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Sleep Apnea and Hypertension
Hypertension is a common ailment, affecting 33.5% of all adults above the age of 20, per the Centers for Disease Control and Prevention (CDC). Overall prevalence of sleep apnea, depending on the study, ranges from 9%-38% of the adult population.1 Prevalence of sleep apnea is greater in males than females but increases with age in both sexes.2 Consequently, the combination of sleep apnea and hypertension is commonly seen in the adult patient.
The intriguing question is, is sleep apnea a cause of or contributor to the development of hypertension, and does treatment of sleep apnea improve hypertension? In trying to understand the linkage between hypertension and sleep apnea part of the problem is that they are both seen with increasing frequency with weight gain and with aging.
There is strong insurer payer support for believing there is a significant link between hypertension and sleep apnea. Medicare will cover treatment for moderate and severe sleep apnea. However, if sleep apnea is mild, (defined as 5-15 apneas/hypopneas per hour) it will only be covered if there is an additional criterion, one of which is a diagnosis of hypertension. Several studies have noted that in resistant hypertension (uncontrolled hypertension or requiring multiple drugs to control), a significant percentage of those patients will have sleep apnea.3,7,8,9,10 This relationship between hypertension and sleep apnea may be important in younger patients and may not hold true for older patients.7
Several interesting physiological findings also suggest a possible linkage. Normally during sleep blood pressure will decrease. In patients with sleep apnea this drop in sleep blood pressure may not be seen. In addition, when there is physiologic stress such as a drop in oxygen levels, as can happen in sleep apnea, blood pressure may increase.
There are multiple studies that look at the treatment of sleep apnea with CPAP and the effect on hypertension. There have been varying results. Part of the variance is that results may be dependent on the severity of sleep apnea and the severity of the hypertension.3-6,8-10 Also, the level of compliance with CPAP treatment can be a factor in these studies.3-6,8-10
In reviewing this data, it seems reasonable to suggest that patients with resistant hypertension should be checked for sleep apnea. It appears that CPAP treatment may lead to statistically significant decrease in blood pressure, although the results may be modest. The best results are probably seen in cases where sleep apnea is more severe. In patients with mild sleep apnea it seems less clear that CPAP treatment is beneficial in improving blood pressure control; the final verdict awaits further clinical studies.
- Prevalence of Obstructive sleep Apnea in the General Population: A Systemic Review. Chamara V.SenaratnaabJennifer L.PerretacCaroline J.LodgeaAdrian J.LoweaBrittany E.CampbellaMelanie C.MathesonaGarun S.Hamiltonde1Shyamali C.Dharmagea1 Sleep Medicine Reviews, Vol. 34, Aug. 2017, pages 70-81.
- Increased prevalence of sleep-disordered breathing in adults.
Peppard PE, Young T, Barnet JH, Palta M, Hagen EW, Hla KM. Am J Epidemiol. 2013 May 1;177(9):1006-14. doi: 10.1093/aje/kws342. Epub 2013 Apr 14.
- Hypertension A companion to Braunwald’s Heart Disease. Third addition. 2018
- The Effect of CPAP RX on Blood Pressure: A Systemic Review and Meta-Analysis of Randomized Controlled Trials.
(Sydney B. Montesi,M.D., et al. Journal Clinical Sleep Med. 2012 Oct 15;8(5):587-596)
- Effectiveness of Continuous Positive Airway Pressure in Lowering Blood Pressure in Patients With Obstructive Sleep: a Critical Review of the Literature.
Fatureto-Borges, et al. Integr Blood Press Control. 2016;9:43-47
- CPAP for Prevention of Cardiovascular Events in Obstructive Sleep Apnea (McEvoy,M.D.,R Doug. et al. NEJM 2016;375:919-931)(Save Study)
- Association of Hypertension and Sleep Disordered Breathing.
Bixler EO, Vgontzas AN, Lin H-M, et al. Arch Intern Med 2000; 160: 2289–2295.
- Refractory hypertension and sleep apnoea: effect of CPAP on blood pressure and baroreflex.A.G. Logan, R. Tkacova, S.M. Perlikowski, R.S. Leung, A. Tisler, J.S. Floras, T.D. Bradley. European Respiratory Journal 2003 21: 241-247; DOI: 10.1183/09031936.03.00035402
- Longitudinal Effect of CPAP on BP in Resistant and Nonresistant Hypertension in a Large Clinic-Based Cohorthttp://journal.chestnet.org/article/S0012-3692(15)00130-0/fulltext – article-footnote-
- Obstuctive sleep apnea and hypertension: Interactions and clinical implications. Syra Kapa, Apoor S. Gami, and Vierend K. Somers. Chapter 11, pages 236-250. Sleep Apnea: Pathogenesis and Treatment. Ed. Alan Pack