Risk of resistant hypertension associated with restless legs syndrome and periodic limb movements during sleep: a study on 673 treated hypertensive individuals

Impact of Intermittent Hypoxia Related to Obstructive Sleep Apnoea Syndrome on Low-Grade Inflammation in Hypertensive Patients: Potential Implications for Cardiovascular Risk

There is evidence for a particular relationship between low-grade inflammation (LGI) and intermittent hypoxia (IH) related to obstructive sleep apnoea syndrome (OSAS). However, despite the potential deleterious cardiovascular consequences associated with this LGI in hypertensive patients, few studies have investigated the impact of IH related to OSAS on CRP levels in this subpopulation. In total, 1404 hypertensive patients were selected retrospectively from the Sleep Laboratory database. CRP levels ≥3 mg/L but <10 mg/L were used as cut-offs to identify hypertensive patients with LGI. Logistic regressions were conducted to examine the risk of LGI associated with IH related to OSAS in hypertensive patients. LGI was frequent (33.8%) in hypertensive patients. After adjustment for confounders, multivariate logistic regressions revealed that only moderate to severe OSAS (apnoea-hypopnoea index ≥ 15/h) with high IH (oxygen desaturation index ≥ 15/h) [OR 1.51 (95% CI 1.06-2.14)] was significantly associated with LGI in hypertensive patients (p-value = 0.045). Consistent with our hypothesis, our results demonstrated the existence of a particular subtype of hypertensive patients at high cardiovascular risk characterised by the presence of LGI induced by IH hypoxia related to moderate to severe OSAS, which justifies the establishment of adequate management of this pathology to allow better cardiovascular prevention in this subpopulation.

Coexistence of periodic limb movements during sleep with restless legs syndrome and its association with hypertension in Japanese patients

BACKGROUND

Caucasian patients with restless legs syndrome (RLS) frequently exhibit periodic limb movements during sleep (PLMS), which may increase the risk of hypertension. We evaluated the positivity rate of PLMS and factors associated with positivity in Japanese patients with RLS, and tested whether the complications of PLMS are associated with the presence of hypertension.

METHODS

We retrospectively investigated polysomnographic data and the presence or absence of hypertension in patients with RLS. Patients with systolic blood pressure ≥140 mmHg or diastolic blood pressure ≥90 mmHg or those taking antihypertensive medication were categorized as the group with hypertension.

RESULTS

Among 468 patients, 200 (42.7%) had periodic limb movement index (PLMI) values ≥ 15/h and 108 (23.1%) met the criteria of positivity for hypertension. Multiple logistic regression analysis revealed that only higher age was significantly associated with PLMI values ≥ 15/h. Multiple linear regression analyses of factors associated with an increased PLMI also showed that increased PLMI was significantly correlated with higher age and male sex, but not with the international restless legs scale scores. Multiple logistic regression analysis also revealed that higher age and body mass index, not PLMI values ≥ 15/h, were significantly associated with the presence of hypertension.

CONCLUSION

The PLMS-positivity rate may be lower in Japanese patients with RLS than in Caucasian patients, and it increases with age and male sex, but not with the severity of the disorder. Furthermore, PLMS complications were not associated with the risk of hypertension in Japanese patients with RLS.

10-Year Risk for Cardiovascular Disease Associated with COMISA (Co-Morbid Insomnia and Sleep Apnea) in Hypertensive Subjects

Due to the few studies available, this study aimed to investigate the 10-year risk for cardiovascular disease (CVD) associated with COMISA (co-morbid insomnia and sleep apnea) in hypertensive subjects. Clinical data of 1009 hypertensive subjects extracted from the Sleep Laboratory database were analyzed. Framingham Risk Score ≥ 10% was used as a cut-off to identify hypertensive subjects with high 10-year risk for CVD. The association between 10-year risk for CVD and COMISA was investigated using logistic regression analyses. 65.3% of hypertensive subjects from our sample presented a high 10-year risk for CVD. After controlling for major confounding factors, multivariate logistic regression analyses demonstrated that unlike its components present separately, COMISA was significantly associated with high 10-year risk for CVD in hypertensive subjects (OR 1.88, 95% CI 1.01-3.51). In this study, we have demonstrated that the negative synergy between obstructive sleep apnea syndrome and insomnia disorder seems to play a central role in the 10-year risk for CVD in hypertensive subjects, which seems to indicate that the establishment of a systematic research and an adapted treatment of COMISA could open new perspectives to promote a better cardiovascular outcome in this specific subgroup of patients.

Periodic limb movements during sleep and risk of hypertension: A systematic review

BACKGROUND

Several studies suggest an association between periodic limb movements during sleep (PLMS) and hypertension; however, a systematic evaluation of this relationship is lacking.

METHODS

We conducted a systematic review and meta-analysis of observational studies that reported odds ratio, relative risk, hazard ratio, or standardized incidence ratio, comparing the risk of hypertension in persons with PLMS (defined by the level of periodic limb movements per hour of sleep depended on individual studies) versus those without PLMS. After assessing heterogeneity and bias, the pooled risk ratio and 95% confidence intervals (CIs) were determined using a random-effect, generic inverse variance method of DerSimonian and Laird.

RESULTS

Out of 572 potentially relevant articles, six eligible studies were included in the data analysis. Studies (6 cross-sectional) included 8949 participants. The statistical heterogeneity of this study was insignificant, with an I² of 0%. A funnel plot and Egger's regression asymmetry test showed no publication bias with P-value ≥0.05. The pooled risk ratio of hypertension in patients with PLMS was 1.26 (95% CI, 1.12-1.41).

CONCLUSIONS

Our analysis demonstrates an increased hypertension risk among patients with PLMS. Prospective or interventional studies are needed to confirm this association.

The association between type 2 diabetes and anhedonic subtype of major depression in hypertensive individuals

Given the limited data in the literature, the aim of this study was to investigate the association between type 2 diabetes and anhedonic subtype of major depression in hypertensive individuals. Demographic and polysomnographic data from 323 hypertensive individuals recruited from the database of the Erasme Hospital Sleep Laboratory were analysed. Only individuals with a diagnosis of type 2 diabetes according to the diagnostic criteria of the American Diabetes Association at admission were included in the "diabetes group". Logistic regression analyses were used to study the association between type 2 diabetes and anhedonic subtype of major depression in hypertensive individuals. The rate of type 2 diabetes was 18.9% in our sample of hypertensive individuals. After adjusting for major confounding factors, multivariate logistic regression analyses demonstrated that unlike the non-anhedonic subtype of major depression, only the anhedonic subtype of major depression was significantly associated with higher likelihood of having type 2 diabetes in hypertensive individuals. In this study, the authors demonstrated that the anhedonic subtype of major depression is significantly associated with type 2 diabetes in hypertensive individuals, which could potentially open up new perspectives for the development of therapeutic strategies complementary to conventional treatments for type 2 diabetes in this subpopulation at high risk of complications related to the co-occurrence of this metabolic disorder.

Risk of Excessive Daytime Sleepiness Associated to Major Depression in Adolescents

Given the limited data currently available in the literature, the aim of this study was to investigate the risk of excessive daytime sleepiness (EDS) associated with major depression in a large sample of adolescents. The clinical and polysomnographic data of 105 adolescents recruited from the database of the Erasme Hospital sleep laboratory were analysed. A score > 10 on the Epworth Sleepiness Scale was used as cut-off for the diagnosis of EDS. The status (remitted or current) and the severity (mild to moderate or severe) of major depressive episodes were determined based on the diagnostic criteria of the DSM-IV-TR during a systematic psychiatric assessment. Logistic regression analyses were performed to determine the risk of EDS associated with major depression in adolescents. The prevalence of EDS was 34.3% in our sample of adolescents. After adjusting for the main confounding factors associated with EDS, multivariate logistic regression analysis demonstrated that unlike mild to moderate major depression, remitted major depression and severe major depression were risk factors for EDS in adolescents. In our study, we have highlighted that in adolescents, the EDS could be both residual symptom and severity marker of major depression, which seems to justify a systematic psychiatric assessment in adolescents with EDS complaints in order to allow better management of this problem in this particular subpopulation.

Restless legs syndrome

Restless legs syndrome (RLS) is a common sensorimotor disorder characterized by an urge to move that appears during rest or is exacerbated by rest, that occurs in the evening or night and that disappears during movement or is improved by movement. Symptoms vary considerably in age at onset, frequency and severity, with severe forms affecting sleep, quality of life and mood. Patients with RLS often display periodic leg movements during sleep or resting wakefulness. RLS is considered to be a complex condition in which predisposing genetic factors, environmental factors and comorbidities contribute to the expression of the disorder. RLS occurs alone or with comorbidities, for example, iron deficiency and kidney disease, but also with cardiovascular diseases, diabetes mellitus and neurological, rheumatological and respiratory disorders. The pathophysiology is still unclear, with the involvement of brain iron deficiency, dysfunction in the dopaminergic and nociceptive systems and altered adenosine and glutamatergic pathways as hypotheses being investigated. RLS is poorly recognized by physicians and it is accordingly often incorrectly diagnosed and managed. Treatment guidelines recommend initiation of therapy with low doses of dopamine agonists or α₂δ ligands in severe forms. Although dopaminergic treatment is initially highly effective, its long-term use can result in a serious worsening of symptoms known as augmentation. Other treatments include opioids and iron preparations.

Restless legs syndrome/Willis-Ekbom disease among patients with resistant hypertension versus stroke patients-a prospective study

BACKGROUND

Epidemiological studies have shown an increased prevalence and incidence of hypertension as well as a higher incidence of stroke among patients suffering from RLS. The objective of this study was to estimate the prevalence of RLS among patients with resistant hypertension (RH) and compare the clinical characteristics of these patients with patients of stroke pre-existing RLS and with patients with primary RLS presenting to the Sleep clinic.

METHODS

Consecutive patients with RH (without any identifiable cause on extensive work up) and consecutive in-patients with stroke were enrolled over a 3-year-period. Patients with RH fulfilling revised-IRLSSG-criteria for RLS comprised group 1 and those with stroke and RLS formed group 2. These were compared with patients diagnosed to have idiopathic RLS (iRLS) (Group 3). Prevalence of RLS in groups 1 and 2 and RLS characteristics in all groups were compared.

RESULTS

Sixteen out of 56 RH patients (29%) formed group 1 and 43 out 346 of stroke patients (12%) formed group 2, while 43 consecutive iRLS patients were included in group 3. Age was significantly higher, with male dominance in group 2. Median age at symptom onset was significantly lower in group 1. Positive family history was similar in RH and iRLS patients and was significantly less common in stroke patients. Asymmetrical/unilateral distribution of symptoms was significantly more common in stroke group, compared to RH and iRLS groups.

CONCLUSION

This study demonstrated a high prevalence of RLS among patients with resistant hypertension. RLS characteristics are different from those in patients with stroke, and very similar to primary RLS.

Jidong Restless Legs Syndrome Cohort Study: Objectives, Design, and Baseline Screening

Background: Restless legs syndrome (RLS) is a common neurological disorder with unpleasant leg sensations and serious negative effects on mental and physical health. Many observational studies showed that people with RLS had a high risk of vascular diseases, including cerebrovascular and cardiovascular diseases (CVD), but the findings were conflicting. The Jidong RLS Cohort Study is a prospective cohort study designed to mainly examine whether or not RLS is associated with an increased risk of CVD. Methods and Design: The study recruited 8,867 healthy participants older than 18 years from October 2014 to December 2015. Participants received a physical examination in the Staff Hospital, Jidong Oilfield Branch, China National Petroleum Corporation. Baseline data and blood samples were collected. Restless legs syndrome was assessed using the international RLS diagnostic criteria. All of subjects would be followed up until December 2025. Major cardiovascular/cerebrovascular events including cardiac death, myocardial infarction, ischemic heart disease, heart failure, atrial fibrillation, ischemic, and hemorrhagic stroke will be the primary outcomes. Secondary outcomes include all-cause mortality, the decline in quality of life, cognitive impairment, and depression. Discussion: This study will contribute to the scientific evidence on the association between RLS and cardiovascular risks and also provide an unprecedented opportunity for early detection and prevention of CVD.

Polysomnographic markers of suicidal ideation in untreated unipolar major depressed individuals

Given the major role played by sleep in the particular relationship between suicidality and major depression, the aim of this study was to empirically identify polysomnographic markers specific to suicidal ideation in major depressed individuals in order to allow better suicide prevention in this high-risk subpopulation. Demographic and polysomnographic data from 190 individuals (34 healthy controls and 156 untreated unipolar major depressed individuals) recruited from the sleep laboratory database were analysed. Suicidal ideation were considered present if the score in item G of the Beck Depression Inventory was ≥1 and/or if they were highlighted during the systematic psychiatric assessment conducted on admission to the sleep laboratory. Independently of depression severity, major depressed individuals with suicidal ideation present a decrease in deep NREM sleep (slow-wave sleep) and an increase in light NREM sleep (stage 1 + stage 2) compared to those without suicidal ideation. There are no significant differences for the other polysomnographic parameters. In our study, we highlighted the existence of potential polysomnographic markers of suicidal ideation in untreated unipolar major depressed individuals, which seems to open up new perspectives for the identification and management of individuals at high-risk of suicide in this particular subpopulation.

[Update on restless legs syndrome]

Restless legs syndrome (RLS), with a lifetime prevalence of up to 10%, is a frequent neurological disease and the most common movement disorder in sleep. A compulsive urge to move the legs with sensory symptoms and sleep disturbances can significantly impair the quality of life. Furthermore, RLS frequently occurs as a comorbidity to various internal and neurological diseases. It is diagnosed clinically based on the five essential diagnostic criteria. For treatment, an iron deficiency should first be excluded. Drugs approved for the treatment of RLS include dopaminergics (L-DOPA/benserazide) and dopamine agonists as well as oxycodone/naloxone, as a second-line treatment in severe cases. Augmentation as a deterioration of symptoms is a clinically defined complication of high-dose dopaminergic treatment, requiring special management strategies. Due to its high prevalence of up to 25%, RLS plays also an important role in the care of pregnant women.

Treating sleep disorders to improve blood pressure control and cardiovascular prevention: a dream come true?-a narrative review

Hypertension is one of the primary risk factors for heart disease and stroke, the leading causes of death worldwide. Current evidence supports the treatment of high blood pressure (BP) values in order to obtain a substantial reduction of cardiovascular burden. Sleep plays an important role in maintaining nocturnal BP control and nocturnal hypertension which, in turn, can be affected by the presence of sleep disorders. Whilst respiratory disturbances have been extensively studied and their causal role in the development of nocturnal hypertension has been demonstrated in both cross sectional and prospective studies, less is known about the impact of other sleep disorders such as insomnia. In this review, we aim to describe the role of sleep disorders in the development of nocturnal and diurnal hypertension. Furthermore, we aim to discuss the potential impact of the treatment of such sleep disorders on BP values as an adjunct treatment for patients with hypertension.

Restless legs syndrome and periodic limb movements of sleep

Restless legs syndrome describes a curious need to stretch and move in response to an unpleasant feeling in the legs. For most people who have this, as they are drifting off to sleep there is a twitch of the toe, foot and ankle followed by another and then another. The limb movements are strikingly periodic and are described as such by frustrated bed partners. The pathophysiology remains debated but is likely to involve dopaminergic dysfunction and ascending arousal systems. Despite a prevalence of 5-10% in the general population, the variable nature of symptoms and difficulty describing the dysaesthesia often leads to delay in treatment. This article outlines the diagnostic criteria, medication and comorbidities that modify symptoms, the impact of restless legs syndrome on health, and symptomatic management. Several licensed therapies are effective but the dopamine agonists in particular can cause challenging side effects and paradoxically worsen symptoms over time. Case histories are reviewed to guide physicians.