Sleep and health-related quality of life in heart failure

Dimensions of sleep characteristics and predictors of sleep quality among heart failure patients: A STROBE compliant cross-sectional study in Jordan

Awareness of poor sleep quality and sleep disturbances, as some of the factors that affect negatively quality of life for patients with the different classes of heart failure (HF) would enable health care providers to offer more comprehensive care. The purposes of this study were to describe sleep quality and predictors of disturbances in sleep in heart failure patients in Jordan. An explanatory cross- sectional design was employed to examine sleep quality, dimensions of sleep characteristics, types of disturbances in sleep within the different classes of HF in Jordan. Data were collected from 2 cardiac clinics and 2 medical clinics at 3 hospitals in Jordan. The most common types of disturbances in sleep in all classes of HF were waking up for urination, waking in the middle of the night or early morning, waking up due to cough and snoring, and difficulty to fall asleep within the 30 minutes. However, waking up due to feeling cold or hot were rarely reported in all classes of patients with HF. Regression analysis revealed that significant correlations were found between sleep quality and gender, disease duration, number of medications currently taken and ejection fraction (P < .05). Our findings indicated that sleep quality and disturbances in sleep were worsening with the increase of the New York heart association functional classification sheet class. Moreover, sleep quality had a significant association with gender, disease duration, ejection fraction, and the number of medications currently taken.

Sleep quality among different classes of heart failure patients in Jordan: A STROBE compliant cross-sectional study

Many researchers emphasize the importance of studying sleep quality among patients with heart failure (HF). Because of the importance of this topic, many studies have been conducted to address the different aspects of sleep-in various populations of patients with HF. The purposes of our study were: to assess the types of disturbances in sleep within the different classes of HF, and to assess whether there were differences in the levels of sleep quality and types of disturbances in sleep within the different classes in non-hospitalized Jordan patients with HF. Data were gathered from 2 cardiac clinics and 2 medical clinics at 3 Jordan hospitals. A minimum sample of 200 people was recruited to participate in this study based on these criteria and factors. The prevalence of low sleep quality and types of disturbances in sleep were increased with the increase in New York Heart Association class. Nearly 3 quarters of the study sample had poor sleep quality 73.5% (n = 147). Using a score of 5 as a cut point, 147 patients with HF in our study sample had poor sleep quality. The most common types in all classes were waking up for urination, waking in the middle of the night or early morning, waking up due to coughing and snoring, and difficulty falling asleep within 30 minutes. However, waking up due to feeling cold or hot were rarely reported in all classes of patients with HF. Poor sleep quality negatively affects the quality of life in patients with HF by decreasing physical cognitive and psychosocial performance in those patients. This is the first study in literature study sleep quality in the different New York Heart Association functional classes.

Association between sleep and quality of life in heart failure patient-caregiver dyads and mediation of fatigue: An actor-partner interdependence mediation model

AIMS

Quality of life is essential to heart failure patients and their family caregivers. This study aimed to examine the mediating role of fatigue in the association between sleep and quality of life in heart failure patient-caregiver dyads.

DESIGN

A cross-sectional descriptive study was conducted from November 2017 to August 2018.

METHODS

A total of 269 heart failure patient-caregiver dyads at two hospitals in China were included. The Chinese version of the Pittsburgh Sleep Quality Index, the Chalder Fatigue Scale and the 12-item Short-Form Health Survey were used to collect data on heart failure patients and their family caregivers. The structural equation model was employed in the dyadic analysis based on the actor-partner interdependence mediation model.

RESULTS

Regarding the actor effects, poor sleep was negatively associated with physical and mental quality of life in heart failure patients and their family caregivers, respectively, and the relationship was mediated by their fatigue. Regarding the partner effects, caregivers' fatigue was positively associated with patients' physical quality of life and mediated the association between caregivers' sleep and patients' physical quality of life.

CONCLUSIONS

Heart failure patients and their family caregivers experience reduced quality of life when they have poor sleep and fatigue, and caregivers' fatigue is related to patients' improved physical quality of life. Hence, dyadic interventions targeting to improving sleep and fatigue may be beneficial to their quality of life.

IMPACT

This study highlights the importance of routinely measuring and managing sleep and fatigue for heart failure patients and their family caregivers. Effective dyadic-based interventions that maintain equal attention to family caregivers should be considered by healthcare providers to maximize the improvement of patients' quality of life.

Validation of a new wearable device for type 3 sleep test without flowmeter

BACKGROUND

Ventilation monitoring during sleep is performed by sleep test instrumentation that is uncomfortable for the patients due to the presence of the flowmeter. The objective of this study was to evaluate if an innovative type 3 wearable system, the X10X and X10Y, is able to correctly detect events of apnea and hypopnea and to classify the severity of sleep apnea without the use of a flowmeter.

METHODS

40 patients with sleep disordered breathing were analyzed by continuous and simultaneous recording of X10X and X10Y and another certified type 3 system, SOMNOtouch, used for comparison. Evaluation was performed in terms of quality of respiratory signals (scores from 1, lowest, to 5, highest), duration and classification of apneas, as well as identification and duration of hypopneas.

RESULTS

580 periods were evaluated. Mean quality assigned score was 3.37±1.42 and 3.25±1.35 for X10X and X10Y and SOMNOtouch, respectively. The agreement between the two systems was evaluated with grades 4 and 5 in 383 out of 580 cases. A high correlation (r2 = 0.921; p<0.001) was found between the AHI indexes obtained from the two systems. X10X and X10Y devices were able to correctly classify 72.3% of the obstructive apneas, 81% of the central apneas, 61.3% of the hypopneas, and 64.6% of the mixed apneas when compared to SOMNOtouch device.

CONCLUSION

The X10X and X10Y devices are able to provide a correct grading of sleep respiratory disorders without the need of a nasal cannula for respiratory flow measurement and can be considered as a type 3 sleep test device for screening tests.

A Randomized Study Examining the Effects of Mild-to-Moderate Group Exercises on Cardiovascular, Physical, and Psychological Well-being in Patients With Heart Failure

PURPOSE

To compare 2 mild-to-moderate group exercises and treatment as usual (TAU) for improvements in physical function and depressive symptoms.

METHODS

Patients with heart failure (n = 70, mean age = 66 yr, range = 45-89 yr) were randomized to 16 wk of tai chi (TC), resistance band (RB) exercise, or TAU.

RESULTS

Physical function differed by group from baseline to follow-up, measured by distance walked in the 6-min walk test (F = 3.19, P = .03). Tai chi participants demonstrated a nonsignificant decrease of 162 ft (95% confidence interval [CI], 21 to -345, P = .08) while distance walked by RB participants remained stable with a nonsignificant increase of 70 ft (95% CI, 267 to -127, P = .48). Treatment as usual group significantly decreased by 205 ft (95% CI, -35 to -374, P = .02) and no group differences occurred over time in end-systolic volume (P = .43) and left ventricular function (LVEF) (P = .67). However, groups differed over time in the Beck Depression Inventory (F = 9.2, P < .01). Both TC and RB groups improved (decreased) by 3.5 points (95% CI, 2-5, P < .01). Treatment as usual group decreased insignificantly 1 point (95% CI, -1 to 3, P = .27).

CONCLUSIONS

Tai chi and RB participants avoided a decrease in physical function decrements as seen with TAU. No groups changed in cardiac function. Both TC and RB groups saw reduced depression symptoms compared with TAU. Thus, both TC and RB groups avoided a decrease in physical function and improved their psychological function when compared with TAU.

Depressive symptoms in asymptomatic stage B heart failure with Type II diabetic mellitus

BACKGROUND

The presence of concomitant Type II diabetic mellitus (T2DM) and depressive symptoms adversely affects individuals with symptomatic heart failure (HF).

HYPOTHESIS

In presymptomatic stage B HF, this study hypothesized the presence of greater inflammation and depressive symptoms in T2DM as compared to non-T2DM Stage B patients.

METHODS

This cross-sectional study examined clinical parameters, inflammatory biomarkers, and depressive symptoms in 349 T2DM and non-T2DM men with asymptomatic stage B HF (mean age 66.4 years ±10.1; range 30-91).

RESULTS

Fewer diabetic HF patients had left ventricular (LV) systolic dysfunction (P < .05) although more had LV diastolic dysfunction (P < .001). A higher percentage of T2DM HF patients were taking ACE-inhibitors, beta-blockers, calcium channel blockers, statins, and diuretics (P values < .05). T2DM HF patients had higher circulating levels of interleukin-6 (IL-6) (P < .01), tumor necrosis factor-alpha (P < .01), and soluble ST2 (sST2) (P < .01) and reported more somatic/affective depressive symptoms (Beck Depression Inventory II) (P < .05) but not cognitive/affective depressive symptoms (P = .20). Among all patients, in a multiple regression analysis predicting presence of somatic/affective depressive symptoms, sST2 (P = .026), IL-6 (P = .010), B-type natriuretic peptide (P = .016), and sleep (Pittsburgh Sleep Quality Index [P < .001]) were significant predictors (overall model F = 15.39, P < .001, adjusted R2 = .207).

CONCLUSIONS

Somatic/affective but not cognitive/affective depressive symptoms are elevated in asymptomatic HF patients with T2DM patients. Linkages with elevated inflammatory and cardiac relevant biomarkers suggest shared pathophysiological mechanisms among T2DM HF patients with somatic depression, and these conditions are responsive to routine interventions, including behavioral. Copyright © 2019 John Wiley & Sons, Ltd.

Integrative Medical Care Plus Mindfulness Training for Patients With Congestive Heart Failure

Congestive heart failure (CHF) has a high rate of morbidity and mortality. It is often accompanied by other medical and psychosocial comorbidities that complicate treatment and adherence. We conducted a proof of concept pilot project to determine the feasibility of providing integrative group medical visits plus mindfulness training for patients recently discharged with CHF. Patients were eligible if they had been discharged from an inpatient stay for CHF within the 12 months prior to the new program. The Compassionate Approach to Lifestyle and Mind–Body (CALM) Skills for Patients with CHF consisted of 8 weekly visits focusing on patient education about medications, diet, exercise, sleep, and stress management; group support; and training in mind–body skills such as mindfulness, self-compassion, and loving-kindness. Over two 8-week sessions, 8/11 (73%) patients completed at least 4 visits. The patients had an average age of 57 years. The most common comorbidities were weight gain, sleep problems, and fatigue. After the sessions, 100% of patients planned to make changes to their diet, exercise, and stress management practices. Over half of the patients who met with a pharmacist had a medication-related problem. Improvements were observed in depression, fatigue, and satisfaction with life. Integrative group visits focusing on healthy lifestyle, support, and skill-building are feasible even among CHF patients and should be evaluated in controlled trials as a patient-centered approach to improving outcomes related to improving medication management, depression, fatigue, and quality of life.

Heart failure and sleep disorders

Awareness of the importance of sleep-related disorders in patients with cardiovascular diseases is growing. In particular, sleep-disordered breathing, short sleep time, and low sleep quality are frequently reported by patients with heart failure (HF). Sleep-disordered breathing, which includes obstructive sleep apnoea (OSA) and central sleep apnoea (CSA), is common in patients with HF and has been suggested to increase the morbidity and mortality in these patients. Both OSA and CSA are associated with increased sympathetic activation, vagal withdrawal, altered haemodynamic loading conditions, and hypoxaemia. Moreover, OSA is strongly associated with arterial hypertension, the most common risk factor for cardiac hypertrophy and failure. Intrathoracic pressure changes are also associated with OSA, contributing to haemodynamic alterations and potentially affecting overexpression of genes involved in ventricular remodelling. HF treatment can decrease the severity of both OSA and CSA. Indeed, furosemide and spironolactone administration, exercise training, cardiac resynchronization therapy, and eventually heart transplantation have shown a positive effect on OSA and CSA in patients with HF. At present, whether CSA should be treated and, if so, which is the optimal therapy is still debated. By contrast, more evidence is available on the beneficial effects of OSA treatment in patients with HF.

The Role of Gratitude in Spiritual Well-being in Asymptomatic Heart Failure Patients

Spirituality and gratitude are associated with wellbeing. Few if any studies have examined the role of gratitude in heart failure (HF) patients or whether it is a mechanism through which spirituality may exert its beneficial effects on physical and mental health in this clinical population. This study examined associations bet ween gratitude, spiritual wellbeing, sleep, mood, fatigue, cardiac-specific self-efficacy, and inflammation in 186 men and women with Stage B asymptomatic HF (age 66.5 years ±10). In correlational analysis, gratitude was associated with better sleep (r=-.25, p<0.01), less depressed mood (r=-.41, p<0.01), less fatigue (r=-.46, p<0.01), and better self-efficacy to maintain cardiac function (r=.42, p<0.01). Patients expressing more gratitude also had lower levels of inflammatory biomarkers (r=-.17, p<0.05). We further explored relationships among these variables by examining a putative pathway to determine whether spirituality exerts its beneficial effects through gratitude. We found that gratitude fully mediated the relationship between spiritual wellbeing and sleep quality (z=-2.35, SE=.03, p=.02) and also the relationship between spiritual wellbeing and depressed mood (z=-4.00, SE=.075, p<.001). Gratitude also partially mediated the relationships between spiritual wellbeing and fatigue (z=-3.85, SE=.18, p<.001), and between spiritual wellbeing and self-efficacy (z=2.91, SE=.04, p=.003). In sum, we report that gratitude and spiritual wellbeing are related to better mood and sleep, less fatigue, and more self-efficacy, and that gratitude fully or partially mediates the beneficial effects of spiritual wellbeing on these endpoints. Efforts to increase gratitude may be a treatment for improving wellbeing in HF patients' lives and be of potential clinical value.

Depressive symptoms and spiritual wellbeing in asymptomatic heart failure patients

Depression adversely predicts prognosis in individuals with symptomatic heart failure. In some clinical populations, spiritual wellness is considered to be a protective factor against depressive symptoms. This study examined associations among depressive symptoms, spiritual wellbeing, sleep, fatigue, functional capacity, and inflammatory biomarkers in 132 men and women with asymptomatic stage B heart failure (age 66.5 years ± 10.5). Approximately 32 % of the patients scored ≥10 on the Beck Depression Inventory, indicating potentially clinically relevant depressive symptoms. Multiple regression analysis predicting fewer depressive symptoms included the following significant variables: a lower inflammatory score comprised of disease-relevant biomarkers (p < 0.02), less fatigue (p < 0.001), better sleep (p < 0.04), and more spiritual wellbeing (p < 0.01) (overall model F = 26.6, p < 0.001, adjusted R square = 0.629). Further analyses indicated that the meaning (p < 0.01) and peace (p < 0.01) subscales, but not the faith (p = 0.332) subscale, of spiritual wellbeing were independently associated with fewer depressive symptoms. Interventions aimed at increasing spiritual wellbeing in patients lives, and specifically meaning and peace, may be a potential treatment target for depressive symptoms asymptomatic heart failure.

Factors contributing to poor sleep quality as perceived by heart transplant recipients in Taiwan

BACKGROUND

The aims of this project were to explore the factors contributing to poor sleep quality at 1 to 3 years after heart transplantation (post-HT), and to explore economic problems and social support for HT recipients (HTRs).

METHODS

This study used a cross-sectional retrospective triangulation approach combining qualitative and quantitative research method designs. Quantitative data included data from the visual analog scale and the Taiwanese version of the World Health Organization Quality of Life questionnaire. Qualitative data were derived from questions that explored physiological, psychological, and economic factors contributing to poor sleep quality postprocedure for HTRs.

RESULTS

Sixty-four subjects (81% male, 19% female) participated in this research. Their ages ranged from 20 to 70 (M = 46.88 ± 12.12) years old. Their post-HT timeframe ranged from 1 to 4.10 years; 33% received preoperative extracorporeal membrane oxygenation support. Sleeping disturbances were reported by 72.7% of subjects after HT. Poor sleeping quality at 2 to 3 years post-HT (P = .028) was a complaint, and was worse than at 1 to 2 years post-HT (P = .008). Six physiological (62.5%) and 3 psychological (37.5%) contributing factors were further identified in qualitative interviews. Physiological factors were the major causes affecting their sleep quality 2 to 3 years after HT, whereas psychological factors arose from various family roles, responsibilities, and economic-related pressures.

CONCLUSIONS

Medical teams should find the causes that lead to sleep disturbances and use the findings to improve HTR sleep quality. When the family financial status is affected, these teams should offer assistance and suggestions for patients who are unable to work due to post-HT physical decline. Establishing and providing good family support systems or patient support groups may allow patients to obtain physical, psychological, and spiritual comfort.

The contribution of heart failure to sleep disturbances and depressive symptoms in older adults

BACKGROUND

The aim of this study was to explore the associations between physical symptoms, sleep disturbances, and depressive symptoms in community-dwelling elderly individuals, comparing persons with and without heart failure (HF).

METHODS

A total of 613 older adults (mean age 78 years) underwent clinical and echocardiographic examinations. Questionnaires were used to evaluate sleep disturbances and depressive symptoms. A model was developed in those with HF (n = 107) and compared with those without HF (n = 506).

RESULTS

Cardiopulmonary symptoms (ie, dyspnea and nighttime palpitations) and pain had significant direct associations with sleep disturbances, which indirectly affected depressive symptoms. The model was essentially the same in those with and without HF except that the effect of sleep disturbances on depressive symptoms was stronger in those with HF (β = 0.64 vs β = 0.45, P = .006).

CONCLUSION

In community-dwelling older adults, regardless of their diagnosis, physical symptoms had a direct effect on sleep disturbances and an indirect effect on depressive symptoms.

The association between the Framingham risk score and sleep: a São Paulo epidemiological sleep study

BACKGROUND

Sleep is an important factor in the maintenance of cardiovascular integrity. It seems that cardiovascular injury and sleep impairment is another chicken or egg puzzle and we hypothesized that the higher the cardiovascular risk factors the higher the sleep impairment. Therefore, the goal of this study is to analyze the sleep profile of a general population based on cardiovascular risk stratification.

METHODS

This population-based survey used a probabilistic three-stage cluster sample of Sao Paulo inhabitants to represent the population. A sample size of 1056 volunteers was defined in order to allow for prevalence estimates with 3% precision. From the 1101 selected and interviewed participants, a complete full-night polysomnogram (PSG) was performed in 1042 participants as well as clinical evaluation and blood samples analyses to assess Framingham risk score.

RESULTS

Nine hundred four subjects were classified according the Framingham score and were included in the analyses. A total of 91.7% were classified as a low risk, 5.8% in the intermediate, and 2.4% in the high risk groups according to Framingham score. All polisomnographic parameters were different between groups, except those related to REM sleep parameters. AHI were greater in the high risk compared to the intermediate and low risk groups (23.9 ± 2.8; 17.7 ± 1.8; 7.2 ± 0.5, respectively, p<0.001), as well as a lower total sleep time in minutes (295.3 ± 16.2; 338.4 ± 10.2; 347.4 ± 2.6, respectively, p=0.01). Sleep efficiency in percentage also exhibits a reduction between groups (67.6 ± 2.5; 78.4 ± 1.6; 82.9 ± 0.4, respectively, p<0.001). After adjustment for confounder factors age (p<0.001) and sleep efficiency (p=0.06) remained strongly associated with high risk population.

CONCLUSION

High Framingham risk score was associated with poor sleep efficiency and aging.

Effects of Heart Failure and its Pharmacological Management on Sleep

Heart failure (HF) patients have a high prevalence of disturbed sleep. Optimal pharmacological management of HF includes the use of angiotensin converting enzyme inhibitors and β-blockers, which have been associated with decreased severity of central sleep apnea, which is likely secondary to improvements in cardiac performance. There is also evidence, however, indicating that other pharmacological treatments for HF might adversely affect sleep. This brief review introduces the topic of disturbed sleep in HF and examines the extent to which its standard pharmacological management impacts sleep quality.

The association between insomnia and cardiovascular diseases

Insomnia, the most common sleep complaint in the general population, is defined by difficulty initiating or maintaining sleep, or nonrestorative sleep, accompanied by some form of daytime impairment. In the current review, we present an overview of recent studies on the association between insomnia and cardiovascular disease. It can be concluded that there is growing evidence for the hypothesis that insomnia is associated with an increased risk for cardiovascular disease independently of classic coronary risk factors. Furthermore, insomnia is likely to be associated with hypertension and elevated resting heart rate, both known to lead to cardiovascular disease. However, the existing evidence is not totally consistent and most findings have not been replicated unequivocally. The major limitations of the cited studies include the failure to use state-of-the-art criteria for insomnia diagnosis, the failure to control for depression, and the use of hypnotic medication and sleep apnea as potential confounders. However, the results suggest that insomnia is associated with an increased risk for cardiovascular disease mediated by hypertension or elevated resting heart rate. Consequently, more effort should be dedicated to cope with the high prevalence of insomnia in the general population.