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Sleep and circadian rhythms in cardiovascular resilience: mechanisms, implications, and a Roadmap for research and interventions

Nature Reviews Cardiology volume 23, pages 116–130 (2026)Cite this article

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Abstract

The interaction between sleep, circadian rhythms and cardiovascular resilience is a crucial yet underexplored research area with important public health implications. Disruptions in sleep and circadian rhythms exacerbate hypertension, diabetes mellitus and obesity, conditions that are increasingly prevalent globally and increase the risk of cardiovascular disease. A National Heart, Lung, and Blood Institute workshop examined these connections, as well as the emerging concept of cardiovascular resilience as a dynamic and multifaceted concept spanning molecular, cellular and systemic levels across an individual’s lifespan. The workshop emphasized the need to expand the focus from solely understanding whether and how sleep and circadian rhythm disturbances contribute to disease, to also exploring how healthy sleep and aligned circadian rhythms can increase cardiovascular resilience. To develop a Roadmap towards this goal, workshop participants identified key knowledge gaps and research opportunities, including the need to integrate biological, behavioural, environmental and societal factors in sleep and circadian health with cardiovascular research to identify therapeutic targets. Proposed interventions encompass behavioural therapies, chronotherapy, lifestyle changes, organizational policies and public health initiatives aimed at improving sleep and circadian health for better cardiovascular outcomes. Future cross-disciplinary research and translation of discoveries into public health strategies and clinical practices could improve cardiovascular resilience across the lifespan in all populations.

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Fig. 1: Conceptual model for defining resilience.
Fig. 2: Influence of social determinants on sleep, circadian rhythms and cardiovascular resilience.
Fig. 3: Sleep and circadian rhythm targets to optimize cardiovascular resilience.
Fig. 4: Cellular pathways of cardiovascular resilience.

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Acknowledgements

The workshop that set the foundation for this article was supported by the NHLBI and the NIH. The authors thank M. Tirumalasetty (New York University Grossman Long Island School of Medicine, USA) for his assistance with Fig. 4 for initial submission, and D. Goff (NHLBI, USA) for his critical review and suggestions on the manuscript. The authors acknowledge the following funding support: B.A.: NIH HL169991; A. Azarbarzin: NIH HL153874, HL161766 and American Academy of Sleep Medicine SR-2217; R.C.A.: NIH AG068577; K.G.B.: NIH NR018891; V.L.B.: NIH HL139950; N.B.: NIH HL151745 and National Institute for Occupational Safety and Health U19OH010154; J.L.B.: NIH HL168081 and DK125653; P.C.: NIH HL159180, HL160870 HL, HL163783 and American Academy of Sleep Medicine 245-SR-21; S.H.C.: NIH HL169503, HL173882, OD037655 and MH134051; R.C.: NIH HL169266; S.J.: NIH HL106041 and HL137234; J.O.L.: NIH HL151368 and NS126547; P.L.L.: NIH HL159246; Q.M.: NIH HL141733 and HL137234; A.A.P.: HL142051; F.K.S.: NIH HL131478; E.T.: NIH DK136214, DK120312, HL146127 and HL146127; I.V.: NIH HL141581; and M.A.G.: NIH MD011600 and DA051321.

Author information

Author notes

  1. These authors jointly supervised this work: Michael A. Grandner; Donald Lloyd-Jones.

Authors and Affiliations

  1. Department of Medicine, Columbia University Medical Center, New York, NY, USA

    Brooke Aggarwal & Sanja Jelic

  2. Division of Cardiovascular Sciences, NHLBI, Bethesda, MD, USA

    Yunling Gao & Zorina Galis

  3. National Center on Sleep Disorder Research, Division of Lung Diseases, NHLBI, Bethesda, MD, USA

    Alfonso Alfini & Marishka Brown

  4. Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA

    Ali Azarbarzin

  5. Division of Sleep Medicine, University of Pennsylvania, Philadelphia, PA, USA

    Ron C. Anafi

  6. Department of Family and Preventive Medicine, University of Utah, Salt Lake City, UT, USA

    Kelly Glazer Baron

  7. Department of Biology and McAllister Heart Institute, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA

    Victoria L. Bautch

  8. Oregon Institute of Occupational Health Sciences, Oregon Health and Science University, Portland, OR, USA

    Nicole Bowles

  9. Department of Health and Exercise Science, Colorado State University, Fort Collins, CO, USA

    Josiane L. Broussard

  10. Sleep Disorders and Research Center, Henry Ford Health and Michigan State University Health Sciences, Detroit, MI, USA

    Philip Cheng

  11. Department of Social and Behavioral Sciences, Department of Biostatistics, School of Global Public Health, New York University, New York, NY, USA

    Stephanie H. Cook

  12. Department of Paediatrics, University of Missouri, Columbia, MO, USA

    Rene Cortese

  13. Department of Psychology, University of Arizona, Tucson, AZ, USA

    Fabian-Xosé Fernandez

  14. Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA

    Dayna A. Johnson

  15. Department of Neurology and Kirby Neurobiology Center, Harvard Medical School, Boston, MA, USA

    Jonathan O. Lipton

  16. School of Public Health, University of Minnesota, Minneapolis, MN, USA

    Pamela L. Lutsey

  17. Department of Foundations of Medicine, New York University Grossman Long Island School of Medicine, Mineola, NY, USA

    Qing Miao

  18. Gerald J. and Dorothy R. Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA, USA

    Jose M. Ordovas

  19. School of Medicine, University of California San Francisco, San Francisco, CA, USA

    Aric A. Prather

  20. Cardiovascular Research Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA

    Filip K. Swirski

  21. Department of Medicine, University of Chicago, Chicago, IL, USA

    Esra Tasali

  22. Department of Psychology, University of Notre Dame, Notre Dame, IN, USA

    Ivan Vargas

  23. Department of Psychiatry, University of Arizona College of Medicine–Tucson, Tucson, AZ, USA

    Michael A. Grandner

  24. Department of Preventive Medicine, Northwestern University, Chicago, IL, USA

    Donald Lloyd-Jones

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  1. Brooke Aggarwal
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Contributions

B.A. and Y.G. researched data for the article. B.A., Y.G., A. Azarbarzin, R.C.A., K.G.B., V.L.B., N.B., J.L.B., P.C., S.H.C., R.C., F.-X.F., D.A.J., S.J., J.O.L., P.L.L., Q.M., J.M.O., A.A.P., F.K.S., E.T., I.V., M.A.G. and D.L.-J. wrote the article. All the authors contributed substantially to the discussion of content, and reviewed and/or edited the manuscript before submission.

Corresponding author

Correspondence to Brooke Aggarwal.

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Competing interests

The views expressed in this article are those of the authors and reflect those of the workshop, and do not necessarily represent those of the NHLBI, the NIH, or the US Department of Health and Human Services. No industry support was used for this project. A. Azarbarzin is a consultant for Apnimed, Cerebra, Eli Lilly, Inspire and Respicardia. D.A.J. has received consulting fees from Idorsia Pharmaceuticals. J.O.L. has received consulting fees from Synchronicity Pharma. E.T. is an adviser to NeuroGeneCES and Vitaliti. The other authors declare no competing interests.

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Nature Reviews Cardiology thanks Linda Van Laake, who co-reviewed with Yvonne Koop; and the other, anonymous, reviewer(s) for their contribution to the peer review of this work.

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Aggarwal, B., Gao, Y., Alfini, A. et al. Sleep and circadian rhythms in cardiovascular resilience: mechanisms, implications, and a Roadmap for research and interventions. Nat Rev Cardiol 23, 116–130 (2026). https://doi.org/10.1038/s41569-025-01188-1

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