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Tobushi T, Floras JS. Sleep Apnea, Autonomic Disturbances, and Blood Pressure Variability. Hypertension 2024; 81:1837-1844. [PMID: 38957967 PMCID: PMC11319079 DOI: 10.1161/hypertensionaha.124.20433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/04/2024]
Abstract
Augmented blood pressure variability has emerged as a quantity predictive of adverse cardiovascular outcomes. Among the range of intrinsic and extrinsic factors shown to increase night-time, circadian, short-term, and long-term blood pressure variations, the presence and severity of obstructive sleep apnea have emerged as one of the most prevalent and potent. Obstructive sleep apnea alters acutely the normal nocturnal equilibrium between sympathetic and parasympathetic tone, magnifying nocturnal blood pressure oscillations, and induces sustained autonomic aftereffects with the capacity to amplify short-term and intersessional blood pressure variabilities. The object of this brief review is to synthesize the current understanding of the potential interrelations between obstructive sleep apnea, the acute and sustained autonomic disturbances that it elicits, and beat-to-beat blood pressure fluctuation during sleep, nocturnal dipping status, and day-to-day blood pressure variability and the consequences of these perturbations for cardiovascular risk.
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Affiliation(s)
- Tomoyuki Tobushi
- University Health Network and Sinai Health Division of Cardiology, Toronto General Hospital Research Institute, and Lunenfeld-Tanenbaum Research Institute, Faculty of Medicine, University of Toronto, ON, Canada (T.T., J.S.F.)
- Department of Internal Medicine, Kyushu University Beppu Hospital, Oita, Japan (T.T.)
| | - John S. Floras
- University Health Network and Sinai Health Division of Cardiology, Toronto General Hospital Research Institute, and Lunenfeld-Tanenbaum Research Institute, Faculty of Medicine, University of Toronto, ON, Canada (T.T., J.S.F.)
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Tangutur A, Cai Y, Seay EG, Thaler ER, Keenan BT, Dedhia RC. The Effect of Surgical Therapy for Obstructive Sleep Apnea on Blood Pressure and Peripheral Arterial Tonometry. Otolaryngol Head Neck Surg 2024; 171:286-294. [PMID: 38509834 DOI: 10.1002/ohn.718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 01/18/2024] [Accepted: 02/17/2024] [Indexed: 03/22/2024]
Abstract
OBJECTIVE To determine the effect of upper airway surgery on cardiovascular function in patients with obstructive sleep apnea (OSA). STUDY DESIGN A prospective, self-controlled study from 2018 to 2023. SETTING Two academic medical centers. METHODS Seventy-four patients underwent surgery for OSA, including: tonsillectomy, adenoidectomy, epiglottidectomy, modified uvulopalatopharyngoplasty, maxillary expansion, and maxillomandibular advancement. Twenty-four-hour ambulatory blood pressure (BP), peripheral arterial tonometry (PAT)-based home sleep study, and sleep-related patient-reported outcomes (PROs) were captured preoperatively and at 6 months postoperatively. Paired T-tests evaluated changes in outcomes after surgery. RESULTS Forty-one patients successfully completed preoperative and postoperative assessments. Patients were generally middle-aged (43.8 ± 12.5 years), obese (BMI 33.0 ± 5.8 kg/m2), male (68%), White (71%), and had severe OSA (apnea-hypopnea index [AHI] 33.9 ± 29.5 events/h). The 4% oxygen desaturation index (ODI) decreased from 30.7 ± 27.1 to 12.2 ± 13.6 events/h (P < .01) after surgery. There was no significant difference in 24-h BP following surgery, though clinically meaningful reductions in nocturnal systolic (-1.95 [-5.34, 1.45] mmHg) and nocturnal diastolic (-2.30 [-5.11, 0.52] mmHg) blood pressure were observed. Stratified analysis showed patients undergoing skeletal surgery (n = 17) demonstrated larger average reductions compared to those undergoing soft tissue surgery in nocturnal systolic (-4.12 [-7.72, -0.51] vs -0.10 [-5.78, 5.58] mmHg) and nocturnal diastolic (-3.94 [-7.90, 0.01] vs -0.90 [-5.11, 3.31] mmHg) pressures. No meaningful changes were observed in PAT Autonomic Index (PAI) measurements. CONCLUSION Surgical therapy for OSA did not demonstrate statistically significant improvements in 24-h BP. However, clinically meaningful reductions in nocturnal BP were observed, particularly in skeletal surgery patients, supporting the need for larger studies of cardiovascular outcomes following OSA surgery.
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Affiliation(s)
- Akshay Tangutur
- Department of Otorhinolaryngology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Yi Cai
- Department of Otorhinolaryngology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Everett G Seay
- Department of Otorhinolaryngology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Erica R Thaler
- Department of Otorhinolaryngology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Brendan T Keenan
- Department of Medicine, Division of Sleep Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Raj C Dedhia
- Department of Otorhinolaryngology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Medicine, Division of Sleep Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Chu YH, Sun ZJ, Chang YF, Yang YC, Chang CJ, Chou YT, Wu JS. Different Factors Associated with Morning Blood Pressure Surge in Antihypertensive-Naïve Dipper and Non-Dipper Subjects. J Clin Med 2023; 12:jcm12072464. [PMID: 37048548 PMCID: PMC10095290 DOI: 10.3390/jcm12072464] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 03/20/2023] [Accepted: 03/21/2023] [Indexed: 04/14/2023] Open
Abstract
The relationship between the morning blood pressure surge (MBPS) and cardiovascular risk is inconclusive. Previous studies have not taken into consideration dipping status in examining the MBPS and its associated factors. The aim was to examine factors associated with the MBPS in dippers and non-dippers. The MBPS was calculated by data obtained from ambulatory blood pressure monitoring, using the definition of sleep-trough morning surge. Dipping systolic blood pressure (DipSBP) was defined as [1 - (SBPsleeping/SBPawake)] × 100%. The value in milliseconds of standard deviation of normal-to-normal RR interval after waking up (SDNNaw) was calculated during the 2 h period after waking up. A total of 140 eligible subjects were divided into dippers (n = 62) and non-dippers (n = 78). Multiple regression analysis on data for all subjects revealed different correlations with the MBPS: positive in age, body mass index (BMI), and DipSBP, and inverse in cholesterol/high density lipoprotein-cholesterol (HDL-C) ratio, fasting blood glucose, and 2 h SDNNaw. When dippers were examined separately, age, female gender, and BMI correlated positively with MBPS, while cholesterol/HDL-C ratio and 2 h SDNNaw correlated negatively. For non-dippers, only age was associated with the MBPS. The factors associated with the MBPS were different for dippers and non-dippers. The MBPS seems to be a physiological response in this dipper group because age and BMI correlated positively with the MBPS, while parasympathetic neural activity after waking up and cholesterol/HDL-C ratio showed inverse correlations.
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Affiliation(s)
- Yi-Hsin Chu
- Department of Family Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 70403, Taiwan
| | - Zih-Jie Sun
- Department of Family Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 70403, Taiwan
- Department of Family Medicine, National Cheng Kung University Hospital, Dou-Liou Branch, College of Medicine, National Cheng Kung University, Yunlin 64043, Taiwan
- Department of Family Medicine, College of Medicine, National Cheng Kung University, Tainan 70101, Taiwan
| | - Yin-Fan Chang
- Department of Family Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 70403, Taiwan
- Department of Family Medicine, College of Medicine, National Cheng Kung University, Tainan 70101, Taiwan
| | - Yi-Ching Yang
- Department of Family Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 70403, Taiwan
- Department of Family Medicine, College of Medicine, National Cheng Kung University, Tainan 70101, Taiwan
| | - Chih-Jen Chang
- Department of Family Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 70403, Taiwan
- Department of Family Medicine, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chiayi 60002, Taiwan
| | - Yu-Tsung Chou
- Department of Family Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 70403, Taiwan
- Department of Health Management Center, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 70403, Taiwan
| | - Jin-Shang Wu
- Department of Family Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 70403, Taiwan
- Department of Family Medicine, National Cheng Kung University Hospital, Dou-Liou Branch, College of Medicine, National Cheng Kung University, Yunlin 64043, Taiwan
- Department of Family Medicine, College of Medicine, National Cheng Kung University, Tainan 70101, Taiwan
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Loh HH, Lim QH, Chai CS, Goh SL, Lim LL, Yee A, Sukor N. Influence and implications of the renin-angiotensin-aldosterone system in obstructive sleep apnea: An updated systematic review and meta-analysis. J Sleep Res 2023; 32:e13726. [PMID: 36104933 PMCID: PMC10078316 DOI: 10.1111/jsr.13726] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 07/30/2022] [Accepted: 08/22/2022] [Indexed: 02/03/2023]
Abstract
Obstructive sleep apnea is a chronic, sleep-related breathing disorder, which is an independent risk factor for cardiovascular disease. The renin-angiotensin-aldosterone system regulates salt and water homeostasis, blood pressure, and cardiovascular remodelling. Elevated aldosterone levels are associated with excess morbidity and mortality. We aimed to analyse the influence and implications of renin-angiotensin-aldosterone system derangement in individuals with and without obstructive sleep apnea. We pooled data from 20 relevant studies involving 2828 participants (1554 with obstructive sleep apnea, 1274 without obstructive sleep apnea). The study outcomes were the levels of renin-angiotensin-aldosterone system hormones, blood pressure and heart rate. Patients with obstructive sleep apnea had higher levels of plasma renin activity (pooled wmd+ 0.25 [95% confidence interval 0.04-0.46], p = 0.0219), plasma aldosterone (pooled wmd+ 30.79 [95% confidence interval 1.05-60.53], p = 0.0424), angiotensin II (pooled wmd+ 5.19 [95% confidence interval 3.11-7.27], p < 0.001), systolic (pooled wmd+ 5.87 [95% confidence interval 1.42-10.32], p = 0.0098) and diastolic (pooled wmd+ 3.40 [95% confidence interval 0.86-5.94], p = 0.0086) blood pressure, and heart rate (pooled wmd+ 3.83 [95% confidence interval 1.57-6.01], p = 0.0009) compared with those without obstructive sleep apnea. The elevation remained significant (except for renin levels) when studies involving patients with resistant hypertension were removed. Sub-group analysis demonstrated that levels of angiotensin II were significantly higher only among the Asian population with obstructive sleep apnea compared with those without obstructive sleep apnea. Body mass index accounted for less than 10% of the between-study variance in elevation of the renin-angiotensin-aldosterone system parameters. Patients with obstructive sleep apnea have higher levels of renin-angiotensin-aldosterone system hormones, blood pressure and heart rate compared with those without obstructive sleep apnea, which remains significant even among patients without resistant hypertension.
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Affiliation(s)
- Huai Heng Loh
- Department of Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Center, Kuala Lumpur, Malaysia.,Department of Medicine, Faculty of Medicine and Health Sciences, Universiti Malaysia Sarawak, Kota Samarahan, Malaysia
| | - Quan Hziung Lim
- Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Chee Shee Chai
- Department of Medicine, Faculty of Medicine and Health Sciences, Universiti Malaysia Sarawak, Kota Samarahan, Malaysia
| | - Siew Li Goh
- Sports and Exercise Medicine Research and Education Group, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Lee-Ling Lim
- Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia.,Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
| | - Anne Yee
- Department of Psychological Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Norlela Sukor
- Department of Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Center, Kuala Lumpur, Malaysia
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Kario K, Hettrick DA, Prejbisz A, Januszewicz A. Obstructive Sleep Apnea-Induced Neurogenic Nocturnal Hypertension: A Potential Role of Renal Denervation? Hypertension 2021; 77:1047-1060. [PMID: 33641363 DOI: 10.1161/hypertensionaha.120.16378] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
There is a bidirectional, causal relationship between obstructive sleep apnea (OSA) and hypertension. OSA-related hypertension is characterized by high rates of masked hypertension, elevated nighttime blood pressure, a nondipper pattern of nocturnal hypertension, and abnormal blood pressure variability. Hypoxia/hypercapnia-related sympathetic activation is a key pathophysiological mechanism linking the 2 conditions. Intermittent hypoxia also stimulates the renin-angiotensin-aldosterone system to promote hypertension development. The negative and additive cardiovascular effects of OSA and hypertension highlight the importance of effectively managing these conditions, especially when they coexist in the same patient. Continuous positive airway pressure is the gold standard therapy for OSA but its effects on blood pressure are relatively modest. Furthermore, this treatment did not reduce the cardiovascular event rate in nonsleepy patients with OSA in randomized controlled trials. Antihypertensive agents targeting sympathetic pathways or the renin-angiotensin-aldosterone system have theoretical potential in comorbid hypertension and OSA, but current evidence is limited and combination strategies are often required in drug resistant or refractory patients. The key role of sympathetic nervous system activation in the development of hypertension in OSA suggests potential for catheter-based renal sympathetic denervation. Although long-term, randomized controlled trials are needed, available data indicate sustained and relevant reductions in blood pressure in patients with hypertension and OSA after renal denervation, with the potential to also improve respiratory parameters. The combination of lifestyle interventions, optimal pharmacological therapy, continuous positive airway pressure therapy, and perhaps also renal denervation might improve cardiovascular risk in patients with OSA.
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Affiliation(s)
- Kazuomi Kario
- From the Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Tochigi, Japan (K.K.)
| | | | - Aleksander Prejbisz
- Department of Hypertension, National Institute of Cardiology, Warsaw, Poland (A.P., A.J.)
| | - Andrzej Januszewicz
- Department of Hypertension, National Institute of Cardiology, Warsaw, Poland (A.P., A.J.)
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Makarem N, Alcántara C, Williams N, Bello NA, Abdalla M. Effect of Sleep Disturbances on Blood Pressure. Hypertension 2021; 77:1036-1046. [PMID: 33611935 DOI: 10.1161/hypertensionaha.120.14479] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
This review summarizes recent literature addressing the association of short sleep duration, shift work, and obstructive sleep apnea with hypertension risk, blood pressure (BP) levels, and 24-hour ambulatory BP. Observational studies demonstrate that subjectively assessed short sleep increases hypertension risk, though conflicting results are observed in studies of objectively assessed short sleep. Intervention studies demonstrate that mild and severe sleep restriction are associated with higher BP. Rotating and night shift work are associated with hypertension as shift work may exacerbate the detrimental impact of short sleep on BP. Further, studies demonstrate that shift work may increase nighttime BP and reduce BP control in patients with hypertension. Finally, moderate to severe obstructive sleep apnea is associated with hypertension, particularly resistant hypertension. Obstructive sleep apnea is also associated with abnormal 24-hour ambulatory BP profiles, including higher daytime and nighttime BP, nondipping BP, and a higher morning surge. Continuous positive airway pressure treatment may lower BP and improve BP dipping. In conclusion, efforts should be made to educate patients and health care providers about the importance of identifying and treating sleep disturbances for hypertension prevention and management. Empirically supported sleep health interventions represent a critical next step to advance this research area and establish causality.
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Affiliation(s)
- Nour Makarem
- From the Department of Epidemiology, Mailman School of Public Health, Columbia University Irving Medical Center, New York, NY (N.M.)
| | | | - Natasha Williams
- Department of Population Health, Center for Healthful Behavior Change, New York University Grossman School of Medicine (N.W.)
| | - Natalie A Bello
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, NY (N.A.B., M.A.)
| | - Marwah Abdalla
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, NY (N.A.B., M.A.)
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Chen Q, Cheng YB, Shen M, Yin B, Yi HH, Feng J, Li M, Li QY, Li Y, Wang JG. A randomized controlled trial on ambulatory blood pressure lowering effect of CPAP in patients with obstructive sleep apnea and nocturnal hypertension. Blood Press 2019; 29:21-30. [PMID: 31696741 DOI: 10.1080/08037051.2019.1686343] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Objective: In a randomised controlled trial, we investigated the blood pressure (BP) lowering effect of continuous positive airway pressure (CPAP) in patients with moderate-severe obstructive sleep apnoea syndrome (OSAS, an apnoea-hypopnoea index, AHI of 15 or higher) and nocturnal hypertension (night-time systolic/diastolic BP ≥120/70 mmHg).Methods: Sixty patients were randomly assigned to CPAP or sham CPAP, while maintaining their antihypertensive treatment. Ambulatory BP monitoring was performed at baseline (first run-in visit) and the end of follow-up. Clinic and home BP were measured at baseline and each of the monthly follow-up visits.Results: Of the 60 patients, 47 completed the 3-month study. CPAP (n = 26), compared with sham CPAP (n = 21), slightly and non-significantly reduced 24-h systolic/diastolic BP by -2.8/-2.5 mmHg (p ≥ 0.27), with a slightly greater between-group difference in the daytime (-4.0/-2.8 mmHg, p ≥ 0.29) than night-time (-0.2/-1.5 mmHg, p ≥ 0.50). The CPAP treatment did not significantly influence clinic or home BP during follow-up (p ≥ 0.27). Nonetheless, simple and partial correlation analyses showed that the ambulatory BP lowering effect was dependent on the daytime pulse rate at baseline (r ≥ 0.47, p ≤ 0.01). In patients with a daytime pulse rate greater than 85 beats/min, the mean changes in daytime systolic BP were significantly greater in the CPAP (n = 10) than sham CPAP group (n = 11), with a between-group mean difference of -10.1 mmHg (p = 0.048).Conclusions: The CPAP treatment did not show significant ambulatory BP lowering effect in patients with moderate-severe OSAS and nocturnal hypertension. However, it may be effective in lowering daytime BP in patients with a faster pulse rate.
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Affiliation(s)
- Qi Chen
- Centre for Epidemiological Studies and Clinical Trials, Shanghai Key Laboratory of Hypertension, the Shanghai Institute of Hypertension, Department of Hypertension, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Yi-Bang Cheng
- Centre for Epidemiological Studies and Clinical Trials, Shanghai Key Laboratory of Hypertension, the Shanghai Institute of Hypertension, Department of Hypertension, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Meng Shen
- Health Systems, Philips Research China, Shanghai, China
| | - Bin Yin
- Health Systems, Philips Research China, Shanghai, China
| | - Hua-Hua Yi
- Department of Respiratory and Critical Care Medicine, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Jing Feng
- Department of Respiratory and Critical Care Medicine, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Min Li
- Department of Respiratory and Critical Care Medicine, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Qing-Yun Li
- Department of Respiratory and Critical Care Medicine, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Yan Li
- Centre for Epidemiological Studies and Clinical Trials, Shanghai Key Laboratory of Hypertension, the Shanghai Institute of Hypertension, Department of Hypertension, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Ji-Guang Wang
- Centre for Epidemiological Studies and Clinical Trials, Shanghai Key Laboratory of Hypertension, the Shanghai Institute of Hypertension, Department of Hypertension, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
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Di Gennaro F, D'Amato C, Morganti R, Greco C, Longo S, Corradini D, Lauro D, Spallone V. Morning blood pressure surge is associated with autonomic neuropathy and peripheral vascular disease in patients with diabetes. J Hum Hypertens 2019; 34:495-504. [PMID: 31624311 DOI: 10.1038/s41371-019-0270-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 09/24/2019] [Accepted: 09/27/2019] [Indexed: 11/09/2022]
Abstract
Although vascular and autonomic nervous system have been involved in the regulation of morning surge in blood pressure (MBPS), data on clinical correlates of MBPS in diabetic population are scarce, in particular with regard to diabetic complications. This study was aimed at investigating predictors and correlates of MBPS in diabetes. In a cross-sectional study including 167 patients with diabetes (age 58.5 ± 11.1 years, duration 15.9 ± 12.1 years), clinical variables, diabetic and neuropathic complications, and MBPS (using 24-h ambulatory blood pressure monitoring) were measured. The upper quartile of MBPS (>30.5 mmHg) was associated with higher values of waist circumference (P = 0.027), triglycerides (P = 0.021), and Michigan Diabetic Neuropathy Score (P = 0.042), with lower HDL cholesterol (P = 0.030), and with the presence of cardiovascular autonomic neuropathy (CAN) (P = 0.016) and peripheral vascular disease (PVD) (P < 0.0001). In a logistic regression analysis, PVD (odds ratio: 10.2, P = 0.001), CAN (odds ratio: 6.09, P = 0.016), and diastolic blood pressure (BP) (odds ratio: 1.06, P = 0.022) predicted MBPS upper quartile (r2 = 0.20, P = 0.0005). In a multiple regression analysis, PVD (P = 0.002) and diastolic BP (P = 0.003) were the only determinants of MBPS (r2 = 0.20). MBPS upper quartile was associated with BP dipping (systolic BP day-night reduction > 10%) (P = 0.012), and MBPS was positively related to systolic (rho = 0.41, P < 0.0001) and diastolic BP day-night reduction. In conclusion, metabolic syndrome stigmata, diastolic BP, CAN and PVD are the main predictors of MBPS in the diabetic population. Excessive MBPS and nondipping are not concurrent 24-h BP alterations. Autonomic dysfunction might exert an exacerbating effect on MBPS phenomenon.
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Affiliation(s)
- Federica Di Gennaro
- Endocrinology, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Cinzia D'Amato
- Endocrinology, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Roberto Morganti
- Endocrinology, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Carla Greco
- Endocrinology, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Susanna Longo
- Endocrinology, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Diana Corradini
- Endocrinology, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Davide Lauro
- Endocrinology, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Vincenza Spallone
- Endocrinology, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy.
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The effect of high evening blood pressure on obstructive sleep apnea-related morning blood pressure elevation: does sex modify this interaction effect? Sleep Breath 2019; 23:1255-1263. [PMID: 31183742 DOI: 10.1007/s11325-019-01869-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Revised: 04/28/2019] [Accepted: 05/24/2019] [Indexed: 12/13/2022]
Abstract
PURPOSE Obstructive sleep apnea (OSA) can lead to increased morning blood pressure (BP). We hypothesized that high evening BP may aggravate OSA-related morning BP elevation. Additionally, this interactional effect may be modified by sex. METHODS This retrospective, cross-sectional study included newly diagnosed OSA patients with an apnea-hypopnea index (AHI) ≥ 5 per hour on a full-night polysomnography. An analysis of covariance (ANCOVA) was used to determine whether severe OSA (AHI ≥ 30) was associated with higher morning BP than mild-to-moderate OSA (5 ≤ AHI < 30) and whether there was an interaction between apnea severity and evening BP on morning BP. To identify the sex effects, analyses were performed separately in each sex group. RESULTS A total of 1445 patients with an average age of 51.9 years (SD 11.7) (male 77.9% vs. female 22.1%; high evening BP group 22.4% vs. normal evening BP group 59.6%) were included in the study. Based on the ANCOVA, patients with severe OSA had significantly higher morning systolic BP (SBP) (p = 0.003), diastolic BP (DBP) (p < 0.001), and mean BP (MBP) (p < 0.001) than the mild-to-moderate group in male subjects. A significant interaction between apnea severity and evening BP was identified on morning DBP and MBP in male subjects. However, there were no differences in morning BP between severe and mild-to-moderate OSA groups in female subjects. CONCLUSIONS In male subjects, severe OSA contributed to higher morning BP than mild-to-moderate OSA. OSA-associated morning BP elevation was more prominent in the high evening BP group than in the normal BP group. Such relations were not found in female subjects.
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Yoo JK, Sun DD, Parker RS, Urey MA, Romero SA, Lawley JS, Sarma S, Vongpatanasin W, Crandall CG, Fu Q. Augmented venoarteriolar response with ageing is associated with morning blood pressure surge. Exp Physiol 2018; 103:1448-1455. [DOI: 10.1113/ep087166] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Accepted: 08/09/2018] [Indexed: 01/06/2023]
Affiliation(s)
- Jeung-Ki Yoo
- Institute for Exercise and Environmental Medicine; Texas Health Presbyterian Hospital Dallas; Dallas TX USA
- The University of Texas Southwestern Medical Center; Dallas TX USA
| | - Dan-Dan Sun
- Institute for Exercise and Environmental Medicine; Texas Health Presbyterian Hospital Dallas; Dallas TX USA
| | - Rosemary S. Parker
- Institute for Exercise and Environmental Medicine; Texas Health Presbyterian Hospital Dallas; Dallas TX USA
| | - Marcus A. Urey
- The University of Texas Southwestern Medical Center; Dallas TX USA
| | - Steven A. Romero
- Institute for Exercise and Environmental Medicine; Texas Health Presbyterian Hospital Dallas; Dallas TX USA
- The University of Texas Southwestern Medical Center; Dallas TX USA
| | - Justin S. Lawley
- Institute for Exercise and Environmental Medicine; Texas Health Presbyterian Hospital Dallas; Dallas TX USA
- The University of Texas Southwestern Medical Center; Dallas TX USA
| | - Satyam Sarma
- Institute for Exercise and Environmental Medicine; Texas Health Presbyterian Hospital Dallas; Dallas TX USA
- The University of Texas Southwestern Medical Center; Dallas TX USA
| | | | - Craig G. Crandall
- Institute for Exercise and Environmental Medicine; Texas Health Presbyterian Hospital Dallas; Dallas TX USA
- The University of Texas Southwestern Medical Center; Dallas TX USA
| | - Qi Fu
- Institute for Exercise and Environmental Medicine; Texas Health Presbyterian Hospital Dallas; Dallas TX USA
- The University of Texas Southwestern Medical Center; Dallas TX USA
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Koc AS, Gorgulu FF, Donmez Y, Icen YK. There is a significant relationship between morning blood pressure surge and increased abdominal aortic intima-media thickness in hypertensive patients. J Med Ultrason (2001) 2018. [PMID: 29536281 DOI: 10.1007/s10396-018-0877-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
PURPOSE There are limited data about increased aortic intima-media thickness (A-IMT) in the presence of subclinical target organ damage in hypertensive (HT) patients. In this study, we aimed to determine the frequency of increased A-IMT, the parameters determining increased A-IMT, and the relationship between increased A-IMT and other vascular IMT measurements. MATERIALS AND METHODS We prospectively included 265 patients (mean age 54.1 ± 10.6 years, male/female 91/174) with essential HT. Physical examination of all patients was performed. Laboratory data and antihypertensive treatments were recorded. Twenty-four-hour ambulatory blood pressure monitoring (ABPM) was performed. Bilateral carotid, brachial, and femoral artery and abdominal A-IMT values were measured by B-mode ultrasonography (USG). Patients were categorized into two main groups: patients with increased A-IMT (≥ 3 mm) or normal A-IMT (< 3 mm). RESULTS Increased A-IMT was detected in 55 patients (20.8%). There was a close relationship between increased A-IMT and advanced age, presence of coronary artery disease, high morning blood pressure surge (MBPS), and bilateral carotid and femoral IMT. Parameters associated with increased A-IMT in univariate analysis were assessed by regression analysis. Left femoral IMT and MBPS were independently associated with increased A-IMT. In the regression model, each 5-mmHg elevation in MBPS increased the risk of increased A-IMT by 34.2%. The cutoff value of MBPS obtained by the ROC curve analysis was 32 mmHg for the prediction of increased A-IMT (sensitivity 76.3%, specificity 63.5%). The area under the curve was 0.784 (95% CI 0.720-0.847, p < 0.001). CONCLUSION Abdominal A-IMT increased at a significant rate in patients with HT. An independent association was found between MBPS and A-IMT, which can both be easily detected by ABPM and B-mode USG. The high MBPS level was considered to be a simple and inexpensive method for detecting subclinical target organ damage. A-IMT measurement should also be a part of abdominal USG, which is a routine examination in HT patients.
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Affiliation(s)
- Ayse Selcan Koc
- Department of Radiology, University of Health Sciences, Adana Health Practice and Research Center, Adana, Turkey.
| | - Ferıde Fatma Gorgulu
- Department of Radiology, University of Health Sciences, Adana Health Practice and Research Center, Adana, Turkey
| | - Yurdaer Donmez
- Department of Cardiology, University of Health Sciences, Adana Health Practice and Research Center, Adana, Turkey
| | - Yahya Kemal Icen
- Department of Cardiology, University of Health Sciences, Adana Health Practice and Research Center, Adana, Turkey
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Marrone O, Bonsignore MR. Blood-pressure variability in patients with obstructive sleep apnea: current perspectives. Nat Sci Sleep 2018; 10:229-242. [PMID: 30174467 PMCID: PMC6109653 DOI: 10.2147/nss.s148543] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Obstructive sleep apnea (OSA) is often associated with hypertension and other cardiovascular diseases. Blood pressure (BP) variability is part of the assessment of cardiovascular risk. In OSA, BP variability has been studied mainly as very short-term (beat-by-beat) and short-term (24-hour BP profile) variability. BP measured on consecutive heartbeats has been demonstrated to be highly variable, due to repeated peaks during sleep, so that an accurate assessment of nocturnal BP levels in OSA may require peculiar methodologies. In 24-hour recordings, BP frequently features a "nondipping" profile, ie, <10% fall from day to night, which may increase cardiovascular risk and occurrence of major cardiovascular events in the nocturnal hours. Also, BP tends to show a large "morning BP surge", a still controversial negative prognostic sign. Increased very short-term BP variability, high morning BP, and nondipping BP profile appear related to the severity of OSA. Treatment of OSA slightly reduces mean 24-hour BP levels and nocturnal beat-by-beat BP variability by abolishing nocturnal BP peaks. In some patients OSA treatment turns a nondipping into a dipping BP profile. Treatment of arterial hypertension in OSA usually requires both antihypertensive pharmacological therapy and treatment of apnea. Addressing BP variability could help improve the management of OSA and reduce cardiovascular risk. Possibly, drug administration at an appropriate time would ensure a dipping-BP profile.
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Affiliation(s)
- Oreste Marrone
- National Research Council of Italy, Institute of Biomedicine and Molecular Immunology,
| | - Maria R Bonsignore
- National Research Council of Italy, Institute of Biomedicine and Molecular Immunology, .,DiBiMIS, University of Palermo, Palermo, Italy
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Mokros Ł, Kuczyński W, Franczak Ł, Białasiewicz P. Morning Diastolic Blood Pressure May Be Independently Associated With Severity of Obstructive Sleep Apnea in Non-Hypertensive Patients: A Cross-Sectional Study. J Clin Sleep Med 2017; 13:905-910. [PMID: 28502282 PMCID: PMC5482582 DOI: 10.5664/jcsm.6664] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Revised: 04/03/2017] [Accepted: 04/24/2017] [Indexed: 12/23/2022]
Abstract
STUDY OBJECTIVES The aim of the study is to verify a possible association between arterial blood pressure and obstructive sleep apnea (OSA) severity in a group of non-hypertensive patients. METHODS This is a retrospective study of 1,171 consecutive patients referred to the sleep laboratory with complaints suggestive of OSA who underwent standard diagnostic polysomnography. In total, 454 patients with no History of arterial hypertension nor had received any such treatment were selected from this group. RESULTS Patients with severe OSA (apnea-hypopnea index [AHI] ≥ 30 events/h) presented with higher diastolic blood pressure (DBP) in the morning than healthy subjects (AHI < 5 events/h) or those suffering from mild (15 < AHI ≥ 5 events/h) or moderate OSA (30 < AHI ≥ 15 events/h): 86.2 ± 11.3 versus 79.2 ± 8.5, 80.3 ± 10.2 and 81.4 ± 9.6 mmHg, P < .01, respectively. In a linear regression model, a rise in morning DBP was predicted by AHI (ß = 0.14, P < .001) and body mass index (BMI) (ß = 0.22, P < .01), but not by age (ß = 0.01, P = .92), male sex (ß = -0.06, P = .19), or smoking (ß = 0.01, P = .86). In contrast, no association existed between morning systolic blood pressure (SBP) and AHI independently of BMI, sex, age, or smoking. High blood pressure (ie, SBP ≥ 140 mmHg or DBP ≥ 90 mmHg on each of three measurements on different occasions) was predicted by age of 42 years or older, BMI of at least 29 kg/m2, and severe OSA. CONCLUSIONS High AHI, independent of obesity, age and sex, was associated with elevated DBP in the morning. Thus, elevated morning DBP may be one of the symptoms related to OSA that warrants specific diagnostics. COMMENTARY A commentary on this article appears in this issue on page 861.
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Affiliation(s)
- Łukasz Mokros
- Department of Clinical Pharmacology, Medical University of Łódź, Łódź, Poland
| | - Wojciech Kuczyński
- Department of Sleep and Metabolic Disorders, Medical University of Łódź, Łódź, Poland
| | - Łukasz Franczak
- Department of Sleep and Metabolic Disorders, Medical University of Łódź, Łódź, Poland
| | - Piotr Białasiewicz
- Department of Sleep and Metabolic Disorders, Medical University of Łódź, Łódź, Poland
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Meta-analysis of effects of obstructive sleep apnea on the renin-angiotensin-aldosterone system. JOURNAL OF GERIATRIC CARDIOLOGY : JGC 2016; 13:333-43. [PMID: 27403143 PMCID: PMC4921546 DOI: 10.11909/j.issn.1671-5411.2016.03.020] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Background Obstructive sleep apnea (OSA) is the most common cause of resistant hypertension, which has been proposed to result from activation of the renin–angiotensin–aldosterone system (RAAS). We meta-analyzed the effects of OSA on plasma levels of RAAS components. Methods Full-text studies published on MEDLINE and EMBASE analyzing fasting plasma levels of at least one RAAS component in adults with OSA with or without hypertension. OSA was diagnosed as an apnea-hypopnea index or respiratory disturbance index ≥ 5. Study quality was evaluated using the Newcastle-Ottawa Scale, and heterogeneity was assessed using the I2 statistic. Results from individual studies were synthesized using inverse variance and pooled using a random-effects model. Subgroup analysis, sensitivity analysis, and meta-regression were performed, and risk of publication bias was assessed. Results The meta-analysis included 13 studies, of which 10 reported results on renin (n = 470 cases and controls), 7 on angiotensin II (AngII, n = 384), and 9 on aldosterone (n = 439). AngII levels were significantly higher in OSA than in controls [mean differences = 3.39 ng/L, 95% CI: 2.00–4.79, P < 0.00001], while aldosterone levels were significantly higher in OSA with hypertension than OSA but not with hypertension (mean differences = 1.32 ng/dL, 95% CI: 0.58–2.07, P = 0.0005). Meta-analysis of all studies suggested no significant differences in aldosterone between OSA and controls, but a significant pooled mean difference of 1.35 ng/mL (95% CI: 0.88–1.82, P < 0.00001) emerged after excluding one small-sample study. No significant risk of publication bias was detected among all included studies. Conclusions OSA is associated with higher AngII and aldosterone levels, especially in hypertensive patients. OSA may cause hypertension, at least in part, by stimulating RAAS activity.
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Kario K, Hamasaki H. Nocturnal Blood Pressure Surge Behind Morning Surge in Obstructive Sleep Apnea Syndrome: Another Phenotype of Systemic Hemodynamic Atherothrombotic Syndrome. J Clin Hypertens (Greenwich) 2015; 17:682-5. [DOI: 10.1111/jch.12576] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Kazuomi Kario
- Division of Cardiovascular Medicine; Department of Medicine; Jichi Medical University School of Medicine; Shimotsuke Tochigi Japan
| | - Haruna Hamasaki
- Division of Cardiovascular Medicine; Department of Medicine; Jichi Medical University School of Medicine; Shimotsuke Tochigi Japan
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