Skip to main content

Main menu

  • Home
  • Content
    • Current Issue
    • Ahead of Print
    • Past Issues
    • Supplements
    • Article Type
  • Specialty
    • Articles by Specialty
  • CME/MOC
    • Articles
    • Calendar
  • Info For
    • Manuscript Submission
    • Authors & Reviewers
    • Subscriptions
    • About CCJM
    • Contact Us
    • Media Kit
  • Conversations with Leaders
  • Conference Coverage
    • Kidney Week 2024
    • CHEST 2024
    • ACR Convergence 2023
    • Kidney Week 2023
    • ObesityWeek 2023
    • IDWeek 2023
    • CHEST 2023
    • MDS 2023
    • IAS 2023
    • ACP 2023
    • AAN 2023
    • ACC / WCC 2023
    • AAAAI Meeting 2023
    • ACR Convergence 2022
    • Kidney Week 2022
    • AIDS 2022
  • Other Publications
    • www.clevelandclinic.org

User menu

  • Register
  • Log in

Search

  • Advanced search
Cleveland Clinic Journal of Medicine
  • Other Publications
    • www.clevelandclinic.org
  • Register
  • Log in
Cleveland Clinic Journal of Medicine

Advanced Search

  • Home
  • Content
    • Current Issue
    • Ahead of Print
    • Past Issues
    • Supplements
    • Article Type
  • Specialty
    • Articles by Specialty
  • CME/MOC
    • Articles
    • Calendar
  • Info For
    • Manuscript Submission
    • Authors & Reviewers
    • Subscriptions
    • About CCJM
    • Contact Us
    • Media Kit
  • Conversations with Leaders
  • Conference Coverage
    • Kidney Week 2024
    • CHEST 2024
    • ACR Convergence 2023
    • Kidney Week 2023
    • ObesityWeek 2023
    • IDWeek 2023
    • CHEST 2023
    • MDS 2023
    • IAS 2023
    • ACP 2023
    • AAN 2023
    • ACC / WCC 2023
    • AAAAI Meeting 2023
    • ACR Convergence 2022
    • Kidney Week 2022
    • AIDS 2022
1-Minute Consult

Should I suspect obstructive sleep apnea if a patient has hard-to-control hypertension?

Harneet K. Walia, MD
Cleveland Clinic Journal of Medicine June 2016, 83 (6) 419-421; DOI: https://doi.org/10.3949/ccjm.83a.15112
Harneet K. Walia
Center for Sleep Disorders, Cleveland Clinic
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • For correspondence: [email protected]
  • Article
  • Figures & Data
  • Info & Metrics
  • PDF
Loading

Yes. Obstructive sleep apnea is common and is associated with hypertension and resistant hypertension. Physicians taking care of patients who have hard-to-control hypertension should be aware of the possible diagnosis of obstructive sleep apnea and screen them for it. In-laboratory polysomnography or home sleep testing should be offered if appropriate, and if obstructive sleep apnea is detected, it should be treated, as this treatment may help to control blood pressure more effectively.

OBSTRUCTIVE SLEEP APNEA IS COMMON

Obstructive sleep apnea is characterized by recurrent episodes of partial or complete collapse of the upper airway during sleep, with partial collapse leading to hypopnea and complete collapse leading to apnea. These episodes result in intermittent hypoxemia, microarousals, sleep fragmentation, daytime sleepiness, and impairment in quality of life.

In tandem with the increasing obesity epidemic, the prevalence of moderate to severe obstructive sleep apnea is 17% in men and 9% in women 50 to 70 years old.1

LINKED TO HYPERTENSION

The respiratory events that occur in obstructive sleep apnea are associated with blood pressure surges during sleep that can cause persistent elevated blood pressure while awake. Obstructive sleep apnea has been independently associated with incident hypertension in large epidemiologic studies, even after correction for confounding factors such as obesity and its surrogate markers.

Moreover, the more severe the obstructive sleep apnea, the greater the risk of incident hypertension.2 And large, long-term observational studies have shown higher incidence rates of hypertension in people with untreated obstructive sleep apnea than in those who underwent treatment for it with continuous positive airway pressure (CPAP).3

BRIEF ANSWERS TO SPECIFIC CLINICAL QUESTIONS

Obstructive sleep apnea is also associated with nocturnal nondipping of blood pressure (defined as failure of blood pressure to decline by at least 10% during sleep), which is an independent marker for worse cardiovascular outcomes and hypertension-induced target organ damage.

Obstructive sleep apnea is particularly common in those with drug-resistant hypertension,4 which is defined as a suboptimal control of blood pressure despite the use of multiple antihypertensive medications of different classes, a condition associated with significant rates of cardiovascular morbidity and mortality. Even in patients at high risk of cardiovascular disease, we found that those with severe obstruction of the upper airway during sleep had fourfold higher odds of having resistant elevated blood pressure.5

Obstructive sleep apnea is common; suspect it if hypertension is difficult to treat

The seventh Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure recognized obstructive sleep apnea as one of the causes of secondary hypertension.6 The 2013 European Society of Hypertension/European Society of Cardiology guidelines7 suggested an evaluation of obstructive sleep apnea symptoms for the management of hypertension.

MECHANISMS LINKING OBSTRUCTIVE SLEEP APNEA AND HYPERTENSION

Pathophysiologic mechanisms that may explain the association between obstructive sleep apnea and hypertension include stimulation of sympathetic activity,8 increased arterial stiffness, and endothelial dysfunction driven by apnea-related intermittent hypoxemia.9 Increased systemic inflammation and oxidative stress caused by obstructive sleep apnea are other proposed mechanisms.

Conversely, resistant hypertension may worsen obstructive sleep apnea. Some propose that activation of the renin-angiotensin-aldosterone system can cause parapharyngeal edema and rostral fluid shifts during sleep and thereby increase upper airway obstruction and worsen the severity of obstructive sleep apnea.10

CONSIDER SCREENING

Patients with resistant hypertension and risk factors for obstructive sleep apnea should be screened for it, as it is very common in this population.

A simple screening tool that can be used to detect sleep apnea is the STOP-BANG questionnaire11:

  • Snore: Have you been told that you snore loudly?

  • Tired: Are you often tired during the day?

  • Observed apnea: Do you know if you stop breathing, or has anyone witnessed you stop breathing while sleeping?

  • Pressure: Do you have or are you being treated for high blood pressure?

  • Body mass index: Is your body mass index greater than 35 kg/m2?

  • Age: older than 50?

  • Neck circumference: greater than 40 cm?

  • Gender: Male?

A score of 3 or more indicates a high risk of obstructive sleep apnea, and further workup for it is appropriate. Some of the other symptoms and signs are listed in Table 1.

View this table:
  • View inline
  • View popup
TABLE 1

Signs and symptoms of obstructive sleep apnea

SLEEP STUDIES: IN THE LABORATORY OR AT HOME

In-laboratory polysomnography entails electrooculography, electromyography, electroencephalography, electrocardiography, pulse oximetry, and measurement of oronasal flow and thoracoabdominal movement (using sensors and belts). It should be performed in patients who have significant comorbid conditions.

A home sleep study, which is more limited than polysomnography, is appropriate in those who have a high probability of obstructive sleep apnea and who do not have other sleep disorders or significant cardiovascular, neurologic, or respiratory disorders.

Subsequently, if obstructive sleep apnea is found, a positive airway pressure titration study is performed to determine the optimal pressure requirements.

CPAP IS THE GOLD STANDARD TREATMENT

Behavioral changes are recommended to correct factors that predispose to obstructive sleep apnea or aggravate it. These changes include avoiding alcohol, sleeping on one’s side rather than supine, weight reduction in overweight individuals, and treating nasal congestion. In some situations, oral appliances or surgical options can be considered. However, CPAP is the gold standard therapy and the one most commonly used.

CPAP LOWERS BLOOD PRESSURE

Effective treatment of obstructive sleep apnea, added to an antihypertensive regimen, can further lower the blood pressure more than the antihypertensive medication regimen by itself.

Several meta-analyses have shown modest improvements in blood pressure with CPAP in hypertensive patients. CPAP’s effect on blood pressure seems to be more pronounced in those with resistant hypertension, in whom a meta-analysis of randomized controlled trials demonstrated a mean reduction in systolic blood pressure of 6.74 mm Hg and a mean reduction in diastolic blood pressure of 5.94 mm Hg.12 A recent clinic-based (“real-world”) study revealed lowering of blood pressure in patients with resistant and nonresistant hypertension—approximately 2 to 3 mm Hg after CPAP therapy.13

Furthermore, a randomized controlled trial in Spain showed that the nocturnal nondipping pattern observed in patients with resistant hypertension was reversed with the use of CPAP.14

  • Copyright © 2016 The Cleveland Clinic Foundation. All Rights Reserved.

REFERENCES

  1. ↵
    1. Peppard PE,
    2. Young T,
    3. Barnet JH,
    4. Palta M,
    5. Hagen EW,
    6. Hla KM
    . Increased prevalence of sleep-disordered breathing in adults. Am J Epidemiol 2013; 177:1006–1014.
    OpenUrlCrossRefPubMed
  2. ↵
    1. Peppard PE,
    2. Young T,
    3. Palta M,
    4. et al
    . Prospective study of the association between sleep-disordered breathing and hypertension. N Engl J Med 2000; 342:1378–1384.
    OpenUrlCrossRefPubMed
  3. ↵
    1. Marin JM,
    2. Agusti A,
    3. Villar I,
    4. et al
    . Association between treated and untreated obstructive sleep apnea and risk of hypertension. JAMA 2012; 307:2169–2176.
    OpenUrlCrossRefPubMed
  4. ↵
    1. Logan AG,
    2. Perlikowski SM,
    3. Mente A,
    4. et al
    . High prevalence of un-recognized sleep apnoea in drug-resistant hypertension. J Hypertens 2001; 19:2271–2277.
    OpenUrlCrossRefPubMed
  5. ↵
    1. Walia HK,
    2. Li H,
    3. Rueschman M,
    4. et al
    . Association of severe obstructive sleep apnea and elevated blood pressure despite antihyperten-sive medication use. J Clin Sleep Med 2014; 10:835–843.
    OpenUrlPubMed
  6. ↵
    1. Chobanian AV,
    2. Bakris GL,
    3. Black HR,
    4. et al
    5. Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure
    6. National Heart, Lung, and Blood Institute
    7. National High Blood Pressure Education Program Coordinating Committee
    . Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension 2003; 42:1206–1252.
    OpenUrlCrossRefPubMed
  7. ↵
    1. Mancia G,
    2. Fagard R,
    3. Narkiewicz K,
    4. et al
    5. Task Force Members
    . 2013 ESH/ESC guidelines for the management of arterial hypertension: the task force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). J Hypertens 2013; 31:1281–1357.
    OpenUrlCrossRefPubMed
  8. ↵
    1. Somers VK,
    2. Dyken ME,
    3. Clary MP,
    4. Abboud FM
    . Sympathetic neural mechanisms in obstructive sleep apnea. J Clin Invest 1995; 96:1897–1904.
    OpenUrlCrossRefPubMed
  9. ↵
    1. Jelic S,
    2. Bartels MN,
    3. Mateika JH,
    4. Ngai P,
    5. DeMeersman RE,
    6. Basner RC
    . Arterial stiffness increases during obstructive sleep apneas. Sleep 2002; 25:850–855.
    OpenUrlPubMed
  10. ↵
    1. Dudenbostel T,
    2. Calhoun DA
    . Resistant hypertension, obstructive sleep apnoea and aldosterone. J Hum Hypertens 2012; 26:281–287.
    OpenUrlCrossRefPubMed
  11. ↵
    1. Chung F,
    2. Yegneswaran B,
    3. Liao P,
    4. et al
    . STOP questionnaire: a tool to screen patients for obstructive sleep apnea. Anesthesiology 2008; 108:812–821.
    OpenUrlCrossRefPubMed
  12. ↵
    1. Iftikhar IH,
    2. Valentine CW,
    3. Bittencourt LR,
    4. et al
    . Effects of continuous positive airway pressure on blood pressure in patients with resistant hypertension and obstructive sleep apnea: a meta-analysis. J Hyper-tens 2014; 32:2341–2350.
    OpenUrlCrossRefPubMed
  13. ↵
    1. Walia HK,
    2. Griffith SD,
    3. Foldvary-Schaefer N,
    4. et al
    . Longitudinal effect of CPAP on BP in resistant and nonresistant hypertension in a large clinic-based cohort. Chest 2016; 149:747–755.
    OpenUrlPubMed
  14. ↵
    1. Martinez-Garcia MA,
    2. Capote F,
    3. Campos-Rodriguez F,
    4. et al
    5. Spanish Sleep Network
    . Effect of CPAP on blood pressure in patients with obstructive sleep apnea and resistant hypertension: the HIPARCO randomized clinical trial. JAMA 2013; 310:2407–2415.
    OpenUrlCrossRefPubMed
PreviousNext
Back to top

In this issue

Cleveland Clinic Journal of Medicine: 83 (6)
Cleveland Clinic Journal of Medicine
Vol. 83, Issue 6
1 Jun 2016
  • Table of Contents
  • Table of Contents (PDF)
  • Index by author
Print
Download PDF
Article Alerts
Sign In to Email Alerts with your Email Address
Email Article

Thank you for your interest in spreading the word on Cleveland Clinic Journal of Medicine.

NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

Enter multiple addresses on separate lines or separate them with commas.
Should I suspect obstructive sleep apnea if a patient has hard-to-control hypertension?
(Your Name) has sent you a message from Cleveland Clinic Journal of Medicine
(Your Name) thought you would like to see the Cleveland Clinic Journal of Medicine web site.
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
Citation Tools
Should I suspect obstructive sleep apnea if a patient has hard-to-control hypertension?
Harneet K. Walia
Cleveland Clinic Journal of Medicine Jun 2016, 83 (6) 419-421; DOI: 10.3949/ccjm.83a.15112

Citation Manager Formats

  • BibTeX
  • Bookends
  • EasyBib
  • EndNote (tagged)
  • EndNote 8 (xml)
  • Medlars
  • Mendeley
  • Papers
  • RefWorks Tagged
  • Ref Manager
  • RIS
  • Zotero
Share
Should I suspect obstructive sleep apnea if a patient has hard-to-control hypertension?
Harneet K. Walia
Cleveland Clinic Journal of Medicine Jun 2016, 83 (6) 419-421; DOI: 10.3949/ccjm.83a.15112
Twitter logo Facebook logo Mendeley logo
  • Tweet Widget
  • Facebook Like
  • Linkedin Share Button

Jump to section

  • Article
    • OBSTRUCTIVE SLEEP APNEA IS COMMON
    • LINKED TO HYPERTENSION
    • BRIEF ANSWERS TO SPECIFIC CLINICAL QUESTIONS
    • MECHANISMS LINKING OBSTRUCTIVE SLEEP APNEA AND HYPERTENSION
    • CONSIDER SCREENING
    • SLEEP STUDIES: IN THE LABORATORY OR AT HOME
    • CPAP IS THE GOLD STANDARD TREATMENT
    • CPAP LOWERS BLOOD PRESSURE
    • REFERENCES
  • Figures & Data
  • Info & Metrics
  • PDF

Related Articles

  • No related articles found.
  • PubMed
  • Google Scholar

Cited By...

  • No citing articles found.
  • Google Scholar

More in this TOC Section

  • Do I need to treat supine hypertension in my hospitalized patient?
  • What diagnostic tests should be done after discovering clubbing in a patient without cardiopulmonary symptoms?
  • Does my adult patient need a measles vaccine?
Show more 1-Minute Consult

Similar Articles

Subjects

  • Cardiology
  • Men's Health
  • Nephrology
  • Preventive Care
  • Sleep Medicine
  • Women's Health

Navigate

  • Current Issue
  • Past Issues
  • Supplements
  • Article Type
  • Specialty
  • CME/MOC Articles
  • CME/MOC Calendar
  • Media Kit

Authors & Reviewers

  • Manuscript Submission
  • Authors & Reviewers
  • Subscriptions
  • About CCJM
  • Contact Us
  • Cleveland Clinic Center for Continuing Education
  • Consult QD

Share your suggestions!

Copyright © 2025 The Cleveland Clinic Foundation. All rights reserved. The information provided is for educational purposes only. Use of this website is subject to the website terms of use and privacy policy. 

Powered by HighWire