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Aims: Arterial hypertension is highly prevalent and difficult to control in patients with obstructive sleep apnea (OSA). High sympathoadrenergic activity is a hallmark physiological phenomenon in OSA. We hypothesized that an antihypertensive drug with inhibitory properties on this activity, such as beta blockers (BBs), may be particularly efficacious in OSA patients., Methods: Hypertensive OSA patients receiving blood pressure-lowing treatment in the European Sleep Apnea Database (ESADA) (n = 5818, 69% men, age 58 ± 11 years, body mass index 33 ± 7 kg/m2, apnea hypopnea index 34 ± 26 events/h) were analyzed. Reported medications [BB, diuretic, renin-angiotensin blocker (RAB), calcium channel blocker (CCB), and centrally acting antihypertensive (CAH)] were classified according to ATC code. Office blood pressure was compared in patients with monotherapy or combination therapy controlling for confounders., Results: Poorly controlled SBP according to the ESC/ESH guidelines was found in 66% of patients. Patients receiving monotherapy with RAB, CCB or CAH had 2.2 (95% CI 1.4-3.0), 3.0 (1.9-4.1) and 3.0 (1.7-4.7) mmHg higher SBP compared with those on BB (adjusted model, P = 0.007, 0.008 and 0.017, respectively). In those with a combination of two antihypertensive drugs, SBP was 5.5 (4.0-7.1), 5.1 (3.7-6.6), 4.3 (2.5-6.1) and 3.1 (1.6-4.6) mmHg higher in those on CCB/RAB, BB/RAB, BB/CCB or diuretic/RAB compared with those on BB/diuretic (adjusted model, P < 0.001, <0.001, 0.018 and 0.036, respectively)., Conclusion: Poorly controlled blood pressure was common in OSA patients with antihypertensive medication. Treatment with BB alone or BB in combination with a diuretic was associated with the lowest systolic pressure in this large clinical cohort., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: Reflection of the finger pulse wave form is a valid measure of arterial stiffness, which may be continuously assessed during sleep. We investigated the relationships between sleep, sleep-disordered breathing, hypertension, and pulse propagation time (PPT) in patients with suspected sleep apnea., Methods: The digital photoplethysmographic signal derived from finger pulse oximetry was recorded during overnight sleep studies in 440 patients (64% men, age 55 ± 12 years, BMI 30 ± 6 kg/m, apnea-hypopnea index 19 ± 19 n/h). PPT, defined as the time interval between the systolic and diastolic peak of the finger pulse wave, was calculated. The influence of sleep stages on PPT were assessed in patients undergoing polysomnography. Generalized linear models were used to study predictors of PPT and hypertension., Results: Mean overnight PPT was independently associated with age (β = -1.34, P < 0.001), height (β = 0.47, P = 0.047), history of smoking (β = -9.44, P = 0.005), and apnea-hypopnea index (β = -0.18, P = 0.043). PPT was shorter in hypertensive patients compared with normotensive patients (160 ± 33 vs. 177 ± 47 ms, P < 0.001) and independently associated with a diagnosis of hypertension (P = 0.043). PPT was influenced by sleep stage (highest PPT during slow wave sleep compared with wake and all other sleep stages, all P < 0.001) and varied across sleep apnea severity groups in normotensive but not in hypertensive patients (P = 0.028 and 0.64, respectively)., Conclusion: Overnight PPT by oximetry was strongly associated with factors known to determine daytime vascular stiffness. In addition, PTT provides information on functional and structural vascular properties during sleep. This novel technique offers new opportunities to noninvasively monitor vascular function during the sleeping period.

Objectives: Conventional methods for cardiovascular disease risk stratification are based on quantification of recognized risk factors or assessment of biomarkers during the wake period. We evaluated an algorithm on the basis of a photoplethysmographic pulse wave recording during sleep for cardiovascular risk assessment., Methods: Five hundred and twenty individuals (346 men, age 55.0 ± 13.4 years, BMI 29.9 ± 6.  kg/m) with suspected sleep apnoea were randomly recruited at five sleep centres. Individual cardiovascular risk scores were calculated in accordance with established cardiovascular risk matrixes (ESH/ESC, Framingham, SCORE, PROCAM scores). A digital photoplethysmographic pulse wave signal was continuously recorded during the night using an oximeter sensor. An algorithm based on eight separate hypoxic and pulse wave derived parameters was trained in 130 individuals and validated in 390 individuals for low/high cardiovascular risk classification., Results: All derived parameters were associated with elevated ESH/ESC risk in univariate analysis and five in the multiple logistic regression model [discrimination index C = 0.8, Chi-square (7) = 69, P < 0.0001]. The combined algorithm detected high-risk patients (validation set, ESH/ESC risk classes 4 and 5) with a sensitivity, specificity, positive predictive value and negative predictive value of 74.5, 76.4, 69.0 and 81.0%, respectively. Significant associations were also found for the Framingham, SCORE and PROCAM scores. The computed risk scores in individuals with/without (n = 34/356) a previous history of cardiovascular event (myocardial infarction, transitory ischemic attack or stroke) were 0.71 ± 0.27 and 0.42 ± 0.34 (P < 0.001), respectively., Conclusion: Parameters derived from modified pulse oximetry during sleep may provide information on cardiovascular function. Combined signal analysis may be used for recognition of individuals with established cardiovascular risk in a sleep laboratory cohort.

Objectives: Apnea hypopnea index (AHI) is used to study the association between obstructive sleep apnea (OSA) and hypertension, but the independent contributions of total sleep time (TST) and apnea/hypopnea event count to hypertension have not been previously investigated. We studied the relationship between polysomnographically assessed TST and hypertension in a sex-balanced community-dwelling cohort of hypertensive patients and normotensive controls (Skara Sleep Cohort)., Methods: Participants (n = 344, men 173, age 61.2 ± 6.5 years, BMI 28.6 ± 4.8 kg/m, mean ± SD) underwent ambulatory home polysomnography. Hypertension was defined according to contemporary Swedish national guidelines. A multivariate logistic regression model was used to predict hypertension status from TST and apnea/hypopnea count (total events/night) adjusting for sex, age and BMI., Results: OSA was highly prevalent in this population (AHI 26 ± 4 events/h). Hypertensive patients had shorter TST than normotensive patients (353 ± 81 vs. 389 ± 65 min, P < 0.001), whereas total apnea/hypopnea count did not differ (167 ± 138 vs. 146 ± 148 events/night, P = 0.2). Multivariate logistic regression analysis revealed that short TST was associated with hypertension status [odds ratio 2.0; 95% confidence interval (95% CI) 1.2-3.3; P = 0.0015]. The significant association between apnea/hypopnea count and hypertension status was nonlinear (odds ratio 2.6; 95% CI 1.2-5.8; P = 0.04). The type of antihypertensive treatment was not found to significantly influence TST., Conclusion: Short sleep time assessed by polysomnography was associated with hypertension in this community-dwelling population. Short sleep and presence of sleep apnea appear to independently link to hypertension.

This article is aimed at addressing the current state of the art in epidemiology, pathophysiology, diagnostic procedures and treatment options for appropriate management of obstructive sleep apnea (OSA) in cardiovascular (particularly hypertensive) patients, as well as for the management of cardiovascular diseases (particularly arterial hypertension) in OSA patients. The present document is the result of the work done by a panel of experts participating in the European Union COST (COoperation in Scientific and Technological research) ACTION B26 on OSA, with the endorsement of the European Respiratory Society (ERS) and the European Society of Hypertension (ESH). These recommendations are particularly aimed at reminding cardiovascular experts to consider the occurrence of sleep-related breathing disorders in patients with high blood pressure. They are at the same time aimed at reminding respiration experts to consider the occurrence of hypertension in patients with respiratory problems at night.

Objective: Obstructive sleep apnoea (OSA) confers a risk of hypertension and cardiovascular complications. Both the renin-angiotensin-aldosterone system and OSA are important determinants of blood pressure, but it is not fully known how they interact. The aim of this study was to explore the interaction between the angiotensin-converting enzyme (ACE) gene insertion/deletion (I/D) polymorphism and OSA in the association with hypertension., Design: A community-based, case-control design with hypertensive patients in primary care (n = 157) and normotensive population controls (n = 181)., Methods: All subjects underwent ambulatory polysomnography during one night. OSA was defined by a minimum of 10 apnoea/hypopnoea events per hour. Office blood pressure was measured and hypertension status was assessed. The genotypes were determined using polymerase chain reaction., Results: An interaction analysis including sex, ACE I/D polymorphism (DD and ID versus II), and OSA identified a significant interaction between OSA and the ACE I/D polymorphism: odds ratio (OR) 6.3, 95% confidence interval (CI) 1.8-22.5, P = 0.004 as well as between OSA and sex: OR 3.3, 95% CI 1.1-9.6, P = 0.033. OSA was significantly associated with hypertension in men but not in women., Conclusion: The interaction between the ACE gene I/D polymorphism and OSA appears to be an important mechanism in the development of hypertension, particularly in men.

Objectives: We investigated whether the severity of obstructive sleep apnea (OSA) predicts blood pressure or cardiac left ventricular thickness in a clinical population of OSA patients, if adjustments are made for age, gender, use of antihypertensive agents, smoking, body mass index, history of coronary artery disease, hypercholesterolemia and circulating C-peptide concentrations., Design: Relationships in this cross-sectional study were investigated with correlation analysis and multiple regression procedures., Patients and Methods: Apnea-hypopnea index (AHI, polysomnography) and office systolic and diastolic blood pressures (SBP and DBP) were measured in 81 subjects referred to a university hospital sleep laboratory. Ambulatory blood pressures were recorded during one 24 h cycle. Left ventricular (LV) muscle size was quantified as two-dimensionally directed M-mode-derived end-diastolic thickness of interventricular septum and posterior chamber wall., Results: After adjustment for separate or the entire set of covariates, AHI predicted office SBP and DBP as well as daytime ambulatory DBP and night-time ambulatory SBP and DBP, but not daytime ambulatory SBP. In contrast, associations between AHI and LV muscle thickness reflected complex inter-relationships with confounding variables. Smoking and age suppressed, whereas body mass index (BMI) and hypertension inflated the relationship between OSA severity and LV muscle thickness in this study., Conclusions: AHI is an independent predictor of several measures of blood pressure. OSA severity and LV muscle thickness appear to be primarily linked via increased blood pressure.

Objective: To test the hypothesis that sleep-related breathing disorder (SRBD) is associated with increasing severity of cardiovascular risk markers., Design: A cross-sectional study of sleep laboratory patients., Setting: University Hospital Sleep Disorders Centre., Patients: We studied 591 patients referred for a sleep study, all of them without a history of systemic hypertension., Interventions: Clinical interview, two unattended sleep studies, and assessment of office blood pressure, cholesterol concentration, alcohol and nicotine consumption and daytime blood gases., Main Outcome Measure: Post-hoc analysis of different cardiovascular risk markers: mean blood pressure, pulse pressure, and the type and grade of systemic hypertension., Results: Patients were classified as normotensive (blood pressure < 140/90 mmHg, n = 228) or hypertensive (blood pressure > or = 140/90 mmHg, n = 363) according to office blood pressure measurements. Mixed (systolic and diastolic) hypertension was the most common type of hypertension (n = 182), followed by isolated diastolic hypertension (n = 101), borderline isolated systolic hypertension (n = 70), and isolated systolic hypertension (n = 10). The frequency of mixed hypertension increased with SRBD activity (P < 0.05) and respiratory disturbance index (RDI; the number of breathing disorders per hour of estimated sleep time) was increased in those with mixed hypertension compared with those with normotension (24.8 compared with 15.7; t test: P < 0.01). In hypertensive patients classified as having grades 1 -3 of hypertension (n = 265, 80 and 18, respectively), there was a progressive increase in RDI (18.9, 27.2 and 30.3, respectively, P < 0.01). Mean blood pressure increased significantly with RDI. Pulse pressure increased significantly with age (P < 0.001), but was unrelated to the degree of SRBD., Conclusion: We conclude that mean blood pressure and the severity of hypertension, but not pulse pressure, increase with the severity of the SRBD.

Objective: To test the hypothesis that sleep-related breathing disorder (SRBD) is associated with poor blood pressure control in hypertensive patients independent from confounding factors such as age, body mass index, alcohol, smoking and daytime blood gases., Design and Methods: This cross-sectional study of a sleep laboratory cohort was carried out at the University Hospital Sleep Disorders Centre, Marburg. The study comprised 599 patients referred for a sleep study, all of them with a documented history of systemic hypertension and/or previously initiated antihypertensive therapy. Data were obtained from a clinical interview, two unattended sleep studies and assessment of clinic blood pressure, cholesterol level, alcohol and nicotine consumption and daytime blood gases. The main outcome measure was a post hoc analysis of predictors for poor blood pressure control., Results: Respiratory disturbance index (RDI) was significantly higher in patients with uncontrolled hypertension (blood pressure > or = 160 and/or 95 mmHg, n = 463) than in those with controlled hypertension (n = 136) (34.0 +/- 26.8 versus 27.0 +/- 23.5, P < 0.01). The relative proportion of patients with uncontrolled hypertension increased significantly as SRBD activity increased (chi2, P< 0.05). Body mass index was the only independent predictor (P = 0.006) of uncontrolled hypertension in the whole study sample. However, in the subset of patients aged < or = 50 years, RDI (P= 0.006) and age (P = 0.016) were the only independent predictors. The probability of uncontrolled hypertension increased by approximately 2% (B = 0.019, P= 0.006) for each RDI unit., Conclusion: SRBD should be considered, in addition to traditional confounders, as a risk factor for poor blood pressure control in younger hypertensive patients (< or = 50 years of age).

Normotensive young men (36 +/- 5 years old) with positive family histories of hypertension (n = 11) and age-matched controls (n = 21) with negative family histories of hypertension were examined. The control group was divided into one group matched for body mass index with those subjects with positive family histories (n = 10) and one group with normal body mass index (n = 11). Blood pressure, central venous pressure (CVP), plasma atrial natriuretic peptide (ANP) and serum aldosterone were examined at a baseline and during an acute volume load with 1000 ml saline solution. Subjects with positive family histories and controls matched for body mass index had a higher blood pressure at baseline than controls with normal body mass index. CVP and serum aldosterone did not differ between the three groups, while sodium intake and plasma concentrations of ANP were significantly higher in subjects with positive family histories. During volume loading, CVP increased significantly more in subjects with positive family histories as compared with the two control groups. A blunted response to ANP was observed during volume loading in subjects with positive family histories, while subjects in the two control groups demonstrated comparable and significant increases in circulating ANP. Serum aldosterone, however, decreased during volume loading in all three groups, with no difference between the groups. We conclude that normotensive subjects with positive family histories are characterized by increased basal concentrations of ANP and exhibit a blunted response to an acute volume load.(ABSTRACT TRUNCATED AT 250 WORDS)

To evaluate cardiac structure and function as well as blood pressure in the obstructive sleep apnoea syndrome (OSAS), we investigated 61 male patients and 61 male controls with M-mode and two-dimensional echocardiography. All patients had a history of habitual snoring and a diagnosed light to severe OSAS by previous investigations of nocturnal oxygen saturation status. No subject in the control group had a history of OSAS or hypertension. Body weight was higher in the OSAS patients than in the controls (P less than 0.001). Fifty per cent (31 out of 61) of the OSAS patients had systemic hypertension; 17 of these 31 were on pharmacological antihypertensive treatment. Neither the systolic nor the diastolic blood pressures were found to correlate to the severity of the OSAS (desaturation index). The heart rate was higher at rest in the OSAS patients with or without systemic hypertension compared to the controls with or without a blood pressure level above 165/95 mmHg (P less than 0.05 and P less than 0.01, respectively). Left ventricular (LV) internal dimensions as assessed by echocardiography did not differ between the two groups, while the interventricular septum and the LV posterior wall were thicker in the OSAS group. Thus, the LV mass and the LV mass index were significantly higher among the OSAS patients (P less than 0.001 and P less than 0.001). The LV mass index was approximately 15% higher among the 30 normotensive OSAS patients with no history of cardiac disease compared with the normotensive controls (P less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)