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Can Sleep Apnea Cause Hypertension

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Summary And Future Directions

Can Obstructive Sleep Apnea leads to Secondary Hypertension? – Dr. Sreenivasa Murthy T M

There is an abundance of evidence implicating OSA as an important secondary cause of hypertension. The mechanisms likely involve sustained, increased sympathetic activation associated with intermittent hypoxia. In the long-term, BP elevation, together with other less well understood processes, is likely to explain the increase in cardiovascular related morbidity, events, and death that are seen in this group. While there is good evidence that effective treatment of more severe OSA in patients with hypertension improves BP, future research should be directed at more clearly identifying factors that determine individual antihypertensive responses with OSA treatment. In addition, further studies are required to explore the effect of long-term treatment of OSA on BP. Whilst OSA-induced hypertension could lead to further vascular remodeling or structural cardiac changes, it also remains to be demonstrated whether BP reduction decreases OSA-mediated cardiovascular risk. Given the consistent relationship between hypertension and risk of cardiovascular disease , it is important to adopt strategies which have a maximal BP lowering effect. In populations with OSA and hypertension, the best strategy likely involves combining OSA treatment with antihypertensive medication. This combination is likely to be more effective in lowering both nocturnal and daytime BP than either treatment alone. The subsequent reduction in cardiovascular risk may be substantial.

Osa Is A Cause Of Hypertension

Hypertension, the most prevalent cardiovascular disease, is also the best established cardiovascular consequence of obstructive sleep apnea . Hypertension affects approximately 30% of adults in the United States with an impact on public health that cannot be overstated. The World Health Organization estimates that even suboptimal blood pressure levels are responsible for 62% of cerebrovascular disease and 49% of ischemic heart disease . On the other hand, OSA affects between 9% and 25% of middle-aged adults . OSA is estimated to be present in 3040% of patients with hypertension, while 40% of patients with OSA are thought to have hypertension . Since both disorders are very prevalent in middle-aged individuals, and coexist in a large portion of the population it had been difficult to elucidate the causeeffect relationship between the two disorders. However, in recent years, mounting evidence from large epidemiological studies, along with human and animal experiments, was able to confirm the presence of this causal relationship between OSA and hypertension. The mechanism of hypertension in patients with OSA remains only partially understood so far. In this article, we will focus on the clinical and epidemiological evidence for the causative relationship between OSA and hypertension. The basic mechanisms of the association between OSA and hypertension were reviewed in the first part of this series.

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What Are The Treatments For Sleep Apnea

Conservative treatments: In mild cases of obstructive sleep apnea, conservative therapy may be all that is needed.

  • Overweight persons can benefit from losing weight. Even a 10% weight loss can reduce the number of apneic events for most patients. However, losing weight can be difficult to do with untreated obstructive sleep apnea due to increased appetite and metabolism changes that can happen with obstructive sleep apnea.
  • Individuals with obstructive sleep apnea should avoid the use of alcohol and certain sleeping pills, which make the airway more likely to collapse during sleep and prolong the apneic periods.
  • In some patients with mild obstructive sleep apnea, breathing pauses occur only when they sleep on their backs. In such cases, using a wedge pillow or other devices that help them sleep in a side position may help.
  • People with sinus problems or nasal congestion should use nasal sprays or breathing strips to reduce snoring and improve airflow for more comfortable nighttime breathing. Avoiding sleep deprivation is important for all patients with sleep disorders.

Hypoglossal nerve stimulator: A stimulator is implanted under the skin on the right side of the chest with electrodes tunneled under the skin to the hypoglossal nerve in the neck and to intercostal muscles in the chest. The device is turned on at bedtime with a remote control. With each breath, the hypoglossal nerve is stimulated, the tongue moves forward out of the airway and the airway is opened.

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High Blood Pressure Linked To Sleep Apnea

A national multi-center study which includes researchers at the Johns Hopkins School of Public Health confirms a possible connection between sleep apnea and hypertension in both older and middle-aged adults. The study, which appears in the April 12, 2000, issue of Journal of the American Medical Association, found those who suffer from moderate to severe sleep apnea were at increased risk of having high blood pressure.

Sleep apnea, characterized by snoring and frequent pauses in breathing during sleep, is a relatively common condition, most notably in those who are overweight. “As a result of this study, we now believe that sleep apnea may be one of the reasons why overweight people are at increased risk for high blood pressure,” said lead author Javier Nieto, MD, associate professor, Epidemiology, Johns Hopkins School of Public Health. “The connection is important because high blood pressure can lead to serious adverse health consequences, including heart attack, stroke, and kidney disease.”

Support for this study was provided by a grant from the National Heart, Lung, and Blood Institute of the National Institutes of Health.

Sleep Apnea Creates Norepinephrine Spikes In The Body

Can Obstructive Sleep Apnea cause Pulmonary Hypertension?

When your airway is blocked or constricted at night when youre asleep, your body must find a way to open up the airway so you can breathe. It does this by releasing norepinephrine, also sometimes referred to as adrenaline. Norepinephrine is the main awake neurotransmitter in the brain, and it arouses the brain to signal the throat to open up and let air in.

Although most people dont actually wake up, the arousal is enough to increase the muscle tone in the throat and return it to how it normally is during the day. Unfortunately, the norepinephrine release also creates a fight or flight response in your body that increases your heart rate, as well as your blood pressure.

Its release is so effective at raising blood pressure in the body, norepinephrine is used in the ICU to treat people in shock and at risk of death for low blood pressure. This is because its the most powerful agent we know of to increase blood pressure.

The more frequently you have these respiratory events at night, the more norepinephrine youre going to release, and the more your blood pressure will rise. This can make keeping blood pressure under control exceedingly difficult if you have undiagnosed sleep apnea or arent properly treated.

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Why Do The Pulmonary Arteries Narrow

Scientists believe that the process starts with injury to the layer of cells that line the small blood vessels of the lungs. This injury, which occurs for unknown reasons, may cause changes in the way these cells interact with the smooth muscle cells in the vessel wall. As a result, the smooth muscle contracts and grows more than is normal and narrows the vessel.

Role Of Obstructive Sleep Apnea In Htn

Heart disease and stroke are leading causes of death and disability. High blood pressure is a major risk factor for both.

The 2017 guidelines regarding Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure were recently published, which is an update incorporating new information from studies regarding BP-related risk of cardiovascular disease and strategies to improve hypertension treatment and control.

Screening for secondary causes of HTN is necessary for new-onset or uncontrolled HTN in adults, including drug-resistant HTN. Screening includes testing for obstructive sleep apnea, which is highly prevalent in this population.

Obstructive sleep apnea is a common chronic condition characterized by recurrent collapse of upper airways during sleep, inducing intermittent episodes of apnea/hypopnea, hypoxemia, and sleep disruption .

It is estimated to affect 17% of US adults but is overwhelmingly underrecognized and untreated . The prevalence is higher in men than women. The major risk factors for OSA are obesity, male sex, and advancing age. Since these conditions oftentimes predispose to and are concomitant with HTN, it can be challenging to determine the independent effects of OSA on the development of HTN.

The relationship between obstructive sleep apnea and HTN has been a point of interest for decades, with untreated OSA being associated with an increased risk for developing new-onset HTN .

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Characteristics Of The Subjects

Of 19 patients with refractory hypertension, 16 were found to have OSA. Of these, 11 agreed to participate in the acute and chronic CPAP intervention studies. Their mean age was 57±2yrs and their mean body mass index was 34.4±2.4kg·m2. All patients had long-standing hypertension with an average duration of 17±3yrs. They had also been on antihypertensive medications for an average of 16yrs . Five subjects had coronary artery disease and two had hypertensive cardiomyopathy. Daytime clinic BP, measured by cuff, was 156±6 over 96±3mmHg. Antihypertensive medication consisted of a diuretic in nine, a calcium-channel blocker in 11, a -adrenergic blocker in eight and an angiotensin-converting enzyme inhibitor in 10 subjects. Subjects had moderately severe OSA, indicated by an AHI of 36.6±6.6 h1, frequency of movement arousals of 39.7±6.0·h1, and a lowest Sa,O2 of 81.4±2.2%.

What Is The Relationship Between Sleep Apnea And Blood Pressure

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Of the two types of sleep apnea, only OSA is linked to high blood pressure. CSA isnt a known cause of hypertension, but it develops in 30 to 50% of people with heart failure.

The prevalence of OSA is estimated to be between 4 and 7% of the general population, but it affects 30 to 40% of people with hypertension. Of people diagnosed with OSA, it is estimated that around half also have high blood pressure.

In healthy individuals, blood pressure naturally lowers by between 10 and 20% at night, a phenomenon that is sometimes referred to as blood pressure dipping. People with severe OSA experience blood pressure dips of less than 10%, which indicates a nondipping blood pressure pattern.

People who have nondipping blood pressure at night face an increased risk for cardiovascular issues. Additionally, many patients with OSA experience a sudden and pronounced elevation of their blood pressure when they wake up in the morning. This morning surge is another factor that may increase risk for cardiovascular disease. Moderate to severe OSA increases all-cause and cardiovascular mortality.

OSA doesnt only affect blood pressure at night. Studies show that daytime blood pressure levels also increase with sleep apnea severity.

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How Hypertension Affects Your Body

Its normal for your blood pressure to fluctuate throughout the day, but its not normal for it to be consistently high.

Left untreated, hypertension can damage your heart and contribute to severe health issues that can lead to a disability or even premature death. Some of these include:

  • Cardiovascular Disease
  • Stroke
  • Kidney Disease or Failure

As mentioned earlier, about half of people experiencing hypertension have obstructive sleep apnea as well. Hypertension doesnt cause sleep apnea, but there is a connection between the two.

Resistant Hypertension And Sleep Apnea

For some with high blood pressure, even after taking your daily medications your numbers can still be dangerously high. This issue, known as Resistant Hypertension, is a medical condition in which blood pressure isnt easily controlled. To resolve resistant hypertension a good place to start is by informing your doctor of the issue.

One of the treatments that can work for Resistant Hypertension is CPAP therapy3. If youre currently undergoing treatment with a CPAP machine and your blood pressure isnt going down, you might want to check your sleep data from the previous night to see if any improvements can be made to ensure your number of nightly apneas are as low as possible.

Here are some tips for improving the quality of your sleep and the effectiveness of CPAP therapy:

  • Use an APAP machine. Unlike CPAPs, which use one set pressure, APAP machines offer the advantage of being able to provide different pressures during the night, depending on what your body needs. If your body needs a higher pressure for any reason your APAP machine is able to automatically adjust and keep you getting restful sleep.
  • Get a machine with smart data. Many machines, like the AirSense 10 APAP, offer advanced data tracking features, allowing you to optimize your sleep without additional visits to the doctors office. With the AirSense, some of the data you can track and improve on includes the following:
  • Usage Hours
  • Mask Seal
  • Apnea Events per Hour

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Does Sleep Apnea Cause High Blood Pressure

Sleep Apnea plays a very important role in causing high blood pressure, but it is not the only cause1. High blood pressure has been linked to many things, including:

  • Diet
  • Caffeine Intake
  • Sleep Conditions

Improving any one of these risk factors can lower your blood pressure. Studies have also found that in instances where a persons blood pressure is being treated but is not fully regulated, Sleep Apnea treatment can help.

Typically, Sleep Apnea treatment involves using Continuous Positive Airway Pressure therapy through either a CPAP machine, APAP machine, or BiPAP machine to blow pressurized air into the airway, causing the relaxed muscles of the airway and throat to open up.

This, in turn, allows air to reach the lungs. Provided you use your therapy equipment regularly, it can help raise blood oxygen during sleep. As blood oxygen saturation goes up, blood pressure goes down.

Sleep Apnea can also indirectly influence blood pressure. If youre not sleeping, you may go through your day tired. In these situations, you may consume more caffeine to help stay awake. Increased caffeine consumption can lead to higher blood pressure readings. If Sleep Apnea is adequately treated, you may need less caffeine to stay awake.

Pharmacological Treatments Effects On Blood Pressure

Study Signals Way to Block Sleep Apnea

There are surprisingly few studies examining the impact of BP lowering medication in OSA patients with hypertension. Only one small RCT with 20 patients examined the five major antihypertensive drug classes. The study used a balanced incomplete block randomization design with each patient receiving two drugs, each for 6 weeks, in a randomized order with a 3 week washout. This resulted in each agent being tested in eight patients. This study found similar reductions in daytime BP across all classes. Although the small sample size could have limited the ability to detect between class differences in BP lowering, beta-blocker and diuretic therapy did reduce nighttime BP more than the other agents. Unfortunately, this poses a problem because both beta-blockers and diuretics have been associated with increased risk of new onset diabetes,, with beta-blocker therapy being associated with a greater incidence of cardiovascular morbidity and mortality. There is, however, some encouraging new data suggesting that antihypertensive treatment with a mineralocorticoid receptor antagonist in OSA patients with resistant hypertension substantially improves both BP and OSA severity. The latter effect may be mediated through a reduction in upper airway edema, and if confirmed in larger randomized trials, these agents may provide a promising treatment for hypertension in this group.

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Even When Awake The Effects Of Obstructive Sleep Apnea Can Cause Your Blood Pressure To Stay Elevated

Apneic periods, or moments when you stop breathing, that occur while you sleep can cause your blood pressure to remain high throughout the day.

âSleep apnea can cause hypertension due to the drops in blood oxygenation during apneic periods,â Liphart Rhoads explains. âWhen this is a frequent occurrence, blood pressure continues to stay elevated even when adequate oxygenation is not a problem.â

Stressed Out: How Sleep Apnea Causes High Blood Pressure

Your body undergoes a great deal of stress during each abnormal breathing event. This triggers something called your “sympathetic nervous system” to kick in. This is also called the “fight or flight response,” which causes a number of negative physiological things to occur inside your body, including a spike in blood pressure and a drop in your oxygen level. Studies that have measured blood pressure directly through a catheter implanted in an arm artery showed systolic blood pressure rising well into the 190s during abnormal obstructive breathing events.

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Current Research Indicates A Connection Between Obstructive Sleep Apnea And Hypertension

A 2018 article published by the Journal of Hypertension notes that the connection between obstructive sleep apnea and both acute and chronic increases in blood pressure is well-established by scientific literature.

While central sleep apnea is common in patients with advanced heart failure, these patients typically have low blood pressure. The relationship between central sleep apnea and hypertension, if there is any, is therefore currently unclear.

What Is The Link Between Obstructive Sleep Apnea And Hypertension

HBP 020- How is snoring and sleep apnea linked to High Blood Pressure

According to the American Heart Association, obstructive sleep apnea is implicated as a factor in the development of hypertension. Recent studies show that 50% of patients with hypertension also have associated obstructive sleep apnea. The Wisconsin Sleep Cohort study, which was a long-term sleep heart health study, also found that individuals with untreated severe sleep-disordered breathing were 2.6 times more likely to experience coronary heart disease or heart failure than adults without this disorder.

So, there is evidence that sleep apnea affects blood pressure. In individuals without these conditions, blood pressure naturally dips at night. Studies show that some people with OSA dont experience this dip in blood pressure. These individuals are referred to as nondipping. The prevalence of nondipping OAS patients may indicate a link between high blood pressure and obstructive sleep apnea.

Obstructive sleep apnea impairs sleep quality by shortening sleep intervals. This causes elevated blood pressure. Why is this? Obstructive sleep apnea causes disrupted or limited breathing while you are asleep. When breathing is limited, oxygen levels in the body can drop. This drop in blood oxygen levels causes an increase in blood flow. Increased blood flow puts pressure on the blood vessels walls which causes elevated blood pressure levels. This suggests a connection between sleep apnea and blood pressure spikes.

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