Prognosis And Treatment Of Pulmonary Hypertension And Sleep Apnea
Between 17% and 53% of patients who suffer from sleep apnea also develop pulmonary hypertension, according to a 2004 American College of Chest Physicians consensus panel. The presence of both conditions makes the patient more susceptible to heart failure, stroke or sudden death. When diagnosed properly and early, treatments can be applied to help reduce the symptoms and the risk of death.
The study Obstructive Sleep Apnea, Cardiovascular Disease, and Pulmonary Hypertension, suggests that continuous positive airway pressure is effective in the treatment of patients to significantly improve cardiac function, sympathetic activity and quality of life. The treatment can help reduce pulmonary artery pressure, increase left ventricular function and functional capacity, and decrease norepinephrine levels.
Obstructive Sleep Apnoea And Hypertension: The Esada Study
Population-based epidemiological studies strongly implicate obstructive sleep apnoea as an independent risk factor for cardiovascular morbidity and mortality . Final proof of a causal relationship between OSA and premature cardiovascular disease, and the true strength of that relationship, will depend on the results of large, well-designed randomised controlled trials of OSA treatment, several of which are ongoing . In the meantime there is considerable interest in the various mechanistic pathways whereby OSA might lead to increased cardiovascular disease/events. A clearer understanding of these pathways will probably have practical therapeutic implications for reducing cardiovascular risk in OSA populations in the future. Devices such as continuous positive airway pressure and mandibular repositioning devices are effective treatments for OSA, but the reality is that they are found to be unacceptable or are used infrequently by many patients with OSA, particularly those who are minimally symptomatic. Other treatments directed specifically at mitigating cardiovascular risk in such patients may be needed and this will require a clear understanding of the dominant mechanisms for increased cardiovascular disease and/or cardiovascular events in OSA.
The Effect Of Osa Interventions On Comorbid Hypertension
Complex treatment of moderate/severe OSA is mandatory in the setting of hypertension, the expected results being a better quality of life of the patients and a more efficient blood pressure control.
The control of modifiable factors which contribute to both conditionsreducing obesity, smoking, and alcohol consumptionis considered a very effective, first step treatment modality of comorbid OSA and hypertension .
Oral appliance therapy, a treatment option in mild and moderate forms of OSA, also could improve blood pressure control in the case of concomitant hypertension .
Regarding the effect of antihypertensive drugs on OSA in hypertensive patients, the data do not support clearly a specific beneficial effect of the usually prescribed drugs . However, hypertensive patients with hyperaldosteronism and those with resistant hypertension could benefit from spironolactone as first choice therapy, with proven beneficial effects on OSA. Generally, diuretics by reducing fluid retention, including that at the level of parapharyngeal tissues, could ameliorate upper airway obstruction and OSA .
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Distinct Associations Between Hypertension And Obstructive Sleep Apnea In Male And Female Patients
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Affiliation Department of Cardiology, the Center Hospital of Minhang District, Shanghai, China
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Affiliation Department of Cardiology, the Center Hospital of Minhang District, Shanghai, China
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Affiliation Department of Cardiology, the Center Hospital of Minhang District, Shanghai, China
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Affiliation Department of Cardiology, the Center Hospital of Minhang District, Shanghai, China
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Affiliation Department of Cardiology, the Center Hospital of Minhang District, Shanghai, China
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Affiliation Department of Cardiology, the Center Hospital of Minhang District, Shanghai, China
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Affiliation Department of Cardiology, the Center Hospital of Minhang District, Shanghai, China
How Does Sleep Affect Ph
Good sleep health
When you get a full 8 hours of uninterrupted sleep, your body has the opportunity to heal damage all the way to the cellular level.
Deep sleep can only be achieved during long periods of consolidated sleep, and during this time, human growth hormone is released into the body to repair and recharge organs and tissues.
Someone who has PH may be able to better manage its symptoms and help prevent it from worsening, if they get enough sleep.
Poor sleep health
Without the benefit of a solid night of sleep, the body loses its opportunity to repair and recharge.
Both PH and OSA also share two common risk factorsone which can be controlled and another which cannot be controlled .
In addition, untreated sleep apnea or other variations of sleep-disordered breathing can contribute to the development and/or progression of PH.
How is sleep apnea related to PH?
According to research from the American College of Chest Physicians, between 17 and 53 percent of people with sleep apnea also develop pulmonary hypertension.
Sleep apnea can lead to increases in pulmonary artery pressure. These increases occur due to the repeating loss of oxygen in the bloodstream due to apneas.
Also problematic are apneas long cessations in breathing, which cause unhealthy changes to the internal pressure of the lungs. This also has an effect on artery and heart health in the long term if apneas are left untreated.
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How Hypertension Affects Your Body
High blood pressure contributes to hundreds of thousands of fatalities each year, with nearly half a million deaths in the United States alone. According to the Center for Disease Control, Tennessee has a high prevalence of hypertension in adults ages 20 and older, with an age-adjusted prevalence between 32 and 38.6 percent.
Left untreated, hypertension can damage your heart and contribute to severe health issues that can lead to a disability or even premature death. Some of these include:
- Cardiovascular Disease
- Kidney Disease or Failure
Changes In Pressure Within The Chest
When a person with obstructive sleep apnea attempts to breathe, they inhale against a narrowed or closed upper airway. These unsuccessful, forced inhalations can cause substantial changes in pressure within the chest cavity. Over time, these repetitive changes in intrathoracic pressure can damage the heart. Intrathoracic pressure changes can lead to atrial fibrillation , problems with blood flow to the heart, and even heart failure.
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Development And Diagnosis Of Pulmonary Hypertension And Sleep Apnea
Sleep apnea is known to contribute to the development of cardiovascular disease and pulmonary hypertension. It happens because the disease increases the risk of hypertension, pulmonary vascular disease, ischemic heart disease, stroke, congestive heart failure and arrhythmias. A study, Obstructive sleep apnea and pulmonary hypertension, concluded that the increase in pulmonary artery pressure is related to repetitive nocturnal arterial oxygen desaturation and hypercapnia, in addition to large intrathoracic negative pressure swings.
Because the disease causes the effects repeatedly, it results in pulmonary vascular remodeling, sustained pulmonary hypertension and right ventricular hypertrophy, as demonstrated in rodent tests. Both conditions share a series of risk factors that include age, gender, obesity, diabetes and hypertension. However, the American College of Chest Physicians does not consider screening for pulmonary hypertension needed for patients with sleep apnea unless there are suspicions, which can delay diagnosis and treatment, as well as accelerate the development of more severe consequences.
How Can Treating Sleep Apnea Lower My Risk
The good news is this: treating sleep apnea immediately lowers blood pressure at night and decreases your chances of stroke and cardiovascular complications.
New guidelines to measure high blood pressure, especially in the elderly, have increased the incidence of high blood pressure and formally recognized obstructive sleep apnea as a cause of secondary hypertension. These guidelines recommend more vigilance when it comes to sleep apnea screening for the elderly. They also recognize CPAP machines as a treatment for both sleep apnea and resistant hypertension.
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Activating The Sympathetic Nervous System
Each time a person with sleep apnea stops breathing, the level of oxygen in the blood decreases. As the body becomes deprived of oxygen, specialized cells called chemoreceptors detect these changes and activate the sympathetic nervous system to respond, which is the part of the nervous system responsible for reacting to stressful or dangerous situations. The sympathetic nervous system triggers the body to gasp for air, which sometimes wakes a person out of sleep.
The sympathetic nervous system also responds to a low level of oxygen by constricting blood vessels and increasing heart rate and blood pressure. As the pauses in breath continue throughout the night, repetitive changes in blood pressure may lead to hypertension or make existing hypertension worse.
What Is Obstructive Sleep Apnea
Obstructive sleep apnea is a sleep disorder in which breathing stops temporarily throughout the sleep cycle. Experts estimate that of the general population of the United States, about 22 million individuals are living with OSA. Out of these individuals, about 80% of the mild to moderate cases are undiagnosed. Breathing can stop for a few seconds or several minutes. These episodes of sleep apnea can occur a few times or dozens of times.
It is important to note that we are only discussing obstructive sleep apnea at the moment. This is because hypertension is only linked to obstructive sleep apnea and not the other kind of sleep apnea central sleep apnea.
Obstructive sleep apnea occurs when the muscles in the back of the throat and tongue relax. Consequently, blocking your airway and preventing breathing from happening. Episodes of obstructive sleep apnea typically end with the person waking up briefly in order to reopen his or her airway.
- Mood changes and difficulty concentrating
- Morning headaches
Diagnosis of obstructive sleep apnea generally requires a sleep study, which often uses a technique called polysomnography to measure breathing. If detected, there are several options for the treatment of OSA. Specific treatments will depend on OSA severity. Specialists measure OSA severity on a scale called the hypopnea index. The index measures the number of apneas that occur per hour.
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Why Do The Pulmonary Arteries Narrow
Scientists believe that the process starts with injury to the layer of cells that line the small blood vessels of the lungs. This injury, which occurs for unknown reasons, may cause changes in the way these cells interact with the smooth muscle cells in the vessel wall. As a result, the smooth muscle contracts and grows more than is normal and narrows the vessel.
The Proportion Of Subjects With Hypertension And Obesity And Age Increased With Osa Exacerbation In Males
The patients were stratified into mild , moderate , and severe OSA groups according to their AHI value, and the proportions with hypertension, diabetes, and obesity were plotted against the AHI stratification. The proportions of subjects with hypertension, diabetes, and obesity in the mild, moderate, and severe OSA groups were 12.3, 22.4, and 24.6% 5.5, 5.5, and 6.8% and 7.7, 13.7, and 15.4%, respectively . The proportion of subjects with hypertension and obesity increased significantly with aggravating OSA, whereas the proportion with diabetes was stable among the three OSA severity groups . Age also increased significantly with aggravating OSA .
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Do Different Antihypertensive Drug Classes Have Different Effects On Osas
Different antihypertensive drug classes may have different effects on the pathophysiological mechanisms involved in the pathogenesis of OSAS-related hypertension. However, the few studies that have comparatively assessed the BP-lowering effects of different drug classes in OSAS have had small sample sizes, and their statistical power has limited consistent conclusions. In a randomized study assessing the effects of different classes of antihypertensive drugs on office and ambulatory BP levels in patients with hypertension and OSAS, no significant differences between drug classes were observed in their ability to reduce office and daytime ambulatory BP levels. However, treatment with -blockers was more effective at reducing nighttime ambulatory BP than the administration of other compounds, most likely because of their effects on sympathetic activation. In general, however, no consistent evidence has shown superior antihypertensive efficacy for any antihypertensive drug in OSA patients. The long-term effects of treatment with different antihypertensive agents on hypertension severity in OSAS have not been systematically addressed in clinical trials. Evidence is therefore still needed to identify preferred compounds for an adequate BP control in this group of high-risk patients.
Sleep Apnea Forces The Heart To Work Harder
The airway blockages created by obstructive sleep apnea cause your blood pressure to increase, because your heart is working harder to get oxygenated blood flowing through your body.
While youre asleep, sleep apnea triggers the brain to pump more blood to key areas like the brain and heart. This puts added pressure on your artery walls and spikes your blood pressure higher than if you were breathing normally while asleep.
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Treating Your Sleep Apnea Can Also Help Treat High Blood Pressure
As your breathing improves and your oxygen levels stabilize in response to treatment for sleep apnea, your blood pressure may also get better. While you should always speak with your doctor before adjusting your medications, some people are able to reduce their intake of blood pressure medications following treatment for sleep apnea.
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.
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Sleep Duration And Hypertension
Hypertension is one of the leading causes of cardiovascular death and disability, with over 1.3 billion people suffering from hypertension across the whole world. Preliminary study suggests that blood pressure increases from extending sleep disorder. Both short as well as prolonged sleep can cause change in blood pressure level.
Research has already shown that short sleep sessions are common among teenagers, and thats the most common reason for fluctuating blood pressure levels. It is recommended to have 7-9 hours of sleep over 40 years of age to have a maintained blood pressure level.
What Are The Sleep Apnea Treatments
The treatments for this condition vary depending on the severity of the case and the type of sleep apnea. Some people use a continuous positive airway pressure machine for treatment, which pushes air through their nose or mouth into their throat, helping them breathe more easily during sleep. Others use oral appliances that hold open their mouth and jaw during sleep to prevent obstructions from occurring in their throats.
Other sleep apnea treatments include weight loss, quitting smoking, medication, or surgery.
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Hormonal And Inflammatory Changes
Intermittent hypoxia, particularly if associated with episodes of intermittent re-oxygenation, promotes the production of reactive oxygen species , activates systemic inflammation, and ultimately impairs endothelial function and patients metabolism. Kato and colleagues demonstrated that patients with OSA exhibited endothelial dysfunction assessed by blood flow responses to intra-arterial infusions of vasodilators .
Moreover there are several studies showing a link between OSA and glucose metabolism alterations . There are also intriguing recent reports on the potential role of mineralcorticoid hormones, in particular of aldosterone, in the relationship between OSA and hypertension, Aldosterone is a hormone produced by the outer portion of the adrenal gland and is involved in the regulation of water and electrolytes balance in the body. Among patients with resistant hypertension, the occurrence of hyperaldosteronism is significantly associated with the prevalence and severity of OSA . In fact, treatment with aldosterone antagonists can reduce not only BP levels, but also the severity of OSA .
One potential mechanism by which hyperaldosteronism contributes to OSA may be an increase in intravascular fluid retention, and the consequent pharyngeal edema. Moreover, aldosterone has been demonstrated to alter endothelial integrity and increase paracellular permeability .
Osa And Blood Pressure Variability
Blood pressure is a biological parameter characterized by continuous and marked variations over time also in healthy people, as a consequence of the response of cardiovascular control mechanisms to external perturbations. BP variability may increase, due to a number of intrinsic and/or extrinsic factors, and several studies have shown that an enhanced BP variability is strongly related to adverse cardiovascular prognosis .
BPV consists of fluctuations of blood pressure values across different measurements over a given time interval , and is influenced by the interaction among behavioural and environmental stimulations on one side, and the response by humoral and neural control factors, both of central and reflex nature, on the other side .
BP variability has been demonstrated, through observational studies and meta-analyses of clinical trials, to be closely related with hypertension mediated target organ damage and to be a significant predictor of mortality, CV events and stroke .
Sleep apnea increases nighttime blood pressure variability in patients with hypertension: in 107 patients BPV measured as the standard deviations of 24 h and night-time BP measurements was higher in subjects with OSA compared to controls . However, in a small randomized controlled study, CPAP did not have any effect on short term BPV while 24-h urine norepinephrine levels were associated with both night-time and daytime BP variability .
Figure 2
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What Is High Blood Pressure
High blood pressure is where the blood pressure in your arteries is higher than normal, either due to increased resistance to blood flow within the artery or increased pumping of blood by the heart.
Hypertension can either be primary or secondary. The former is due to no identifiable cause, while the latter may be due to kidney disease, certain heart conditions, or other problems.
Contribution Of Genetic Variation To Osas
Hypertension and OSAS represent complex polygenic disorders. The pathophysiology for both implies joint actions of different genes acting at different levels and their interactions with intrinsic and extrinsic environmental factors. Although genetic variation may explain 3040% of BP variation, identifying a genetic etiology for OSAS-related hypertension is difficult. Genome-wide association studies have yielded inconsistent results, and identified associations with some candidate genes have not always been replicated. The limited amount of data, the small sample size of the studies and the failure to properly phenotype the clinical characteristics of OSAS patients have prevented the identification of a genetic etiology of OSAS-related hypertension.
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