Sleep and Breathing

, Volume 16, Issue 1, pp 31–40

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

  • Jing Feng
  • Quan-ying He
  • Xi-long Zhang
  • Bao-yuan Chen
  • Sleep Breath Disorder Group, Society of Respiratory Medicine
Original Article



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).


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.


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/χ2 = −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 (r2 = 0.049, P < 0.001).


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


Epworth sleepiness scale (ESS) Obstructive sleep apnea (OSA) Blood pressure (BP) Polysomnography (PSG) Apnea–hypopnea index (AHI) Gender Age Body mass index (BMI) Coronary artery disease (CAD) Cerebrovascular disease (CVD) Dipping of blood pressure Hypertension 


  1. 1.
    Peppard PE, Young T, Palta M, Skatrud J (2000) Prospective study of the association between sleep-disordered breathing and hypertension. N Engl J Med 342:1378–1384PubMedCrossRefGoogle Scholar
  2. 2.
    Nieto FJ, Young TB, Lind BK, Shahar E, Samet JM, Redline S, D’Agostino RB, Newman AB, Lebowitz MD, Pickering TG (2002) Association of sleep-disordered breathing, sleep apnea, and hypertension in a large community-based study. Sleep Heart Health Study. JAMA 283:1829–1836CrossRefGoogle Scholar
  3. 3.
    Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL Jr, Jones DW, Materson BJ, Oparil S, Wright JT Jr, Roccella EJ, National Heart, Lung, and Blood Institute Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure; National High Blood Pressure Education Program Coordinating Committee (2003) The seventh report of the joint national committee on prevention, detection, evaluation, and treatment of high blood pressure: the JNC 7 report. JAMA 289:2560–2572PubMedCrossRefGoogle Scholar
  4. 4.
    Robinson GV, Smith DM, Langford BA, Davies RJ, Stradling JR (2006) Continuous positive airway pressure does not reduce blood pressure in nonsleepy hypertensive OSA patients. Eur Respir J 27:1229–1235PubMedCrossRefGoogle Scholar
  5. 5.
    Barbé F, Mayoralas LR, Duran J, Masa JF, Maimó A, Montserrat JM, Monasterio C, Bosch M, Ladaria A, Rubio M, Rubio R, Medinas M, Hernandez L, Vidal S, Douglas NJ, Agustí AG (2001) Treatment with continuous positive airway pressure is not effective in patients with sleep apnea but no daytime sleepiness. a randomized, controlled trial. Ann Intern Med 134:1015–1023PubMedGoogle Scholar
  6. 6.
    Gami AS, Howard DE, Olson EJ, Somers VK (2005) Day-night pattern of sudden death in obstructive sleep apnea. N Engl J Med 352:1206–1214PubMedCrossRefGoogle Scholar
  7. 7.
    Yaggi HK, Concato J, Kernan WN, Lichtman JH, Brass LM, Mohsenin V (2005) Obstructive sleep apnea as a risk factor for stroke and death. N Engl J Med 353:2034–2041PubMedCrossRefGoogle Scholar
  8. 8.
    Phillips B (2005) Sleep-disordered breathing and cardiovascular disease. Sleep Med Rev 9:131–140PubMedCrossRefGoogle Scholar
  9. 9.
    Marin JM, Carrizo SJ, Vicente E, Agusti AG (2005) Long-term cardiovascular outcomes in men with obstructive sleep apnoea–hypopnoea with or without treatment with continuous positive airway pressure: an observational study. Lancet 365:1046–1053PubMedGoogle Scholar
  10. 10.
    Goldstein IB, Ancoli-Israel S, Shapiro D (2004) Relationship between daytime sleepiness and blood pressure in healthy older adults. Am J Hypertens 17:787–792PubMedCrossRefGoogle Scholar
  11. 11.
    He QY, Feng J, Zhang XL, Liang ZA, Huang SG, Kang J, Wang GF, Zhang LQ, Ma LJ, Wang B, Lin QC, Zhang JN, Liu HG, Luo YM, Liu JH, Wang S, Xiao GH, Lu G, Zhang J, Feng XW, Chen BY, Sleep Breath Disorder Group; Society of Respiratory Medicine; Chinese Medical Association (2010) Relationship of daytime blood pressure and severity of obstructive sleep apnea among Chinese: a multi-center investigation in China. Chin Med J (Engl) 123:18–22Google Scholar
  12. 12.
    Johns MW (1991) A new method for measuring daytime sleepiness: the Epworth sleepiness scale. Sleep 14:540–545PubMedGoogle Scholar
  13. 13.
    Johns MW (1992) Reliability and factor analysis of the Epworth Sleepiness Scale. Sleep 15:376–381PubMedGoogle Scholar
  14. 14.
    American Academy of Sleep Medicine (2005) The International Classification of Sleep Disorders: diagnostic and coding manual, 2nd edn. American Academy of Sleep Medicine, Westchester, pp 165–167Google Scholar
  15. 15.
    American Academy of Sleep Medicine Task Force (1999) 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 22:667–689Google Scholar
  16. 16.
    Loredo JS, Nelesen R, Ancoli-Israel S, Dimsdale JE (2004) Sleep quality and blood pressure dipping in normal adults. Sleep 27:1097–1103PubMedGoogle Scholar
  17. 17.
    Newman AB, Spiekerman CF, Enright P, Lefkowitz D, Manolio T, Reynolds CF, Robbins J (2000) Daytime sleepiness predicts mortality and cardiovascular disease in older adults. The Cardiovascular Health Study Research Group. J Am Geriatr Soc 48:115–123PubMedGoogle Scholar
  18. 18.
    Lindberg E, Janson C, Svärdsudd K, Gislason T, Hetta J, Boman G (1998) Increased mortality among sleepy snorers: a prospective population-based study. Thorax 53:631–637PubMedCrossRefGoogle Scholar
  19. 19.
    Pepperell JC, Davies RJ, Stradling JR (2002) Systemic hypertension and obstructive sleep apnoea. Sleep Med Rev 6:157–173PubMedCrossRefGoogle Scholar
  20. 20.
    Whitney CW, Enright PL, Newman AB, Bonekat W, Foley D, Quan SF (1998) Correlates of daytime sleepiness in 4578 elderly persons: the Cardiovascular Health Study. Sleep 21:27–36PubMedGoogle Scholar
  21. 21.
    MacMahon S, Peto R, Cutler J, Collins R, Sorlie P, Neaton J, Abbott R, Godwin J, Dyer A, Stamler J (1990) Blood pressure, stroke, and coronary heart disease. Part 1, Prolonged differences in blood pressure: prospective observational studies corrected for the regression dilution bias. Lancet 335:765–774PubMedCrossRefGoogle Scholar
  22. 22.
    Robinson GV, Langford BA, Smith DM, Stradling JR (2008) Predictors of blood pressure fall with continuous positive airway pressure (CPAP) treatment of obstructive sleep apnoea (OSA). Thorax 63:855–859PubMedCrossRefGoogle Scholar
  23. 23.
    Parish JM, Somers VK (2004) Obstructive sleep apnea and cardiovascular disease. Mayo Clin Proc 79:1036–1046PubMedCrossRefGoogle Scholar
  24. 24.
    Cooper VL, Bowker CM, Pearson SB, Elliott MW, Hainsworth R (2004) Effects of simulated obstructive sleep apnoea on the human carotid baroreceptor-vascular resistance reflex. J Physiol 557:1055–1065PubMedCrossRefGoogle Scholar
  25. 25.
    Punjabi NM, Haponik E (2000) Ask about daytime sleepiness! J Am Geriatr Soc 48:228–229PubMedGoogle Scholar
  26. 26.
    Feng J, Chen BY, Cui LY, Wang BL, Liu CX, Chen PF, Guo MN, Dong LX, Li S (2009) Inflammation status of rabbit carotid artery model endothelium during intermittent hypoxia exposure and its relationship with leptin. Sleep Breath 13:277–283PubMedCrossRefGoogle Scholar
  27. 27.
    Feng J, Chen BY (2009) Prevalence and incidence of hypertension in obstructive sleep apnea patients and the relationship between obstructive sleep apnea and its confounders. Chin Med J (Engl) 122:1464–1468Google Scholar
  28. 28.
    Feng J, Chen BY, Cui LY (2008) Carotid body-mediated changes of sympathetic nerve and their relationships with hypertension. Chin Med J (Engl) 121:1732–1735Google Scholar
  29. 29.
    Veasey SC, Davis CW, Fenik P, Zhan G, Hsu YJ, Pratico D, Gow A (2004) Long-term intermittent hypoxia in mice: protracted hypersomnolence with oxidative injury to sleep-wake brain regions. Sleep 27:194–201PubMedGoogle Scholar
  30. 30.
    Pack AI (2006) Advances in sleep-disordered breathing. Am J Respir Crit Care Med 173:7–15PubMedCrossRefGoogle Scholar
  31. 31.
    Crowley K, Colrain IM (2000) Self-reported sleep patterns and daytime sleepiness in the neurologically healthy aged. J Sleep Res 9:97–98PubMedCrossRefGoogle Scholar
  32. 32.
    O’Brien E, Sheridan J, O’Malley K (1988) Dippers and non-dippers. Lancet 2:397PubMedCrossRefGoogle Scholar
  33. 33.
    Dopp JM, Reichmuth KJ, Morgan BJ (2007) Obstructive sleep apnea and hypertension: mechanisms, evaluation, and management. Curr Hypertens Rep 9:529–534PubMedCrossRefGoogle Scholar
  34. 34.
    Kario K (2005) Time for focus on morning hypertension: pitfall of current antihypertensive medication. Am J Hypertens 18:149–151PubMedCrossRefGoogle Scholar
  35. 35.
    Sayk F, Teckentrup C, Becker C, Heutling D, Wellhöner P, Lehnert H, Dodt C (2010) Effects of selective slow-wave sleep deprivation on nocturnal blood pressure dipping and daytime blood pressure regulation. Am J Physiol Regul Integr Comp Physiol 298:R191–197PubMedCrossRefGoogle Scholar
  36. 36.
    Sega R, Facchetti R, Bombelli M, Cesana G, Corrao G, Grassi G, Mancia G (2005) Prognostic value of ambulatory and home blood pressures compared with office blood pressure in the general population: follow-up results from the Pressioni Arteriose Monitorate e Loro Associazioni (PAMELA) study. Circulation 111:1777–1783PubMedCrossRefGoogle Scholar
  37. 37.
    Elwood P, Hack M, Pickering J, Hughes J, Gallacher J (2006) Sleep disturbance, stroke, and heart disease events: evidence from the Caerphilly cohort. J Epidemiol Community Health 60:69–73PubMedCrossRefGoogle Scholar
  38. 38.
    Qureshi AI, Giles WH, Croft JB, Bliwise DL (1997) Habitual sleep patterns and risk for stroke and coronary heart disease: a 10-year follow-up from NHANES I. Neurology 48:904–911PubMedGoogle Scholar
  39. 39.
    Kapur VK, Resnick HE, Gottlieb DJ, Sleep Heart Health Study Group (2008) Sleep disordered breathing and hypertension: does self-reported sleepiness modify the association? Sleep 31:1127–1132PubMedGoogle Scholar
  40. 40.
    Kanbay M, Turgut F, Uyar ME, Akcay A, Covic A (2008) Causes and mechanisms of nondipping hypertension. Clin Exp Hypertens 30:585–597PubMedCrossRefGoogle Scholar
  41. 41.
    de la Sierra A, Redon J, Banegas JR, Segura J, Parati G, Gorostidi M, de la Cruz JJ, Sobrino J, Llisterri JL, Alonso J, Vinyoles E, Pallarés V, Sarría A, Aranda P, Ruilope LM, Spanish Society of Hypertension Ambulatory Blood Pressure Monitoring Registry Investigators (2009) Prevalence and factors associated with circadian blood pressure patterns in hypertensive patients. Hypertension 53:466–472PubMedCrossRefGoogle Scholar
  42. 42.
    Silva AP, Moreira C, Bicho M, Paiva T, Clara JG (2000) Nocturnal sleep quality and circadian blood pressure variation. Rev Port Cardiol 19:991–1005PubMedGoogle Scholar
  43. 43.
    Li AM, Au CT, Ho C, Fok TF, Wing YK (2009) Blood pressure is elevated in children with primary snoring. J Pediatr 155:362–368PubMedCrossRefGoogle Scholar
  44. 44.
    Chung KF (2005) Insomnia subtypes and their relationships to daytime sleepiness in patients with obstructive sleep apnea. Respiration 72:460–465PubMedCrossRefGoogle Scholar
  45. 45.
    Vgontzas AN, Liao D, Bixler EO, Chrousos GP, Vela-Bueno A (2009) Insomnia with objective short sleep duration is associated with a high risk for hypertension. Sleep 32:491–497PubMedGoogle Scholar
  46. 46.
    Gus M, Gonçalves SC, Martinez D, de Abreu Silva EO, Moreira LB, Fuchs SC, Fuchs FD (2008) Risk for Obstructive Sleep Apnea by Berlin Questionnaire, but not daytime sleepiness, is associated with resistant hypertension: a case-control study. Am J Hypertens 21:832–835PubMedCrossRefGoogle Scholar
  47. 47.
    Gus M, Silva DN, Fernandes J, Cunha CP, Sant’Anna GD (2002) Epworth’s sleepiness scale in outpatients with different values of arterial blood pressure. Arq Bras Cardiol 78:17–24PubMedGoogle Scholar
  48. 48.
    O’Connor GT, Caffo B, Newman AB, Quan SF, Rapoport DM, Redline S, Resnick HE, Samet J, Shahar E (2009) Prospective study of sleep-disordered breathing and hypertension: the Sleep Heart Health Study. Am J Respir Crit Care Med 179:1159–1164PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag 2011

Authors and Affiliations

  • Jing Feng
    • 1
  • Quan-ying He
    • 2
  • Xi-long Zhang
    • 3
  • Bao-yuan Chen
    • 1
  • Sleep Breath Disorder Group, Society of Respiratory Medicine
  1. 1.Respiratory DepartmentTianjin Medical University General HospitalTianjinChina
  2. 2.Respiratory DepartmentBeijing University People’s HospitalBeijingChina
  3. 3.Respiratory DepartmentNanjing Medical University First HospitalNanjingChina

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