Effects of continuous positive airway pressure on blood pressure and daytime sleepiness in obstructive sleep apnea patients with coronary heart diseases under optimal medications

Effects of continuous positive airway pressure on cardiac events and metabolic components in patients with moderate to severe obstructive sleep apnea and coronary artery disease: a meta-analysis

STUDY OBJECTIVES

This meta-analysis aimed to systematically assess the effects of continuous positive airway pressure (CPAP) in secondary prevention of major cardiovascular events (MACEs) in patients with moderate-to-severe obstructive sleep apnea and coronary artery disease.

METHODS

PubMed, Embase, the Cochrane Library, and ClinicalTrials.gov were searched for observational studies and randomized controlled trials that compared CPAP with usual care in patients with moderate-to-severe obstructive sleep apnea with coronary artery disease. The primary outcomes were MACEs, all-cause death, acute coronary syndrome, rehospitalization for heart failure, repeat revascularization, and arrhythmia.

RESULTS

A total of 11 studies (5 randomized controlled trials and 6 observational studies) with 5,410 patients reported outcomes of MACEs. Treatment with CPAP was associated with a modest risk reduction in MACEs (risk ratio [RR] 0.87, 95% confidence interval [CI] 0.78 to 0.98; P = .02). Similarly, CPAP significantly reduced the risk of all-cause and cardiovascular death by 23% (RR 0.77, 95% CI 0.60 to 0.99; P = .04; I2 = 0%). Subgroup analysis revealed that CPAP adherence time ≥ 4 hours/night had a greater benefit on MACEs by 42% (RR 0.58, 95% CI 0.42 to 0.79; P < .001; I2 = 0%) and repeat revascularization by 44% (RR 0.56, 95% CI 0.34 to 0.92; P = .02; I2 = 0%). Also, CPAP had a positive effect on systolic and diastolic blood pressure.

CONCLUSIONS

CPAP therapy might prevent subsequent MACEs and all-cause death among patients with moderate to severe obstructive sleep apnea and concomitant coronary artery disease. CPAP use exceeding 4 hours/night may add more benefits on MACEs, repeat revascularization, and blood pressure.

CLINICAL TRIAL REGISTRATION

Registry: PROSPERO database; Name: Effects of Continuous Positive Airway Pressure on Cardiovascular Events and Metabolic Components in Patients with Obstructive Sleep Apnea and Coronary Artery Disease; URL: https://www.crd.york.ac.uk/prospero/display_record.php?ID= CRD42020213546; Identifier: CRD42020213546.

CITATION

Yang D, Li L, Dong J, Yang W, Liu Z. Effects of continuous positive airway pressure on cardiac events and metabolic components in patients with moderate to severe obstructive sleep apnea and coronary artery disease: a meta-analysis. J Clin Sleep Med. 2023;19(12):2015-2025.

Effect of different treatments for obstructive sleep apnoea on blood pressure

OBJECTIVE

Obstructive sleep apnoea (OSA) is a common cause of secondary hypertension. This network meta-analysis (NMA) assessed the effect of different OSA treatments on lowering blood pressure.

METHODS

PubMed, EMBASE, Web of Science, and Cochrane Library databases were searched for relevant randomized controlled trials. The search strategies included the concepts of OSA, blood pressure, hypertension, and blood pressure-reducing treatments without language or data restriction (from inception to 1 June 2021). The outcomes included office SBP, office DBP, daytime SBP (dSBP) and DBP (dDBP), and night-time SBP (nSBP) and DBP (nDBP). A Bayesian network meta-analysis was performed, and mean differences with 95% credibility intervals were calculated.

RESULTS

We reviewed 49 randomized controlled trials involving 4893 patients and the following interventions: continuous positive-airway pressure (CPAP), mandibular advancement devices, nocturnal supplemental oxygen, surgery, β-blocker, angiotensin-converting enzyme inhibitors (ACEIs)/angiotensin receptor blockers (ARBs), renal sympathetic denervation (RDN), mineralocorticoid receptor antagonists (MRAs), calcium channel blockers. MRAs were significantly associated with blood pressure reduction followed by ACEI/ARB. RDN could reduce office SBP, office DBP, 24-h SBP, 24-h DBP, dSBP, and dDBP. CPAP also demonstrated modest blood pressure lowering.

CONCLUSION

MRAs and ACEIs/ARBs can reduce blood pressure effectively in patients with OSA. RDN is a novel hypertension treatment that lowered blood pressure in such patients. CPAP was associated with mild but stable blood pressure reduction, and it might be helpful as an adjunctive therapy in OSA patients with hypertension.

REVIEW REGISTRATION

This systematic review and meta-analysis was registered in PROSPERO: CRD42021240891.

Exercise Attenuates Intermittent Hypoxia-Induced Cardiac Fibrosis Associated with Sodium-Hydrogen Exchanger-1 in Rats

Purpose: To investigate the role of sodium–hydrogen exchanger-1 (NHE-1) and exercise training on intermittent hypoxia-induced cardiac fibrosis in obstructive sleep apnea (OSA), using an animal model mimicking the intermittent hypoxia of OSA.

Methods: Eight-week-old male Sprague–Dawley rats were randomly assigned to control (CON), intermittent hypoxia (IH), exercise (EXE), or IH combined with exercise (IHEXE) groups. These groups were randomly assigned to subgroups receiving either a vehicle or the NHE-1 inhibitor cariporide. The EXE and IHEXE rats underwent exercise training on an animal treadmill for 10 weeks (5 days/week, 60 min/day, 24–30 m/min, 2–10% grade). The IH and IHEXE rats were exposed to 14 days of IH (30 s of hypoxia—nadir of 2–6% O₂—followed by 45 s of normoxia) for 8 h/day. At the end of 10 weeks, rats were sacrificed and then hearts were removed to determine the myocardial levels of fibrosis index, oxidative stress, antioxidant capacity, and NHE-1 activation.

Results: Compared to the CON rats, IH induced higher cardiac fibrosis, lower myocardial catalase, and superoxidative dismutase activities, higher myocardial lipid and protein peroxidation and higher NHE-1 activation (p < 0.05 for each), which were all abolished by cariporide. Compared to the IH rats, lower cardiac fibrosis, higher myocardial antioxidant capacity, lower myocardial lipid, and protein peroxidation and lower NHE-1 activation were found in the IHEXE rats (p < 0.05 for each).

Conclusion: IH-induced cardiac fibrosis was associated with NHE-1 hyperactivity. However, exercise training and cariporide exerted an inhibitory effect to prevent myocardial NHE-1 hyperactivity, which contributed to reduced IH-induced cardiac fibrosis. Therefore, NHE-1 plays a critical role in the effect of exercise on IH-induced increased cardiac fibrosis.

Clinical effectiveness and cost-effectiveness results from the randomised controlled Trial of Oral Mandibular Advancement Devices for Obstructive sleep apnoea-hypopnoea (TOMADO) and long-term economic analysis of oral devices and continuous positive airway pressure

BACKGROUND

Obstructive sleep apnoea-hypopnoea (OSAH) causes excessive daytime sleepiness (EDS), impairs quality of life (QoL) and increases cardiovascular disease and road traffic accident risks. Continuous positive airway pressure (CPAP) treatment is clinically effective but undermined by intolerance, and its cost-effectiveness is borderline in milder cases. Mandibular advancement devices (MADs) are another option, but evidence is lacking regarding their clinical effectiveness and cost-effectiveness in milder disease.

OBJECTIVES

(1) Conduct a randomised controlled trial (RCT) examining the clinical effectiveness and cost-effectiveness of MADs against no treatment in mild to moderate OSAH. (2) Update systematic reviews and an existing health economic decision model with data from the Trial of Oral Mandibular Advancement Devices for Obstructive sleep apnoea-hypopnoea (TOMADO) and newly published results to better inform long-term clinical effectiveness and cost-effectiveness of MADs and CPAP in mild to moderate OSAH.

TOMADO

A crossover RCT comparing clinical effectiveness and cost-effectiveness of three MADs: self-moulded [SleepPro 1™ (SP1); Meditas Ltd, Winchester, UK]; semibespoke [SleepPro 2™ (SP2); Meditas Ltd, Winchester, UK]; and fully bespoke [bespoke MAD (bMAD); NHS Oral-Maxillofacial Laboratory, Addenbrooke's Hospital, Cambridge, UK] against no treatment, in 90 adults with mild to moderate OSAH. All devices improved primary outcome [apnoea-hypopnoea index (AHI)] compared with no treatment: relative risk 0.74 [95% confidence interval (CI) 0.62 to 0.89] for SP1; relative risk 0.67 (95% CI 0.59 to 0.76) for SP2; and relative risk 0.64 (95% CI 0.55 to 0.76) for bMAD (p < 0.001). Differences between MADs were not significant. Sleepiness [as measured by the Epworth Sleepiness Scale (ESS)] was scored 1.51 [95% CI 0.73 to 2.29 (SP1)] to 2.37 [95% CI 1.53 to 3.22 (bMAD)] lower than no treatment (p < 0.001), with SP2 and bMAD significantly better than SP1. All MADs improved disease-specific QoL. Compliance was lower for SP1, which was unpopular at trial exit. At 4 weeks, all devices were cost-effective at £20,000/quality-adjusted life-year (QALY), with SP2 the best value below £39,800/QALY.

META-ANALYSIS

A MEDLINE, EMBASE and Science Citation Index search updating two existing systematic reviews (one from November 2006 and the other from June 2008) to August 2013 identified 77 RCTs in adult OSAH patients comparing MAD with conservative management (CM), MADs with CPAP or CPAP with CM. MADs and CPAP significantly improved AHI [MAD -9.3/hour (p < 0.001); CPAP -25.4/hour (p < 0.001)]. Effect difference between CPAP and MADs was 7.0/hour (p < 0.001), favouring CPAP. No trials compared CPAP with MADs in mild OSAH. MAD and CPAP reduced the ESS score similarly [MAD 1.6 (p < 0.001); CPAP 1.6 (p < 0.001)].

LONG-TERM COST-EFFECTIVENESS

An existing model assessed lifetime cost-utility of MAD and CPAP in mild to moderate OSAH, using the revised meta-analysis to update input values. The TOMADO provided utility estimates, mapping ESS score to European Quality of Life-5 Dimensions three-level version for device cost-utility. Using SP2 as the standard device, MADs produced higher mean costs and mean QALYs than CM [incremental cost-effectiveness ratio (ICER) £6687/QALY]. From a willingness to pay (WTP) of £15,367/QALY, CPAP is cost-effective, although the likelihood of MADs (p = 0.48) and CPAP (p = 0.49) being cost-effective is very similar. Both were better than CM, but there was much uncertainty in the choice between CPAP and MAD (at a WTP £20,000/QALY, the probability of being the most cost-effective was 47% for MAD and 52% for CPAP). When SP2 lifespan increased to 18 months, the ICER for CPAP compared with MAD became £44,066. The ICER for SP1 compared with CM was £1552, and for bMAD compared with CM the ICER was £13,836. The ICER for CPAP compared with SP1 was £89,182, but CPAP produced lower mean costs and higher mean QALYs than bMAD. Differential compliance rates for CPAP reduces cost-effectiveness so MADs become less costly and more clinically effective with CPAP compliance 90% of SP2.

CONCLUSIONS

Mandibular advancement devices are clinically effective and cost-effective in mild to moderate OSAH. A semi-bespoke MAD is the appropriate first choice in most patients in the short term. Future work should explore whether or not adjustable MADs give additional clinical and cost benefits. Further data on longer-term cardiovascular risk and its risk factors would reduce uncertainty in the health economic model and improve precision of effectiveness estimates.

TRIAL REGISTRATION

This trial is registered as ISRCTN02309506.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 18, No. 67. See the NIHR Journals Library website for further project information.

Long-term effects of continuous positive airway pressure on blood pressure and prognosis in hypertensive patients with coronary heart disease and obstructive sleep apnea: a randomized controlled trial

BACKGROUND

Obstructive sleep apnea (OSA) can result in hypertension and significantly increase cardiovascular morbidity and mortality. There are few reports on the long-term effects of continuous positive airway pressure (CPAP) on blood pressure in patients with uncontrolled hypertension with coronary heart disease (CHD) and OSA.

METHODS

We conducted a prospective, long-term follow-up study in 83 patients with uncontrolled hypertension, CHD, and OSA randomized to control or CPAP groups. Daytime systolic blood pressure (SBP), diastolic blood pressure (DBP), and severe cardiovascular and cerebrovascular events (SCCEs) were recorded at baseline and follow-up.

RESULTS

Seventy-three patients completed the study with a median follow-up of 36 (interquartile range = 24-54) months. The 2 groups had similar characteristics at baseline. CPAP was used for 4.5±1.1 hour/night. SBP in the CPAP group was significantly reduced at follow-up (143±7 mm Hg vs. 139±7 mm Hg, P = 0.04), and SBP decreased by 8mm Hg (95% confidence interval = 1.4-9.9; P = 0.01). Hypertension control was improved (CPAP, 69.4% for CPAP users vs. 43.2% for control subjects; P = 0.02); however, DBP did not reach statistical difference between the groups (81±10 mm Hg vs. 79±8 mm Hg; P = 0.49). In the CPAP group, the Epworth Sleepiness Scale was markedly reduced (7.0±3.4 vs. 3.7±2.3; P < 0.001). There was 1 SCCE in the CPAP group (heart failure), and 5 SCCEs in the control group (acute myocardial infarction: 2 (with 1 death); stroke: 3), but there was no significant difference identified.

CONCLUSIONS

Long-term CPAP application in uncontrolled hypertension with CHD and OSA significantly reduced daytime SBP, improved hypertension control and daytime sleepiness, and decreased the trend in SCCEs compared with control subjects.

CLINICAL TRIAL REGISTRATION NUMBER

ClinicalTrials.gov NCT02059993.

Predictors of Blood Pressure Fall With Continuous Positive Airway Pressure Treatment in Hypertension With Coronary Artery Disease and Obstructive Sleep Apnea

BACKGROUND

The present study aimed to investigate the predictors of changes in blood pressure (BP) with continuous positive airway pressure (CPAP) treatment in hypertensive patients with coronary heart disease (CHD) and obstructive sleep apnea (OSA).

METHODS

Seventy-one hypertensive patients with CHD and OSA were enrolled in this study. Daytime systolic BP (SBP), diastolic BP (DBP), Epworth Sleepiness Scale (ESS), and anthropometric characteristics were assessed at baseline and follow-up.

RESULTS

Sixty-six patients completed the study. The median follow-up period was 36 months (interquartile range, 24-60 months). The mean duration of CPAP application was 4.3 ± 1.2 hours per night. From baseline to follow-up, SBP and DBP were reduced by 5.6 mm Hg (95% confidence interval [CI], 3.0-8.1) and 3.0 mm Hg (95% CI, 0.8-5.3), respectively. Daytime somnolence was significantly improved (ESS, from 9.5 ± 3.4 at baseline to 3.6 ± 2.0 at follow-up; P < 0.001); the mean improvement in ESS was 6.0 (95% CI, 5.1-6.9). Correlation analysis of the fall in mean BP (MBP) showed that baseline MBP, change in ESS, heart rate, and CPAP compliance showed a positive correlation, whereas the baseline body mass index (BMI) and ESS had an inverse relationship. Stepwise multiple linear regression analysis, however, indicated that only baseline BMI, baseline MBP, and CPAP compliance were independently correlated with the fall in MBP.

CONCLUSIONS

Long-term CPAP treatment reduces BP in hypertensive patients with CHD and moderate/severe OSA; baseline BMI, baseline MBP, and CPAP compliance are independent predictors of the decrease in BP with CPAP treatment in these patients.

The efficacy of antihypertensive drugs in chronic intermittent hypoxia conditions

Sleep apnea/hypopnea disorders include centrally originated diseases and obstructive sleep apnea (OSA). This last condition is renowned as a frequent secondary cause of hypertension (HT). The mechanisms involved in the pathogenesis of HT can be summarized in relation to two main pathways: sympathetic nervous system stimulation mediated mainly by activation of carotid body (CB) chemoreflexes and/or asphyxia, and, by no means the least important, the systemic effects of chronic intermittent hypoxia (CIH). The use of animal models has revealed that CIH is the critical stimulus underlying sympathetic activity and hypertension, and that this effect requires the presence of functional arterial chemoreceptors, which are hyperactive in CIH. These models of CIH mimic the HT observed in humans and allow the study of CIH independently without the mechanical obstruction component. The effect of continuous positive airway pressure (CPAP), the gold standard treatment for OSA patients, to reduce blood pressure seems to be modest and concomitant antihypertensive therapy is still required. We focus this review on the efficacy of pharmacological interventions to revert HT associated with CIH conditions in both animal models and humans. First, we explore the experimental animal models, developed to mimic HT related to CIH, which have been used to investigate the effect of antihypertensive drugs (AHDs). Second, we review what is known about drug efficacy to reverse HT induced by CIH in animals. Moreover, findings in humans with OSA are cited to demonstrate the lack of strong evidence for the establishment of a first-line antihypertensive regimen for these patients. Indeed, specific therapeutic guidelines for the pharmacological treatment of HT in these patients are still lacking. Finally, we discuss the future perspectives concerning the non-pharmacological and pharmacological management of this particular type of HT.

Potential role of bone marrow mesenchymal stem cells in obstructive sleep apnea

Obstructive sleep apnea syndrome (OSA) is a prevalent disease caused by increased collapsibility of the upper airway. OSA induces oxidative stress, inflammation and endothelial dysfunction, with important clinical consequences such as neurocognitive alterations and cardiovascular diseases. Although it has been shown that bone marrow-derived stem cells play a protective and reparative function in several diseases involving inflammatory processes and endothelial dysfunction, the data currently available on the potential role of adult stem cells in OSA are scarce. The present review presents recent data on the potential role of bone marrow-derived mesenchymal stem cells (MSC) in OSA. The results obtained in animal models that realistically mimic the events characterizing this sleep breathing disorder strongly support the notion that MSC are mobilized in circulating blood and then activated to play an anti-inflammatory role in OSA.

Addressing sleep disturbances: an opportunity to prevent cardiometabolic disease?

There is increasing awareness of the role of sleep disturbance as an important factor in health and disease. Although sub-clinical sleep disturbances (insufficient sleep duration or inadequate sleep quality) may be difficult to assess with conceptual and/or methodological clarity, this review attempts to summarize and synthesize these findings. First, the concept of sleep disturbance in a public health context is introduced, to provide context and rationale. Second, operational definitions of 'cardiometabolic disease' and 'sleep disturbance' are offered, to address many unclear operationalizations. Third, the extant literature is summarized regarding short or long sleep duration and/or insufficient sleep, insomnia and insomnia symptoms, general (non-specific sleep disturbances), circadian rhythm abnormalities that result in sleep disturbances, and, briefly, sleep-disordered breathing. Fourth, the review highlights the social/behavioural context of sleep, including discussions of sleep and race/ethnicity, socio-economic position, and other social/environmental factors, in order to place these findings in a social-environmental context relevant to public health. Fifth, the review highlights the issue of sleep as a domain of health behaviour and addresses issues regarding development of healthy sleep interventions. Finally, a research agenda of future directions is proposed.

Evaluation of an individualised programme to promote self-care in sleep-activity in patients with coronary artery disease -- a randomised intervention study

AIMS AND OBJECTIVES

To evaluate the effectiveness of an individualised programme to promote self-care in sleep-activity in patients with coronary artery disease.

BACKGROUND

Recent scientific findings have shown that low physical exercise and stress interfere with coronary artery disease patients' sleep quality and sleep efficiency independent of gender, age and co-morbidity.

DESIGN

A randomised pretest-post-test control design.

METHODS

Forty-seven patients who had undergone a coronary revascularisation procedure and/or pharmacological treatment three to seven weeks earlier at a general hospital were randomised to either an intervention group or a control group. Data collection was carried out by questionnaires, a study-specific sleep diary and actigraphy registration for 10 consecutive 24-hour periods, with a follow-up after three to four months. The intervention group underwent a nurse-led individualised education programme to promote self-care of sleep-activity. Sleep habits and sleep-related lifestyle together formed the basis for setting up individual goals together with the nurse. Individual advice on physical training, relaxation exercise and a CD-based relaxation programme was provided by a physiotherapist. Both groups received a brochure about sleep and stress.

RESULTS

At a three- to four-month follow-up, the main improvements were seen in the intervention group regarding sleep quality, sleep duration and sleep efficiency in the sleep diary and sleep efficiency in actigraphy. Statistical improvements in health-related quality of life were revealed. This was not so obvious in the control group.

CONCLUSIONS

An individualised intervention programme to promote self-care of sleep-activity including relaxation in patients with coronary artery disease led by a nurse may improve sleep quality. However, a longitudinal study to promote self-care in sleep-activity should be performed using a larger sample and multiple sites with continuous follow-ups to determine whether any positive effects remain stable over time.

RELEVANCE TO CLINICAL PRACTICE

Implementation of a multiprofessional individualised programme to promote self-care of sleep-activity including relaxation based on patients' needs, supported by a healthcare team and led by nurses, is important in clinical practice.

The association between the phenotype of excessive daytime sleepiness and blood pressure in patients with obstructive sleep apnea-hypopnea syndrome

OBJECTIVE

Investigate the clinical features and the blood pressure (BP) pattern of the phenotype of excessive daytime sleepiness (EDS) in OSAHS.

METHODS

A total of 508 Chinese adults with suspected OSAHS were referred to our sleep laboratory from October 2009 to May 2012. On the same night of polysomnography (PSG), the levels of blood pressure were measured before sleeping (bedtime BP) and immediately after waking up in the next morning (morning BP). EDS was recognized as Epworth Sleepiness Scale (ESS)≥9. Subjects were classified into four groups based on the apnea-hypopnea index (AHI) from PSG as follows: control (simple snoring) group (control, n=104) with AHI<5; mild group (mild, n=89) with AHI≥5 and <15; moderate group (moderate, n=70) with AHI≥15 and<30; and severe group (severe, n=245) with AHI ≥30. The differences and correlations between BP and PSG parameters in EDS and non-EDS group of OSAHS patients were analyzed.

RESULTS

In all subjects, ESS was positively correlated with morning diastolic blood pressure (DBP), Mean arterial pressure (MAP) and bedtime DBP (r=0.144, 0.102 and 0.114, respectively, each P value<0.05). In OSAHS patients, ESS was only positively correlated with morning DBP (r=0.137, P<0.05). OSAHS patients with EDS phenotype were younger and were more likely to have the symptom of waking up feeling tired (36.1% vs. 23.2%, p=0.023), who had lower MSaO2, longer SIT90 (the ratio of time of SpO2 below 90% in total sleep time) and higher DBP (bedtime as well as morning). In patients with AHI≥15, ESS was correlated positively with both bedtime and morning DBP after controlling the confounding effects of age, sex, BMI, AHI and nadir nocturnal oxygen saturation( r=0.126,0.143, respectively, both P values<0.05). And in OSAHS patients of EDS phenotype, the bedtime DBP, bedtime MAP, morning DBP, and morning MAP were 3~5 mm Hg higher than that in patients of non-EDS phenotype(P<0.05). In the moderate and severe OSAHS group, patients with EDS phenotype were younger and had a lower mean blood oxygen saturation (MSaO2), longer time of SpO2 below 90% and higher SIT90 than patients with non-EDS phenotype (P<0.05). In hypertensive OSAHS patients, patients with EDS were also younger and had higher micro-arousal index (MiI), as well as higher morning DBP, morning MAP and bedtime DBP than that in non-EDS group (P<0.05).

CONCLUSIONS

EDS in OSAHS patients is a special phenotype, which was characterized by younger age, higher DBP and more severe hypoxic load. This feature is mainly manifested in moderate and severe OSAHS patients. It is very important to identify the phenotype of EDS in patients with OSAHS, who may meet more benefits from effective treatment of OSAHS by correcting the intermittent nocturnal hypoxia and sleep fragmentation.

Health behavior and adherence to treatment for sleep breathing disorder in the patient with heart failure

BACKGROUND

Heart failure can be complicated by a variety of comorbidities including sleep breathing disorder (SBD). Treatment for SBD in the heart failure patient can improve quality of life and decrease mortality. Few studies have sought to examine the reasons why patients with heart failure who screen positive for SBD do not follow through with diagnostic testing and recommendations for evidence based treatments.

PURPOSE

The purpose of this study was to describe and compare the characteristics of patients with heart failure who adhered to recommendations for evaluation and treatment of SBD with those who did not. Additionally, the study sought to examine reasons for nonadherence.

METHODS

A descriptive comparative design was used. Descriptive statistics were used to define and compare the study population in terms of demographic data, which included age, gender, ethnicity, New York Heart Association heart failure classification, and comorbidities. Additionally, patients were surveyed to determine reasons for nonadherence to recommended overnight sleep study evaluation and or treatment with positive airway pressure.

RESULTS

Demographics with higher percentages of adherence to evaluation and treatment included younger individuals and male gender. Prevalent reasons for nonadherence for evaluation and treatment included negative perceptions of an overnight sleep study evaluation and advanced age.

IMPLICATIONS FOR PRACTICE

The community nurse educator can use the descriptive comparative findings in this study to tailor educational programs toward individuals with heart failure who have screened positive for SBD who are most at risk for nonadherence.

Approaches for targeting blood pressure control in sleep disorders

PURPOSE OF REVIEW

One of the underappreciated causes of hypertension is disordered sleep. There have been a number of studies evaluating sleep in the context of blood pressure control, and these will be reviewed.

RECENT FINDINGS

Original novel articles document that disruption of deep sleep stage, regardless of cause, if chronic, contributes to an increased risk for development of hypertension. Studies have evaluated disrupted sleep especially in older people requiring use of the bathroom at night and demonstrate higher risk of hypertension in such people. Correction of sleep apnea with continuous positive airway pressure (CPAP) reduces blood pressure in those who are adherent; however, as the reduction is only from 2 to 5 mmHg systolic, adjunctive medications are almost always needed. Use of angiotensin receptor blockers and some β-blockers has shown some improvement in blood pressure. Renal denervation has also been shown in a pilot study to offer benefit on blood pressure reduction.

SUMMARY

Innovations of combined use of devices with certain classes of antihypertensive medications help reduce blood pressure in people with sleep disorders. CPAP alone provides only modest reduction in blood pressure; however, restoration of deep sleep reduces blood pressure and reduces variability.