CHEST
Volume 148, Issue 3, September 2015, Pages 824-832
Journal home page for CHEST

Contemporary Reviews in Sleep Medicine
Relationship Between OSA and Hypertension

https://doi.org/10.1378/chest.15-0136Get rights and content

There is a bidirectional association between OSA and systemic hypertension. The strengths of this relationship appear to be modulated by factors such as age, sex, and somnolence. The 24-h BP circadian pattern also appears to be influenced by OSA. Patients with this syndrome exhibit a high prevalence of nondipping or riser circadian patterns, which are related to clinical and subclinical organ damage in the heart and brain. However, the influence of OSA on nocturnal hypertension development has not yet been clarified. A special area of interest is the recognized relationship between OSA and resistant hypertension. The majority of patients with resistant hypertension suffer OSA. CPAP treatment significantly reduces BP in such patients and could play a clinical role in the management of BP in these patients. Several meta-analyses have demonstrated a concordant mild effect of CPAP on systemic hypertension. This effect is related to CPAP compliance, somnolence status, and baseline BP. The effects of oral appliances on BP in patients with OSA must be evaluated in randomized controlled trials. In the absence of additional data reported by clinical studies on other antihypertensive drug treatments, diuretics, particularly antialdosteronic diuretic agents, should be considered the first-line antihypertensive drug treatment in patients with OSA. By reducing parapharyngeal edema and secondary upper airway obstruction, these drugs appear to improve OSA severity and also to reduce BP.

Section snippets

OSA and the Incident Risk of Hypertension

Epidemiologic studies show that patients with OSA have a high prevalence of obesity.2, 11 Therefore, obesity may be the nexus that explains the high prevalence of hypertension in these patients. However, the results of a large, prospective, longitudinal study, the Wisconsin Sleep Cohort Study (WSCS), suggest that moderate to severe OSA (apnea-hypopnea index [AHI] > 15/h) is an independent cause of hypertension. Subjects with this degree of OSA severity showed a 3.2-fold increase in the odds of

Circadian Pattern of BP in Patients With OSA

Studies involving 24-h ambulatory BP monitoring (ABPM) have shown that subjects with hypertension with a decrease in BP of ≤ 10% during the night (nondippers) and those who present an increase in BP at night (risers)23 exhibit greater organ damage and worse cardiovascular outcomes than do subjects with hypertension who present a decrease of > 10% during the night (dippers).24, 25 Initial case-control studies using 24-h ABPM showed that patients with OSA had a high prevalence of an unfavorable

OSA and Resistant Hypertension

Resistant hypertension is defined as the clinical situation in which lifestyle changes plus pharmacologic treatment with three drugs (including a diuretic) fail to lower the BP to below 140/90 mm Hg.23, 40 Depending on the population studied, the prevalence of this condition ranges from 5% to 30% of subjects with hypertension.40

The reported data have shown a high prevalence of OSA in patients with resistant hypertension (71%-83%).5, 41 In a study that included 125 subjects with resistant

CPAP Treatment

Many studies have evaluated the effect of CPAP treatment on BP in patients with OSA (Fig 1). However, most of these studies evaluated short-term effects and had important limitations and design differences.45 These differences and limitations can be divided into two categories. One set of factors depends on the study population, such as age, sex, BMI, hypertension degree, and adequate antihypertensive treatment, as well as OSA severity. Another set of factors depends on the methodology, such as

Effects of Hypertension Treatment on OSA

According to the available physiopathologic knowledge of the relationship between OSA and hypertension, antihypertensive drugs that modulate sympathetic activity and the renin-angiotensin-aldosterone axis may be the best treatment options for hypertension in patients with OSA. To date, the studies that have evaluated the effects of antihypertensive drug treatment on OSA severity have included small subject samples and no comparable populations, and they have had important methodologic

Conclusions and Future Directions

There is an epidemiologic relationship between OSA and hypertension that is especially important in subjects with resistant hypertension. Despite this, the causal relationship between OSA and hypertension is probably not as important as initially thought. Certain population characteristics, such as age, sleepiness associated with OSA, and sex, may be important in determining the role of OSA as a cause of hypertension. OSA may also lead to the development of an unfavorable circadian pattern of

Acknowledgments

Financial/nonfinancial disclosures: The authors have reported to CHEST the following conflicts of interest: Dr Barbé received research grants from ResMed, Australia, a company that develops products related to sleep apnea; the Health Research Fund, Spanish Ministry of Health; the Spanish Respiratory Society (SEPAR); the Catalonian Cardiology Society, Esteve-Teijin (Spain); Oxigen Salud (Spain); and ALLER to develop the ISAACC clinical trial (NCT01335087). Drs Torres and Sánchez-de-la-Torre have

References (74)

  • D Zou et al.

    A double-blind crossover study of Doxazosin and Enalapril on peripherical vascular tone and nocturnal blood pressure in sleep apnea patients

    Sleep Med.

    (2010)
  • L Grote et al.

    Association between blood pressure reduction with antihypertensive treatment and sleep apnea activity

    Am J Hypertens

    (2000)
  • JH Peter et al.

    Effects of cilazapril on hypertension, sleep, and apnea

    Am J Med

    (1989)
  • A Cicolin et al.

    Angiotensin-converting enzyme inhibitors and obstructive sleep apnea

    Mayo Clin Proc

    (2006)
  • CB Bucca et al.

    Diuretics in obstructive sleep apnea with diastolic heart failure

    Chest

    (2007)
  • J Durán et al.

    Obstructive sleep apnea-hypopnea and related clinical features in a population-based sample of subjects aged 30 to 70 yr

    Am J Respir Crit Care Med

    (2001)
  • PE Peppard et al.

    Increased prevalence of sleep-disordered breathing in adults

    Am J Epidemiol

    (2013)
  • DS Silverberg et al.

    Are sleep-related breathing disorders important contributing factors to the production of essential hypertension?

    Curr Hypertens Rep

    (2001)
  • AG Logan et al.

    High prevalence of unrecognized sleep apnoea in drug-resistant hypertension.

    J Hypertens

    (2001)
  • T Young et al.

    Population-based study of sleep-disordered breathing as a risk factor for hypertension

    Arch Intern Med

    (1997)
  • FJ Nieto et al.

    Association of sleep-disordered breathing, sleep apnea, and hypertension in a large community-based study. Sleep Heart Health Study

    JAMA

    (2000)
  • P Lavie et al.

    Obstructive sleep apnoea syndrome as a risk factor for hypertension: population study

    BMJ

    (2000)
  • M Jhamb et al.

    Bidirectional relationship of hypertension with obstructive sleep apnea

    Curr Opin Pulm Med

    (2014)
  • O Friedman et al.

    Relationship between overnight rostral fluid shift and obstructive sleep apnea in drug-resistant hypertension

    Hypertension

    (2010)
  • R Wolk et al.

    Obesity-related cardiovascular disease: implications of obstructive sleep apnea

    Diabetes Obes Metab

    (2006)
  • PE Peppard et al.

    Prospective study of the association between sleep-disordered breathing and hypertension

    N Engl J Med

    (2000)
  • AV Chobanian et al.

    National Heart, Lung, and Blood Institute; National High Blood Pressure Education Program Coordinating Committee; National Hight Blood Pressure Education Program Coordinating Committee. Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of high blood pressure

    Hypertension

    (2003)
  • JM Marin et al.

    Association between treated and untreated obstructive sleep apnea and risk of hypertension

    JAMA

    (2012)
  • EO Bixler et al.

    Association of hypertension and sleep-disordered breathing

    Arch Intern Med

    (2000)
  • DC Haas et al.

    Age-dependent associations between sleep-disordered breathing and hypertension: importance of discriminating between systolic/diastolic hypertension and isolated systolic hypertension in the Sleep Heart Health Study

    Circulation

    (2005)
  • GT O'Connor et al.

    Prospective study of sleep-disordered breathing and hypertension: the Sleep Heart Health Study

    Am J Respir Crit Care Med

    (2009)
  • VK Kapur et al.

    Sleep disordered breathing and hypertension: does self-reported sleepiness modify the association?

    Sleep

    (2008)
  • F Barbé et al.

    Effect of continuous positive airway pressure on the incidence of hypertension and cardiovascular events in nonsleepy patients with obstructive sleep apnea: a randomized controlled tria

    JAMA

    (2012)
  • J Hedner et al.

    Hypertension prevalence in obstructive sleep apnoea and sex: a population-based case-control study

    Eur Respir J

    (2006)
  • I Cano-Pumarega et al.

    Obstructive sleep apnea and systemic hypertension: longitudinal study in the general population: the Vitoria Sleep Cohort

    Am J Respir Crit Care Med.

    (2011)
  • JF Masa et al.

    Effectiveness of three sleep apnea management alternatives

    Sleep

    (2013)
  • ESH/ESC Task Force for the Management of Arterial Hypertension

    2013 Practice guidelines for the management of arterial hypertension of the European Society of Hypertension (ESH) and the European Society of Cardiology (ESC): ESH/ESC Task Force for the Management of Arterial Hypertension

    JHypertens

    (2013)
  • Cited by (119)

    • Obstructive sleep apnea and cardiovascular risk

      2024, Clinica e Investigacion en Arteriosclerosis
    • Sex-specific differences in diagnostic approaches of inpatient sleep testing for obstructive sleep apnea

      2023, Sleep Medicine
      Citation Excerpt :

      As such, it is imperative to better understand the validity of hypoxia measures in Type III sleep testing to better gauge the role of sleep apnea-specific hypoxia and health outcomes in hospitalized patients with OSA. Lastly, several risk factors have been associated with increased risk for moderate to severe OSA, and data has consistently found BMI and cardiovascular diseases, such as stroke, CAD, and HTN, to be associated with OSA [36–44]. In our inpatient cohort, BMI, CAD, atrial fibrillation, diabetes, and COPD were identified as risk factors in well-performing predictive models for varying OSA diagnostic thresholds and sleep related hypoxia by inpatient sleep study type in women versus men.

    View all citing articles on Scopus

    originally published Online First April 16, 2015.

    FUNDING/SUPPORT: This study was funded by Fondo de Investigación Sanitaria [PI10/02763, PI10/02745, and PI14/01266], the Spanish Respiratory Society (SEPAR), and Associació Lleidatana de Respiratori (ALLER).

    © 2015 AMERICAN COLLEGE OF CHEST PHYSICIANS. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.

    View full text