Prospective Bidirectional Relationship Between Sleep Duration and Posttraumatic Stress Disorder Symptoms After Suspected Acute Coronary Syndrome.

OBJECTIVE: Sleep disturbance is a "hallmark" symptom of posttraumatic stress disorder (PTSD). Poor sleep (including short sleep) after combat-related trauma can also predict subsequent PTSD. Less is known about the association between sleep duration and PTSD symptoms when PTSD is induced by acute coronary syndrome (ACS). We examined the bidirectional relationship between sleep duration and PTSD symptoms over the year after hospital evaluation for ACS. METHODS: Participants were enrolled in this observational study after emergency department evaluation for ACS. Sleep duration ("During the past month, how many hours of actual sleep did you get at night?") and cardiac event or hospitalization-induced PTSD symptoms (PTSD Checklist) were assessed at 1, 6, and 12 months after hospital discharge. Cross-lagged path analysis was used to model the effects of sleep duration and PTSD symptoms on each other. Covariates included age, sex, race/ethnicity, cardiac severity, baseline depression symptoms, and early acute stress disorder symptoms. RESULTS: The sample included 1145 participants; 16% screened positive for probable PTSD (PTSD Checklist score ≥33). Mean sleep duration across time points was 6.1 hours. Higher PTSD symptoms predicted shorter sleep duration at the next time point (i.e., 1-6 and 6-12 months; B = -0.14 hours/10-point difference, SE = 0.03, p < .001). Shorter sleep duration was associated with higher PTSD symptoms at the next time point (B = -0.25 points/hour, SE = 0.12, p = .04). CONCLUSIONS: Short sleep duration and PTSD symptoms are mutually reinforcing across the first year after ACS evaluation. Findings suggest that sleep, PTSD symptoms, and their relationship should be considered in the post-ACS period.

Day-to-day associations of intersectional minority stressors with sleep health in sexual and gender minority people of color.

OBJECTIVE: To determine the day-to-day associations between minority stressors (i.e., anticipated and experienced discrimination) and sleep health outcomes (i.e., total sleep time (TST), sleep disturbances, and sleep-related impairment) among sexual and gender minority (SGM) people of color. METHOD: An online sample of SGM people of color living in the United States participated in a 30-day daily diary study. Daily anticipated and experienced discrimination as well as subjective sleep outcomes were assessed via electronic diaries using validated measures. Wrist-worn actigraphy was used to objectively assess TST. Multilevel linear models (MLMs) were used to estimate the independent associations of daily intersectional minority stressors with subsequent sleep outcomes, adjusted for demographic factors and lifetime discrimination. RESULTS: The sample included 43 SGM people of color with a mean age of 27.0 years (± 7.7) of which 84% were Latinx, 47% were multiracial, and 37% were bisexual. Results of MLMs indicated that greater report of daily experienced discrimination was positively associated with same-night sleep disturbances, B (SE) = 0.45 (0.10), p < .001. Daily anticipated discrimination was positively associated with sleep-related impairment on the following day, B (SE) = 0.77 (0.17), p < .001. However, daily anticipated and experienced discrimination were not associated with same-night TST. CONCLUSIONS: Findings highlight the importance of considering the differential effects of daily intersectional minority stressors on the sleep health of SGM people of color. Further research is needed to identify factors driving the link between daily minority stressors and sleep outcomes to inform sleep health interventions tailored to this population. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Association between cardiac event-induced PTSD symptoms and daily intrusive thoughts about cardiac risk: An ecological momentary assessment study.

OBJECTIVE: Posttraumatic stress symptoms (PSS) due to acute cardiac events are common and may lead patients to avoid secondary prevention behaviors. However, patients' daily experience of cardiac event-induced PSS has not been studied after a potentially traumatic cardiac hospitalization. METHOD: In an observational cohort study, 108 mostly male patients with coronary heart disease were recruited after evaluation for suspected acute coronary syndrome (ACS). One month later, PSS were assessed via telephone-administered PTSD Checklist for DSM-5 (PCL-5). The exposure of interest was elevated (PCL-5 ≥ 20) vs. non-elevated PSS (PCL-5 ≤ 5). The occurrence and severity of cardiac-related intrusive thoughts were assessed 5 times daily for 2 weeks via electronic surveys on a wrist-worn device. RESULTS: Moderate-to-severe intrusive thoughts were experienced by 48.1% of patients but more commonly by elevated-PSS (n = 36; 66.7%) than non-elevated-PSS (n = 72; 38.9%) patients. After adjustment for demographic and clinical characteristics, elevated- vs. non-elevated-PSS patients had a 9-fold higher odds of experiencing a moderate-to-severe intrusive thought during each 2-h assessment interval (adjusted OR = 9.14, 95% CI [2.99, 27.92], p < .01). After adjustment, intrusive thoughts on a 0-to-6 point scale were over two times as intense for elevated-PSS vs. non-elevated-PSS patients. CONCLUSIONS: Intrusive thoughts about cardiac risk were common in patients recently evaluated for ACS, but much more prevalent and intense in those with elevated vs non-elevated PSS.

The relationship of shift work disorder with symptoms of depression, anxiety, and stress.

Shift workers commonly suffer from disturbed sleep, which is known to affect mental health in other populations. Shift work disorder (SWD) is characterized by complaints of insomnia and/or excessive daytime sleepiness temporally associated with working non-standard schedules that occur during the usual time for sleep. Few studies have explored the extent to which workers with vs. without SWD experience worse mental health. We administered the Shift Work Disorder Screening Questionnaire to 60 adults engaged in various shift work schedules to categorize workers as being at high or low risk for SWD. Mental health outcomes were measured using the Depression Anxiety Stress Scale-21 (DASS-21). Linear regression was performed for each DASS-21 subscale, adjusting for age, sex, shift type, sleep duration, and frequency of alcohol use. Most participants (55 %) were at high risk for SWD. High-risk participants had higher depressive symptoms than low-risk participants, B = 3.59, 95 % CI [0.54, 6.65], p = .02. The estimated value for those at high risk for SWD corresponded to clinically significant mild depressive symptoms, (M = 13.43), compared to those at low risk, (M = 9.84). High risk for SWD was marginally associated with increased stress symptoms, B = 2.48, 95 % CI [-0.06,5.02], p = .06. Our findings add to the body of evidence that SWD is associated with poor mental health outcomes. Providing interventions specific to the sleep impacts of SWD, including tailored cognitive behavioral therapy for insomnia, may improve shift workers' mental health.

Well-being therapy and sleep hygiene in a non-clinical population of adults reporting poor sleep quality and distress: A remote pilot randomized controlled study.

OBJECTIVES: This pilot randomized controlled study evaluates the feasibility and preliminary efficacy of a 7-week remote intervention combining well-being therapy and sleep hygiene to improve sleep and psychological outcomes among adults reporting poor sleep and distress. METHODS: Thirty-one participants (81% women, 40.2 ± 13.0 y, 48% racial/ethnic minority) were recruited from the community during the COVID-19 pandemic through online and local advertisement, and randomized to well-being therapy+sleep hygiene or sleep hygiene-only. Study outcomes were evaluated by self-reported questionnaires administered at baseline and post-intervention and a daily sleep diary. RESULTS: Compared to sleep hygiene-only, well-being therapy+sleep hygiene led to greater improvements in wake after sleep onset (time-by-group interaction: 3.6 ± 1.5 min, p = .017), personal growth (ß -3.0, 95%CI -5.2, -0.8, p = .01), and purpose in life (ß -3.5, 95%CI -6.1, -0.9, p = .009). Anxiety, perceived stress, sleep quality, and insomnia symptoms improved similarly in both groups (between-group differences, p > .05). Improvements in sleep quality, insomnia, and sleep duration were associated with reductions in multiple measures of psychological distress (all p < .05). CONCLUSIONS: These findings suggest that, in a non-clinical setting of individuals suffering from combined poor sleep and psychological distress, the addition of well-being therapy to sleep hygiene may provide additional benefits for sleep by promoting sleep continuity and well-being.

Rest-Activity Rhythms Are Associated With Prevalent Cardiovascular Disease, Hypertension, Obesity, and Central Adiposity in a Nationally Representative Sample of US Adults.

BACKGROUND: Rest-activity rhythms (RARs), a measure of circadian rhythmicity in the free-living setting, are related to mortality risk, but evidence is limited on associations with cardiovascular disease (CVD) and its risk factors. METHODS AND RESULTS: Participants included 4521 adults from the 2013 to 2014 National Health and Nutrition Examination Survey physical activity monitoring examination. Wrist-worn ActiGraph GT3X+ data were used to estimate RARs. Multivariable logistic models evaluated associations of RARs with prevalent CVD, hypertension, obesity, and central adiposity. Participants (mean age, 49 years) in the highest versus lowest tertile of relative amplitude (greater circadian rhythmicity) had 39% to 62% lower odds of prevalent CVD, hypertension, obesity, and central adiposity. A more active wake period was associated with 19% to 72% lower CVD, hypertension, obesity, and central adiposity odds. Higher interdaily stability (regular sleep-wake and rest-activity patterns) was related to 52% and 23% lower CVD and obesity odds, respectively. In contrast, participants in the highest versus lowest tertile of intradaily variability (fragmented RAR and inefficient sleep) had >3-fold and 24% higher CVD and obesity odds, respectively. A later and less restful sleep period was associated with 36% to 2-fold higher CVD, hypertension, obesity, and central adiposity odds. A statistically significant linear trend was observed for all associations (P-trend<0.05). CONCLUSIONS: A robust, stable, and less fragmented RAR, an active wake period, and an earlier and more restful sleep period are associated with lower prevalent CVD, hypertension, obesity, and central adiposity, with evidence of a dose-response relationship. The magnitude, timing, and regularity of sleep-wake and rest-activity patterns may be important targets for reducing cardiovascular risk.

Sleep Disturbance and Burnout in Emergency Department Health Care Workers.

This cross-sectional study examines the association of sleep disturbances with burnout among emergency medicine health care workers.

A Series of Remote Melatonin Supplement Interventions for Poor Sleep: Protocol for a Feasibility Pilot Study for a Series of Personalized (N-of-1) Trials.

BACKGROUND: Poor sleep, defined as short-duration or poor-quality sleep, is a frequently reported condition with many deleterious effects including poorer cognitive functioning, increased accidents, and poorer health. Melatonin has been shown to be an efficacious treatment to manage symptoms of poor sleep. However, the treatment effects of melatonin on sleep can vary greatly between participants. Personalized, or N-of-1, trial designs represent a method for identifying the best treatment for individual participants. Although using N-of-1 trials of melatonin to treat poor sleep is possible, the feasibility, acceptability, and effectiveness of N-of-1 trials using melatonin are unknown. Using the National Institutes of Health Stage Model for Behavioral Intervention Development, a stage IB (intervention refinement, modification, and adaptation and pilot testing) design appeared to be needed to address these feasibility questions. OBJECTIVE: This trial series evaluates the feasibility, acceptability, and effectiveness of a series of personalized interventions for remote delivery of melatonin dose (3 and 0.5 mg) versus placebo supplements for self-reported poor sleep among 60 participants. The goal of this study is to provide valuable information about implementing remote N-of-1 randomized controlled trials to improve poor sleep. METHODS: Participants will complete a 2-week baseline followed by six 2-week alternating intervention periods of 3 mg of melatonin, 0.5 mg of melatonin, and placebo. Participants will be randomly assigned to 2 intervention orders. The feasibility and acceptability of the personalized trial approach will be determined with participants' ratings of usability and satisfaction with the remote, personalized intervention delivery system. The effectiveness of the intervention will be measured using participants' self-reported sleep quality and duration and Fitbit tracker-measured sleep duration and efficiency. Additional measures will include ecological momentary assessment measures of fatigue, stress, pain, mood, concentration, and confidence as well as measures of participant adherence to the intervention, use of the Fitbit tracker, and survey data collection. RESULTS: As of the submission of this protocol, recruitment for this National Institutes of Health stage IB personalized trial series is approximately 78.3% complete (47/60). We expect recruitment and data collection to be finalized by June 2023. CONCLUSIONS: Evaluating the feasibility, acceptability, and effectiveness of a series of personalized interventions of melatonin will address the longer term aim of this program of research-is integrating N-of-1 trials useful patient care? The personalized trial series results will be published in a peer-reviewed journal and will follow the CONSORT (Consolidated Standards of Reporting Trials) extension for N-of-1 trials (CENT 2015) reporting guidelines. This trial series was approved by the Northwell Health institutional review board. TRIAL REGISTRATION: ClinicalTrials.gov NCT05349188; https://www.clinicaltrials.gov/study/NCT05349188. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/45313.

A First Look at Childhood Abuse in Women with Obstructive Sleep Apnea.

Study objectives. Women who experienced childhood sexual abuse have higher rates of obesity, a risk factor for obstructive sleep apnea (OSA). We assessed if prior childhood sexual abuse was more common in women with OSA vs. control, with possible mediation by obesity. Methods . We studied 21 women with OSA (age mean±s.d. 59±12 years, body mass index (BMI) 33±8 kg/m 2 , respiratory event index [REI] 25±16 events/hour, Epworth Sleepiness Scale [ESS] 8±5) and 21 women without OSA (age 53±9 years, BMI 25±5 kg/m 2 , REI (in 7/21 women) 1±1 events/hour, ESS 5±3). We evaluated four categories of trauma (general trauma, physical, emotional, and sexual abuse) with the early trauma inventory self-report-short form (ETISR-SF). We assessed group differences in trauma scores with independent samples t-tests and multiple regressions. Parametric Sobel tests were used to model BMI as a mediator for individual trauma scores predicting OSA in women. Results. Early childhood sexual abuse reported on the ETISR-SF was 2.4 times more common in women with vs. without OSA ( p =0.02 for group difference). Other trauma scores were not significantly different between women with and without OSA. However, BMI was a significant mediator ( p =0.02) in predicting OSA in women who experienced childhood physical abuse. Conclusions. Childhood sexual abuse was more common in a group of women with OSA than those without OSA. Additionally, BMI was a mediator for OSA of childhood physical but not sexual abuse. There may be physiological impacts of childhood trauma in women that predispose them to OSA.

Post-stroke sleep disturbance and recurrent cardiovascular and cerebrovascular events: A systematic review and meta-analysis.

Despite improvements in survival rates, risk of recurrent events following stroke remains high. Identifying intervention targets to reduce secondary cardiovascular risk in stroke survivors is a priority. The relationship between sleep and stroke is complex: sleep disturbances are likely both a contributor to, and consequence of, stroke. The current aim was to examine the association between sleep disturbance and recurrent major acute coronary events or all-cause mortality in the post-stroke population. Thirty-two studies were identified, including 22 observational studies and 10 randomized clinical trials (RCTs). Identified studies included the following as predictors of post-stroke recurrent events: obstructive sleep apnea (OSA, n = 15 studies), treatment of OSA with positive airway pressure (PAP, n = 13 studies), sleep quality and/or insomnia (n = 3 studies), sleep duration (n = 1 study), polysomnographic sleep/sleep architecture metrics (n = 1 study), and restless legs syndrome (n = 1 study). A positive relationship of OSA and/or OSA severity with recurrent events/mortality was seen. Findings on PAP treatment for OSA were mixed. Positive findings indicating a benefit of PAP for post-stroke risk came largely from observational studies (pooled RR [95% CI] for association between PAP and recurrent cardiovascular event: 0.37 [0.17-0.79], I2 = 0%). Negative findings came largely from RCTs (RR [95% CI] for association between PAP and recurrent cardiovascular event + death: 0.70 [0.43-1.13], I2 = 30%). From the limited number of studies conducted to date, insomnia symptoms/poor sleep quality and long sleep duration were associated with increased risk. Sleep, a modifiable behavior, may be a secondary prevention target to reduce the risk of recurrent event and death following stroke. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42021266558.

Assessing sleep health dimensions in frontline registered nurses during the COVID-19 pandemic: implications for psychological health and wellbeing.

The COVID-19 pandemic altered work environments of nurses, yielding high rates of stress and burnout. Potential protective factors, including effective sleep, may influence psychological health and wellbeing. Evidence about sleep in nurses may help develop interventions that mitigate burnout and poor psychological outcomes. A cross sectional survey was distributed across three hospitals to nurses in New York City (NYC). During the first wave of the pandemic (March-April 2020), NYC had the highest incidence of laboratory-confirmed COVID-19 cases (915/100 000) and half of all COVID-related deaths nationwide. Multivariable logistic regression was used to determine associations between Pittsburgh Sleep Quality Index (PSQI) global sleep score, PSQI sleep dimensions, and psychological health (burnout, depression, anxiety, and compassion fatigue), unadjusted and then controlling for individual and professional characteristics. More than half of the participants reported burnout (64%), depression, (67%), and anxiety (77%). Eighty percent of participants had PSQI global scores >5 (poor sleep) (mean 9.27, SD 4.14). Respondents reporting good sleep (PSQI ≤ 5) had over five times the odds of no burnout (OR: 5.65, 95% CI: 2.60, 12.27); increased odds of screening negative for depression (OR: 6.91, 95% CI: 3.24, 14.72), anxiety (OR: 10.75, 95% CI: 4.22, 27.42), and compassion fatigue (OR: 7.88, 95% CI: 1.97, 31.51). Poor subjective sleep quality PSQI subcomponent was associated with burnout (OR: 2.21, 95% CI: 1.41, 3.48) but sleep duration subcomponent was not (OR: 0.84, 95% CI: 0.59, 1.19). Daytime dysfunction was significantly associated with all psychological outcomes. Sleep disturbances and medications yielded higher anxiety odds. Overall, sleep quality appears more strongly related to burnout than sleep duration in nurses working during the COVID-19 pandemic. Sleep interventions should target individual sleep dimensions in nurses.

Ultra-processed foods and the development of obesity in adults.

Ultra-processed foods (UPF) are ubiquitous in the modern-day food supply and widely consumed. High consumption of these foods has been suggested to contribute to the development of obesity in adults. The purpose of this review is to present and evaluate current literature on the relationship between UPF consumption and adult obesity. Cross-sectional studies (n = 9) among different populations worldwide show a positive association between UPF consumption and obesity. Longitudinal studies (n = 7) further demonstrate a positive association between UPF consumption and development of obesity, suggesting a potential causal influence of UPF consumption on obesity risk. However, only one randomized controlled trial has tested the causality of this association. The study included in this review found greater energy intake and weight gain with consumption of a high UPF diet compared to a high unprocessed food diet. The potential mechanisms by which UPF increase the risk of obesity include increased energy intake due to increased sugar consumption, decreased fiber consumption, and decreased protein density; however, more research is needed. Overall, the evidence identified in the current review consistently support a positive relation between high UPF consumption and obesity. While there is a need for more experimental research to establish causality and elucidate the mechanisms, the sum of the evidence supports a need for research on treatment modalities that include reductions in UPF consumption for the management of adult obesity.

Sleep and Circadian Disturbance in Cardiovascular Risk.

PURPOSE OF REVIEW: We discuss the relationship between sleep and circadian factors with cardiovascular disease (CVD) risk, including physiologic, behavioral, and psychological mechanisms along this pathway. RECENT FINDINGS: The relationship between short and long sleep duration, as well as insomnia, with CVD risk is well-established. Recent work has highlighted how other sleep factors, such as sleep regularity (i.e., consistency of sleep timing), multidimensional sleep health, and circadian factors like chronotype and social jetlag, relate to CVD risk. Sleep-focused interventions (e.g., cognitive behavioral therapy for insomnia and sleep extension) may be effective to reduce CVD risk and disease burden. Sleep is increasingly recognized as an integral component of cardiovascular health. This was underscored by the recent inclusion of sleep duration as a health behavior in the American Heart Association's Life's Essential 8 for defining optimal cardiovascular health.

The association between race- and ethnicity-related stressors and sleep: the role of rumination and anxiety sensitivity.

STUDY OBJECTIVES: This study was designed to investigate the association between psychosocial factors and self-reported sleep duration and two indices of sleep quality in a racially and ethnically diverse sample of adults. We investigated the relations between both rumination and anxiety sensitivity with these self-reported sleep outcomes. We also examined rumination and anxiety sensitivity as moderators of three race- and ethnicity-related stressors: discrimination, acculturative stress, and socioeconomic status. METHODS: In a cross-sectional design, we assessed 1326 adults (ages 18-48 years) selected for self-reported racial and ethnic minority status. Regression analyses were used to examine the associations between demographic, social/environmental stressors, depression severity, rumination, and anxiety sensitivity and three sleep outcomes: sleep duration, sleep quality subscale, and global sleep quality. RESULTS: Our findings supported the hypothesized role of rumination as an amplification factor for the influence of race- and ethnicity-related stressors on sleep duration and quality. Rumination was associated with all three sleep outcomes (sleep duration, sleep quality subscale, and global sleep quality) and was a moderator of the associations between discrimination and all 3 sleep outcomes. Anxiety sensitivity was not consistently associated with these sleep outcomes. Depression symptoms did not account for these findings. CONCLUSIONS: If confirmed in longitudinal study, our findings introduce a potentially important treatment target-rumination-for addressing sleep disparities in prevention or intervention models. Rumination appears to amplify the negative sleep consequences of race- and ethnicity-related stressors and is a modifiable treatment target.

The association between sleep and psychological distress among New York City healthcare workers during the COVID-19 pandemic.

BACKGROUND: Healthcare workers (HCWs) treating patients with COVID-19 report psychological distress. We examined whether disturbed sleep was associated with psychological distress in New York City (NYC) HCWs during the initial peak of the COVID-19 pandemic (April-May 2020). METHODS: HCWs completed a survey screening for acute stress (4-item Primary Care PTSD screen), depressive (Patient Health Questionaire-2), and anxiety (2-item Generalized Anxiety Disorder scale) symptoms. Insomnia symptoms (modified item from the Insomnia Severity Index) and short sleep (SS, sleep duration <6 h/day) were assessed. Poisson regression analyses predicting psychological distress from SS and insomnia symptoms, adjusting for demographics, clinical role/setting, redeployment status, shifts worked, and multiple comparisons were performed. RESULTS: Among 813 HCWs (80.6% female, 59.0% white) mean sleep duration was 5.8 ± 1.2 h/night. Prevalence of SS, insomnia, acute stress, depressive, and anxiety symptoms were 38.8%, 72.8%, 57.9%, 33.8%, and 48.2%, respectively. Insomnia symptoms was associated with acute stress (adjusted prevalence ratio [PR]: 1.51, 95% CI: 1.35, 1.69), depressive (PR: 2.04, 95% CI: 1.78, 2.33), and anxiety (PR: 1.74, 95% CI: 1.55, 1.94) symptoms. SS was also associated with acute stress (PR: 1.17, 95% CI: 1.07, 1.29), depressive (PR: 1.36, 95% CI: 1.233, 1.51), and anxiety (PR: 1.38, 95% CI: 1.26, 1.50) symptoms. LIMITATIONS: Our cross-sectional analysis may preclude the identification of temporal associations and limit causal claims. CONCLUSIONS: In our study, SS and insomnia were associated with psychological distress symptoms in NYC HCWs during the COVID-19 pandemic. Sleep may be a target for interventions to decrease psychological distress among HCWs.

The Prospective Association of Patient Hospitalization with Spouse Depressive Symptoms and Self-Reported Heath.

After hospital discharge, patients experience a period of generalized risk for adverse mental and physical health outcomes (post-hospital syndrome [PHS]). Hospital stressors can explain these effects in patients (e.g., sleep disruption, deconditioning). Patients' partners also experience adverse outcomes following patient hospitalization, but mechanisms of these effects are unknown. The purpose of this study was to test whether greater times and nights of patient hospitalization (proxies for partner exposure to hospital stressors) are prospectively associated with greater increases in partner depression and in partner self-reported poor health. Participants were 7,490 married couples (11,208 individuals) enrolled in the Health and Retirement Study. Outcomes were prospective changes in depressive symptoms and self-reported poor health, and primary predictors were spouse hospitalization over the past two years (yes/no), spouse hospitalized ≥ two times (yes/no), and spouse spent ≥ eight nights in-hospital (yes/no). Covariates included age, gender, race, ethnicity, income, own hospitalization experiences during the past 12 months, and one's own and spouse comorbidities. Having a spouse who experienced two or more hospitalizations was associated with an increase in one's own depression over time, as was having a spouse who spent eight or more nights in-hospital. Spouse hospitalization was not associated with prospective changes in self-reported health. Results suggest that PHS mechanisms may account for adverse post-hospitalization outcomes in patients' partners.

COVID-19 and the amplification of cardiovascular risk by psychological distress.

The COVID-19 pandemic has unleashed a tidal wave of psychological distress. Here, we discuss the biobehavioral mechanisms through which psychological distress amplifyies the adverse effects of SARS-CoV-2-infection on cardiovascular outcomes. We also examine how the stress of caring for patients with COVID-19 increases cardiovascular risk in healthcare workers.