Enhancement of sleep stability and circadian rhythm through cardiac telerehabilitation in patients recently hospitalised for acute decompensated heart failure
V A A Van Es, M M C J Van Leunen, I L J De Lathauwer, D M Janssen, C C A G Verstappen, R A Tio, Y Lu, R F Spee, G Handjaras, E Ricciardi, M Betta, H M C KempsAbstract
Background
Sleep- and circadian rhythm disruptions are hallmarks of heart failure (HF) and contribute to autonomic dysregulation.[1] Normally, circadian clocks in the suprachiasmatic nucleus and heart coordinate day–night variation in heart rate (HR), blood pressure and myocardial recovery. In HF, this regulation is blunted, with elevated nocturnal HR and reduced dipping linked to arrhythmias, decompensation and mortality.[1,2] Structured daytime activity and exercise can consolidate sleep and enhance autonomic recovery, making sleep a therapeutic target in HF.[3]
Purpose
To examine whether a comprehensive cardiac telerehabilitation (CTR) programme improves circadian HR rhythmicity in recently hospitalised HF patients, and whether such changes are accompanied by better sleep, higher activity levels and improved quality of life (QoL).
Methods
In this two-centre randomised controlled trial, patients after acute decompensated HF were assigned to CTR or standard care. CTR combined exercise training, nutritional counselling, psychosocial support and occupational therapy, emphasising balanced daytime activity and regular routines.[4] Continuous smartwatch-derived HR and accelerometry data were collected for seven days at baseline (T0) and 18 weeks (T1). Cosinor modelling yielded mesor (rhythm-adjusted mean HR), amplitude (day–night HR variation) and acrophase (timing of the HR peak). Actigraphy outcomes included sleep duration, wake after sleep onset (WASO) and sleep efficiency. Daily steps indexed adherence to activity behaviour. QoL was assessed with HADS-depression, KCCQ-12 and MLHFQ.
Results
Fifty-two patients (median age 75 years; LVEF 39.8 ± 16.1%) completed follow-up (CTR n=27, control n=25). Compared with baseline, CTR increased sleep duration (7.0 (1.6) to 7.5 (1.3) h, p=0.049), WASO decreased (53.5 (30.7) to 42.8 (21.7) min, p=0.036) and sleep efficiency rose (84.0 (7.5) to 87.8 (7.1) %, p=0.043). Daily steps increased (4,350 (3000) to 5,600 (2100), p=0.021). Circadian HR regulation improved with a lower mesor (71.5 ± 7.5 to 64.2 ± 8.6 bpm, p<0.01) and higher amplitude (8.2 ± 4.0 to 13.0 ± 4.1 bpm, p<0.001), while acrophase remained stable. At T1, mesor and amplitude differed from controls (64.2 ± 8.6 vs 69.4 ± 6.3 bpm, p<0.01; 13.0 ± 4.1 vs 8.6 ± 3.1 bpm, p<0.001). QoL improved only in CTR, with reductions in HADS-depression (4.0 (7.0) to 2.0 (5.0), p=0.012) and increases in KCCQ-12 (66.0 ± 17.1 to 78.1 ± 17.5, p=0.001); MLHFQ improved similarly in both groups.
Conclusion
CTR strengthened the daily activity–rest rhythm, leading to more consolidated sleep and a more physiological circadian HR profile, characterised by lower resting HR and restored day–night HR variation. These findings support sleep restoration, achieved through structured daily activity, as a central therapeutic pathway to improve autonomic stability and wellbeing in patients recently hospitalised for acute decompensated HF.For image description, please refer to the figure legend and surrounding text.For image description, please refer to the figure legend and surrounding text.