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OBSTRUCTIVE SLEEP APNEA AS A CAUSE OF HYPERTENSION Yüksel Peker MD, PhD, Associate Professor

OBSTRUCTIVE SLEEP APNEA AS A CAUSE OF HYPERTENSION Yüksel Peker MD, PhD, Associate Professor Sleep Medicine Unit, Skaraborg Hospital, Skövde & University of Gothenburg, Sweden. ASSOCIATIONS. OSA. Hypertension. Hypertension. OSA. OSAS. Obesity. OSA. Hypertension.

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OBSTRUCTIVE SLEEP APNEA AS A CAUSE OF HYPERTENSION Yüksel Peker MD, PhD, Associate Professor

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  1. OBSTRUCTIVE SLEEP APNEA AS A CAUSE OF HYPERTENSION Yüksel Peker MD, PhD, Associate Professor Sleep Medicine Unit, Skaraborg Hospital, Skövde & University of Gothenburg, Sweden

  2. ASSOCIATIONS

  3. OSA Hypertension

  4. Hypertension OSA OSAS

  5. Obesity OSA Hypertension

  6. Aging Hypertension OSA Gender Obesity

  7. OSA • Immediate changes • Long-term effects

  8. Grote L. et al., J. Cardiovasc. Pharmacol. 1994

  9. Cardiovascular mechanisms (I) Repeated nocturnal hypoxemia Coccogna G et al, 1972; Podszus T et al, 1986 Sympathetic nervous activity Fletcher EC et al, 1987; Hedner J et al, 1988; Narkiewicz K & Somers VK 2003 Vascular endothelial dysfunction Carlson J et al, 1996; Remsburg S et al, 1999; Kraiczi H et al, 2000

  10. Cardiovascular mechanisms (II) Enhanced release of superoxide from polymorphonuclear neutrophils in OSA. Impact of CPAP. Schulz Ret al, AJRCCM 2000 Plasma vascular endothelial growth factor in OSAS: Effects of CPAP. Lavie L et al, AJRCCM 2002 Elevated levels of C-reactive protein and interleukin-6 in patients with OSAS are decreased by CPAP. Yokoe Tet al, Circulation 2003

  11. OSA & Hypertension • Sleep clinic population • Hypertensive population • General population

  12. OSAS as a risk factor for hypertension (sleep-clinic population, n=2677) Lavie P et al; BMJ 2000;320:479-482

  13. OSA & Hypertension • Sleep clinic population • Hypertensive population • General population

  14. Prevalence of OSA in hypertension-clinic populations OSA 30% in unselected patients with hypertension Kales et al, 1984; Fletcher et al, 1985 OSA 56% in non-responding HT, 19% in responding HT Isaksson & Svanborg, 1991 All “non-dippers” (n=10) but none in “dippers” had OSA Portaluppi F et al, J Hypertension 1997

  15. OSA & Hypertension • Sleep clinic population • Hypertensive population • General population

  16. OSA & Hypertension (cross-sectional data) Adjusted OR for HT 1.37 (95% CI 1.03-1.83) (comparing AHI>30 vs AHI<1.5)

  17. CAUSAL RELATIONSHIP

  18. Causal relation • OSA causes hypertension? • Hypertension causes OSA?

  19. 50-60 apneas / h of sleep

  20. All normotensive at baseline AJRCCM 2002

  21. Ambulatory BP after therapeutic and subtherapeutic CPAP for OSA: a randomised parallel trial • Normotensive & Hypertensive • OSAS (n=118) • More BP-reduction in hypertensives • More BP-reduction in severe OSAS Pepperell J et al, LANCET 2001; 359: 204-210

  22. Effect of CPAP treatment on BP in patients with OSAS • Moderate to severe OSAS with HT (n=60) • Randomized to therapeutic vs subtherapeutic CPAP; follow-up 9 w • 32 subjects completed (16 in each group) • AHI reduction 95% versus 50% • BP reduction 10 mmHg versus no change (p=0.01) • Reduction in both systolic & diastolic BP, both daytime & at night • The drop in mean BP by 10mmHg would be predicted to reduce CAD-event risk by 37% and stroke risk by 56% Becker HF et al, Circulation 2003;107:68-73

  23. OSA & Hypertension (cross-sectional data) Adjusted OR for HT 1.37 (95% CI 1.03-1.83) (comparing AHI>30 vs AHI<1.5)

  24. n.s.? Gender differences? Nieto FJ et al, JAMA 2000; 283:1829-36

  25. OSA & Hypertension (cross-sectional data) • Gender differences in a population-based cohort • n=344 patients • 183 HT, 161 normotensives • Matched for age and gender • Ambulatory home PSG • Independent association between OSA and hypertension in men • Not identifiable in these essentially postmenopausal females • The contribution of OSA to hypertension risk may be sex-dependent and higher in males than in females

  26. Endothelial function during menstrual, follicular and luteal phase S-Estradiol: M phase: 122 pmol/L; F phase: 632 pmol/L; L phase: 534 pmol/L adapted from Hashimoto M et al, Circulation 1995; 92:3431-5

  27. GENDER AND HYPERTENSION Endothelial dysfunction Endothelial dysfunction starts in men a decade earlier than in women Celermajer DS et al, J Am Coll Cardiol 1994; 24:71-6 Age related impairment of endothelium-dependent vasodilatation is only observed after menopause Taddei S et al, Hypertension 1996; 28:576-82

  28. Influence of menopause on blood pressure Staessen JA et al, J Hum Hypertens 1998; 12:587-92

  29. Hormone Replacement Therapy and Longitudinal Changes in BP in Postmenopausal Women After 10 Years n=226 Normotensive at baseline Scuteri A et al, Ann Intern Med 2001;135:229-38

  30. Obesity causes hypertension? OSA causes hypertension?

  31. CONCLUSIONS (I) • Recurrent obstructive events during sleep, independently or in concert with other recognized risk factors, seem to have harmful effects on vascular structure and function • Development of hypertension in OSA is likely to depend on genotypic and phenotypic factors • Not only may OSA induce hypertension but also the events in themselves may worsen the response to antihypertensive medication

  32. CONCLUSIONS (II) • OSA should be considered among factors regarding the primary and secondary prevention models of hypertension • OSA should be treated not only to eliminate daytime sleepiness. Treatment may also have a beneficial prognostic impact by reducing blood pressure levels in hypertensive patients. • However, more RCT are necessary to address this impact in “non-sleepy” OSA subjects with hypertension

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