Cardiac Monitoring During Sleep

  • Conrad Iber
    Corresponding author. Department of Medicine, Hennepin County Medical Center, 701 Park Avenue South, Minneapolis, MN 55415.
    Department of Medicine, Hennepin County Medical Center, 701 Park Avenue South, Minneapolis, MN 55415, USA

    University of Minnesota, Minneapolis, MN, USA
    Search for articles by this author
  • Kyuhyun Wang
    Division of Cardiology, Department of Medicine, University of Minnesota, Mayo Mail Code 508, 420 Delaware Street Southeast, Minneapolis, MN 55455, USA
    Search for articles by this author
      Normal sleep is associated with slowing of the heart rate and occasional asymptomatic selflimited rhythm disturbances. Obstructive sleep apnea produces cyclical changes in heart rate and an increase in the occurrence of cardiac dysrhythmias. Sleep medicine practitioners should be familiar with routine methods, limitations, and scoring of cardiac events, including sinus tachycardia, sinus bradycardia, narrow and wide complex tachycardias, atrial fibrillation, and cardiac asystole. Other cardiac rhythms that are recognizable within the context of the sleep study should be reported. Changes in cardiac rhythm during polysomnography seldom result in adverse outcomes. Decisions regarding interventions for identified cardiac rhythms should be influenced by the nature of the dysrhythmia, risks identified by patient characteristics and comorbidities, and prevailing patient care strategies in managing heart disease.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Sleep Medicine Clinics
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Trinder J.
        • Kleiman J.
        • Carrington M.
        • et al.
        Autonomic activity during human sleep as a function of time and sleep stage.
        J Sleep Res. 2001; 10: 253-264
        • Viitasalo M.T.
        • Kala R.
        • Eisalo A.
        Ambulatory electrocardiographic recording in endurance athletes.
        Br Heart J. 1982; 47: 213-220
        • Guilleminault C.
        • Connolly S.J.
        • Winkle R.A.
        Cardiac arrhythmia and conduction disturbances during sleep in 400 patients with sleep apnea syndrome.
        Am J Cardiol. 1983; 52: 490-494
        • Roche F.
        • Xuong A.N.
        • Court-Fortune I.
        • et al.
        Relationship among the severity of sleep apnea syndrome, cardiac arrhythmias, and autonomic imbalance.
        Pacing Clin Electrophysiol. 2003; 26: 669-677
        • Mehra R.
        • Strohl K.P.
        Incidence of serious adverse events during nocturnal polysomnography.
        Sleep. 2004; 27: 1379-1383
        • Kadish A.H.
        • Buxton A.E.
        • Kennedy H.L.
        • et al.
        ACC/AHA clinical competence statement on electrocardiography and ambulatory electrocardiography. A report of the ACC/AHA/ACP-ASIM Task Force on Clinical Competence (ACC/AHA Committee to Develop a Clinical Competence Statement on Electrocardiography and Ambulatory Electrocardiography).
        J Am Coll Cardiol. 2001; 38: 2091-2100
        • Kadish A.H.
        • Buxton A.E.
        • Kennedy H.L.
        • et al.
        ACC/AHA clinical competence statement on electrocardiography and ambulatory electrocardiography: A report of the ACC/AHA/ACP-ASIM task force on clinical competence (ACC/AHA Committee to develop a clinical competence statement on electrocardiography and ambulatory electrocardiography) endorsed by the International Society for Holter and Noninvasive Electrocardiology.
        Circulation. 2001; 104: 3169-3178
        • Crawford M.H.
        • Bernstein S.J.
        • Deedwania P.C.
        • et al.
        ACC/AHA guidelines for ambulatory electrocardiography: executive summary and recommendations. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the Guidelines for Ambulatory Electrocardiography) developed in collaboration with the North American Society for Pacing and Electrophysiology.
        Circulation. 1999; 100: 886-893
        • Anonymous
        Indications and standards for cardiopulmonary sleep studies. American Thoracic Society. Medical Section of the American Lung Association.
        Am Rev Respir Dis. 1989; 139: 559-568
        • Anonymous
        Standards and indications for cardiopulmonary sleep studies in children. American Thoracic Society.
        Am J Respir Crit Care Med. 1996; 153: 866-878
        • Block A.J.
        • Cohn M.A.
        • Conway W.A.
        • et al.
        Indications and standards for cardiopulmonary sleep studies.
        Sleep. 1985; 8: 371-379
        • George C.F.
        Standards for polysomnography in Canada. The Standards Committees of the Canadian Sleep Society and the Canadian Thoracic Society.
        CMAJ. 1996; 155: 1673-1678
        • Caples S.M.
        • Rosen C.L.
        • Shen W.K.
        • et al.
        The scoring of cardiac events during sleep.
        J Clin Sleep Med. 2007; 3: 147-154
        • Iber C.
        • Chesson A.
        • Ancoli-Israel S.
        • et al.
        The scoring of sleep and associated events: rules, terminology, and technical specifications.
        1st edition. American Academy of Sleep Medicine, Westchester (IL)2007
        • Crawford C.
        Sleep recording in the home with automatic analysis of results.
        Eur Neurol. 1986; 25: 30-35
        • Carrington M.
        • Walsh M.
        • Stambas T.
        • et al.
        The influence of sleep onset on the diurnal variation in cardiac activity and cardiac control.
        J Sleep Res. 2003; 12: 213-221
        • Cajochen C.
        • Pischke J.
        • Aeschbach D.
        • et al.
        Heart rate dynamics during human sleep.
        Physiol Behav. 1994; 55: 769-774
        • Janssens W.
        • Willems R.
        • Pevernagie D.
        • et al.
        REM sleep-related brady–arrhythmia syndrome.
        Sleep Breath. 2007; 11: 195-199
        • Elsenbruch S.
        • Harnish M.J.
        • Orr W.C.
        Heart rate variability during waking and sleep in healthy males and females.
        Sleep. 1999; 22: 1067-1071
        • Bonnet M.H.
        • Arand D.L.
        Heart rate variability: sleep stage, time of night, and arousal influences.
        Electroencephalogr Clin Neurophysiol. 1997; 102: 390-396
        • Vanoli E.
        • Adamson P.B.
        • Ba L.
        • et al.
        Heart rate variability during specific sleep stages. A comparison of healthy subjects with patients after myocardial infarction.
        Circulation. 1995; 91: 1918-1922
        • Okada H.
        • Iwase S.
        • Mano T.
        • et al.
        Changes in muscle sympathetic nerve activity during sleep in humans.
        Neurology. 1991; 41: 1961-1966
        • Valladares E.M.
        • Eljammal S.M.
        • Motivala S.
        • et al.
        Sex differences in cardiac sympathovagal balance and vagal tone during nocturnal sleep.
        Sleep Med. 2008; 9: 310-316
        • Northcote R.
        • Canning G.
        • Ballantyne D.
        Electrocardiographic findings in male veteran endurance athletes.
        Br Heart J. 1989; 61: 155-160
        • Viola A.U.
        • Simon C.
        • Doutreleau S.
        • et al.
        Abnormal heart rate variability in a subject with second- degree atrioventricular blocks during sleep.
        Clin Neurophysiol. 2004; 115: 946-950
        • Coccagna G.
        Cardiac arrhythmias during sleep.
        Somnologie. 2000; 4: 103-110
        • Viitasalo M.
        • Halonen L.
        • Partinen M.
        • et al.
        Sleep and cardiac rhythm in healthy men.
        Ann Med. 1991; 23: 135-139
        • Griefahn B.
        • Brode P.
        • Marks A.
        • et al.
        Autonomic arousals related to traffic noise during sleep.
        Sleep. 2008; 31: 569-577
        • Behr E.
        • Wood D.A.
        • Wright M.
        • et al.
        Cardiological assessment of first-degree relatives in sudden arrhythmic death syndrome.
        Lancet. 2003; 362: 1457-1459
        • Wever E.F.
        • Robles de Medina E.O.
        Sudden death in patients without structural heart disease.
        J Am Coll Cardiol. 2004; 43: 1137-1144
        • Abdalla I.S.
        • Prineas R.J.
        • Neaton J.D.
        • et al.
        Relation between ventricular premature complexes and sudden cardiac death in apparently healthy men.
        Am J Cardiol. 1987; 60: 1036-1042
        • Zipes D.P.
        • Camm A.J.
        • Borggrefe M.
        • et al.
        ACC/AHA/ESC 2006 guidelines for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death—executive summary: a report of the American College of Cardiology/American Heart Association Task Force and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Develop Guidelines for Management of Patients with Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death) developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society.
        Eur Heart J. 2006; 27: 2099-2140
        • Haissaguerre M.
        • Derval N.
        • Sacher F.
        • et al.
        Sudden cardiac arrest associated with early repolarization.
        N Engl J Med. 2008; 358: 2016-2023
        • Marill K.A.
        • Ellinor P.T.
        • Marill K.A.
        • et al.
        Case records of the Massachusetts General Hospital. Case 372005. A 35-year-old man with cardiac arrest while sleeping.
        N Engl J Med. 2005; 353: 2492-2501
        • Parrish R.G.
        • Tucker M.
        • Ing R.
        • et al.
        Sudden unexplained death syndrome in Southeast Asian refugees: a review of CDC surveillance.
        MMWR CDC Surveill Summ. 1987; 36: 43SS-53SS
        • Guilleminault C.
        • Connolly S.
        • Winkle R.
        • et al.
        Cyclical variation of the heart rate in sleep apnoea syndrome. Mechanisms, and usefulness of 24 h electrocardiography as a screening technique.
        Lancet. 1984; 1: 126-131
        • Gula L.J.
        • Krahn A.D.
        • Skanes A.
        • et al.
        Heart rate variability in obstructive sleep apnea: a prospective study and frequency domain analysis.
        Ann Noninvasive Electrocardiol. 2003; 8: 144-149
        • Stein P.K.
        • Duntley S.P.
        • Domitrovich P.P.
        • et al.
        A simple method to identify sleep apnea using Holter recordings.
        J Cardiovasc Electrophysiol. 2003; 14: 467-473
        • Spicuzza L.
        • Bernardi L.
        • Calciati A.
        • et al.
        Autonomic modulation of heart rate during obstructive versus central apneas in patients with sleep-disordered breathing.
        Am J Respir Crit Care Med. 2003; 167: 902-910
        • Gosselin N.
        • Lanfranchi P.
        • Michaud M.
        • et al.
        Age and gender effects on heart rate activation associated with periodic leg movements in patients with restless legs syndrome.
        Clin Neurophysiol. 2003; 114: 2188-2195
        • Sforza E.
        • Juony C.
        • Ibanez V.
        Time-dependent variation in cerebral and autonomic activity during periodic leg movements in sleep: implications for arousal mechanisms.
        Clin Neurophysiol. 2002; 113: 883-891
        • Thomas R.J.
        • Mietus J.E.
        • Peng C.K.
        • et al.
        Differentiating obstructive from central and complex sleep apnea using an automated electrocardiogram-based method.
        Sleep. 2007; 30: 1756-1769
        • Pittman S.D.
        • Pillar G.
        • Berry R.B.
        • et al.
        Follow-up assessment of CPAP efficacy in patients with obstructive sleep apnea using an ambulatory device based on peripheral arterial tonometry.
        Sleep Breath. 2006; 10: 123-131
        • Pepin J.L.
        • Delavie N.
        • Pin I.
        • et al.
        Pulse transit time improves detection of sleep respiratory events and microarousals in children.
        Chest. 2005; 127: 722-730
        • Bar A.
        • Pillar G.
        • Dvir I.
        • et al.
        Evaluation of a portable device based on peripheral arterial tone for unattended home sleep studies.
        Chest. 2003; 123: 695-703
        • Freimark D.
        • Adler Y.
        • Sheffy J.
        • et al.
        Oscillations in peripheral arterial tone in congestive heart failure patients: a new marker for Cheyne-Stokes breathing.
        Cardiology. 2002; 98: 21-24
        • Smith R.P.
        • Argod J.
        • Pepin J.L.
        • et al.
        Pulse transit time: an appraisal of potential clinical applications.
        Thorax. 1999; 54: 452-457
        • Bresler M.
        • Sheffy K.
        • Pillar G.
        • et al.
        Differentiating between light and deep sleep stages using an ambulatory device based on peripheral arterial tonometry.
        Physiol Meas. 2008; 29: 571-584
        • Chen L.Y.
        • Shen W.K.
        Epidemiology of atrial fibrillation: a current perspective.
        Heart Rhythm. 2007; 4: S1-S6
        • Gami A.S.
        • Hodge D.O.
        • Herges R.M.
        • et al.
        Obstructive sleep apnea, obesity, and the risk of incident atrial fibrillation.
        J Am Coll Cardiol. 2007; 49: 565-571
        • Harbison J.
        • O'Reilly P.
        • McNicholas W.T.
        Cardiac rhythm disturbances in the obstructive sleep apnea syndrome: effects of nasal continuous positive airway pressure therapy.
        Chest. 2000; 118: 591-595
        • Kanagala R.
        • Murali N.S.
        • Friedman P.A.
        • et al.
        Obstructive sleep apnea and the recurrence of atrial fibrillation.
        Circulation. 2003; 107: 2589-2594
        • Mooe T.
        • Gullsby S.
        • Rabben T.
        • et al.
        Sleep-disordered breathing: a novel predictor of atrial fibrillation after coronary artery bypass surgery.
        Coron Artery Dis. 1996; 7: 475-478
        • Schulz R.
        • Blau A.
        • Borgel J.
        • et al.
        Sleep apnoea in heart failure.
        Eur Respir J. 2007; 29: 1201-1205
        • Javaheri S.
        • Parker T.J.
        • Liming J.D.
        • et al.
        Sleep apnea in 81 ambulatory male patients with stable heart failure. Types and their prevalences, consequences, and presentations.
        Circulation. 1998; 97: 2154-2159
        • Sin D.D.
        • Fitzgerald F.
        • Parker J.D.
        • et al.
        Risk factors for central and obstructive sleep apnea in 450 men and women with congestive heart failure.
        Am J Respir Crit Care Med. 1999; 160: 1101-1106
        • Ferrier K.
        • Campbell A.
        • Yee B.
        • et al.
        Sleep-disordered breathing occurs frequently in stable outpatients with congestive heart failure.
        Chest. 2005; 128: 2116-2122
        • Tkacova R.
        • Wang H.
        • Bradley T.D.
        Night-to-night alterations in sleep apnea type in patients with heart failure.
        J Sleep Res. 2006; 15: 321-328
        • Ryan C.M.
        • Bradley T.D.
        Periodicity of obstructive sleep apnea in patients with and without heart failure.
        Chest. 2005; 127: 536-542
        • Bailey J.J.
        • Berson A.S.
        • Garson Jr., A.
        • et al.
        Recommendations for standardization and specifications in automated electrocardiography: bandwidth and digital signal processing. A report for health professionals by an ad hoc writing group of the Committee on Electrocardiography and Cardiac Electrophysiology of the Council on Clinical Cardiology, American Heart Association.
        Circulation. 1990; 81: 730-739
        • Poets C.F.
        • Stebbens V.A.
        • Alexander J.R.
        • et al.
        Breathing patterns and heart rates at ages 6 weeks and 2 years.
        Am J Dis Child. 1991; 145: 1393-1396
        • Poets C.F.
        • Samuels M.P.
        • Noyes J.P.
        Home event recordings of oxygenation, breathing movements, and heart rate and rhythm in infants with recurrent life-threatening events.
        J Pediatr. 1992; 123: 693-701
        • Findley L.J.
        • Blackburn M.R.
        • Goldberger A.L.
        • et al.
        Apneas and oscillation of cardiac ectopy in Cheyne-Stokes breathing during sleep.
        Am Rev Respir Dis. 1984; 130: 937-939
        • Anonymous
        Scoring manual FAQs.
        (Available at:) (Accessed October 1, 2008)