Rational antihypertensive therapy in patients with obstructive sleep apnea

Background. The relationship between obstructive sleep apnea (OSA) and hypertension (AH) is well known. In numerous studies it was found that obstructive sleep apnea was an independent predictor of the development of resistant AH (RAH), and the severity of apnea was directly correlated with the severity of RAH with the exception of the such confounders as age, obesity, sex.

The purpose of this publication is to present a new strategy and modern approaches of drug and non-drug therapy of resistant hypertension in patients with OAS with the possibility of their implementation in real clinical practice.

Conclusion. Currently, for a practitioner, the therapy of the patient with OSA and RAH is a serious clinical problem. A new rational therapeutic strategy for the treatment of such patients includes a combination of three-component drug therapy and non-drug continuous positive air pressure therapy (CPAP therapy). A reasonable duration of CPAP therapy should exceed 12 weeks. The proposed strategy for the treatment of patients with OAS+RAH has the highest efficiency of achieving blood pressure levels and significantly reduces the risks of fatal cardiovascular events.

1. Obstructive Sleep Apnea Syndrome (780.53-0). The International Classification of Sleep Disorders. American Academy of Sleep Medicine. 2010; 52-8. Internet resource: https://link.springer.com/chapter/10.1007%2F978-1-4939-6578-6_27 (date of the application 13.03.19)

2. Farney R.J., Walker B.S., Farney R.M., Snow G.L., Walker J.M. The STOP-Bang equivalent model and prediction of severity of obstructive sleep apnea: relation to polysomnographic measurements of the apnea/hypopnea index. J Clin Sleep Med.2011;7(5):459-465. doi: 10.5664/JCSM.1306.

3. Lombardi C1., Tobaldini E., Montano N., Losurdo A., Parati G. Obstructive Sleep Apnea Syndrome (OSAS) and Cardiovascular System. Med Lav. 2017 Aug 28; 108 (4):276-282. doi: 10.23749/mdl. v108i4.6427. PMID: 28853425.

4. Floras J.S. Hypertension and Sleep Apnea. Can J Cardiol. 2015 Jul; 31(7): 889-97, doi: 10.1016/j.cjca.2015.05.003. PMID: 26112299.

5. Khan A., Patel N.K., O'Hearn D.J., Khan S. Resistant hypertension and obstructive sleep apnea. Int J Hypertens. 2013; 2013:193010. doi: 10.1155/2013/193010.

6. Logan A.G., Perlikowski S.M., Mente A. et al. High prevalence of unrecognized sleep apnoea in drug-resistant hypertension. J Hypertens. 2001 Dec;19 (12):2271-7.

7. Walia H.K., Li H., Rueschman M. et al. Association of severe obstructive sleep apnea and elevated blood pressure despite antihypertensive medication use. J Clin Sleep Med. 2014 Aug 15; 10 (8):835-43. doi: 10.5664/jcsm.3946.

8. Pedrosa R.P., Drager L.F., Gonzaga C.C. et al. Obstructive sleep apnea: the most common secondary cause of hypertension associated with resistant hypertension. Hypertension. 2011 Nov;58 (5):811-7. doi: 10.1161/HYPERTENSIONAHA.111.179788.

9. Dudenbostel T., Calhoun D.A. Resistant hypertension, obstructive sleep apnoea and aldosterone. J Hum Hypertens. 2012 May; 26 (5): 281-7. doi: 10.1038/jhh.2011.47.

10. Wolf J., Narkiewicz K. Optimizing the management of uncontrolled/ resistant hypertension. The importance of sleep apnoea syndrome. Curr Vasc Pharmacol. 2017 Apr 14. doi: 10.2174/1570161115666170414115705.

11. Ziegler M.G., Milic M. Sympathetic nerves and hypertension in stress, sleep apnea, and caregiving. Curr Opin Nephrol Hypertens. 2017 Jan;26 (1):26-30.

12. Malyavin A.G., Babak S.L., Adasheva T.V. et al. Diagnosis and management of patients with resistant arterial hypertension and obstructive sleep apnea (Clinical guidelines). Therapy. 2018; 1 (19): 4-42.

13. Sullivan C.E., Issa F.G., Berthon-Jones M., Eves L. Reversal of obstructive sleep apnoea by continuous positive airway pressure applied through the nares. Lancet. 1981 Apr 18;1 (8225):862-5.

14. Jin Z.N., Wei Y.X. Meta-analysis of effects of obstructive sleep apnea on the renin-angiotensin-aldosterone system. J Geriatr Cardiol. 2016 May;13 (4):333-43. doi: 10.11909/j.issn.1671-5411.2016.03.020.

15. Ziegler M.G., Milic M., Lu X. et al. Effect of obstructive sleep apnea on the response to hypertension therapy. Clin Exp Hypertens. 2017; 39 (5): 409-415. doi: 10.1080/10641963.2016.1259327.

16. Meng F, Ma J, Wang W, Lin B. Obstructive sleep apnea syndrome is a risk factor of hypertension. Minerva Med. 2016 Oct;107(5):294-9. Epub 2016 May 10.

17. Zhao X, Li X, Xu H, Qian Y, et al. Relationships between cardiometabolic disorders and obstructive sleep apnea: Implications for cardiovascular disease risk. J Clin Hypertens (Greenwich). 2019 Feb;21(2):280-290. doi: 10.1111/jch.13473.

18. Beaudin AE, Waltz X, Hanly PJ, Poulin MJ. Impact of obstructive sleep apnoea and intermittent hypoxia on cardiovascular and cerebrovascular regulation. Exp Physiol. 2017 Jul 1;102(7):743-763. doi: 10.1113/EP086051.

19. Chung F, Abdullah HR, Liao P. STOP-Bang Questionnaire: A Practical Approach to Screen for Obstructive Sleep Apnea. Chest. 2016 Mar;149(3):631-8. doi: 10.1378/chest.15-0903.

20. Wolf J, Narkiewicz K. Optimizing the Management of Uncontrolled/ Resistant Hypertension. The Importance of Sleep Apnoea Syndrome. Curr Vasc Pharmacol. 2017;16(1):44-53. doi: 10.2174/1570161115666170414115705.

21. Heitmann J., Greulich T., Reinke C. et al. Comparison of the effects of nebivolol and valsartan on BP reduction and sleep apnoea activity in patients with essential hypertension and OSA. Curr Med Res Opin. 2010 Aug;26 (8):1925-32. doi: 10.1185/03007995.2010.497326.

22. Ziegler MG, Milic M, Sun P. Antihypertensive therapy for patients with obstructive sleep apnea. Curr Opin Nephrol Hypertens. 2011 Jan;20(1):50-5. doi: 10.1097/MNH.0b013e3283402eb5.

23. Kasai T., Bradley T.D., Friedman O., Logan A.G. Effect of intensified diuretic therapy on overnight rostral fluid shift and obstructive sleep apnoea in patients with uncontrolled hypertension. J Hypertens. 2014 Mar;32 (3):673-80. doi: 10.1097/HJH.0000000000000047.

24. Yang L., Zhang H., Cai M. et al. Effect of spironolactone on patients with resistant hypertension and obstructive sleep apnea. Clin Exp Hypertens. 2016;38 (5):464-8. doi: 10.3109/10641963.2015.1131290.

25. Elfimova EM, Litvin AY, Chazova IE. The effectiveness of combination antihypertensive therapy in patients with arterial hypertension and additional risk factors: obesity and obstructive sleep apnea syndrome. Ter Arkh. 2018 Dec 30;90(12):28-33. doi: 10.26442/00403660.2018.12.000005.

26. Sullivan CE, Issa FG, Berthon-Jones M, Eves L. Reversal of obstructive sleep apnoea by continuous positive airway pressure applied through the nares. Lancet. 1981 Apr 18;1(8225):862-5.

27. Varounis C, Katsi V, Kallikazaros IE, et al. Effect of CPAP on blood pressure in patients with obstructive sleep apnea and resistant hypertension: a systematic review and meta-analysis. Int J Cardiol. 2014 Jul 15;175(1):195-8. doi: 10.1016/j.ijcard.2014.04.240.

28. Martlnez-Garcla M.A., Capote F., Campos-Rodriguez F. et al. Effect of CPAP on blood pressure in patients with obstructive sleep apnea and resistant hypertension: the HIPARCO randomized clinical trial. JAMA. 2013 Dec 11; 310 (22):2407-15. doi:10.1001/jama.2013.281250.

29. Sapina E, Torres G, Barbe F, et al. The Use of Precision Medicine to Manage Obstructive Sleep Apnea Treatment in Patients with Resistant Hypertension: Current Evidence and Future Directions. Curr Hypertens Rep. 2018 Jun 8;20(7):60. doi: 10.1007/s11906-018-0853-3.

30. Joyeux-Faure M, Baguet JP, Barone-Rochette G, et al. Continuous Positive Airway Pressure Reduces Night-Time Blood Pressure and Heart Rate in Patients With Obstructive Sleep Apnea and Resistant Hypertension: The RHOOSAS Randomized Controlled Trial. Front Neurol. 2018 May 8;9:318. doi: 10.3389/fneur.2018.00318.