The Effect of a Supervised Hospital Based Exercise Program on Sleep Quality in Recently Discharged Heart Failure Patients

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Despite favourable trends in survival, heart failure (HF) remains a leading cause of mortality and morbidity across the developed world. Consequently, emphasis has been placed upon identifying solutions for the treatable co-morbidities associated with this chronic, incurable disease. Sleep disorders are one of the most commonly reported features of HF. Sleep disorders are a group of syndromes which are characterised by disturbance in the amount, quality, timing or architecture of sleep. The most frequent and troubling of these in HF includes Obstructive Sleep Apnoea (OSA) syndrome, Central Sleep Apnoea syndrome (CSA), periodic limb movement disorder and insomnia. These disorders impair quality of life (QOL) and are linked with repeat health care visits. Exercise is an important component of the multidisciplinary management of HF and has recently been established in the ACTION:HF study as an effective means of improving the QOL of HF patients. Exercise is also thought to improve sleep in this population however this theory remains controversial in light of small number of studies conducted in the area to date. The hypothesis that exercise improves sleep in HF patients has been developed in reflection of the positive effect of exercise on sleep seen in elderly populations and patients with other chronic diseases. These studies are valuable sources of information as the typical HF patient shares many of the co-morbidities seen in patients studied. The common theme established in these publications is that physically active patients have improved sleep duration and quality when compared to their sedentary counterparts. Physical activity has been identified to relieve problems associated with frailty and disease co-morbidities and lacks many of the negative side-affects related to sleep medications such as confusion and falls. It is linked with improvements in vitality, symptom severity, daytime sleepiness, depression, QOL, pain and strength. Physically active patients also exhibit improved ventilatory capacity, reduced vascular resistance and improvements in endothelial dysfunction. Polysomnography (PSG) is the current gold standard device for the examination of sleep disorders but is expensive, labour intensive and limited in its availability. Reliance on quantitative measures to identify sleep disturbance may not be practical in this population given the limited availability of PSG combined with the fact that HF is an increasingly common disease with correspondingly high rates of sleep disorders. In addition, as it is often the individual’s perception of their sleep state which motivates them to seek treatment, examination of sleep quality may be cost-effective, convenient alternative to ensure the prompt identification of sleep disturbance. Appropriate medical management of HF is thought to alleviate sleep disturbance however studies suggest that treatments produce only minor improvements in sleep in this population. The most common non-pharmacological form of treatment for diagnosed sleep apnoeas is continuous positive airway pressure (CPAP). Several studies have found that although CPAP may decrease the number of apnoeas and hypopneas and improve sympathetic activity it fails to improve cardiovascular variables or overall survival in HF. CPAP machines are also difficult to use and cause significant patient discomfort. Given issues associated with current screening and treatment methods of sleep disorders and in light of increasing demand on the health care resources in this population there is a need to identify alternative solutions for sleep problems in HF patients. Exercise presents a potential therapeutic alternative given poor CPAP compliance and limited alternative treatment options. The examination of the effect of exercise on sleep quality in contrast to sleep architecture is important as an outcome of improved sleep is one which carries a real meaning for patients and is likely to improve compliance with exercise regimes. In addition, the improvement of sleep through exercise is expected to have direct physiological benefits for HF patients and may improve cardiovascular variables and overall survival.

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