What is the link between sleep health and heart failure?
[by Tamara Sellman RPSGT CCSH for Advanced Cardiovascular Sleep Disorders Center]
FROM OUR MONTH-LONG SERIES, "SWEET DREAMS SWEET HEARTS," FOR NATIONAL HEART HEALTH AWARENESS MONTH
First things first: What is heart failure?
Simply put, this describes the situation when the heart becomes too weak to fill up with blood or pump it adequately. Heart failure is not the same as a heart attack, which is a sudden or acute heart problem. Heart failure is chronic and progressive, and it has no cure.
The heart is a clever organ possessing several backup strategies to keep itself pumping. When the heart muscle becomes weak, it can:
- Enlarge itself to keep up with the demand for circulating blood throughout the body
- Pump faster to increase the amount of blood circulating in the vascular system (the veins and arteries)
- Increase its own mass to pump more intensely
When these efforts by the heart do not improve its capacity to keep blood moving in your system, other systems jump in to help:
- Blood vessels like veins and arteries narrow themselves to help improve blood pressure when the heart's power is low
- The body prioritizes the circulation of blood to the most important tissues and organs
Still, these are impermanent solutions. As the heart continues to fail, the symptoms of heart failure become more pronounced. Most people discover that their heart has failed on the left side, though it can fail on the right side or simultaneously with both sides. The symptoms of heart failure are many:
- Shortness of breath
- Swollen legs or feet
- Rapid heartbeat
- Chest pain
- Dry or phlegmy cough
- Inability to exercise
- Loss of appetite
- Excessive urination at night (nocturia)
CONGESTIVE HEART FAILURE
This acute type of heart failure requires immediate medical attention. It occurs when there is a backup of blood flow in and out of the heart. This creates blockages in the body's tissues which result in swelling (edema), especially in the legs and ankles. Fluids may even collect in the lungs (a condition known as pulmonary edema), leading to respiratory distress. The kidneys are also affected, as they are overburdened with the task of eliminating the added sodium and water that is a product of the body's swelling.
Congestive heart failure results in roughly 300,000 deaths in the US every year.
Heart failure: Statistics
More than 200,000 people develop heart failure in the US annually. Current statistics estimate that 5.7 million Americans suffer from heart failure.
Who gets heart failure?
- People who are age 65 or older (congestive heart failure is the leading cause of hospitalization for this group)
- People of African descent
- People who are obese*
- People with type 2 diabetes*
- People who have had heart attacks in the past
*Heart failure expert and former president of the American Heart Association Dr. Mariell Jessup says that “the epidemics of diabetes and obesity both contribute to the rising number of patients who acquire heart failure. Our growing population of the elderly are particularly susceptible.”
How does sleep health influence heart health?
Good sleep can make a huge difference in those who are at higher risk for heart failure. Healthy sleep allows the body to rest enough to allow the heart to recuperate after a day's worth of stresses.
However, two kinds of sleep disorders can disrupt the eight-hour period of sleep we all need to restore and rejuvenate ourselves.
Sleep disorders that contribute to heart failure
Research shows that insomnia can increase one's risk for developing heart failure as well as a number of other heart problems such as high blood pressure and coronary heart disease. Insomnia is defined by three symptom categories:
- having difficulty initiating sleep
- having difficulty maintaining sleep for most of the night, and
- experiencing non-restorative sleep
People may occasionally experience a night of insomnia, but these temporary and infrequent occurrences are not a problem. It's when insomnia becomes chronic, happening several times a week over several weeks' time, that it becomes associated with the development of another chronic problem, heart failure. In fact, the worse one's symptoms of chronic insomnia, the more severe their case of heart failure.
Why does insomnia influence heart health? Insomnia occurs as the result of hyperarousal (racing thoughts) which leads to the chronic release of stress hormones. These imbalances in the bloodstream can increase one's pulse and blood pressure and lead to body-wide inflammation. Other important concerns relate to the development of insulin resistance.
It's not so surprising that insomnia is related to heart failure, when you consider that it is also associated with other lifestyle behaviors that are unhealthy, such as eating poorly and being a couch potato. When insomnia leads to nightly hormone imbalances, it only makes it harder on the heart, kidneys, and vascular system to meet the demands of the body even at night when it should be resting.
Studies show that more than half of all heart failure patients suffer from the sleep-breathing disorder known as sleep apnea (obstructive or central sleep apnea, or both). Sleep apnea is a condition in which breathing while asleep is disrupted by pauses that last 10 or more seconds, causing shortages in blood oxygen and surges in stress hormones.
Obstructive sleep apnea (OSA), a mechanical disruption of sleep breathing, links to heart failure because it leads to problematic imbalances in oxygen and carbon dioxide in the bloodstream. Apneas (those pauses in breathing) are followed by arousals meant to awaken you so that you will voluntarily breathe to replace low oxygen levels in the blood. However, the stress response that occurs following apneas leads to increases in blood pressure and heart rate and stress hormones that flood the bloodstream. Other heart complications related to sleep apnea include higher risk for heart attack and stroke, as well as the development of heart arrhythmias such as atrial fibrillation, or Afib.
Central sleep apnea (CSA) is a failure of the brain to signal to the lungs to breathe as you sleep. For some, it results in a specific kind of pattern called Cheyne Stokes respiration (CSR). CSA-CSR has been implicated in heart failure because of the enormous amount of stress it places on the heart muscle. Unfortunately, as much as 40 percent of heart failure patients have been shown to suffer from CSA.
Fortunately, there are therapies for patients suffering from both OSA and CSA which can help prevent chronic stress from damaging the heart over time. Without these therapies, however, the heart will have to continue to work harder precisely at the time of day when it should be resting. Ultimately, it will enlarge, wear out, and fail to keep up with the body's need for blood circulation.
It's thought that men have a 58 percent higher risk for developing heart failure if they do not treat their sleep apnea.
You have heart failure… what now?
If you have congestive heart failure, you have probably already seen a doctor about it, as the symptoms are severe and difficult to endure.
However, if you have ordinary heart failure, there are a number of things you can do to help yourself.
First things first: address your sleep disorders! If you suffer from insomnia, sleep apnea, or (often) both disorders, now is the time to apply therapies and get back your eight hours of rest at night.
For those with insomnia, looking for the root cause can be instructive. Many times, people with insomnia who have not been able to treat it with sleep aids may be suffering from undetected sleep apnea.
For some, practicing better sleep hygiene practices and participating in cognitive behavior therapy for insomnia (CBT-i) can be helpful. CBT-i typically uses a variety of strategies, such as cognitive techniques, relaxation training, sleep consolidation, and stimulus control to help you fall asleep and stay asleep.
It's thought that CBT-i can result in clinically significant improvements in as many as 80 percent of all adult insomnia sufferers. Two recent studies with heart failure patients showed sleep quality, fatigue, and physical functioning improved in those receiving this kind of therapy.
For those with OSA, noninvasive ventilation therapies are considered the gold standard. These include continuous positive airway pressure (CPAP), bilevel positive airway pressure (BiPAP), automatic positive airway pressure (APAP or AutoPAP) and adaptive servo-ventilation (ASV).
Alternatives to the PAP therapies include oral devices which advance the jaw to promote a wider airway to prevent obstructions, and surgeries to remove excessive tissue in order to widen the airway. For mild sleep apnea, weight loss and a reduction in body mass index (BMI) can also be helpful.
For those with CSA, some forms of PAP therapies used for OSA can also be useful. In addition, the new pacemaker-like implants available today can help to restore natural breathing patterns in those with CSA-CSR.
William Abraham, MD, professor of internal medicine and chief of the division of cardiovascular medicine at The Ohio State University Wexner Medical Center, says, “Central sleep apnea is very common in cardiac patients, especially patients with heart failure, and is associated with a significantly greater risk for morbidity and mortality. Being able to treat CSA offers a new hope to improve the quality of life for my patients.”
What if heart failure runs in your family?
The American Heart Association offers a preventative program they refer to as “Life’s Simple 7.” These are positive actions you can take to lower your risk for heart failure. They include:
- smoking avoidance or cessation
- staying physically active
- eating a healthy diet
- maintaining a normal body weight
- controlling cholesterol
- controlling blood pressure, and
- controlling blood sugar
Not surprisingly, practicing Life's Simple 7 will also improve your sleep!
If you're concerned that you might have a sleep disorder, it's worthwhile to undergo a sleep study. These comprehensive tests can often identify hidden cardiac problems in people who are otherwise completely unaware they were experiencing arrhythmias, high blood pressure, or the beginning signs of heart failure.
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