A personal story explores why women with cardiovascular disease deserve earlier conversations about sleep-disordered breathing.
By Brooke Quinn, MSc, RPSGT, CSSC
My grandmother’s sleep study was scheduled for the following week. She never made it.
Her name was Winnie Ann Watson, though everyone who loved her knew her as Penny. Years later, I would give my son her maiden name—Watson.
Penny had congestive heart failure, a diagnosis that carried an especially heavy weight in our family. Her father and her brother had also died from complications related to heart failure.
But my perspective on her condition was shaped by a lens most family members do not have.
I had spent my career in sleep medicine—thousands of hours beside patients overnight, observing the human body speaking. Through brain waves. Through breathing. Through oxygen levels. Through movement. Through heart rhythms.
A polysomnogram is not simply a test that tells us whether someone snores or stops breathing. It is a window into physiology. And once you spend enough nights watching the body communicate, you cannot stop seeing the signals.
Seeing the Signals
When my husband and I relocated to the Wilmington, NC, area, I temporarily lived with my grandparents on Oak Island while we searched for a home. That time became a gift—shared meals, quiet conversations, ordinary moments that only reveal their weight in hindsight.
It was also during that time that I noticed things. The body does not stop communicating when someone falls asleep. Sometimes that is precisely when it reveals what has been missing. When Penny was asleep, I noticed changes in her breathing. Patterns that, given my training, I could not ignore.
I was not looking at her as a patient. She was Penny. But clinical training has a way of changing what you see—and what you cannot unsee. I encouraged her to raise the question of sleep testing with her physician. Her pulmonologist agreed. The study was scheduled.
But before that night came, she passed away.
I cannot tell you what her sleep study would have shown. I cannot tell you whether it would have changed anything. Science requires humility, and I hold that humility carefully. What I can tell you is why I believed sleep belonged in the conversation—and why I still do.
The Heart Does Not Clock Out at Night
Cardiovascular disease remains one of the greatest threats to women’s health, and the awareness campaigns working to change that deserve recognition. The advocacy matters. The research matters. The visibility matters.
But as those conversations unfold in exam rooms, on social media, and in policy spaces, I find myself returning to the hours we still do not discuss enough.
The hours when the lights are off. When patients are no longer sitting in front of their clinicians. When the heart is still working—and still asking to be heard.
Sleep is part of cardiovascular health. The American Heart Association formally acknowledged this in 2022 when sleep duration was added to Life’s Essential 8—joining blood pressure, cholesterol, blood glucose, nutrition, physical activity, nicotine exposure, and weight management as a measurable component of cardiovascular wellness.¹ That addition was meaningful. But recognition must become implementation. If sleep belongs in the framework, it cannot remain an afterthought in clinical practice.
The philosophy I explored in these pages before—that the body gives us clues, and earlier recognition changes trajectories—does not end in childhood. It extends across the lifespan, and the intersection of sleep and women’s cardiovascular health may be one of the places where that principle matters most.
When Sleep Reveals Cardiovascular Physiology
Heart failure offers a vivid example of how sleep and cardiovascular function intersect.
Many sleep professionals are familiar with Cheyne–Stokes respiration—a cyclical breathing pattern associated with central sleep apnea in patients with heart failure, characterized by a waxing and waning respiratory effort that reflects complex interactions among circulation, respiratory drive, carbon dioxide regulation, and cardiac output.² Unlike obstructive sleep apnea, where breathing is repeatedly limited by upper airway collapse, central sleep apnea reflects instability in the neurochemical control of breathing itself.
This distinction matters clinically. The relationship between cardiovascular disease and sleep-disordered breathing is not a simple equation, and treatment decisions in this population require careful patient selection. Discussions around adaptive servo-ventilation, for example, have evolved considerably following evidence that raised important questions about outcomes in specific heart failure populations—a reminder that this intersection demands ongoing clinical vigilance and individualized decision-making rather than protocol shortcuts.3,4
Sleep-disordered breathing is not one condition with one presentation. Some patients experience primarily obstructive events. Some experience central events. Many experience both, with patterns that shift across the night, across illness trajectories, and across time. That complexity is not a reason to overlook sleep. It is a reason to take it more seriously.
Women and the Signals We Are Trained to Miss
That clinical nuance is especially important when caring for women—because the canonical presentation we were trained to recognize was never the full picture.
For decades, the textbook image of obstructive sleep apnea was narrow: older, male, larger body habitus, loud snoring, witnessed apneas. That presentation exists and remains clinically important. But its dominance in training curricula and public awareness campaigns has contributed to persistent, measurable underdiagnosis in women.5,6
Women with sleep-disordered breathing often present through a different clinical lens. In practice, this means a patient who reports difficulty staying asleep, a mind that will not quiet at night, morning fatigue that no amount of rest seems to resolve, or a persistent and diffuse sense that something is physiologically wrong—symptoms that are real, diagnostically relevant, and too frequently attributed to stress, hormones, or the general burden of midlife before anyone thinks to ask what is actually happening during sleep.7,8
As clinicians, the question we should be asking is not only: How many hours are you sleeping? It is: What is occurring during those hours?
Duration is one part of the story. What we are missing—in the history, referral patterns, the evaluation—may be the rest of it.
Diagnosis Is Not a Device
One barrier that deserves direct clinical attention is anticipatory avoidance.
Many patients—women in particular—delay or decline sleep evaluation not because of the diagnostic process itself, but because of what they assume follows it. “I don’t want a sleep study because I don’t want a machine” is a sentence most sleep clinicians have heard many times.
It is worth saying clearly: a sleep evaluation is not a prescription. It is information.
Positive airway pressure therapy remains a cornerstone treatment, and for many patients it is genuinely life-changing. But modern sleep medicine has broadened considerably. Oral appliance therapy, positional strategies, surgical airway evaluation, behavioral approaches, and emerging interventional options mean that the conversation after a diagnosis is not predetermined. What an accurate diagnosis opens is choice—individualized, informed clinical decision-making between clinician and patient.
The goal was never simply to stop snoring. The goal is to restore the physiologic conditions the body needs to function well.
Listening Earlier
Years of symptoms. Years of partial explanations. Years of adapting to a level of exhaustion that was normalized because no one had named it otherwise. Across sleep medicine, a pattern (not unique to sleep apnea) recurs in patient histories. Patients living with insomnia disorder, hypersomnia, circadian disruption, and other sleep conditions describe similar journeys—long delays between first symptom and accurate diagnosis, with significant quality-of-life and health costs accumulated along the way.9
The clues were there. We are still learning how to see them.
My grandmother’s story does not have a different ending.
I have made my peace with that, though it took time. I cannot go backward. I cannot know what her sleep study would have shown, or whether what we might have found was already beyond the window where intervention could help.
But I can carry the lesson forward.
Her maiden name became my son’s name. And unexpectedly, that name became part of my professional mission: teaching the next generation—and this one—that the body gives us clues. That symptoms are signals. That curiosity changes care.
As we raise awareness for women’s hearts, let’s celebrate the progress, support the research, and honor the campaigns that are bringing this conversation into living rooms, waiting rooms, and policy chambers alike. And then let’s keep asking the question that follows: What are we missing before the heart breaks?
Because maybe she is not just tired. Maybe her body has been trying to tell us something. And maybe it is time—finally, fully—to listen.
References
1. Lloyd-Jones DM, Allen NB, Anderson CAM, et al; American Heart Association. Life’s Essential 8: Updating and enhancing the American Heart Association’s construct of cardiovascular health: A presidential advisory from the American Heart Association. Circulation. 2022 Aug 2;146(5):e18-43.
2. Javaheri S, Dempsey JA. Central sleep apnea. Compr Physiol. 2013;3(1):141-63.
3. Aurora RN, Bista SR, Casey KR, et al. Updated adaptive servo-ventilation recommendations for the 2012 AASM Guideline: “The treatment of central sleep apnea syndromes in adults: Practice parameters with an evidence-based literature review and meta-analyses”. J Clin Sleep Med. 2016 May 15;12(5):757-61.
4. Cowie MR, Woehrle H, Wegscheider K, et al. Adaptive servo-ventilation for central sleep apnea in systolic heart failure. N Engl J Med. 2015 Sep 17;373(12):1095-105.
5. Wimms A, Woehrle H, Ketheeswaran S, et al. Obstructive sleep apnea in women: Specific issues and interventions. Biomed Res Int. 2016;2016:1764837.
6. Valipour A. Gender-related differences in the obstructive sleep apnea syndrome. Pneumologie. 2012 Oct;66(10):584-8.
7. Bonsignore MR, Saaresranta T, Riha RL. Sex differences in obstructive sleep apnoea. Eur Respir Rev. 2019 Nov 6;28(154):190030.
8. Theorell-Haglöw J, Miller CB, Bartlett DJ, et al. Gender differences in obstructive sleep apnoea, insomnia and restless legs syndrome in adults – What do we know? A clinical update. Sleep Med Rev. 2018 Apr;38:28-38.
9. Thorpy MJ, Krieger AC. Delayed diagnosis of narcolepsy: characterization and impact. Sleep Med. 2014 May;15(5):502-7. [Cited as one documented example of diagnostic delay in sleep medicine; similar patterns are documented in OSA and insomnia literature.]
Photo: The author and her grandmother, Penny Watson, in 2013 at the author’s graduation from Pitt Community College’s polysomnography program.
