Abstract
Obstructive sleep apnea (OSA) is considered to be a secondary form of hypertension and in clinical practice OSA is frequently associated with hypertension, even if proof of causality cannot be established. Growing evidence suggests that OSA is associated with worse blood pressure control, alterations in night-time blood pressure dipping, increased target organ damage, and arterial stiffness in patients with hypertension. This review summarizes the current evidence for managing hypertension in patients with OSA. Particular focus will be devoted to discuss the impact of lifestyle changes, preferences for anti-hypertensive treatment in patients with OSA, and the effects of OSA treatment with continuous positive airway pressure on blood pressure.
Similar content being viewed by others
References
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
Sleep-related breathing disorders in adults: recommendations for syndrome definition and measurement techniques in clinical research. The Report of an American Academy of Sleep Medicine Task Force. Sleep. 1999;22(5):667–9.
Peppard PE, Young T, Barnet JH, et al. Increased prevalence of sleep-disordered breathing in adults. Am J Epidemiol. 2013;177(9):1006–14. This is an update of the prevalence of sleep-disordered breathing in US adults. Comparing data from 2 decades ago, the current estimates represent an increase of millions of additional afflicted persons and are mainly explained by the ongoing obesity epidemic.
Drager LF, Togeiro SM, Polotsky VY, et al. Obstructive sleep apnoea: a cardiometabolic risk in obesity and the metabolic syndrome. J Am Coll Cardiol. 2013;62(7):569–76. Comprehensive review approaching the potential impact of obstructive sleep apnea in exacerbating the cardiovascular risk in patients with obesity and the metabolic syndrome.
Drager LF, Genta PR, Pedrosa RP, et al. Characteristics and predictors of obstructive sleep apnea in patients with systemic hypertension. Am J Cardiol. 2010;105(8):1135–9.
Drager LF, Pereira AC, Barreto-Filho JA, Figueiredo AC, Krieger JE, Krieger EM, et al. Phenotypic characteristics associated with hypertension in patients with obstructive sleep apnea. J Hum Hypertens. 2006;20(7):523–8.
Logan AG, Perlikowski SM, Mente A, et al. High prevalence of unrecognized sleep apnoea in drug-resistant hypertension. J Hypertens. 2001;19(12):2271–7.
Pedrosa RP, Drager LF, Gonzaga CC, et al. Obstructive sleep apnea: the most common secondary cause of hypertension associated with resistant hypertension. Hypertension. 2011;58(5):811–7.
Peppard PE, Young T, Palta M, Skatrud J. Prospective study of the association between sleep-disordered breathing and hypertension. N Engl J Med. 2000;342(19):1378–84.
Grote L, Ploch T, Heitmann J, Knaack L, Penzel T, Peter JH. Sleep-related breathing disorder is an independent risk factor for systemic hypertension. Am J Respir Crit Care Med. 1999;160(6):1875–82.
Lavie P, Herer P, Hoffstein V. Obstructive sleep apnoea syndrome as a risk factor for hypertension: population study. BMJ. 2000;320(7233):479–82.
Nieto FJ, Young TB, Lind BK, Shahar E, Samet JM, Redline S, et al. Association of sleep-disordered breathing, sleep apnea, and hypertension in a large community-based study. Sleep Heart Health Study. JAMA. 2000;283(14):1829–36.
Shahar E, Whitney CW, Redline S, Lee ET, Newman AB, Javier Nieto F, et al. Sleep-disordered breathing and cardiovascular disease: cross-sectional results of the Sleep Heart Health Study. Am J Respir Crit Care Med. 2001;163(1):19–25.
Gottlieb DJ, Yenokyan G, Newman AB, O'Connor GT, Punjabi NM, Quan SF, et al. Prospective study of obstructive sleep apnea and incident coronary heart disease and heart failure: the sleep heart health study. Circulation. 2010;122(4):352–60.
Marin JM, Carrizo SJ, Vicente E, Agusti AG. Long-term cardiovascular outcomes in men with obstructive sleep apnoea–hypopnoea with or without treatment with continuous positive airway pressure: an observational study. Lancet. 2005;365:1046–53.
Martínez-García MA, Campos-Rodríguez F, Catalán-Serra P, Soler-Cataluña JJ, Almeida-Gonzalez C, De la Cruz Morón I, et al. Cardiovascular mortality in obstructive sleep apnea in the elderly: role of long-term continuous positive airway pressure treatment: a prospective observational study. Am J Respir Crit Care Med. 2012;186(9):909–16.
Campos-Rodriguez F, Martinez-Garcia MA, de la Cruz-Moron I, Almeida-Gonzalez C, Catalan-Serra P, Montserrat JM. Cardiovascular mortality in women with obstructive sleep apnea with or without continuous positive airway pressure treatment: a cohort study. Ann Intern Med. 2012;156(2):115–22.
Uchôa CH, Danzi-Soares Nde J, Nunes FS, de Souza AA, Nerbass FB, Pedrosa RP, et al. Impact of OSA on cardiovascular events after coronary artery bypass surgery. Chest. 2015;147(5):1352–60.
Costa LE, Uchôa CH, Harmon RR, Bortolotto LA, Lorenzi-Filho G, Drager LF. Potential underdiagnosis of obstructive sleep apnoea in the cardiology outpatient setting. Heart. 2015;101(16):1288–92. Systematic evaluation of the underdiagnosis of OSA in the Cardiology setting. Studying consecutive outpatients from different subspecialties, the authors found a huge percentage of patients unaware about OSA condition.
Pedrosa RP, Krieger EM, Lorenzi-Filho G, Drager LF. Recent advances of the impact of obstructive sleep apnea on systemic hypertension. Arq Bras Cardiol. 2011;97(2):40–7.
Kapa S, Sert Kuniyoshi FH, Somers VK. Sleep apnea and hypertension: interactions and implications for management. Hypertension. 2008;51(3):605–8.
Somers VK, Dyken ME, Clary MP, Abboud FM. Sympathetic neural mechanisms in obstructive sleep apnea. J Clin Invest. 1995;96(4):1897–904.
Pankow W, Nabe B, Lies A, Becker H, Köhler U, Kohl FV, et al. Influence of sleep apnea on 24-hour blood pressure. Chest. 1997;112(5):253–8.
Loredo JS, Ancoli-Israel S, Dimsdale JE. Sleep quality and blood pressure dipping in obstructive sleep apnea. Am J Hypertens. 2001;14(9):887–92.
Ohkubo T, Hozawa A, Yamaguchi J, Kikuya M, Ohmori K, Michimata M, et al. Prognostic significance of nocturnal decline in blood pressure in individuals with and without high 24-h blood pressure: the Ohsama study. J Hypertens. 2002;20(11):2183–9.
Dolan E, Stanton A, Thijs L, Hinedi K, Atkins N, Mcclory S, et al. Superiority of ambulatory over clinic blood pressure measurement in predicting mortality. The Dublin Outcome Study. Hypertension. 2005;46(1):156–61.
Hansen TW, Li Y, Boggia J, Thijs L, Richart T, Staessen JA. Predictive role of nighttime blood pressure. Hypertension. 2011;57(1):3–10.
Drager LF, Diegues-Silva L, Diniz PM, Bortolotto LA, Pedrosa RP, Couto RB, et al. Obstructive sleep apnea, masked hypertension, and arterial stiffness in men. Am J Hypertens. 2010;23(3):249–54.
Drager LF, Pedrosa RP, Diniz PM, Diegues-Silva L, Marcondes B, Couto RB, et al. The effects of continuous positive airway pressure on prehypertension and masked hypertension in men with severe obstructive sleep apnea. Hypertension. 2011;57(3):549–55.
Goodfriend TL, Calhoun DA. Resistant hypertension, obesity, sleep apnea, and aldosterone theory and therapy. Hypertension. 2004;43(3):518–24.
Shiota S, Ryan CM, Chiu KL, Ruttanaumpawan P, Haight J, Arzt M, et al. Alterations in upper airway cross-sectional area in response to lower body positive pressure in healthy subjects. Thorax. 2007;62(10):868–72.
Friedman O, Bradley TD, Chan CT, Parkes R, Logan AG. Relationship between overnight rostral fluid shift and obstructive sleep apnea in drug-resistant hypertension. Hypertension. 2010;56(6):1077–82.
Maki-Nunes C, Toschi-Dias E, Cepeda FX, Rondon MUPB, Alves MJNN, Fraga RF, et al. Diet and exercise improve chemoreflex sensitivity in patients with metabolic syndrome and obstructive sleep apnea. Obesity. 2015;23(8):1582–90.
Chirinos JA, Gurubhagavatula I, Teff K, Rader DJ, Wadden TA, Townsend R, et al. CPAP, weight loss, or both for obstructive sleep apnea. N Engl J Med. 2014;370(24):2265–75. Randomized trial that compared CPAP, weight loss or both for treating OSA. In as secondary analyses, adherence to a regimen of weight loss and CPAP resulted in incremental reductions in blood pressure as compared with either intervention alone.
Friedman O, Bradley TD, Logan AG. Influence of lower body positive pressure on upper airway cross-sectional area in drug-resistant hypertension. Hypertension. 2013;61(1):240–5.
Yadollahi A, Gabriel JM, White LH, Taranto Montemurro L, Kasai T, Bradley TD. A randomized, double crossover study to investigate the influence of saline infusion on sleep apnea severity in men. Sleep. 2014;37(10):1699–705.
Pépin JL, Tamisier R, Barone-Rochette G, Launois SH, Lévy P, Baguet JP. Comparison of continuous positive airway pressure and valsartan in hypertensive patients with sleep apnea. Am J Respir Crit Care Med. 2010;182(7):954–60.
Drager LF, Bortolotto LA, Figueiredo AC, Krieger EM, Lorenzi GF. Effects of continuous positive airway pressure on early signs of atherosclerosis in obstructive sleep apnea. Am J Respir Crit Care Med. 2007;176(7):706–12.
Issa FG. Effect of clonidine in obstructive sleep apnea. Am Rev Respir Dis. 1992;145(2):435–9.
Grote L, Wutkewicz K, Knaack L, Ploch T, Hedner J, Peter JH. Association between blood pressure reduction with antihypertensive treatment and sleep apnea activity. Am J Hypertens. 2000;13(12):1280–7.
Planès C, Foucher A, Leroy M, Dartois N, Juste K, Baillart O, et al. Effect of celiprolol treatment in hypertensive patients with sleep apnea. Sleep. 1999;22(4):507–13.
Kraiczi H, Hedner J, Peker Y, Grote L. Comparison of atenolol, amlodipine, enalapril, hydrochlorothiazide, and losartan for antihypertensive treatment in patients with obstructive sleep apnea. Am J Respir Crit Care Med. 2000;161(5):1423–8.
Gaddam K, Pimenta E, Thomas SJ, Cofield SS, Oparil S, Harding SM, et al. Spironolactone reduces severity of obstructive sleep apnoea in patients with resistant hypertension: a preliminary report. J Hum Hypertens. 2010;24(8):532–7.
Kasai T, Bradley TD, Friedman O, Logan AG. Effect of intensified diuretic therapy on overnight rostral fluid shift and obstructive sleep apnoea in patients with uncontrolled hypertension. J Hypertens. 2014;32(3):673–80.
Kasiakogias A, Tsioufis C, Thomopoulos C, Andrikou I, Aragiannis D, Dimitriadis K, et al. Evening versus morning dosing of antihypertensive drugs in hypertensive patients with sleep apnoea: a cross-over study. J Hypertens. 2015;33(2):393–400.
Campos-Rodriguez F, Grilo-Reina A, Perez-Ronchel J, Merino-Sanchez M. Effect of continuous positive airway pressure on ambulatory BP in patients with sleep apnea and hypertension: a placebo-controlled trial. Chest. 2006;129(6):1459–67.
Nguyen PK, Katikireddy CK, McConnell MV, et al. Nasal continuous positive airway pressure improves myocardial perfusion reserve and endothelial-dependent vasodilation in patients with obstructive sleep apnea. J Cardiovasc Magn Reson. 2010;12:50.
Robinson GV, Smith DM, Langford BA, et al. Continuous positive airway pressure does not reduce blood pressure in nonsleepy hypertensive OSA patients. Eur Respir J. 2006;27(6):1229–35.
Durán-Cantolla J, Aizpuru F, Montserrat JM, et al. Continuous positive airway pressure as treatment for systemic hypertension in people with obstructive sleep apnoea: randomised controlled trial. BMJ. 2010;341:c5991.
Barbé F, Durán-Cantolla J, Capote F, de la Peña M, et al. Long-term effect of continuous positive airway pressure in hypertensive patients with sleep apnea. Am J Respir Crit Care Med. 2010;181(7):718–26.
Lozano L, Tovar JL, Sampol G, et al. Continuous positive airway pressure treatment in sleep apnea patients with resistant hypertension: a randomized, controlled trial. J Hypertens. 2010;28(10):2161–8.
Pedrosa RP, Drager LF, de Paula LK, Amaro AC, Bortolotto LA, Lorenzi-Filho G. Effects of obstructive sleep apnea treatment on blood pressure in patients with resistant hypertension: a randomized trial. Chest. 2013;144(5):1487–94.
Martínez-García MA, Capote F, Campos-Rodríguez F, Lloberes P, Díaz de Atauri MJ, Somoza M, et al. Effect of CPAP on blood pressure in patients with obstructive sleep apnea and resistant hypertension: the HIPARCO randomized clinical trial. JAMA. 2013;310(22):2407–15. Multicentric randomized study that evaluated the impact of CPAP on blood pressure in patients with OSA and resistant hypertension.
De Oliveira AC, Martinez D, Massierer D, et al. The antihypertensive effect of positive airway pressure on resistant hypertension of patients with obstructive sleep apnea: a randomized, double-blind, clinical trial. Am J Respir Crit Care Med. 2014;190(3):345–7.
Muxfeldt ES, Margallo V, Costa LM, et al. Effects of continuous positive airway pressure treatment on clinic and ambulatory blood pressures in patients with obstructive sleep apnea and resistant hypertension: a randomized controlled trial. Hypertension. 2015;65(4):736–42.
Litvin AY, Sukmarova ZN, Elfimova EM, et al. Effects of CPAP on "vascular" risk factors in patients with obstructive sleep apnea and arterial hypertension. Vasc Health Risk Manag. 2013;9:229–35.
Drager LF, Brunoni AR, Jenner R, Lorenzi-Filho G, Benseñor IM, Lotufo PA. Effects of CPAP on body weight in patients with obstructive sleep apnoea: a meta-analysis of randomised trials. Thorax. 2015;70(3):258–64. Meta-analysis evaluating the impact of CPAP on weight and BMI in randomized studies. Surprisingly, the authors found a modest but significant increase in weight and BMI in the CPAP group.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of Interest
Sofia F. Furlan, Caio V. Braz, Geraldo Lorenzi-Filho, and Luciano F. Drager declare that they have no conflict of interest.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
Additional information
This article is part of the Topical Collection on Hypertension
Rights and permissions
About this article
Cite this article
Furlan, S.F., Braz, C.V., Lorenzi-Filho, G. et al. Management of Hypertension in Obstructive Sleep Apnea. Curr Cardiol Rep 17, 108 (2015). https://doi.org/10.1007/s11886-015-0663-z
Published:
DOI: https://doi.org/10.1007/s11886-015-0663-z