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Parasomnias are sleep disorders involving undesirable physical events or experiences occurring during sleep onset, while sleeping, or on arousal. They include non-rapid eye movement (REM) parasomnias (eg, confusional arousals, sleep terrors, sleepwalking) and REM-related parasomnias (eg, nightmare disorder, REM sleep behavior disorder, sleep paralysis). Notable among these is REM sleep behavior disorder, which is closely linked to neurodegenerative conditions such as Parkinson disease. Early detection of this disorder is essential because it often precedes the motor symptoms of neurodegenerative conditions. Diagnostic evaluation of parasomnias typically involves polysomnography, in some cases with video monitoring, to differentiate parasomnias from other conditions. Nonpharmacologic treatments, including sleep hygiene and sleep safety measures, are first-line approaches. Cognitive behavior therapy is also effective. Pharmacotherapy may be required in severe cases. Referral to a sleep specialist is recommended for patients with complex or dangerous parasomnias and for patients with frequent sleep paralysis.

Hospitalized patients often experience sleep deprivation due to poorly designed hospital environments. Patients face challenges such as loud noises, poor control of ambient light, and frequent nighttime disruptions, all of which contribute to inadequate rest. This sleep deprivation has significant physiologic consequences, including cardiovascular, immune, and cognitive dysfunction. Poor sleep quality is associated with adverse hospital outcomes, including increased readmission rates, higher hospital-acquired infection rates, and decreased patient satisfaction. To improve sleep quality, hospitals should provide patients with earplugs and eye masks, limit noise and disruptions, and align lighting with natural sleep cycles. Physicians often endure significant sleep deprivation, beginning in their training and continuing throughout their careers, that negatively affects their well-being and patient care. It also can contribute to burnout. Addressing sleep deprivation for physicians is essential for maintaining their health and improving quality of care and requires policy and culture changes.

Sleep is essential for overall well-being and vital to maintaining health. As a complex process with various stages and cycles, sleep can be evaluated using polysomnography and consumer sleep trackers, although the latter are less accurate for monitoring sleep stages. Sleep needs and patterns evolve throughout life, from infancy to older adulthood, with adults ages 18 to 64 years typically requiring 7 to 9 hours per night for optimal health. Insufficient sleep is associated with an increased risk of chronic conditions, including cardiovascular disease, diabetes, and obesity, and a weakened immune system. It also impairs cognitive function, decreases productivity and quality of life, and increases the risk of motor vehicle crashes. Sleep deprivation is closely tied to mental health issues, such as anxiety and depression. Although napping or sleep banking may offer temporary relief from sleep deprivation, they cannot be a substitute for regular, high-quality sleep. Consistently sleeping more than 9 to 10 hours per night, known as hypersomnia, has been linked to health issues including weight gain, mental health conditions, and cardiovascular disease. Prioritizing appropriate sleep duration and quality is essential for physical and mental health, helps prevent a variety of health issues, and promotes better daily functioning.

Sleep insufficiency, insomnia, and related sleep disorders are concerns that affect millions of US adults. The disorders also contribute to significant cognitive, emotional, and physical health challenges. Insomnia affects approximately 30% of the US population. It is characterized by difficulty falling asleep, difficulty staying asleep, and early-morning waking and is linked to daytime distress and impairment. Common sleep disruptors include environmental factors such as noise, light, and air pollution and also personal habits such as excessive screen use before bedtime. Evaluating patients with insomnia in primary care requires integrating sleep health assessments into routine visits and use of insomnia screening tools and sleep diaries for accurate diagnosis. Nonpharmacologic therapies such as sleep hygiene and cognitive behavior therapy for insomnia are the preferred treatments. Pharmacotherapy or combination therapy (with cognitive behavior therapy for insomnia and pharmacotherapy) may be considered when these interventions are ineffective. Family physicians should weigh the risks and benefits of insomnia medication use carefully for all patients but especially for older adults because of potential adverse effects. Managing insomnia effectively in primary care involves a comprehensive approach, prioritizing nonpharmacologic strategies, regular monitoring, and patient-centered care.

Cardiovascular disease risk assessment is an evolving field with new research indicating that more recommendations tailored to and personalized for patients are possible. Pooled cohort equations continue to be the foundation of risk assessment in patients 40 to 75 years of age, with the PREVENT (Predicting Risk of Cardiovascular Disease Events) calculator emerging as a successor to the 2013 American College of Cardiology/American Heart Association pooled cohort equation. All major calculators have similar predictive outcomes in longitudinal studies. Lipoprotein(a) is a readily available biomarker that is useful in patients with a strong family history of early major adverse cardiovascular events or treatment-resistant dyslipidemia. Current guidelines discourage the use of routine screening electrocardiography for risk stratification. Coronary artery calcium scoring is useful in intermediate-risk patients to reclassify the risk of coronary artery disease based on the presence and burden of coronary atherosclerosis. However, there are limited data on how it improves patient outcomes. No functional or radiographic studies are recommended for screening purposes; their primary role is in the diagnostic evaluation of patients presenting with nonacute chest pain. Treatment goals for primary prevention continue to emphasize a low-density lipoprotein cholesterol reduction of 50% from baseline in patients determined to be candidates for statins based on risk assessment.

Chronic coronary disease, previously known as stable ischemic heart disease, is a spectrum of coronary artery disease characterized by obstructive or nonobstructive atherosclerotic plaque accumulation in the coronary arteries. Functional noninvasive tests used to diagnose obstructive coronary artery disease can detect myocardial ischemia through electrocardiographic changes, wall motion abnormalities, or cardiac perfusion changes. These tests include stress echocardiography, stress cardiac magnetic resonance imaging, or stress single-photon emission computed tomography. The goals when treating chronic coronary disease are to improve patients' quality of life and extend their lifespan. Management includes lifestyle and risk factor optimization through diet and exercise; control of hyperlipidemia, blood pressure, and diabetes; long-term beta-blocker therapy; antianginal treatment; and antiplatelet therapy. Treatments should aim to reduce cardiac death, nonfatal ischemic events, and progression of atherosclerosis, using guideline-directed medical therapy. Clinicians should assess the socioeconomic status of patients who have chronic coronary disease and provide resources to community-based health workers when available.

Peripheral artery disease (PAD) is caused by atherosclerosis that leads to the narrowing or obstruction of the peripheral arteries, most commonly those that supply blood to the legs. The classic symptom is intermittent claudication-reproducible pain in the lower extremities consistently induced by exercise and relieved with rest. However, only about 10% of patients with PAD present with classic symptoms of claudication. Patients who have symptoms suggestive of PAD should undergo diagnostic testing using the ankle-brachial index (ABI). An ABI value of 0.9 or less is consistent with a diagnosis of PAD. An exercise ABI should be considered if ABI is normal and there is a high clinical suspicion for PAD. An ABI of 1.4 or greater is considered inconclusive or noncompressible and warrants further evaluation with alternative testing. This is most common in patients with diabetes and end-stage renal disease. Treatment for PAD includes structured exercise therapy, a single antiplatelet medication (clopidogrel preferred), a high-intensity statin, blood pressure control, antidiabetic agents (glucagon-like peptide-1 receptor agonists and sodium-glucose cotransporter-2 inhibitors), and smoking cessation when applicable. Patients who do not improve with initial treatment and those with chronic limb-threatening ischemia should be evaluated for revascularization, using imaging to determine the location and severity of arterial disease. Patients with acute limb ischemia require urgent evaluation to preserve limb viability.

Heart failure (HF) is a clinical condition characterized by the heart's inability to pump blood effectively enough to meet the body's metabolic demands; typically this happens because of impaired ventricular filling or ejection. HF affects millions of people in the United States, with increasing prevalence, hospitalizations, and deaths. Classification of HF by left ventricular ejection fraction divides it into HF with preserved ejection fraction (HFpEF), mildly reduced ejection fraction, and reduced ejection fraction (HFrEF). Early diagnosis and appropriate staging, using tools such as natriuretic peptides and echocardiography, are essential for identifying HF and implementing effective treatment. In patients with HFrEF, guideline-directed medical therapy, comprising renin-angiotensin system inhibitors, beta blockers, mineralocorticoid receptor antagonists, and sodium-glucose cotransporter-2 inhibitors, has demonstrated reductions in morbidity, mortality, and hospitalizations. Management of comorbidities such as the use of glucagon-like peptide-1 receptor agonists for obesity in patients with HFpEF has improved outcomes. Advanced therapies, cardiac rehabilitation, and supportive interventions, including vaccinations and mental health screening, contribute to improved patient quality of life. Focusing on pharmacologic and nonpharmacologic strategies is essential to reduce HF progression, minimize hospitalizations, and improve overall survival.