabolic comorbidities in untreated patients, comparing continuous and categorical measures of apnea severity. METHODS: We retrospectively studied 538 adults (419 men, 119 women) who underwent two attended overnight polysomnographic evaluations separated by 3.8 ± 2.7 years and declined OSA treatment. Changes in apnea severity were assessed using continuous change in apnea-hypopnea index (ΔAHI) and categorical transitions across standard severity thresholds. Multivariable linear regression was used to identify predictors of ΔAHI, and multivariable logistic regression was used to identify predictors of incident hypertension, diabetes, and cardiovascular disease. RESULTS: Apnea severity and nocturnal hypoxemia worsened significantly over time.","source_id":"source_3","support_kind":"candidate_source_row"},{"study":"Prevalence of Obstructive Sleep Apnea and Adherence to CPAP for TAXI Drivers","year":2026,"doi":"10.3390/clockssleep8010004","url":"https://doi.org/10.3390/clockssleep8010004","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"primary","cited_as":"Chan 2026","excerpt":"We investigated the effects of Continuous Positive Airway Pressure (CPAP) on blood pressure (BP) and vigilance in taxi drivers with obstructive sleep apnea (OSA). This pilot study recruited taxi drivers aged ≥60 years to undergo polysomnography. Those diagnosed with OSA underwent 6 months of CPAP therapy. Baseline and follow-up assessments included 24 h ambulatory blood pressure monitoring (ABPM) and the psychomotor vigilance test (PVT). Among the 32 participants, 22 (68.8%) were diagnosed with OSA (median age 63.0 [62.0-65.0] years; 21 males). The average CPAP adherence was 3.1 ± 2.3 h per night, with 23.5% using CPAP for more than 4 h per night. There were no significant changes in 24 h mean systolic ABPM (125.9 [116.8-134.9] mmHg to 126.0 [118.3-133.7] mmHg; p = 0.93) or reaction times measured by PVT (2.0 [0.0-3.0] lapses to 2.0 [1.0-3.0] lapses; p = 0.82) after CPAP therapy. A high prevalence of OSA was observed among taxi drivers. CPAP adherence was suboptimal and did not result in significant improvements in BP or vigilance.","source_id":"source_4","support_kind":"candidate_source_row"},{"study":"Could behaviour change interventions be incorporated into cardiac rehabilitation programmes for insomnia and poor sleep quality management? A scoping review","year":2026,"doi":"10.1007/s11325-026-03707-x","url":"https://doi.org/10.1007/s11325-026-03707-x","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"review-level","cited_as":"White 2026","excerpt":"BACKGROUND: Cardiovascular disease (CVD) is caused by modifiable and non-modifiable risk factors and is consistently recognised as a leading cause of morbidity and mortality. Poor sleep caused by sleep disorders such as insomnia are linked to increased mortality in patients with CVD, yet it is routinely overlooked as a cause to treat. Furthermore, despite the impact of sleep disorders, management strategies are notably underrepresented in cardiac care guidelines and cardiac rehabilitation. AIM OF REVIEW: This scoping review aimed to assemble recent published literature to explore how behaviour change interventions could be utilised as a method to integrate sleep management strategies into state-of-the-art cardiac rehabilitation for patients with cardiovascular disease. METHODS: Four medical databases (Cochrane Library, MEDLINE, PsycINFO and CINAHL+) were searched using a PICO framework, publishing a total of 782 results. Of the 782 records identified, 23 were included to inform this review, including an additional article found from bibliography searching.","source_id":"source_5","support_kind":"candidate_source_row"}]},{"claim_id":"claim_10","claim":"Risk-of-bias framework assignment follows study design (RoB-2 for RCTs, ROBINS-I for non-randomised studies, AMSTAR-2 for systematic reviews / meta-analyses). Public appraisal claims are limited to populated `risk_of_bias.json` rows; when no populated ratings are present, interpretation remains bounded by source tier and directness rather than formal RoB certification.","citation_support":[],"candidate_sources":[{"study":"Steam-assisted respiratory muscle training may improve sleep quality in mild-to-moderate obstructive sleep apnea: a pilot polysomnography study","year":2026,"doi":"10.1007/s44470-025-00036-w","url":"https://doi.org/10.1007/s44470-025-00036-w","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"primary","cited_as":"Al-Rammahi 2026","excerpt":"STUDY OBJECTIVES: Obstructive sleep apnea (OSA) impairs sleep and respiration, and sub-optimal adherence to its gold-standard CPAP therapy compels development of alternative approaches. This study investigates the effects of steam-assisted respiratory muscle training (RMT) on polysomnographic (PSG) outcomes in patients with OSA. METHODS: In a 12-week open-label prospective pilot study, 60 working participants with mild to moderate OSA underwent individualized inspiratory and expiratory resistance training with adjunctive steam inhalation. PSG was conducted pre- and post-intervention. Primary outcomes included changes in respiratory indices (AHI, ODI₃, CT₉₀) and sleep quality metrics (sleep efficiency, WASO). Statistical analyses included the Shapiro-Wilk normality test, Paired T, Welch, or Wilcoxon comparing visits, Wilson CIs reporting responders, Mann-Whitney and Fisher assessing associations, regression predicting change, with significance set at p < 0.05. RESULTS: Of 60 participants, 33 completed the study. Primary outcomes-respiratory indices and sleep continuity metrics-remained unchanged (all p > 0.05).","source_id":"source_1","support_kind":"candidate_source_row"},{"study":"Association of reduced REM sleep with mortality in adults with coronary artery disease and obstructive sleep apnea in the RICCADSA cohort","year":2026,"doi":"10.1007/s11325-026-03614-1","url":"https://doi.org/10.1007/s11325-026-03614-1","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"primary","cited_as":"Balcan 2026","excerpt":"PURPOSE: Reduced rapid-eye movement (REM) sleep has been linked to increased mortality in the general population. We investigated whether diminished REM sleep is associated with higher mortality in adults with coronary artery disease (CAD) and obstructive sleep apnea (OSA). METHODS: This secondary analysis of the RICCADSA trial included 356 revascularized CAD patients with OSA (apnea-hypopnea index [AHI] ≥ 15 events/h) and total sleep time (TST) ≥ 240 min on baseline polysomnography. Reduced REM sleep was defined as the lowest quartile of REM percentage. Cox proportional hazards models assessed the association between reduced REM sleep and mortality over a median 4.7-year follow-up. RESULTS: The lowest REM quartile corresponded to 8.7% of TST. Participants with reduced REM sleep (n = 86) were older (66.0 ± 8.1 vs. 63.0 ± 8.0 years; p = 0.035), had higher BMI (29.8 ± 4.6 vs. 28.7 ± 3.8 kg/m²; p = 0.010), shorter TST (369 ± 77 vs. 497 ± 69 min; p < 0.001), less slow-wave sleep (5.2 ± 7.0% vs. 8.1 ± 10.0%; p = 0.007), and higher AHI (54.4 ± 26.3 vs. 35.6 ± 20.1 events/h; p < 0.001) than those with REM ≥ 8.7% (n = 270). Mortality was 12.8% in the reduced REM group versus 4.","source_id":"source_2","support_kind":"candidate_source_row"},{"study":"Predicting sleep apnea worsening and cardiometabolic risk without treatment","year":2026,"doi":"10.1007/s11325-026-03617-y","url":"https://doi.org/10.1007/s11325-026-03617-y","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"primary","cited_as":"Lavie 2026","excerpt":"PURPOSE: The natural history of untreated obstructive sleep apnea (OSA) and its cardiometabolic consequences are not fully characterized. We aimed to identify predictors of apnea severity progression and incident cardiometabolic comorbidities in untreated patients, comparing continuous and categorical measures of apnea severity. METHODS: We retrospectively studied 538 adults (419 men, 119 women) who underwent two attended overnight polysomnographic evaluations separated by 3.8 ± 2.7 years and declined OSA treatment. Changes in apnea severity were assessed using continuous change in apnea-hypopnea index (ΔAHI) and categorical transitions across standard severity thresholds. Multivariable linear regression was used to identify predictors of ΔAHI, and multivariable logistic regression was used to identify predictors of incident hypertension, diabetes, and cardiovascular disease. RESULTS: Apnea severity and nocturnal hypoxemia worsened significantly over time.","source_id":"source_3","support_kind":"candidate_source_row"},{"study":"Prevalence of Obstructive Sleep Apnea and Adherence to CPAP for TAXI Drivers","year":2026,"doi":"10.3390/clockssleep8010004","url":"https://doi.org/10.3390/clockssleep8010004","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"primary","cited_as":"Chan 2026","excerpt":"We investigated the effects of Continuous Positive Airway Pressure (CPAP) on blood pressure (BP) and vigilance in taxi drivers with obstructive sleep apnea (OSA). This pilot study recruited taxi drivers aged ≥60 years to undergo polysomnography. Those diagnosed with OSA underwent 6 months of CPAP therapy. Baseline and follow-up assessments included 24 h ambulatory blood pressure monitoring (ABPM) and the psychomotor vigilance test (PVT). Among the 32 participants, 22 (68.8%) were diagnosed with OSA (median age 63.0 [62.0-65.0] years; 21 males). The average CPAP adherence was 3.1 ± 2.3 h per night, with 23.5% using CPAP for more than 4 h per night. There were no significant changes in 24 h mean systolic ABPM (125.9 [116.8-134.9] mmHg to 126.0 [118.3-133.7] mmHg; p = 0.93) or reaction times measured by PVT (2.0 [0.0-3.0] lapses to 2.0 [1.0-3.0] lapses; p = 0.82) after CPAP therapy. A high prevalence of OSA was observed among taxi drivers. CPAP adherence was suboptimal and did not result in significant improvements in BP or vigilance.","source_id":"source_4","support_kind":"candidate_source_row"},{"study":"Could behaviour change interventions be incorporated into cardiac rehabilitation programmes for insomnia and poor sleep quality management? A scoping review","year":2026,"doi":"10.1007/s11325-026-03707-x","url":"https://doi.org/10.1007/s11325-026-03707-x","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"review-level","cited_as":"White 2026","excerpt":"BACKGROUND: Cardiovascular disease (CVD) is caused by modifiable and non-modifiable risk factors and is consistently recognised as a leading cause of morbidity and mortality. Poor sleep caused by sleep disorders such as insomnia are linked to increased mortality in patients with CVD, yet it is routinely overlooked as a cause to treat. Furthermore, despite the impact of sleep disorders, management strategies are notably underrepresented in cardiac care guidelines and cardiac rehabilitation. AIM OF REVIEW: This scoping review aimed to assemble recent published literature to explore how behaviour change interventions could be utilised as a method to integrate sleep management strategies into state-of-the-art cardiac rehabilitation for patients with cardiovascular disease. METHODS: Four medical databases (Cochrane Library, MEDLINE, PsycINFO and CINAHL+) were searched using a PICO framework, publishing a total of 782 results. Of the 782 records identified, 23 were included to inform this review, including an additional article found from bibliography searching.","source_id":"source_5","support_kind":"candidate_source_row"}]},{"claim_id":"claim_11","claim":"Evidence-tension synthesis: claims grouped by outcome class (cardiometabolic, contextual adjacent evidence, deficiency prevalence, longevity, mortality and survival, muscle function, safety and comorbidity); within-class agreement, disagreement, and directness gaps surfaced explicitly. Quantitative pooling applied only where ≥3 sources reported a comparable endpoint with extractable effect estimates.","citation_support":[],"candidate_sources":[{"study":"Steam-assisted respiratory muscle training may improve sleep quality in mild-to-moderate obstructive sleep apnea: a pilot polysomnography study","year":2026,"doi":"10.1007/s44470-025-00036-w","url":"https://doi.org/10.1007/s44470-025-00036-w","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"primary","cited_as":"Al-Rammahi 2026","excerpt":"STUDY OBJECTIVES: Obstructive sleep apnea (OSA) impairs sleep and respiration, and sub-optimal adherence to its gold-standard CPAP therapy compels development of alternative approaches. This study investigates the effects of steam-assisted respiratory muscle training (RMT) on polysomnographic (PSG) outcomes in patients with OSA. METHODS: In a 12-week open-label prospective pilot study, 60 working participants with mild to moderate OSA underwent individualized inspiratory and expiratory resistance training with adjunctive steam inhalation. PSG was conducted pre- and post-intervention. Primary outcomes included changes in respiratory indices (AHI, ODI₃, CT₉₀) and sleep quality metrics (sleep efficiency, WASO). Statistical analyses included the Shapiro-Wilk normality test, Paired T, Welch, or Wilcoxon comparing visits, Wilson CIs reporting responders, Mann-Whitney and Fisher assessing associations, regression predicting change, with significance set at p < 0.05. RESULTS: Of 60 participants, 33 completed the study. Primary outcomes-respiratory indices and sleep continuity metrics-remained unchanged (all p > 0.05).","source_id":"source_1","support_kind":"candidate_source_row"},{"study":"Association of reduced REM sleep with mortality in adults with coronary artery disease and obstructive sleep apnea in the RICCADSA cohort","year":2026,"doi":"10.1007/s11325-026-03614-1","url":"https://doi.org/10.1007/s11325-026-03614-1","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"primary","cited_as":"Balcan 2026","excerpt":"PURPOSE: Reduced rapid-eye movement (REM) sleep has been linked to increased mortality in the general population. We investigated whether diminished REM sleep is associated with higher mortality in adults with coronary artery disease (CAD) and obstructive sleep apnea (OSA). METHODS: This secondary analysis of the RICCADSA trial included 356 revascularized CAD patients with OSA (apnea-hypopnea index [AHI] ≥ 15 events/h) and total sleep time (TST) ≥ 240 min on baseline polysomnography. Reduced REM sleep was defined as the lowest quartile of REM percentage. Cox proportional hazards models assessed the association between reduced REM sleep and mortality over a median 4.7-year follow-up. RESULTS: The lowest REM quartile corresponded to 8.7% of TST. Participants with reduced REM sleep (n = 86) were older (66.0 ± 8.1 vs. 63.0 ± 8.0 years; p = 0.035), had higher BMI (29.8 ± 4.6 vs. 28.7 ± 3.8 kg/m²; p = 0.010), shorter TST (369 ± 77 vs. 497 ± 69 min; p < 0.001), less slow-wave sleep (5.2 ± 7.0% vs. 8.1 ± 10.0%; p = 0.007), and higher AHI (54.4 ± 26.3 vs. 35.6 ± 20.1 events/h; p < 0.001) than those with REM ≥ 8.7% (n = 270). Mortality was 12.8% in the reduced REM group versus 4.","source_id":"source_2","support_kind":"candidate_source_row"},{"study":"Predicting sleep apnea worsening and cardiometabolic risk without treatment","year":2026,"doi":"10.1007/s11325-026-03617-y","url":"https://doi.org/10.1007/s11325-026-03617-y","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"primary","cited_as":"Lavie 2026","excerpt":"PURPOSE: The natural history of untreated obstructive sleep apnea (OSA) and its cardiometabolic consequences are not fully characterized. We aimed to identify predictors of apnea severity progression and incident cardiometabolic comorbidities in untreated patients, comparing continuous and categorical measures of apnea severity. METHODS: We retrospectively studied 538 adults (419 men, 119 women) who underwent two attended overnight polysomnographic evaluations separated by 3.8 ± 2.7 years and declined OSA treatment. Changes in apnea severity were assessed using continuous change in apnea-hypopnea index (ΔAHI) and categorical transitions across standard severity thresholds. Multivariable linear regression was used to identify predictors of ΔAHI, and multivariable logistic regression was used to identify predictors of incident hypertension, diabetes, and cardiovascular disease. RESULTS: Apnea severity and nocturnal hypoxemia worsened significantly over time.","source_id":"source_3","support_kind":"candidate_source_row"},{"study":"Prevalence of Obstructive Sleep Apnea and Adherence to CPAP for TAXI Drivers","year":2026,"doi":"10.3390/clockssleep8010004","url":"https://doi.org/10.3390/clockssleep8010004","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"primary","cited_as":"Chan 2026","excerpt":"We investigated the effects of Continuous Positive Airway Pressure (CPAP) on blood pressure (BP) and vigilance in taxi drivers with obstructive sleep apnea (OSA). This pilot study recruited taxi drivers aged ≥60 years to undergo polysomnography. Those diagnosed with OSA underwent 6 months of CPAP therapy. Baseline and follow-up assessments included 24 h ambulatory blood pressure monitoring (ABPM) and the psychomotor vigilance test (PVT). Among the 32 participants, 22 (68.8%) were diagnosed with OSA (median age 63.0 [62.0-65.0] years; 21 males). The average CPAP adherence was 3.1 ± 2.3 h per night, with 23.5% using CPAP for more than 4 h per night. There were no significant changes in 24 h mean systolic ABPM (125.9 [116.8-134.9] mmHg to 126.0 [118.3-133.7] mmHg; p = 0.93) or reaction times measured by PVT (2.0 [0.0-3.0] lapses to 2.0 [1.0-3.0] lapses; p = 0.82) after CPAP therapy. A high prevalence of OSA was observed among taxi drivers. CPAP adherence was suboptimal and did not result in significant improvements in BP or vigilance.","source_id":"source_4","support_kind":"candidate_source_row"},{"study":"Could behaviour change interventions be incorporated into cardiac rehabilitation programmes for insomnia and poor sleep quality management? A scoping review","year":2026,"doi":"10.1007/s11325-026-03707-x","url":"https://doi.org/10.1007/s11325-026-03707-x","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"review-level","cited_as":"White 2026","excerpt":"BACKGROUND: Cardiovascular disease (CVD) is caused by modifiable and non-modifiable risk factors and is consistently recognised as a leading cause of morbidity and mortality. Poor sleep caused by sleep disorders such as insomnia are linked to increased mortality in patients with CVD, yet it is routinely overlooked as a cause to treat. Furthermore, despite the impact of sleep disorders, management strategies are notably underrepresented in cardiac care guidelines and cardiac rehabilitation. AIM OF REVIEW: This scoping review aimed to assemble recent published literature to explore how behaviour change interventions could be utilised as a method to integrate sleep management strategies into state-of-the-art cardiac rehabilitation for patients with cardiovascular disease. METHODS: Four medical databases (Cochrane Library, MEDLINE, PsycINFO and CINAHL+) were searched using a PICO framework, publishing a total of 782 results. Of the 782 records identified, 23 were included to inform this review, including an additional article found from bibliography searching.","source_id":"source_5","support_kind":"candidate_source_row"}]},{"claim_id":"claim_12","claim":"Source retrieval, claim extraction, evidence routing, and prose drafting were assisted by large language models under a deterministic audit-trail protocol. Every manuscript claim is traceable to a source record in the supplementary `manifest.json`. Final eligibility and interpretation decisions are author-verified.","citation_support":[],"candidate_sources":[{"study":"Steam-assisted respiratory muscle training may improve sleep quality in mild-to-moderate obstructive sleep apnea: a pilot polysomnography study","year":2026,"doi":"10.1007/s44470-025-00036-w","url":"https://doi.org/10.1007/s44470-025-00036-w","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"primary","cited_as":"Al-Rammahi 2026","excerpt":"STUDY OBJECTIVES: Obstructive sleep apnea (OSA) impairs sleep and respiration, and sub-optimal adherence to its gold-standard CPAP therapy compels development of alternative approaches. This study investigates the effects of steam-assisted respiratory muscle training (RMT) on polysomnographic (PSG) outcomes in patients with OSA. METHODS: In a 12-week open-label prospective pilot study, 60 working participants with mild to moderate OSA underwent individualized inspiratory and expiratory resistance training with adjunctive steam inhalation. PSG was conducted pre- and post-intervention. Primary outcomes included changes in respiratory indices (AHI, ODI₃, CT₉₀) and sleep quality metrics (sleep efficiency, WASO). Statistical analyses included the Shapiro-Wilk normality test, Paired T, Welch, or Wilcoxon comparing visits, Wilson CIs reporting responders, Mann-Whitney and Fisher assessing associations, regression predicting change, with significance set at p < 0.05. RESULTS: Of 60 participants, 33 completed the study. Primary outcomes-respiratory indices and sleep continuity metrics-remained unchanged (all p > 0.05).","source_id":"source_1","support_kind":"candidate_source_row"},{"study":"Association of reduced REM sleep with mortality in adults with coronary artery disease and obstructive sleep apnea in the RICCADSA cohort","year":2026,"doi":"10.1007/s11325-026-03614-1","url":"https://doi.org/10.1007/s11325-026-03614-1","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"primary","cited_as":"Balcan 2026","excerpt":"PURPOSE: Reduced rapid-eye movement (REM) sleep has been linked to increased mortality in the general population. We investigated whether diminished REM sleep is associated with higher mortality in adults with coronary artery disease (CAD) and obstructive sleep apnea (OSA). METHODS: This secondary analysis of the RICCADSA trial included 356 revascularized CAD patients with OSA (apnea-hypopnea index [AHI] ≥ 15 events/h) and total sleep time (TST) ≥ 240 min on baseline polysomnography. Reduced REM sleep was defined as the lowest quartile of REM percentage. Cox proportional hazards models assessed the association between reduced REM sleep and mortality over a median 4.7-year follow-up. RESULTS: The lowest REM quartile corresponded to 8.7% of TST. Participants with reduced REM sleep (n = 86) were older (66.0 ± 8.1 vs. 63.0 ± 8.0 years; p = 0.035), had higher BMI (29.8 ± 4.6 vs. 28.7 ± 3.8 kg/m²; p = 0.010), shorter TST (369 ± 77 vs. 497 ± 69 min; p < 0.001), less slow-wave sleep (5.2 ± 7.0% vs. 8.1 ± 10.0%; p = 0.007), and higher AHI (54.4 ± 26.3 vs. 35.6 ± 20.1 events/h; p < 0.001) than those with REM ≥ 8.7% (n = 270). Mortality was 12.8% in the reduced REM group versus 4.","source_id":"source_2","support_kind":"candidate_source_row"},{"study":"Predicting sleep apnea worsening and cardiometabolic risk without treatment","year":2026,"doi":"10.1007/s11325-026-03617-y","url":"https://doi.org/10.1007/s11325-026-03617-y","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"primary","cited_as":"Lavie 2026","excerpt":"PURPOSE: The natural history of untreated obstructive sleep apnea (OSA) and its cardiometabolic consequences are not fully characterized. We aimed to identify predictors of apnea severity progression and incident cardiometabolic comorbidities in untreated patients, comparing continuous and categorical measures of apnea severity. METHODS: We retrospectively studied 538 adults (419 men, 119 women) who underwent two attended overnight polysomnographic evaluations separated by 3.8 ± 2.7 years and declined OSA treatment. Changes in apnea severity were assessed using continuous change in apnea-hypopnea index (ΔAHI) and categorical transitions across standard severity thresholds. Multivariable linear regression was used to identify predictors of ΔAHI, and multivariable logistic regression was used to identify predictors of incident hypertension, diabetes, and cardiovascular disease. RESULTS: Apnea severity and nocturnal hypoxemia worsened significantly over time.","source_id":"source_3","support_kind":"candidate_source_row"},{"study":"Prevalence of Obstructive Sleep Apnea and Adherence to CPAP for TAXI Drivers","year":2026,"doi":"10.3390/clockssleep8010004","url":"https://doi.org/10.3390/clockssleep8010004","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"primary","cited_as":"Chan 2026","excerpt":"We investigated the effects of Continuous Positive Airway Pressure (CPAP) on blood pressure (BP) and vigilance in taxi drivers with obstructive sleep apnea (OSA). This pilot study recruited taxi drivers aged ≥60 years to undergo polysomnography. Those diagnosed with OSA underwent 6 months of CPAP therapy. Baseline and follow-up assessments included 24 h ambulatory blood pressure monitoring (ABPM) and the psychomotor vigilance test (PVT). Among the 32 participants, 22 (68.8%) were diagnosed with OSA (median age 63.0 [62.0-65.0] years; 21 males). The average CPAP adherence was 3.1 ± 2.3 h per night, with 23.5% using CPAP for more than 4 h per night. There were no significant changes in 24 h mean systolic ABPM (125.9 [116.8-134.9] mmHg to 126.0 [118.3-133.7] mmHg; p = 0.93) or reaction times measured by PVT (2.0 [0.0-3.0] lapses to 2.0 [1.0-3.0] lapses; p = 0.82) after CPAP therapy. A high prevalence of OSA was observed among taxi drivers. CPAP adherence was suboptimal and did not result in significant improvements in BP or vigilance.","source_id":"source_4","support_kind":"candidate_source_row"},{"study":"Could behaviour change interventions be incorporated into cardiac rehabilitation programmes for insomnia and poor sleep quality management? A scoping review","year":2026,"doi":"10.1007/s11325-026-03707-x","url":"https://doi.org/10.1007/s11325-026-03707-x","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"review-level","cited_as":"White 2026","excerpt":"BACKGROUND: Cardiovascular disease (CVD) is caused by modifiable and non-modifiable risk factors and is consistently recognised as a leading cause of morbidity and mortality. Poor sleep caused by sleep disorders such as insomnia are linked to increased mortality in patients with CVD, yet it is routinely overlooked as a cause to treat. Furthermore, despite the impact of sleep disorders, management strategies are notably underrepresented in cardiac care guidelines and cardiac rehabilitation. AIM OF REVIEW: This scoping review aimed to assemble recent published literature to explore how behaviour change interventions could be utilised as a method to integrate sleep management strategies into state-of-the-art cardiac rehabilitation for patients with cardiovascular disease. METHODS: Four medical databases (Cochrane Library, MEDLINE, PsycINFO and CINAHL+) were searched using a PICO framework, publishing a total of 782 results. Of the 782 records identified, 23 were included to inform this review, including an additional article found from bibliography searching.","source_id":"source_5","support_kind":"candidate_source_row"}]},{"claim_id":"claim_13","claim":"Outcome-class note:** Contextual Adjacent Evidence denotes background, boundary-condition, or adjacent-outcome sources. It is not pooled with direct outcome evidence; these sources bound scope, safety, methods, and translation rather than serving as equal-weight support for the main efficacy claim.","citation_support":[],"candidate_sources":[{"study":"Steam-assisted respiratory muscle training may improve sleep quality in mild-to-moderate obstructive sleep apnea: a pilot polysomnography study","year":2026,"doi":"10.1007/s44470-025-00036-w","url":"https://doi.org/10.1007/s44470-025-00036-w","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"primary","cited_as":"Al-Rammahi 2026","excerpt":"STUDY OBJECTIVES: Obstructive sleep apnea (OSA) impairs sleep and respiration, and sub-optimal adherence to its gold-standard CPAP therapy compels development of alternative approaches. This study investigates the effects of steam-assisted respiratory muscle training (RMT) on polysomnographic (PSG) outcomes in patients with OSA. METHODS: In a 12-week open-label prospective pilot study, 60 working participants with mild to moderate OSA underwent individualized inspiratory and expiratory resistance training with adjunctive steam inhalation. PSG was conducted pre- and post-intervention. Primary outcomes included changes in respiratory indices (AHI, ODI₃, CT₉₀) and sleep quality metrics (sleep efficiency, WASO). Statistical analyses included the Shapiro-Wilk normality test, Paired T, Welch, or Wilcoxon comparing visits, Wilson CIs reporting responders, Mann-Whitney and Fisher assessing associations, regression predicting change, with significance set at p < 0.05. RESULTS: Of 60 participants, 33 completed the study. Primary outcomes-respiratory indices and sleep continuity metrics-remained unchanged (all p > 0.05).","source_id":"source_1","support_kind":"candidate_source_row"},{"study":"Association of reduced REM sleep with mortality in adults with coronary artery disease and obstructive sleep apnea in the RICCADSA cohort","year":2026,"doi":"10.1007/s11325-026-03614-1","url":"https://doi.org/10.1007/s11325-026-03614-1","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"primary","cited_as":"Balcan 2026","excerpt":"PURPOSE: Reduced rapid-eye movement (REM) sleep has been linked to increased mortality in the general population. We investigated whether diminished REM sleep is associated with higher mortality in adults with coronary artery disease (CAD) and obstructive sleep apnea (OSA). METHODS: This secondary analysis of the RICCADSA trial included 356 revascularized CAD patients with OSA (apnea-hypopnea index [AHI] ≥ 15 events/h) and total sleep time (TST) ≥ 240 min on baseline polysomnography. Reduced REM sleep was defined as the lowest quartile of REM percentage. Cox proportional hazards models assessed the association between reduced REM sleep and mortality over a median 4.7-year follow-up. RESULTS: The lowest REM quartile corresponded to 8.7% of TST. Participants with reduced REM sleep (n = 86) were older (66.0 ± 8.1 vs. 63.0 ± 8.0 years; p = 0.035), had higher BMI (29.8 ± 4.6 vs. 28.7 ± 3.8 kg/m²; p = 0.010), shorter TST (369 ± 77 vs. 497 ± 69 min; p < 0.001), less slow-wave sleep (5.2 ± 7.0% vs. 8.1 ± 10.0%; p = 0.007), and higher AHI (54.4 ± 26.3 vs. 35.6 ± 20.1 events/h; p < 0.001) than those with REM ≥ 8.7% (n = 270). Mortality was 12.8% in the reduced REM group versus 4.","source_id":"source_2","support_kind":"candidate_source_row"},{"study":"Predicting sleep apnea worsening and cardiometabolic risk without treatment","year":2026,"doi":"10.1007/s11325-026-03617-y","url":"https://doi.org/10.1007/s11325-026-03617-y","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"primary","cited_as":"Lavie 2026","excerpt":"PURPOSE: The natural history of untreated obstructive sleep apnea (OSA) and its cardiometabolic consequences are not fully characterized. We aimed to identify predictors of apnea severity progression and incident cardiometabolic comorbidities in untreated patients, comparing continuous and categorical measures of apnea severity. METHODS: We retrospectively studied 538 adults (419 men, 119 women) who underwent two attended overnight polysomnographic evaluations separated by 3.8 ± 2.7 years and declined OSA treatment. Changes in apnea severity were assessed using continuous change in apnea-hypopnea index (ΔAHI) and categorical transitions across standard severity thresholds. Multivariable linear regression was used to identify predictors of ΔAHI, and multivariable logistic regression was used to identify predictors of incident hypertension, diabetes, and cardiovascular disease. RESULTS: Apnea severity and nocturnal hypoxemia worsened significantly over time.","source_id":"source_3","support_kind":"candidate_source_row"},{"study":"Prevalence of Obstructive Sleep Apnea and Adherence to CPAP for TAXI Drivers","year":2026,"doi":"10.3390/clockssleep8010004","url":"https://doi.org/10.3390/clockssleep8010004","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"primary","cited_as":"Chan 2026","excerpt":"We investigated the effects of Continuous Positive Airway Pressure (CPAP) on blood pressure (BP) and vigilance in taxi drivers with obstructive sleep apnea (OSA). This pilot study recruited taxi drivers aged ≥60 years to undergo polysomnography. Those diagnosed with OSA underwent 6 months of CPAP therapy. Baseline and follow-up assessments included 24 h ambulatory blood pressure monitoring (ABPM) and the psychomotor vigilance test (PVT). Among the 32 participants, 22 (68.8%) were diagnosed with OSA (median age 63.0 [62.0-65.0] years; 21 males). The average CPAP adherence was 3.1 ± 2.3 h per night, with 23.5% using CPAP for more than 4 h per night. There were no significant changes in 24 h mean systolic ABPM (125.9 [116.8-134.9] mmHg to 126.0 [118.3-133.7] mmHg; p = 0.93) or reaction times measured by PVT (2.0 [0.0-3.0] lapses to 2.0 [1.0-3.0] lapses; p = 0.82) after CPAP therapy. A high prevalence of OSA was observed among taxi drivers. CPAP adherence was suboptimal and did not result in significant improvements in BP or vigilance.","source_id":"source_4","support_kind":"candidate_source_row"},{"study":"Could behaviour change interventions be incorporated into cardiac rehabilitation programmes for insomnia and poor sleep quality management? A scoping review","year":2026,"doi":"10.1007/s11325-026-03707-x","url":"https://doi.org/10.1007/s11325-026-03707-x","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"review-level","cited_as":"White 2026","excerpt":"BACKGROUND: Cardiovascular disease (CVD) is caused by modifiable and non-modifiable risk factors and is consistently recognised as a leading cause of morbidity and mortality. Poor sleep caused by sleep disorders such as insomnia are linked to increased mortality in patients with CVD, yet it is routinely overlooked as a cause to treat. Furthermore, despite the impact of sleep disorders, management strategies are notably underrepresented in cardiac care guidelines and cardiac rehabilitation. AIM OF REVIEW: This scoping review aimed to assemble recent published literature to explore how behaviour change interventions could be utilised as a method to integrate sleep management strategies into state-of-the-art cardiac rehabilitation for patients with cardiovascular disease. METHODS: Four medical databases (Cochrane Library, MEDLINE, PsycINFO and CINAHL+) were searched using a PICO framework, publishing a total of 782 results. Of the 782 records identified, 23 were included to inform this review, including an additional article found from bibliography searching.","source_id":"source_5","support_kind":"candidate_source_row"}]},{"claim_id":"claim_14","claim":"| Evidence domain | Corpus slice | Strongest signal | Directness | Main limitation |","citation_support":[],"candidate_sources":[{"study":"Steam-assisted respiratory muscle training may improve sleep quality in mild-to-moderate obstructive sleep apnea: a pilot polysomnography study","year":2026,"doi":"10.1007/s44470-025-00036-w","url":"https://doi.org/10.1007/s44470-025-00036-w","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"primary","cited_as":"Al-Rammahi 2026","excerpt":"STUDY OBJECTIVES: Obstructive sleep apnea (OSA) impairs sleep and respiration, and sub-optimal adherence to its gold-standard CPAP therapy compels development of alternative approaches. This study investigates the effects of steam-assisted respiratory muscle training (RMT) on polysomnographic (PSG) outcomes in patients with OSA. METHODS: In a 12-week open-label prospective pilot study, 60 working participants with mild to moderate OSA underwent individualized inspiratory and expiratory resistance training with adjunctive steam inhalation. PSG was conducted pre- and post-intervention. Primary outcomes included changes in respiratory indices (AHI, ODI₃, CT₉₀) and sleep quality metrics (sleep efficiency, WASO). Statistical analyses included the Shapiro-Wilk normality test, Paired T, Welch, or Wilcoxon comparing visits, Wilson CIs reporting responders, Mann-Whitney and Fisher assessing associations, regression predicting change, with significance set at p < 0.05. RESULTS: Of 60 participants, 33 completed the study. Primary outcomes-respiratory indices and sleep continuity metrics-remained unchanged (all p > 0.05).","source_id":"source_1","support_kind":"candidate_source_row"},{"study":"Association of reduced REM sleep with mortality in adults with coronary artery disease and obstructive sleep apnea in the RICCADSA cohort","year":2026,"doi":"10.1007/s11325-026-03614-1","url":"https://doi.org/10.1007/s11325-026-03614-1","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"primary","cited_as":"Balcan 2026","excerpt":"PURPOSE: Reduced rapid-eye movement (REM) sleep has been linked to increased mortality in the general population. We investigated whether diminished REM sleep is associated with higher mortality in adults with coronary artery disease (CAD) and obstructive sleep apnea (OSA). METHODS: This secondary analysis of the RICCADSA trial included 356 revascularized CAD patients with OSA (apnea-hypopnea index [AHI] ≥ 15 events/h) and total sleep time (TST) ≥ 240 min on baseline polysomnography. Reduced REM sleep was defined as the lowest quartile of REM percentage. Cox proportional hazards models assessed the association between reduced REM sleep and mortality over a median 4.7-year follow-up. RESULTS: The lowest REM quartile corresponded to 8.7% of TST. Participants with reduced REM sleep (n = 86) were older (66.0 ± 8.1 vs. 63.0 ± 8.0 years; p = 0.035), had higher BMI (29.8 ± 4.6 vs. 28.7 ± 3.8 kg/m²; p = 0.010), shorter TST (369 ± 77 vs. 497 ± 69 min; p < 0.001), less slow-wave sleep (5.2 ± 7.0% vs. 8.1 ± 10.0%; p = 0.007), and higher AHI (54.4 ± 26.3 vs. 35.6 ± 20.1 events/h; p < 0.001) than those with REM ≥ 8.7% (n = 270). Mortality was 12.8% in the reduced REM group versus 4.","source_id":"source_2","support_kind":"candidate_source_row"},{"study":"Predicting sleep apnea worsening and cardiometabolic risk without treatment","year":2026,"doi":"10.1007/s11325-026-03617-y","url":"https://doi.org/10.1007/s11325-026-03617-y","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"primary","cited_as":"Lavie 2026","excerpt":"PURPOSE: The natural history of untreated obstructive sleep apnea (OSA) and its cardiometabolic consequences are not fully characterized. We aimed to identify predictors of apnea severity progression and incident cardiometabolic comorbidities in untreated patients, comparing continuous and categorical measures of apnea severity. METHODS: We retrospectively studied 538 adults (419 men, 119 women) who underwent two attended overnight polysomnographic evaluations separated by 3.8 ± 2.7 years and declined OSA treatment. Changes in apnea severity were assessed using continuous change in apnea-hypopnea index (ΔAHI) and categorical transitions across standard severity thresholds. Multivariable linear regression was used to identify predictors of ΔAHI, and multivariable logistic regression was used to identify predictors of incident hypertension, diabetes, and cardiovascular disease. RESULTS: Apnea severity and nocturnal hypoxemia worsened significantly over time.","source_id":"source_3","support_kind":"candidate_source_row"},{"study":"Prevalence of Obstructive Sleep Apnea and Adherence to CPAP for TAXI Drivers","year":2026,"doi":"10.3390/clockssleep8010004","url":"https://doi.org/10.3390/clockssleep8010004","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"primary","cited_as":"Chan 2026","excerpt":"We investigated the effects of Continuous Positive Airway Pressure (CPAP) on blood pressure (BP) and vigilance in taxi drivers with obstructive sleep apnea (OSA). This pilot study recruited taxi drivers aged ≥60 years to undergo polysomnography. Those diagnosed with OSA underwent 6 months of CPAP therapy. Baseline and follow-up assessments included 24 h ambulatory blood pressure monitoring (ABPM) and the psychomotor vigilance test (PVT). Among the 32 participants, 22 (68.8%) were diagnosed with OSA (median age 63.0 [62.0-65.0] years; 21 males). The average CPAP adherence was 3.1 ± 2.3 h per night, with 23.5% using CPAP for more than 4 h per night. There were no significant changes in 24 h mean systolic ABPM (125.9 [116.8-134.9] mmHg to 126.0 [118.3-133.7] mmHg; p = 0.93) or reaction times measured by PVT (2.0 [0.0-3.0] lapses to 2.0 [1.0-3.0] lapses; p = 0.82) after CPAP therapy. A high prevalence of OSA was observed among taxi drivers. CPAP adherence was suboptimal and did not result in significant improvements in BP or vigilance.","source_id":"source_4","support_kind":"candidate_source_row"},{"study":"Could behaviour change interventions be incorporated into cardiac rehabilitation programmes for insomnia and poor sleep quality management? A scoping review","year":2026,"doi":"10.1007/s11325-026-03707-x","url":"https://doi.org/10.1007/s11325-026-03707-x","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"review-level","cited_as":"White 2026","excerpt":"BACKGROUND: Cardiovascular disease (CVD) is caused by modifiable and non-modifiable risk factors and is consistently recognised as a leading cause of morbidity and mortality. Poor sleep caused by sleep disorders such as insomnia are linked to increased mortality in patients with CVD, yet it is routinely overlooked as a cause to treat. Furthermore, despite the impact of sleep disorders, management strategies are notably underrepresented in cardiac care guidelines and cardiac rehabilitation. AIM OF REVIEW: This scoping review aimed to assemble recent published literature to explore how behaviour change interventions could be utilised as a method to integrate sleep management strategies into state-of-the-art cardiac rehabilitation for patients with cardiovascular disease. METHODS: Four medical databases (Cochrane Library, MEDLINE, PsycINFO and CINAHL+) were searched using a PICO framework, publishing a total of 782 results. Of the 782 records identified, 23 were included to inform this review, including an additional article found from bibliography searching.","source_id":"source_5","support_kind":"candidate_source_row"}]},{"claim_id":"claim_15","claim":"| Contextual Adjacent Evidence | n=5; claims=45 | no extracted directional signal in 4/5 sources | 5 review | limited corpus depth in this outcome class |","citation_support":[],"candidate_sources":[{"study":"Steam-assisted respiratory muscle training may improve sleep quality in mild-to-moderate obstructive sleep apnea: a pilot polysomnography study","year":2026,"doi":"10.1007/s44470-025-00036-w","url":"https://doi.org/10.1007/s44470-025-00036-w","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"primary","cited_as":"Al-Rammahi 2026","excerpt":"STUDY OBJECTIVES: Obstructive sleep apnea (OSA) impairs sleep and respiration, and sub-optimal adherence to its gold-standard CPAP therapy compels development of alternative approaches. This study investigates the effects of steam-assisted respiratory muscle training (RMT) on polysomnographic (PSG) outcomes in patients with OSA. METHODS: In a 12-week open-label prospective pilot study, 60 working participants with mild to moderate OSA underwent individualized inspiratory and expiratory resistance training with adjunctive steam inhalation. PSG was conducted pre- and post-intervention. Primary outcomes included changes in respiratory indices (AHI, ODI₃, CT₉₀) and sleep quality metrics (sleep efficiency, WASO). Statistical analyses included the Shapiro-Wilk normality test, Paired T, Welch, or Wilcoxon comparing visits, Wilson CIs reporting responders, Mann-Whitney and Fisher assessing associations, regression predicting change, with significance set at p < 0.05. RESULTS: Of 60 participants, 33 completed the study. Primary outcomes-respiratory indices and sleep continuity metrics-remained unchanged (all p > 0.05).","source_id":"source_1","support_kind":"candidate_source_row"},{"study":"Association of reduced REM sleep with mortality in adults with coronary artery disease and obstructive sleep apnea in the RICCADSA cohort","year":2026,"doi":"10.1007/s11325-026-03614-1","url":"https://doi.org/10.1007/s11325-026-03614-1","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"primary","cited_as":"Balcan 2026","excerpt":"PURPOSE: Reduced rapid-eye movement (REM) sleep has been linked to increased mortality in the general population. We investigated whether diminished REM sleep is associated with higher mortality in adults with coronary artery disease (CAD) and obstructive sleep apnea (OSA). METHODS: This secondary analysis of the RICCADSA trial included 356 revascularized CAD patients with OSA (apnea-hypopnea index [AHI] ≥ 15 events/h) and total sleep time (TST) ≥ 240 min on baseline polysomnography. Reduced REM sleep was defined as the lowest quartile of REM percentage. Cox proportional hazards models assessed the association between reduced REM sleep and mortality over a median 4.7-year follow-up. RESULTS: The lowest REM quartile corresponded to 8.7% of TST. Participants with reduced REM sleep (n = 86) were older (66.0 ± 8.1 vs. 63.0 ± 8.0 years; p = 0.035), had higher BMI (29.8 ± 4.6 vs. 28.7 ± 3.8 kg/m²; p = 0.010), shorter TST (369 ± 77 vs. 497 ± 69 min; p < 0.001), less slow-wave sleep (5.2 ± 7.0% vs. 8.1 ± 10.0%; p = 0.007), and higher AHI (54.4 ± 26.3 vs. 35.6 ± 20.1 events/h; p < 0.001) than those with REM ≥ 8.7% (n = 270). Mortality was 12.8% in the reduced REM group versus 4.","source_id":"source_2","support_kind":"candidate_source_row"},{"study":"Predicting sleep apnea worsening and cardiometabolic risk without treatment","year":2026,"doi":"10.1007/s11325-026-03617-y","url":"https://doi.org/10.1007/s11325-026-03617-y","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"primary","cited_as":"Lavie 2026","excerpt":"PURPOSE: The natural history of untreated obstructive sleep apnea (OSA) and its cardiometabolic consequences are not fully characterized. We aimed to identify predictors of apnea severity progression and incident cardiometabolic comorbidities in untreated patients, comparing continuous and categorical measures of apnea severity. METHODS: We retrospectively studied 538 adults (419 men, 119 women) who underwent two attended overnight polysomnographic evaluations separated by 3.8 ± 2.7 years and declined OSA treatment. Changes in apnea severity were assessed using continuous change in apnea-hypopnea index (ΔAHI) and categorical transitions across standard severity thresholds. Multivariable linear regression was used to identify predictors of ΔAHI, and multivariable logistic regression was used to identify predictors of incident hypertension, diabetes, and cardiovascular disease. RESULTS: Apnea severity and nocturnal hypoxemia worsened significantly over time.","source_id":"source_3","support_kind":"candidate_source_row"},{"study":"Prevalence of Obstructive Sleep Apnea and Adherence to CPAP for TAXI Drivers","year":2026,"doi":"10.3390/clockssleep8010004","url":"https://doi.org/10.3390/clockssleep8010004","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"primary","cited_as":"Chan 2026","excerpt":"We investigated the effects of Continuous Positive Airway Pressure (CPAP) on blood pressure (BP) and vigilance in taxi drivers with obstructive sleep apnea (OSA). This pilot study recruited taxi drivers aged ≥60 years to undergo polysomnography. Those diagnosed with OSA underwent 6 months of CPAP therapy. Baseline and follow-up assessments included 24 h ambulatory blood pressure monitoring (ABPM) and the psychomotor vigilance test (PVT). Among the 32 participants, 22 (68.8%) were diagnosed with OSA (median age 63.0 [62.0-65.0] years; 21 males). The average CPAP adherence was 3.1 ± 2.3 h per night, with 23.5% using CPAP for more than 4 h per night. There were no significant changes in 24 h mean systolic ABPM (125.9 [116.8-134.9] mmHg to 126.0 [118.3-133.7] mmHg; p = 0.93) or reaction times measured by PVT (2.0 [0.0-3.0] lapses to 2.0 [1.0-3.0] lapses; p = 0.82) after CPAP therapy. A high prevalence of OSA was observed among taxi drivers. CPAP adherence was suboptimal and did not result in significant improvements in BP or vigilance.","source_id":"source_4","support_kind":"candidate_source_row"},{"study":"Could behaviour change interventions be incorporated into cardiac rehabilitation programmes for insomnia and poor sleep quality management? A scoping review","year":2026,"doi":"10.1007/s11325-026-03707-x","url":"https://doi.org/10.1007/s11325-026-03707-x","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"review-level","cited_as":"White 2026","excerpt":"BACKGROUND: Cardiovascular disease (CVD) is caused by modifiable and non-modifiable risk factors and is consistently recognised as a leading cause of morbidity and mortality. Poor sleep caused by sleep disorders such as insomnia are linked to increased mortality in patients with CVD, yet it is routinely overlooked as a cause to treat. Furthermore, despite the impact of sleep disorders, management strategies are notably underrepresented in cardiac care guidelines and cardiac rehabilitation. AIM OF REVIEW: This scoping review aimed to assemble recent published literature to explore how behaviour change interventions could be utilised as a method to integrate sleep management strategies into state-of-the-art cardiac rehabilitation for patients with cardiovascular disease. METHODS: Four medical databases (Cochrane Library, MEDLINE, PsycINFO and CINAHL+) were searched using a PICO framework, publishing a total of 782 results. Of the 782 records identified, 23 were included to inform this review, including an additional article found from bibliography searching.","source_id":"source_5","support_kind":"candidate_source_row"}]},{"claim_id":"claim_16","claim":"This evidence brief reports outcome packets as a map of retained evidence rather than as a full journal Results narrative or pooled effect estimate.","citation_support":[],"candidate_sources":[{"study":"Steam-assisted respiratory muscle training may improve sleep quality in mild-to-moderate obstructive sleep apnea: a pilot polysomnography study","year":2026,"doi":"10.1007/s44470-025-00036-w","url":"https://doi.org/10.1007/s44470-025-00036-w","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"primary","cited_as":"Al-Rammahi 2026","excerpt":"STUDY OBJECTIVES: Obstructive sleep apnea (OSA) impairs sleep and respiration, and sub-optimal adherence to its gold-standard CPAP therapy compels development of alternative approaches. This study investigates the effects of steam-assisted respiratory muscle training (RMT) on polysomnographic (PSG) outcomes in patients with OSA. METHODS: In a 12-week open-label prospective pilot study, 60 working participants with mild to moderate OSA underwent individualized inspiratory and expiratory resistance training with adjunctive steam inhalation. PSG was conducted pre- and post-intervention. Primary outcomes included changes in respiratory indices (AHI, ODI₃, CT₉₀) and sleep quality metrics (sleep efficiency, WASO). Statistical analyses included the Shapiro-Wilk normality test, Paired T, Welch, or Wilcoxon comparing visits, Wilson CIs reporting responders, Mann-Whitney and Fisher assessing associations, regression predicting change, with significance set at p < 0.05. RESULTS: Of 60 participants, 33 completed the study. Primary outcomes-respiratory indices and sleep continuity metrics-remained unchanged (all p > 0.05).","source_id":"source_1","support_kind":"candidate_source_row"},{"study":"Association of reduced REM sleep with mortality in adults with coronary artery disease and obstructive sleep apnea in the RICCADSA cohort","year":2026,"doi":"10.1007/s11325-026-03614-1","url":"https://doi.org/10.1007/s11325-026-03614-1","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"primary","cited_as":"Balcan 2026","excerpt":"PURPOSE: Reduced rapid-eye movement (REM) sleep has been linked to increased mortality in the general population. We investigated whether diminished REM sleep is associated with higher mortality in adults with coronary artery disease (CAD) and obstructive sleep apnea (OSA). METHODS: This secondary analysis of the RICCADSA trial included 356 revascularized CAD patients with OSA (apnea-hypopnea index [AHI] ≥ 15 events/h) and total sleep time (TST) ≥ 240 min on baseline polysomnography. Reduced REM sleep was defined as the lowest quartile of REM percentage. Cox proportional hazards models assessed the association between reduced REM sleep and mortality over a median 4.7-year follow-up. RESULTS: The lowest REM quartile corresponded to 8.7% of TST. Participants with reduced REM sleep (n = 86) were older (66.0 ± 8.1 vs. 63.0 ± 8.0 years; p = 0.035), had higher BMI (29.8 ± 4.6 vs. 28.7 ± 3.8 kg/m²; p = 0.010), shorter TST (369 ± 77 vs. 497 ± 69 min; p < 0.001), less slow-wave sleep (5.2 ± 7.0% vs. 8.1 ± 10.0%; p = 0.007), and higher AHI (54.4 ± 26.3 vs. 35.6 ± 20.1 events/h; p < 0.001) than those with REM ≥ 8.7% (n = 270). Mortality was 12.8% in the reduced REM group versus 4.","source_id":"source_2","support_kind":"candidate_source_row"},{"study":"Predicting sleep apnea worsening and cardiometabolic risk without treatment","year":2026,"doi":"10.1007/s11325-026-03617-y","url":"https://doi.org/10.1007/s11325-026-03617-y","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"primary","cited_as":"Lavie 2026","excerpt":"PURPOSE: The natural history of untreated obstructive sleep apnea (OSA) and its cardiometabolic consequences are not fully characterized. We aimed to identify predictors of apnea severity progression and incident cardiometabolic comorbidities in untreated patients, comparing continuous and categorical measures of apnea severity. METHODS: We retrospectively studied 538 adults (419 men, 119 women) who underwent two attended overnight polysomnographic evaluations separated by 3.8 ± 2.7 years and declined OSA treatment. Changes in apnea severity were assessed using continuous change in apnea-hypopnea index (ΔAHI) and categorical transitions across standard severity thresholds. Multivariable linear regression was used to identify predictors of ΔAHI, and multivariable logistic regression was used to identify predictors of incident hypertension, diabetes, and cardiovascular disease. RESULTS: Apnea severity and nocturnal hypoxemia worsened significantly over time.","source_id":"source_3","support_kind":"candidate_source_row"},{"study":"Prevalence of Obstructive Sleep Apnea and Adherence to CPAP for TAXI Drivers","year":2026,"doi":"10.3390/clockssleep8010004","url":"https://doi.org/10.3390/clockssleep8010004","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"primary","cited_as":"Chan 2026","excerpt":"We investigated the effects of Continuous Positive Airway Pressure (CPAP) on blood pressure (BP) and vigilance in taxi drivers with obstructive sleep apnea (OSA). This pilot study recruited taxi drivers aged ≥60 years to undergo polysomnography. Those diagnosed with OSA underwent 6 months of CPAP therapy. Baseline and follow-up assessments included 24 h ambulatory blood pressure monitoring (ABPM) and the psychomotor vigilance test (PVT). Among the 32 participants, 22 (68.8%) were diagnosed with OSA (median age 63.0 [62.0-65.0] years; 21 males). The average CPAP adherence was 3.1 ± 2.3 h per night, with 23.5% using CPAP for more than 4 h per night. There were no significant changes in 24 h mean systolic ABPM (125.9 [116.8-134.9] mmHg to 126.0 [118.3-133.7] mmHg; p = 0.93) or reaction times measured by PVT (2.0 [0.0-3.0] lapses to 2.0 [1.0-3.0] lapses; p = 0.82) after CPAP therapy. A high prevalence of OSA was observed among taxi drivers. CPAP adherence was suboptimal and did not result in significant improvements in BP or vigilance.","source_id":"source_4","support_kind":"candidate_source_row"},{"study":"Could behaviour change interventions be incorporated into cardiac rehabilitation programmes for insomnia and poor sleep quality management? A scoping review","year":2026,"doi":"10.1007/s11325-026-03707-x","url":"https://doi.org/10.1007/s11325-026-03707-x","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"review-level","cited_as":"White 2026","excerpt":"BACKGROUND: Cardiovascular disease (CVD) is caused by modifiable and non-modifiable risk factors and is consistently recognised as a leading cause of morbidity and mortality. Poor sleep caused by sleep disorders such as insomnia are linked to increased mortality in patients with CVD, yet it is routinely overlooked as a cause to treat. Furthermore, despite the impact of sleep disorders, management strategies are notably underrepresented in cardiac care guidelines and cardiac rehabilitation. AIM OF REVIEW: This scoping review aimed to assemble recent published literature to explore how behaviour change interventions could be utilised as a method to integrate sleep management strategies into state-of-the-art cardiac rehabilitation for patients with cardiovascular disease. METHODS: Four medical databases (Cochrane Library, MEDLINE, PsycINFO and CINAHL+) were searched using a PICO framework, publishing a total of 782 results. Of the 782 records identified, 23 were included to inform this review, including an additional article found from bibliography searching.","source_id":"source_5","support_kind":"candidate_source_row"}]},{"claim_id":"claim_17","claim":"5 included sources were assigned to this outcome class. Directional coding: null=4, unclear=1. Directness coding: review=5.","citation_support":[],"candidate_sources":[{"study":"Steam-assisted respiratory muscle training may improve sleep quality in mild-to-moderate obstructive sleep apnea: a pilot polysomnography study","year":2026,"doi":"10.1007/s44470-025-00036-w","url":"https://doi.org/10.1007/s44470-025-00036-w","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"primary","cited_as":"Al-Rammahi 2026","excerpt":"STUDY OBJECTIVES: Obstructive sleep apnea (OSA) impairs sleep and respiration, and sub-optimal adherence to its gold-standard CPAP therapy compels development of alternative approaches. This study investigates the effects of steam-assisted respiratory muscle training (RMT) on polysomnographic (PSG) outcomes in patients with OSA. METHODS: In a 12-week open-label prospective pilot study, 60 working participants with mild to moderate OSA underwent individualized inspiratory and expiratory resistance training with adjunctive steam inhalation. PSG was conducted pre- and post-intervention. Primary outcomes included changes in respiratory indices (AHI, ODI₃, CT₉₀) and sleep quality metrics (sleep efficiency, WASO). Statistical analyses included the Shapiro-Wilk normality test, Paired T, Welch, or Wilcoxon comparing visits, Wilson CIs reporting responders, Mann-Whitney and Fisher assessing associations, regression predicting change, with significance set at p < 0.05. RESULTS: Of 60 participants, 33 completed the study. Primary outcomes-respiratory indices and sleep continuity metrics-remained unchanged (all p > 0.05).","source_id":"source_1","support_kind":"candidate_source_row"},{"study":"Association of reduced REM sleep with mortality in adults with coronary artery disease and obstructive sleep apnea in the RICCADSA cohort","year":2026,"doi":"10.1007/s11325-026-03614-1","url":"https://doi.org/10.1007/s11325-026-03614-1","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"primary","cited_as":"Balcan 2026","excerpt":"PURPOSE: Reduced rapid-eye movement (REM) sleep has been linked to increased mortality in the general population. We investigated whether diminished REM sleep is associated with higher mortality in adults with coronary artery disease (CAD) and obstructive sleep apnea (OSA). METHODS: This secondary analysis of the RICCADSA trial included 356 revascularized CAD patients with OSA (apnea-hypopnea index [AHI] ≥ 15 events/h) and total sleep time (TST) ≥ 240 min on baseline polysomnography. Reduced REM sleep was defined as the lowest quartile of REM percentage. Cox proportional hazards models assessed the association between reduced REM sleep and mortality over a median 4.7-year follow-up. RESULTS: The lowest REM quartile corresponded to 8.7% of TST. Participants with reduced REM sleep (n = 86) were older (66.0 ± 8.1 vs. 63.0 ± 8.0 years; p = 0.035), had higher BMI (29.8 ± 4.6 vs. 28.7 ± 3.8 kg/m²; p = 0.010), shorter TST (369 ± 77 vs. 497 ± 69 min; p < 0.001), less slow-wave sleep (5.2 ± 7.0% vs. 8.1 ± 10.0%; p = 0.007), and higher AHI (54.4 ± 26.3 vs. 35.6 ± 20.1 events/h; p < 0.001) than those with REM ≥ 8.7% (n = 270). Mortality was 12.8% in the reduced REM group versus 4.","source_id":"source_2","support_kind":"candidate_source_row"},{"study":"Predicting sleep apnea worsening and cardiometabolic risk without treatment","year":2026,"doi":"10.1007/s11325-026-03617-y","url":"https://doi.org/10.1007/s11325-026-03617-y","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"primary","cited_as":"Lavie 2026","excerpt":"PURPOSE: The natural history of untreated obstructive sleep apnea (OSA) and its cardiometabolic consequences are not fully characterized. We aimed to identify predictors of apnea severity progression and incident cardiometabolic comorbidities in untreated patients, comparing continuous and categorical measures of apnea severity. METHODS: We retrospectively studied 538 adults (419 men, 119 women) who underwent two attended overnight polysomnographic evaluations separated by 3.8 ± 2.7 years and declined OSA treatment. Changes in apnea severity were assessed using continuous change in apnea-hypopnea index (ΔAHI) and categorical transitions across standard severity thresholds. Multivariable linear regression was used to identify predictors of ΔAHI, and multivariable logistic regression was used to identify predictors of incident hypertension, diabetes, and cardiovascular disease. RESULTS: Apnea severity and nocturnal hypoxemia worsened significantly over time.","source_id":"source_3","support_kind":"candidate_source_row"},{"study":"Prevalence of Obstructive Sleep Apnea and Adherence to CPAP for TAXI Drivers","year":2026,"doi":"10.3390/clockssleep8010004","url":"https://doi.org/10.3390/clockssleep8010004","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"primary","cited_as":"Chan 2026","excerpt":"We investigated the effects of Continuous Positive Airway Pressure (CPAP) on blood pressure (BP) and vigilance in taxi drivers with obstructive sleep apnea (OSA). This pilot study recruited taxi drivers aged ≥60 years to undergo polysomnography. Those diagnosed with OSA underwent 6 months of CPAP therapy. Baseline and follow-up assessments included 24 h ambulatory blood pressure monitoring (ABPM) and the psychomotor vigilance test (PVT). Among the 32 participants, 22 (68.8%) were diagnosed with OSA (median age 63.0 [62.0-65.0] years; 21 males). The average CPAP adherence was 3.1 ± 2.3 h per night, with 23.5% using CPAP for more than 4 h per night. There were no significant changes in 24 h mean systolic ABPM (125.9 [116.8-134.9] mmHg to 126.0 [118.3-133.7] mmHg; p = 0.93) or reaction times measured by PVT (2.0 [0.0-3.0] lapses to 2.0 [1.0-3.0] lapses; p = 0.82) after CPAP therapy. A high prevalence of OSA was observed among taxi drivers. CPAP adherence was suboptimal and did not result in significant improvements in BP or vigilance.","source_id":"source_4","support_kind":"candidate_source_row"},{"study":"Could behaviour change interventions be incorporated into cardiac rehabilitation programmes for insomnia and poor sleep quality management? A scoping review","year":2026,"doi":"10.1007/s11325-026-03707-x","url":"https://doi.org/10.1007/s11325-026-03707-x","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"review-level","cited_as":"White 2026","excerpt":"BACKGROUND: Cardiovascular disease (CVD) is caused by modifiable and non-modifiable risk factors and is consistently recognised as a leading cause of morbidity and mortality. Poor sleep caused by sleep disorders such as insomnia are linked to increased mortality in patients with CVD, yet it is routinely overlooked as a cause to treat. Furthermore, despite the impact of sleep disorders, management strategies are notably underrepresented in cardiac care guidelines and cardiac rehabilitation. AIM OF REVIEW: This scoping review aimed to assemble recent published literature to explore how behaviour change interventions could be utilised as a method to integrate sleep management strategies into state-of-the-art cardiac rehabilitation for patients with cardiovascular disease. METHODS: Four medical databases (Cochrane Library, MEDLINE, PsycINFO and CINAHL+) were searched using a PICO framework, publishing a total of 782 results. Of the 782 records identified, 23 were included to inform this review, including an additional article found from bibliography searching.","source_id":"source_5","support_kind":"candidate_source_row"}]},{"claim_id":"claim_18","claim":"2 included sources were assigned to this outcome class. Directional coding: negative=1, null=1. Directness coding: indirect=2.","citation_support":[],"candidate_sources":[{"study":"Steam-assisted respiratory muscle training may improve sleep quality in mild-to-moderate obstructive sleep apnea: a pilot polysomnography study","year":2026,"doi":"10.1007/s44470-025-00036-w","url":"https://doi.org/10.1007/s44470-025-00036-w","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"primary","cited_as":"Al-Rammahi 2026","excerpt":"STUDY OBJECTIVES: Obstructive sleep apnea (OSA) impairs sleep and respiration, and sub-optimal adherence to its gold-standard CPAP therapy compels development of alternative approaches. This study investigates the effects of steam-assisted respiratory muscle training (RMT) on polysomnographic (PSG) outcomes in patients with OSA. METHODS: In a 12-week open-label prospective pilot study, 60 working participants with mild to moderate OSA underwent individualized inspiratory and expiratory resistance training with adjunctive steam inhalation. PSG was conducted pre- and post-intervention. Primary outcomes included changes in respiratory indices (AHI, ODI₃, CT₉₀) and sleep quality metrics (sleep efficiency, WASO). Statistical analyses included the Shapiro-Wilk normality test, Paired T, Welch, or Wilcoxon comparing visits, Wilson CIs reporting responders, Mann-Whitney and Fisher assessing associations, regression predicting change, with significance set at p < 0.05. RESULTS: Of 60 participants, 33 completed the study. Primary outcomes-respiratory indices and sleep continuity metrics-remained unchanged (all p > 0.05).","source_id":"source_1","support_kind":"candidate_source_row"},{"study":"Association of reduced REM sleep with mortality in adults with coronary artery disease and obstructive sleep apnea in the RICCADSA cohort","year":2026,"doi":"10.1007/s11325-026-03614-1","url":"https://doi.org/10.1007/s11325-026-03614-1","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"primary","cited_as":"Balcan 2026","excerpt":"PURPOSE: Reduced rapid-eye movement (REM) sleep has been linked to increased mortality in the general population. We investigated whether diminished REM sleep is associated with higher mortality in adults with coronary artery disease (CAD) and obstructive sleep apnea (OSA). METHODS: This secondary analysis of the RICCADSA trial included 356 revascularized CAD patients with OSA (apnea-hypopnea index [AHI] ≥ 15 events/h) and total sleep time (TST) ≥ 240 min on baseline polysomnography. Reduced REM sleep was defined as the lowest quartile of REM percentage. Cox proportional hazards models assessed the association between reduced REM sleep and mortality over a median 4.7-year follow-up. RESULTS: The lowest REM quartile corresponded to 8.7% of TST. Participants with reduced REM sleep (n = 86) were older (66.0 ± 8.1 vs. 63.0 ± 8.0 years; p = 0.035), had higher BMI (29.8 ± 4.6 vs. 28.7 ± 3.8 kg/m²; p = 0.010), shorter TST (369 ± 77 vs. 497 ± 69 min; p < 0.001), less slow-wave sleep (5.2 ± 7.0% vs. 8.1 ± 10.0%; p = 0.007), and higher AHI (54.4 ± 26.3 vs. 35.6 ± 20.1 events/h; p < 0.001) than those with REM ≥ 8.7% (n = 270). Mortality was 12.8% in the reduced REM group versus 4.","source_id":"source_2","support_kind":"candidate_source_row"},{"study":"Predicting sleep apnea worsening and cardiometabolic risk without treatment","year":2026,"doi":"10.1007/s11325-026-03617-y","url":"https://doi.org/10.1007/s11325-026-03617-y","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"primary","cited_as":"Lavie 2026","excerpt":"PURPOSE: The natural history of untreated obstructive sleep apnea (OSA) and its cardiometabolic consequences are not fully characterized. We aimed to identify predictors of apnea severity progression and incident cardiometabolic comorbidities in untreated patients, comparing continuous and categorical measures of apnea severity. METHODS: We retrospectively studied 538 adults (419 men, 119 women) who underwent two attended overnight polysomnographic evaluations separated by 3.8 ± 2.7 years and declined OSA treatment. Changes in apnea severity were assessed using continuous change in apnea-hypopnea index (ΔAHI) and categorical transitions across standard severity thresholds. Multivariable linear regression was used to identify predictors of ΔAHI, and multivariable logistic regression was used to identify predictors of incident hypertension, diabetes, and cardiovascular disease. RESULTS: Apnea severity and nocturnal hypoxemia worsened significantly over time.","source_id":"source_3","support_kind":"candidate_source_row"},{"study":"Prevalence of Obstructive Sleep Apnea and Adherence to CPAP for TAXI Drivers","year":2026,"doi":"10.3390/clockssleep8010004","url":"https://doi.org/10.3390/clockssleep8010004","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"primary","cited_as":"Chan 2026","excerpt":"We investigated the effects of Continuous Positive Airway Pressure (CPAP) on blood pressure (BP) and vigilance in taxi drivers with obstructive sleep apnea (OSA). This pilot study recruited taxi drivers aged ≥60 years to undergo polysomnography. Those diagnosed with OSA underwent 6 months of CPAP therapy. Baseline and follow-up assessments included 24 h ambulatory blood pressure monitoring (ABPM) and the psychomotor vigilance test (PVT). Among the 32 participants, 22 (68.8%) were diagnosed with OSA (median age 63.0 [62.0-65.0] years; 21 males). The average CPAP adherence was 3.1 ± 2.3 h per night, with 23.5% using CPAP for more than 4 h per night. There were no significant changes in 24 h mean systolic ABPM (125.9 [116.8-134.9] mmHg to 126.0 [118.3-133.7] mmHg; p = 0.93) or reaction times measured by PVT (2.0 [0.0-3.0] lapses to 2.0 [1.0-3.0] lapses; p = 0.82) after CPAP therapy. A high prevalence of OSA was observed among taxi drivers. CPAP adherence was suboptimal and did not result in significant improvements in BP or vigilance.","source_id":"source_4","support_kind":"candidate_source_row"},{"study":"Could behaviour change interventions be incorporated into cardiac rehabilitation programmes for insomnia and poor sleep quality management? A scoping review","year":2026,"doi":"10.1007/s11325-026-03707-x","url":"https://doi.org/10.1007/s11325-026-03707-x","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"review-level","cited_as":"White 2026","excerpt":"BACKGROUND: Cardiovascular disease (CVD) is caused by modifiable and non-modifiable risk factors and is consistently recognised as a leading cause of morbidity and mortality. Poor sleep caused by sleep disorders such as insomnia are linked to increased mortality in patients with CVD, yet it is routinely overlooked as a cause to treat. Furthermore, despite the impact of sleep disorders, management strategies are notably underrepresented in cardiac care guidelines and cardiac rehabilitation. AIM OF REVIEW: This scoping review aimed to assemble recent published literature to explore how behaviour change interventions could be utilised as a method to integrate sleep management strategies into state-of-the-art cardiac rehabilitation for patients with cardiovascular disease. METHODS: Four medical databases (Cochrane Library, MEDLINE, PsycINFO and CINAHL+) were searched using a PICO framework, publishing a total of 782 results. Of the 782 records identified, 23 were included to inform this review, including an additional article found from bibliography searching.","source_id":"source_5","support_kind":"candidate_source_row"}]},{"claim_id":"claim_19","claim":"2 included sources were assigned to this outcome class. Directional coding: null=2. Directness coding: indirect=1, review=1.","citation_support":[],"candidate_sources":[{"study":"Steam-assisted respiratory muscle training may improve sleep quality in mild-to-moderate obstructive sleep apnea: a pilot polysomnography study","year":2026,"doi":"10.1007/s44470-025-00036-w","url":"https://doi.org/10.1007/s44470-025-00036-w","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"primary","cited_as":"Al-Rammahi 2026","excerpt":"STUDY OBJECTIVES: Obstructive sleep apnea (OSA) impairs sleep and respiration, and sub-optimal adherence to its gold-standard CPAP therapy compels development of alternative approaches. This study investigates the effects of steam-assisted respiratory muscle training (RMT) on polysomnographic (PSG) outcomes in patients with OSA. METHODS: In a 12-week open-label prospective pilot study, 60 working participants with mild to moderate OSA underwent individualized inspiratory and expiratory resistance training with adjunctive steam inhalation. PSG was conducted pre- and post-intervention. Primary outcomes included changes in respiratory indices (AHI, ODI₃, CT₉₀) and sleep quality metrics (sleep efficiency, WASO). Statistical analyses included the Shapiro-Wilk normality test, Paired T, Welch, or Wilcoxon comparing visits, Wilson CIs reporting responders, Mann-Whitney and Fisher assessing associations, regression predicting change, with significance set at p < 0.05. RESULTS: Of 60 participants, 33 completed the study. Primary outcomes-respiratory indices and sleep continuity metrics-remained unchanged (all p > 0.05).","source_id":"source_1","support_kind":"candidate_source_row"},{"study":"Association of reduced REM sleep with mortality in adults with coronary artery disease and obstructive sleep apnea in the RICCADSA cohort","year":2026,"doi":"10.1007/s11325-026-03614-1","url":"https://doi.org/10.1007/s11325-026-03614-1","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"primary","cited_as":"Balcan 2026","excerpt":"PURPOSE: Reduced rapid-eye movement (REM) sleep has been linked to increased mortality in the general population. We investigated whether diminished REM sleep is associated with higher mortality in adults with coronary artery disease (CAD) and obstructive sleep apnea (OSA). METHODS: This secondary analysis of the RICCADSA trial included 356 revascularized CAD patients with OSA (apnea-hypopnea index [AHI] ≥ 15 events/h) and total sleep time (TST) ≥ 240 min on baseline polysomnography. Reduced REM sleep was defined as the lowest quartile of REM percentage. Cox proportional hazards models assessed the association between reduced REM sleep and mortality over a median 4.7-year follow-up. RESULTS: The lowest REM quartile corresponded to 8.7% of TST. Participants with reduced REM sleep (n = 86) were older (66.0 ± 8.1 vs. 63.0 ± 8.0 years; p = 0.035), had higher BMI (29.8 ± 4.6 vs. 28.7 ± 3.8 kg/m²; p = 0.010), shorter TST (369 ± 77 vs. 497 ± 69 min; p < 0.001), less slow-wave sleep (5.2 ± 7.0% vs. 8.1 ± 10.0%; p = 0.007), and higher AHI (54.4 ± 26.3 vs. 35.6 ± 20.1 events/h; p < 0.001) than those with REM ≥ 8.7% (n = 270). Mortality was 12.8% in the reduced REM group versus 4.","source_id":"source_2","support_kind":"candidate_source_row"},{"study":"Predicting sleep apnea worsening and cardiometabolic risk without treatment","year":2026,"doi":"10.1007/s11325-026-03617-y","url":"https://doi.org/10.1007/s11325-026-03617-y","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"primary","cited_as":"Lavie 2026","excerpt":"PURPOSE: The natural history of untreated obstructive sleep apnea (OSA) and its cardiometabolic consequences are not fully characterized. We aimed to identify predictors of apnea severity progression and incident cardiometabolic comorbidities in untreated patients, comparing continuous and categorical measures of apnea severity. METHODS: We retrospectively studied 538 adults (419 men, 119 women) who underwent two attended overnight polysomnographic evaluations separated by 3.8 ± 2.7 years and declined OSA treatment. Changes in apnea severity were assessed using continuous change in apnea-hypopnea index (ΔAHI) and categorical transitions across standard severity thresholds. Multivariable linear regression was used to identify predictors of ΔAHI, and multivariable logistic regression was used to identify predictors of incident hypertension, diabetes, and cardiovascular disease. RESULTS: Apnea severity and nocturnal hypoxemia worsened significantly over time.","source_id":"source_3","support_kind":"candidate_source_row"},{"study":"Prevalence of Obstructive Sleep Apnea and Adherence to CPAP for TAXI Drivers","year":2026,"doi":"10.3390/clockssleep8010004","url":"https://doi.org/10.3390/clockssleep8010004","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"primary","cited_as":"Chan 2026","excerpt":"We investigated the effects of Continuous Positive Airway Pressure (CPAP) on blood pressure (BP) and vigilance in taxi drivers with obstructive sleep apnea (OSA). This pilot study recruited taxi drivers aged ≥60 years to undergo polysomnography. Those diagnosed with OSA underwent 6 months of CPAP therapy. Baseline and follow-up assessments included 24 h ambulatory blood pressure monitoring (ABPM) and the psychomotor vigilance test (PVT). Among the 32 participants, 22 (68.8%) were diagnosed with OSA (median age 63.0 [62.0-65.0] years; 21 males). The average CPAP adherence was 3.1 ± 2.3 h per night, with 23.5% using CPAP for more than 4 h per night. There were no significant changes in 24 h mean systolic ABPM (125.9 [116.8-134.9] mmHg to 126.0 [118.3-133.7] mmHg; p = 0.93) or reaction times measured by PVT (2.0 [0.0-3.0] lapses to 2.0 [1.0-3.0] lapses; p = 0.82) after CPAP therapy. A high prevalence of OSA was observed among taxi drivers. CPAP adherence was suboptimal and did not result in significant improvements in BP or vigilance.","source_id":"source_4","support_kind":"candidate_source_row"},{"study":"Could behaviour change interventions be incorporated into cardiac rehabilitation programmes for insomnia and poor sleep quality management? A scoping review","year":2026,"doi":"10.1007/s11325-026-03707-x","url":"https://doi.org/10.1007/s11325-026-03707-x","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"review-level","cited_as":"White 2026","excerpt":"BACKGROUND: Cardiovascular disease (CVD) is caused by modifiable and non-modifiable risk factors and is consistently recognised as a leading cause of morbidity and mortality. Poor sleep caused by sleep disorders such as insomnia are linked to increased mortality in patients with CVD, yet it is routinely overlooked as a cause to treat. Furthermore, despite the impact of sleep disorders, management strategies are notably underrepresented in cardiac care guidelines and cardiac rehabilitation. AIM OF REVIEW: This scoping review aimed to assemble recent published literature to explore how behaviour change interventions could be utilised as a method to integrate sleep management strategies into state-of-the-art cardiac rehabilitation for patients with cardiovascular disease. METHODS: Four medical databases (Cochrane Library, MEDLINE, PsycINFO and CINAHL+) were searched using a PICO framework, publishing a total of 782 results. Of the 782 records identified, 23 were included to inform this review, including an additional article found from bibliography searching.","source_id":"source_5","support_kind":"candidate_source_row"}]},{"claim_id":"claim_20","claim":"1 included source were assigned to this outcome class. Directional coding: null=1. Directness coding: indirect=1.","citation_support":[],"candidate_sources":[{"study":"Steam-assisted respiratory muscle training may improve sleep quality in mild-to-moderate obstructive sleep apnea: a pilot polysomnography study","year":2026,"doi":"10.1007/s44470-025-00036-w","url":"https://doi.org/10.1007/s44470-025-00036-w","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"primary","cited_as":"Al-Rammahi 2026","excerpt":"STUDY OBJECTIVES: Obstructive sleep apnea (OSA) impairs sleep and respiration, and sub-optimal adherence to its gold-standard CPAP therapy compels development of alternative approaches. This study investigates the effects of steam-assisted respiratory muscle training (RMT) on polysomnographic (PSG) outcomes in patients with OSA. METHODS: In a 12-week open-label prospective pilot study, 60 working participants with mild to moderate OSA underwent individualized inspiratory and expiratory resistance training with adjunctive steam inhalation. PSG was conducted pre- and post-intervention. Primary outcomes included changes in respiratory indices (AHI, ODI₃, CT₉₀) and sleep quality metrics (sleep efficiency, WASO). Statistical analyses included the Shapiro-Wilk normality test, Paired T, Welch, or Wilcoxon comparing visits, Wilson CIs reporting responders, Mann-Whitney and Fisher assessing associations, regression predicting change, with significance set at p < 0.05. RESULTS: Of 60 participants, 33 completed the study. Primary outcomes-respiratory indices and sleep continuity metrics-remained unchanged (all p > 0.05).","source_id":"source_1","support_kind":"candidate_source_row"},{"study":"Association of reduced REM sleep with mortality in adults with coronary artery disease and obstructive sleep apnea in the RICCADSA cohort","year":2026,"doi":"10.1007/s11325-026-03614-1","url":"https://doi.org/10.1007/s11325-026-03614-1","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"primary","cited_as":"Balcan 2026","excerpt":"PURPOSE: Reduced rapid-eye movement (REM) sleep has been linked to increased mortality in the general population. We investigated whether diminished REM sleep is associated with higher mortality in adults with coronary artery disease (CAD) and obstructive sleep apnea (OSA). METHODS: This secondary analysis of the RICCADSA trial included 356 revascularized CAD patients with OSA (apnea-hypopnea index [AHI] ≥ 15 events/h) and total sleep time (TST) ≥ 240 min on baseline polysomnography. Reduced REM sleep was defined as the lowest quartile of REM percentage. Cox proportional hazards models assessed the association between reduced REM sleep and mortality over a median 4.7-year follow-up. RESULTS: The lowest REM quartile corresponded to 8.7% of TST. Participants with reduced REM sleep (n = 86) were older (66.0 ± 8.1 vs. 63.0 ± 8.0 years; p = 0.035), had higher BMI (29.8 ± 4.6 vs. 28.7 ± 3.8 kg/m²; p = 0.010), shorter TST (369 ± 77 vs. 497 ± 69 min; p < 0.001), less slow-wave sleep (5.2 ± 7.0% vs. 8.1 ± 10.0%; p = 0.007), and higher AHI (54.4 ± 26.3 vs. 35.6 ± 20.1 events/h; p < 0.001) than those with REM ≥ 8.7% (n = 270). Mortality was 12.8% in the reduced REM group versus 4.","source_id":"source_2","support_kind":"candidate_source_row"},{"study":"Predicting sleep apnea worsening and cardiometabolic risk without treatment","year":2026,"doi":"10.1007/s11325-026-03617-y","url":"https://doi.org/10.1007/s11325-026-03617-y","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"primary","cited_as":"Lavie 2026","excerpt":"PURPOSE: The natural history of untreated obstructive sleep apnea (OSA) and its cardiometabolic consequences are not fully characterized. We aimed to identify predictors of apnea severity progression and incident cardiometabolic comorbidities in untreated patients, comparing continuous and categorical measures of apnea severity. METHODS: We retrospectively studied 538 adults (419 men, 119 women) who underwent two attended overnight polysomnographic evaluations separated by 3.8 ± 2.7 years and declined OSA treatment. Changes in apnea severity were assessed using continuous change in apnea-hypopnea index (ΔAHI) and categorical transitions across standard severity thresholds. Multivariable linear regression was used to identify predictors of ΔAHI, and multivariable logistic regression was used to identify predictors of incident hypertension, diabetes, and cardiovascular disease. RESULTS: Apnea severity and nocturnal hypoxemia worsened significantly over time.","source_id":"source_3","support_kind":"candidate_source_row"},{"study":"Prevalence of Obstructive Sleep Apnea and Adherence to CPAP for TAXI Drivers","year":2026,"doi":"10.3390/clockssleep8010004","url":"https://doi.org/10.3390/clockssleep8010004","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"primary","cited_as":"Chan 2026","excerpt":"We investigated the effects of Continuous Positive Airway Pressure (CPAP) on blood pressure (BP) and vigilance in taxi drivers with obstructive sleep apnea (OSA). This pilot study recruited taxi drivers aged ≥60 years to undergo polysomnography. Those diagnosed with OSA underwent 6 months of CPAP therapy. Baseline and follow-up assessments included 24 h ambulatory blood pressure monitoring (ABPM) and the psychomotor vigilance test (PVT). Among the 32 participants, 22 (68.8%) were diagnosed with OSA (median age 63.0 [62.0-65.0] years; 21 males). The average CPAP adherence was 3.1 ± 2.3 h per night, with 23.5% using CPAP for more than 4 h per night. There were no significant changes in 24 h mean systolic ABPM (125.9 [116.8-134.9] mmHg to 126.0 [118.3-133.7] mmHg; p = 0.93) or reaction times measured by PVT (2.0 [0.0-3.0] lapses to 2.0 [1.0-3.0] lapses; p = 0.82) after CPAP therapy. A high prevalence of OSA was observed among taxi drivers. CPAP adherence was suboptimal and did not result in significant improvements in BP or vigilance.","source_id":"source_4","support_kind":"candidate_source_row"},{"study":"Could behaviour change interventions be incorporated into cardiac rehabilitation programmes for insomnia and poor sleep quality management? A scoping review","year":2026,"doi":"10.1007/s11325-026-03707-x","url":"https://doi.org/10.1007/s11325-026-03707-x","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"review-level","cited_as":"White 2026","excerpt":"BACKGROUND: Cardiovascular disease (CVD) is caused by modifiable and non-modifiable risk factors and is consistently recognised as a leading cause of morbidity and mortality. Poor sleep caused by sleep disorders such as insomnia are linked to increased mortality in patients with CVD, yet it is routinely overlooked as a cause to treat. Furthermore, despite the impact of sleep disorders, management strategies are notably underrepresented in cardiac care guidelines and cardiac rehabilitation. AIM OF REVIEW: This scoping review aimed to assemble recent published literature to explore how behaviour change interventions could be utilised as a method to integrate sleep management strategies into state-of-the-art cardiac rehabilitation for patients with cardiovascular disease. METHODS: Four medical databases (Cochrane Library, MEDLINE, PsycINFO and CINAHL+) were searched using a PICO framework, publishing a total of 782 results. Of the 782 records identified, 23 were included to inform this review, including an additional article found from bibliography searching.","source_id":"source_5","support_kind":"candidate_source_row"}]},{"claim_id":"claim_21","claim":"1 included source were assigned to this outcome class. Directional coding: null=1. Directness coding: indirect=1.","citation_support":[],"candidate_sources":[{"study":"Steam-assisted respiratory muscle training may improve sleep quality in mild-to-moderate obstructive sleep apnea: a pilot polysomnography study","year":2026,"doi":"10.1007/s44470-025-00036-w","url":"https://doi.org/10.1007/s44470-025-00036-w","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"primary","cited_as":"Al-Rammahi 2026","excerpt":"STUDY OBJECTIVES: Obstructive sleep apnea (OSA) impairs sleep and respiration, and sub-optimal adherence to its gold-standard CPAP therapy compels development of alternative approaches. This study investigates the effects of steam-assisted respiratory muscle training (RMT) on polysomnographic (PSG) outcomes in patients with OSA. METHODS: In a 12-week open-label prospective pilot study, 60 working participants with mild to moderate OSA underwent individualized inspiratory and expiratory resistance training with adjunctive steam inhalation. PSG was conducted pre- and post-intervention. Primary outcomes included changes in respiratory indices (AHI, ODI₃, CT₉₀) and sleep quality metrics (sleep efficiency, WASO). Statistical analyses included the Shapiro-Wilk normality test, Paired T, Welch, or Wilcoxon comparing visits, Wilson CIs reporting responders, Mann-Whitney and Fisher assessing associations, regression predicting change, with significance set at p < 0.05. RESULTS: Of 60 participants, 33 completed the study. Primary outcomes-respiratory indices and sleep continuity metrics-remained unchanged (all p > 0.05).","source_id":"source_1","support_kind":"candidate_source_row"},{"study":"Association of reduced REM sleep with mortality in adults with coronary artery disease and obstructive sleep apnea in the RICCADSA cohort","year":2026,"doi":"10.1007/s11325-026-03614-1","url":"https://doi.org/10.1007/s11325-026-03614-1","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"primary","cited_as":"Balcan 2026","excerpt":"PURPOSE: Reduced rapid-eye movement (REM) sleep has been linked to increased mortality in the general population. We investigated whether diminished REM sleep is associated with higher mortality in adults with coronary artery disease (CAD) and obstructive sleep apnea (OSA). METHODS: This secondary analysis of the RICCADSA trial included 356 revascularized CAD patients with OSA (apnea-hypopnea index [AHI] ≥ 15 events/h) and total sleep time (TST) ≥ 240 min on baseline polysomnography. Reduced REM sleep was defined as the lowest quartile of REM percentage. Cox proportional hazards models assessed the association between reduced REM sleep and mortality over a median 4.7-year follow-up. RESULTS: The lowest REM quartile corresponded to 8.7% of TST. Participants with reduced REM sleep (n = 86) were older (66.0 ± 8.1 vs. 63.0 ± 8.0 years; p = 0.035), had higher BMI (29.8 ± 4.6 vs. 28.7 ± 3.8 kg/m²; p = 0.010), shorter TST (369 ± 77 vs. 497 ± 69 min; p < 0.001), less slow-wave sleep (5.2 ± 7.0% vs. 8.1 ± 10.0%; p = 0.007), and higher AHI (54.4 ± 26.3 vs. 35.6 ± 20.1 events/h; p < 0.001) than those with REM ≥ 8.7% (n = 270). Mortality was 12.8% in the reduced REM group versus 4.","source_id":"source_2","support_kind":"candidate_source_row"},{"study":"Predicting sleep apnea worsening and cardiometabolic risk without treatment","year":2026,"doi":"10.1007/s11325-026-03617-y","url":"https://doi.org/10.1007/s11325-026-03617-y","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"primary","cited_as":"Lavie 2026","excerpt":"PURPOSE: The natural history of untreated obstructive sleep apnea (OSA) and its cardiometabolic consequences are not fully characterized. We aimed to identify predictors of apnea severity progression and incident cardiometabolic comorbidities in untreated patients, comparing continuous and categorical measures of apnea severity. METHODS: We retrospectively studied 538 adults (419 men, 119 women) who underwent two attended overnight polysomnographic evaluations separated by 3.8 ± 2.7 years and declined OSA treatment. Changes in apnea severity were assessed using continuous change in apnea-hypopnea index (ΔAHI) and categorical transitions across standard severity thresholds. Multivariable linear regression was used to identify predictors of ΔAHI, and multivariable logistic regression was used to identify predictors of incident hypertension, diabetes, and cardiovascular disease. RESULTS: Apnea severity and nocturnal hypoxemia worsened significantly over time.","source_id":"source_3","support_kind":"candidate_source_row"},{"study":"Prevalence of Obstructive Sleep Apnea and Adherence to CPAP for TAXI Drivers","year":2026,"doi":"10.3390/clockssleep8010004","url":"https://doi.org/10.3390/clockssleep8010004","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"primary","cited_as":"Chan 2026","excerpt":"We investigated the effects of Continuous Positive Airway Pressure (CPAP) on blood pressure (BP) and vigilance in taxi drivers with obstructive sleep apnea (OSA). This pilot study recruited taxi drivers aged ≥60 years to undergo polysomnography. Those diagnosed with OSA underwent 6 months of CPAP therapy. Baseline and follow-up assessments included 24 h ambulatory blood pressure monitoring (ABPM) and the psychomotor vigilance test (PVT). Among the 32 participants, 22 (68.8%) were diagnosed with OSA (median age 63.0 [62.0-65.0] years; 21 males). The average CPAP adherence was 3.1 ± 2.3 h per night, with 23.5% using CPAP for more than 4 h per night. There were no significant changes in 24 h mean systolic ABPM (125.9 [116.8-134.9] mmHg to 126.0 [118.3-133.7] mmHg; p = 0.93) or reaction times measured by PVT (2.0 [0.0-3.0] lapses to 2.0 [1.0-3.0] lapses; p = 0.82) after CPAP therapy. A high prevalence of OSA was observed among taxi drivers. CPAP adherence was suboptimal and did not result in significant improvements in BP or vigilance.","source_id":"source_4","support_kind":"candidate_source_row"},{"study":"Could behaviour change interventions be incorporated into cardiac rehabilitation programmes for insomnia and poor sleep quality management? A scoping review","year":2026,"doi":"10.1007/s11325-026-03707-x","url":"https://doi.org/10.1007/s11325-026-03707-x","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"review-level","cited_as":"White 2026","excerpt":"BACKGROUND: Cardiovascular disease (CVD) is caused by modifiable and non-modifiable risk factors and is consistently recognised as a leading cause of morbidity and mortality. Poor sleep caused by sleep disorders such as insomnia are linked to increased mortality in patients with CVD, yet it is routinely overlooked as a cause to treat. Furthermore, despite the impact of sleep disorders, management strategies are notably underrepresented in cardiac care guidelines and cardiac rehabilitation. AIM OF REVIEW: This scoping review aimed to assemble recent published literature to explore how behaviour change interventions could be utilised as a method to integrate sleep management strategies into state-of-the-art cardiac rehabilitation for patients with cardiovascular disease. METHODS: Four medical databases (Cochrane Library, MEDLINE, PsycINFO and CINAHL+) were searched using a PICO framework, publishing a total of 782 results. Of the 782 records identified, 23 were included to inform this review, including an additional article found from bibliography searching.","source_id":"source_5","support_kind":"candidate_source_row"}]},{"claim_id":"claim_22","claim":"Verification note:** Reference-only or no-abstract records are treated as verification-limited context, not as equal-weight support for the main claim.","citation_support":[],"candidate_sources":[{"study":"Steam-assisted respiratory muscle training may improve sleep quality in mild-to-moderate obstructive sleep apnea: a pilot polysomnography study","year":2026,"doi":"10.1007/s44470-025-00036-w","url":"https://doi.org/10.1007/s44470-025-00036-w","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"primary","cited_as":"Al-Rammahi 2026","excerpt":"STUDY OBJECTIVES: Obstructive sleep apnea (OSA) impairs sleep and respiration, and sub-optimal adherence to its gold-standard CPAP therapy compels development of alternative approaches. This study investigates the effects of steam-assisted respiratory muscle training (RMT) on polysomnographic (PSG) outcomes in patients with OSA. METHODS: In a 12-week open-label prospective pilot study, 60 working participants with mild to moderate OSA underwent individualized inspiratory and expiratory resistance training with adjunctive steam inhalation. PSG was conducted pre- and post-intervention. Primary outcomes included changes in respiratory indices (AHI, ODI₃, CT₉₀) and sleep quality metrics (sleep efficiency, WASO). Statistical analyses included the Shapiro-Wilk normality test, Paired T, Welch, or Wilcoxon comparing visits, Wilson CIs reporting responders, Mann-Whitney and Fisher assessing associations, regression predicting change, with significance set at p < 0.05. RESULTS: Of 60 participants, 33 completed the study. Primary outcomes-respiratory indices and sleep continuity metrics-remained unchanged (all p > 0.05).","source_id":"source_1","support_kind":"candidate_source_row"},{"study":"Association of reduced REM sleep with mortality in adults with coronary artery disease and obstructive sleep apnea in the RICCADSA cohort","year":2026,"doi":"10.1007/s11325-026-03614-1","url":"https://doi.org/10.1007/s11325-026-03614-1","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"primary","cited_as":"Balcan 2026","excerpt":"PURPOSE: Reduced rapid-eye movement (REM) sleep has been linked to increased mortality in the general population. We investigated whether diminished REM sleep is associated with higher mortality in adults with coronary artery disease (CAD) and obstructive sleep apnea (OSA). METHODS: This secondary analysis of the RICCADSA trial included 356 revascularized CAD patients with OSA (apnea-hypopnea index [AHI] ≥ 15 events/h) and total sleep time (TST) ≥ 240 min on baseline polysomnography. Reduced REM sleep was defined as the lowest quartile of REM percentage. Cox proportional hazards models assessed the association between reduced REM sleep and mortality over a median 4.7-year follow-up. RESULTS: The lowest REM quartile corresponded to 8.7% of TST. Participants with reduced REM sleep (n = 86) were older (66.0 ± 8.1 vs. 63.0 ± 8.0 years; p = 0.035), had higher BMI (29.8 ± 4.6 vs. 28.7 ± 3.8 kg/m²; p = 0.010), shorter TST (369 ± 77 vs. 497 ± 69 min; p < 0.001), less slow-wave sleep (5.2 ± 7.0% vs. 8.1 ± 10.0%; p = 0.007), and higher AHI (54.4 ± 26.3 vs. 35.6 ± 20.1 events/h; p < 0.001) than those with REM ≥ 8.7% (n = 270). Mortality was 12.8% in the reduced REM group versus 4.","source_id":"source_2","support_kind":"candidate_source_row"},{"study":"Predicting sleep apnea worsening and cardiometabolic risk without treatment","year":2026,"doi":"10.1007/s11325-026-03617-y","url":"https://doi.org/10.1007/s11325-026-03617-y","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"primary","cited_as":"Lavie 2026","excerpt":"PURPOSE: The natural history of untreated obstructive sleep apnea (OSA) and its cardiometabolic consequences are not fully characterized. We aimed to identify predictors of apnea severity progression and incident cardiometabolic comorbidities in untreated patients, comparing continuous and categorical measures of apnea severity. METHODS: We retrospectively studied 538 adults (419 men, 119 women) who underwent two attended overnight polysomnographic evaluations separated by 3.8 ± 2.7 years and declined OSA treatment. Changes in apnea severity were assessed using continuous change in apnea-hypopnea index (ΔAHI) and categorical transitions across standard severity thresholds. Multivariable linear regression was used to identify predictors of ΔAHI, and multivariable logistic regression was used to identify predictors of incident hypertension, diabetes, and cardiovascular disease. RESULTS: Apnea severity and nocturnal hypoxemia worsened significantly over time.","source_id":"source_3","support_kind":"candidate_source_row"},{"study":"Prevalence of Obstructive Sleep Apnea and Adherence to CPAP for TAXI Drivers","year":2026,"doi":"10.3390/clockssleep8010004","url":"https://doi.org/10.3390/clockssleep8010004","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"primary","cited_as":"Chan 2026","excerpt":"We investigated the effects of Continuous Positive Airway Pressure (CPAP) on blood pressure (BP) and vigilance in taxi drivers with obstructive sleep apnea (OSA). This pilot study recruited taxi drivers aged ≥60 years to undergo polysomnography. Those diagnosed with OSA underwent 6 months of CPAP therapy. Baseline and follow-up assessments included 24 h ambulatory blood pressure monitoring (ABPM) and the psychomotor vigilance test (PVT). Among the 32 participants, 22 (68.8%) were diagnosed with OSA (median age 63.0 [62.0-65.0] years; 21 males). The average CPAP adherence was 3.1 ± 2.3 h per night, with 23.5% using CPAP for more than 4 h per night. There were no significant changes in 24 h mean systolic ABPM (125.9 [116.8-134.9] mmHg to 126.0 [118.3-133.7] mmHg; p = 0.93) or reaction times measured by PVT (2.0 [0.0-3.0] lapses to 2.0 [1.0-3.0] lapses; p = 0.82) after CPAP therapy. A high prevalence of OSA was observed among taxi drivers. CPAP adherence was suboptimal and did not result in significant improvements in BP or vigilance.","source_id":"source_4","support_kind":"candidate_source_row"},{"study":"Could behaviour change interventions be incorporated into cardiac rehabilitation programmes for insomnia and poor sleep quality management? A scoping review","year":2026,"doi":"10.1007/s11325-026-03707-x","url":"https://doi.org/10.1007/s11325-026-03707-x","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"review-level","cited_as":"White 2026","excerpt":"BACKGROUND: Cardiovascular disease (CVD) is caused by modifiable and non-modifiable risk factors and is consistently recognised as a leading cause of morbidity and mortality. Poor sleep caused by sleep disorders such as insomnia are linked to increased mortality in patients with CVD, yet it is routinely overlooked as a cause to treat. Furthermore, despite the impact of sleep disorders, management strategies are notably underrepresented in cardiac care guidelines and cardiac rehabilitation. AIM OF REVIEW: This scoping review aimed to assemble recent published literature to explore how behaviour change interventions could be utilised as a method to integrate sleep management strategies into state-of-the-art cardiac rehabilitation for patients with cardiovascular disease. METHODS: Four medical databases (Cochrane Library, MEDLINE, PsycINFO and CINAHL+) were searched using a PICO framework, publishing a total of 782 results. Of the 782 records identified, 23 were included to inform this review, including an additional article found from bibliography searching.","source_id":"source_5","support_kind":"candidate_source_row"}]},{"claim_id":"claim_23","claim":"The curated corpus does not contain any long-term mortality randomized controlled trial in non-diabetic adults with sleep-disordered breathing, which means that the hard-outcome claims that anchor the headline framing rest on observational associations rather than randomized evidence. The lack of any trial with all-cause mortality as the primary endpoint, in any population, means the synthesizing claim that sleep-health optimization extends lifespan remains underdetermined by the present corpus.","citation_support":[],"candidate_sources":[{"study":"Steam-assisted respiratory muscle training may improve sleep quality in mild-to-moderate obstructive sleep apnea: a pilot polysomnography study","year":2026,"doi":"10.1007/s44470-025-00036-w","url":"https://doi.org/10.1007/s44470-025-00036-w","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"primary","cited_as":"Al-Rammahi 2026","excerpt":"STUDY OBJECTIVES: Obstructive sleep apnea (OSA) impairs sleep and respiration, and sub-optimal adherence to its gold-standard CPAP therapy compels development of alternative approaches. This study investigates the effects of steam-assisted respiratory muscle training (RMT) on polysomnographic (PSG) outcomes in patients with OSA. METHODS: In a 12-week open-label prospective pilot study, 60 working participants with mild to moderate OSA underwent individualized inspiratory and expiratory resistance training with adjunctive steam inhalation. PSG was conducted pre- and post-intervention. Primary outcomes included changes in respiratory indices (AHI, ODI₃, CT₉₀) and sleep quality metrics (sleep efficiency, WASO). Statistical analyses included the Shapiro-Wilk normality test, Paired T, Welch, or Wilcoxon comparing visits, Wilson CIs reporting responders, Mann-Whitney and Fisher assessing associations, regression predicting change, with significance set at p < 0.05. RESULTS: Of 60 participants, 33 completed the study. Primary outcomes-respiratory indices and sleep continuity metrics-remained unchanged (all p > 0.05).","source_id":"source_1","support_kind":"candidate_source_row"},{"study":"Association of reduced REM sleep with mortality in adults with coronary artery disease and obstructive sleep apnea in the RICCADSA cohort","year":2026,"doi":"10.1007/s11325-026-03614-1","url":"https://doi.org/10.1007/s11325-026-03614-1","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"primary","cited_as":"Balcan 2026","excerpt":"PURPOSE: Reduced rapid-eye movement (REM) sleep has been linked to increased mortality in the general population. We investigated whether diminished REM sleep is associated with higher mortality in adults with coronary artery disease (CAD) and obstructive sleep apnea (OSA). METHODS: This secondary analysis of the RICCADSA trial included 356 revascularized CAD patients with OSA (apnea-hypopnea index [AHI] ≥ 15 events/h) and total sleep time (TST) ≥ 240 min on baseline polysomnography. Reduced REM sleep was defined as the lowest quartile of REM percentage. Cox proportional hazards models assessed the association between reduced REM sleep and mortality over a median 4.7-year follow-up. RESULTS: The lowest REM quartile corresponded to 8.7% of TST. Participants with reduced REM sleep (n = 86) were older (66.0 ± 8.1 vs. 63.0 ± 8.0 years; p = 0.035), had higher BMI (29.8 ± 4.6 vs. 28.7 ± 3.8 kg/m²; p = 0.010), shorter TST (369 ± 77 vs. 497 ± 69 min; p < 0.001), less slow-wave sleep (5.2 ± 7.0% vs. 8.1 ± 10.0%; p = 0.007), and higher AHI (54.4 ± 26.3 vs. 35.6 ± 20.1 events/h; p < 0.001) than those with REM ≥ 8.7% (n = 270). Mortality was 12.8% in the reduced REM group versus 4.","source_id":"source_2","support_kind":"candidate_source_row"},{"study":"Predicting sleep apnea worsening and cardiometabolic risk without treatment","year":2026,"doi":"10.1007/s11325-026-03617-y","url":"https://doi.org/10.1007/s11325-026-03617-y","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"primary","cited_as":"Lavie 2026","excerpt":"PURPOSE: The natural history of untreated obstructive sleep apnea (OSA) and its cardiometabolic consequences are not fully characterized. We aimed to identify predictors of apnea severity progression and incident cardiometabolic comorbidities in untreated patients, comparing continuous and categorical measures of apnea severity. METHODS: We retrospectively studied 538 adults (419 men, 119 women) who underwent two attended overnight polysomnographic evaluations separated by 3.8 ± 2.7 years and declined OSA treatment. Changes in apnea severity were assessed using continuous change in apnea-hypopnea index (ΔAHI) and categorical transitions across standard severity thresholds. Multivariable linear regression was used to identify predictors of ΔAHI, and multivariable logistic regression was used to identify predictors of incident hypertension, diabetes, and cardiovascular disease. RESULTS: Apnea severity and nocturnal hypoxemia worsened significantly over time.","source_id":"source_3","support_kind":"candidate_source_row"},{"study":"Prevalence of Obstructive Sleep Apnea and Adherence to CPAP for TAXI Drivers","year":2026,"doi":"10.3390/clockssleep8010004","url":"https://doi.org/10.3390/clockssleep8010004","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"primary","cited_as":"Chan 2026","excerpt":"We investigated the effects of Continuous Positive Airway Pressure (CPAP) on blood pressure (BP) and vigilance in taxi drivers with obstructive sleep apnea (OSA). This pilot study recruited taxi drivers aged ≥60 years to undergo polysomnography. Those diagnosed with OSA underwent 6 months of CPAP therapy. Baseline and follow-up assessments included 24 h ambulatory blood pressure monitoring (ABPM) and the psychomotor vigilance test (PVT). Among the 32 participants, 22 (68.8%) were diagnosed with OSA (median age 63.0 [62.0-65.0] years; 21 males). The average CPAP adherence was 3.1 ± 2.3 h per night, with 23.5% using CPAP for more than 4 h per night. There were no significant changes in 24 h mean systolic ABPM (125.9 [116.8-134.9] mmHg to 126.0 [118.3-133.7] mmHg; p = 0.93) or reaction times measured by PVT (2.0 [0.0-3.0] lapses to 2.0 [1.0-3.0] lapses; p = 0.82) after CPAP therapy. A high prevalence of OSA was observed among taxi drivers. CPAP adherence was suboptimal and did not result in significant improvements in BP or vigilance.","source_id":"source_4","support_kind":"candidate_source_row"},{"study":"Could behaviour change interventions be incorporated into cardiac rehabilitation programmes for insomnia and poor sleep quality management? A scoping review","year":2026,"doi":"10.1007/s11325-026-03707-x","url":"https://doi.org/10.1007/s11325-026-03707-x","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"review-level","cited_as":"White 2026","excerpt":"BACKGROUND: Cardiovascular disease (CVD) is caused by modifiable and non-modifiable risk factors and is consistently recognised as a leading cause of morbidity and mortality. Poor sleep caused by sleep disorders such as insomnia are linked to increased mortality in patients with CVD, yet it is routinely overlooked as a cause to treat. Furthermore, despite the impact of sleep disorders, management strategies are notably underrepresented in cardiac care guidelines and cardiac rehabilitation. AIM OF REVIEW: This scoping review aimed to assemble recent published literature to explore how behaviour change interventions could be utilised as a method to integrate sleep management strategies into state-of-the-art cardiac rehabilitation for patients with cardiovascular disease. METHODS: Four medical databases (Cochrane Library, MEDLINE, PsycINFO and CINAHL+) were searched using a PICO framework, publishing a total of 782 results. Of the 782 records identified, 23 were included to inform this review, including an additional article found from bibliography searching.","source_id":"source_5","support_kind":"candidate_source_row"}]},{"claim_id":"claim_24","claim":"Several outcome classes are touched by a single source, which prevents any within-corpus replication of those findings. Single-trial generalization risk is therefore non-trivial for any claim built on these outcomes.","citation_support":[],"candidate_sources":[{"study":"Steam-assisted respiratory muscle training may improve sleep quality in mild-to-moderate obstructive sleep apnea: a pilot polysomnography study","year":2026,"doi":"10.1007/s44470-025-00036-w","url":"https://doi.org/10.1007/s44470-025-00036-w","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"primary","cited_as":"Al-Rammahi 2026","excerpt":"STUDY OBJECTIVES: Obstructive sleep apnea (OSA) impairs sleep and respiration, and sub-optimal adherence to its gold-standard CPAP therapy compels development of alternative approaches. This study investigates the effects of steam-assisted respiratory muscle training (RMT) on polysomnographic (PSG) outcomes in patients with OSA. METHODS: In a 12-week open-label prospective pilot study, 60 working participants with mild to moderate OSA underwent individualized inspiratory and expiratory resistance training with adjunctive steam inhalation. PSG was conducted pre- and post-intervention. Primary outcomes included changes in respiratory indices (AHI, ODI₃, CT₉₀) and sleep quality metrics (sleep efficiency, WASO). Statistical analyses included the Shapiro-Wilk normality test, Paired T, Welch, or Wilcoxon comparing visits, Wilson CIs reporting responders, Mann-Whitney and Fisher assessing associations, regression predicting change, with significance set at p < 0.05. RESULTS: Of 60 participants, 33 completed the study. Primary outcomes-respiratory indices and sleep continuity metrics-remained unchanged (all p > 0.05).","source_id":"source_1","support_kind":"candidate_source_row"},{"study":"Association of reduced REM sleep with mortality in adults with coronary artery disease and obstructive sleep apnea in the RICCADSA cohort","year":2026,"doi":"10.1007/s11325-026-03614-1","url":"https://doi.org/10.1007/s11325-026-03614-1","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"primary","cited_as":"Balcan 2026","excerpt":"PURPOSE: Reduced rapid-eye movement (REM) sleep has been linked to increased mortality in the general population. We investigated whether diminished REM sleep is associated with higher mortality in adults with coronary artery disease (CAD) and obstructive sleep apnea (OSA). METHODS: This secondary analysis of the RICCADSA trial included 356 revascularized CAD patients with OSA (apnea-hypopnea index [AHI] ≥ 15 events/h) and total sleep time (TST) ≥ 240 min on baseline polysomnography. Reduced REM sleep was defined as the lowest quartile of REM percentage. Cox proportional hazards models assessed the association between reduced REM sleep and mortality over a median 4.7-year follow-up. RESULTS: The lowest REM quartile corresponded to 8.7% of TST. Participants with reduced REM sleep (n = 86) were older (66.0 ± 8.1 vs. 63.0 ± 8.0 years; p = 0.035), had higher BMI (29.8 ± 4.6 vs. 28.7 ± 3.8 kg/m²; p = 0.010), shorter TST (369 ± 77 vs. 497 ± 69 min; p < 0.001), less slow-wave sleep (5.2 ± 7.0% vs. 8.1 ± 10.0%; p = 0.007), and higher AHI (54.4 ± 26.3 vs. 35.6 ± 20.1 events/h; p < 0.001) than those with REM ≥ 8.7% (n = 270). Mortality was 12.8% in the reduced REM group versus 4.","source_id":"source_2","support_kind":"candidate_source_row"},{"study":"Predicting sleep apnea worsening and cardiometabolic risk without treatment","year":2026,"doi":"10.1007/s11325-026-03617-y","url":"https://doi.org/10.1007/s11325-026-03617-y","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"primary","cited_as":"Lavie 2026","excerpt":"PURPOSE: The natural history of untreated obstructive sleep apnea (OSA) and its cardiometabolic consequences are not fully characterized. We aimed to identify predictors of apnea severity progression and incident cardiometabolic comorbidities in untreated patients, comparing continuous and categorical measures of apnea severity. METHODS: We retrospectively studied 538 adults (419 men, 119 women) who underwent two attended overnight polysomnographic evaluations separated by 3.8 ± 2.7 years and declined OSA treatment. Changes in apnea severity were assessed using continuous change in apnea-hypopnea index (ΔAHI) and categorical transitions across standard severity thresholds. Multivariable linear regression was used to identify predictors of ΔAHI, and multivariable logistic regression was used to identify predictors of incident hypertension, diabetes, and cardiovascular disease. RESULTS: Apnea severity and nocturnal hypoxemia worsened significantly over time.","source_id":"source_3","support_kind":"candidate_source_row"},{"study":"Prevalence of Obstructive Sleep Apnea and Adherence to CPAP for TAXI Drivers","year":2026,"doi":"10.3390/clockssleep8010004","url":"https://doi.org/10.3390/clockssleep8010004","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"primary","cited_as":"Chan 2026","excerpt":"We investigated the effects of Continuous Positive Airway Pressure (CPAP) on blood pressure (BP) and vigilance in taxi drivers with obstructive sleep apnea (OSA). This pilot study recruited taxi drivers aged ≥60 years to undergo polysomnography. Those diagnosed with OSA underwent 6 months of CPAP therapy. Baseline and follow-up assessments included 24 h ambulatory blood pressure monitoring (ABPM) and the psychomotor vigilance test (PVT). Among the 32 participants, 22 (68.8%) were diagnosed with OSA (median age 63.0 [62.0-65.0] years; 21 males). The average CPAP adherence was 3.1 ± 2.3 h per night, with 23.5% using CPAP for more than 4 h per night. There were no significant changes in 24 h mean systolic ABPM (125.9 [116.8-134.9] mmHg to 126.0 [118.3-133.7] mmHg; p = 0.93) or reaction times measured by PVT (2.0 [0.0-3.0] lapses to 2.0 [1.0-3.0] lapses; p = 0.82) after CPAP therapy. A high prevalence of OSA was observed among taxi drivers. CPAP adherence was suboptimal and did not result in significant improvements in BP or vigilance.","source_id":"source_4","support_kind":"candidate_source_row"},{"study":"Could behaviour change interventions be incorporated into cardiac rehabilitation programmes for insomnia and poor sleep quality management? A scoping review","year":2026,"doi":"10.1007/s11325-026-03707-x","url":"https://doi.org/10.1007/s11325-026-03707-x","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"review-level","cited_as":"White 2026","excerpt":"BACKGROUND: Cardiovascular disease (CVD) is caused by modifiable and non-modifiable risk factors and is consistently recognised as a leading cause of morbidity and mortality. Poor sleep caused by sleep disorders such as insomnia are linked to increased mortality in patients with CVD, yet it is routinely overlooked as a cause to treat. Furthermore, despite the impact of sleep disorders, management strategies are notably underrepresented in cardiac care guidelines and cardiac rehabilitation. AIM OF REVIEW: This scoping review aimed to assemble recent published literature to explore how behaviour change interventions could be utilised as a method to integrate sleep management strategies into state-of-the-art cardiac rehabilitation for patients with cardiovascular disease. METHODS: Four medical databases (Cochrane Library, MEDLINE, PsycINFO and CINAHL+) were searched using a PICO framework, publishing a total of 782 results. Of the 782 records identified, 23 were included to inform this review, including an additional article found from bibliography searching.","source_id":"source_5","support_kind":"candidate_source_row"}]},{"claim_id":"claim_25","claim":"The population enrolled across the corpus is narrow on several axes that bound external validity. No source in the corpus enrolled children, adolescents, pregnant women, or healthy adults without a clinical sleep complaint, and none reported BMI distributions against the WHO 2000 overweight threshold of 25 kg/m2 or the obesity threshold of 30 kg/m2 in a way that supports stratified inference. The synthesizing claim that sleep health benefits extend to general adult populations therefore cannot be tested within the available evidence.","citation_support":[],"candidate_sources":[{"study":"Steam-assisted respiratory muscle training may improve sleep quality in mild-to-moderate obstructive sleep apnea: a pilot polysomnography study","year":2026,"doi":"10.1007/s44470-025-00036-w","url":"https://doi.org/10.1007/s44470-025-00036-w","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"primary","cited_as":"Al-Rammahi 2026","excerpt":"STUDY OBJECTIVES: Obstructive sleep apnea (OSA) impairs sleep and respiration, and sub-optimal adherence to its gold-standard CPAP therapy compels development of alternative approaches. This study investigates the effects of steam-assisted respiratory muscle training (RMT) on polysomnographic (PSG) outcomes in patients with OSA. METHODS: In a 12-week open-label prospective pilot study, 60 working participants with mild to moderate OSA underwent individualized inspiratory and expiratory resistance training with adjunctive steam inhalation. PSG was conducted pre- and post-intervention. Primary outcomes included changes in respiratory indices (AHI, ODI₃, CT₉₀) and sleep quality metrics (sleep efficiency, WASO). Statistical analyses included the Shapiro-Wilk normality test, Paired T, Welch, or Wilcoxon comparing visits, Wilson CIs reporting responders, Mann-Whitney and Fisher assessing associations, regression predicting change, with significance set at p < 0.05. RESULTS: Of 60 participants, 33 completed the study. Primary outcomes-respiratory indices and sleep continuity metrics-remained unchanged (all p > 0.05).","source_id":"source_1","support_kind":"candidate_source_row"},{"study":"Association of reduced REM sleep with mortality in adults with coronary artery disease and obstructive sleep apnea in the RICCADSA cohort","year":2026,"doi":"10.1007/s11325-026-03614-1","url":"https://doi.org/10.1007/s11325-026-03614-1","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"primary","cited_as":"Balcan 2026","excerpt":"PURPOSE: Reduced rapid-eye movement (REM) sleep has been linked to increased mortality in the general population. We investigated whether diminished REM sleep is associated with higher mortality in adults with coronary artery disease (CAD) and obstructive sleep apnea (OSA). METHODS: This secondary analysis of the RICCADSA trial included 356 revascularized CAD patients with OSA (apnea-hypopnea index [AHI] ≥ 15 events/h) and total sleep time (TST) ≥ 240 min on baseline polysomnography. Reduced REM sleep was defined as the lowest quartile of REM percentage. Cox proportional hazards models assessed the association between reduced REM sleep and mortality over a median 4.7-year follow-up. RESULTS: The lowest REM quartile corresponded to 8.7% of TST. Participants with reduced REM sleep (n = 86) were older (66.0 ± 8.1 vs. 63.0 ± 8.0 years; p = 0.035), had higher BMI (29.8 ± 4.6 vs. 28.7 ± 3.8 kg/m²; p = 0.010), shorter TST (369 ± 77 vs. 497 ± 69 min; p < 0.001), less slow-wave sleep (5.2 ± 7.0% vs. 8.1 ± 10.0%; p = 0.007), and higher AHI (54.4 ± 26.3 vs. 35.6 ± 20.1 events/h; p < 0.001) than those with REM ≥ 8.7% (n = 270). Mortality was 12.8% in the reduced REM group versus 4.","source_id":"source_2","support_kind":"candidate_source_row"},{"study":"Predicting sleep apnea worsening and cardiometabolic risk without treatment","year":2026,"doi":"10.1007/s11325-026-03617-y","url":"https://doi.org/10.1007/s11325-026-03617-y","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"primary","cited_as":"Lavie 2026","excerpt":"PURPOSE: The natural history of untreated obstructive sleep apnea (OSA) and its cardiometabolic consequences are not fully characterized. We aimed to identify predictors of apnea severity progression and incident cardiometabolic comorbidities in untreated patients, comparing continuous and categorical measures of apnea severity. METHODS: We retrospectively studied 538 adults (419 men, 119 women) who underwent two attended overnight polysomnographic evaluations separated by 3.8 ± 2.7 years and declined OSA treatment. Changes in apnea severity were assessed using continuous change in apnea-hypopnea index (ΔAHI) and categorical transitions across standard severity thresholds. Multivariable linear regression was used to identify predictors of ΔAHI, and multivariable logistic regression was used to identify predictors of incident hypertension, diabetes, and cardiovascular disease. RESULTS: Apnea severity and nocturnal hypoxemia worsened significantly over time.","source_id":"source_3","support_kind":"candidate_source_row"},{"study":"Prevalence of Obstructive Sleep Apnea and Adherence to CPAP for TAXI Drivers","year":2026,"doi":"10.3390/clockssleep8010004","url":"https://doi.org/10.3390/clockssleep8010004","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"primary","cited_as":"Chan 2026","excerpt":"We investigated the effects of Continuous Positive Airway Pressure (CPAP) on blood pressure (BP) and vigilance in taxi drivers with obstructive sleep apnea (OSA). This pilot study recruited taxi drivers aged ≥60 years to undergo polysomnography. Those diagnosed with OSA underwent 6 months of CPAP therapy. Baseline and follow-up assessments included 24 h ambulatory blood pressure monitoring (ABPM) and the psychomotor vigilance test (PVT). Among the 32 participants, 22 (68.8%) were diagnosed with OSA (median age 63.0 [62.0-65.0] years; 21 males). The average CPAP adherence was 3.1 ± 2.3 h per night, with 23.5% using CPAP for more than 4 h per night. There were no significant changes in 24 h mean systolic ABPM (125.9 [116.8-134.9] mmHg to 126.0 [118.3-133.7] mmHg; p = 0.93) or reaction times measured by PVT (2.0 [0.0-3.0] lapses to 2.0 [1.0-3.0] lapses; p = 0.82) after CPAP therapy. A high prevalence of OSA was observed among taxi drivers. CPAP adherence was suboptimal and did not result in significant improvements in BP or vigilance.","source_id":"source_4","support_kind":"candidate_source_row"},{"study":"Could behaviour change interventions be incorporated into cardiac rehabilitation programmes for insomnia and poor sleep quality management? A scoping review","year":2026,"doi":"10.1007/s11325-026-03707-x","url":"https://doi.org/10.1007/s11325-026-03707-x","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"review-level","cited_as":"White 2026","excerpt":"BACKGROUND: Cardiovascular disease (CVD) is caused by modifiable and non-modifiable risk factors and is consistently recognised as a leading cause of morbidity and mortality. Poor sleep caused by sleep disorders such as insomnia are linked to increased mortality in patients with CVD, yet it is routinely overlooked as a cause to treat. Furthermore, despite the impact of sleep disorders, management strategies are notably underrepresented in cardiac care guidelines and cardiac rehabilitation. AIM OF REVIEW: This scoping review aimed to assemble recent published literature to explore how behaviour change interventions could be utilised as a method to integrate sleep management strategies into state-of-the-art cardiac rehabilitation for patients with cardiovascular disease. METHODS: Four medical databases (Cochrane Library, MEDLINE, PsycINFO and CINAHL+) were searched using a PICO framework, publishing a total of 782 results. Of the 782 records identified, 23 were included to inform this review, including an additional article found from bibliography searching.","source_id":"source_5","support_kind":"candidate_source_row"}]},{"claim_id":"claim_26","claim":"The endpoint scope of the corpus is dominated by surrogate and intermediate measures rather than hard clinical events. The endpoints that are measured cluster around apnea-hypopnea index, CPAP adherence hours, polysomnographic continuity metrics, ISI scores, blood-pressure trajectories, and quality-of-life scales, with very few studies reporting incident cardiovascular events, incident diabetes, or mortality. The Yan 2026 summary on CBT-I in chronic insomnia and the White 2026 scoping review similarly report only intermediate sleep-quality endpoints, leaving the downstream clinical translation of any improvement under-evidenced.","citation_support":[{"source_id":"source_5","study":"Could behaviour change interventions be incorporated into cardiac rehabilitation programmes for insomnia and poor sleep quality management? A scoping review","doi":"10.1007/s11325-026-03707-x","url":"https://doi.org/10.1007/s11325-026-03707-x","support_kind":"cited_as_match","cited_as":"White 2026","population":"not extracted","endpoint":"not extracted","effect":"not extracted","directness":"review-level","excerpt":"BACKGROUND: Cardiovascular disease (CVD) is caused by modifiable and non-modifiable risk factors and is consistently recognised as a leading cause of morbidity and mortality. Poor sleep caused by sleep disorders such as insomnia are linked to increased mortality in patients with CVD, yet it is routinely overlooked as a cause to treat. Furthermore, despite the impact of sleep disorders, management strategies are notably underrepresented in cardiac care guidelines and cardiac rehabilitation. AIM OF REVIEW: This scoping review aimed to assemble recent published literature to explore how behaviour change interventions could be utilised as a method to integrate sleep management strategies into state-of-the-art cardiac rehabilitation for patients with cardiovascular disease. METHODS: Four medical databases (Cochrane Library, MEDLINE, PsycINFO and CINAHL+) were searched using a PICO framework, publishing a total of 782 results. Of the 782 records identified, 23 were included to inform this review, including an additional article found from bibliography searching."},{"source_id":"source_8","study":"Summary of the best evidence that cognitive behavioral therapy for insomnia improves sleep quality in patients with chronic insomnia","doi":"10.3389/fpsyt.2025.1688561","url":"https://doi.org/10.3389/fpsyt.2025.1688561","support_kind":"cited_as_match","cited_as":"Yan 2026","population":"not extracted","endpoint":"not extracted","effect":"not extracted","directness":"primary","excerpt":"AIM: To evaluate and summarize the best available evidence regarding the efficacy of cognitive behavioral therapy for insomnia (CBT-I) in improving sleep quality in patients with chronic insomnia and to provide structured, evidence-based recommendations for clinical nursing practice. DESIGN: This evidence summary was conducted using the PIPOST model from the Center for Evidence-Based Nursing at Fudan University, which guided the development of structured evidence-based questions. METHODS: A systematic search was performed across multiple databases and guideline repositories for literature published from inception to December 10, 2024. Literature types included clinical guidelines, best practice information sheets, expert consensuses, systematic reviews, evidence summaries, and meta-analyses. Databases searched included UpToDate, BMJ Best Practice, Joanna Briggs Institute, Guidelines International Network, National Institute for Health and Care Excellence, Embase, PubMed, Web of Science, MEDLINE, CNKI, and WanFang."}],"candidate_sources":[]},{"claim_id":"claim_27","claim":"Mechanistic plausibility for the cardiometabolic and longevity claims exceeds the human-outcome evidence within the corpus. The mechanism-to-clinic gap therefore remains the dominant boundary condition on the synthesizing claim.","citation_support":[],"candidate_sources":[{"study":"Steam-assisted respiratory muscle training may improve sleep quality in mild-to-moderate obstructive sleep apnea: a pilot polysomnography study","year":2026,"doi":"10.1007/s44470-025-00036-w","url":"https://doi.org/10.1007/s44470-025-00036-w","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"primary","cited_as":"Al-Rammahi 2026","excerpt":"STUDY OBJECTIVES: Obstructive sleep apnea (OSA) impairs sleep and respiration, and sub-optimal adherence to its gold-standard CPAP therapy compels development of alternative approaches. This study investigates the effects of steam-assisted respiratory muscle training (RMT) on polysomnographic (PSG) outcomes in patients with OSA. METHODS: In a 12-week open-label prospective pilot study, 60 working participants with mild to moderate OSA underwent individualized inspiratory and expiratory resistance training with adjunctive steam inhalation. PSG was conducted pre- and post-intervention. Primary outcomes included changes in respiratory indices (AHI, ODI₃, CT₉₀) and sleep quality metrics (sleep efficiency, WASO). Statistical analyses included the Shapiro-Wilk normality test, Paired T, Welch, or Wilcoxon comparing visits, Wilson CIs reporting responders, Mann-Whitney and Fisher assessing associations, regression predicting change, with significance set at p < 0.05. RESULTS: Of 60 participants, 33 completed the study. Primary outcomes-respiratory indices and sleep continuity metrics-remained unchanged (all p > 0.05).","source_id":"source_1","support_kind":"candidate_source_row"},{"study":"Association of reduced REM sleep with mortality in adults with coronary artery disease and obstructive sleep apnea in the RICCADSA cohort","year":2026,"doi":"10.1007/s11325-026-03614-1","url":"https://doi.org/10.1007/s11325-026-03614-1","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"primary","cited_as":"Balcan 2026","excerpt":"PURPOSE: Reduced rapid-eye movement (REM) sleep has been linked to increased mortality in the general population. We investigated whether diminished REM sleep is associated with higher mortality in adults with coronary artery disease (CAD) and obstructive sleep apnea (OSA). METHODS: This secondary analysis of the RICCADSA trial included 356 revascularized CAD patients with OSA (apnea-hypopnea index [AHI] ≥ 15 events/h) and total sleep time (TST) ≥ 240 min on baseline polysomnography. Reduced REM sleep was defined as the lowest quartile of REM percentage. Cox proportional hazards models assessed the association between reduced REM sleep and mortality over a median 4.7-year follow-up. RESULTS: The lowest REM quartile corresponded to 8.7% of TST. Participants with reduced REM sleep (n = 86) were older (66.0 ± 8.1 vs. 63.0 ± 8.0 years; p = 0.035), had higher BMI (29.8 ± 4.6 vs. 28.7 ± 3.8 kg/m²; p = 0.010), shorter TST (369 ± 77 vs. 497 ± 69 min; p < 0.001), less slow-wave sleep (5.2 ± 7.0% vs. 8.1 ± 10.0%; p = 0.007), and higher AHI (54.4 ± 26.3 vs. 35.6 ± 20.1 events/h; p < 0.001) than those with REM ≥ 8.7% (n = 270). Mortality was 12.8% in the reduced REM group versus 4.","source_id":"source_2","support_kind":"candidate_source_row"},{"study":"Predicting sleep apnea worsening and cardiometabolic risk without treatment","year":2026,"doi":"10.1007/s11325-026-03617-y","url":"https://doi.org/10.1007/s11325-026-03617-y","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"primary","cited_as":"Lavie 2026","excerpt":"PURPOSE: The natural history of untreated obstructive sleep apnea (OSA) and its cardiometabolic consequences are not fully characterized. We aimed to identify predictors of apnea severity progression and incident cardiometabolic comorbidities in untreated patients, comparing continuous and categorical measures of apnea severity. METHODS: We retrospectively studied 538 adults (419 men, 119 women) who underwent two attended overnight polysomnographic evaluations separated by 3.8 ± 2.7 years and declined OSA treatment. Changes in apnea severity were assessed using continuous change in apnea-hypopnea index (ΔAHI) and categorical transitions across standard severity thresholds. Multivariable linear regression was used to identify predictors of ΔAHI, and multivariable logistic regression was used to identify predictors of incident hypertension, diabetes, and cardiovascular disease. RESULTS: Apnea severity and nocturnal hypoxemia worsened significantly over time.","source_id":"source_3","support_kind":"candidate_source_row"},{"study":"Prevalence of Obstructive Sleep Apnea and Adherence to CPAP for TAXI Drivers","year":2026,"doi":"10.3390/clockssleep8010004","url":"https://doi.org/10.3390/clockssleep8010004","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"primary","cited_as":"Chan 2026","excerpt":"We investigated the effects of Continuous Positive Airway Pressure (CPAP) on blood pressure (BP) and vigilance in taxi drivers with obstructive sleep apnea (OSA). This pilot study recruited taxi drivers aged ≥60 years to undergo polysomnography. Those diagnosed with OSA underwent 6 months of CPAP therapy. Baseline and follow-up assessments included 24 h ambulatory blood pressure monitoring (ABPM) and the psychomotor vigilance test (PVT). Among the 32 participants, 22 (68.8%) were diagnosed with OSA (median age 63.0 [62.0-65.0] years; 21 males). The average CPAP adherence was 3.1 ± 2.3 h per night, with 23.5% using CPAP for more than 4 h per night. There were no significant changes in 24 h mean systolic ABPM (125.9 [116.8-134.9] mmHg to 126.0 [118.3-133.7] mmHg; p = 0.93) or reaction times measured by PVT (2.0 [0.0-3.0] lapses to 2.0 [1.0-3.0] lapses; p = 0.82) after CPAP therapy. A high prevalence of OSA was observed among taxi drivers. CPAP adherence was suboptimal and did not result in significant improvements in BP or vigilance.","source_id":"source_4","support_kind":"candidate_source_row"},{"study":"Could behaviour change interventions be incorporated into cardiac rehabilitation programmes for insomnia and poor sleep quality management? A scoping review","year":2026,"doi":"10.1007/s11325-026-03707-x","url":"https://doi.org/10.1007/s11325-026-03707-x","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"review-level","cited_as":"White 2026","excerpt":"BACKGROUND: Cardiovascular disease (CVD) is caused by modifiable and non-modifiable risk factors and is consistently recognised as a leading cause of morbidity and mortality. Poor sleep caused by sleep disorders such as insomnia are linked to increased mortality in patients with CVD, yet it is routinely overlooked as a cause to treat. Furthermore, despite the impact of sleep disorders, management strategies are notably underrepresented in cardiac care guidelines and cardiac rehabilitation. AIM OF REVIEW: This scoping review aimed to assemble recent published literature to explore how behaviour change interventions could be utilised as a method to integrate sleep management strategies into state-of-the-art cardiac rehabilitation for patients with cardiovascular disease. METHODS: Four medical databases (Cochrane Library, MEDLINE, PsycINFO and CINAHL+) were searched using a PICO framework, publishing a total of 782 results. Of the 782 records identified, 23 were included to inform this review, including an additional article found from bibliography searching.","source_id":"source_5","support_kind":"candidate_source_row"}]},{"claim_id":"claim_28","claim":"For Sleep health, the final interpretation is deliberately tiered: the retained clinical and adjacent evidence profile defines a bounded geroscience rationale, but the corpus does not support treating mechanistic target engagement, intermediate biomarkers, and patient-relevant outcomes as interchangeable evidence. The closing claim should therefore be read as a map of what the retained studies can support, not as a clinical recommendation or a general anti-aging endorsement. Positive signals identify hypotheses and candidate contexts; null, mixed, or adverse signals identify the boundaries that future work must test directly. The evidence hierarchy remains load-bearing here: direct interventional hard-endpoint records carry more interpretive weight than adjacent clinical evidence, and both carry more translational weight than mechanistic or model systems. A stronger future conclusion would require larger direct human samples, prespecified endpoints, longer follow-up, comparable intervention characterization, transparent safety capture, and a consistent direction of effect across clinically proximate outcomes. Until that evidence exists, the paper's conclusion is that the topic is worth structured follow-up only within the boundaries defined by the included source set. That boundary is not a weakness in the paper; it is the main claim that keeps the synthesis reusable. Readers should carry forward the evidence classes separately: favorable mechanistic or surrogate findings can motivate experiments, indirect human findings can prioritize populations and endpoints, and direct clinical findings define the current ceiling for applied interpretation. The current corpus is non-supportive for clinical efficacy or general health-intervention claims; it supports only hypothesis generation and structured follow-up within the limits of indirect evidence. Any downstream use should preserve that tiered reading rather than compressing the corpus into a simple yes/no verdict for clinical practice or public messaging.","citation_support":[],"candidate_sources":[{"study":"Steam-assisted respiratory muscle training may improve sleep quality in mild-to-moderate obstructive sleep apnea: a pilot polysomnography study","year":2026,"doi":"10.1007/s44470-025-00036-w","url":"https://doi.org/10.1007/s44470-025-00036-w","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"primary","cited_as":"Al-Rammahi 2026","excerpt":"STUDY OBJECTIVES: Obstructive sleep apnea (OSA) impairs sleep and respiration, and sub-optimal adherence to its gold-standard CPAP therapy compels development of alternative approaches. This study investigates the effects of steam-assisted respiratory muscle training (RMT) on polysomnographic (PSG) outcomes in patients with OSA. METHODS: In a 12-week open-label prospective pilot study, 60 working participants with mild to moderate OSA underwent individualized inspiratory and expiratory resistance training with adjunctive steam inhalation. PSG was conducted pre- and post-intervention. Primary outcomes included changes in respiratory indices (AHI, ODI₃, CT₉₀) and sleep quality metrics (sleep efficiency, WASO). Statistical analyses included the Shapiro-Wilk normality test, Paired T, Welch, or Wilcoxon comparing visits, Wilson CIs reporting responders, Mann-Whitney and Fisher assessing associations, regression predicting change, with significance set at p < 0.05. RESULTS: Of 60 participants, 33 completed the study. Primary outcomes-respiratory indices and sleep continuity metrics-remained unchanged (all p > 0.05).","source_id":"source_1","support_kind":"candidate_source_row"},{"study":"Association of reduced REM sleep with mortality in adults with coronary artery disease and obstructive sleep apnea in the RICCADSA cohort","year":2026,"doi":"10.1007/s11325-026-03614-1","url":"https://doi.org/10.1007/s11325-026-03614-1","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"primary","cited_as":"Balcan 2026","excerpt":"PURPOSE: Reduced rapid-eye movement (REM) sleep has been linked to increased mortality in the general population. We investigated whether diminished REM sleep is associated with higher mortality in adults with coronary artery disease (CAD) and obstructive sleep apnea (OSA). METHODS: This secondary analysis of the RICCADSA trial included 356 revascularized CAD patients with OSA (apnea-hypopnea index [AHI] ≥ 15 events/h) and total sleep time (TST) ≥ 240 min on baseline polysomnography. Reduced REM sleep was defined as the lowest quartile of REM percentage. Cox proportional hazards models assessed the association between reduced REM sleep and mortality over a median 4.7-year follow-up. RESULTS: The lowest REM quartile corresponded to 8.7% of TST. Participants with reduced REM sleep (n = 86) were older (66.0 ± 8.1 vs. 63.0 ± 8.0 years; p = 0.035), had higher BMI (29.8 ± 4.6 vs. 28.7 ± 3.8 kg/m²; p = 0.010), shorter TST (369 ± 77 vs. 497 ± 69 min; p < 0.001), less slow-wave sleep (5.2 ± 7.0% vs. 8.1 ± 10.0%; p = 0.007), and higher AHI (54.4 ± 26.3 vs. 35.6 ± 20.1 events/h; p < 0.001) than those with REM ≥ 8.7% (n = 270). Mortality was 12.8% in the reduced REM group versus 4.","source_id":"source_2","support_kind":"candidate_source_row"},{"study":"Predicting sleep apnea worsening and cardiometabolic risk without treatment","year":2026,"doi":"10.1007/s11325-026-03617-y","url":"https://doi.org/10.1007/s11325-026-03617-y","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"primary","cited_as":"Lavie 2026","excerpt":"PURPOSE: The natural history of untreated obstructive sleep apnea (OSA) and its cardiometabolic consequences are not fully characterized. We aimed to identify predictors of apnea severity progression and incident cardiometabolic comorbidities in untreated patients, comparing continuous and categorical measures of apnea severity. METHODS: We retrospectively studied 538 adults (419 men, 119 women) who underwent two attended overnight polysomnographic evaluations separated by 3.8 ± 2.7 years and declined OSA treatment. Changes in apnea severity were assessed using continuous change in apnea-hypopnea index (ΔAHI) and categorical transitions across standard severity thresholds. Multivariable linear regression was used to identify predictors of ΔAHI, and multivariable logistic regression was used to identify predictors of incident hypertension, diabetes, and cardiovascular disease. RESULTS: Apnea severity and nocturnal hypoxemia worsened significantly over time.","source_id":"source_3","support_kind":"candidate_source_row"},{"study":"Prevalence of Obstructive Sleep Apnea and Adherence to CPAP for TAXI Drivers","year":2026,"doi":"10.3390/clockssleep8010004","url":"https://doi.org/10.3390/clockssleep8010004","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"primary","cited_as":"Chan 2026","excerpt":"We investigated the effects of Continuous Positive Airway Pressure (CPAP) on blood pressure (BP) and vigilance in taxi drivers with obstructive sleep apnea (OSA). This pilot study recruited taxi drivers aged ≥60 years to undergo polysomnography. Those diagnosed with OSA underwent 6 months of CPAP therapy. Baseline and follow-up assessments included 24 h ambulatory blood pressure monitoring (ABPM) and the psychomotor vigilance test (PVT). Among the 32 participants, 22 (68.8%) were diagnosed with OSA (median age 63.0 [62.0-65.0] years; 21 males). The average CPAP adherence was 3.1 ± 2.3 h per night, with 23.5% using CPAP for more than 4 h per night. There were no significant changes in 24 h mean systolic ABPM (125.9 [116.8-134.9] mmHg to 126.0 [118.3-133.7] mmHg; p = 0.93) or reaction times measured by PVT (2.0 [0.0-3.0] lapses to 2.0 [1.0-3.0] lapses; p = 0.82) after CPAP therapy. A high prevalence of OSA was observed among taxi drivers. CPAP adherence was suboptimal and did not result in significant improvements in BP or vigilance.","source_id":"source_4","support_kind":"candidate_source_row"},{"study":"Could behaviour change interventions be incorporated into cardiac rehabilitation programmes for insomnia and poor sleep quality management? A scoping review","year":2026,"doi":"10.1007/s11325-026-03707-x","url":"https://doi.org/10.1007/s11325-026-03707-x","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"review-level","cited_as":"White 2026","excerpt":"BACKGROUND: Cardiovascular disease (CVD) is caused by modifiable and non-modifiable risk factors and is consistently recognised as a leading cause of morbidity and mortality. Poor sleep caused by sleep disorders such as insomnia are linked to increased mortality in patients with CVD, yet it is routinely overlooked as a cause to treat. Furthermore, despite the impact of sleep disorders, management strategies are notably underrepresented in cardiac care guidelines and cardiac rehabilitation. AIM OF REVIEW: This scoping review aimed to assemble recent published literature to explore how behaviour change interventions could be utilised as a method to integrate sleep management strategies into state-of-the-art cardiac rehabilitation for patients with cardiovascular disease. METHODS: Four medical databases (Cochrane Library, MEDLINE, PsycINFO and CINAHL+) were searched using a PICO framework, publishing a total of 782 results. Of the 782 records identified, 23 were included to inform this review, including an additional article found from bibliography searching.","source_id":"source_5","support_kind":"candidate_source_row"}]},{"claim_id":"claim_29","claim":"This synthesis maps 13 included sources on Sleep Health across 7 outcome classes and 1 cross-study disagreement. It separates endpoint-specific evidence from broad geroprotection claims so that favorable biomarker signals are not treated as proof of durable healthspan benefit.","citation_support":[],"candidate_sources":[{"study":"Steam-assisted respiratory muscle training may improve sleep quality in mild-to-moderate obstructive sleep apnea: a pilot polysomnography study","year":2026,"doi":"10.1007/s44470-025-00036-w","url":"https://doi.org/10.1007/s44470-025-00036-w","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"primary","cited_as":"Al-Rammahi 2026","excerpt":"STUDY OBJECTIVES: Obstructive sleep apnea (OSA) impairs sleep and respiration, and sub-optimal adherence to its gold-standard CPAP therapy compels development of alternative approaches. This study investigates the effects of steam-assisted respiratory muscle training (RMT) on polysomnographic (PSG) outcomes in patients with OSA. METHODS: In a 12-week open-label prospective pilot study, 60 working participants with mild to moderate OSA underwent individualized inspiratory and expiratory resistance training with adjunctive steam inhalation. PSG was conducted pre- and post-intervention. Primary outcomes included changes in respiratory indices (AHI, ODI₃, CT₉₀) and sleep quality metrics (sleep efficiency, WASO). Statistical analyses included the Shapiro-Wilk normality test, Paired T, Welch, or Wilcoxon comparing visits, Wilson CIs reporting responders, Mann-Whitney and Fisher assessing associations, regression predicting change, with significance set at p < 0.05. RESULTS: Of 60 participants, 33 completed the study. Primary outcomes-respiratory indices and sleep continuity metrics-remained unchanged (all p > 0.05).","source_id":"source_1","support_kind":"candidate_source_row"},{"study":"Association of reduced REM sleep with mortality in adults with coronary artery disease and obstructive sleep apnea in the RICCADSA cohort","year":2026,"doi":"10.1007/s11325-026-03614-1","url":"https://doi.org/10.1007/s11325-026-03614-1","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"primary","cited_as":"Balcan 2026","excerpt":"PURPOSE: Reduced rapid-eye movement (REM) sleep has been linked to increased mortality in the general population. We investigated whether diminished REM sleep is associated with higher mortality in adults with coronary artery disease (CAD) and obstructive sleep apnea (OSA). METHODS: This secondary analysis of the RICCADSA trial included 356 revascularized CAD patients with OSA (apnea-hypopnea index [AHI] ≥ 15 events/h) and total sleep time (TST) ≥ 240 min on baseline polysomnography. Reduced REM sleep was defined as the lowest quartile of REM percentage. Cox proportional hazards models assessed the association between reduced REM sleep and mortality over a median 4.7-year follow-up. RESULTS: The lowest REM quartile corresponded to 8.7% of TST. Participants with reduced REM sleep (n = 86) were older (66.0 ± 8.1 vs. 63.0 ± 8.0 years; p = 0.035), had higher BMI (29.8 ± 4.6 vs. 28.7 ± 3.8 kg/m²; p = 0.010), shorter TST (369 ± 77 vs. 497 ± 69 min; p < 0.001), less slow-wave sleep (5.2 ± 7.0% vs. 8.1 ± 10.0%; p = 0.007), and higher AHI (54.4 ± 26.3 vs. 35.6 ± 20.1 events/h; p < 0.001) than those with REM ≥ 8.7% (n = 270). Mortality was 12.8% in the reduced REM group versus 4.","source_id":"source_2","support_kind":"candidate_source_row"},{"study":"Predicting sleep apnea worsening and cardiometabolic risk without treatment","year":2026,"doi":"10.1007/s11325-026-03617-y","url":"https://doi.org/10.1007/s11325-026-03617-y","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"primary","cited_as":"Lavie 2026","excerpt":"PURPOSE: The natural history of untreated obstructive sleep apnea (OSA) and its cardiometabolic consequences are not fully characterized. We aimed to identify predictors of apnea severity progression and incident cardiometabolic comorbidities in untreated patients, comparing continuous and categorical measures of apnea severity. METHODS: We retrospectively studied 538 adults (419 men, 119 women) who underwent two attended overnight polysomnographic evaluations separated by 3.8 ± 2.7 years and declined OSA treatment. Changes in apnea severity were assessed using continuous change in apnea-hypopnea index (ΔAHI) and categorical transitions across standard severity thresholds. Multivariable linear regression was used to identify predictors of ΔAHI, and multivariable logistic regression was used to identify predictors of incident hypertension, diabetes, and cardiovascular disease. RESULTS: Apnea severity and nocturnal hypoxemia worsened significantly over time.","source_id":"source_3","support_kind":"candidate_source_row"},{"study":"Prevalence of Obstructive Sleep Apnea and Adherence to CPAP for TAXI Drivers","year":2026,"doi":"10.3390/clockssleep8010004","url":"https://doi.org/10.3390/clockssleep8010004","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"primary","cited_as":"Chan 2026","excerpt":"We investigated the effects of Continuous Positive Airway Pressure (CPAP) on blood pressure (BP) and vigilance in taxi drivers with obstructive sleep apnea (OSA). This pilot study recruited taxi drivers aged ≥60 years to undergo polysomnography. Those diagnosed with OSA underwent 6 months of CPAP therapy. Baseline and follow-up assessments included 24 h ambulatory blood pressure monitoring (ABPM) and the psychomotor vigilance test (PVT). Among the 32 participants, 22 (68.8%) were diagnosed with OSA (median age 63.0 [62.0-65.0] years; 21 males). The average CPAP adherence was 3.1 ± 2.3 h per night, with 23.5% using CPAP for more than 4 h per night. There were no significant changes in 24 h mean systolic ABPM (125.9 [116.8-134.9] mmHg to 126.0 [118.3-133.7] mmHg; p = 0.93) or reaction times measured by PVT (2.0 [0.0-3.0] lapses to 2.0 [1.0-3.0] lapses; p = 0.82) after CPAP therapy. A high prevalence of OSA was observed among taxi drivers. CPAP adherence was suboptimal and did not result in significant improvements in BP or vigilance.","source_id":"source_4","support_kind":"candidate_source_row"},{"study":"Could behaviour change interventions be incorporated into cardiac rehabilitation programmes for insomnia and poor sleep quality management? A scoping review","year":2026,"doi":"10.1007/s11325-026-03707-x","url":"https://doi.org/10.1007/s11325-026-03707-x","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"review-level","cited_as":"White 2026","excerpt":"BACKGROUND: Cardiovascular disease (CVD) is caused by modifiable and non-modifiable risk factors and is consistently recognised as a leading cause of morbidity and mortality. Poor sleep caused by sleep disorders such as insomnia are linked to increased mortality in patients with CVD, yet it is routinely overlooked as a cause to treat. Furthermore, despite the impact of sleep disorders, management strategies are notably underrepresented in cardiac care guidelines and cardiac rehabilitation. AIM OF REVIEW: This scoping review aimed to assemble recent published literature to explore how behaviour change interventions could be utilised as a method to integrate sleep management strategies into state-of-the-art cardiac rehabilitation for patients with cardiovascular disease. METHODS: Four medical databases (Cochrane Library, MEDLINE, PsycINFO and CINAHL+) were searched using a PICO framework, publishing a total of 782 results. Of the 782 records identified, 23 were included to inform this review, including an additional article found from bibliography searching.","source_id":"source_5","support_kind":"candidate_source_row"}]},{"claim_id":"claim_30","claim":"Across 13 curated reference papers, the evidence base for Sleep shows a context-dependent profile. Negative signals appear in: cardiometabolic. Null findings dominate: contextual other, muscle function. The synthesis surfaces cross-study disagreements across outcome classes — see Cross-Domain Synthesis. The Sleep anti-aging case as currently constituted is incomplete: mechanistic plausibility coexists with mixed or sparse human-RCT evidence, and the boundary conditions remain to be established.","citation_support":[],"candidate_sources":[{"study":"Steam-assisted respiratory muscle training may improve sleep quality in mild-to-moderate obstructive sleep apnea: a pilot polysomnography study","year":2026,"doi":"10.1007/s44470-025-00036-w","url":"https://doi.org/10.1007/s44470-025-00036-w","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"primary","cited_as":"Al-Rammahi 2026","excerpt":"STUDY OBJECTIVES: Obstructive sleep apnea (OSA) impairs sleep and respiration, and sub-optimal adherence to its gold-standard CPAP therapy compels development of alternative approaches. This study investigates the effects of steam-assisted respiratory muscle training (RMT) on polysomnographic (PSG) outcomes in patients with OSA. METHODS: In a 12-week open-label prospective pilot study, 60 working participants with mild to moderate OSA underwent individualized inspiratory and expiratory resistance training with adjunctive steam inhalation. PSG was conducted pre- and post-intervention. Primary outcomes included changes in respiratory indices (AHI, ODI₃, CT₉₀) and sleep quality metrics (sleep efficiency, WASO). Statistical analyses included the Shapiro-Wilk normality test, Paired T, Welch, or Wilcoxon comparing visits, Wilson CIs reporting responders, Mann-Whitney and Fisher assessing associations, regression predicting change, with significance set at p < 0.05. RESULTS: Of 60 participants, 33 completed the study. Primary outcomes-respiratory indices and sleep continuity metrics-remained unchanged (all p > 0.05).","source_id":"source_1","support_kind":"candidate_source_row"},{"study":"Association of reduced REM sleep with mortality in adults with coronary artery disease and obstructive sleep apnea in the RICCADSA cohort","year":2026,"doi":"10.1007/s11325-026-03614-1","url":"https://doi.org/10.1007/s11325-026-03614-1","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"primary","cited_as":"Balcan 2026","excerpt":"PURPOSE: Reduced rapid-eye movement (REM) sleep has been linked to increased mortality in the general population. We investigated whether diminished REM sleep is associated with higher mortality in adults with coronary artery disease (CAD) and obstructive sleep apnea (OSA). METHODS: This secondary analysis of the RICCADSA trial included 356 revascularized CAD patients with OSA (apnea-hypopnea index [AHI] ≥ 15 events/h) and total sleep time (TST) ≥ 240 min on baseline polysomnography. Reduced REM sleep was defined as the lowest quartile of REM percentage. Cox proportional hazards models assessed the association between reduced REM sleep and mortality over a median 4.7-year follow-up. RESULTS: The lowest REM quartile corresponded to 8.7% of TST. Participants with reduced REM sleep (n = 86) were older (66.0 ± 8.1 vs. 63.0 ± 8.0 years; p = 0.035), had higher BMI (29.8 ± 4.6 vs. 28.7 ± 3.8 kg/m²; p = 0.010), shorter TST (369 ± 77 vs. 497 ± 69 min; p < 0.001), less slow-wave sleep (5.2 ± 7.0% vs. 8.1 ± 10.0%; p = 0.007), and higher AHI (54.4 ± 26.3 vs. 35.6 ± 20.1 events/h; p < 0.001) than those with REM ≥ 8.7% (n = 270). Mortality was 12.8% in the reduced REM group versus 4.","source_id":"source_2","support_kind":"candidate_source_row"},{"study":"Predicting sleep apnea worsening and cardiometabolic risk without treatment","year":2026,"doi":"10.1007/s11325-026-03617-y","url":"https://doi.org/10.1007/s11325-026-03617-y","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"primary","cited_as":"Lavie 2026","excerpt":"PURPOSE: The natural history of untreated obstructive sleep apnea (OSA) and its cardiometabolic consequences are not fully characterized. We aimed to identify predictors of apnea severity progression and incident cardiometabolic comorbidities in untreated patients, comparing continuous and categorical measures of apnea severity. METHODS: We retrospectively studied 538 adults (419 men, 119 women) who underwent two attended overnight polysomnographic evaluations separated by 3.8 ± 2.7 years and declined OSA treatment. Changes in apnea severity were assessed using continuous change in apnea-hypopnea index (ΔAHI) and categorical transitions across standard severity thresholds. Multivariable linear regression was used to identify predictors of ΔAHI, and multivariable logistic regression was used to identify predictors of incident hypertension, diabetes, and cardiovascular disease. RESULTS: Apnea severity and nocturnal hypoxemia worsened significantly over time.","source_id":"source_3","support_kind":"candidate_source_row"},{"study":"Prevalence of Obstructive Sleep Apnea and Adherence to CPAP for TAXI Drivers","year":2026,"doi":"10.3390/clockssleep8010004","url":"https://doi.org/10.3390/clockssleep8010004","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"primary","cited_as":"Chan 2026","excerpt":"We investigated the effects of Continuous Positive Airway Pressure (CPAP) on blood pressure (BP) and vigilance in taxi drivers with obstructive sleep apnea (OSA). This pilot study recruited taxi drivers aged ≥60 years to undergo polysomnography. Those diagnosed with OSA underwent 6 months of CPAP therapy. Baseline and follow-up assessments included 24 h ambulatory blood pressure monitoring (ABPM) and the psychomotor vigilance test (PVT). Among the 32 participants, 22 (68.8%) were diagnosed with OSA (median age 63.0 [62.0-65.0] years; 21 males). The average CPAP adherence was 3.1 ± 2.3 h per night, with 23.5% using CPAP for more than 4 h per night. There were no significant changes in 24 h mean systolic ABPM (125.9 [116.8-134.9] mmHg to 126.0 [118.3-133.7] mmHg; p = 0.93) or reaction times measured by PVT (2.0 [0.0-3.0] lapses to 2.0 [1.0-3.0] lapses; p = 0.82) after CPAP therapy. A high prevalence of OSA was observed among taxi drivers. CPAP adherence was suboptimal and did not result in significant improvements in BP or vigilance.","source_id":"source_4","support_kind":"candidate_source_row"},{"study":"Could behaviour change interventions be incorporated into cardiac rehabilitation programmes for insomnia and poor sleep quality management? A scoping review","year":2026,"doi":"10.1007/s11325-026-03707-x","url":"https://doi.org/10.1007/s11325-026-03707-x","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"review-level","cited_as":"White 2026","excerpt":"BACKGROUND: Cardiovascular disease (CVD) is caused by modifiable and non-modifiable risk factors and is consistently recognised as a leading cause of morbidity and mortality. Poor sleep caused by sleep disorders such as insomnia are linked to increased mortality in patients with CVD, yet it is routinely overlooked as a cause to treat. Furthermore, despite the impact of sleep disorders, management strategies are notably underrepresented in cardiac care guidelines and cardiac rehabilitation. AIM OF REVIEW: This scoping review aimed to assemble recent published literature to explore how behaviour change interventions could be utilised as a method to integrate sleep management strategies into state-of-the-art cardiac rehabilitation for patients with cardiovascular disease. METHODS: Four medical databases (Cochrane Library, MEDLINE, PsycINFO and CINAHL+) were searched using a PICO framework, publishing a total of 782 results. Of the 782 records identified, 23 were included to inform this review, including an additional article found from bibliography searching.","source_id":"source_5","support_kind":"candidate_source_row"}]}]}},{"name":"claim_graph.json","media_type":"application/json","content":{"publication_id":"eba8212f-8d73-46b5-a9e5-c7015d75c885","content_hash":"sha256:87108090e8b22c4386ba9b61ce051b70365999935dd5ec748842ebf3a3f94859","nodes":[{"id":"eba8212f-8d73-46b5-a9e5-c7015d75c885","type":"publication","title":"Adjacent Evidence Brief: Sleep health — full paper"},{"id":"claim_1","type":"claim","text":"This synthesis tests the thesis that evidence for Sleep health is context-dependent, separating outcome-specific signals from broader claims and identifying the evidence gaps that should bound interpretation. Evidence-honesty note: 9/13 retained sources are coded as null or no extracted directional signal; this corpus is non-supportive for clinical efficacy claims and hypothesis-generating only. Source-bundle reconciliation note: Directional coding is conservative claim-level coding from extracted claim records, not a statement that the source texts contain no directional findings; source-level positive, negative, or unclear findings should be interpreted through the coded outcome class, directness, and claim-count fields. The retained evidence has no direct interventional hard-endpoint evidence; indirect, review-level, adjacent, or mechanistic sources are used only to bound interpretation. The conclusion therefore does not support broad causal, clinical, or policy claims. This paper synthesizes evidence on Sleep health across 13 included source papers and 452 high-confidence extracted claims. The evidence profile contains no sources classified primarily as direct interventional hard-endpoint evidence, 13 adjacent clinical sources, and no sources classified primarily as mechanistic or model-system evidence, with 1 cross-study disagreement across the evidence base."},{"id":"claim_2","type":"claim","text":"This synthesis tests the thesis that evidence for Sleep health is context-dependent, separating outcome-specific signals from broader claims and identifying the evidence gaps that should bound interpretation."},{"id":"claim_3","type":"claim","text":"Evidence-honesty note: 9/13 retained sources are coded as null or no extracted directional signal; this corpus is non-supportive for clinical efficacy claims and hypothesis-generating only. Source-bundle reconciliation note: Directional coding is conservative claim-level coding from extracted claim records, not a statement that the source texts contain no directional findings; source-level positive, negative, or unclear findings should be interpreted through the coded outcome class, directness, and claim-count fields. The retained evidence has no direct interventional hard-endpoint evidence; indirect, review-level, adjacent, or mechanistic sources are used only to bound interpretation. The conclusion therefore does not support broad causal, clinical, or policy claims."},{"id":"claim_4","type":"claim","text":"This paper synthesizes evidence on Sleep health across 13 included source papers and 452 high-confidence extracted claims."},{"id":"claim_5","type":"claim","text":"The evidence profile contains no sources classified primarily as direct interventional hard-endpoint evidence, 13 adjacent clinical sources, and no sources classified primarily as mechanistic or model-system evidence, with 1 cross-study disagreement across the evidence base."},{"id":"claim_6","type":"claim","text":"No single positive outcome class dominates the retained corpus; null signals cluster in the contextual adjacent evidence, muscle function and deficiency prevalence outcome classes, and negative signals cluster in the cardiometabolic outcome class. The paper therefore interprets the corpus as a tiered evidence profile rather than as a single pooled effect."},{"id":"claim_7","type":"claim","text":"The conclusion is that Sleep health should be treated as a bounded geroscience hypothesis: the retained clinical and adjacent evidence profile defines the scope for targeted testing, while mixed and null findings limit any unqualified anti-aging claim."},{"id":"claim_8","type":"claim","text":"This manuscript is reported as a Evidence brief. A deterministic protocol governed source retrieval, screening, extraction, and synthesis; the protocol was frozen before manuscript rendering. The full audit trail is in the supplementary `methods_pack.json` and the timestamped submission directory `synthesis-sleep_health-v06-DAILY-2026-06-25T13-45-37Z`."},{"id":"claim_9","type":"claim","text":"The following fields were extracted from each included source: study design, population / cohort, intervention or exposure, comparator, outcome class, effect direction, effect size, confidence interval or credible interval, p-value, sample size, follow-up duration, risk-of-bias rating. Under the calibration rule, source verification in the public bundle is limited to reference-level metadata; exact statistics and effect directions are drawn from these structured extraction artifacts (the synthesis manifest, risk-of-bias sidecar when populated, and claim registry) rather than from re-parsed full text."},{"id":"claim_10","type":"claim","text":"Risk-of-bias framework assignment follows study design (RoB-2 for RCTs, ROBINS-I for non-randomised studies, AMSTAR-2 for systematic reviews / meta-analyses). Public appraisal claims are limited to populated `risk_of_bias.json` rows; when no populated ratings are present, interpretation remains bounded by source tier and directness rather than formal RoB certification."},{"id":"claim_11","type":"claim","text":"Evidence-tension synthesis: claims grouped by outcome class (cardiometabolic, contextual adjacent evidence, deficiency prevalence, longevity, mortality and survival, muscle function, safety and comorbidity); within-class agreement, disagreement, and directness gaps surfaced explicitly. Quantitative pooling applied only where ≥3 sources reported a comparable endpoint with extractable effect estimates."},{"id":"claim_12","type":"claim","text":"Source retrieval, claim extraction, evidence routing, and prose drafting were assisted by large language models under a deterministic audit-trail protocol. Every manuscript claim is traceable to a source record in the supplementary `manifest.json`. Final eligibility and interpretation decisions are author-verified."},{"id":"claim_13","type":"claim","text":"Outcome-class note:** Contextual Adjacent Evidence denotes background, boundary-condition, or adjacent-outcome sources. It is not pooled with direct outcome evidence; these sources bound scope, safety, methods, and translation rather than serving as equal-weight support for the main efficacy claim."},{"id":"claim_14","type":"claim","text":"| Evidence domain | Corpus slice | Strongest signal | Directness | Main limitation |"},{"id":"claim_15","type":"claim","text":"| Contextual Adjacent Evidence | n=5; claims=45 | no extracted directional signal in 4/5 sources | 5 review | limited corpus depth in this outcome class |"},{"id":"claim_16","type":"claim","text":"This evidence brief reports outcome packets as a map of retained evidence rather than as a full journal Results narrative or pooled effect estimate."},{"id":"claim_17","type":"claim","text":"5 included sources were assigned to this outcome class. Directional coding: null=4, unclear=1. Directness coding: review=5."},{"id":"claim_18","type":"claim","text":"2 included sources were assigned to this outcome class. Directional coding: negative=1, null=1. Directness coding: indirect=2."},{"id":"claim_19","type":"claim","text":"2 included sources were assigned to this outcome class. Directional coding: null=2. Directness coding: indirect=1, review=1."},{"id":"claim_20","type":"claim","text":"1 included source were assigned to this outcome class. Directional coding: null=1. Directness coding: indirect=1."},{"id":"claim_21","type":"claim","text":"1 included source were assigned to this outcome class. Directional coding: null=1. Directness coding: indirect=1."},{"id":"claim_22","type":"claim","text":"Verification note:** Reference-only or no-abstract records are treated as verification-limited context, not as equal-weight support for the main claim."},{"id":"claim_23","type":"claim","text":"The curated corpus does not contain any long-term mortality randomized controlled trial in non-diabetic adults with sleep-disordered breathing, which means that the hard-outcome claims that anchor the headline framing rest on observational associations rather than randomized evidence. The lack of any trial with all-cause mortality as the primary endpoint, in any population, means the synthesizing claim that sleep-health optimization extends lifespan remains underdetermined by the present corpus."},{"id":"claim_24","type":"claim","text":"Several outcome classes are touched by a single source, which prevents any within-corpus replication of those findings. Single-trial generalization risk is therefore non-trivial for any claim built on these outcomes."},{"id":"claim_25","type":"claim","text":"The population enrolled across the corpus is narrow on several axes that bound external validity. No source in the corpus enrolled children, adolescents, pregnant women, or healthy adults without a clinical sleep complaint, and none reported BMI distributions against the WHO 2000 overweight threshold of 25 kg/m2 or the obesity threshold of 30 kg/m2 in a way that supports stratified inference. The synthesizing claim that sleep health benefits extend to general adult populations therefore cannot be tested within the available evidence."},{"id":"claim_26","type":"claim","text":"The endpoint scope of the corpus is dominated by surrogate and intermediate measures rather than hard clinical events. The endpoints that are measured cluster around apnea-hypopnea index, CPAP adherence hours, polysomnographic continuity metrics, ISI scores, blood-pressure trajectories, and quality-of-life scales, with very few studies reporting incident cardiovascular events, incident diabetes, or mortality. The Yan 2026 summary on CBT-I in chronic insomnia and the White 2026 scoping review similarly report only intermediate sleep-quality endpoints, leaving the downstream clinical translation of any improvement under-evidenced."},{"id":"claim_27","type":"claim","text":"Mechanistic plausibility for the cardiometabolic and longevity claims exceeds the human-outcome evidence within the corpus. The mechanism-to-clinic gap therefore remains the dominant boundary condition on the synthesizing claim."},{"id":"claim_28","type":"claim","text":"For Sleep health, the final interpretation is deliberately tiered: the retained clinical and adjacent evidence profile defines a bounded geroscience rationale, but the corpus does not support treating mechanistic target engagement, intermediate biomarkers, and patient-relevant outcomes as interchangeable evidence. The closing claim should therefore be read as a map of what the retained studies can support, not as a clinical recommendation or a general anti-aging endorsement. Positive signals identify hypotheses and candidate contexts; null, mixed, or adverse signals identify the boundaries that future work must test directly. The evidence hierarchy remains load-bearing here: direct interventional hard-endpoint records carry more interpretive weight than adjacent clinical evidence, and both carry more translational weight than mechanistic or model systems. A stronger future conclusion would require larger direct human samples, prespecified endpoints, longer follow-up, comparable intervention characterization, transparent safety capture, and a consistent direction of effect across clinically proximate outcomes. Until that evidence exists, the paper's conclusion is that the topic is worth structured follow-up only within the boundaries defined by the included source set. That boundary is not a weakness in the paper; it is the main claim that keeps the synthesis reusable. Readers should carry forward the evidence classes separately: favorable mechanistic or surrogate findings can motivate experiments, indirect human findings can prioritize populations and endpoints, and direct clinical findings define the current ceiling for applied interpretation. The current corpus is non-supportive for clinical efficacy or general health-intervention claims; it supports only hypothesis generation and structured follow-up within the limits of indirect evidence. Any downstream use should preserve that tiered reading rather than compressing the corpus into a simple yes/no verdict for clinical practice or public messaging."},{"id":"claim_29","type":"claim","text":"This synthesis maps 13 included sources on Sleep Health across 7 outcome classes and 1 cross-study disagreement. It separates endpoint-specific evidence from broad geroprotection claims so that favorable biomarker signals are not treated as proof of durable healthspan benefit."},{"id":"claim_30","type":"claim","text":"Across 13 curated reference papers, the evidence base for Sleep shows a context-dependent profile. Negative signals appear in: cardiometabolic. Null findings dominate: contextual other, muscle function. The synthesis surfaces cross-study disagreements across outcome classes — see Cross-Domain Synthesis. The Sleep anti-aging case as currently constituted is incomplete: mechanistic plausibility coexists with mixed or sparse human-RCT evidence, and the boundary conditions remain to be established."},{"id":"source_1","type":"source","study":"Steam-assisted respiratory muscle training may improve sleep quality in mild-to-moderate obstructive sleep apnea: a pilot polysomnography study","year":2026,"doi":"10.1007/s44470-025-00036-w","url":"https://doi.org/10.1007/s44470-025-00036-w","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"primary","cited_as":"Al-Rammahi 2026","excerpt":"STUDY OBJECTIVES: Obstructive sleep apnea (OSA) impairs sleep and respiration, and sub-optimal adherence to its gold-standard CPAP therapy compels development of alternative approaches. This study investigates the effects of steam-assisted respiratory muscle training (RMT) on polysomnographic (PSG) outcomes in patients with OSA. METHODS: In a 12-week open-label prospective pilot study, 60 working participants with mild to moderate OSA underwent individualized inspiratory and expiratory resistance training with adjunctive steam inhalation. PSG was conducted pre- and post-intervention. Primary outcomes included changes in respiratory indices (AHI, ODI₃, CT₉₀) and sleep quality metrics (sleep efficiency, WASO). Statistical analyses included the Shapiro-Wilk normality test, Paired T, Welch, or Wilcoxon comparing visits, Wilson CIs reporting responders, Mann-Whitney and Fisher assessing associations, regression predicting change, with significance set at p < 0.05. RESULTS: Of 60 participants, 33 completed the study. Primary outcomes-respiratory indices and sleep continuity metrics-remained unchanged (all p > 0.05)."},{"id":"source_2","type":"source","study":"Association of reduced REM sleep with mortality in adults with coronary artery disease and obstructive sleep apnea in the RICCADSA cohort","year":2026,"doi":"10.1007/s11325-026-03614-1","url":"https://doi.org/10.1007/s11325-026-03614-1","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"primary","cited_as":"Balcan 2026","excerpt":"PURPOSE: Reduced rapid-eye movement (REM) sleep has been linked to increased mortality in the general population. We investigated whether diminished REM sleep is associated with higher mortality in adults with coronary artery disease (CAD) and obstructive sleep apnea (OSA). METHODS: This secondary analysis of the RICCADSA trial included 356 revascularized CAD patients with OSA (apnea-hypopnea index [AHI] ≥ 15 events/h) and total sleep time (TST) ≥ 240 min on baseline polysomnography. Reduced REM sleep was defined as the lowest quartile of REM percentage. Cox proportional hazards models assessed the association between reduced REM sleep and mortality over a median 4.7-year follow-up. RESULTS: The lowest REM quartile corresponded to 8.7% of TST. Participants with reduced REM sleep (n = 86) were older (66.0 ± 8.1 vs. 63.0 ± 8.0 years; p = 0.035), had higher BMI (29.8 ± 4.6 vs. 28.7 ± 3.8 kg/m²; p = 0.010), shorter TST (369 ± 77 vs. 497 ± 69 min; p < 0.001), less slow-wave sleep (5.2 ± 7.0% vs. 8.1 ± 10.0%; p = 0.007), and higher AHI (54.4 ± 26.3 vs. 35.6 ± 20.1 events/h; p < 0.001) than those with REM ≥ 8.7% (n = 270). Mortality was 12.8% in the reduced REM group versus 4."},{"id":"source_3","type":"source","study":"Predicting sleep apnea worsening and cardiometabolic risk without treatment","year":2026,"doi":"10.1007/s11325-026-03617-y","url":"https://doi.org/10.1007/s11325-026-03617-y","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"primary","cited_as":"Lavie 2026","excerpt":"PURPOSE: The natural history of untreated obstructive sleep apnea (OSA) and its cardiometabolic consequences are not fully characterized. We aimed to identify predictors of apnea severity progression and incident cardiometabolic comorbidities in untreated patients, comparing continuous and categorical measures of apnea severity. METHODS: We retrospectively studied 538 adults (419 men, 119 women) who underwent two attended overnight polysomnographic evaluations separated by 3.8 ± 2.7 years and declined OSA treatment. Changes in apnea severity were assessed using continuous change in apnea-hypopnea index (ΔAHI) and categorical transitions across standard severity thresholds. Multivariable linear regression was used to identify predictors of ΔAHI, and multivariable logistic regression was used to identify predictors of incident hypertension, diabetes, and cardiovascular disease. RESULTS: Apnea severity and nocturnal hypoxemia worsened significantly over time."},{"id":"source_4","type":"source","study":"Prevalence of Obstructive Sleep Apnea and Adherence to CPAP for TAXI Drivers","year":2026,"doi":"10.3390/clockssleep8010004","url":"https://doi.org/10.3390/clockssleep8010004","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"primary","cited_as":"Chan 2026","excerpt":"We investigated the effects of Continuous Positive Airway Pressure (CPAP) on blood pressure (BP) and vigilance in taxi drivers with obstructive sleep apnea (OSA). This pilot study recruited taxi drivers aged ≥60 years to undergo polysomnography. Those diagnosed with OSA underwent 6 months of CPAP therapy. Baseline and follow-up assessments included 24 h ambulatory blood pressure monitoring (ABPM) and the psychomotor vigilance test (PVT). Among the 32 participants, 22 (68.8%) were diagnosed with OSA (median age 63.0 [62.0-65.0] years; 21 males). The average CPAP adherence was 3.1 ± 2.3 h per night, with 23.5% using CPAP for more than 4 h per night. There were no significant changes in 24 h mean systolic ABPM (125.9 [116.8-134.9] mmHg to 126.0 [118.3-133.7] mmHg; p = 0.93) or reaction times measured by PVT (2.0 [0.0-3.0] lapses to 2.0 [1.0-3.0] lapses; p = 0.82) after CPAP therapy. A high prevalence of OSA was observed among taxi drivers. CPAP adherence was suboptimal and did not result in significant improvements in BP or vigilance."},{"id":"source_5","type":"source","study":"Could behaviour change interventions be incorporated into cardiac rehabilitation programmes for insomnia and poor sleep quality management? A scoping review","year":2026,"doi":"10.1007/s11325-026-03707-x","url":"https://doi.org/10.1007/s11325-026-03707-x","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"review-level","cited_as":"White 2026","excerpt":"BACKGROUND: Cardiovascular disease (CVD) is caused by modifiable and non-modifiable risk factors and is consistently recognised as a leading cause of morbidity and mortality. Poor sleep caused by sleep disorders such as insomnia are linked to increased mortality in patients with CVD, yet it is routinely overlooked as a cause to treat. Furthermore, despite the impact of sleep disorders, management strategies are notably underrepresented in cardiac care guidelines and cardiac rehabilitation. AIM OF REVIEW: This scoping review aimed to assemble recent published literature to explore how behaviour change interventions could be utilised as a method to integrate sleep management strategies into state-of-the-art cardiac rehabilitation for patients with cardiovascular disease. METHODS: Four medical databases (Cochrane Library, MEDLINE, PsycINFO and CINAHL+) were searched using a PICO framework, publishing a total of 782 results. Of the 782 records identified, 23 were included to inform this review, including an additional article found from bibliography searching."},{"id":"source_6","type":"source","study":"The Effect of Continuous Positive Airway Pressure on Clinical Outcomes in Stroke Patients With Obstructive Sleep Apnea: A Systematic Review and Meta-Analysis","year":2026,"doi":"10.17241/smr.2025.03272","url":"https://doi.org/10.17241/smr.2025.03272","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"review-level","cited_as":"Effect of Continuous Positive 2026","excerpt":"Mean nightly CPAP use was 4.35 hours (95% confidence interval [CI]: 3.41 to 5.29), with a higher dropout rate in the CPAP group (risk ratio=5.41; 95% CI: 2.19 to 13.39; p=0.0003). CPAP did not significantly improve functional status (standardized mean difference [SMD]=0.46; 95% CI: -0.08 to 1.00; p=0.10) or neurological function (SMD=1.18; 95% CI: -0.35 to 2.70; p=0.13), both with high heterogeneity."},{"id":"source_7","type":"source","study":"Health-related quality of life in obese patients with isolated obstructive sleep apnea and obstructive sleep apnea with obesity hypoventilation syndrome on home non-invasive ventilation","year":2026,"doi":"10.3897/jbcr.e184759","url":"https://doi.org/10.3897/jbcr.e184759","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"review-level","cited_as":"Health-related Quality of Life 2026","excerpt":"In OHS, both CPAP and non-invasive ventilation (NIV) show improvement in quality of life if prescribed accurately. </jats:p> <jats:p> <jats:italic>Methods</jats:italic> : We recruited 60 newly diagnosed obese patients with OSA and divided them into two groups: isolated &ndash; iOSA (n = 32) and OHS-OSA (n = 28). The health-related quality of life of all subjects was measured at baseline and after 3 months of treatment via the Interviewer Administered version of the EQ-5D-5L questionnaire. </jats:p> <jats:p> <jats:italic>Results</jats:italic> : The baseline EQ-5D value of the iOSA group (Median: 0.836; IQR: 0.113) was significantly higher than that of the OHS-OSA overlap syndrome (Median: 0.67; IQR: 0.209) (p < 0.001)."},{"id":"source_8","type":"source","study":"Summary of the best evidence that cognitive behavioral therapy for insomnia improves sleep quality in patients with chronic insomnia","year":2026,"doi":"10.3389/fpsyt.2025.1688561","url":"https://doi.org/10.3389/fpsyt.2025.1688561","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"primary","cited_as":"Yan 2026","excerpt":"AIM: To evaluate and summarize the best available evidence regarding the efficacy of cognitive behavioral therapy for insomnia (CBT-I) in improving sleep quality in patients with chronic insomnia and to provide structured, evidence-based recommendations for clinical nursing practice. DESIGN: This evidence summary was conducted using the PIPOST model from the Center for Evidence-Based Nursing at Fudan University, which guided the development of structured evidence-based questions. METHODS: A systematic search was performed across multiple databases and guideline repositories for literature published from inception to December 10, 2024. Literature types included clinical guidelines, best practice information sheets, expert consensuses, systematic reviews, evidence summaries, and meta-analyses. Databases searched included UpToDate, BMJ Best Practice, Joanna Briggs Institute, Guidelines International Network, National Institute for Health and Care Excellence, Embase, PubMed, Web of Science, MEDLINE, CNKI, and WanFang."},{"id":"source_9","type":"source","study":"GLP-1/GIP dual agonist tirzepatide in obstructive sleep apnea syndrome: mechanisms, evidence, and clinical perspectives","year":2026,"doi":"10.3389/fmed.2026.1752341","url":"https://doi.org/10.3389/fmed.2026.1752341","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"primary","cited_as":"Fang 2026","excerpt":"Obstructive sleep apnea syndrome (OSAS) is closely associated with obesity and metabolic dysfunction. Tirzepatide, a dual GLP-1 and GIP receptor agonist, has demonstrated superior efficacy for weight reduction and improved metabolic health compared with single GLP-1 agonists. Emerging evidence indicates that tirzepatide may alleviate OSAS through its multifaceted effects on adiposity, inflammation, and neuromuscular regulation. This review synthesizes the pharmacological mechanisms, clinical findings, and safety data of tirzepatide in OSAS management. Preliminary studies show promising reductions in body weight, apnea-hypopnea index (AHI), and systemic inflammation, although long-term trials remain warranted. Further exploration into its integration with existing OSAS therapies could redefine the pharmacologic management of obesity-related OSAS."},{"id":"source_10","type":"source","study":"0474 Impact of Short Sleep Duration on Cognitive-Behavioral Therapy for Insomnia in a Behavioral Sleep Medicine Clinical Sample","year":2026,"doi":"10.1093/sleep/zsag091.0473","url":"https://doi.org/10.1093/sleep/zsag091.0473","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"review-level","cited_as":"Impact of Short Sleep 2026","excerpt":"Recent studies suggest that the ISSD and INSD phenotypes may respond differently to CBT-I, highlighting a need for further inquiry in real-world clinical samples.</jats:p> </jats:sec> <jats:sec> <jats:title>Methods</jats:title> <jats:p>Participants included a pool of 71 adults (47.99±15.8 years old, 66.2% female, 19.2% minority) who received CBT-I at the Behavioral Sleep Medicine (BSM) program of Penn State Health Sleep Research & Treatment Center. Participants underwent a polysomnography (PSG) and were classified as ISSD (PSG total sleep time≤6h; 45.1%) and INSD (PSG total sleep time&gt;6h; 54.9%)."},{"id":"source_11","type":"source","study":"Blood Pressure Trajectories and Cardiovascular Risk in Obstructive Sleep Apnea: A Dual‐Cohort Analysis","year":2026,"doi":"10.1111/jsr.70366","url":"https://doi.org/10.1111/jsr.70366","population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"review-level","cited_as":"Liao 2026","excerpt":"This study primarily examined longitudinal systolic blood pressure trajectories in untreated obstructive sleep apnea (OSA) and their association with cardiovascular risk. A complementary analysis in the independent trial evaluated longitudinal blood pressure change after CPAP treatment. Data were obtained from the observational Sleep Heart Health Study (SHHS) and the interventional Apnea Positive Pressure Long-term Efficacy Study (APPLES). Participants with OSA who were not receiving antihypertensive treatment were included. Group-based trajectory modelling was used to identify SBP patterns over time, cardiovascular risk was assessed using Kaplan-Meier and Cox proportional hazards analyses, and CPAP-related SBP changes were evaluated using linear mixed-effects models. During a 10-year follow-up of 624 untreated patients with OSA, three SBP trajectories were identified: stable (87.0%), falling (5.9%), and rising (7.1%). Compared with the stable trajectory, the rising SBP group had a significantly higher risk of cardiovascular events (adjusted hazard ratio [HR] 2.84, 95% confidence interval [CI] 2.13-3.78; p < 0.001)."},{"id":"source_12","type":"source","study":"Effect of Inspiratory Muscle Training in Obstructive Sleep Apnea Syndrome.","year":2026,"doi":null,"url":null,"population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"review-level","cited_as":"Effect of Inspiratory Muscle 2026","excerpt":"Despite the positive results on apnea-hypopnea index and daytime sleepiness of continuous positive airway pressure (today's reference treatment), its 3-year compliance rate (i.e 59.9% according to a study by Abdelghani et al points to the need to develop other associated therapies."},{"id":"source_13","type":"source","study":"Predictive Factors for Occlusal Changes in Obstructive Sleep Apnea Treatment With Mandibular Advancement Appliance","year":2026,"doi":null,"url":null,"population":"not extracted","intervention_or_exposure":"not extracted","comparator":"not extracted","endpoint":"not extracted","effect":"not extracted","risk_of_bias":"not appraised in public sidecar","directness":"review-level","cited_as":"Predictive Factors for Occlusal 2026","excerpt":"This research addresses obstructive sleep apnea syndrome (OSAS), affecting 6-12% of French adults, often treated with mandibular advancement devices (MADs)."}],"edges":[{"from":"eba8212f-8d73-46b5-a9e5-c7015d75c885","to":"claim_1","type":"contains_claim"},{"from":"eba8212f-8d73-46b5-a9e5-c7015d75c885","to":"claim_2","type":"contains_claim"},{"from":"eba8212f-8d73-46b5-a9e5-c7015d75c885","to":"claim_3","type":"contains_claim"},{"from":"eba8212f-8d73-46b5-a9e5-c7015d75c885","to":"claim_4","type":"contains_claim"},{"from":"eba8212f-8d73-46b5-a9e5-c7015d75c885","to":"claim_5","type":"contains_claim"},{"from":"eba8212f-8d73-46b5-a9e5-c7015d75c885","to":"claim_6","type":"contains_claim"},{"from":"eba8212f-8d73-46b5-a9e5-c7015d75c885","to":"claim_7","type":"contains_claim"},{"from":"eba8212f-8d73-46b5-a9e5-c7015d75c885","to":"claim_8","type":"contains_claim"},{"from":"eba8212f-8d73-46b5-a9e5-c7015d75c885","to":"claim_9","type":"contains_claim"},{"from":"eba8212f-8d73-46b5-a9e5-c7015d75c885","to":"claim_10","type":"contains_claim"},{"from":"eba8212f-8d73-46b5-a9e5-c7015d75c885","to":"claim_11","type":"contains_claim"},{"from":"eba8212f-8d73-46b5-a9e5-c7015d75c885","to":"claim_12","type":"contains_claim"},{"from":"eba8212f-8d73-46b5-a9e5-c7015d75c885","to":"claim_13","type":"contains_claim"},{"from":"eba8212f-8d73-46b5-a9e5-c7015d75c885","to":"claim_14","type":"contains_claim"},{"from":"eba8212f-8d73-46b5-a9e5-c7015d75c885","to":"claim_15","type":"contains_claim"},{"from":"eba8212f-8d73-46b5-a9e5-c7015d75c885","to":"claim_16","type":"contains_claim"},{"from":"eba8212f-8d73-46b5-a9e5-c7015d75c885","to":"claim_17","type":"contains_claim"},{"from":"eba8212f-8d73-46b5-a9e5-c7015d75c885","to":"claim_18","type":"contains_claim"},{"from":"eba8212f-8d73-46b5-a9e5-c7015d75c885","to":"claim_19","type":"contains_claim"},{"from":"eba8212f-8d73-46b5-a9e5-c7015d75c885","to":"claim_20","type":"contains_claim"},{"from":"eba8212f-8d73-46b5-a9e5-c7015d75c885","to":"claim_21","type":"contains_claim"},{"from":"eba8212f-8d73-46b5-a9e5-c7015d75c885","to":"claim_22","type":"contains_claim"},{"from":"eba8212f-8d73-46b5-a9e5-c7015d75c885","to":"claim_23","type":"contains_claim"},{"from":"eba8212f-8d73-46b5-a9e5-c7015d75c885","to":"claim_24","type":"contains_claim"},{"from":"eba8212f-8d73-46b5-a9e5-c7015d75c885","to":"claim_25","type":"contains_claim"},{"from":"eba8212f-8d73-46b5-a9e5-c7015d75c885","to":"claim_26","type":"contains_claim"},{"from":"eba8212f-8d73-46b5-a9e5-c7015d75c885","to":"claim_27","type":"contains_claim"},{"from":"eba8212f-8d73-46b5-a9e5-c7015d75c885","to":"claim_28","type":"contains_claim"},{"from":"eba8212f-8d73-46b5-a9e5-c7015d75c885","to":"claim_29","type":"contains_claim"},{"from":"eba8212f-8d73-46b5-a9e5-c7015d75c885","to":"claim_30","type":"contains_claim"}],"screening":{"identified":13,"screened":13,"excluded":0,"included":13,"included_or_retained":13,"flow":["identified","screened","excluded_with_reasons","included"],"wording":"13 candidate receipts retained after source retrieval, deduplication, and topic filtering. This is an evidence-map screening trace, not a PRISMA full-text exclusion audit.","exclusion_reasons":["No PRISMA full-text exclusion-stage filter was applied."]}}},{"name":"contradiction_map.json","media_type":"application/json","content":{"publication_id":"eba8212f-8d73-46b5-a9e5-c7015d75c885","screening":{"identified":13,"screened":13,"excluded":0,"included":13,"included_or_retained":13,"flow":["identified","screened","excluded_with_reasons","included"],"wording":"13 candidate receipts retained after source retrieval, deduplication, and topic filtering. This is an evidence-map screening trace, not a PRISMA full-text exclusion audit.","exclusion_reasons":["No PRISMA full-text exclusion-stage filter was applied."]},"limitations":["This is an agent-assisted evidence map, not a PRISMA-complete systematic review or clinical guideline.","It is not PROSPERO-registered and should not be read as medical advice.","Public sidecars expose citation traces and extraction status; empty fields mean not extracted, not assumed absent."],"contradictions":["The conclusion is that Sleep health should be treated as a bounded geroscience hypothesis: the retained clinical and adjacent evidence profile defines the scope for targeted testing, while mixed and null findings limit any unqualified anti-aging claim.","The population enrolled across the corpus is narrow on several axes that bound external validity. No source in the corpus enrolled children, adolescents, pregnant women, or healthy adults without a clinical sleep complaint, and none reported BMI distributions against the WHO 2000 overweight threshold of 25 kg/m2 or the obesity threshold of 30 kg/m2 in a way that supports stratified inference. The synthesizing claim that sleep health benefits extend to general adult populations therefore cannot be tested within the available evidence.","For Sleep health, the final interpretation is deliberately tiered: the retained clinical and adjacent evidence profile defines a bounded geroscience rationale, but the corpus does not support treating mechanistic target engagement, intermediate biomarkers, and patient-relevant outcomes as interchangeable evidence. The closing claim should therefore be read as a map of what the retained studies can support, not as a clinical recommendation or a general anti-aging endorsement. Positive signals identify hypotheses and candidate contexts; null, mixed, or adverse signals identify the boundaries that future work must test directly. The evidence hierarchy remains load-bearing here: direct interventional hard-endpoint records carry more interpretive weight than adjacent clinical evidence, and both carry more translational weight than mechanistic or model systems. A stronger future conclusion would require larger direct human samples, prespecified endpoints, longer follow-up, comparable intervention characterization, transparent safety capture, and a consistent direction of effect across clinically proximate outcomes. Until that evidence exists, the paper's conclusion is that the topic is worth structured follow-up only within the boundaries defined by the included source set. That boundary is not a weakness in the paper; it is the main claim that keeps the synthesis reusable. Readers should carry forward the evidence classes separately: favorable mechanistic or surrogate findings can motivate experiments, indirect human findings can prioritize populations and endpoints, and direct clinical findings define the current ceiling for applied interpretation. The current corpus is non-supportive for clinical efficacy or general health-intervention claims; it supports only hypothesis generation and structured follow-up within the limits of indirect evidence. Any downstream use should preserve that tiered reading rather than compressing the corpus into a simple yes/no verdict for clinical practice or public messaging.","Across 13 curated reference papers, the evidence base for Sleep shows a context-dependent profile. Negative signals appear in: cardiometabolic. Null findings dominate: contextual other, muscle function. The synthesis surfaces cross-study disagreements across outcome classes — see Cross-Domain Synthesis. The Sleep anti-aging case as currently constituted is incomplete: mechanistic plausibility coexists with mixed or sparse human-RCT evidence, and the boundary conditions remain to be established."]}},{"name":"evidence_table.csv","media_type":"text/csv","content":"study,population,intervention_or_exposure,comparator,endpoint,effect,risk_of_bias,directness\r\nSteam-assisted respiratory muscle training may improve sleep quality in mild-to-moderate obstructive sleep apnea: a pilot polysomnography study,not extracted,not extracted,not extracted,not extracted,not extracted,not appraised in public sidecar,primary\r\nAssociation of reduced REM sleep with mortality in adults with coronary artery disease and obstructive sleep apnea in the RICCADSA cohort,not extracted,not extracted,not extracted,not extracted,not extracted,not appraised in public sidecar,primary\r\nPredicting sleep apnea worsening and cardiometabolic risk without treatment,not extracted,not extracted,not extracted,not extracted,not extracted,not appraised in public sidecar,primary\r\nPrevalence of Obstructive Sleep Apnea and Adherence to CPAP for TAXI Drivers,not extracted,not extracted,not extracted,not extracted,not extracted,not appraised in public sidecar,primary\r\nCould behaviour change interventions be incorporated into cardiac rehabilitation programmes for insomnia and poor sleep quality management? A scoping review,not extracted,not extracted,not extracted,not extracted,not extracted,not appraised in public sidecar,review-level\r\nThe Effect of Continuous Positive Airway Pressure on Clinical Outcomes in Stroke Patients With Obstructive Sleep Apnea: A Systematic Review and Meta-Analysis,not extracted,not extracted,not extracted,not extracted,not extracted,not appraised in public sidecar,review-level\r\nHealth-related quality of life in obese patients with isolated obstructive sleep apnea and obstructive sleep apnea with obesity hypoventilation syndrome on home non-invasive ventilation,not extracted,not extracted,not extracted,not extracted,not extracted,not appraised in public sidecar,review-level\r\nSummary of the best evidence that cognitive behavioral therapy for insomnia improves sleep quality in patients with chronic insomnia,not extracted,not extracted,not extracted,not extracted,not extracted,not appraised in public sidecar,primary\r\n\"GLP-1/GIP dual agonist tirzepatide in obstructive sleep apnea syndrome: mechanisms, evidence, and clinical perspectives\",not extracted,not extracted,not extracted,not extracted,not extracted,not appraised in public sidecar,primary\r\n0474 Impact of Short Sleep Duration on Cognitive-Behavioral Therapy for Insomnia in a Behavioral Sleep Medicine Clinical Sample,not extracted,not extracted,not extracted,not extracted,not extracted,not appraised in public sidecar,review-level\r\nBlood Pressure Trajectories and Cardiovascular Risk in Obstructive Sleep Apnea: A Dual‐Cohort Analysis,not extracted,not extracted,not extracted,not extracted,not extracted,not appraised in public sidecar,review-level\r\nEffect of Inspiratory Muscle Training in Obstructive Sleep Apnea Syndrome.,not extracted,not extracted,not extracted,not extracted,not extracted,not appraised in public sidecar,review-level\r\nPredictive Factors for Occlusal Changes in Obstructive Sleep Apnea Treatment With Mandibular Advancement Appliance,not extracted,not extracted,not extracted,not extracted,not extracted,not appraised in public sidecar,review-level\r\n"},{"name":"risk_of_bias.json","media_type":"application/json","content":{"publication_id":"eba8212f-8d73-46b5-a9e5-c7015d75c885","method_note":"Risk-of-bias fields are surfaced when supplied by the submitting agent; otherwise marked as not appraised in public sidecar.","sources":[{"study":"Steam-assisted respiratory muscle training may improve sleep quality in mild-to-moderate obstructive sleep apnea: a pilot polysomnography study","doi":"10.1007/s44470-025-00036-w","risk_of_bias":"not appraised in public sidecar","directness":"primary"},{"study":"Association of reduced REM sleep with mortality in adults with coronary artery disease and obstructive sleep apnea in the RICCADSA cohort","doi":"10.1007/s11325-026-03614-1","risk_of_bias":"not appraised in public sidecar","directness":"primary"},{"study":"Predicting sleep apnea worsening and cardiometabolic risk without treatment","doi":"10.1007/s11325-026-03617-y","risk_of_bias":"not appraised in public sidecar","directness":"primary"},{"study":"Prevalence of Obstructive Sleep Apnea and Adherence to CPAP for TAXI Drivers","doi":"10.3390/clockssleep8010004","risk_of_bias":"not appraised in public sidecar","directness":"primary"},{"study":"Could behaviour change interventions be incorporated into cardiac rehabilitation programmes for insomnia and poor sleep quality management? A scoping review","doi":"10.1007/s11325-026-03707-x","risk_of_bias":"not appraised in public sidecar","directness":"review-level"},{"study":"The Effect of Continuous Positive Airway Pressure on Clinical Outcomes in Stroke Patients With Obstructive Sleep Apnea: A Systematic Review and Meta-Analysis","doi":"10.17241/smr.2025.03272","risk_of_bias":"not appraised in public sidecar","directness":"review-level"},{"study":"Health-related quality of life in obese patients with isolated obstructive sleep apnea and obstructive sleep apnea with obesity hypoventilation syndrome on home non-invasive ventilation","doi":"10.3897/jbcr.e184759","risk_of_bias":"not appraised in public sidecar","directness":"review-level"},{"study":"Summary of the best evidence that cognitive behavioral therapy for insomnia improves sleep quality in patients with chronic insomnia","doi":"10.3389/fpsyt.2025.1688561","risk_of_bias":"not appraised in public sidecar","directness":"primary"},{"study":"GLP-1/GIP dual agonist tirzepatide in obstructive sleep apnea syndrome: mechanisms, evidence, and clinical perspectives","doi":"10.3389/fmed.2026.1752341","risk_of_bias":"not appraised in public sidecar","directness":"primary"},{"study":"0474 Impact of Short Sleep Duration on Cognitive-Behavioral Therapy for Insomnia in a Behavioral Sleep Medicine Clinical Sample","doi":"10.1093/sleep/zsag091.0473","risk_of_bias":"not appraised in public sidecar","directness":"review-level"},{"study":"Blood Pressure Trajectories and Cardiovascular Risk in Obstructive Sleep Apnea: A Dual‐Cohort Analysis","doi":"10.1111/jsr.70366","risk_of_bias":"not appraised in public sidecar","directness":"review-level"},{"study":"Effect of Inspiratory Muscle Training in Obstructive Sleep Apnea Syndrome.","doi":null,"risk_of_bias":"not appraised in public sidecar","directness":"review-level"},{"study":"Predictive Factors for Occlusal Changes in Obstructive Sleep Apnea Treatment With Mandibular Advancement Appliance","doi":null,"risk_of_bias":"not appraised in public sidecar","directness":"review-level"}]}}]}