From the Guidelines
Melatonin is a reasonable option for sleep in cardiac unit patients, typically starting with 1-3 mg taken 30-60 minutes before bedtime, as it is generally considered safe and has minimal drug interactions compared to traditional sedative-hypnotics. For elderly patients, begin with the lower dose of 1 mg. According to the American Academy of Sleep Medicine clinical practice guideline 1, ramelteon is also considered effective for sleep onset, but melatonin is a more suitable option for cardiac patients due to its benign side effect profile. Melatonin works by supplementing the body's natural sleep hormone, helping regulate circadian rhythm that may be disrupted in the hospital environment due to noise, lighting, and frequent monitoring. Non-pharmacological approaches should also be implemented, including:
- Maintaining a dark, quiet environment
- Minimizing nighttime disruptions when possible
- Encouraging relaxation techniques If melatonin proves ineffective, consult with the patient's cardiologist before considering other sleep medications, as many traditional hypnotics may have cardiovascular effects or interact with cardiac medications, as noted in the clinical practice guidelines for the prevention and management of pain, agitation/sedation, delirium, immobility, and sleep disruption in adult patients in the ICU 1. Additionally, the FDA has recommended warnings for adverse effects associated with benzodiazepine receptor agonistic modulators, which are commonly used for insomnia treatment 1.
From the FDA Drug Label
- 1 Controlled Clinical Trials Chronic Insomnia Three randomized, doubleblind trials in subjects with chronic insomnia employing polysomnography (PSG) were provided as objective support of ramelteon's effectiveness in sleep initiation Ramelteon reduced the average latency to persistent sleep at each of the time points when compared to placebo.
The medication that can be given to a patient in the cardiac unit for sleep is ramelteon (PO), considering melatonin is not mentioned in the provided drug label.
- Ramelteon has been shown to reduce sleep latency in patients with chronic insomnia.
- The recommended dose is 8 mg, as the 16 mg dose conferred no additional benefit for sleep initiation and was associated with higher incidences of fatigue, headache, and next-day somnolence 2.
From the Research
Medication Options for Sleep in Cardiac Unit Patients
Considering melatonin as a potential medication for sleep in cardiac unit patients, the following points are relevant:
- Melatonin may be a safe somniferous drug for cardiac patients, as it does not aggravate sleep-disordered breathing in patients with coronary artery disease (CAD) 3.
- Ramelteon, a melatonin MT1/MT2 receptor agonist, has been shown to maintain cardiac rhythms during non-REM sleep in rats, suggesting a potential remedial effect on cardiac activity 4.
- Melatonin therapy may improve cardiac function and quality of life in heart failure patients, with benefits including increased ejection fraction, improved NYHA class, and reduced fatigue 5.
- However, there is also evidence to suggest that sleep medications containing melatonin can potentially induce ventricular arrhythmias in structurally normal hearts, highlighting the importance of careful consideration and monitoring 6.
- Activation of melatonin receptors by ramelteon has been shown to induce cardioprotection by postconditioning in the rat heart, suggesting a potential mechanism for melatonin's beneficial effects on cardiac function 7.
Key Considerations
- The use of melatonin or melatonin receptor agonists like ramelteon for sleep in cardiac unit patients should be carefully considered and monitored, taking into account the potential benefits and risks.
- Patients with a history of ventricular arrhythmias or other cardiac conditions may require closer monitoring or alternative treatment options.
- Further research is needed to fully understand the effects of melatonin and melatonin receptor agonists on cardiac function and sleep in cardiac unit patients.