HYPERTENSIONINOSAHS Consequenceorco existence DrCRavindranMD DTCD MBADeanMedicalCollege Calicutprincipalmcc ICS DrCVRamakrishnanOration2010 ObstructiveSleepApnoea HypopnoeaSyndrome OSAHSisacommonbutoftenunrecognizedentitySleepdisorderedbreathingoccurinbothmen 25 andwomen 10 ofvaryingethnicgroupsPrevalenceofsymptomaticsleepapneahasbeenreportedtobe4 formenand2 forwomen ICS DrCVRamakrishnanOration2010 OSAHS Obstructivesleepapnea OSA isaffectinganestimated15millionAmericans withaprevalencethatisprobablyalsorisingasaconsequenceofincreasingobesity EpidemiologicdatasupportalinkbetweenobesityandhypertensionaswellasbetweenOSAandhypertension ICS DrCVRamakrishnanOration2010 OSAHS Cardiovasculardisease CardiovasculardiseaserepresentstheprincipalphysicalmorbidityandcauseofdeathinOSAHS Hypertension Ischaemicheartdisease CerebrovasculardiseaseTheprecisemechanismsareunclearbutarelikelytobemultifactorial InteractionBetweenSleepandHeartPathology Primary Secondary SleepApneas Hypopneas Secondary Primary CardiovascularPathology ICS DrCVRamakrishnanOration2010 WhathappensinOSA CardiometabolicconsequenceofObstructiveSleepApnea ICS DrCVRamakrishnanOration2010 ICS DrCVRamakrishnanOration2010 DistributionbyBMI HarilakshmananP RavindranC InstituteofChestDiseases Calicut ICS DrCVRamakrishnanOration2010 ICS DrCVRamakrishnanOration2010 MetabolicSyndromeinOSA WhetherOSAformspartofthemetabolicsyndrome orOSAitselfisasyndromewithmulti organdysfunctionRoleofOSAinregulationofmetabolismandtheirinteractionswithinthecomplexnetworkwilldeterminetheoutcomeineachindividual Cardiovascularmorbidityinobstructivesleepapneahypopneasyndrome Acrosssectionalstudy PauloVargheseAkkara Suraj K P SajeevC G James P T Ravindran CInstituteofChestDiseases MedicalCollege Calicut ICS DrCVRamakrishnanOration2010 ICS DrCVRamakrishnanOration2010 Cardiovascularco morbidities ICS DrCVRamakrishnanOration2010 Cardiovascularriskfactors ICS DrCVRamakrishnanOration2010 Echocardiographicparameters ICS DrCVRamakrishnanOration2010 OSAHSandhypertension Upto50 60 ofpatientswithsleepapneamayhavehypertension PrevalenceofOSAHSisgreaterinhypertensivepatientsthaningeneralpopulation Hypertensioninpatientswithsleepapneaisoftenresistanttoantihypertensivetherapy ICS DrCVRamakrishnanOration2010 OSASandhypertension UntreatedOSApredisposestoanincreasedriskofnewhypertension andtreatmentofOSAlowersbloodpressure evenduringthedaytime ICS DrCVRamakrishnanOration2010 JNC7 SeventhreportoftheJointNationalCommitteeonPrevention Evaluation andTreatmentofHighBloodPressurenowrecognizessleepapneaasanidentifiablecauseofsecondaryhypertension ICS DrCVRamakrishnanOration2010 IdentifiableCausesofHypertension SleepapneaDrug inducedorrelatedcausesChronickidneydiseasePrimaryaldosteronismRenovasculardiseaseChronicsteroidtherapyandCushing ssyndromePheochromocytomaCoarctationoftheaortaThyroidorparathyroiddisease ICS DrCVRamakrishnanOration2010 Mechanism ThevariationsinBPoccurundertheinfluenceoffourpredominantstimuli OxygendesaturationIncreaseinPCO2IncreasedrespiratoryeffortMicro arousalattheendoftheapnea ICS DrCVRamakrishnanOration2010 14nightsofintermittenthypoxiaelevatedaytimeBPandsympatheticactivityinhealthyhumans Tamisier2010 Modelofintermittenthypoxia12normaladultsDaytimeBPelevatedIncreasedmusclesympatheticnerveactivityanddecreasedbaroreflexcontrolNochangeinsystemicinflammatorymarkersorvascularreactivity WisconsinSleepCohortStudy Aprospective population basedstudyoftheassociationbetweenobjectivelymeasuredsleep disorderedbreathingandhypertensionHypertensionisdefinedasalaboratory measuredbloodpressureofatleast140 90mmHgortheuseofantihypertensivemedications 709subjectswithfollowupof4yearsAge30 65years Peppardetal NEJM 2000 ICS DrCVRamakrishnanOration2010 TheWisconsinSleepCohortStudy Showedalinearrelationshipbetweenseverityofsleepapneaandincidenceofnewhypertensionthatwasnotexplainedbyotherfactors suchasbaselinebloodpressure bodyhabitus age gender andcigaretteandalcoholconsumption ICS DrCVRamakrishnanOration2010 Peppardetal NEJM 2000 ICS DrCVRamakrishnanOration2010 Adjustedoddsratiosforthepresenceofincidenthypertensionat4 yearfollow upaccordingtotheapnea hypopneaindex AHI atbaseline ICS DrCVRamakrishnanOration2010 WisconsinSleepCohortStudy SDBwasaccompaniedbyasubstantiallyincreasedriskofdevelopinghypertension Subjectswithanapnoea hypopnoeaindex AHI of 15eventshadathree foldincreasedriskofdevelopingnewhypertensionovera4 yrperiod ICS DrCVRamakrishnanOration2010 SleepHeartHealthStudy Cross sectionalanalysesofparticipantsintheSleepHeartHealthStudy acommunity basedmulticenterstudyconductedbetweenNovember1995andJanuary19986132subjectsAge40 97years Nietoetal Jama 2000 ICS DrCVRamakrishnanOration2010 Nietoetal Jama 2000 ICS DrCVRamakrishnanOration2010 SleepHeartHealthStudy Inthisstudy theoddsratio OR inthegroupwiththemostseveresleepapnea AHI 30 was1 37 95 confidenceinterval CI 1 03 1 83 Pfortrend 0 005 comparedwiththosewithlowestAHI 1 5 afteradjustingforconfoundingfactors includingobesity ICS DrCVRamakrishnanOration2010 ICS DrCVRamakrishnanOration2010 ICS DrCVRamakrishnanOration2010 OSAHS Hypertension AlargeprospectivestudydemonstratedasignificantriskforhypertensioninthesettingofunderlyingOSAwithanoddsratiofordevelopinghypertensionof2 895Thedataregardingrefractoryhypertensionisevenmoreimpressive withonestudydemonstratingthepresenceofOSAin83 ofpatientswhoareuncontrolledonthreeormoreantihypertensivemedications Inarelatedstudybythesameauthors thetreatmentofOSAcompletelyabolishedpreviouslyuncontrolledhypertension IsHomemonitoringusefulinOSA ICS DrCVRamakrishnanOration2010 ResistantHypertension ResistantorrefractoryHTNisaconditionwheretherapeuticplanincludingattentiontolifestylemeasuresandprescriptionofatleastthreedrugsatadequatedoseshasfailedtolowersystolicanddiastolicpressuretothetargetedvalues5 18 ofthehypertensivepopulationinanHTclinic Patientswithresistanthypertensionareatgreaterriskforstroke renalinsufficiencyandco morbidcardiovascularevents ManciaGetal JHypertens2007 25 1105 87 OSA Hypertension KrishnakumarEV RavindranC InstituteofChestdiseases MedicalCollege Calicut ICS DrCVRamakrishnanOration2010 OSAinNonobesePatientsScienceDaily June17 2009 Fifty fourpercent 2 906 of5 426non obesepatientswereOSApositive 57percentofthemweremiddleaged MaleprevalenceandnecksizeweresignificantlyhigherinthegroupwithmoderatetosevereOSA AssociationshavebeenfoundbetweenOSAandseriousmedicalconditionssuchasheartdisease diabetes obesity hypertensionandincreasedriskformortality MetabolicSyndromeinnon obese SignificantlyhigherpercentageofpatientswithOSAS 19 vs4 hadatleasttwoofthefollowing hypertension hyperglycemia anddyslipidemia Apnea hypopneaindexvaluewasthepredictorofnumberofmetabolicsyndromeparameters Independentofvisceralfatobesity OSASwasassociatedwithhypertension dyslipidemia andhyperglycemia ItispossiblethatOSASmaypredisposeevennon obesepatientstothedevelopmentofmetabolicsyndrome CHESTMay2007 131 5 1387 1392 Epidemiologic andclinic basedstudiesinbothadultsandchildrenhaveconsistentlyshownthatbloodpressurelevelandtheriskofhypertensionincreasedwithincreasingAHIlevelsaftercorrectionforconfounderssuchasobesity ageandgender N Engl J Med 342 19 1378 1384 2000 AnAHIofgreaterthan15wasassociatedwithelevationof3 6mmHgand1 8mmHgforsystolicanddiastolicbloodpressure respectively OR1 8 Itisalsoshowedthateachadditionalapneiceventperhourofsleepwasassociatedwithincreasesof0 1and0 04mmHginsystolicanddiastolicbloodpressure respectively OSA ChildhoodHypertension ChildrenwithOSAhadsignificantlyhigherBPthannormalhealthychildrenduringbothsleepandwakefulness BPlevelsincreasedwiththeseverityofOSA andchildrenwithmoderatetoseveredisease AHI 5 wereatsignificantlyhigherriskfornocturnalsystolic OR3 9 95 CI1 4to10 5 anddiastolic OR3 3 95 CI1 4to8 1 hypertension Thorax63 9 803 809 2008 OSA HypertensioninPregnancy HypertensionisoftenassociatedwithOSA 5of7reportedcaseshavealsohadpreeclampsia Habitualsnoring themostcommonsymptomofOSA hasbeenassociatedwithhypertension preeclampsiaandintrauterinegrowthrestriction NasalCPAPisthemainstayoftherapyforOSAandhasbeenshowntosignificantlyreducebloodpressureanduricacidlevelsinwomenwithpreeclampsiaAmJHypertens2001 14 1090 5 OSA HypertensioninPregnancy PrevalenceofOSAishighamongthosewithgestationalhypertension preeclampsiaduringpregnancy Incidentsnoring whichisamarkerforOSA isassociatedwithanincreasedriskofdevelopinggestationalhypertension RecentstudiesindicatethatOSAperseisanindependentriskfactorforgestationalhypertension pre eclampsiaContributetootherpoorobstetricaloutcomesIndianJMedRes 2010Feb 131 285 301 OSA HTN CPAP 118patientswithODIof17 hronCPAPVssub therapeuticCPAP 1cm x4weeksMeanBPdecreasedby2 4 3 4 sleep wake Vsanincreaseof0 8CPAP 5hoursneededPepperelletal ICS DrCVRamakrishnanOration2010 Changesinmean MAP systolic anddiastolicbloodpressurewitheffective closedbars andsub therapeutic openbars CPAP ICS DrCVRamakrishnanOration2010 OSA HTN CPAP 32patientsonCPAPvssub therapeuticCPAP 1cm x9weeksSBP DBPdecreasedby10mmvsnochangeAHIdecreasedfrom65to3vs65to33Beckeretal ICS DrCVRamakrishnanOration2010 Beckeretal Circulation 2003 N 768 ICS DrCVRamakrishnanOration2010 ICS DrCVRamakrishnanOration2010 Long termEffectofContinuousPositiveAirwayPressureinHypertensivePatientswi