Sleep Problems Related to Heart Failure and How to Manage Them

Restful sleep is paramount to living well with heart failure. For overall health, the Centers for Disease Control and Prevention (CDC) recommends that everyone get seven to nine hours of sleep each night. But for people living with heart failure, a good night’s sleep may be only a dream. A study published in May 2021 in Nursing Reports found that over 75 percent of patients with heart failure experience sleep disorders such as sleep apnea, insomnia, waking up throughout the night, and restless legs syndrome, which can steal opportunities for peaceful slumber.

“There’s an intricate interplay between sleep disorders and heart failure. Undertreated or untreated sleep apnea, for example, can potentially cause heart failure, and those with heart failure may have undertreated sleep apnea,” says Andrew Freeman, MD, a cardiologist with National Jewish Health in Denver.

If you wake up feeling not refreshed, you have daytime sleepiness or if you need to curtail your daytime activity because of lack of energy, these could be signs your heart failure isn’t being managed as well as it could be, Dr. Freeman says.

Here’s the rundown on common sleep disturbances associated with heart failure and what you can do to get a good night’s sleep and feel better.

4 Common Heart Failure-Related Sleep Stealers and How to Fix Them

1. Sleep Apnea

Sleep apnea is present in up to 52 percent of heart failure patients, according to the American College of Cardiology.

There are two types of sleep apnea: obstructive sleep apnea (OSA), the most common type in which the muscles in the back of the throat collapse too much during sleep, partially or completely blocking the airway. Less common is central sleep apnea (CSA), which tends to affect those with more severe cases of heart failure, and men in particular, says Rami Khayat, MD, a pulmonologist and sleep medicine expert with UCI Health in Orange, California, who works with cardiac patients.

“In some heart failure cases, you can have one or the other, or both,” says David Markham, MD, an associate professor of medicine at Emory University in Atlanta and an expert in advanced heart failure and transplant cardiology. Both OSA and CSA interrupt nighttime breathing and contribute to daytime fatigue.

“Both conditions can result in a periodic drop in blood oxygen levels, which increase the adrenaline levels in the body and result in awakening,” says Dr. Khayat. “And all these activities are detrimental to heart failure control.”

Sleep Rx

Get screened for sleep apnea. Since sleep apnea is so common among people with heart failure, screening for OSA is a good place to start. “Whenever one of my patients has heart failure, I always send them for a sleep evaluation, but it’s low-hanging fruit to improve heart failure by checking for sleep apnea,” Freeman says. In cases of OSA, a continuous positive airway pressure (CPAP) machine or other treatment may be prescribed. “In some of the patients who have this [CPAP] treatment, we see improvement of the ejection fraction, which is the pumping function of the heart, and there’s even some data to support that arrhythmias may be decreased by this intervention as well,” says Markham. A study published in June 2018 in JAMA Cardiology found that CPAP helped patients treated for atrial fibrillation, a heart rhythm disorder, maintain a normal heart rhythm.

A newer treatment option for central sleep apnea is phrenic nerve stimulation, an implantable device that stimulates the phrenic nerve. In a review published October 1, 2022, in the American Journal of Cardiology, researchers concluded that the Remede System (produced by Respicardia Inc.), which is currently the only FDA-approved phrenic nerve stimulation device for sleep apnea on the market, can safely and effectively treat moderate to severe sleep apnea in heart disease patients and improve quality of life.

If you have mild OSA and can’t tolerate wearing a CPAP machine, ask your doctor about eXciteOSA, a daytime therapy for mild OSA and snoring. Approved by the FDA on February 5, 2021, the mouthpiece delivers electrical impulses to the tongue to strengthen muscle tone. Over time, use of eXciteOSA can reduce snoring and other symptoms of mild OSA by preventing your tongue from collapsing backward and blocking your airway during sleep. You’ll wear the device when you’re awake for 20 minutes once a day (while you’re awake) for six weeks, then once a week after that.

Change your sleep position. If you have sleep apnea, side sleeping can also be beneficial for those who don’t tolerate CPAP, says Khayat. “In heart failure patients, lateral sleep positions — on the side, left or right — can often decrease sleep apnea.”

It’s controversial whether the left or right side is best, says Khayat. If you have an implanted defibrillator, sleep on the opposite side. Most defibrillators are implanted on the left side, so sleeping on the right side may feel more comfortable.

“If they don’t have an implant, sometimes the left side is more comfortable because, just like in pregnancy, it relieves the pressure off the inferior vena cava (IVC), the body’s largest vein, which is on the right,” says Khayat.

2. Insomnia

If you often find yourself tossing and turning instead of getting solid shut-eye, you’re far from alone. According to a study published August 2017 in the journal Chest, 23 to 73 percent of people with heart failure report chronic insomnia — difficulty falling or staying asleep or waking early in the morning, with sleep that’s not restorative for at least one month. The research notes common reasons for insomnia in this population, including disease-related depression or anxiety, medications, and Cheyne-Stokes respiration, a type of abnormal breathing pattern.

“If you have a chronic condition, often there’s a degree of concern or anxiety. Sometimes there’s concern over hospitalizations and medication schedules. Or there’s decreased activity. All of these things affect your ability to maintain sleep,” says Khayat.

Sleep Rx

Change the timing of your medication. If you’re waking up frequently during the night because you need to use the bathroom and you’re taking diuretic medication, it may be the cause. “Something most people don’t realize is that diuretics can last in the body for six hours,” Freeman says. “If you take it after 4 p.m. and go to bed at around 10 p.m., you’ll be up peeing all night.” To increase your chances of getting the recommended seven hours of quality sleep, try taking your diuretic earlier in the day.

Seek help for depression and anxiety. If you feel depressed or anxious most of the day, nearly every day, for two consecutive weeks, tell your doctor. Medications are available for depression and anxiety disorders in people with heart failure, which may, in turn, help improve your sleep.

Psychotherapy may also be effective. A traditional type of psychotherapy, cognitive behavioral therapy (CBT), may help reduce anxiety and depression symptoms in people with heart disease, according to the American Heart Association. CBT helps people challenge the negative thoughts that can fuel anxiety and depression. Likewise, an emerging form of psychotherapy, known as metacognitive therapy (MCT), which focuses on reducing the amount of time spent absorbed in negative thoughts, has been shown to improve depression and anxiety symptoms in cardiac patients, according to a study published June 21, 2021, in Circulation.

3. Orthopnea

Many people with heart failure also experience orthopnea, a feeling of breathlessness while lying down, or paroxysmal nocturnal dyspnea — shortness of breath that wakes them up after one or two hours of sleep, says Dr. Markham. Orthopnea can be a symptom your body is retaining fluid and that fluid may be congesting your lungs. “Patients will often tell me, ‘I need to prop myself up on four pillows to fall asleep,’” Freeman says.

Sleep Rx

Step on the scale. If you’re finding it harder to fall asleep and need more pillows or other props to make sleeping comfortable, weigh yourself to see if you might be retaining water. “If your weight goes up two or three pounds in a day or five or six pounds in a week, it's almost always water,” Freeman says. “That’s a reason to get in touch with your doctor.”

If you’re experiencing orthopnea without fast weight gain, it’s still a good reason to call your doctor. “A symptom like orthopnea would prompt me to order a chest X-ray to see if there’s fluid in the lungs,” Freeman says. Adjusting diuretic medication can often help improve the symptom to prevent being hospitalized.

Elevate the head of your bed. “Some people need more pillows or need to elevate the head of the bed just to sleep,” says Markham. Sleeping on an incline can reduce the anatomical and volume overload of lung congestion, including orthopnea and paroxysmal nocturnal dyspnea.

Medicare Part B covers the rental or purchase of adjustable hospital beds provided your doctor prescribes the equipment as medically necessary. Your 20 percent copay and deductible apply. Extra pillows also work, but your entire back, along with your head, needs to be elevated.

4. Periodic Limb Movement Disorder (PLMD)

In PLMD, a type of restless leg syndrome, increased nerve traffic in the legs and arms causes them to twitch involuntarily while you sleep, which may awaken you, says Khayat. “A person wouldn’t remember these twitches because they are very brief episodes. But they can disrupt sleep and you can wake up feeling not refreshed or just tired.”

Sleep Rx

Ask your doctor about treatment for restless legs syndrome. A study published in February 2021 in the Journal of the American Heart Association found that treatment for restless leg syndrome may help reduce heart disease risk. Still, research is ongoing about the relationship between restless leg syndrome and heart failure: standard tests to diagnose restless leg syndrome aren’t sensitive enough to diagnose it in heart failure patients, but studies are showing that drugs for restless leg syndrome may help patients with heart failure once the condition is diagnosed.

More Strategies to Help You Sleep Better

To get a better night's sleep with heart failure or any chronic condition, the main focus should be on good sleep hygiene, says Khayat. He recommends maintaining a regular sleep and wake time, avoiding alcohol and caffeine before bedtime — both of which can disrupt sleep — and putting your electronic devices to bed several hours before your bedtime. The light emitted from electronic devices can make it more difficult to fall asleep.

If your doctor says it’s okay, Khayat also suggests those with heart failure get daily brisk exercise. “A cardiovascular routine that lasts 20 or 30 minutes about four to five hours before bedtime helps in improving their sleep consolidation, their ability to generate sleep and to stay asleep,” he says.

Freeman is also a big fan of managing stress, whether it’s yoga, meditation, getting a handle on your finances or other issues that keep you up at night. “Today, stress is at an all-time high,” he says. “The expression ‘I’ll lose sleep over it,’ is true. Stress really impacts how we sleep. It’s important to do something mindful and stress relieving for 30 minutes every day.”

Lifestyle medicine, as Freeman calls it, which includes managing stress, getting seven hours of sleep each night, exercising regularly, eating a predominantly low-fat, whole food, low-salt plant-based diet, and not smoking, can help manage heart failure symptoms and even prevent the condition from developing in the first place.

Additional reporting by Sandra Gordon.