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Association of novel measures of sleep disturbances with blood pressure: the Multi-Ethnic Study of Atherosclerosis
  1. John S. Kim1,
  2. Ali Azarbarzin2,
  3. Rui Wang3,4,
  4. Ina E. Djonlagic5,
  5. Naresh M. Punjabi6,
  6. Phyllis C. Zee7,
  7. Brian B. Koo8,
  8. Elsayed Z. Soliman9,
  9. Magdy Younes10,
  10. Susan Redline2,11
  1. 1 Department of Medicine, Columbia University Medical Center, New York City, New York, USA
  2. 2 Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
  3. 3 Department of Biostatistics, Harvard University T.H. Chan School of Public Health, Boston, Massachusetts, United States
  4. 4 Department of Population Medicine, Harvard Pilgrim Health Care Institute, Boston, Massachusetts, United States
  5. 5 Department of Neurology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
  6. 6 Department of Medicine, Johns Hopkins University, Baltimore, Maryland, United States
  7. 7 Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
  8. 8 Department of Neurology, Yale University School of Medicine, New Haven, Connecticut, USA
  9. 9 Department of Medicine, Wake Forest University, Winston-Salem, North Carolina, USA
  10. 10 Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
  11. 11 Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States
  1. Correspondence to John S. Kim, Medicine, Columbia University Medical Center, New York City, NY 10032, USA; jk3862{at}


Background Mechanisms underlying blood pressure (BP) changes in obstructive sleep apnoea (OSA) are incompletely understood. We assessed the associations between BP and selected polysomnography (PSG) traits: sleep depth, airflow limitation measurements and OSA-specific hypoxic burden.

Methods This cross-sectional analysis included 2055 participants from the Multi-Ethnic Study of Atherosclerosis who underwent PSG and BP measurements in 2010–2013. Sleep depth was assessed using the ‘OR product’, a continuous measure of arousability. Airflow limitation was assessed by duty cycle (Ti/Tt) and % of breaths with flow limitation, and hypoxia by ‘hypoxic burden’. Primary outcomes were medication-adjusted systolic BP (SBP) and diastolic BP (DBP). We used generalised linear models adjusted for age, sex, race/ethnicity, smoking, education, body mass index, alcohol use, periodic limb movements and alternative physiological disturbances.

Results The sample had a mean age of 68.4 years and apnoea–hypopnoea index of 14.8 events/hour. Sleep depth was not significantly associated with BP. Every 1 SD increment in log-transformed non-rapid eye movement duty cycle was associated with 0.9% decrease in SBP (95% CI: 0.1% to 1.6%), even after adjusting for sleep depth and hypoxic burden. Every 1 SD increment in log-transformed hypoxic burden was associated with a 1.1% increase in SBP (95% CI: 0.1% to 2.1%) and 1.9% increase in DBP (95% CI: 1.0% to 2.8%) among those not using hypertension medications.

Conclusions Higher duty cycle was associated with lower SBP overall and hypoxic burden with higher SBP and DBP among non-BP medication users. These findings suggest changes in both respiratory effort and oxygenation during sleep influence BP.

  • hypertension
  • hypoxia
  • duty cycle
  • inspiratory flow limitation
  • sleep apnoea

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  • Contributors Not applicable.

  • Funding Multi-Ethnic Study of Atherosclerosis (MESA) is supported by the National Heart, Lung, and Blood Institute (NHLBI) in collaboration with MESA investigators. Support for MESA is provided by NHLBI contracts HHSN268201500003I, N01-HC-95159, N01-HC-95160, N01-HC-95161, N01-HC-95162, N01-HC-95163, N01-HC-95164, N01-HC-95165, N01-HC-95166, N01-HC-95167, N01-HC-95168, N01-HC-95169, UL1-TR-000040, UL1-TR-001079, UL1-TR-001881 and DK06349. MESA Sleep was supported by R01HL098433. SR was partly supported by NIH R35HL135818. Funding support for the Sleep Polysomnography dataset was provided by grant HL56984 from the NHLBI. This research was also supported by T32-HL-105323 from NHLBI.

  • Competing interests AA has received personal fees from Somnifx and Apnimed. MY has received personal fees from Cerebra Health. MY has patent for method and software to determine quality of sleep and wakefulness. MY has patent for method and apparatus for arousal intensity scoring. SSR has received grants and personal fees from Jazz Pharma. SSR has received personal fees from Respircardia.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available upon reasonable request.

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