4 Sleep Problems Related to Heart Failure, and How to Manage Them

Signs your sleep may be disrupted — or that your heart failure isn’t being managed properly — may include waking up feeling unrefreshed, experiencing daytime sleepiness, or adjusting your daytime activities because of low energy, says Andrew Freeman, MD, a cardiologist with National Jewish Health in Denver. However, certain lifestyle changes may help improve those symptoms.

Here’s a rundown of common sleep disturbances associated with heart failure — and what you can do to get a better night’s sleep.

1. Sleep Apnea

There are two main types of sleep apnea: Obstructive sleep apnea (OSA) — the most common type — occurs when muscles in the back of the throat collapse too much during sleep, partially or completely blocking the airway. In central sleep apnea (CSA), the brain doesn’t send the necessary message to the muscles that control breathing. 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 Rami Khayat, MD, a pulmonologist and sleep medicine expert with UCI Health in Orange, California, who works with cardiac patients. “And all these activities are detrimental to heart failure control.”

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,” Dr. 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 David Markham, MD, an associate professor of medicine at Emory University in Atlanta and an expert in advanced heart failure and transplant cardiology.

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 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 Dr. 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 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.

Change the timing of your medication. If you’re taking diuretic medication and waking up frequently during the night to use the bathroom, the diuretic 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.

3. Orthopnea (Shortness of Breath)

“Patients will often tell me, ‘I need to prop myself up on four pillows to fall asleep,’” Freeman says.

Step on the scale. If you’re finding it harder to fall asleep and need more pillows to make sleeping comfortable, weigh yourself to see if you might be retaining water. “If your weight goes up 2 or 3 pounds in a day or 5 or 6 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 and prevent potential hospitalization.

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.

4. Periodic Limb Movement Disorder (PLMD)

In PLMD, a type of restless legs 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.”

To get a better night’s sleep with heart failure or any chronic condition, you should make good sleep hygiene a priority, 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 all right, Khayat also suggests that 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 also encourages stress management, whether it’s through yoga, meditation, getting a handle on your finances, or addressing 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, can help manage heart failure symptoms and even prevent the condition from developing in the first place. Examples of lifestyle medicine include 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.

• Sleep disorders such as sleep apnea, insomnia, orthopnea, and periodic limb movement disorder are a common occurrence among people with heart failure.
• Addressing sleep disorders can help you sleep better and manage the symptoms of heart failure.
• Other lifestyle approaches, such as regular exercise, stress management, and improved diet, may help.
• If you have heart failure, talk to a doctor about what steps you can take to improve your sleep.

Additional reporting by Sandra Gordon.