Nocturia, sleep and daytime function in stable heart failure.

BACKGROUND: The aim of this study was to evaluate nocturia severity and nocturia-related differences in sleep, daytime symptoms and functional performance among patients with stable heart failure (HF). METHODS AND RESULTS: In this cross-sectional observational study, we recruited 173 patients [mean age 60.3 ± 16.8 years; female n = 60 (35%); mean left ventricular ejection fraction 32 ± 14.6%] with stable chronic HF from HF disease management programs in the northeastern United States. Participants reported nocturia and completed a 6-minute walk test (6MWT), 1 night of ambulatory polysomnography, and the SF-36 Medical Outcomes Study, Epworth Sleepiness, Pittsburgh Sleep Quality Index, Multidimensional Assessment of Fatigue, and Centers for the Epidemiological Studies of Depression scales. Participants reported 0 (n = 30; 17.3%), 1-2 (n = 87; 50.2%), and ≥3 (n = 56; 32.4%) nightly episodes of nocturia. There were decreases in sleep duration and efficiency, REM and stage 3-4 sleep, physical function, and 6MWT distance and increases in the percentage of wake time after sleep onset, insomnia symptoms, fatigue, and sleepiness across levels of nocturia severity. CONCLUSIONS: Nocturia is common, severe, and closely associated with decrements in sleep and functional performance and increases in fatigue and sleepiness in patients with stable HF.

Sleep disordered breathing, daytime symptoms, and functional performance in stable heart failure.

STUDY OBJECTIVES: To evaluate characteristics of sleep disordered breathing (SDB); clinical and demographic correlates of SDB; and the extent to which SDB explains functional performance and symptoms in stable heart failure patients receiving care in structured HF disease management programs. DESIGN: Cross-sectional, observational study. SETTING: Structured heart failure disease management programs. PARTICIPANTS: 170 stable chronic heart failure patients (mean age = 60.3 +/- 16.8 years; n = 60 [35%] female; n = 50 [29%] African American; left ventricular ejection fraction mean = 32 +/- 14.6). INTERVENTIONS: N/A. MEASUREMENTS AND RESULTS: Full polysomnography was obtained for one night on participants in their homes. Participants completed the 6-minute walk, 3 days of actigraphy, MOS-SF 36, Epworth Sleepiness Scale, Pittsburgh Sleep Quality Index, Multi-Dimensional Assessment of Fatigue Scale, and the Centers for the Epidemiological Studies of Depression Scale. Fifty-one percent had significant SDB; Sixteen (9%) of the total sample had central sleep apnea. Severe SDB was associated with a 4-fold increase in the likelihood of poor self-reported physical function (OR = 4.15, 95%CI = 1.19-14.57) and CSA was associated with low levels of daytime mobility (OR = 4.09, 95%CI = 1.23-13.62) after controlling for clinical and demographic variables. There were no statistically significant relationships between SDB and daytime symptoms or self-reported sleep, despite poorer objective sleep quality in patients with SDB. CONCLUSIONS: Severe SDB is associated with poor physical function in patients with stable HF but not with daytime symptoms or self-reported sleep, despite poorer objective sleep quality in patients with SDB.

Strategies to reduce hospitalization in the management of heart failure.

Progressive and debilitating heart failure (HF) affects almost 5 million, mostly elderly, individuals in the United States. As the elderly population grows in coming decades, the prevalence of HF is expected to increase substantially. In addition to its human toll, HF yields a substantial economic burden, with direct and indirect cost estimates ranging from $27 to $56 billion annually. It is associated with an unacceptably high rehospitalization rate--50% within 6 months--which not only drives burgeoning costs but also provides a signal that current management approaches to HF are less than optimal. Evidence-based treatment approaches, which include the use of beta-blockers, angiotensin-converting enzyme inhibitors, spironolactone, and nesiritide, may offer opportunities for reducing mortality and rehospitalization rates in HF. Yet, because of inadequate discharge guidance and follow-up, many patients with HF are caught in a "revolving door" process that ultimately culminates in exacerbation and rehospitalization. Hospital-based disease management programs have consistently been shown to optimize care and reduce rehospitalization rates in patients with HF. The Hackensack University Medical Center HF program is discussed as an example of a successful HF program. This program represents a multidisciplinary, multifaceted approach to care that emphasizes case management. The core goal of this program is to provide a continuum of care that extends through hospitalization and into the patients' home environment.