Sleep disorders in chronic heart failure: a comprehensive review of mechanisms, clinical evaluation, and management

Abstract

Sleep disorders are highly prevalent in patients with chronic heart failure (CHF) and represent an important yet underrecognized contributor to symptom burden, impaired quality of life, and adverse clinical outcomes. Insomnia and sleep-disordered breathing (SDB), including obstructive sleep apnea (OSA) and central sleep apnea (CSA), frequently coexist and interact with cardiac dysfunction through complex bidirectional mechanisms involving neurohormonal activation, fluid redistribution, and ventilatory instability. This review provides a comprehensive and clinically oriented overview of sleep disorders in CHF. We summarize current insights into pathophysiology and highlight the heterogeneity of sleep phenotypes across heart failure populations. A practical diagnostic framework is proposed, integrating clinical screening tools with objective testing modalities, including Home Sleep Apnea Testing (HSAT) and Polysomnography (PSG), with emphasis on appropriate patient selection. Management strategies are discussed using a phenotype-driven approach. Cognitive behavioral therapy for insomnia remains the first-line treatment for chronic insomnia, while continuous positive airway pressure (CPAP) is the cornerstone therapy for OSA. In contrast, management of CSA requires careful patient selection, with avoidance of adaptive servo-ventilation in patients with reduced ejection fraction. Optimization of Guideline-Directed Medical Therapy (GDMT) plays a complementary role in improving sleep-related outcomes. Finally, we address implementation in clinical practice, emphasizing multidisciplinary care models, patient education, adherence monitoring, and integration into heart failure management pathways. Emerging directions, including digital health technologies and precision medicine approaches, are also discussed. A structured, integrated approach to the recognition and management of sleep disorders in CHF has the potential to improve both patient-centered outcomes and long-term cardiovascular prognosis.

Keywords

Heart failure / sleep disorders / sleep-disordered breathing / obstructive sleep apnea / central sleep apnea / polysomnography / continuous positive airway pressure

References

[1] McDonagh TA,Adamo M.2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: developed by the Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC) With the special contribution of the Heart Failure Association (HFA) of the ESC.Eur Heart J2021;42:3599-726

[2] Riegel B,Dickson VV.Self care in patients with chronic heart failure.Nat Rev Cardiol2011;8:644-54

[3] Redeker NS.Characteristics of sleep in patients with stable heart failure versus a comparison group.Heart Lung2006;35:252-61

[4] Atay ME.Hospital-acquired insomnia in patients with heart failure: a mixed methods study.BMC Nurs2026;25:151 PMCID:PMC12895911

[5] Javaheri S,Liming JD.Sleep apnea in 81 ambulatory male patients with stable heart failure: types and their prevalences, consequences, and presentations.Circulation1998;97:2154-9

[6] Arzt M,Oldenburg O.Prevalence and predictors of sleep-disordered breathing in patients with stable chronic heart failure: the SchlaHF registry.JACC Heart Fail2016;4:116-25

[7] Javaheri S.Sleep and breathing disorders in heart failure.Handb Clin Neurol2022;189:295-307

[8] Lin Y,Tu W.Comparative effectiveness of therapies for sleep-disordered breathing in heart failure patients: a comprehensive systematic review and network meta-analysis.Respir Med2025;236:107907

[9] Naughton MT.Pathophysiology and treatment of Cheyne-Stokes respiration.Thorax1998;53:514-8 PMCID:PMC1745239

[10] Hudgel DW.Mechanisms of obstructive sleep apnea.Chest1992;101:541-9

[11] Solin P,Richardson M,Walters EH.Influence of pulmonary capillary wedge pressure on central apnea in heart failure.Circulation1999;99:1574-9

[12] Yumino D.Central sleep apnea and Cheyne-Stokes respiration.Proc Am Thorac Soc2008;5:226-36

[13] Bradley TD.Sleep apnea and heart failure: part II: central sleep apnea.Circulation2003;107:1822-6

[14] Yumino D,Ruttanaumpawan P.Nocturnal rostral fluid shift: a unifying concept for the pathogenesis of obstructive and central sleep apnea in men with heart failure.Circulation2010;121:1598-605

[15] Bradley TD.Sleep apnea and heart failure: part I: obstructive sleep apnea.Circulation2003;107:1671-8

[16] Somers VK,Clary MP.Sympathetic neural mechanisms in obstructive sleep apnea.J Clin Invest1995;96:1897-904 PMCID:PMC185826

[17] Narkiewicz K.Sympathetic nerve activity in obstructive sleep apnoea.Acta Physiol Scand2003;177:385-90

[18] Schulz R,Blum A.Decreased plasma levels of nitric oxide derivatives in obstructive sleep apnoea: response to CPAP therapy.Thorax2000;55:1046-51 PMCID:PMC1745665

[19] Lavie L.Oxidative stress in obstructive sleep apnea and intermittent hypoxia-revisited-the bad ugly and good: implications to the heart and brain.Sleep Med Rev2015;20:27-45

[20] Somers VK,Amin R.Sleep apnea and cardiovascular disease: an American Heart Association/American College of Cardiology Foundation Scientific Statement From the American Heart Association Council for High Blood Pressure Research Professional Education Committee, Council on Clinical Cardiology, Stroke Council, and Council on Cardiovascular Nursing In Collaboration With the National Heart, Lung, and Blood Institute National Center on Sleep Disorders Research (National Institutes of Health).Circulation2008;118:1080-111

[21] Javaheri S,Campos-Rodriguez F.Sleep apnea: types, mechanisms, and clinical cardiovascular consequences.J Am Coll Cardiol2017;69:841-58 PMCID:PMC5393905

[22] Wang H,Newton GE.Influence of obstructive sleep apnea on mortality in patients with heart failure.J Am Coll Cardiol2007;49:1625-31

[23] Oldenburg O,Buchholz A.Nocturnal hypoxaemia is associated with increased mortality in stable heart failure patients.Eur Heart J2016;37:1695-703

[24] Hirshkowitz M,Albert SM.National sleep foundation’s sleep time duration recommendations: methodology and results summary.Sleep Health2015;1:40-3

[25] Lévy P,Tamisier R,Bradley TD.Sleep apnoea and heart failure.Eur Respir J2022;59:2101640

[26] Holleck ME,Holleck JL.Reducing nighttime interruptions and improving sleep for hospitalized patients by restructuring nighttime clinical workflow.J Gen Intern Med2023;38:2091-7 PMCID:PMC10361944

[27] Kato M,Sigurdsson G,Pesek CA.Effects of sleep deprivation on neural circulatory control.Hypertension2000;35:1173-5

[28] Kazimierczak A,Krzyżanowski K.Sleep-disordered breathing in patients with heart failure: new trends in therapy.Biomed Res Int2013;2013:459613 PMCID:PMC3745910

[29] Khayat R,Porter K.Sleep disordered breathing and post-discharge mortality in patients with acute heart failure.Eur Heart J2015;36:1463-9 PMCID:PMC4465635

[30] Senaratna CV,Lodge CJ.Prevalence of obstructive sleep apnea in the general population: a systematic review.Sleep Med Rev2017;34:70-81

[31] Morin CM.Epidemiology of insomnia: prevalence, course, risk factors, and public health burden.Sleep Med Clin2022;17:173-91

[32] Klompstra L,Stromberg A.Factors associated with sleeping difficulties in patients with heart failure.Eur Heart J2024;45:ehae666.3409

[33] Lee KS,Heo S,Moser DK.Prognostic importance of sleep quality in patients with heart failure.Am J Crit Care2016;25:516-25

[34] Oldenburg O,Faber L,Horstkotte D.Sleep-disordered breathing in patients with symptomatic heart failure: a contemporary study of prevalence in and characteristics of 700 patients.Eur J Heart Fail2007;9:251-7

[35] Al-Rawashdeh SY,Chung ML.The association of sleep disturbances with quality of life in heart failure patient-caregiver dyads.West J Nurs Res2017;39:492-506

[36] Javaheri S.A mechanism of central sleep apnea in patients with heart failure.N Engl J Med1999;341:949-54

[37] Francis DP,Davies LC,Piepoli M.Quantitative general theory for periodic breathing in chronic heart failure and its clinical implications.Circulation2000;102:2214-21

[38] Lorenzi-Filho G,Bies I.Effects of inhaled carbon dioxide and oxygen on Cheyne-Stokes respiration in patients with heart failure.Am J Respir Crit Care Med1999;159:1490-8

[39] White LH.Role of nocturnal rostral fluid shift in the pathogenesis of obstructive and central sleep apnoea.J Physiol2013;591:1179-93 PMCID:PMC3607865

[40] Redolfi S,Ruttanaumpawan P.Relationship between overnight rostral fluid shift and obstructive sleep apnea in nonobese men.Am J Respir Crit Care Med2009;179:241-6

[41] Mann DL.Mechanisms and models in heart failure: the biomechanical model and beyond.Circulation2005;111:2837-49

[42] Triposkiadis F,Giamouzis G,Louridas G.The sympathetic nervous system in heart failure physiology, pathophysiology, and clinical implications.J Am Coll Cardiol2009;54:1747-62

[43] Celano CM,Albanese AM,Huffman JC.Depression and anxiety in heart failure: a review.Harv Rev Psychiatry2018;26:175-84 PMCID:PMC6042975

[44] Nanduri J,Kumar GK,Prabhakar NR.Transcriptional responses to intermittent hypoxia.Respir Physiol Neurobiol2008;164:277-81 PMCID:PMC3390913

[45] Ryan S,McNicholas WT.Selective activation of inflammatory pathways by intermittent hypoxia in obstructive sleep apnea syndrome.Circulation2005;112:2660-7

[46] Ghiasi M.Investigating the NF-κB signaling pathway in heart failure: exploring potential therapeutic approaches.Heliyon2024;10:e40812 PMCID:PMC11664283

[47] Fan H,Zhao B.Inflammation in obstructive sleep apnea: a global bibliometric perspective.Nat Sci Sleep2025;17:2275-95 PMCID:PMC12467178

[48] Wei M,Mashaqi S.Obstructive sleep apnea, the NLRP3 inflammasome and the potential effects of incretin therapies.Front Sleep2024;3:1524593 PMCID:PMC12713997

[49] Anker SD,Germany R.Sleep-disordered breathing and cardiovascular disease.Indian Heart J2016;68 Suppl 1:S69-76 PMCID:PMC4824338

[50] Kasai T.Obstructive sleep apnea and heart failure: pathophysiologic and therapeutic implications.J Am Coll Cardiol2011;57:119-27

[51] Naughton MT.The link between obstructive sleep apnea and heart failure: underappreciated opportunity for treatment.Curr Heart Fail Rep2006;3:183-8

[52] Javaheri S.Central sleep apnea in congestive heart failure: prevalence, mechanisms, impact, and therapeutic options.Semin Respir Crit Care Med2005;26:44-55

[53] Nakamura S,Kubota Y.Impact of sleep-disordered breathing and efficacy of positive airway pressure on mortality in patients with chronic heart failure and sleep-disordered breathing: a meta-analysis.Clin Res Cardiol2015;104:208-16

[54] Riemann D,Feige B.The hyperarousal model of insomnia: a review of the concept and its evidence.Sleep Med Rev2010;14:19-31

[55] Kalmbach DA,Tonnu CV.Hyperarousal and sleep reactivity in insomnia: current insights.Nat Sci Sleep2018;10:193-201 PMCID:PMC6054324

[56] Vgontzas AN,Lin HM.Chronic insomnia is associated with nyctohemeral activation of the hypothalamic-pituitary-adrenal axis: clinical implications.J Clin Endocrinol Metab2001;86:3787-94

[57] Tamura A,Naono S,Kadota J.Relationship between beta-blocker treatment and the severity of central sleep apnea in chronic heart failure.Chest2007;131:130-5

[58] McMurray JJV,Inzucchi SE.Dapagliflozin in patients with heart failure and reduced ejection fraction.N Engl J Med2019;381:1995-2008

[59] Qaseem A,Forciea MA,Denberg TD.Management of chronic insomnia disorder in adults: a clinical practice guideline from the American College of Physicians.Ann Intern Med2016;165:125-33

[60] Redeker NS,Andrews L,Mohsenin V.Effects of cognitive behavioral therapy for insomnia on sleep-related cognitions among patients with stable heart failure.Behav Sleep Med2019;17:342-54 PMCID:PMC5904007

[61] Redeker NS,Anderson G.Effects of cognitive behavioral therapy for insomnia on sleep, symptoms, stress, and autonomic function among patients with heart failure.Behav Sleep Med2020;18:190-202 PMCID:PMC6529289

[62] Redeker NS,Jacoby D.Cognitive behavioral therapy for insomnia has sustained effects on insomnia, fatigue, and function among people with chronic heart failure and insomnia: the HeartSleep Study.Sleep2022;45 PMCID:PMC8754495

[63] Ash G,Conley S.Day-to-day relationships between physical activity and sleep characteristics among people with heart failure and insomnia.Behav Sleep Med2021;19:602-14 PMCID:PMC8496686

[64] Paulino A,Margarit L.Prevalence of sleep-disordered breathing in a 316-patient French cohort of stable congestive heart failure.Arch Cardiovasc Dis2009;102:169-75

[65] Johns MW.Reliability and factor analysis of the Epworth Sleepiness Scale.Sleep1992;15:376-81

[66] Chung F,Liao P.STOP-bang questionnaire: a practical approach to screen for obstructive sleep apnea.Chest2016;149:631-8

[67] Buysse DJ,Monk TH,Kupfer DJ.The Pittsburgh Sleep Quality Index: a new instrument for psychiatric practice and research.Psychiatry Res1989;28:193-213

[68] Bastien CH,Morin CM.Validation of the insomnia severity index as an outcome measure for insomnia research.Sleep Med2001;2:297-307

[69] Carney CE,Ancoli-Israel S.The consensus sleep diary: standardizing prospective sleep self-monitoring.Sleep2012;35:287-302 PMCID:PMC3250369

[70] Hartmann JA,Lachowski A.Exploring the construct of subjective sleep quality in patients with insomnia.J Clin Psychiatry2015;76:e768-73

[71] Damy T,Margarit L.Left ventricle remodelling is associated with sleep-disordered breathing in non-ischaemic cardiopathy with systolic dysfunction.J Sleep Res2011;20:101-9

[72] Miyata M,Yamauchi H.Impact of sleep-disordered breathing on myocardial damage and metabolism in patients with chronic heart failure.Heart Vessels2015;30:318-24

[73] Quintana-Gallego E,Carmona-Bernal C.Home respiratory polygraphy for diagnosis of sleep-disordered breathing in heart failure.Eur Respir J2004;24:443-8

[74] Markun LC.Clinician-Focused overview and developments in polysomnography.Curr Sleep Med Rep2020;6:309-21 PMCID:PMC7683038

[75] Sateia MJ.International classification of sleep disorders-third edition: highlights and modifications.Chest2014;146:1387-94

[76] Kapur VK,Chowdhuri S.Clinical practice guideline for diagnostic testing for adult obstructive sleep apnea: an American Academy of sleep medicine clinical practice guideline.J Clin Sleep Med2017;13:479-504 PMCID:PMC5337595

[77] Zambotti M, Rosas L, Colrain IM, Baker FC. The sleep of the ring: comparison of the OURA sleep tracker against polysomnography.Behav Sleep Med2019;17:124-36 PMCID:PMC6095823

[78] Abdelrazik A,Antoun I.Wearable devices for arrhythmia detection: advancements and clinical implications.Sensors2025;25:2848 PMCID:PMC12074175

[79] Zambotti M,Goldstone A,Baker FC.Wearable sleep technology in clinical and research settings.Med Sci Sports Exerc2019;51:1538-57 PMCID:PMC6579636

[80] Nakano H,Sadamitsu Y.Monitoring sound to quantify snoring and sleep apnea severity using a smartphone: proof of concept.J Clin Sleep Med2014;10:73-8 PMCID:PMC3869073

[81] Massagram W,Host-madsen A.Assessment of heart rate variability and respiratory sinus arrhythmia via doppler radar.IEEE Trans Microwave Theory Techn2009;57:2542-9

[82] Wang W,Chen Z.Detection of sleep apnea-hypopnea events using millimeter-wave radar and pulse oximeter.Annu Int Conf IEEE Eng Med Biol Soc2024;2024:1-5

[83] Brandt J.Benzodiazepines and Z-drugs: an updated review of major adverse outcomes reported on in epidemiologic research.Drugs R D2017;17:493-507 PMCID:PMC5694420

[84] Gerlach LB,Maust DT.Prescription benzodiazepine use among older adults: a critical review.Harv Rev Psychiatry2018;26:264-73 PMCID:PMC6129989

[85] Herring WJ,Snyder E.Suvorexant in patients with insomnia: pooled analyses of three-month data from phase-3 randomized controlled clinical trials.J Clin Sleep Med2016;12:1215-25 PMCID:PMC4990943

[86] Wichniak A,Walęcka M.Effects of antidepressants on sleep.Curr Psychiatry Rep2017;19:63 PMCID:PMC5548844

[87] Abuzaid AS,Elbadawi A.Meta-analysis of cardiovascular outcomes with continuous positive airway pressure therapy in patients with obstructive sleep apnea.Am J Cardiol2017;120:693-9

[88] Kaneko Y,Usui K.Cardiovascular effects of continuous positive airway pressure in patients with heart failure and obstructive sleep apnea.N Engl J Med2003;348:1233-41

[89] Cowie MR,Wegscheider K.Adaptive servo-ventilation for central sleep apnoea in systolic heart failure: results of the major substudy of SERVE-HF.Eur J Heart Fail2018;20:536-44

[90] Oldenburg O,Bitter T.Adaptive servo-ventilation to treat central sleep apnea in heart failure with reduced ejection fraction: the Bad Oeynhausen prospective ASV registry.Clin Res Cardiol2018;107:719-28

[91] Yoshihisa A,Yamaki T.Impact of adaptive servo-ventilation on cardiovascular function and prognosis in heart failure patients with preserved left ventricular ejection fraction and sleep-disordered breathing.Eur J Heart Fail2013;15:543-50

[92] Heidenreich PA,Aguilar D.2022 AHA/ACC/HFSA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Joint Committee on clinical practice guidelines.J Am Coll Cardiol2022;79:e263-421

[93] Ponikowski P,AlHabib KF.Heart failure: preventing disease and death worldwide.ESC Heart Fail2014;1:4-25

[94] Cowie MR,Redline S,Simonds AK.Sleep disordered breathing and cardiovascular disease: JACC state-of-the-art review.J Am Coll Cardiol2021;78:608-24

[95] Erickson VS,Dracup KA,Hage A.Sleep disturbance symptoms in patients with heart failure.AACN Clin Issues2003;14:477-87

[96] Rissardo JP,Bhal N,Zlatin L.Drug-induced myoclonus: a systematic review.Medicina2025;61:131 PMCID:PMC11767161

[97] Trupp RJ.Sleep-disordered breathing, cognitive functioning, and adherence in heart failure: linked through pathology?.Prog Cardiovasc Nurs2008;23:32-6

[98] Weaver TE.Adherence to continuous positive airway pressure therapy: the challenge to effective treatment.Proc Am Thorac Soc2008;5:173-8 PMCID:PMC2645251

[99] Bakker JP,Parthasarathy S.Adherence to CPAP: what should we be aiming for, and how can we get there?.Chest2019;155:1272-87

[100] Zuraikat FM,Barragán R.Sleep and diet: mounting evidence of a cyclical relationship.Annu Rev Nutr2021;41:309-32 PMCID:PMC8511346

[101] Arzt M,Graml A.Phenotyping of sleep-disordered breathing in patients with chronic heart failure with reduced ejection fraction-the SchlaHF registry.J Am Heart Assoc2017;6

[102] Schmickl CN,Orr JE.Acetazolamide for OSA and central sleep apnea: a comprehensive systematic review and meta-analysis.Chest2020;158:2632-45 PMCID:PMC7768933

[103] Shah SJ,Selvaraj S.Phenomapping for novel classification of heart failure with preserved ejection fraction.Circulation2015;131:269-79 PMCID:PMC4302027

[104] Peker Y.Cardiovascular outcomes of continuous positive airway pressure therapy for obstructive sleep apnea.J Thorac Dis2018;10:S4262-79 PMCID:PMC6321890