• Many patients with heart failure have disturbed sleep patterns. Possible causes:
  • Nocturnal dyspnea (orthopnea, paroxysmal nocturnal dyspnea, etc.), causing the patient to wake up and have to sit up.
  • Side effects of medications (beta blockers, amiodarone, statins, diuretics, corticosteroids, antidepressants (SSRIs, TCAs), nasal sprays, nicotine replacement, inhalation therapy with beta-2 sympathomimetics, etc.).
  • Disturbed breathing pattern and sleep apnea.
  • Psychological (stress, anxiety, worry, ...).
  • Caffeine (coffee, in painkillers, ...), smoking, alcohol consumption before sleeping.
  • Bad sleeping habits.
  • …

• In sleep apnea, the patient stops breathing for more than 10 seconds at least 5 times per hour during sleep. There are two types of sleep apnea: obstructive sleep apnea syndrome (OSAS) and central sleep apnea syndrome (CSAS).
  • OSAS is the most common. In obstructive sleep apnea, the patient stops breathing during sleep due to narrowing or closing of the upper airways due to external pressure and relaxation of the muscles during sleep. This is usually accompanied by snoring. Obesity often plays an important role in OSAS.
  • CSAS occurs less frequently. It mainly occurs in patients with severe heart failure. In central sleep apnea, the patient stops breathing while sleeping due to reduced functioning of the respiratory center in the brain. This is caused by a reduced cardiac output.
  • Sometimes there is also a mixed pattern of these two forms.
    
    During the apnea, the oxygen saturation in the blood drops, causing the patient to (unconsciously) slightly wake up briefly and start breathing again. This reduces sleep quality.
    Sometimes the patient suddenly experiences a tight or suffocating feeling while sleeping. There is also sympathetic activation and increased renal EPO production. Blood pressure and heart rate increase, as do red blood cells in the long term.
    
    Consequences of sleep apnea:
    • Still feeling tired or having a headache when waking up.
    • Being tired and sleepy during the day.
    • Concentration problems, memory problems, irritability.
    • Higher risk of atrial fibrillation, arterial hypertension, ...
    • Increase in red blood cells (polycythemia).
    • Worse prognosis in heart failure.

• •  
• The diagnosis is made with a polysomnography (sleep study), performed in a sleep laboratory via the pneumology department.
• In case of OSAS and obesity, weight loss should be pursued. Sleeping with nocturnal CPAP treatment for OSAS can be started after a polysomnography (via the treating pneumologist). Sometimes treatment can be suggested by an ENT doctor.
• In CSAS, above all, optimization of heart failure therapy is essential.
• Adaptive servo-ventilation (ASV) should be avoided in patients with heart failure and an LVEF < 45% and especially central sleep apnea, as mortality has been shown to increase with this therapy in these patients (SERVE-HF study).

Also read: Central sleep apnoea - Heart Failure Matters