Blood-pressure variability in patients with obstructive sleep apnea: current perspectives

Figures & data

Figure 1 Measurements of morning blood pressure surge (MBPS).

Notes: Sleep-trough MBPS definition: mean blood pressure in the 2 hours following morning awakening – lowest nocturnal blood pressure (measured as the mean of three measurements centered on the lowest nocturnal value). Prewaking MBPS definition: mean blood pressure in the 2 hours following morning awakening – mean blood pressure in the 2 hours preceding morning awakening. Copyright ©2003. American Heart Association, Inc. Reproduced from Kario K, Pickering TG, Umeda Y, et al. Morning surge in blood pressure as a predictor of silent and clinical cerebrovascular disease in elderly hypertensives: a prospective study. Circulation. 2003;107(10):1401–1406 (https://www.ahajournals.org/doi/10.1161/01.cir.0000056521.67546.aa).²⁹

Figure 2 Different blood-pressure profiles in two subjects with high sleep-trough morning blood pressure surge (MBPS).

Notes: High MBPS may or may not be associated with low nocturnal blood pressure. Copyright ©2005. American Journal of Hypertension, Ltd. Reproduced from Kario K. Time for focus on morning hypertension: pitfall of current antihypertensive medication. Am J Hypertens. 2005;18(2 Pt 1):149–151, by permission of Oxford University Press.³⁵

Figure 3 Means ± SD of (A) ΔPs and (B) ΔPd values in control (□) and obstructive sleep apnea (◊) subjects for each sampling interval.

Notes: ΔPs and ΔPd: differences in mmHg between the mean nocturnal blood pressure values, respectively systolic and diastolic, obtained from sampled single heart beats and from all heart beats. Copyright ©2000. ERS Journals Ltd. Reproduced from Marrone O, Romano S, Insalaco G, Bonsignore MR, Salvaggio A, Bonsignore G. Influence of sampling interval on the evaluation of nocturnal blood pressure in subjects with and without obstructive sleep apnoea. Eur Respir J. 2000;16(4):653–658.⁵³

Figure 4 Fragment of a polygraph recording in a representative sleepy patient with severe obstructive sleep apnea.

Notes: Patient undergoing simultaneous continuous finger blood pressure monitoring and ambulatory blood pressure monitoring (ABPM). Top to bottom: pressure detected by an open hose placed under the cuff for ABPM measurements; beat-by-beat blood pressure (BP); nasal airflow; oxyhemoglobin saturation (SaO₂). A flat airflow signal identifies apnea time. In this patient, apnea duration was similar before and during ABPM measurement, which indicates that the cuff inflation did not cause any arousal shortening habitual apnea duration. ABPM measurement required a time exceeding the duration of an apnea cycle, ie, of an apnea and following ventilation. During that period, BP values largely varied, but only one systolic and one diastolic value were obtained by ABPM.

Table 1 Studies based on morning and evening BP measurements

Authors	Subjects under study	Findings
Hoffstein and Mateika^Citation58	611 suspected OSA	If AHI <10: BP morning < BP evening If AHI 10–≤50: BP morning = BP evening If AHI >50: BP morning > BP evening
Sforza and Lugaresi^Citation48	253 suspected OSA	In both simple snorers and OSA: BP morning > BP evening SBP evening-to-morning rise correlated to AHI
Stradling et al^Citation59	448 subjects from general population	ODI4 and mean nocturnal respiratory effort independently correlated with evening-to-morning BP rise
Lavie-Nevo and Pillar^Citation61	2,009 suspected OSA	SBP and DBP evening-to-morning rise correlated with AHI in men, but not in women
Ting et al^Citation63	263 simple snorers, UARS or OSA	Subjects with morning:evening BP ratio >11% (“morning surge” pattern) or with mean both morning and evening BP >130 mmHg (“constant high”) had higher AHI, lower lowest SaO2, longer T<90% and higher arousal index than subjects with morning:evening BP ratio <11% (“morning drop”) or both morning and evening mean BP <130 mmHg (“constant low”); similar percentage of sleep stages in all groups
Huang et al^Citation64	105 positional and 266 non- positional OSA	Morning BP higher in nonpositional OSA; evening BP and evening-to-morning BP difference similar in positional and nonpositional OSA
Wang et al^Citation60	3246 OSA + 354 controls	Progressive increase in morning/evening mean BP with increasing OSA severity
Mokros et al^Citation62	454 normotensive suspected OSA	AHI linearly correlated with evening-to-morning DBP rise, but not SBP rise

Note: Arousal index, number of arousals per hour; ODI₄, number of oxyhemoglobin saturation falls ≥4% per hour.

Abbreviations: AHI, apnea/hypopnea index; BP, blood pressure; DBP, diastolic BP; ODI, oxygen desaturation index; OSA, obstructive sleep apnea; SaO₂, oxyhemoglobin saturation; SBP, systolic BP; T<90%, time spent with oxyhemoglobin saturation <90%; UARS, upper airway resistance syndrome.

Table 2 24-Hour BP characteristics in obstructive sleep apnea: beyond dipping and nondipping

Authors	Subjects under study	Profiles
Noda et al^Citation76	21 OSA + 123 non-OSA	Type 1: normal BP throughout the 24-hour period with nocturnal BP fall (OSA + non-OSA) Type 2: progressive BP elevation from onset of sleep to early morning (hypertensive OSA) Type 3: elevated BP at any time (hypertensive OSA)
Nagata et al^Citation77	5 non-OSA, 10 mild OSA, 12 moderate OSA, 27 severe OSA	Nocturnal BP: moderate and severe OSA > non OSA Morning BP: severe OSA > non OSA Nocturnal BP fall: severe OSA < non OSA Diurnal and evening BP: OSA = non OSA
Sasaki et al^Citation78	103 OSA	Sustained type: both diurnal and nocturnal hypertension; profile related to OSA severity and sleep disruption Surge type: only morning hypertension; profile related to reduced SWS Control type: neither diurnal nor nocturnal hypertension Nocturnal hypertension only: not analyzed, few patients
Cho et al^Citation79	Hypertensives, 35 OSA + 23 non-OSA	Sleep-trough morning SBP surge: OSA > non-OSA

Abbreviations: BP, blood pressure; OSA, obstructive sleep apnea; SBP, systolic BP; SWS, slow-wave sleep.

Table 3 Changes in BP variability associated with CPAP treatment

Methodology	Authors	Subjects, design	BP variability changes
Beat-by-beat BP measurements	Ali et al^Citation39	8 OSA with and without CPAP	In a 30-minute period during sleep, lower coefficient of variation of SBP and DBP with than without CPAP
	Sforza et al^Citation46	25 OSA with and without CPAP	During first night with CPAP, decreased coefficient of variation of SBP and DBP in all sleep stages
	Bonsignore et al^Citation116	10 normotensive OSA before OSA treatment and after treatment withdrawal	In the first night of CPAP withdrawal after a 5.5±3.7-month treatment, lower SD of SBP and DBP during stage NREM2, but not during waking, than before CPAP initiation
	Marrone et al^Citation50	13 OSA under no pharmacological therapy before OSA treatment and after treatment withdrawal	In apneic cycles during the first night of CPAP withdrawal after a 4.9±3.4-month treatment, smaller SBP and DBP surges than in apneic cycles occurring before CPAP initiation
	Bonsignore et al^Citation114	18 OSA with and without CPAP	In the first night with CPAP, decrease in SD of both SBP and DBP in stages NREM2 and REM, and decrease only in SD of DBP during nocturnal waking
	Carter et al^Citation115	17 OSA with OHS with and without CPAP	During the first night (titration) and after 6 weeks with CPAP, similar reduction in the rate of nocturnal BP surges
ABPM measurements	Pankow et al^Citation67	34 OSA with and without CPAP	After 2–4 nights with CPAP, 17 of 27 who were nondippers at baseline showed dipping
	Engleman et al^Citation117	13 OSA with placebo and CPAP (crossover RCT)	After ≥3-week treatment, nonsignificant change in prevalence of nondipping BP pattern
	Akashiba et al^Citation70	38 OSA without and with CPAP	15 of 22 nondippers at baseline showed dipping at the third day of CPAP therapy
	Bao et al^Citation86	41 OSA with placebo or CPAP (parallel RCT)	In patients receiving CPAP for either 1 or for 7 nights and in patients receiving placebo, similar decrease in SD of SBP, DBP, and MBP both during the day and during the night
	Dursunoğlu et al^Citation118	12 OSA with and without auto- CPAP	The first day with autoadjusting CPAP, reduction in SD of SBP, DBP and MBP at night, but not during the day
	Campos-Rodriguez et al^Citation119	68 hypertensive OSA with placebo or CPAP (parallel RCT)	After a 4-week treatment, proportion of patients turning BP pattern from nondipper to dipper not significantly different between placebo and CPAP
	Wang et al^Citation120	60 mild OSA and 48 moderate–severe OSA with hypertension with and without CPAP	After 3-month CPAP or surgery, 23 of 31 mild OSA and 19 of 28 moderate–severe OSA patients turned from nondippers to dippers
	Martínez-García et al^Citation121	194 OSA with resistant hypertension with and without CPAP (parallel RCT)	After 12 weeks, fewer patients treated by CPAP than controls showed nondipper or riser profiles
	Muxfeldt et al^Citation122	117 moderate–severe OSA with resistant hypertension with placebo or CPAP (parallel RCT)	After 6 months, NS difference between CPAP and placebo treatment in prevalence of nondipping and riser BP patterns
	Lemmer et al^Citation123	17 OSA with and without CPAP	5 of 14 nondippers at baseline showed dipping after 8 weeks with CPAP
Office or home BP measurements	Pengo et al^Citation124	78 OSA with and without auto- CPAP	After a 3-week autoadjusting CPAP therapy, decrease in SD of three repeated waking SBP but not DBP measurements
	Lettau et al^Citation92	175 OSA continuing or withdrawing CPAP (parallel RCT)	After a 2-week CPAP withdrawal, increased SD of three consecutive office morning SBP but not of DBP measurements; in the same period, no effect on day-to-day BP variability

Abbreviations: ABPM, ambulatory blood pressure monitoring; CPAP, continuous positive airway pressure; DBP, diastolic BP; MBP, mean BP; NREM, non-rapid eye movement; OSA, obstructive sleep apnea; RCT, randomized controlled trial; SBP, systolic BP.

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