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Cabrini ML, Macedo TA, Castro E, de Barros S, Azam I, Pio-Abreu A, Silva GV, Lorenzi-Filho G, Bortolotto LA, Drager LF. Obstructive sleep apnea and hypertension-mediated organ damage in nonresistant and resistant hypertension. Hypertens Res 2023; 46:2033-2043. [PMID: 37264121 DOI: 10.1038/s41440-023-01320-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 04/12/2023] [Accepted: 05/02/2023] [Indexed: 06/03/2023]
Abstract
The potential role of obstructive sleep apnea (OSA) in hypertension-mediated organ damage (HMOD) may be influenced by the presence of resistant hypertension (RH). Herein, we enrolled patients with hypertension from a tertiary center for clinical evaluation and performed a sleep study to identify OSA (apnea-hypopnea index ≥15 events/h) and a blinded analysis of four standard HMOD parameters (left ventricular hypertrophy [LVH], increased arterial stiffness [≥10 m/s], presence of retinopathy, and nephropathy). RH was diagnosed based on uncontrolled blood pressure (BP) (≥140/90 mmHg) despite concurrent use of at least three antihypertensive drug classes or controlled BP with concurrent use of ≥4 antihypertensive drug classes at optimal doses. To avoid the white-coat effect, ambulatory BP monitoring was performed to confirm RH diagnosis. One-hundred patients were included in the analysis (mean age: 54 ± 8 years, 65% females, body mass index: 30.4 ± 4.5 kg/m²). OSA was detected in 52% of patients. Among patients with non-RH (n = 53), the presence of OSA (52.8%) was not associated with an increased frequency of HMOD. Conversely, among patients with RH, OSA (51.1%) was associated with a higher incidence of LVH (RH-OSA,61%; RH + OSA,87%; p = 0.049). Logistic regression analysis using the total sample revealed that RH (OR:7.89; 95% CI:2.18-28.52; p = 0.002), systolic BP (OR:1.04; 95% CI:1.00-1.07; p = 0.042) and OSA (OR:4.31; 95% CI:1.14-16.34; p = 0.032) were independently associated with LVH. No significant association was observed between OSA and arterial stiffness, retinopathy, or nephropathy. In conclusion, OSA is independently associated with LVH in RH, suggesting a potential role of OSA in RH prognosis.
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Affiliation(s)
- Mayara L Cabrini
- Unidade de Hipertensão, Departamento de Clinica Medica, Disciplina de Nefrologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Thiago A Macedo
- Unidade de Hipertensão, Instituto do Coração (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Emerson Castro
- Unidade de Hipertensão, Instituto do Coração (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Silvana de Barros
- Unidade de Hipertensão, Departamento de Clinica Medica, Disciplina de Nefrologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Indira Azam
- Unidade de Hipertensão, Departamento de Clinica Medica, Disciplina de Nefrologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Andrea Pio-Abreu
- Unidade de Hipertensão, Departamento de Clinica Medica, Disciplina de Nefrologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Giovanio V Silva
- Unidade de Hipertensão, Departamento de Clinica Medica, Disciplina de Nefrologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Geraldo Lorenzi-Filho
- Laboratório do Sono, Divisão de Pneumologia, Instituto do Coração (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Luiz A Bortolotto
- Unidade de Hipertensão, Instituto do Coração (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Luciano F Drager
- Unidade de Hipertensão, Departamento de Clinica Medica, Disciplina de Nefrologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil.
- Unidade de Hipertensão, Instituto do Coração (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil.
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Effect of CPAP treatment on BP in resistant hypertensive patients according to the BP dipping pattern and the presence of nocturnal hypertension. Hypertens Res 2021; 45:436-444. [PMID: 34952953 DOI: 10.1038/s41440-021-00762-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 08/14/2021] [Accepted: 08/19/2021] [Indexed: 11/08/2022]
Abstract
High heterogeneity in the blood pressure (BP) response to continuous positive airway pressure (CPAP) exists in patients with resistant hypertension (RH). Only nondipper normotensive and hypertensive patients exhibited BP reductions when treated with CPAP; the baseline BP dipping pattern has been proposed as a predictor of BP response to CPAP but has never been explored in patients with RH. This study aimed to assess the effect of CPAP on BP in subjects with RH with respect to BP dipping pattern or nocturnal hypertension. This is an ancillary study of the SARAH study. RH subjects with an apnea/hypopnea index (AHI) ≥ 15/h and who received CPAP treatment for 1 year were included. Subjects underwent a sleep study and ambulatory BP monitoring (ABPM) at baseline and at the 1-year follow-up. Eighty-nine RH subjects were included. The subjects were mainly male (77.5%) and obese, with a mean age of 66 years (25th-75th percentile; 59.0; 70.0) and an AHI of 32.7/h (25th-75th percentile; 25.0; 54.7). A total of 68.5% of participants were nondippers, and 71.9% had nocturnal hypertension. After 1 year of CPAP, no significant differences in ABPM parameters were observed between dippers and nondippers. According to nighttime BP, subjects with nocturnal normotension did not show significant changes in ABPM parameters, while nocturnal hypertensive subjects achieved a significant reduction in mean nighttime BP of -4.38 mmHg (-7.10 to -1.66). The adjusted difference between groups was 3.04 (-2.25 to 8.34), which was not significant. This study shows that the BP response to CPAP in patients with RH does not differ according to the BP dipping pattern (dipper and nondipper) and suggests a differential response according to the presence of nocturnal hypertension (ClinicalTrials.gov: NCT03002558).
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Zhang X, Zhang N, Yang Y, Wang S, Yu P, Guan BY, Wang CX. Characteristics of Obstructive Sleep Apnea Patients With Hypertension and Factors Associated With Autotitration Acceptance. Front Psychiatry 2021; 12:706275. [PMID: 35058810 PMCID: PMC8764373 DOI: 10.3389/fpsyt.2021.706275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 11/29/2021] [Indexed: 12/01/2022] Open
Abstract
In order to explore the characteristics and treatment status of obstructive sleep apnea (OSA) patients with hypertension, a retrospective study was conducted on 306 patients admitted from October 2018 to December 2019. According to the apnea hypopnea index (AHI), OSA patients with hypertension were divided into three groups. 69 cases were mild OSA (5 ≤ AHI < 15), 86 cases were moderate (15 ≤ AHI < 30), and 151 cases were severe (AHI ≥ 30). Compared with patients in the mild and moderate groups, the severe group had more male patients, with higher body mass index (BMI) and non-rapid eye movement stage 1 accounted for total sleep time (N1%), and lower non-rapid eye movement stage 2 accounted for total sleep time (N2%), average and minimum blood oxygen. Among all the patients, those who underwent the titration test accounted for 20.6% (63/306). Multivariate analysis showed that sleep efficiency (p < 0.001) and AHI (p < 0.001) were independent factors for patients to accept titration test. OSA patients with hypertension had a low acceptance of titration therapy. These people with higher sleep efficiency and AHI were more likely to receive autotitration.
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Affiliation(s)
- Xuan Zhang
- Department of Neurology, Beijing Tian Tan Hospital, Capital Medical University, Beijing, China.,Department of Neuropsychiatry and Behavioral Neurology and Clinical Psychology, Beijing Tian Tan Hospital, Capital Medical University, Beijing, China
| | - Ning Zhang
- Department of Neuropsychiatry and Behavioral Neurology and Clinical Psychology, Beijing Tian Tan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Department of Clinical Psychology, Capital Medical University, Beijing, China
| | - Yang Yang
- Department of Neuropsychiatry and Behavioral Neurology and Clinical Psychology, Beijing Tian Tan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Shuo Wang
- Department of Neuropsychiatry and Behavioral Neurology and Clinical Psychology, Beijing Tian Tan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Ping Yu
- Department of Neurology, Beijing Tian Tan Hospital, Capital Medical University, Beijing, China.,Department of Neuropsychiatry and Behavioral Neurology and Clinical Psychology, Beijing Tian Tan Hospital, Capital Medical University, Beijing, China
| | - Bo-Yuan Guan
- Department of Neuropsychiatry and Behavioral Neurology and Clinical Psychology, Beijing Tian Tan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Chun-Xue Wang
- Department of Neuropsychiatry and Behavioral Neurology and Clinical Psychology, Beijing Tian Tan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Department of Clinical Psychology, Capital Medical University, Beijing, China.,Beijing Institute of Brain Disorders, Beijing, China
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The HIPARCO-2 study: long-term effect of continuous positive airway pressure on blood pressure in patients with resistant hypertension: a multicenter prospective study. J Hypertens 2020; 39:302-309. [PMID: 33239552 DOI: 10.1097/hjh.0000000000002664] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Short-term treatment with continuous positive airway pressure (CPAP) produces a clinically significant reduction in blood pressure (BP) in patients with obstructive sleep apnea (OSA) and resistant hypertension. However, it is unknown whether this effect continues over the long-term. Our objective was to assess the effect of long-term CPAP on BP in patients with OSA and resistant hypertension. METHODS The study included 161 patients diagnosed with both OSA [apnea--hypopnea index (AHI) ≥15] and resistant hypertension diagnosed via 24-hour ambulatory BP measurement (24-h ABPM), in whom a second analysis via 24-h ABPM was performed at the end of the follow-up. RESULTS Patients were followed up within 59 months [interquartile range (IQR): 44-70]. CPAP treatment was prescribed to 82% of the patients (70% with good adherence to CPAP defined as use of CPAP at least 4 h/night). A comparison between the adherent group and nonadherent group (including those with CPAP not prescribed) showed that CPAP adherents had a significant drop in the 24-h BP, both systolic [-3.9 mmHg; 95% confidence interval (CI): -8.1 to 0.3] and diastolic pressure (-3.5 mmHg [95% [CI]: -6.4-0.5]), with a higher magnitude during the night (-5.5 and -4.9 mmHg, respectively). The CPAP adherent group needed a mean of 1.1 less antihypertensive drugs (particularly spironolactone). Finally, there was a positive correlation between the drop in 24-h SBP and the hours of CPAP use (r = 0.24; P = 0.01). CONCLUSION Good adherence to long-term CPAP treatment largely succeeded in significantly reducing BP in those patients with OSA and resistant hypertension, despite the use of a lower number of antihypertensive drugs.
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Posadas T, Campos-Rodriguez F, Sapiña-Beltrán E, Oscullo G, Torres G, Martinez-Garcia MA. Obstructive Sleep Apnea and Arterial Hypertension: Implications of Treatment Adherence. Curr Hypertens Rep 2020; 22:12. [DOI: 10.1007/s11906-020-1015-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Resistant/Refractory Hypertension and Sleep Apnoea: Current Knowledge and Future Challenges. J Clin Med 2019; 8:jcm8111872. [PMID: 31694223 PMCID: PMC6912579 DOI: 10.3390/jcm8111872] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Revised: 10/28/2019] [Accepted: 11/01/2019] [Indexed: 12/20/2022] Open
Abstract
Hypertension is one of the most frequent cardiovascular risk factors. The population of hypertensive patients includes some phenotypes whose blood pressure levels are particularly difficult to control, thus putting them at greater cardiovascular risk. This is especially true of so-called resistant hypertension (RH) and refractory hypertension (RfH). Recent findings suggest that the former may be due to an alteration in the renin-angiotensin-aldosterone axis, while the latter seems to be more closely related to sympathetic hyper-activation. Both these pathophysiological mechanisms are also activated in patients with obstructive sleep apnoea (OSA). It is not surprising, therefore, that the prevalence of OSA in RH and RfH patients is very high (as reflected in several studies) and that treatment with continuous positive airway pressure (CPAP) manages to reduce blood pressure levels in a clinically significant way in both these groups of hypertensive patients. It is therefore necessary to incorporate into the multidimensional treatment of patients with RH and RfH (changes in lifestyle, control of obesity and drug treatment) a study of the possible existence of OSA, as this is a potentially treatable disease. There are many questions that remain to be answered, especially regarding the ideal combination of treatment in patients with RH/RfH and OSA (drugs, renal denervation, CPAP treatment) and patients' varying response to CPAP treatment.
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Prevalence, Characteristics, and Association of Obstructive Sleep Apnea with Blood Pressure Control in Patients with Resistant Hypertension. Ann Am Thorac Soc 2019; 16:1414-1421. [DOI: 10.1513/annalsats.201901-053oc] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
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Drager LF, Lorenzi-Filho G. POINT: Should Sleep Studies Be Performed for All Patients With Poorly Controlled Hypertension? Yes. Chest 2019; 155:1095-1097. [DOI: 10.1016/j.chest.2019.04.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Accepted: 04/04/2019] [Indexed: 01/20/2023] Open
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Rebuttal From Drs Cardoso and Salles. Chest 2019; 155:1102-1103. [DOI: 10.1016/j.chest.2019.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Accepted: 04/04/2019] [Indexed: 11/19/2022] Open
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Rebuttal From Drs Drager and Lorenzi-Filho. Chest 2019; 155:1101-1102. [DOI: 10.1016/j.chest.2019.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Accepted: 04/04/2019] [Indexed: 11/19/2022] Open
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Kramer HJ, Townsend RR, Griffin K, Flynn JT, Weiner DE, Rocco MV, Choi MJ, Weir MR, Chang TI, Agarwal R, Beddhu S. KDOQI US Commentary on the 2017 ACC/AHA Hypertension Guideline. Am J Kidney Dis 2019; 73:437-458. [PMID: 30905361 PMCID: PMC6740329 DOI: 10.1053/j.ajkd.2019.01.007] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Accepted: 01/08/2019] [Indexed: 02/07/2023]
Abstract
Hypertension is a modifiable risk factor for cardiovascular morbidity and mortality and reduction of elevated blood pressure (BP) remains an important intervention for slowing kidney disease progression. Over the past decade, the most appropriate BP target for initiation and titration of BP-lowering medications has been an area of intense research and debate within the clinical community. In 2017, the American College of Cardiology and the American Heart Association (ACC/AHA) in conjunction with several other professional societies released new hypertension guidelines based on data from a systematic review of clinical trials and observational data. While many of the recommendations in the ACC/AHA hypertension guideline are relevant to nephrology practice, BP targets and management strategies for patients receiving dialysis are not discussed. This Kidney Disease Outcomes Quality Initiative (KDOQI) commentary focuses largely on recommendations from the ACC/AHA hypertension guidelines that are pertinent to individuals at risk of chronic kidney disease or with non-dialysis-dependent chronic kidney disease. This KDOQI commentary also includes a brief discussion of the consensus statement regarding hypertension diagnosis and management for adults receiving maintenance dialysis published by the European Renal and Cardiovascular Medicine Working Group of the European Renal Association-European Dialysis and Transplant Association (ERA-EDTA) and the Hypertension and the Kidney working group of the European Society of Hypertension. Overall, we support the vast majority of the ACC/AHA recommendations and highlight select areas in which best diagnosis and treatment options remain controversial.
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Affiliation(s)
- Holly J Kramer
- Department of Public Health Sciences, Loyola University Chicago Stritch School of Medicine, Maywood; Department of Medicine, Loyola University Chicago Stritch School of Medicine, Maywood; Hines VA Medical Center, Hines, IL.
| | - Raymond R Townsend
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Karen Griffin
- Department of Medicine, Loyola University Chicago Stritch School of Medicine, Maywood; Hines VA Medical Center, Hines, IL
| | - Joseph T Flynn
- Department of Pediatrics, University of Washington School of Medicine, Seattle WA
| | | | - Michael V Rocco
- Department of Medicine, Wake Forest School of Medicine, Winston-Salem, NC
| | - Michael J Choi
- Department of Medicine, Johns Hopkins School of Medicine
| | - Matthew R Weir
- Division of Nephrology, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD
| | - Tara I Chang
- Department of Medicine, Stanford Medical School, Palo Alto, CA
| | - Rajiv Agarwal
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN
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The Use of Precision Medicine to Manage Obstructive Sleep Apnea Treatment in Patients with Resistant Hypertension: Current Evidence and Future Directions. Curr Hypertens Rep 2018; 20:60. [PMID: 29884918 DOI: 10.1007/s11906-018-0853-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE OF REVIEW The significant prevalence of resistant hypertension (RH) and the high cardiovascular risk of the population of patients with RH have indicated the necessity to identify its main causes. Among these, obstructive sleep apnea (OSA) is considered the most well-established cause. RECENT FINDINGS In recent years, several studies have shown a beneficial effect of continuous positive airway pressure (CPAP) treatment on blood pressure (BP), but this effect exhibits great variability. The diagnosis and management of OSA in patients with RH suggest a clinical option for a phenotype of patients for whom therapeutic strategies are limited to pharmaceutical therapy and renal denervation. However, the great variability in the CPAP response has increased the necessity to develop instruments to identify patients who could benefit from a treatment that reduces BP. Application of precision medicine to these patients should be considered as a first-line intervention to avoid the prescription of ineffective treatments and excessive consumption of pharmacological drugs that do not ameliorate the cardiovascular risk.
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