On February 13th 2016, Antonin Scalia, one of the most famous Supreme Court Justices in the history of the United States passed away in his sleep. He died suddenly. The presumed cause of death was a heart attack. This came as a shock as Justice Scalia seemed to be relatively healthy, living an active lifestyle when not on the bench. He was a highly functioning individual up until the time when he went to bed on the night of the 12th. Heart attacks are less likely during the night than daytime at at time, when activity increases stressing the heart. Therefore, when cardiovascular events like heart attacks or strokes take place at night we should question the underlying cause. Some conspiracy theorists have suggested foul play. I doubt that. I believe a medical explanation might be more reasonable to explain what might have predisposed Justice Scalia to having a heart attack during sleep.

Heart attacks most likely the morning

In the general population the peak occurrence of cardiovascular events takes place between the hours of 6 AM and 11 AM, shortly after waking. Normally, waking causes a natural surge in cortisol and sympathetic activity to get you going. Consequently, blood pressure and heart rate rise and this increases the risk of cardiovascular events. Heart rate and blood pressure increase further during activity. In contrast, blood pressure and heart rate normally decrease during sleep giving your heart a rest along with the rest of your body.

What could have caused Scalia’s heart attack?

The exception exists in patients with uncontrolled sleep apnea who are predisposed to having heart attacks at night. As these individuals struggle to breath against a closed airway, their blood pressure and heart rate spikes upwards. This leads to a peak of heart attacks and strokes between the sleeping hours of 12 AM and 6 AM.

When I heard of Antonin Scalia dying in his sleep one of the first things that came to mind was the relationship between sudden death at night and sleep apnea. Justice Scalia was also reported to be overweight and have hypertension, two other risk factors for sleep apnea. While the general population enjoy sleep as a refreshing experience for their mind and body, and their blood pressure and heart rate also decrease, those with untreated sleep apnea may experience the opposite. They see a spike in their heart rate and blood pressure increasing the risk of dying from a heart attack or stroke in their sleep.


Gami AS et al. Day-Night pattern of sudden death in obstructive sleep apnea, NEJM 2005; 352:1206-14.
Kohli P, Balachandran JS, Malhotra A. Obstructive sleep apnea and the risk for cardiovascular disease.