Cognitive Behavioral Therapy for Insomnia in the Context of Cardiovascular Conditions

Sleep is Essential for Cardiovascular Health: An Analytic Review of the Relationship Between Sleep and Cardiovascular Mortality

The American Heart Association recently included sleep health as one of eight factors that define cardiovascular health. Restorative sleep is a pillar of lifestyle medicine influenced by sleep duration, quality, and disorders. Short and long sleep duration are associated with greater risk of cardiovascular disease. Short sleep appears causally related to cardiovascular risk. Long sleep is more strongly predictive of cardiovascular risk, which may be due to comorbidities and other risk factors. Good-quality sleep appears to protect against the increased risk and is independently associated with risk of cardiovascular disease (CVD). Insomnia, particularly difficulty falling asleep and non-restorative sleep, is associated with an increase in cardiac events. Obstructive sleep apnea (OSA) is associated with cardiac risk and outcomes, which is typically observed in the context of contributing comorbidities. However, treating OSA with continuous positive airway pressure (CPAP) may not improve prognosis. Further research is needed to understand the causal mechanisms connecting sleep health with CVD and whether modifying sleep can improve outcomes. Sleep health should be considered as part of a holistic approach to improving cardiovascular health, as reflected in the scoring of LE8 and as one of the interrelated components of lifestyle medicine.

Insomnia and Early Incident Atrial Fibrillation: A 16-Year Cohort Study of Younger Men and Women Veterans

Background There is growing consideration of sleep disturbances and disorders in early cardiovascular risk, including atrial fibrillation (AF). Obstructive sleep apnea confers risk for AF but is highly comorbid with insomnia, another common sleep disorder. We sought to first determine the association of insomnia and early incident AF risk, and second, to determine if AF onset is earlier among those with insomnia. Methods and Results This retrospective analysis used electronic health records from a cohort study of US veterans who were discharged from military service since October 1, 2001 (ie, post-9/11) and received Veterans Health Administration care, 2001 to 2017. Time-varying, multivariate Cox proportional hazard models were used to examine the independent contribution of insomnia diagnosis to AF incidence while serially adjusting for demographics, lifestyle factors, clinical comorbidities including obstructive sleep apnea and psychiatric disorders, and health care utilization. Overall, 1 063 723 post-9/11 veterans (Mean age=28.2 years, 14% women) were followed for 10 years on average. There were 4168 cases of AF (0.42/1000 person-years). Insomnia was associated with a 32% greater adjusted risk of AF (95% CI, 1.21-1.43), and veterans with insomnia showed AF onset up to 2 years earlier. Insomnia-AF associations were similar after accounting for health care utilization (adjusted hazard ratio [aHR], 1.27 [95% CI, 1.17-1.39]), excluding veterans with obstructive sleep apnea (aHR, 1.38 [95% CI, 1.24-1.53]), and among those with a sleep study (aHR, 1.26 [95% CI, 1.07-1.50]). Conclusions In younger adults, insomnia was independently associated with incident AF. Additional studies should determine if this association differs by sex and if behavioral or pharmacological treatment for insomnia attenuates AF risk.

10-Year Risk for Cardiovascular Disease Associated with COMISA (Co-Morbid Insomnia and Sleep Apnea) in Hypertensive Subjects

Due to the few studies available, this study aimed to investigate the 10-year risk for cardiovascular disease (CVD) associated with COMISA (co-morbid insomnia and sleep apnea) in hypertensive subjects. Clinical data of 1009 hypertensive subjects extracted from the Sleep Laboratory database were analyzed. Framingham Risk Score ≥ 10% was used as a cut-off to identify hypertensive subjects with high 10-year risk for CVD. The association between 10-year risk for CVD and COMISA was investigated using logistic regression analyses. 65.3% of hypertensive subjects from our sample presented a high 10-year risk for CVD. After controlling for major confounding factors, multivariate logistic regression analyses demonstrated that unlike its components present separately, COMISA was significantly associated with high 10-year risk for CVD in hypertensive subjects (OR 1.88, 95% CI 1.01-3.51). In this study, we have demonstrated that the negative synergy between obstructive sleep apnea syndrome and insomnia disorder seems to play a central role in the 10-year risk for CVD in hypertensive subjects, which seems to indicate that the establishment of a systematic research and an adapted treatment of COMISA could open new perspectives to promote a better cardiovascular outcome in this specific subgroup of patients.

Improvement of Insomnia Symptoms following a Single 4-Hour CBT-I Workshop

STUDY OBJECTIVES

: Cognitive behavioral treatment for insomnia (CBT-I) is the first line of treatment for insomnia. However, the expanded use of CBT-I is limited by the number of specialty-trained clinicians in addition to the duration and cost of individual treatment sessions. One viable option is a single-session educational group format delivered by a trained health educator.

METHODS

: In a preliminary, single group pretest-posttest design, the effectiveness of group CBT-I delivered to community dwelling individuals with self-reported insomnia symptoms was evaluated. Participants completed the Insomnia Severity Index (ISI) and provided information on sleep aid use, prior to and 1-month post attendance of a single 4-hour CBT-I workshop.

RESULTS

: Participants (N = 45) were 54 ± 16 years and 71% female. ISI scores significantly improved from baseline (20.09 ± 4.1) to 1-month follow-up (11.89 ±5.7; t = 10.1, p < .001) with an average change of 8.2 ± 5.4 points. Frequency of sleep aid use significantly dropped (χ² = 105.7, p = .017). Eighty percent of participants reported sleeping better or much better at follow-up. Twenty percent of participants met criteria for remission of insomnia and 35.6% of participants had ISI change scores meeting criteria for a Minimally Important Difference associated with improvements in fatigue, work productivity, and health related quality of life.

CONCLUSIONS

: These preliminary data suggest that a single 4-hour CBT-I workshop delivered by a health educator can significantly improve insomnia symptoms, improve subjective sleep quality, and reduce sleep aid use among community dwelling adults with and without co-morbidities within 1-month.

Sleep quality, depressive symptoms, and transplant outcomes: Follow-up analyses from the ADAPT prospective pilot study

BACKGROUND

Previous studies suggested that depressive symptoms and sleep quality may be important for long-term clinical outcomes following cardiothoracic transplant. Few studies, however, have systematically examined objective markers of these behavioral factors among ambulatory transplant recipients, or their association with clinical outcomes.

METHODS

We examined sleep quality and depressive symptoms with subsequent clinical outcomes (hospitalizations and death) in a sample of 66 lung or heart transplant recipients using a single-center, prospective cohort study. Recipients were assessed at approximately 6 months post-transplant and completed one week of actigraphy assessment to examine sleep quality and self-report measures of mood (Centers for Epidemiologic Studies of Depression [CESD]). Recipients were followed for clinical outcomes.

RESULTS

At 6-months following transplantation, recipients spent the majority of daytime activity at a sedentary level (61% of daily activity [SD = 10]) and elevated depressive symptoms were common (subclinical = 17%, mild = 12%, or moderate = 8%). Over a median follow-up of 4.5 years (IQR = 0.9, 5.1), 51 participants (77%) had at least one unplanned hospitalization and 11 (17%) participants died. In addition, sleep efficiency measurements suggested that a subset of participants exhibited suboptimal sleep (mean efficiency = 87% [SD = 7]). Poorer sleep quality, indexed by lower sleep efficiency and greater sleep fragmentation, was associated with greater depressive symptoms (r's = 0.37-0.50, P < .01). Better sleep quality at 6-months (HR = 0.75 [0.60, 0.95], P = .015), including sleep efficiency (HR = 0.74 [0.56, 0.99], P = .041) and sleep fragmentation (HR = 0.71 [0.53, 0.95], P = .020) were associated with lower risk of hospitalization or death. Compared with individuals without elevated depressive symptoms or sleep difficulties, individuals with either factor (HR = 1.72 [1.05, 2.81], P = .031) or both factors (HR = 2.37 [1.35, 4.18], P = .003) exhibited greater risk of clinical events in adjusted analyses.

CONCLUSIONS

Sleep quality is associated with depressive symptoms among cardiothoracic transplant recipients and enhances the prognostic association between biobehavioral risk factors and clinical outcomes.

Cardiovascular Complications of Sleep Disorders: A Better Night's Sleep for a Healthier Heart / From Bench to Bedside

Sleep is essential to and an integral part of life and when lacking or disrupted, a multitude of mental and physical pathologies ensue, including cardiovascular (CV) disease, which increases health care costs. Several prospective studies and meta-analyses show that insomnia, short (<7h) or long (>9h) sleep and other sleep disorders are associated with an increased risk of hypertension, metabolic syndrome, myocardial infarction, heart failure, arrhythmias, CV disease risk and/or mortality. The mechanisms by which insomnia and other sleep disorders lead to increased CV risk may encompass inflammatory, immunological, neuro-autonomic, endocrinological, genetic and microbiome perturbations. Guidelines are emerging that recommend a target of >7 h of sleep for all adults >18 years for optimal CV health. Treatment of sleep disorders includes cognitive-behavioral therapy considered the mainstay of non-pharmacologic management of chronic insomnia, and drug treatment with benzodiazepine receptor agonists binding to gamma aminobutyric acid type A (benzodiazepine and non-benzodiazepine agents) and some antidepressants. However, observational studies and meta-analyses indicate an increased mortality risk of anxiolytics and hypnotics, although bias may be involved due to confounding and high heterogeneity in these studies. Nevertheless, it seems that the risk incurred by the non-benzodiazepine hypnotic agents (Z drugs) may be relatively less than the risk of anxiolytics, with evidence indicating that at least one of these agents, zolpidem, may even confer a lower risk of mortality in adjusted models. All these issues are herein reviewed.

The effect of nurse-led Internet-based cognitive behavioural therapy for insomnia on patients with cardiovascular disease: A randomized controlled trial with 6-month follow-up

Aim

To test the effect of nurse‐led Internet‐based cognitive behavioural therapy for insomnia (I‐CBTI), tailored for patients with cardiovascular disease (CVD), with a 6‐month follow‐up.

Design

A two‐arm parallel‐group randomized controlled trial (RCT) registered at clinicaltrials.gov (NTC03938805) and reported according to the CONSORT checklist.

Methods

Forty‐eight patients (mean age 72 years, 65% men) diagnosed with CVD and insomnia were randomized to either 9‐week nurse‐led I‐CBTI with support, or an Internet‐based self‐study programme without support (control group). Insomnia Severity Index (ISI) and Short Form Health Survey (SF‐12) were used as primary and secondary outcomes.

Results

ISI showed a significant treatment effect of I‐CBTI compared to the control group at 9‐week follow‐up. The mean ISI score in the I‐CBTI group at 9 weeks post‐treatment was maintained at the 6‐month follow‐up. Patients' adherence to I‐CBTI was associated with a better effect on both the ISI and SF‐12.

Cognitive-Behavioral Therapy for Insomnia Tailored to Patients With Cardiovascular Disease: A Pre-Post Study

Objective: There is little research assessing the use of cognitive-behavioral therapy for insomnia (CBT-I) among patients with cardiovascular disease (CVD), even less on the effects of CBT-I on CVD risk factors such as anxiety and depression, and to our knowledge, only limited studies of the efficacy of CBT-I protocols with cardiac disease-specific modifications. The objective of this study is to evaluate a group-based CBT-I intervention tailored to patients with CVD on sleep quality, duration, and mental health. Participants: A sample of 47 participants (25 men) diagnosed with primary insomnia were included in this study. Methods: This study used a pre-post design comparing outcomes before and after a group intervention. Clinicians in a cardiac center referred CVD patients with self-reported sleep disturbance to the intervention group. Following screening and confirmation of insomnia disorder, participants completed a six-week CBT-I group-based intervention tailored for patients with CVD. Participants completed sleep diaries and questionnaires, including the Insomnia Severity Index, Beck Depression Inventory-II, and Beck Anxiety Inventory, pre- and postintervention. Results: Participants' sleep outcomes (sleep duration, maintenance, efficiency, latency, and quality) were significantly improved and patients reported significantly fewer symptoms of anxiety, depression, and insomnia following the CBT-I intervention (p values < .05). Conclusions: After participating in a CBT-I group intervention tailored for cardiac patients, patients reported improved sleep and significantly lower levels of anxiety and depression. Randomized trials of this intervention are warranted.

Short Sleep Duration After Hospital Evaluation for Acute Coronary Syndrome Is Associated With Increased Risk of 6-Month Readmission

OBJECTIVE

Hospital readmission after acute coronary syndrome (ACS) is associated with worsened patient outcomes and financial burden. Short sleep duration is a risk factor for cardiovascular events and may therefore represent a behavioral factor that increases risk of adverse posthospitalization outcomes. This study examined whether short sleep duration in the month after hospital evaluation for ACS is associated with 6-month all-cause emergency department (ED) and hospital readmission.

METHODS

The current analyses entail a secondary analysis of a larger prospective observational cohort study. Sleep duration during the month after hospital evaluation for ACS was assessed subjectively and dichotomized as short (<6 hours) or not short (≥6 hours). A Cox proportional hazards model was used to assess the association between short sleep duration during the month after ACS hospital evaluation and 6-month all-cause ED/hospital readmission.

RESULTS

A total of 576 participants with complete data were included in analyses. Approximately 34% of participants reported short sleep duration during the month after ACS evaluation. Short sleep duration was significantly associated with 6-month all-cause ED/hospital readmission (hazard ratio = 2.03; 95% confidence interval = 1.12-3.66) in the model adjusted for age, sex, race/ethnicity, clinical severity, cardiac and renal markers, depression, acute stress, and including a sleep duration by ACS status interaction.

CONCLUSIONS

Short sleep duration after ACS hospital evaluation is prevalent and is associated with increased risk of all-cause readmission within 6 months of discharge. Current findings suggest that short sleep duration is an important modifiable behavioral factor to consider after hospital evaluation for ACS.

Short Sleep, Insomnia, and Cardiovascular Disease

PURPOSE OF REVIEW

This review summarizes key findings linking insomnia, short sleep duration, and cardiovascular health.

RECENT FINDINGS

Early studies associations between insomnia with short sleep and cardiovascular disease Recent studies have incorporated objective data to assess sleep and identify comorbid sleep disorders (e.g. sleep apnea). Use of objective metrics has facilitated understanding of the impacts of insufficient sleep on autonomic dysregulation, metabolic syndrome, coronary artery disease and overall cardiovascular mortality. Emerging research suggests treatment of insomnia (CBT-I) may be beneficial in terms of reducing cardiovascular disease risk.

SUMMARY

From short term effects on the autonomic nervous system to lasting effects on metabolic syndrome and coronary artery disease, there is growing evidence to support a physiologic pathway by which insomnia with short sleep contributes to cardiovascular disease. More research is needed to understand the effect of insomnia treatment on cardiovascular risk.

Combined effect of work stress and impaired sleep on coronary and cardiovascular mortality in hypertensive workers: The MONICA/KORA cohort study

BACKGROUND

Although work stress and impaired sleep are established risk factors for cardiovascular disease (CVD) among healthy individuals, their impact on hypertensive workers is largely unknown.

DESIGN

Prospective cohort study design.

METHODS

Hypertensive workers (N = 1959), derived from the population-based MONICA/KORA study in Southern Germany, who were free of any cardiovascular disease and diabetes were interviewed at baseline for work stress (high demand plus low control) and impaired sleep (difficulties falling asleep and/or maintaining sleep). Hazard ratios and 95% confidence intervals (CIs) were estimated by multivariate Cox proportional hazards models with adjustment for relevant covariates.

RESULTS

During a mean follow-up of 17.8 years covering 34,900 person-years, 134 fatal CVD and 73 coronary heart disease (CHD) events were observed. In comparison to participants with low work stress and non-impaired sleep, participants with work stress (hazard ratio (HR) 1.56, 95% CI 0.81-2.98), or impaired sleep (HR 1.76, 95% CI 0.96-3.22) had an increased risk of CVD, while participants with both work stress and impaired sleep had the highest risk of CVD mortality (HR 2.94, 95% CI 1.18-7.33). Participants with both risk conditions had an absolute CVD mortality risk of 7.13 cases per 1000 person-years in comparison to 3.05 cases per 1000-person years in the reference group. Similar risk patterns were found for CHD mortality.

CONCLUSIONS

Our findings add a new piece of evidence that work stress together with impaired sleep increase risk of coronary and cardiovascular mortality in hypertensive workers.

Delivering Cognitive Behavioral Therapy for Insomnia in the Real World: Considerations and Controversies

Cognitive-behavioral therapy for insomnia (CBT-I) has emerged as the first-line treatment for chronic insomnia but remains massively underused relative to the prevalence of insomnia disorder. This article focuses on 3 key issues in the delivery of CBT-I in the real world. First, where and how should CBT-I be delivered and who should deliver it? Second, who is an appropriate candidate for CBT-I? Third, how do you measure quality care with CBT-I? These issues give rise to targets for future research aimed at improving the implementation science of CBT-I in the real world.

Effect of Digital Cognitive Behavioral Therapy for Insomnia on Health, Psychological Well-being, and Sleep-Related Quality of Life: A Randomized Clinical Trial

Importance

Digital cognitive behavioral therapy (dCBT) is a scalable and effective intervention for treating insomnia. Most people with insomnia, however, seek help because of the daytime consequences of poor sleep, which adversely affects quality of life.

Objectives

To investigate the effect of dCBT for insomnia on functional health, psychological well-being, and sleep-related quality of life and to determine whether a reduction in insomnia symptoms was a mediating factor.

Design, Setting, and Participants

This online, 2-arm, parallel-group randomized trial comparing dCBT for insomnia with sleep hygiene education (SHE) evaluated 1711 participants with self-reported symptoms of insomnia. Participants were recruited between December 1, 2015, and December 1, 2016, and dCBT was delivered using web and/or mobile channels plus treatment as usual; SHE comprised a website and a downloadable booklet plus treatment as usual. Online assessments took place at 0 (baseline), 4 (midtreatment), 8 (posttreatment), and 24 (follow-up) weeks. Programs were completed within 12 weeks after inclusion.

Main Outcomes and Measures

Primary outcomes were scores on self-reported measures of functional health (Patient-Reported Outcomes Measurement Information System: Global Health Scale; range, 10-50; higher scores indicate better health); psychological well-being (Warwick-Edinburgh Mental Well-being Scale; range, 14-70; higher scores indicate greater well-being); and sleep-related quality of life (Glasgow Sleep Impact Index; range, 1-100; higher scores indicate greater impairment). Secondary outcomes comprised mood, fatigue, sleepiness, cognitive failures, work productivity, and relationship satisfaction. Insomnia was assessed with the Sleep Condition Indicator (range: 0-32; higher scores indicate better sleep).

Results

Of the 1711 participants included in the intention-to-treat analysis, 1329 (77.7%) were female, mean (SD) age was 48.0 (13.8) years, and 1558 (91.1%) were white. Use of dCBT was associated with a small improvement in functional health compared with SHE (adjusted difference [95% CI] at week 4, 0.90 [0.40-1.40]; week 8, 1.76 [1.24-2.28]; week 24, 1.76 [1.22-2.30]) and psychological well-being (adjusted difference [95% CI] at week 4, 1.04 [0.28-1.80]; week 8, 2.68 [1.89-3.47]; week 24, 2.95 [2.13-3.76]), and with a large improvement in sleep-related quality of life (at week 4, -8.76 [-11.83 to -5.69]; week 8, -17.60 [-20.81 to -14.39]; week 24, -18.72 [-22.04 to -15.41]) (all P < .01). A large improvement in insomnia mediated these outcomes (range mediated, 45.5%-84.0%).

Conclusions and Relevance

Use of dCBT is effective in improving functional health, psychological well-being, and sleep-related quality of life in people reporting insomnia symptoms. A reduction in insomnia symptoms mediates these improvements. These results confirm that dCBT improves both daytime and nighttime aspects of insomnia, strengthening existing recommendations of CBT as the treatment of choice for insomnia.

Trial Registration

isrctn.org identifier: ISRCTN60530898.

Effects of Cognitive Behavioral Therapy for Insomnia on Sleep-Related Cognitions Among Patients With Stable Heart Failure

OBJECTIVE/BACKGROUND

Cognitive behavioral therapy for insomnia (CBT-I) improves insomnia and fatigue among chronic heart failure (HF) patients, but the extent to which sleep-related cognitions explain CBT-I outcomes in these patients is unknown. We examined the effects of CBT-I on sleep-related cognitions, associations between changes in sleep-related cognitions and changes in sleep and symptoms after CBT-I, and the extent to which cognitions mediated the effects of CBT-I.

PARTICIPANTS

Stable New York Heart Association Class II-III HF patients (total n = 51; n = 26 or 51.0% women; M age = 59.1 ± 15.1 years).

METHODS

HF patients were randomized in groups to group CBT-I (n = 30) or attention control (HF self-management education, n = 21) and completed actigraphy, the Insomnia Severity Index, Pittsburgh Sleep Quality Index, Dysfunctional Beliefs and Attitudes about Sleep (DBAS) and Sleep Disturbance Questionnaires (SDQ), and self-reported fatigue, depression, anxiety, and sleepiness (baseline, immediately after treatment, six months). We used mixed-effects modeling, mediation analysis with a bootstrapping approach, and Pearson correlations.

RESULTS

There was a statistically significant group × mult time effect on DBAS. DBAS mediated the effects of CBT-I on insomnia severity and partially mediated CBT-I effects on fatigue. Improvements in dysfunctional cognitions were associated with improved sleep quality, insomnia severity, sleep latency and decreased fatigue, depression, and anxiety, with sustained effects at six months.

CONCLUSIONS

Improvement in dysfunctional sleep-related cognitions is an important mechanism for CBT-I effects among HF patients who are especially vulnerable to poor sleep and high symptom burden.

Development and Evaluation of a Cognitive Behavioural Intervention for Chronic Post-Stroke Insomnia

BACKGROUND

Cognitive behavioural therapy for insomnia (CBTI) has been successfully applied to those with chronic illness. However, despite the high prevalence of post-stroke insomnia, the applicability of CBTI for this population has not been substantially researched or routinely used in clinical practice.

AIMS

The present study developed a 'CBTI+' protocol for those with post-stroke insomnia and tested its efficacy. The protocol also incorporated additional management strategies that considered the consequences of stroke.

METHOD

A single-case experimental design was used with five community-dwelling individuals with post-stroke insomnia. Daily sleep diaries were collected over 11 weeks, including a 2-week baseline, 7-week intervention and 2-week follow-up. The Insomnia Severity Index, Dysfunctional Attitudes and Beliefs About Sleep Scale, Epworth Sleepiness Scale, Fatigue Severity Scale and Stroke Impact Scale were administered pre- and post-treatment, as well as at 2-week follow-up.

RESULTS

At post-treatment, three participants no longer met diagnostic criteria for insomnia and all participants showed improvements on two or more sleep parameters, including sleep duration and sleep onset latency. Three participants showed a reduction in daytime sleepiness, increased quality of life and reduction in unhelpful beliefs about sleep.

CONCLUSIONS

This study provides initial evidence that CBTI+ is a feasible and acceptable intervention for post-stroke insomnia. Furthermore, it indicates that sleep difficulties in community-dwelling stroke populations are at least partly maintained by unhelpful beliefs and behaviours. The development and delivery of the CBTI+ protocol has important clinical implications for managing post-stroke insomnia and highlights directions for future research.

Objective sleep alterations and long-term use of short or intermediate half-life benzodiazepine receptor agonists are risk factors for high blood pressure in individuals with insomnia: a study in 1272 individuals referred for sleep examinations

INTRODUCTION

Given conflicting data in the literature, the aim of this study was to examine the risk of high blood pressure (HBP) associated with sleep alterations, measured during polysomnography, and long-term use of benzodiazepine receptor agonists in a large sample of individuals with insomnia.

METHODS

Demographic and polysomnographic data from 1272 individuals with insomnia recruited from the research database of the sleep laboratory of Erasme Hospital were analyzed. HBP status was defined by the presence of one of the following: self-report at interview of either a physician's diagnosis or taking antihypertensive medication; or an average systolic blood pressure ≥140 mm Hg or an average diastolic blood pressure ≥90 mm Hg at the medical examination. Logistic regression analyses were conducted to examine the risk of HBP associated with objective sleep alterations and long-term use of benzodiazepine receptor agonists in individuals with insomnia.

RESULTS

The prevalence of HBP in individuals with insomnia is 30.03%. After adjustment for major confounding factors associated with HBP, multivariate logistic regression analysis revealed that short sleep duration (<5 h), severely reduced sleep efficiency (<65%), high sleep fragmentation (sleep fragmentation index ≥18/h), and long-term use of short or intermediate half-life benzodiazepine receptor agonists were significant risk factors for HBP in individuals with insomnia.

CONCLUSION

In individuals with insomnia, objective sleep alterations and long-term use of short or intermediate half-life benzodiazepine receptor agonists are associated with higher risk of HBP. Therefore, better management of these reversible risk factors is required to avoid the negative consequences of the co-occurrence of insomnia and HBP.

Sleep Disturbance, Daytime Symptoms, and Functional Performance in Patients With Stable Heart Failure: A Mediation Analysis

BACKGROUND

Sleep disturbance is common among patients with heart failure (HF) who also experience symptom burden and poor functional performance.

OBJECTIVE

We evaluated the extent to which sleep-related, daytime symptoms (fatigue, excessive daytime sleepiness, and depressive symptoms) mediate the relationship between sleep disturbance and functional performance among patients with stable HF.

METHODS

We recruited patients with stable HF for this secondary analysis of data from a cross-sectional, observational study. Participants completed unattended ambulatory polysomnography from which the Respiratory Disturbance Index was calculated, along with a Six-Minute Walk Test, questionnaires to elicit sleep disturbance (Pittsburgh Sleep Quality Index, Insomnia Symptoms from the Sleep Habits Questionnaire), daytime symptoms (Center for Epidemiologic Studies Depression Scale, Global Fatigue Index, Epworth Sleepiness Scale), and self-reported functional performance (Medical Outcomes Study SF36 V2 Physical Function Scale). We used structural equation modeling with latent variables for the key analysis. Follow-up, exploratory regression analysis with bootstrapped samples was used to examine the extent to which individual daytime symptoms mediated effects of sleep disturbance on functional performance after controlling for clinical and demographic covariates.

RESULTS

The sample included 173 New York Heart Association Class I-IV HF patients (n = 60/34.7% women; M = 60.7, SD = 16.07 years of age). Daytime symptoms mediated the relationship between sleep disturbance and functional performance. Fatigue and depression mediated the relationship between insomnia symptoms and self-reported functional performance, whereas fatigue and sleepiness mediated the relationship between sleep quality and functional performance. Sleepiness mediated the relationship between the respiratory index and self-reported functional performance only in people who did not report insomnia.

CONCLUSIONS

Daytime symptoms explain the relationships between sleep disturbance and functional performance in stable HF.

Sleep, health behaviors, and behavioral interventions: Reducing the risk of cardiovascular disease in adults

Numerous health behaviors, including physical activity, diet, smoking, and sleep, play a major role in preventing the development and progression of cardiovascular disease (CVD). Among these behaviors, sleep may play a pivotal role, yet it has been studied somewhat less than other behaviors and there have been few well-designed sleep intervention studies targeting CVD. Furthermore, despite the fact that these behaviors are often interrelated, interventions tend to focus on changing one health behavior rather than concurrently intervening on multiple behaviors. Psychological constructs from depression to positive affect may also have a major effect on these health behaviors and ultimately on CVD. In this review, we summarize the existing literature on the impact of sleep and other cardiac health behaviors on CVD onset and prognosis. We also describe interventions that may promote these behaviors, from established interventions such as motivational interviewing and cognitive behavioral therapy, to more novel approaches focused on mindfulness and other positive psychological constructs. Finally, we outline population-health-level care management approaches for patients with psychiatric conditions (e.g., depression) that may impact cardiac health, and discuss their potential utility in improving mental health, promoting health behaviors, and reducing CVD-related risk. Much work is still needed to better understand how sleep and other health behaviors may uniquely contribute to CVD risk, and additional high-quality studies of interventions designed to modify cardiac health behaviors are required to improve cardiovascular health in individuals and the population at large.

Cognitive behavioral therapy for insomnia in stable heart failure: Protocol for a randomized controlled trial

BACKGROUND

Chronic insomnia is associated with disabling symptoms and decrements in functional performance. It may contribute to the development of heart failure (HF) and incident mortality. In our previous work, cognitive-behavioral therapy for insomnia (CBT-I), compared to HF self-management education, provided as an attention control condition, was feasible, acceptable, and had large effects on insomnia and fatigue among HF patients.

OBJECTIVES

The purpose of this randomized controlled trial (RCT) is to evaluate the sustained effects of group CBT-I compared with HF self-management education (attention control) on insomnia severity, sleep characteristics, daytime symptoms, symptom clusters, functional performance, and health care utilization among patients with stable HF. We will estimate the cost-effectiveness of CBT-I and explore the effects of CBT-I on event-free survival (EFS).

METHODS

Two hundred participants will be randomized in clusters to a single center parallel group (CBT-I vs. attention control) RCT. Wrist actigraphy and self-report will elicit insomnia, sleep characteristics, symptoms, and functional performance. We will use the psychomotor vigilance test to evaluate sleep loss effects and the Six Minute Walk Test to evaluate effects on daytime function. Medical record review and interviews will elicit health care utilization and EFS. Statistical methods will include general linear mixed models and latent transition analysis. Stochastic cost-effectiveness analysis with a competing risk approach will be employed to conduct the cost-effectiveness analysis.

DISCUSSION

The results will be generalizable to HF patients with chronic comorbid insomnia and pave the way for future research focused on the dissemination and translation of CBT-I into HF settings.

Insomnia and Risk of Cardiovascular Disease

Insomnia is the most prevalent sleep disorder in the United States and has high comorbidity with a number of cardiovascular diseases (CVDs). In the past decade, a number of observational studies have demonstrated an association between insomnia and incident cardiovascular disease (CVD) morbidity and mortality, including hypertension (HTN), coronary heart disease (CHD), and heart failure (HF). Despite some inconsistencies in the literature, likely due to variations in how insomnia is defined and measured, the existing data suggest that insomnia, especially when accompanied by short sleep duration, is associated with increased risk for HTN, CHD and recurrent acute coronary syndrome, and HF. Purported mechanisms likely relate to dysregulation of the hypothalamic-pituitary axis, increased sympathetic nervous system activity, and increased inflammation. This paper reviews the most recent studies of insomnia and CVD and the potential pathophysiological mechanisms underlying this relationship and highlights the need for randomized trials to further elucidate the nature of the relationship between insomnia and CVD.

The insomnia with short sleep duration phenotype: an update on it's importance for health and prevention

PURPOSE OF REVIEW

It was first proposed in the late 1990s that objective markers of sleep disturbance could serve as an index of the biological severity of insomnia. In 2013, a heuristic model of two insomnia phenotypes based on objective sleep duration was proposed. Herein, we review the studies conducted in the past 3 years on the insomnia with short sleep duration phenotype and its implications for a clinical research agenda.

RECENT FINDINGS

Studies have shown that insomnia with objective short sleep duration is associated with physiologic hyperarousal and cardiometabolic and neurocognitive morbidity, whereas insomnia with normal sleep duration is not. Both insomnia phenotypes are associated with psychiatric morbidity albeit through different psychobiological mechanisms. Novel recent studies have included occupational outcomes, developmental approaches, at-home objective sleep testing, diagnostic accuracy measures, and response to cognitive-behavioral treatment.

SUMMARY

Accumulating evidence in the past years has continued to support that insomnia with short sleep duration is a more severe phenotype of the disorder associated with physiologic changes, significant morbidity and mortality and, potentially, a differential response to treatment.