Sleep Health: Healthy Sleep, Healthy Heart

Thank you so much for the opportunity to be here to talk on this topic of sleep. Let me share with you. 20 years ago, I never would have thought I'd be up here giving this discussion. One of the conversations that really allows me to talk about this as an internist is that discussion of heart health. In the year 2000, an important study came out in the sleep world called Sleep Heart Health Study based out of Wisconsin and a lot of other centers that really opened up the doors to the conversation of sleep, in particular that of sleep apnea. And since that time, really into this new discussion. But one of the things is, is that this is such a misunderstood topic. What do I mean by that? Like, just like so many other things, we kind of intuitively know that this is important. As I oops, I forgot to mention, I have no financial disclosures. And the real emphasis is I'm going to stick to the evidence, even though there's always a temptation to look at this with a myopic lenses. I'll tell you some of the controversies that are coming up within the sleep world that we've overstated. So getting into this conversation. Why do we just intuitively, why does sleep appeal to us? Well, it's like grandma's medicine. What did Grandma ask us to do, my friends. She said, what? Eat your vegetables. Right? Go out and play. And. And what did Grandma ask all of us to do? Get that sleep. Right? We kind of get this appreciation. But again, is this just. Woof, woof. Is this the real medicine that we want to be a part of? The conversation really is as again, traditional wisdom has now gone prime time with a conversation of some of the newer science. This has been out there in the literature for 100 years. 80 years ago, Stanford got into this and now again since the year 2000, it's a lot of fun to speak of it. What am I going to talk about? First and foremost, let's understand sleep before we understand sleep in the heart. So again, sleep is misunderstood. One of my first mentors back in Baltimore at Hopkins used to have a 100 year old dictionary. And every time I started a topic, we'd look up what the word meant. What is sleep defined 100 years ago? A passive dormant time in our life. Doesn't sound very exciting at all. So now what I wish to do is to demystify a little bit of what's going on. Every single night my friends, we look to cool down. One of the coldest times of your day is that of bedtime. Like a machine. If it does not cool down, it burns out. A little bit of trivia. What is the coolest time during your sleep? Dreams. We see this in a sleep lab when somebody is grabbing more sheets and more layers on top. We know they're about to go into a dream. So the next time you see your loved one doing that, you'll be curious of what's about to happen next. Going even further than that every single night. Sodium, potassium chloride. It goes on and on with the calcium. If we do not honor this, that's the conversation that is beginning to do. The discussion of seizure like activity and arrhythmias. Going from there, probably the biggest topic right now in sports medicine is that of sleep. Every professional organization now is getting a sleep consult. There's a few major guys in academia that have really brought this through. Just like when people come to Tucson and Canyon Ranch, we often know that they haven’t exercised for a while. So they're feeling a feel muscles they haven't felt in a while. And they say, do you want to get the full benefit of that exercise? You got to get that sleep. When I get in the stages of sleep, I'll talk about that physical repair. What does it mean from down to the biochemical level? What do you feel like doing if you have the fever or the flu? Sleeping, right? Sleep is a natural antioxidant. A natural anti-inflammatory, my friends. So it's such an important conversation to appreciate that. We're going to get into some of the understandings of the laboratories of inflammatory markers. And as I've gotten a chance to move into this integrative medicine space, of course it was all about the biochemistry in the labs. But we do know our thoughts, feelings influence how we act. That's cognitive behavioral therapy in three discussions. Thoughts, actions, behavior. But that move in mood conversation, what we do now is right. IQ For many years has been celebrated, and more recent years, what are we looking at EQ. Until somebody can emotionally connect to who they are, they can connect to others. What I find clearly, as many of the people I work with that kind of know what to do, but they don't always do it. And what is going on there? A big part of what was really helped me put that conversation of lifestyle is helping people be more connected to their emotions. Sleep does that and I'll speak about this when I get into dreams, not interpreting dreams. I'm just going to talk about what happens during dream phase of sleep. One of the conversations that we have going here is that without question it is cardioprotective and anything that's good for the heart is good for that of the brain. This is a real exciting conversation. Year 1998 Neuroplasticity was coined as a term, but really which has been exciting at the sleep meetings is the last six years we've been learning not just about neuroplasticity but the lymphatic system, lymphatic flush. Every single night, especially in that of our dreams., we have a flush. It's clearing out amyloid and it's clearing out tangles. Yeah. Are we not hearing more and more about autopsy on those with Alzheimer's? What? The amyloid buildup and tangles? It's not saying it's only sleep, but sleep is a connection to that, whether you feel your memory slipped or not. All of us want to have a robust memory. Some of the most intriguing memory work out there is understanding sleep. The quantity and quality. When I talk about lifestyle, what I do know is that I have to connect to where people are and how they want to live their lives. Joy is a conversation as such. If we don't enjoy how we're living our lives are unlikely to do it. I've been 40 pounds from where I am now multiple times in my life. That's the reason I knew in medical school I wanted to talk about exercise. I wanted to talk about nutrition. But again, just because I knew it didn't mean I did it. Let me say it another way. If we don't enjoy the way we eat, what do we call that? A diet. How long do diets last? 1% of people will continue on a diet outside of six months. Ouch. If we don't enjoy our exercise, what do you call that exercise? Torture. Boot camp. No. Soldiers mean permanently put in there. What we do know, without question, mood and that of quality of life is so directly connected to that of sleep. When I can honor somebody's ability to be rested, the way they eat, the way they move does shift. We'll talk about that much more. And here's the one for you and I. What is the goal of sleep? What is a promise of sleep so you can wake up in the morning, have that morning, that afternoon and that evening. How many of us can tolerate being tired or sluggish during the day? Now, it's interesting. Some of you saw I was supposed to be given this talk first thing in the morning. Right? And instead, what am I doing? I'm talking to you at one of the sleepiest hours of your day. What we do now is the Nobel Prize was given to the three scientists that discovered the connection between that which now is called the circadian rhythm. What is circadian say we get a bucket of energy in the morning, say all at 10 a.m. and we get the next big bucket somewhere between five, six, 7 p.m. What does that leave relatively in the middle, a bit of a dip. Somebody like I should just walk out and take that nap. Right. And that might be a part of what we're looking at. But the bigger conversation is appreciating that there is this chronobiology, there's these swings we go through. So again, what we can talk about is sluggishness, but not exhaustion during the daytime. And this is going to be a big clue when I talk about putting this into our lives. So as we take the next step, we're going to honor how we honor our sleep so we connect to that of our health and the healing we want to be a part of. So what are we talking about? Good enough, right? When we are here, honoring what you guys have done is really helping to optimize the health that people have. A big conversation that I always want to start with is quantity of sleep and the world that you and I are living in. We're sleeping less and less. The first conversation we almost are always recommending in every textbook of sleep is that of quantity. All right. Some of you are looking at that. Some of you have your tracking devices overall are getting much better. The data from about seven years ago is showing tracking devices that your patients are coming to you. It was roughly 70% correlated. So it's a great way to engage people and to be able to get a better understanding. But it's just the beginning really. The harder conversation is quality. I'm going to let you know the real difficult part of this. What I want us to do is appreciate some people are aware that they're not getting quality sleep, but many people are unaware, Right? I'm talking to a group of esteemed colleagues. What do we know? For the most part, How many of us got through medical school just by complaining? And that gave us good grades? How many of Give it a Ribbon award? A bonus for complaining? None of us. So therefore, we've learned to suck it up. And a big part of this conversation is that many of us don't realize how sleepy we are. As I go through this and give this talk, you're going to see me talk about clues, symptoms, signs that you might be that sleepy person. It's really rudimentary. We ask people, Are you sleepy? Are you not? That's not getting us everywhere. We'll take it when somebody is aware of it. But many people are unaware. We need quantity and we need quality. Quantity being the first discussion always. Now, 20 years ago when I started looking into sleep, I was curious about it. When I first started out practicing, I was a primary care physician and academia. I love talking about exercise. I love to talk about nutrition. But I got really squirrely when I got the conversation of sleep going on because what did I really know? I was given an optional chapter in medical school to read but never tested on the topic. So what I want us to appreciate you have these myths and I want to debunk them. Here's the one. How many times have we heard this? We all wish we could sleep like a baby. Are babies, my friends, the best sleepers. And what age group are we the best sleepers? Teen agers are the rock stars of sleep, right? Don't let anybody tell you any different. Okay. Teenagers today are very different than you are in my teen age career. What do we really know about that? What are teenagers do? They get to sleep. They stay asleep. And if you try to wake up a teenager before they're ready? Should have just left them alone. My friends, you and I were once that teenager. Almost everybody I can speak to will say, Yeah, I used to sleep better. I'm like, Yeah, I get it. But what do you mean you get it? Like you were once a teenager. During your teenage career, you could do this much easier. We were wired for that. My first fellowship was in that of geriatrics. I'm going to teach you a quick little snippet. The Baltimore Longitudinal Study on Aging. At what age, my friends, do we get to our first peak muscle aerobics bone density without even trying? What age? Between 28 to 32. In your teens? In your twenties? Did you have to think that much about how you ate? How you exercised? How you got to sleep or stayed asleep and it all just kind of happened? So one of the things that I really want us to appreciate is that this is one of those things that slowly but surely picks up after the third decade of life. So among the things I want is to appreciate, I moved out academia, Canyon Ranch, I love the practice. It is steeped, though, in this concept of something that's called wellness. You know, wellness is a gray zone, and some of those conversations like this are very gray. A statement like this drives me bananas, but it's partially true and therefore partially not true. Compared to our teenage years, right. We do know we were the best sleepers then and now we're not as quite well. So what do we know compared to our teenagers? How much sleep do we need as teenagers? My friends? Nine, nine plus hours of sleep. Most teenagers are not getting it. What can we appreciate? How much sleep do you and I need? 7 to 9 hours. Now let you know, the data shows less than 5., really hurting that health, but particularly that of the heart. Above 5, you're starting to do the cardio protection, really. The data slants towards 6 hours and the revisit to the data. But the head to toe ultimate conversation is 7 to 9 hours. So let's really appreciate here's the confusion on that earlier statement. Compared to our teenagers, we need less sleep. As you and I get older and older, we need less sleep. No. The truth of the matter is, you do need that sleep. You need that sleep as you get older. But it's not as easy to get it. But we get acclimated. We get acculturated to this less sleep over time. That's the hard part. What happens to us over time? As adults, we get less deep sleep. We also appreciate that we are more easy to wake up and you and I could suck that up. Right? You wake us up. All right, let me get a cup of coffee. I'll be ready to go. Versus that teenager that the world is ending. Right? So this is a part of the conversation of engaging people, because many people, you and I potentially have normalized our exhaustion. We will get there someday of looking at other biomarkers. But right now we're just asking questionnaires, are you sleepy or not? As I go through this, I can give you some other clues. So what we want to appreciate, sleep will evolve throughout your life. The conversation that was brought up earlier is menopause, and I'll bring up that as well. That's definitely a pivot on our sleep as well. But in the last hundred years, my friends, what do we know? We're sleeping less compared to our great grandparents. Ever since we've had the light bulb, we're sleeping an hour and a half to 2 hours less. What does that mean? That means essentially, what? We have one less sleep cycle in the last 100 years. I’m going to define what a sleep cycle is, and once I do, you won't want to donate it away anymore. And we have been doing that. So let's talk about sleep. How to really begin? That EKG set of wires was put on the scalp and wallah, there's a set of electricity that comes off the brain that can be staged as being awake. Stage one and two. Stage one and two is now the slowing of the brain, but not truly slow sleep and slow wave sleep. Stage one and two is typically called light sleep. It's probably the most unfortunate nomenclature in sleep medicine. Who here wants to be a light sleeper? No one. When I first learned this, I'm like, How do I get rid of this stuff? How do I get to the good stuff? It's not about that. 50 to 60% of your night ought to be that of light sleep. It's the conversation that I see that many people are getting much more than just 50 or 60%. What I want us to focus on here is getting into this the famous deep sleep and that other cool stuff called Rapid Eye Movement. What you and I will colloquially call dreams. Dream, sleep and deep sleep, my friends, is something I want to focus on. Why? This is recovery sleep and is a key opportunity. As you and I get older and older, light sleep goes up by virtue what is going on? The deep sleep and the dream sleep is becoming less. Here's what I want us to focus on, and it's not being written enough out there. So you and I want to do it for ourselves and for the people we serve. I want us to focus on the things that we can do to maintain our deep and dream sleep. If we do nothing, the natural tendency is to backslide to less. And this is the recovery sleep that which again can be in our conversation every single night. So let's think about sleep. As you take a look at this, focus on the far right side. What are we seeing there? We see we go from being awake. We go in to just drop your eyes down to one and two. You see that? The three, That's the deep sleep. So what do we see more of in the first half of the night as a color coded? There, say, more or less. 7 to 9 hours, 8 hours of bedtime. The first 4 hours tends to be more deep sleep. Do you see that there? Okay. Really important What goes on during deep sleep? You put out growth hormone. You put out proteins that repair the body. Honor the fact that this is really amazing. There is some testosterone throughout your entire night, but it's a huge physical repair that's going on during the first half. Deep sleep, physical repair. Second half of the night, what do you see more of there with that blue color? You're seeing more REM, more dreams. What goes on during dreams? I’m not gonna interpret dreams for us. But I'm just going to simply explain part of your brain called the limbic system opens up. That's your emotions. The guy who cut you off today, somebody who said something rude to you and all negative thoughts, that is not letting go. What do we tell to forget about it? Get over it. I wish it were that easy. What we do know is every single night you are opening up this area and you're coughing up coughing up those hairballs. We all have them. So what we need to appreciate we need to do is appreciate that this is an emotional clearing. Every single night the first half is deep physical repair. The second half of night is letting go of negative thoughts. Where your thoughts go is where you go. We have Velcro for the negative and we have Teflon for the positive. If I told you 50 nice things and a rude statement, what will you remember? The rude statement. We want to have people be positive and looking forward to things being well-rested. We tend to be more positive. Positive psychology keeps building on itself. Now let's look at this one more time. I want to talk about memory. Here's an important part. The first half of the night deep sleep. Imagine a panorama of the day you just lived. And what are you going to do in that first half of the night? As if you were saying, Ah, that's an important point you're taking these little Post-it notes into your mind. You're basically imprinting facts. You might say, Oh, that's a good picture. Oh, that's another one I want to bring in. You're putting these Polaroids. So during your deep sleep every single night, you're bringing in facts, whether it be that of words that have concepts, that have pictures. Now, the second half of the night is way cool. What do you see in the second half of the night? You're going to go to those Post-it notes, you're going to go to those Polaroids. You're going to make connections to things that were not spoon fed to you during the day you just lived. What do we call that?Creativity, problem solving. Who here wants to give up any of our deep sleep, our dream sleep? None of us. The first conversation is getting enough time, which if you don't have enough time, you will not necessarily get this. Now, here's an interesting concept. Say you don't sleep well. Interestingly, the body, the sleep will always look to give you more dreams.But it is the deep sleep that just doesn't come back as quickly. And I'm going to tell you now, I'm going to tell you later what you do during the daytime is going to set up that of your night. I want you to hear it again and again. Exercise and nutrition. Yeah, yeah, yeah. We've all heard it. And we have to do it.The more activity during the daytime, the more deep sleep. The more real food you eat, the more energy going to burn. The processed foods, ee tend to get energy swings so we know people exercise and eat more or less closer to nature, are able to recover more of their deep sleep. It's not perfect, but it's very important. I'm going to tell you later, but I'll tell you now because you tend to be awake during the first 20 minutes of this talk.What we do now is that we find that more or less when you are drinking caffeine, we do now appreciate that it can reduce the ability to get deeper sleep. Even if you get to sleep fine. And even if you have no questions about how well you're sleeping, you will likely decrease your deep sleep if you have caffeine on the second half of your day.I know I lose friends bringing this up, but it is so vital important. Enjoy your antioxidant, your team, your coffee. But let's just make sure that we don't limit that of our quality of our sleep now. Oh, I'm going to go back for a moment. What I want us to appreciate here is that it's very natural every 90 minutes to have a brief awakening.It's very natural. Think of schoolchildren. They're all curled up. What do they do every 90 minutes? They might smack their lips, they might look around and they ultimately put their head on the pillow, go right back to sleep, wake up saying, mom, Dad woke up five times last night worried about my deep sleep and my physical repair and my emotional clearing.A quick call, Uncle Param, and get this thing figured out? Now, tonight what will almost exactly happen to every one of us, we’ll get more or less an ache, a pain, a negative thought any event. And if you start focusing on sleep, you're awake. When you start thinking about sleep, does it help you sleep? No. Right. We've done this in studies.You take half the room. Think I need you to sleep tonight? Over here. You need to stay awake all night with me. What tends to occur? The opposite. Paradoxical intention. So I want you and I to appreciate. Get back into your breath. Get into your relaxation. I'll talk about at the very end. So what are the things, though, from our M.D.hat? Our D.O hat? Our medical hat that we need to take a look at? First and foremost, my friends, we have to talk about the big one, sleep apnea. What do we know? Many people misunderstand that. Is it snoring or not? 65% of people snore, have a sleep breathing problem. It's the most misunderstood and the least well studied because qualitatively it is really variable.Loudness does not correlate with severity of disease. The sounds of your muffler, the noise coming off of it does not dictate exactly what's going on in the engine. So I want you and I to really look at this much better. But in my perfect world, I would want everybody snoring to get checked out because even if it's not affecting that person, it might be affecting the bed partner, which is obviously very important.But what we want to do and we're going to talk about apnea hypopneas per hour. And what I want us to know is what is an apnea? A without pnea that of air. For the most part I'm talking obstructive can be in the nose, back of the throat or down lower. It is more or less a full collapse of the airway for 10 seconds or more.The Hollywood version is the snore snore pause. And then what does that guy in the plane do next to us? The choke, the snort, the chortle. Right. We want to appreciate. That's what people say. I don't have that. I people call my office saying, I know I don't have it. Like, how do you know you're sleeping at night?I mean, so it's really awkward, but they're really almost disgusted with the thought they might have this with so much more common. And of all the sleep studies I look at on a daily basis, the hypopnea hypo less air partial collapse, it's heavy breathing. It may not have any sound. 10 seconds of a pause, followed by a deep sigh of breath.How noticeable is that? It isn't so. Among the reasons why we do need to go to testing, because just reporting alone doesn't get us there. Why would we bring this up As severe sleep apnea as equivalent of being a tobacco user on heart health and brain health? That's the reason why I'm allowed to speak here today. This is very important.It gets missed all the time. Restless leg syndrome. They got rid of that term. What are we calling it now? Willis F-bomb disease. Yeah, we're all calling it restless legs. Still, just because nobody remembers Willis F-bomb. What is it? It is most commonly described in the legs. It can be the arms. It can be your torso. What I want you to know night to night.It can greatly vary. Can greatly vary. So some nights rambunctious, other nights very innocent. So what you'd want to know, it could be rubbing the feet, fanning out the toes, needing to stretch a creepy crawly sensation, a need to more or less just kind of kick shift and or just reposition that person is the lovely pillow, the great comforter.But every night it's a new advent to try to get comfortable, start asking about this. And let me share with you. I have restlessness and I didn't know about it. And one of the other things is, is that it's not always noticeable. Keep asking about it. Look at the sleep study report you get back. It is almost never talked about in the final couple of sentences. But if you see somebody having this, everybody focuses on apnea first. And I get it, but do not miss this. This is a disrupter of sleep. It would be weird, but say I snuck into a hotel room tonight. Creepy, weird. I'll never do that. But say I did that with a feather in my hand. Touched you on the face, maybe in your ear and just kept messing with you all night and have you just kind of swat me away but didn't wake you?How great would you feel in the morning? You wouldn't. Restlessness, therefore, kind of along with this one. Teeth grinding. Two out of three people are restless. Are teeth grinders. Teeth grinders. Two out of three tend to be restless. Both of these do not miss. I have a dental appliance now. Why? Because I've cracked two teeth in my head and I blew my dentist off for over 20 years.It's so important. Please don't miss. This is such an important clue. Keep going. When you're hurt. Does it help you sleep? No. The opposite is true. They did this many years ago. They kept medical students up for three nights straight. They sent them to the rheumatologist, said half of them have fibromyalgia, half having slept for three nights. What did they find? The specialistcould not tell them apart. Please make sure that we you need to take a look at it. What we also want to appreciate and take a deeper look at is getting at this one. We know that your caffeine, your alcohol and your medications, pain, drugs, as well as those medicines that more or less for depression are very important to look at.So let me share with you, because I might run out of time toward the end is this important conversation. For every one glass of caffeine you have? It takes about 7 hours to reduce your caffeine by 50%. So an 8 a.m. cup of Java is what, a half cup at 3 p.m. and at 10 p.m. it's a quarter cup.And if you have that afternoon, pick me up. Half of it's there. Now some of you say, no, no, I have the faster genetics. What I want you to hear is this. We know when you do muscle work you break down adenosine. Adenosine when it goes to the brain, put you into deeper sleep. That's the reason we have to do our muscle work and our aerobic work every single night , excuse me, every day so we can sleep better at night.So even if you can get to sleep, take that espresso just before bed. Don't have to worry about that. Please. Just give it an experience. Move your caffeine earlier, move into the decaf. See what you guys can do from this perspective. Now, alcohol, this is where I lose any remaining friends I might have. For every one drink you have, it reducesexcuse me, what you'll find is that you need 2 hours of time for it to wash out of the body in the brain. The first hour you're more relaxed and so is your airway. You tend to snore more or your bed partner. If there is a nightcap. And what we do know is the second hour, your brain's more fidgety.So for every one drink, which is what, 12 ounces of beer, ounce and a half of spirits. How many people are measuring their shots? Not very many. Five ounces of wine. How many ounces in a bottle of wine? 26. How many servings in a bottle? Five. People like, no, no. I can get it all into one glass. No, that's not what I'm saying.So again, what I want you to appreciate is I have so many because I came to your talk. I do a ritual every night. The spouse and I, we take a half a bottle, we split a bottle of wine. So, I mean, they have a half a bottle wine. Half a bottle of wine is how many servings? Two and a half.How many hours will that affect the body for? 5. Somebody saying, I'll drink in the morning. That's still not what we're talking about here, right? I know. I know. I don't get invited to dinner parties. Really. I mean, I’m kind of a joy kill. So what I want you and I to take a look at is enjoy it. But let's retime our capping in our alcohol.The room environment. Cool, comfortable, dark, dark, dark, quiet. What do I want all of you guys to focus on? The sunshine is a greatest way to wake up the body. Anywhere in the body it can send a signal to your circadian, but the back of the eye is the quickest way to wake up your brain. So what I want you and I to be able to think about and to look at here is really something important.What I want us to do is just try this. Decrease your exposure to screens. I know it's easy, but the blue light degrades that of your melatonin. Melatonin, all of us. What else, to a group of cardiologist would affect melatonin production? Beta blockers unless it's selective. Selective beta blockers like Carvedilol do not affect melatonin like general beta blockers do. So that's something I want you to keep in the back of your mind. You start looking at this, you'll start seeing a lot more sleep disorders when somebody is going on that of a beta blocker. Just pay attention. That squeeze work out of Ohio is really helped me understand this much more. Now at the last sleep meeting, what do they encourage all of us to do? I do not own stock in Amazon, but you can go on to that famous portal or any place else Uvex. It's a pair of blue blocking glasses and I have ten of my friends, family members and myself doing this at nighttime. I don't know if it's placebo, but I will share with you my friend, my co intern at Hopkins, who now runs the Circadian lab at the Mayo Clinic, Robbie Auger, he goes, it's better than nothing because we all live in electronic world. More or less, look at this conversation. Decrease blue light at nighttime. Any screen is going to give you a blue light. Now, I know we have a few minutes remaining and I have a ton of information in the slide. The very last slide is going to have my contact information, connect to me through LinkedIn, email me any of those, but I don't want you to miss these. This is a really big. What I want you to take a look at here is an important fact. The first half of your night is more deep sleep. The second half a night that of the dreams where you open up your limbic system. How many people say do I have no problem? I get to sleep, but in the middle night, my mind gets going, and, whoa, it's so amazing, right? If we do not do some emotional clearing during the daytime, it's going to be so much harder to get the second half of night. And we used to say middle of night awakening was pathognomonic depression. No, it's not. But it is highly associated. Let's not miss that there. Hormones as it was brought up, estrogen progesterone affects skeletal muscles, but also the airway muscles. You'll have more sleep related breathing disorder. Call it apnea hypopnea related to that of the conversations during menopause. Very controversial to use hormone therapy just for sleep. But there is some data that shows that it helps the breathing. Very important to consider. Very important. All right. How many times is it normal to get up and go to the loo? 0 to 1 is normal. 2 normal ish. 3 or more., you might want to talk to someone. So what I would want us to think about really clearly here is that 35% of the time we find it's a kidneys, ureter, bladder and the prostate. 65% of time something woke you up and you're like, oh, but I got to go. What else do you think about when you got to go? Nothing. You better go otherwise it's going to be messy and awkward, right? So if something woke you up during the night, you won't have that much of a notice. I use this as a classic screening for the nocturia in terms of doing a bigger sleep conversation. Now, these two points, what has really been shown in the literature, in the slides, have this. We know heart health. What’s the biggest data we have? Blood pressure and sleep. When somebody is not sleeping well, we see a dramatic change in blood pressure. Congestive heart disease, an elegant, beautiful talk earlier on congestive heart disease. The big conversation right now is how to use that as a tool in sleep and vice versa. What I want you to know is one of the things we know is that a lot of these people with congestive heart failure need to have some of the most aggressive treatments for their sleep apnea. What we do know is everybody talks about CPAP for congestive heart failure. We use an advanced form called adaptive servo ventilation. It's like a mini ventilator. But three years ago, three years ago, it came out, it was big news. Everybody in the sleep, medicine world shook. They had to stop the trial early. More people were dying on ASV adaptive servo ventilation. So one of the things is, is when somebody has congestive heart failure, we know if we treat them earlier, you're going to minimize the the decrease in ejection fraction over time. But how you treat them, you got to partner tightly with the pulmonologist. It's gotten very confusing. You can still help them. But let me now get to a couple of summary points as I bring this in. What we want to know is severe apnea is like being a tobacco user that's 30 times or more of having a full or partial collapse. Anything greater than 15 times is considered moderate apnea. Most insurance companies will let us treat that. Here's the tough one. Mild sleep apnea. You can ask to sleep doctors and get three different opinions of what to do when you have mild apnea. Now, I work at a place where people are paying out of pocket. I have people that will be aggressive. There are some passionate reasons to be aggressive, but if you're looking at endpoints, severe apnea, you're going to do a great disservice to the heart and their brain health. And why I want us to bring up on this is that if we miss this, we miss it. But be curious. Keep reading. Email me, reach out, keep bringing speakers into your meetings. Learn about what to do with mild or moderate sleep, sleep apnea and what it does to that of heart attack risk, blood pressure risks. And also what I want you to know is this one, any time somebody has atrial fibrillation, please consider their sleep. The reports are anywhere from 30 to 50% of people with atrial fibrillation have sleep apnea. If you don't treat it, you're more likely to need shocks to the heart and or more medications to keep them in rhythm. So, please, you're going to look brilliant. Every year I had 12 people that say I had eight new A-fib. I checked them like, how did you know? They had no signs or symptoms that they knew of? Be curious about this one last point. When I talk about brain and heart, somebody with new arrhythmia consider their sleep, somebody with that of a mini heart attack, look at their sleep. If they have apnea or another sleep disorder, they're more likely to go on to a bigger event later. We want to appreciate also is if somebody has a mini stroke, seizure like activity, concussion, look at their sleep. If you don't treat it, they're likely to go on to a prolonged or worsening connection. The last one is that sleep is an anti-inflammatory. C-reactive protein markers, you take a look at IL6, IL18, tumor necrosis factor, nitric oxide is being implied with this and dramatically some data on hyperlipidemia and also that of dyslipidemia and HDL factors. Sleep now is being looked at so much more. What I want you to know is that again I know my time is up here, but don't miss the conversation of being curious about the sleep. Engage people. When somebody comes to you with their data that they're wearing on the wrist, be curious about it. You engage them in a meaningful way. The signs and the symptoms are not going to get you there all the time. So I want you to start thinking about this. I'm going to just close with this. The following should make all of us curious if you find yourself being tired in the afternoon when reading. That's not normal. If you find yourself falling asleep in the afternoon with a book or at a lecture, be curious. If you find that person that's falling asleep on a plane, not a red eye flight, get curious. If you're finding that person falling asleep as a passenger in a car for an hour without a break. Be curious. Somebody is falling asleep at stop signs or red light. Be very curious. My friends, that's much more common than any of us want to know. Drinking and driving kills people every year. More deaths behind the wheel because of sleepiness. Sleepiness is an impairment. When someone says I'm a great sleeper, I can fall asleep within one or 2 minutes. That's not normal. That's exhaustion. So I want you to be very curious. If somebody comes in with any new cardiovascular disease, I just will close with this. Be curious. I know there's a lot more questions and thoughts. We're going to have my email address, find me on LinkedIn, reach out to me if I can be of service. I'd be honored to do so. Thank you guys so much.