Effect of CPAP treatment on BP in resistant hypertensive patients according to the BP dipping pattern and the presence of nocturnal hypertension

Obstructive sleep apnea and non-dipper: epiphenomena or risks of Alzheimer's disease?: a review from the HOPE Asia Network

Obstructive sleep apnea (OSA) and associated nocturnal blood pressure (BP) surges is associated with non-dipper. On the other hand, the relationship between neurodegenerative diseases and non-dipper hypertension has been reported. To date, few studies have evaluated the relationships of nocturnal BP dipping patterns and OSA in relation to neurodegenerative diseases, particularly Alzheimer's disease (AD). This review examines the etiology of the association between OSA and the non-dipper pattern of hypertension and how both are involved in the development of AD. To set the stage for this review, we first focus on the pathophysiology of AD, which is interrelated with sleep apnea and non-dipper through dysregulation of central autonomic network.

Resistant hypertension: consensus document from the Korean society of hypertension

Although reports vary, the prevalence of true resistant hypertension and apparent treatment-resistant hypertension (aTRH) has been reported to be 10.3% and 14.7%, respectively. As there is a rapid increase in the prevalence of obesity, chronic kidney disease, and diabetes mellitus, factors that are associated with resistant hypertension, the prevalence of resistant hypertension is expected to rise as well. Frequently, patients with aTRH have pseudoresistant hypertension [aTRH due to white-coat uncontrolled hypertension (WUCH), drug underdosing, poor adherence, and inaccurate office blood pressure (BP) measurements]. As the prevalence of WUCH is high among patients with aTRH, the use of out-of-office BP measurements, both ambulatory blood pressure monitoring (ABPM) and home blood pressure monitoring (HBPM), is essential to exclude WUCH. Non-adherence is especially problematic, and methods to assess adherence remain limited and often not clinically feasible. Therefore, the use of HBPM and higher utilization of single-pill fixed-dose combination treatments should be emphasized to improve drug adherence. In addition, primary aldosteronism and symptomatic obstructive sleep apnea are quite common in patients with hypertension and more so in patients with resistant hypertension. Screening for these diseases is essential, as the treatment of these secondary causes may help control BP in patients who are otherwise difficult to treat. Finally, a proper drug regimen combined with lifestyle modifications is essential to control BP in these patients.

Role of home blood pressure monitoring in resistant hypertension

The definition of resistant hypertension (RHT) has been updated to include failure to achieve target blood pressure (BP) despite treatment with ≥3 antihypertensive drugs, including diuretics, renin-angiotensin system blockers, and calcium channel blockers, prescribed at the maximum or maximally tolerated doses, or as success in achieving the target blood pressure but requiring ≥4 drugs. RHT is a major clinical problem, as it is associated with higher mortality and morbidity than non-RHT. Therefore, it is crucial to accurately identify RHT patients to effectively manage their disease. Out-of-clinic BP measurement, including home BP monitoring and ambulatory BP monitoring is gaining prominence for the diagnosis and management of RHT. Home BP monitoring is advantageous as it is feasibly repetitive, inexpensive, widely available, and because of its reproducibility over long periods. In addition, home BP monitoring has crucial advantage of allowing safe titration for the maximum or maximally tolerable dose, and for self-monitoring, thereby improving clinical inertia and nonadherence, and allowing true RHT to be more accurately identified.

The combination of nondipper pulse rate pattern and nighttime high pulse rate variability is associated with an increase of brain natriuretic peptide: the J-HOP study

The association between pulse rate (PR) and short-term PR variability and hypertensive organ damage has not been clarified. We enrolled 1439 patients from the J-HOP study. We calculated the standard deviation (SD) of PR in the nighttime using nighttime PR measurements at 30-min intervals. The SDs of PR (PR-SD) at nighttime were divided into quartiles (Q1-Q4). Nondipper PR was defined as (awake PR-sleep PR) < 0.1. Brain natriuretic peptide (BNP) levels were higher in patients with nondipper PR status in Q4 of PR-SD (nondipper PR/PR-SD Q4) than those with nondipper PR/PR-SD Q1-Q3 (37.8 vs 21.9 pg/mL, p = 0.041). The percentage of BNP > 100 pg/mL for patients with dipper PR/PR-SD Q1-Q3 was 5.2%, that for dipper PR/PR-SD Q4 was 4.8%, that for nondipper PR/PR-SD Q1-Q3 was 13.0%, and that for nondipper PR/PR-SD Q4 was 20.0% (ANOVA p < 0.001). In conclusion, BNP was high in patients having nondipper PR and high nocturnal PR-SD. Conceptual figure of subclinical heart failure and nondipper PR, PR variability. PR: pulse rate.

Association of matrix metalloproteinase‐9 and nitric oxide with hypertension in obstructive sleep apnea

Background

Patients with obstructive sleep apnea (OSA) are more likely to suffer from hypertension. At the same time, the serum levels of matrix metalloproteinase‐9 (MMP‐9) and nitric oxide (NO) in patients with OSA are also changed in OSA patients. We investigated the correlation between serum levels of MMP‐9, NO in patients with OSA and their association with hypertension in those patients, and the effects of continuous positive airway pressure therapy (CPAP) on these serum biomarkers and blood pressure.

Methods

Serum MMP‐9 and NO levels and blood pressure of 57 patients with newly diagnosed OSA and 30 controls were measured; among them, 30 patients with moderate to severe OSA underwent 3‐month CPAP treatment.

Results

In comparison to the control group, the MMP‐9 serum levels were higher (232.8 ± 103.2 ng/ml versus 161.6 ± 56.5 ng/ml, p < .001*), there was no statistical significance difference among serum NO (26.7 ± 9.1 IU/ml versus 31.0 ± 11.7 IU/ml, p = .06), and MMP‐9 was negatively correlated to NO, especially in patients with hypertension (r = −.644, p = .02*). MMP‐9, NO, and blood pressure were significantly recovered in the patients with OSA after CPAP treatment for 3 months (p < .05*).

Conclusion

The MMP‐9 level and the NO level were altered in OSA patients. The relationship between the two especially in patients with hypertension suggests the potential mechanism of OSA‐induced hypertension.