Integrating sleep and circadian health into cardiac rehabilitation: A narrative review and practical framework for...

Cardiac rehabilitation (CR) aims to enhance cardiovascular health and quality of life, as well as survival through structured exercise training, lifestyle education, cardiovascular risk factor management, and psychosocial support. Despite growing evidence linking sleep disorders, poor sleep health, and circadian rhythm disruption to impaired cardiac recovery, reduced exercise adherence, and increased adverse cardiovascular events, systematic assessment and management of sleep and circadian health remain underutilized in CR programs. In this narrative review, we aim to explore and characterize the gap and address the potential benefits of incorporating sleep and circadian rhythm assessment into CR practice. Sleep disorders commonly encountered in patients undergoing CR, including obstructive sleep apnea, central sleep apnea, and insomnia, may adversely affect CR participation, functional recovery, and cardiovascular prognosis. Practical strategies include routine sleep screening with validated assessment tools, selective use of objective sleep assessments, sleep hygiene education, chronotype-informed exercise scheduling, and referral pathways to sleep medicine specialists. Integrating sleep-circadian considerations into CR may enhance cardiac recovery, improve exercise tolerance and adherence, and support more comprehensive, personalized secondary prevention strategies. Artificial intelligence may further support early detection of sleep disturbances, individualized exercise prescription, remote monitoring, and precision CR approaches integrating sleep and circadian health.