Does managing insomnia help control heart failure?

Managing Insomnia to Control Heart Failure

Treating insomnia in heart failure patients can improve heart failure outcomes by reducing fatigue, improving functional capacity, and enhancing quality of life. 1, 2

Connection Between Insomnia and Heart Failure

• Sleep disorders, including insomnia, are common in heart failure patients and are associated with worse heart failure outcomes 3, 1
• Sleep-disordered breathing is associated with a 2.38 relative risk of heart failure, exceeding the risk for other cardiovascular diseases 3
• Poor sleep phenotypes in heart failure patients predict time to hospitalizations and emergency department visits (hazard ratios 0.35-0.60) 4
• Patients with heart failure and sleep apnea have a 2.7-fold greater risk of reduced survival than patients with heart failure or apnea alone 1

First-Line Treatment: Cognitive Behavioral Therapy for Insomnia (CBT-I)

• CBT-I is the recommended first-line treatment for insomnia in heart failure patients 1, 3
• CBT-I has demonstrated sustained effects on insomnia severity, sleep quality, fatigue, daytime sleepiness, and physical function in heart failure patients for up to 12 months 2
• CBT-I improves six-minute walk distance, indicating better functional capacity in heart failure patients 2, 5
• Key components of effective CBT-I include:
  • Sleep restriction therapy (limiting time in bed to increase sleep efficiency) 1
  • Stimulus control (associating bed with sleep rather than wakefulness) 1
  • Sleep hygiene education (as part of comprehensive treatment) 1

Benefits of Treating Insomnia in Heart Failure

• Improved sleep quality leads to reduced fatigue, a common symptom that limits activity in heart failure patients 2, 6
• Better sleep is associated with improved cognitive function in heart failure patients 5
• Treating insomnia can improve rest-activity rhythms and autonomic function, which are important for heart failure management 6
• Healthier sleep phenotypes are associated with lower fatigue levels in heart failure patients 4

Special Considerations for Heart Failure Patients

• Optimize heart failure treatment first, as improved cardiac function may alleviate some sleep disturbances 1
• For heart failure patients with obstructive sleep apnea, continuous positive airway pressure (CPAP) therapy should be considered to improve left ventricular ejection fraction and functional status 1
• CPAP has been shown to improve nocturnal oxygenation and increase exercise capacity in heart failure patients with sleep apnea 1

Pharmacological Options (Second-Line)

• Pharmacological options should be considered with extreme caution in heart failure patients due to potential cardiovascular effects and interactions with heart failure medications 1
• If medication is necessary after failed CBT-I:
  • Low-dose doxepin may be considered for sleep maintenance insomnia with less cardiovascular risk than benzodiazepines 1
  • Ramelteon (melatonin receptor agonist) may be considered for sleep onset difficulties with minimal respiratory depression 1
• Avoid benzodiazepines and non-benzodiazepine hypnotics when possible due to risks of respiratory depression, falls, and cognitive impairment 1, 3

Common Pitfalls to Avoid

• Using sedative medications as first-line treatment can worsen respiratory function in heart failure patients 1
• Failing to screen for sleep-disordered breathing, which requires specific treatment approaches 1
• Using sleep hygiene education alone is insufficient for treating chronic insomnia 1
• Over-restricting fluid intake in heart failure patients with insomnia (fluid restriction of 1.5–2 L/day should only be considered in severe heart failure) 3

Treatment Algorithm

1. Optimize heart failure management according to current guidelines 3
2. Implement CBT-I as the primary intervention for insomnia 1, 7
3. Address sleep-disordered breathing if present (consider CPAP for obstructive sleep apnea) 3, 1
4. If CBT-I is ineffective after adequate trial, consider cautious use of medications with the lowest risk profile 3, 1
5. Monitor for improvements in fatigue, functional capacity, and heart failure symptoms 2, 6