Heart Failure and Insomnia

Insomnia. Duncan Walker/ Getty Images

Almost 75% of people who have heart failure report frequent insomnia, making this one of the most common symptoms of heart failure.

Insomnia is characterized by difficulty falling asleep, difficulty staying asleep, or waking up too early in the morning (or all three), followed by symptoms of sleep deprivation during the daytime, such as sleepiness, fatigue, lack of energy, moodiness, and/or difficulty concentrating.

While anyone can experience insomnia occasionally, people with heart failure are likely to suffer from it more frequently and more severely than other people.

What Causes Insomnia?

There are many causes of insomnia. These include genetic predisposition (such as increased metabolic rate or hyperactivity); behavioral factors (such as work schedule, family demands, or nighttime eating or activity habits); psychological factors (such as depression, a tendency to worry, chronic stress, or a recent life crisis); and illness (such as heart failure).

Many behavioral specialists believe that, whatever precipitates insomnia, the condition can be prolonged by worrying about not getting enough sleep (which itself makes it harder to sleep), or by counterproductive coping mechanisms (such as watching TV or playing video games at bedtime). So temporary bouts of insomnia are often perpetuated by our reaction to it.

Why Is Heart Failure Associated With Insomnia?

People with heart failure are as prone to the usual causative factors of insomnia as anyone else. In fact, because they are under the stress of having a chronic illness, and because they are especially likely to develop depression, the “usual causative factors” of insomnia are often increased.

But aside from being at least as likely as anyone else to experience the usual causes of insomnia, people with heart failure are subject to several additional problems that often produce sleep disturbances.

Sleep and the Symptoms of Heart Failure

The common symptoms of heart failure can disrupt sleep. Orthopnea - shortness of breath when lying flat - can make it difficult to get to sleep. A related condition - paroxysmal nocturnal dyspnea, or PND - causes sudden awakening from sleep, and is often so frightening an experience that getting back to sleep after an episode of PND is often impossible. The diuretic medication prescribed to most patients with heart failure can disrupt sleep by causing nocturia - the need to get up and urinate at night. So heart failure itself can be disruptive of sleep.

Sleep Apnea and Heart Failure

Sleep apnea is common in heart failure. Patients with sleep apnea have prolonged pauses in their breathing during sleep. These breathing pauses cause sudden arousal from deep sleep, often scores of time per night, and result in significant sleep deprivation.

Patients with sleep apnea are often unaware of their nocturnal arousals, and may not complain of insomnia - but they do experience many of the signs of sleep deprivation.

When it is looked for, sleep apnea is found in up to 50% of patients with heart failure. Sleep apnea tends to make heart failure worse, and worsening heart failure often makes sleep apnea worse - so a vicious cycle can ensue. For this reason, it is particularly important for heart failure patients with sleep apnea to have optimal treatment for both conditions.

Nocturnal Movement Disorders and Heart Failure

It has recently been recognized that patients with heart failure are more likely than the general population to develop two kinds of nocturnal movement disorder that can interrupt sleep - restless leg syndrome and periodic limb movement disorder.

Restless leg syndrome (RLS) is characterized by several very uncomfortable symptoms in the legs that that typically occur upon getting into bed for a night’s sleep. These symptoms include burning, twitching, and/or creeping sensations that compel sufferers to begin moving their legs around for relief (hence, “restless legs”). They will report making almost involuntary sudden jerks, or shaking movements of their legs. As a result, these patients very often have a lot of trouble getting to sleep. Fortunately, treatment can be quite effective.

Periodic limb movement disorder (PLMD) is similar to restless leg syndrome, in that it involves an involuntary movement of the legs (jerking, kicking or twitching) associated with sleep. The main difference is that PLMD occurs during sleep, and may not be directly noticed by the sufferer (though it is likely to be noticed, often painfully, by a sleeping partner). However, PLMD often causes an interruption in deep sleep, and thus produces sleep deprivation. Similarly to RLS, PLMD can be treated once it is recognized.

The Bottom Line

If you have heart failure there’s a good chance that you are suffering from sleep deprivation, which might be caused by sleep apnea, nocturnal movement disorders, or “simple” insomnia. Optimal therapy of your heart failure is very important in treating all of these sleep disorders, so you and your doctor need to make sure that you are receiving all the heart failure therapy you should be getting.

However, treatment aimed at specific sleep disorders - in particular, sleep apnea and nocturnal movement disorders - may be critical in treating your sleep deprivation. If you have heart failure and you are experiencing symptoms of sleep deprivation - such as daytime somnolence, fatigue, poor concentration, extreme moodiness - whether or not you’re aware of a sleep problem, you should talk to your doctor about it. A sleep study - a polysomnogram - may be needed to make a specific diagnosis, so that appropriate treatment can be initiated.


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Ohayon MM,Hara R, Vitiello MV. Epidemiology of restless legs syndrome: a synthesis of the literature. Sleep Med Rev 2012; 16:283.

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