Management of Insomnia in Heart Failure with Reduced Ejection Fraction
For patients with heart failure with reduced ejection fraction (HFrEF) and insomnia, cognitive behavioral therapy for insomnia (CBT-I) should be the first-line treatment due to its proven efficacy in improving sleep quality, reducing fatigue, and enhancing functional performance without adverse cardiovascular effects.
Non-Pharmacological Approaches
Cognitive Behavioral Therapy for Insomnia (CBT-I)
- CBT-I has demonstrated sustained improvements in insomnia severity, fatigue, daytime sleepiness, and objectively measured physical function among adults with chronic heart failure compared to standard heart failure self-management programs 1
- CBT-I shows efficacy as a treatment for chronic insomnia in stable HF patients with benefits lasting up to 12 months post-intervention 1
- CBT-I may also improve cognitive function in adults with chronic HF, which is an important consideration given the cognitive impairment often seen in this population 2
- Group-based CBT-I specifically tailored for cardiac patients has shown significant improvements in sleep duration, maintenance, efficiency, latency, and quality 3
Sleep Hygiene and Self-Management
- Daily weight monitoring and adherence to an exercise training program when clinically stable are recommended components of HF management that can also benefit sleep 4
- Sodium restriction (<2-3g daily) and fluid restriction if hyponatremia is present may help reduce nocturnal symptoms that disrupt sleep 4
Medication Management Considerations
Optimizing Heart Failure Medications
- SGLT2 inhibitors should be prioritized in the medication regimen as they have minimal impact on blood pressure while providing mortality benefits and may not worsen sleep-related symptoms 5
- When managing medications in patients with sleep disturbances, consider spacing out medications to reduce synergistic hypotensive effects that may cause nocturnal symptoms 6
- For patients with symptomatic low blood pressure affecting sleep, consider the following medication adjustment algorithm:
Avoiding Sleep-Disrupting Medications
- Beta-blockers should ideally be administered in the morning rather than at night to minimize potential sleep disturbances 6
- If beta-blocker therapy is necessary but causing sleep disturbances, consider replacing carvedilol with metoprolol or bisoprolol which may have different effects on sleep architecture 6
Monitoring and Follow-up
- Close follow-up within 1-2 weeks of medication changes is recommended, with monitoring of blood pressure, heart rate, renal function, and electrolytes 4
- Regular assessment of sleep quality, insomnia symptoms, and daytime functioning should be incorporated into routine HF follow-up visits 1
- Identify sleep health phenotypes (Unstable Sleep, Short Sleep, Low Sleep Efficiency, Good Sleep) to better target interventions and predict outcomes 7
Special Considerations
- Patients with the poorest sleep phenotype at baseline have higher risk for hospitalizations and emergency department visits (hazard ratios 0.35-0.60) 7
- Multidisciplinary care coordination should include selection of appropriate alternatives with lesser BP-lowering effect for non-cardiac medications that may affect sleep (e.g., medications for prostate hypertrophy, antidepressants) 6
- In persistent hypotension with sleep disturbances and inability to optimize GDMT, consider early referral to HF specialist or advanced therapy programs 6
Clinical Pitfalls to Avoid
- Avoid prescribing sedative-hypnotic medications as first-line therapy for insomnia in HFrEF patients, as these may worsen respiratory function and increase fall risk 1
- Don't reduce or discontinue guideline-directed medical therapy (GDMT) for asymptomatic or mildly symptomatic low BP, as this could compromise long-term outcomes 6
- Recognize that improved sleep can positively impact HF outcomes through reduced fatigue, improved cognitive function, and enhanced quality of life 1, 2