Evening-to-Morning Blood Pressure Variations in Snoring Patients with and without Obstructive Sleep Apnea

doi:10.1378/chest.101.2.379

Chest

Volume 101, Issue 2, February 1992, Pages 379-384

https://doi.org/10.1378/chest.101.2.379 Get rights and content

This study was designed to test a hypothesis that patients with sleep apnea have higher blood pressure in the morning, following a night spent in apnea and hypoxemia, than in the evening. To accomplish this, we prospectively studied a set of 611 patients referred to our clinic because of suspicion of sleep apnea. All patients had full nocturnal polysomnography, including measurement of snoring. Blood pressure was measured in the evening, prior to onset of sleep, and in the morning, immediately on awakening. We found that patients without apnea and hypoxemia had lower blood pressure in the morning compared with the evening value, while patients with severe sleep apnea and hypoxemia had higher blood pressure in the morning; these evening-to-morning blood pressure differences, although statistically significant, were small, typically 1 to 4 mm Hg. Morning blood pressures were higher in patients with sleep apnea and hypoxemia than in nonapneic normoxic patients. However, this difference disappeared after the groups were matched for age and body mass index. We conclude that (1) patients with sleep apnea and nocturnal hypoxemia lose the expected morning dip in arterial blood pressure, and (2) age and body mass index are more important correlates of blood pressure than apnea and nocturnal oxygen desaturation. We speculate that the loss of evening-to-morning drop in blood pressure, if present over a long period of time, may lead to sustained elevations in arterial blood pressure frequently observed in patients with sleep apnea.

Section snippets

Patients

This report is a part of an ongoing prospective study dealing with various clinical aspects of sleep apnea syndrome. Up to October 1990, there were 1,201 patients entered into the computer data base at the sleep clinic at St. Michaels Hospital, Toronto. Six hundred eleven of them satisfied the following criteria: (1) all were referred because of suspected sleep apnea; (2) all presented with snoring as their main complaint; (3) none had a history of hypertension; (4) none was receiving

RESULTS

Table 1 shows the anthropometric characteristics and sleep, snoring, and blood pressure data for the entire set of 611 patients, which consisted of 444 male and 167 female subjects.

Univariate regression analysis revealed that morning and evening mean arterial blood pressures correlated significantly (p<0.05) with age, BMI, AHI, SI, dBmax, and awake, lowest, and mean nocturnal oxygen saturations. However, not all of these variables are independent; for example, lowest nocturnal oxygen saturation

DISCUSSION

This study shows that patients with significant sleep apnea and oxygen desaturation do not show the expected morning decline in blood pressure. However, it appears that age and weight, rather than sleep apnea and the severity of oxygen desaturation, are major correlates of morning blood pressure.

Although the evening-to-morning changes in blood pressure found in this study are small, it would be incorrect to entirely dismiss the influence of sleep apnea and oxygen desaturation on blood pressure

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Cited by (63)

Effect of CPAP Withdrawal on BP in OSA: Data from Three Randomized Controlled Trials
2016, Chest
Based on meta-analyses, the BP-lowering effect of CPAP therapy in patients with OSA is reported to be approximately 2 to 3 mm Hg. This figure is derived from heterogeneous trials, which are often limited by poor CPAP adherence, and thus the treatment effect may possibly be underestimated. We analyzed morning BP data from three randomized controlled CPAP withdrawal trials, which included only patients with optimal CPAP compliance.
Within the three trials, 149 patients with OSA who were receiving CPAP were randomized to continue therapeutic CPAP (n = 65) or to withdraw CPAP (n = 84) for 2 weeks. Morning BP was measured at home before and after sleep studies in the hospital.
CPAP withdrawal was associated with a return of OSA (apnea-hypopnea index [AHI] at a baseline of 2.8/h and at follow-up of 33.2/h). Office systolic BP (SBP) increased in the CPAP withdrawal group compared with the CPAP continuation group by +5.4 mm Hg (95% CI, 1.8-8.9 mm Hg; P = .003) and in the home SBP group by +9.0 mm Hg (95% CI, 5.7-12.3 mm Hg; P < .001). Office diastolic BP (DBP) increased by +5.0 mm Hg (95% CI, 2.7-7.3 mm Hg; P < .001), and home DBP increased by +7.8 mm Hg (95% CI, 5.6-10.4 mm Hg; P < .001).
AHI, baseline home SBP, use of statin drugs, sex, and the number of antihypertensive drugs prescribed were all independently associated with SBP change in multivariate analysis, controlling for age, BMI, smoking status, diabetes, and sleepiness.
CPAP withdrawal results in a clinically relevant increase in BP, which is considerably higher than in conventional CPAP trials; it is also underestimated when office BP is used. Greater OSA severity is associated with a higher BP rise in response to CPAP withdrawal.
ClinicalTrials.gov; No.: NCT01332175 and NCT01797653) URL: www.clinicaltrials.gov and ISRCTN registry (ISRCTN 93153804) URL: http://www.isrctn.com/.
Gender differences in the clinical manifestation of obstructive sleep apnea
2009, Sleep Medicine
Citation Excerpt :
Some studies have demonstrated the cardiovascular risk was similar between genders [4,15,79], but one recent study in a gender-balanced community sample found that the contribution of OSA to hypertension was higher in men than in women [85]. Increased blood pressure during sleep and higher blood pressure in the morning than evening have been demonstrated in patients with OSA [86,87], and morning surges in blood pressure may be associated with subsequent stroke risk and silent hypertensive cardiovascular diseases [88]. One study found that the evening to morning change in blood pressure was linearly related to the severity of OSA in men both with and without hypertension, whereas there were no such relationships in women.
Obstructive sleep apnea (OSA) has been historically described as a disease primarily of men. However, it is now widely recognized that OSA in women is not as rare as was originally believed. The alarming degree to which OSA is clinically underdiagnosed in women raises the critical concern that women manifest OSA differently. The purpose of this review is to examine the issue of clinically significant gender differences in OSA disease manifestation, which pose unique challenges to diagnosis and management. Within this review, current findings regarding gender differences in OSA polysomnographic features and demographic factors, symptom presentation, functional status, comorbidities, health care utilization, and therapeutic management have been reviewed. Further research in this field is proposed to examine the impact of gender on functional status in individuals with OSA, and the potential gender differences in therapeutic management, particularly the response to continuous positive airway pressure (CPAP) treatment. Additional studies describing the clinical manifestations in men and women at different levels of OSA severity may substantially contribute to the ability to identify and treat OSA in women across a wide spectrum of disease severity.
Post- to pre-overnight sleep systolic blood pressures are associated with sleep respiratory disturbance, pro-inflammatory state and metabolic situation in patients with sleep-disordered breathing
2009, Sleep Medicine
Citation Excerpt :
Solid evidence is emerging that the apneic or hypopneic events that occur during sleep lead to hemodynamic changes, including elevated sympathetic tone, decreased stroke volume, lower cardiac output, increased heart rate, worsened systemic hypertension and changes in circulating hormones that regulate BP, fluid volume, vasoconstriction, and vasodilation [8,9]. The BP changes in patients with SDB may occur in the early morning [3,5] and the increased BP is maintained during the first three to four hours of the morning [10]. Thus, the pre- versus post-overnight sleep BP measurements in patients with SDB are crucial for studying the relationship of BP changes and severity of SDB.
The aim of the current study was to investigate whether changes in post- to pre-overnight sleep systolic blood pressure (SSBP) are associated with sleep respiratory disturbance, pro-inflammatory state, and metabolic situation in patients with sleep-disordered breathing (SDB).
Anthropometry, sleep polysomnography, biochemical markers, and pre- and post-overnight sleep BP were measured from 263 SDB patients. All SDB patients were further subgrouped into MORNING SURGE (% changes from post- to pre-overnight SSBP >+1SD of this cohort), MORNING DROP (% changes <−1SD), CONSTANT HIGH (% changes within ± 1SD, averaged SSBP > 130 mmHg) and CONSTANT LOW (% changes within ± 1SD, averaged SSBP < 130 mmHg).
BMI, neck circumference, waistline circumference, respiratory disturbance index, arousal index, lowest oxygen saturation, duration of SaO₂ < 90%, blood glucose, hs-CRP, and metabolic syndrome score in MORNING SURGE and CONSTANT HIGH were significantly greater than those in CONSTANT LOW. Except metabolic syndrome score, all other parameters in MORNING DROP were similar to those in CONSTANT LOW.
Patients with SDB whose post- to pre-overnight SSBPs were elevated or maintained a constant high have more sleep respiratory disturbance, more pro-inflammatory state, and higher metabolic syndrome indices than the rest. Without subdividing into CONSTANT LOW, MORNING DROP, CONSTANT HIGH, and MORNING SURGE, the important pathophysiologic points of SDB patients will possibly be missed.
A clinical overview: Obstructive sleep apnea and hypertension
2008, Diabetes and Metabolic Syndrome: Clinical Research and Reviews
Citation Excerpt :
The 24 h blood pressure data showed that the patients with OSA were clearly more hypertensive than the control subjects (average daytime diastolic pressure 4.6 mmHg higher), although this difference was less in the afternoon and greatest in the more immediate post-sleep period. This morning dominance of the OSA hypertensive effect had been noted previously [14,49]. Here again the study was carried out before one knew of the effect of caffeine consumption and more over physical activity levels were not taken into consideration.
Obstructive sleep apnea is now increasingly being linked as risk factor for cardiovascular disorders and T2DM, although there is a distinct need for harder evidence. Whether this is an independent association or though its relationship with the cluster of risk factors associated with the metabolic syndrome, remains to be proven. Amongst this cluster of confounders, the association between obstructive sleep apnea (OSA) and diurnal hypertension, has been the most investigated and in this brief review, we look at the strength, or otherwise, of this relationship. Although much is known about the patho-physiology of hypertension, one must accept that there are areas which are still “grey”. Can OSA explain some of these grey areas? Moreover, one does come across many cases of what has been termed as “resistant” hypertension which does not come under optimal control in spite of the use of the best available management strategies. Could OSA be the cause of this resistance? Where precisely do we stand when faced with a patient of hypertension in clinical practice in so far as investigating for the presence of OSA and what severity should we treat this co-morbid condition, as it would not seem feasible, medically, economically or even practically, to put all patients with hypertension through tests of polysomnography and CPAP therapy.
Evening-Morning Differences in Blood Pressure in Sleep Apnea Syndrome: Effect of Gender
2006, American Journal of Hypertension
Citation Excerpt :
Also they showed that with increasing apnea severity the physiologic nocturnal BP decline was reduced. Likewise, Hoffstein and Mateika9 showed that patients with OSA and nocturnal hypoxemia did not show the expected reduction in morning BP. The increase in morning BP with apnea severity, is in concert with our recent finding of deterioration in endothelial function in the morning compared with the evening in patients with OSA.13
Obstructive sleep apnea (OSA) is associated with hypertension. In the current study we sought to determine whether the evening–morning differences in blood pressure (BP) would correlate with the severity of OSA and whether there are gender-related differences.
A total of 2009 consecutive patients referred to sleep examination because of suspected sleep apnea were retrospectively included. The patients comprised 1566 men, of whom 870 were nonhypertensive (non-HT) and 696 hypertensive (HT) and 443 women, of whom 258 were non-HT and 185 HT. Four BP measurements, two in the evening and two in the morning, were taken. The relationship between evening–morning differences in BP and the number of apneas/hypopneas divided by hours of sleep (AHI) were analyzed separately for HT and non-HT men and women.
In men, increase in AHI was associated with increase in morning BP, and the evening–morning difference for both systolic and diastolic BP became negative. These trends were found to be significant by linear regression analyses both for HT (for systolic BP, r = 0.75, P < .05, for diastolic BP r = 0.96, P < .05) and non-HT patients (for systolic BP r = 0.93, P < .05, for diastolic BP r = 0.94, P < .05). In women (unlike in men), increasing AHI was not associated with a linear increase in the evening–morning BP differences. None of the regression lines fitted to the data was significant.
Our results demonstrate that the evening to morning difference in BP in men with OSA is linearly related to the severity of OSA, both in patients with HT and in those with non-HT. These results may have practical relevance in screening for patients with OSA and may have prognostic clinical value in predicting future cardiovascular events.
How to objectively measure snoring: a systematic review
2024, Sleep and Breathing

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Chest

Clinical InvestigationsEvening-to-Morning Blood Pressure Variations in Snoring Patients with and without Obstructive Sleep Apnea

Section snippets

Patients

RESULTS

DISCUSSION

Lancet

Am J Cardiol

Lancet

Lancet

Am Heart J

Chest

Chest

Chest

Hemodynamics in sleep-induced apnea

Ann Intern Med.

Nocturnal hemodynamics in patients with sleep apnea

Eur J Respir Dis

Continuous recording of the pulmonary and systemic arterial pressure in syndromes of hypersomnia with periodic breathing

Bull Physiol Pathol Respir

Hypertension, erectile dysfunction, and occult sleep apnea

Sleep

Clinical Investigations
Evening-to-Morning Blood Pressure Variations in Snoring Patients with and without Obstructive Sleep Apnea