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Epworth Sleepiness Scale may be an indicator for blood pressure profile and prevalence of coronary artery disease and cerebrovascular disease in patients with obstructive sleep apnea

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Abstract

Objective

This study seeks to determine whether scores of a short questionnaire assessing subjective daytime sleepiness (Epworth Sleepiness Scale [ESS]) are associated with blood pressure (BP) level, BP profile, and prevalence of related coronary artery disease (CAD) and cerebrovascular disease (CVD) in obstructive sleep apnea (OSA) patients diagnosed by polysomnography (PSG).

Methods

Twenty university hospital sleep centers in China mainland were organized by the Chinese Medical Association to participate in this study. Between January 2004 and April 2006, 2,297 consecutive patients (aged 18–85 years; 1,981 males and 316 females) referred to these centers were recruited. BP assessments were evaluated at four time points (daytime, evening, nighttime, and morning) under standardized conditions. Anthropometric measurements, medical history of hypertension, CAD, and CVD were collected. ESS score was calculated for each participant and at the night of BP assessment, nocturnal PSG was performed and subjects were classified into four groups based on the apnea–hypopnea index (AHI) from PSG as follows: control group (control, n = 213) with AHI < 5; mild sleep apnea (mild, n = 420) with AHI ≥ 5 and <15; moderate sleep apnea (moderate, n = 460) with AHI ≥ 15 and <30; and severe sleep apnea (severe, n = 1,204) with AHI ≥ 30. SPSS 11.5 software package was used for the relationships between ESS and BP profile and prevalence of CAD and CVD.

Results

ESS is correlated positively with average daytime, nighttime, evening, and morning BP before and even after controlling for confounding effects of age, sex, BMI, AHI, and nadir nocturnal oxygen saturation (before—r = 0.182, 0.326, 0.245, and 0.329, respectively, all P values < 0.001; after—r = 0.069, 0.212, 0.137, and 0.208, respectively, all P values < 0.001). In the severe group, nighttime, evening, morning average BPs (ABPs), the ratio of nighttime/daytime average BP (ratio of nighttime average BP to daytime average BP), and prevalence of hypertension, drug-resistant hypertension (R-HTN), isolated nighttime hypertension (IN-HTN), CAD, and CVD in excessive daytime sleepiness (EDS, ESS ≥ 11) subjects are higher than those in non-EDS (ESS 0–10; t/χ 2 = −8.388, −6.207, −8.607, −5.901, 12.742, 38.980, 16.343, 59.113, and 67.113, respectively; all P values < 0.05). For EDS subjects in the moderate group but not in the control and mild group, nighttime ABP and the ratio of nighttime/daytime average BP are higher (t = −2.086 and −3.815, respectively, all P values < 0.05). Linear fitting with ESS and the ratio of nighttime/daytime average BP shows a positive correlation (r 2 = 0.049, P < 0.001).

Conclusions

In severe OSA patients with comparable AHI, EDS may identify a subset of individuals with OSA at higher risk of hypertension, R-HTN, IN-HTN, CAD, and CVD. Overall, nighttime ABP seems to be more sensitive to be influenced by EDS than other ABP parameters. Future studies should investigate the potential dose–effect relationship between EDS and hypertension and the possibility that diagnosis and treatment of EDS could aid in BP reduction and ultimately in decreased morbidity and mortality from cardiovascular and cerebrovascular complications (TMUIRB20010002 at www.clinicaltrials.gov).

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Acknowledgments

We are grateful to the information and correction from Danielle Speer and Ambrose Chiang at Division of Pulmonary and Critical Care Medicine in Duke University Medical Center, Durham, NC 27710, USA. As an observational clinical trial, this study has been registered at www.clinicaltrials.gov and the registered ID is TMUIRB20010002. This study was supported by the grants from National Natural Science Foundation of China (Nos. 30800507 and 30770934). None of the authors in the study group has a financial relationship with a commercial entity that has an interest in the subject of this manuscript.

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Authors and Affiliations

  1. Respiratory Department, Tianjin Medical University General Hospital, 300052, Tianjin, China

    Jing Feng & Bao-yuan Chen

  2. Respiratory Department, Beijing University People’s Hospital, 100044, Beijing, China

    Quan-ying He

  3. Respiratory Department, Nanjing Medical University First Hospital, 210029, Nanjing, China

    Xi-long Zhang

Authors
  1. Jing Feng
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  2. Quan-ying He
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Sleep Breath Disorder Group, Society of Respiratory Medicine

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Correspondence to Bao-yuan Chen.

Appendix

Appendix

Name list of Society of Respiratory Medicine Sleep Breath Disorder Group in Chinese Medical Association:

Jing FENG1, M.D., Ph.D.; Quan-ying HE2, M.D., FCCP; Xi-long ZHANG3, M.D.; Zong-an LIANG4, M.D.; Shao-guang HUANG5, M.D., FCCP; Jian KANG6, M.D., FCCP; Guang-fa WANG7, M.D.; Li-qiang ZHANG8, M.D.; Li-jun MA9, M.D.; Bei WANG10, M.D.; Qi-chang LIN11, M.D.; Jing-nong ZHANG12, M.D.; Hui-guo LIU13, M.D.; Yuan-ming LUO14, M.D.; Jian-hong LIU15, M.D.; Shi WANG16, M.D.; Gao-hui XIAO17, M.D.; Gan LU18, M.D.; Jin ZHANG19, M.D.; Xue-wei FENG20, M.D.; Bao-yuan CHEN1, M.D., FCCP.

  1. 1.

    Tianjin Medical University General Hospital, Tianjin, China.

  2. 2.

    Beijing University People’s Hospital, Beijing, China.

  3. 3.

    Nanjing Medical University First Hospital, Nanjing, China.

  4. 4.

    Sichuan University Huaxi Hospital, Chengdu, China.

  5. 5.

    Shanghai Communication University Ruijin Hospital, Shanghai, China.

  6. 6.

    First Affiliated Hospital of China Medical University, Shenyang, China.

  7. 7.

    Beijing University First Hospital, Beijing, China.

  8. 8.

    Beijing University Third Hospital, Beijing, China.

  9. 9.

    Henan Province Renmin Hospital, Zhengzhou, China.

  10. 10.

    Shanxi Medical University Second Hospital, Taiyuan, China.

  11. 11.

    Fujian Medical University First Hospital, Fuzhou, China.

  12. 12.

    First Affiliated Hospital of Huazhong Scientific University Tongji Medical College, Shanghai, China.

  13. 13.

    Tongji Affiliated Hospital of Huazhong Scientific University Tongji Medical College, Shanghai, China.

  14. 14.

    Guangzhou Institute of Respiratory Disease, First Affiliated Hospital of Guangzhou Medical College, Guangzhou, China.

  15. 15.

    Guangxi Zhuang Autonomous Region Renmin Hospital, Nanning, China.

  16. 16.

    Central Hospital of Shenyang Medical College, Shenyang, China.

  17. 17.

    Beijing Gongan Hospital, Beijing, China.

  18. 18.

    Jiangsu Senility Hospital, Nanjing, China.

  19. 19.

    Affiliated Hospital of Ningxia College, Yinchuan, China.

  20. 20.

    Second Affiliated Hospital of China Medical University, Shenyang, China.

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Feng, J., He, Qy., Zhang, Xl. et al. Epworth Sleepiness Scale may be an indicator for blood pressure profile and prevalence of coronary artery disease and cerebrovascular disease in patients with obstructive sleep apnea. Sleep Breath 16, 31–40 (2012). https://doi.org/10.1007/s11325-011-0481-5

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