Get 20M+ Full-Text Papers For Less Than $1.50/day. Start a 14-Day Trial for You or Your Team.

Learn More →

Causes and Consequences of Blood Pressure Alterations in Obstructive Sleep Apnea

Causes and Consequences of Blood Pressure Alterations in Obstructive Sleep Apnea Abstract The obstructive sleep apnea (OSA) syndrome has been considered to be a cause of both transient blood pressure elevations during sleep and sustained hypertension during the awake state. The purpose of this review was to examine critically the existing literature regarding (1) the blood pressure alterations associated with OSA, (2) causal mechanisms relating specific blood pressure alterations to OSA, and (3) potential consequences of the systemic circulatory abnormalities associated with OSA. Particular attention was directed at studies that assessed the prevalence of OSA in patients with hypertension and that examined the effects on blood pressure of treatment of OSA. We conclude that patients with OSA have abnormal sleep blood pressure patterns, manifested most frequently by apnea-associated blood pressure elevations. Confounding factors such as obesity and antihypertensive drug therapy, and conflicting evidence regarding changes in daytime blood pressure after therapy for OSA, make it premature to conclude that OSA and daytime hypertension are directly associated. Circumstantial evidence suggests that the blood pressure alterations that occur during sleep could contribute to the high cardiovascular morbidity in patients with OSA. Further research into the relationship between OSA and hypertension should improve the future care of patients with these conditions and enhance our understanding of cardiopulmonary pathophysiology. (Arch Intern Med. 1991;151:455-462) References 1. Bradley TD, Phillipson EA. Pathogenesis and pathophysiology of the obstructive sleep apnea syndrome . Med Clin North Am. 1985;69:1169-1185. 2. Weil JV, Cherniack NS, Dempsey JA, et al. Respiratory disorders of sleep: pathophysiology, clinical implications, and therapeutic approaches . Am Rev Respir Dis. 1987;136:755-761.Crossref 3. Millman RP. Snoring and apnea . Clin Chest Med. 1987;8:253-264. 4. Lavie P. Incidence of sleep apnea in a presumably healthy working population: a significant relationship with excessive daytime sleepiness . Sleep. 1983;6:312-318. 5. Telakivi T, Partinen M, Koskenvuo M, Salmi T, Kaprio J. Periodic breathing and hypoxia in snorers and controls: validation of snoring history and association with blood pressure and obesity . Acta Neurol Scand. 1987;76:69-75.Crossref 6. Gislason T, Almqvist M, Eriksson G, Taube A, Boman G. Prevalence of sleep apnea syndrome among Swedish men: an epidemiological study . J Clin Epidemiol. 1988;41:571-576.Crossref 7. Guilleminault C. Obstructive sleep apnea: the clinical syndrome and historical perspective . Med Clin North Am. 1985;69:1187-1203. 8. Guilleminault C, Simmons FB, Motta H, et al. Obstructive sleep apnea syndrome and tracheostomy: long-term follow-up experience . Arch Intern Med. 1981;141:985-988.Crossref 9. Burack B. The hypersomnia-sleep apnea syndrome: its recognition in clinical cardiology . Am Heart J. 1984;107:543-548.Crossref 10. Shepard JW Jr, Garrison MW, Grither DA, Dolan GF. Relationship of ventricular ectopy to oxyhemoglobin desaturation in patients with obstructive sleep apnea . Chest. 1985;88:335-340.Crossref 11. Coccagna G, Mantovani M, Brignani F, Parchi C, Lugaresi E. Continuous recording of the pulmonary and systemic arterial pressure during sleep in syndromes of hypersomnia with periodic breathing . Bull Physiopath Resp. 1972;8:1159-1172. 12. Tilkian AG, Guilleminault C, Schroeder JS, Lehrman KL, Simmons FB, Dement WC. Hemodynamics in sleep-induced apnea studies during wakefulness and sleep . Ann Intern Med. 1976;85:714-719.Crossref 13. Motta H, Guilleminault C, Schroeder JS, Dement WC. Tracheostomy and hemodynamic changes in sleep-induced apnea . Ann Intern Med. 1978;89:454-458.Crossref 14. Kales A, Cadieux RJ, Shaw LC, et al. Sleep apnea in a hypertensive population . Lancet. 1984;2:1005-1008.Crossref 15. Fletcher EC, DeBehnke RD, Lovoi MS, Gorin AB. Undiagnosed sleep apnea in patients with essential hypertension . Ann Intern Med. 1985;103:190-195.Crossref 16. Williams AJ, Houston D, Finberg S, Lam C, Kinney JL, Santiago S. Sleep apnea syndrome and essential hypertension . Am J Cardiol. 1985;55:1019-1022.Crossref 17. Kaplan NM. Clinical Hypertension . 4th ed. Baltimore, Md: Williams & Wilkins; 1986:1-28,434-446. 18. Partinen M, Jamieson A, Guilleminault C. Long-term outcome for obstructive sleep apnea syndrome patients: mortality . Chest. 1988;94:1200-1204.Crossref 19. He J, Kryger MH, Zorick FJ, Conway W, Roth T. Mortality and apnea index in obstructive sleep apnea: experience in 385 male patients . Chest. 1988;94:9-14.Crossref 20. Partinen M, Guilleminault C. Daytime sleepiness and vascular morbidity at seven-year follow-up in obstructive sleep apnea patients . Chest. 1990;97:27-32.Crossref 21. Waller PC, Bhopal RS. Is snoring a cause of vascular disease? an epidemiologic review . Lancet. 1989;1:143-146.Crossref 22. Stradling JR. Sleep apnoea and hypertension . Thorax. 1989;44:984-989.Crossref 23. Hubert HB, Feinleib M, McNamara PM, Castelli WP. Obesity as an independent risk factor for cardiovascular disease: a 26-year follow-up of participants in the Framingham Heart Study . Circulation. 1983;67:968-977.Crossref 24. National Institutes of Health Consensus Development Panel on the Health Implications of Obesity. Health implications of obesity: National Institutes of Health Consensus Development Conference statement . Ann Intern Med. 1985;103:147-151.Crossref 25. Higgins M, Kannel W, Garrison R, Pinsky J, Stokes J. Hazards of obesity: the Framingham experience . Acta Med Scand. 1989;723( (suppl) ):23-36. 26. Brooks H, Carrol JH. A clinical study of the effects of sleep and rest on blood pressure . Arch Intern Med. 1912;10:97-102.Crossref 27. Snyder F, Hobson JA, Morrison DF. Changes in respiration, heart rate, and systolic blood pressure in human sleep . J Appl Physiol. 1964;19:417-422. 28. Khatri I, Freis ED. Hemodynamic changes during sleep . J Appl Physiol. 1967;22:867-873. 29. Bristow JD, Honour AJ, Pickering TG. Cardiovascular and respiratory changes during sleep in normal and hypertensive subjects . Cardiovasc Res. 1969;3:476-485.Crossref 30. Coccagna G, Mantovani M, Brignani F, Manzini A, Lugaresi E. Arterial pressure changes during spontaneous sleep in man . Electroencephalogr Clin Neurophysiol. 1971;31:277-281.Crossref 31. Drayer JIM, Weber MA, Nakamura DK. Automated ambulatory blood pressure monitoring: a study in age-matched normotensive and hypertensive men . Am Heart J. 1985;109:1334-1338.Crossref 32. Pickering TG. The clinical significance of diurnal blood pressure variations: dippers and non-dippers . Circulation. 1990;81:700-702.Crossref 33. Pickering TG. The influence of daily activity on ambulatory blood pressure . Am Heart J. 1988;116:1141-1145.Crossref 34. Podszus T, Mayer J, Penzel T, Peter JH, von Wichert P. Nocturnal hemodynamics in patients with sleep apnea . Eur J Respir Dis. 1986;69( (suppl 146) ):435-442. 35. Shepard JW Jr. Hemodynamics in obstructive apnea . In: Fletcher EC, ed. Abnormalities of Respiration During Sleep: Diagnosis, Pathophysiology, and Treatment . New York, NY: Grune & Stratton; 1986:39-61. 36. Scharf SM. Influence of sleep state and breathing on cardiovascular function . In: Saunders NA, Sullivan CE, eds. Sleep and Breathing . New York, NY: Marcel Dekker Inc; 1984:221-240. 37. Schroeder JS, Motta J, Guilleminault C. Hemodynamic studies in sleep apnea . In: Guilleminault C, Dement WC, eds. Sleep Apnea Syndromes . New York, NY: Alan R Liss Inc; 1978:177-196. 38. Jennum P, Borgeson SE. Intracranial pressure and obstructive sleep apnea . Chest. 1990;95:279-283.Crossref 39. McGinty D, Beahm E, Stern N, Littner M, Sowers J, Reige W. Nocturnal hypotension in older men with sleep-related breathing disorders . Chest. 1988;94:305-311.Crossref 40. Lavie P, Ben-Yosef R, Rubin AE. Prevalence of sleep apnea syndrome among patients with essential hypertension . Am Heart J. 1984;108:373-376.Crossref 41. Warley ARH, Mitchell JH, Stradling JR. Prevalence of nocturnal hypoxaemia amongst men with mild to moderate hypertension . Q J Med. 1988;256:637-644. 42. Hirshkowitz M, Karacan I, Gurakar A, Williams RL. Hypertension, erectile dysfunction, and occult sleep apnea . Sleep. 1989;12:223-232. 43. Knight H, Millman RP, Gur RC, Saykin AJ, Doherty JU, Pack AI. Clinical significance of sleep apnea in the elderly . Am Rev Respir Dis. 1987;136:845-850.Crossref 44. Lahive KC, Weiss JW, Weinberger SE. Alpha-methyldopa selectively reduces nasi activity . Clin Sci. 1988;74:547-551. 45. Sullivan CE, Konar LF, Murphy E, Phillipson EA. Primary role of respiratory afferents in sustaining breathing rhythm . J Appl Physiol. 1985;45:11-17. 46. Boudoulas H, Schmidt H, Gelens P, Clark RW, Lewis RP. Case reports on deterioration of sleep apnea during therapy with propranolol: preliminary studies . Res Commun Chem Pathol Pharmacol. 1983;39:3-10. 47. Coccagna G, Mantovani M, Brignani F, Parchi C, Lugaresi E. Tracheostomy in hypersomnia with periodic breathing . Bull Physiopath Resp. 1972;8:1217-1227. 48. Jennum P, Wildschiodtz G, Christenson NJ, Schwartz T. Blood pressure, catecholamines, and pancreatic polypeptide in obstructive sleep apnea with and without nasal continuous positive airway pressure (nCPAP) treatment . Am J Hypertens. 1989;2:847-852.Crossref 49. Heistad DD, Abboud FM. Circulatory adjustments to hypoxia . Circulation. 1980;61:463-470.Crossref 50. Shepherd JT, Vanhoutte PM, eds. The Human Cardiovascular System: Facts and Concepts . New York, NY: Raven Press; 1979:107-155. 51. Daly MD, Scott MJ. An analysis of the primary cardiovascular reflex effects of stimulation of the carotid body chemoreceptors in the dog . J Physiol. 1962;162:555-573. 52. Pelletier C. Circulatory responses to graded stimulation of the carotid chemoreceptors in the dog . Circ Res. 1972;31:431-443.Crossref 53. Rowell LB, Blackman JR. Human cardiovascular adjustments to acute hypoxemia . Clin Physiol. 1987;7:349-376.Crossref 54. Vatner SF, Rutherford JD. Interaction of carotid chemoreceptor and pulmonary inflation reflexes in circulatory regulation in conscious dogs . Fed Proc. 1981;40:2188-2193. 55. Angell James JE, Daly MD. Cardiovascular responses in apnoeic asphyxia: role of arterial chemoreceptors and the modification of their effects by a pulmonary vagal inflation reflex . J Physiol. 1969;201:87-104. 56. Guilleminault C, Motta J, Mihm F, Melvin K. Obstructive sleep apnea and cardiac index . Chest. 1986;89:331-334.Crossref 57. Coleridge JCG, Coleridge HM. Chemoreflex regulation of the heart . In: Berne RM, Sperelakis N, Geiger SR, eds. Handbook of Physiology: The Cardiovascular System . Baltimore, Md: Williams & Wilkins; 1979:653-676. 58. Scharf S, Brown R, Tow DE, Parisi AE. Cardiac effects of increased lung volume and decreased pleural pressure in man . J Appl Physiol. 1979;47:257-262. 59. Buda AJ, Pinsky MR, Ingels NB Jr, Daughters GT, Stinson EB, Alderman EL. Effect of intrathoracic pressure on left ventricular performance . N Engl J Med. 1979;301:453-459.Crossref 60. Taylor RR, Corell JW, Sonnenblick EH, Ross J. Dependence of ventricular distensibility on filling of the opposite ventricle . Am J Physiol. 1967;213:711-718. 61. Bromberger-Barnea B. Mechanical effects of inspiration on heart functions: a review . Fed Proc. 1981;40:2172-2177. 62. Tolle FA, Judy WV, Yu PL, Markand ON. Reduced stroke volume related to pleural pressure in obstructive sleep apnea . J Appl Physiol. 1983;55:1718-1724. 63. Buda AJ, Schroeder JS, Guilleminault C. Abnormalities of pulmonary artery wedge pressure in sleep-induced apnea . Int J Cardiol. 1981;1:67-74.Crossref 64. Loeppky JA, Voyles WF, Eldridge MW, Sikes CW. Sleep apnea and autonomic cerebrovascular dysfunction . Sleep. 1987;10:25-34. 65. Gislason T, Almqvist M, Boman G, Lindholm CE, Terenius L. Increased CSF opioid activity in sleep apnea syndrome: regression after successful treatment . Chest. 1989;96:250-254.Crossref 66. Somers VK, Mark AL, Abboud FM. Potentiation of sympathetic nerve responses to hypoxia in borderline hypertensive subjects . Hypertension. 1988;11:608-612.Crossref 67. Hedner J, Ejnell H, Sellgren J, Hedner T, Wallin G. Is high and fluctuating muscle nerve sympathetic activity in the sleep apnoea syndrome of pathogenetic importance for the development of hypertension? J Hypertens. 1988;6( (suppl 4) ):S259-S531.Crossref 68. Fletcher EC, Miller J, SchaafJW, Fletcher JG. Urinary catecholamines before and after tracheostomy in patients with obstructive sleep apnea and hypertension . Sleep. 1987;10:35-44. 69. Vitiello MV, Giblin EC, Schoene RB, Halter JB, Prinz PN. Obstructive apnea: sympathetic activity, respiration, and sleep: a case report . Neurobiol Aging. 1982;3:263-266.Crossref 70. Prinz PN, Vitiello MV, Smallwood RG, Schoene RB, Halter JB. Plasma norepinephrine in normal young and aged men: relationship with sleep . J Gerontol. 1984;39:561-567.Crossref 71. Cryer PE. Physiology and pathophysiology of the human sympathoadrenal neuroendocrine system . N Engl J Med. 1980;303:436-443.Crossref 72. Brown MJ, Macquin I. Is adrenaline the cause of essential hypertension? Lancet. 1981;2:1079-1082.Crossref 73. Goldstein DS, Eisenhofer G, Garty M, et al. Implications of plasma levels of catechols in the evaluation of sympathoadrenomedullary function . Am J Hypertens. 1989;2:133S-139S. 74. Mancia G, Ferrari A, Gregorini L, et al. Plasma catecholamines do not invariably reflect sympathetically-induced changes in blood pressure in man . Clin Sci. 1983;65:227-235. 75. Grassi G, Gavazzi C, Cesura AM, Picotti GB, Mancia G. Changes in plasma catecholamines in response to reflex modulation of sympathetic vasoconstrictor tone by cardiopulmonary receptors . Clin Sci. 1985;68:503-510. 76. Vanhoutte PM. Endothelium and control of vascular function: state of the art lecture . Hypertension. 1989;13:658-667.Crossref 77. Kannel WB, Brand N, Skinner JJ Jr, Dawber TR, McNamara PM. The relation of adiposity to blood pressure and development of hypertension: the Framingham Study . Ann Intern Med. 1969;67:48-59.Crossref 78. Sims EAH. Mechanism of hypertension in the overweight . Hypertension. 1982;4( (suppl 3) ):III43-III49.Crossref 79. Harman EM, Wynne JW, Block AJ. The effect of weight loss on sleepdisordered breathing and oxygen desaturation in morbidly obese men . Chest. 1982;82:291-294.Crossref 80. Hoffstein V, Mateika S, Rubinstein I, Slutsky AS. Determinants of blood pressure in snorers . Lancet. 1988;2:992-994.Crossref 81. Reisin E. Weight reduction in the management of hypertension: epidemiologic and mechanistic evidence . Can J Physiol Pharmacol. 1986;64:818-824.Crossref 82. Kaplan NM. Non-drug treatment of hypertension . Ann Intern Med. 1985;102:359-373.Crossref 83. Reisin E, Abel R, Modan M, Silverberg DS, Eliahou HE, Modan B. Effect of weight loss without salt restriction on the reduction of blood pressure in overweight hypertensive patients . N Engl J Med. 1978;298:1-6.Crossref 84. Maxwell MH, Kushiro T, Dornfeld LP, Tuck M, Waks AU. Blood pressure changes in obese hypertensive subjects during rapid weight loss: comparison of restricted vs. unchanged salt intake . Arch Intern Med. 1984;144:1581-1584.Crossref 85. Rubinstein I, Colapinto N, Rotstein L, Brown IG, Hoffstein V. Improvement in upper airway function after weight loss in patients with obstructive sleep apnea . Am Rev Respir Dis. 1988;138:1192-1195.Crossref 86. Suratt PM, McTier RF, Findley LJ, Pohl SL, Wilhoit SC. Changes in breathing and the pharynx after weight loss in obstructive sleep apnea . Chest. 1987;92:631-637.Crossref 87. Smith PL, Gold AR, Mayers DA, Haponik EF, Bleecker ER. Weight loss in mildly to moderately obese patients with obstructive sleep apnea . Ann Intern Med. 1985;103:850-855.Crossref 88. Peiser J, Lavie P, Ovnat A, Charuzi I. Sleep apnea syndrome in the morbidly obese as an indication for weight reduction surgery . Ann Surg. 1984;199:112-115.Crossref 89. Van Itallie TB. Topography of body fat: relationship to risk of cardiovascular and other diseases . In: Lohman TG, Roche AF, Martorell R, eds. Anthropometric Standardization Reference Manual . Champaign, Ill: Human Kinetics Books; 1988:143-150. 90. Bray GA. Classification and evaluation of the obesities . Med Clin North Am. 1989;73:161-184. 91. Peiris AN, Sothman MS, Hoffman RE, et al. Adiposity, fat distribution, and cardiovascular risk . Ann Intern Med. 1989;110:867-872.Crossref 92. Kaplan NM. The deadly quartet: upper body obesity, glucose intolerance, hypertriglyceridemia, and hypertension . Arch Intern Med. 1989;149:1514-1520.Crossref 93. Kreiger DR, Landsberg L. Mechanisms in obesity-related hypertension: role of insulin and catecholamines . Am J Hypertens. 1988;1:84-90. 94. Reaven GM. Role of insulin resistance in human disease . Diabetes. 1988;37:1595-1607.Crossref 95. Horner RL, Mohiaddin RH, Lowell DG, et al. Sites and sizes of fat deposits around the pharynx in obese patients with obstructive sleep apnoea and weight matched controls . Eur Respir J. 1989;2:613-622. 96. Folkow B. Cardiovascular structural adaptation: its role in the inhibition and maintenance of primary hypertension . Clin Sci. 1978;55:3S-22S. 97. Lever AF. Slow pressor mechanisms in hypertension: a role for hypertrophy of resistance vessels? J Hypertens. 1986;4:515-524.Crossref 98. Clark RW, Boudoulas H, Schaal SF, Schmidt HS. Adrenergic hyperactivity and cardiac abnormality in primary disorders of sleep . Neurology. 1980;30:113-119.Crossref 99. Przybylski J, Sabbah HN, Stein PD. Why do patients with essential hypertension experience sleep apnea syndrome . Med Hypotheses. 1986;20: 173-177. 100. Trzebski A, Tafil M, Zoltowski M, Przybylski J. Increased sensitivity of the arterial chemoreceptor drive in young men with mild hypertension . Cardiovasc Res. 1982;16:163-172.Crossref 101. Daskalopoulou-Vlachogianni E, Sandhagen B, Gislason T, Stalenheim G. High ventilatory response to hypoxia in hypertensive patients with sleep apnea . Ups J Med Sci. 1989;94:89-94.Crossref 102. Heath D. The human carotid body . Thorax. 1983;38:561-564.Crossref 103. Goldstein DS, Levinson PD, Zimlichman R, Pitterman A, Stull R, Keiser HR. Clonidine suppression testing in essential hypertension . Ann Intern Med. 1985;102:42-48.Crossref 104. Abboud FM. The sympathetic system in hypertension: state-of-the-art review . Hypertension. 1982;4( (suppl 2) ):II208-II225. 105. Ramirez G, Bittle PA, Hammond M, Ayers CW, Dietz JR, Colice GL. Regulation of aldosterone secretion during hypoxemia at sea level and moderately high altitude . J Clin Endocrinol Metab. 1988;67:1162-1165.Crossref 106. Richards AM, Ikram H, Nicholls MG, Espiner EA, Hamilton EJ, Richards RD. Ambulatory pulmonary arterial pressures in humans: relationship to arterial pressure and hormones . Am J Physiol. 1986;251:H101-H108. 107. Heyes MP, Farber MD, Manfredi F, et al. Acute effect of hypoxia on renal and endocrine function in normal humans . Am J Physiol. 1982;243:R265-R270. 108. Rose CE Jr, Godine RL Jr, Rose KY, Anderson RJ, Carey RM. Role of arginine vasopressin and angiotensin II in cardiovascular responses to combined acute hypoxemia and hypercapnic acidosis in conscious dogs . J Clin Invest. 1984;74:321-331.Crossref 109. Krieger J, Schmidt M, Sforza E, et al. Urinary excretion of guanosine 3′:5,-cyclic monophosphate during sleep in obstructive sleep apnea patients with and without nasal continuous positive airway pressure treatment . Clin Sci. 1989;76:31-37. 110. Warley ARH, Stradling JR. Abnormal diurnal variation in salt and water excretion in patients with obstructive sleep apnoea . Clin Sci. 1988;74:183-185. 111. Bilder GE, Schofield TL, Blaine EH. Release of atrial natriuretic factor: effects of repetitive stretch and temperature . Am J Physiol. 1986;251:F817-F821. 112. Baertschi AJ, Adams JM, Sullivan MP. Acute hypoxemia stimulates atrial natriuretic factor secretion in vivo . Am J Physiol. 1988;255:H295-H300. 113. Perloff S, Sokolow M, Cowan R. The prognostic value of ambulatory blood pressure . JAMA. 1983;249:2793-2798Crossref 114. Casale PN, Devereux RB, Milner M, et al. Value of echocardiographic measurement of left ventricular mass in predicting cardiovascular morbid events in hypertensive men . Ann Intern Med. 1986;105:173-178.Crossref 115. Devereux RB, Pickering TG. Relationship between ambulatory and exercise blood pressure and cardiac structure . Am Heart J. 1988;116:1124-1133.Crossref 116. Drayer JIM, Weber MA, DeYoung JL. Blood pressure as a determinant of cardiac left ventricular muscle mass . Arch Intern Med. 1983;143:90-92.Crossref 117. Rowland DB, Ireland MA, Stallard TJ, et al. Assessment of left ventricular mass and its response to antihypertensive treatment . Lancet. 1982;1:467-470.Crossref 118. White WB, Dey HM, Schulman P. Assessment of the daily blood pressure load as a determinant of cardiac function in patients with mild-to-moderate hypertension . Am Heart J. 1989;118:782-795.Crossref 119. Verdecchia P, Schillaci G, Guerrieri M, et al. Circadian blood pressure changes and left ventricular hypertrophy in essential hypertension . Circulation. 1990;81:528-536.Crossref 120. Pickering TG, Harshfield GA, Kleinert HD, Blank S, Laragh JH. Blood pressure during normal daily activities, sleep, and exercise: comparison of values in normal and hypertensive subjects . JAMA. 1982;247:992-996.Crossref 121. Gosse P, Campello G, Roudaut R, Dallocchio M. High night blood pressure in treated hypertensive patients: not harmless . Am J Hypertens. 1988;1:195S-198S.Crossref 122. Peter JH, Siegrist J, Podszus T, Mayer J, Selzer K, von Wichert P. Prevalence of sleep apnea in healthy industrial workers . Klin Wochenschr. 1985;63:807-811.Crossref 123. Devereux RB, Pickering TG, Harshfield GA, et al. Left ventricular hypertrophy in patients with hypertension: importance of blood pressure response to regularly recurring stress . Circulation. 1983;68:470-476.Crossref 124. Ostman-Smith I. Cardiac sympathetic nerves as the final common pathway in induction of adaptive cardiac hypertrophy . Clin Sci. 1981;61:265-272. 125. Frohlich ED, Messerli FH, Reisin E, Dunn FG. The problem of obesity and hypertension . Hypertension. 1983;5( (suppl 3) ):III71-III78.Crossref 126. Messerli FH. Obesity in hypertension: how innocent a bystander? Am J Med. 1984;77:1077-1082.Crossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Internal Medicine American Medical Association

Causes and Consequences of Blood Pressure Alterations in Obstructive Sleep Apnea

Loading next page...
 
/lp/american-medical-association/causes-and-consequences-of-blood-pressure-alterations-in-obstructive-X06DvG5vkC
Publisher
American Medical Association
Copyright
Copyright © 1991 American Medical Association. All Rights Reserved.
ISSN
0003-9926
eISSN
1538-3679
DOI
10.1001/archinte.1991.00400030025005
Publisher site
See Article on Publisher Site

Abstract

Abstract The obstructive sleep apnea (OSA) syndrome has been considered to be a cause of both transient blood pressure elevations during sleep and sustained hypertension during the awake state. The purpose of this review was to examine critically the existing literature regarding (1) the blood pressure alterations associated with OSA, (2) causal mechanisms relating specific blood pressure alterations to OSA, and (3) potential consequences of the systemic circulatory abnormalities associated with OSA. Particular attention was directed at studies that assessed the prevalence of OSA in patients with hypertension and that examined the effects on blood pressure of treatment of OSA. We conclude that patients with OSA have abnormal sleep blood pressure patterns, manifested most frequently by apnea-associated blood pressure elevations. Confounding factors such as obesity and antihypertensive drug therapy, and conflicting evidence regarding changes in daytime blood pressure after therapy for OSA, make it premature to conclude that OSA and daytime hypertension are directly associated. Circumstantial evidence suggests that the blood pressure alterations that occur during sleep could contribute to the high cardiovascular morbidity in patients with OSA. Further research into the relationship between OSA and hypertension should improve the future care of patients with these conditions and enhance our understanding of cardiopulmonary pathophysiology. (Arch Intern Med. 1991;151:455-462) References 1. Bradley TD, Phillipson EA. Pathogenesis and pathophysiology of the obstructive sleep apnea syndrome . Med Clin North Am. 1985;69:1169-1185. 2. Weil JV, Cherniack NS, Dempsey JA, et al. Respiratory disorders of sleep: pathophysiology, clinical implications, and therapeutic approaches . Am Rev Respir Dis. 1987;136:755-761.Crossref 3. Millman RP. Snoring and apnea . Clin Chest Med. 1987;8:253-264. 4. Lavie P. Incidence of sleep apnea in a presumably healthy working population: a significant relationship with excessive daytime sleepiness . Sleep. 1983;6:312-318. 5. Telakivi T, Partinen M, Koskenvuo M, Salmi T, Kaprio J. Periodic breathing and hypoxia in snorers and controls: validation of snoring history and association with blood pressure and obesity . Acta Neurol Scand. 1987;76:69-75.Crossref 6. Gislason T, Almqvist M, Eriksson G, Taube A, Boman G. Prevalence of sleep apnea syndrome among Swedish men: an epidemiological study . J Clin Epidemiol. 1988;41:571-576.Crossref 7. Guilleminault C. Obstructive sleep apnea: the clinical syndrome and historical perspective . Med Clin North Am. 1985;69:1187-1203. 8. Guilleminault C, Simmons FB, Motta H, et al. Obstructive sleep apnea syndrome and tracheostomy: long-term follow-up experience . Arch Intern Med. 1981;141:985-988.Crossref 9. Burack B. The hypersomnia-sleep apnea syndrome: its recognition in clinical cardiology . Am Heart J. 1984;107:543-548.Crossref 10. Shepard JW Jr, Garrison MW, Grither DA, Dolan GF. Relationship of ventricular ectopy to oxyhemoglobin desaturation in patients with obstructive sleep apnea . Chest. 1985;88:335-340.Crossref 11. Coccagna G, Mantovani M, Brignani F, Parchi C, Lugaresi E. Continuous recording of the pulmonary and systemic arterial pressure during sleep in syndromes of hypersomnia with periodic breathing . Bull Physiopath Resp. 1972;8:1159-1172. 12. Tilkian AG, Guilleminault C, Schroeder JS, Lehrman KL, Simmons FB, Dement WC. Hemodynamics in sleep-induced apnea studies during wakefulness and sleep . Ann Intern Med. 1976;85:714-719.Crossref 13. Motta H, Guilleminault C, Schroeder JS, Dement WC. Tracheostomy and hemodynamic changes in sleep-induced apnea . Ann Intern Med. 1978;89:454-458.Crossref 14. Kales A, Cadieux RJ, Shaw LC, et al. Sleep apnea in a hypertensive population . Lancet. 1984;2:1005-1008.Crossref 15. Fletcher EC, DeBehnke RD, Lovoi MS, Gorin AB. Undiagnosed sleep apnea in patients with essential hypertension . Ann Intern Med. 1985;103:190-195.Crossref 16. Williams AJ, Houston D, Finberg S, Lam C, Kinney JL, Santiago S. Sleep apnea syndrome and essential hypertension . Am J Cardiol. 1985;55:1019-1022.Crossref 17. Kaplan NM. Clinical Hypertension . 4th ed. Baltimore, Md: Williams & Wilkins; 1986:1-28,434-446. 18. Partinen M, Jamieson A, Guilleminault C. Long-term outcome for obstructive sleep apnea syndrome patients: mortality . Chest. 1988;94:1200-1204.Crossref 19. He J, Kryger MH, Zorick FJ, Conway W, Roth T. Mortality and apnea index in obstructive sleep apnea: experience in 385 male patients . Chest. 1988;94:9-14.Crossref 20. Partinen M, Guilleminault C. Daytime sleepiness and vascular morbidity at seven-year follow-up in obstructive sleep apnea patients . Chest. 1990;97:27-32.Crossref 21. Waller PC, Bhopal RS. Is snoring a cause of vascular disease? an epidemiologic review . Lancet. 1989;1:143-146.Crossref 22. Stradling JR. Sleep apnoea and hypertension . Thorax. 1989;44:984-989.Crossref 23. Hubert HB, Feinleib M, McNamara PM, Castelli WP. Obesity as an independent risk factor for cardiovascular disease: a 26-year follow-up of participants in the Framingham Heart Study . Circulation. 1983;67:968-977.Crossref 24. National Institutes of Health Consensus Development Panel on the Health Implications of Obesity. Health implications of obesity: National Institutes of Health Consensus Development Conference statement . Ann Intern Med. 1985;103:147-151.Crossref 25. Higgins M, Kannel W, Garrison R, Pinsky J, Stokes J. Hazards of obesity: the Framingham experience . Acta Med Scand. 1989;723( (suppl) ):23-36. 26. Brooks H, Carrol JH. A clinical study of the effects of sleep and rest on blood pressure . Arch Intern Med. 1912;10:97-102.Crossref 27. Snyder F, Hobson JA, Morrison DF. Changes in respiration, heart rate, and systolic blood pressure in human sleep . J Appl Physiol. 1964;19:417-422. 28. Khatri I, Freis ED. Hemodynamic changes during sleep . J Appl Physiol. 1967;22:867-873. 29. Bristow JD, Honour AJ, Pickering TG. Cardiovascular and respiratory changes during sleep in normal and hypertensive subjects . Cardiovasc Res. 1969;3:476-485.Crossref 30. Coccagna G, Mantovani M, Brignani F, Manzini A, Lugaresi E. Arterial pressure changes during spontaneous sleep in man . Electroencephalogr Clin Neurophysiol. 1971;31:277-281.Crossref 31. Drayer JIM, Weber MA, Nakamura DK. Automated ambulatory blood pressure monitoring: a study in age-matched normotensive and hypertensive men . Am Heart J. 1985;109:1334-1338.Crossref 32. Pickering TG. The clinical significance of diurnal blood pressure variations: dippers and non-dippers . Circulation. 1990;81:700-702.Crossref 33. Pickering TG. The influence of daily activity on ambulatory blood pressure . Am Heart J. 1988;116:1141-1145.Crossref 34. Podszus T, Mayer J, Penzel T, Peter JH, von Wichert P. Nocturnal hemodynamics in patients with sleep apnea . Eur J Respir Dis. 1986;69( (suppl 146) ):435-442. 35. Shepard JW Jr. Hemodynamics in obstructive apnea . In: Fletcher EC, ed. Abnormalities of Respiration During Sleep: Diagnosis, Pathophysiology, and Treatment . New York, NY: Grune & Stratton; 1986:39-61. 36. Scharf SM. Influence of sleep state and breathing on cardiovascular function . In: Saunders NA, Sullivan CE, eds. Sleep and Breathing . New York, NY: Marcel Dekker Inc; 1984:221-240. 37. Schroeder JS, Motta J, Guilleminault C. Hemodynamic studies in sleep apnea . In: Guilleminault C, Dement WC, eds. Sleep Apnea Syndromes . New York, NY: Alan R Liss Inc; 1978:177-196. 38. Jennum P, Borgeson SE. Intracranial pressure and obstructive sleep apnea . Chest. 1990;95:279-283.Crossref 39. McGinty D, Beahm E, Stern N, Littner M, Sowers J, Reige W. Nocturnal hypotension in older men with sleep-related breathing disorders . Chest. 1988;94:305-311.Crossref 40. Lavie P, Ben-Yosef R, Rubin AE. Prevalence of sleep apnea syndrome among patients with essential hypertension . Am Heart J. 1984;108:373-376.Crossref 41. Warley ARH, Mitchell JH, Stradling JR. Prevalence of nocturnal hypoxaemia amongst men with mild to moderate hypertension . Q J Med. 1988;256:637-644. 42. Hirshkowitz M, Karacan I, Gurakar A, Williams RL. Hypertension, erectile dysfunction, and occult sleep apnea . Sleep. 1989;12:223-232. 43. Knight H, Millman RP, Gur RC, Saykin AJ, Doherty JU, Pack AI. Clinical significance of sleep apnea in the elderly . Am Rev Respir Dis. 1987;136:845-850.Crossref 44. Lahive KC, Weiss JW, Weinberger SE. Alpha-methyldopa selectively reduces nasi activity . Clin Sci. 1988;74:547-551. 45. Sullivan CE, Konar LF, Murphy E, Phillipson EA. Primary role of respiratory afferents in sustaining breathing rhythm . J Appl Physiol. 1985;45:11-17. 46. Boudoulas H, Schmidt H, Gelens P, Clark RW, Lewis RP. Case reports on deterioration of sleep apnea during therapy with propranolol: preliminary studies . Res Commun Chem Pathol Pharmacol. 1983;39:3-10. 47. Coccagna G, Mantovani M, Brignani F, Parchi C, Lugaresi E. Tracheostomy in hypersomnia with periodic breathing . Bull Physiopath Resp. 1972;8:1217-1227. 48. Jennum P, Wildschiodtz G, Christenson NJ, Schwartz T. Blood pressure, catecholamines, and pancreatic polypeptide in obstructive sleep apnea with and without nasal continuous positive airway pressure (nCPAP) treatment . Am J Hypertens. 1989;2:847-852.Crossref 49. Heistad DD, Abboud FM. Circulatory adjustments to hypoxia . Circulation. 1980;61:463-470.Crossref 50. Shepherd JT, Vanhoutte PM, eds. The Human Cardiovascular System: Facts and Concepts . New York, NY: Raven Press; 1979:107-155. 51. Daly MD, Scott MJ. An analysis of the primary cardiovascular reflex effects of stimulation of the carotid body chemoreceptors in the dog . J Physiol. 1962;162:555-573. 52. Pelletier C. Circulatory responses to graded stimulation of the carotid chemoreceptors in the dog . Circ Res. 1972;31:431-443.Crossref 53. Rowell LB, Blackman JR. Human cardiovascular adjustments to acute hypoxemia . Clin Physiol. 1987;7:349-376.Crossref 54. Vatner SF, Rutherford JD. Interaction of carotid chemoreceptor and pulmonary inflation reflexes in circulatory regulation in conscious dogs . Fed Proc. 1981;40:2188-2193. 55. Angell James JE, Daly MD. Cardiovascular responses in apnoeic asphyxia: role of arterial chemoreceptors and the modification of their effects by a pulmonary vagal inflation reflex . J Physiol. 1969;201:87-104. 56. Guilleminault C, Motta J, Mihm F, Melvin K. Obstructive sleep apnea and cardiac index . Chest. 1986;89:331-334.Crossref 57. Coleridge JCG, Coleridge HM. Chemoreflex regulation of the heart . In: Berne RM, Sperelakis N, Geiger SR, eds. Handbook of Physiology: The Cardiovascular System . Baltimore, Md: Williams & Wilkins; 1979:653-676. 58. Scharf S, Brown R, Tow DE, Parisi AE. Cardiac effects of increased lung volume and decreased pleural pressure in man . J Appl Physiol. 1979;47:257-262. 59. Buda AJ, Pinsky MR, Ingels NB Jr, Daughters GT, Stinson EB, Alderman EL. Effect of intrathoracic pressure on left ventricular performance . N Engl J Med. 1979;301:453-459.Crossref 60. Taylor RR, Corell JW, Sonnenblick EH, Ross J. Dependence of ventricular distensibility on filling of the opposite ventricle . Am J Physiol. 1967;213:711-718. 61. Bromberger-Barnea B. Mechanical effects of inspiration on heart functions: a review . Fed Proc. 1981;40:2172-2177. 62. Tolle FA, Judy WV, Yu PL, Markand ON. Reduced stroke volume related to pleural pressure in obstructive sleep apnea . J Appl Physiol. 1983;55:1718-1724. 63. Buda AJ, Schroeder JS, Guilleminault C. Abnormalities of pulmonary artery wedge pressure in sleep-induced apnea . Int J Cardiol. 1981;1:67-74.Crossref 64. Loeppky JA, Voyles WF, Eldridge MW, Sikes CW. Sleep apnea and autonomic cerebrovascular dysfunction . Sleep. 1987;10:25-34. 65. Gislason T, Almqvist M, Boman G, Lindholm CE, Terenius L. Increased CSF opioid activity in sleep apnea syndrome: regression after successful treatment . Chest. 1989;96:250-254.Crossref 66. Somers VK, Mark AL, Abboud FM. Potentiation of sympathetic nerve responses to hypoxia in borderline hypertensive subjects . Hypertension. 1988;11:608-612.Crossref 67. Hedner J, Ejnell H, Sellgren J, Hedner T, Wallin G. Is high and fluctuating muscle nerve sympathetic activity in the sleep apnoea syndrome of pathogenetic importance for the development of hypertension? J Hypertens. 1988;6( (suppl 4) ):S259-S531.Crossref 68. Fletcher EC, Miller J, SchaafJW, Fletcher JG. Urinary catecholamines before and after tracheostomy in patients with obstructive sleep apnea and hypertension . Sleep. 1987;10:35-44. 69. Vitiello MV, Giblin EC, Schoene RB, Halter JB, Prinz PN. Obstructive apnea: sympathetic activity, respiration, and sleep: a case report . Neurobiol Aging. 1982;3:263-266.Crossref 70. Prinz PN, Vitiello MV, Smallwood RG, Schoene RB, Halter JB. Plasma norepinephrine in normal young and aged men: relationship with sleep . J Gerontol. 1984;39:561-567.Crossref 71. Cryer PE. Physiology and pathophysiology of the human sympathoadrenal neuroendocrine system . N Engl J Med. 1980;303:436-443.Crossref 72. Brown MJ, Macquin I. Is adrenaline the cause of essential hypertension? Lancet. 1981;2:1079-1082.Crossref 73. Goldstein DS, Eisenhofer G, Garty M, et al. Implications of plasma levels of catechols in the evaluation of sympathoadrenomedullary function . Am J Hypertens. 1989;2:133S-139S. 74. Mancia G, Ferrari A, Gregorini L, et al. Plasma catecholamines do not invariably reflect sympathetically-induced changes in blood pressure in man . Clin Sci. 1983;65:227-235. 75. Grassi G, Gavazzi C, Cesura AM, Picotti GB, Mancia G. Changes in plasma catecholamines in response to reflex modulation of sympathetic vasoconstrictor tone by cardiopulmonary receptors . Clin Sci. 1985;68:503-510. 76. Vanhoutte PM. Endothelium and control of vascular function: state of the art lecture . Hypertension. 1989;13:658-667.Crossref 77. Kannel WB, Brand N, Skinner JJ Jr, Dawber TR, McNamara PM. The relation of adiposity to blood pressure and development of hypertension: the Framingham Study . Ann Intern Med. 1969;67:48-59.Crossref 78. Sims EAH. Mechanism of hypertension in the overweight . Hypertension. 1982;4( (suppl 3) ):III43-III49.Crossref 79. Harman EM, Wynne JW, Block AJ. The effect of weight loss on sleepdisordered breathing and oxygen desaturation in morbidly obese men . Chest. 1982;82:291-294.Crossref 80. Hoffstein V, Mateika S, Rubinstein I, Slutsky AS. Determinants of blood pressure in snorers . Lancet. 1988;2:992-994.Crossref 81. Reisin E. Weight reduction in the management of hypertension: epidemiologic and mechanistic evidence . Can J Physiol Pharmacol. 1986;64:818-824.Crossref 82. Kaplan NM. Non-drug treatment of hypertension . Ann Intern Med. 1985;102:359-373.Crossref 83. Reisin E, Abel R, Modan M, Silverberg DS, Eliahou HE, Modan B. Effect of weight loss without salt restriction on the reduction of blood pressure in overweight hypertensive patients . N Engl J Med. 1978;298:1-6.Crossref 84. Maxwell MH, Kushiro T, Dornfeld LP, Tuck M, Waks AU. Blood pressure changes in obese hypertensive subjects during rapid weight loss: comparison of restricted vs. unchanged salt intake . Arch Intern Med. 1984;144:1581-1584.Crossref 85. Rubinstein I, Colapinto N, Rotstein L, Brown IG, Hoffstein V. Improvement in upper airway function after weight loss in patients with obstructive sleep apnea . Am Rev Respir Dis. 1988;138:1192-1195.Crossref 86. Suratt PM, McTier RF, Findley LJ, Pohl SL, Wilhoit SC. Changes in breathing and the pharynx after weight loss in obstructive sleep apnea . Chest. 1987;92:631-637.Crossref 87. Smith PL, Gold AR, Mayers DA, Haponik EF, Bleecker ER. Weight loss in mildly to moderately obese patients with obstructive sleep apnea . Ann Intern Med. 1985;103:850-855.Crossref 88. Peiser J, Lavie P, Ovnat A, Charuzi I. Sleep apnea syndrome in the morbidly obese as an indication for weight reduction surgery . Ann Surg. 1984;199:112-115.Crossref 89. Van Itallie TB. Topography of body fat: relationship to risk of cardiovascular and other diseases . In: Lohman TG, Roche AF, Martorell R, eds. Anthropometric Standardization Reference Manual . Champaign, Ill: Human Kinetics Books; 1988:143-150. 90. Bray GA. Classification and evaluation of the obesities . Med Clin North Am. 1989;73:161-184. 91. Peiris AN, Sothman MS, Hoffman RE, et al. Adiposity, fat distribution, and cardiovascular risk . Ann Intern Med. 1989;110:867-872.Crossref 92. Kaplan NM. The deadly quartet: upper body obesity, glucose intolerance, hypertriglyceridemia, and hypertension . Arch Intern Med. 1989;149:1514-1520.Crossref 93. Kreiger DR, Landsberg L. Mechanisms in obesity-related hypertension: role of insulin and catecholamines . Am J Hypertens. 1988;1:84-90. 94. Reaven GM. Role of insulin resistance in human disease . Diabetes. 1988;37:1595-1607.Crossref 95. Horner RL, Mohiaddin RH, Lowell DG, et al. Sites and sizes of fat deposits around the pharynx in obese patients with obstructive sleep apnoea and weight matched controls . Eur Respir J. 1989;2:613-622. 96. Folkow B. Cardiovascular structural adaptation: its role in the inhibition and maintenance of primary hypertension . Clin Sci. 1978;55:3S-22S. 97. Lever AF. Slow pressor mechanisms in hypertension: a role for hypertrophy of resistance vessels? J Hypertens. 1986;4:515-524.Crossref 98. Clark RW, Boudoulas H, Schaal SF, Schmidt HS. Adrenergic hyperactivity and cardiac abnormality in primary disorders of sleep . Neurology. 1980;30:113-119.Crossref 99. Przybylski J, Sabbah HN, Stein PD. Why do patients with essential hypertension experience sleep apnea syndrome . Med Hypotheses. 1986;20: 173-177. 100. Trzebski A, Tafil M, Zoltowski M, Przybylski J. Increased sensitivity of the arterial chemoreceptor drive in young men with mild hypertension . Cardiovasc Res. 1982;16:163-172.Crossref 101. Daskalopoulou-Vlachogianni E, Sandhagen B, Gislason T, Stalenheim G. High ventilatory response to hypoxia in hypertensive patients with sleep apnea . Ups J Med Sci. 1989;94:89-94.Crossref 102. Heath D. The human carotid body . Thorax. 1983;38:561-564.Crossref 103. Goldstein DS, Levinson PD, Zimlichman R, Pitterman A, Stull R, Keiser HR. Clonidine suppression testing in essential hypertension . Ann Intern Med. 1985;102:42-48.Crossref 104. Abboud FM. The sympathetic system in hypertension: state-of-the-art review . Hypertension. 1982;4( (suppl 2) ):II208-II225. 105. Ramirez G, Bittle PA, Hammond M, Ayers CW, Dietz JR, Colice GL. Regulation of aldosterone secretion during hypoxemia at sea level and moderately high altitude . J Clin Endocrinol Metab. 1988;67:1162-1165.Crossref 106. Richards AM, Ikram H, Nicholls MG, Espiner EA, Hamilton EJ, Richards RD. Ambulatory pulmonary arterial pressures in humans: relationship to arterial pressure and hormones . Am J Physiol. 1986;251:H101-H108. 107. Heyes MP, Farber MD, Manfredi F, et al. Acute effect of hypoxia on renal and endocrine function in normal humans . Am J Physiol. 1982;243:R265-R270. 108. Rose CE Jr, Godine RL Jr, Rose KY, Anderson RJ, Carey RM. Role of arginine vasopressin and angiotensin II in cardiovascular responses to combined acute hypoxemia and hypercapnic acidosis in conscious dogs . J Clin Invest. 1984;74:321-331.Crossref 109. Krieger J, Schmidt M, Sforza E, et al. Urinary excretion of guanosine 3′:5,-cyclic monophosphate during sleep in obstructive sleep apnea patients with and without nasal continuous positive airway pressure treatment . Clin Sci. 1989;76:31-37. 110. Warley ARH, Stradling JR. Abnormal diurnal variation in salt and water excretion in patients with obstructive sleep apnoea . Clin Sci. 1988;74:183-185. 111. Bilder GE, Schofield TL, Blaine EH. Release of atrial natriuretic factor: effects of repetitive stretch and temperature . Am J Physiol. 1986;251:F817-F821. 112. Baertschi AJ, Adams JM, Sullivan MP. Acute hypoxemia stimulates atrial natriuretic factor secretion in vivo . Am J Physiol. 1988;255:H295-H300. 113. Perloff S, Sokolow M, Cowan R. The prognostic value of ambulatory blood pressure . JAMA. 1983;249:2793-2798Crossref 114. Casale PN, Devereux RB, Milner M, et al. Value of echocardiographic measurement of left ventricular mass in predicting cardiovascular morbid events in hypertensive men . Ann Intern Med. 1986;105:173-178.Crossref 115. Devereux RB, Pickering TG. Relationship between ambulatory and exercise blood pressure and cardiac structure . Am Heart J. 1988;116:1124-1133.Crossref 116. Drayer JIM, Weber MA, DeYoung JL. Blood pressure as a determinant of cardiac left ventricular muscle mass . Arch Intern Med. 1983;143:90-92.Crossref 117. Rowland DB, Ireland MA, Stallard TJ, et al. Assessment of left ventricular mass and its response to antihypertensive treatment . Lancet. 1982;1:467-470.Crossref 118. White WB, Dey HM, Schulman P. Assessment of the daily blood pressure load as a determinant of cardiac function in patients with mild-to-moderate hypertension . Am Heart J. 1989;118:782-795.Crossref 119. Verdecchia P, Schillaci G, Guerrieri M, et al. Circadian blood pressure changes and left ventricular hypertrophy in essential hypertension . Circulation. 1990;81:528-536.Crossref 120. Pickering TG, Harshfield GA, Kleinert HD, Blank S, Laragh JH. Blood pressure during normal daily activities, sleep, and exercise: comparison of values in normal and hypertensive subjects . JAMA. 1982;247:992-996.Crossref 121. Gosse P, Campello G, Roudaut R, Dallocchio M. High night blood pressure in treated hypertensive patients: not harmless . Am J Hypertens. 1988;1:195S-198S.Crossref 122. Peter JH, Siegrist J, Podszus T, Mayer J, Selzer K, von Wichert P. Prevalence of sleep apnea in healthy industrial workers . Klin Wochenschr. 1985;63:807-811.Crossref 123. Devereux RB, Pickering TG, Harshfield GA, et al. Left ventricular hypertrophy in patients with hypertension: importance of blood pressure response to regularly recurring stress . Circulation. 1983;68:470-476.Crossref 124. Ostman-Smith I. Cardiac sympathetic nerves as the final common pathway in induction of adaptive cardiac hypertrophy . Clin Sci. 1981;61:265-272. 125. Frohlich ED, Messerli FH, Reisin E, Dunn FG. The problem of obesity and hypertension . Hypertension. 1983;5( (suppl 3) ):III71-III78.Crossref 126. Messerli FH. Obesity in hypertension: how innocent a bystander? Am J Med. 1984;77:1077-1082.Crossref

Journal

Archives of Internal MedicineAmerican Medical Association

Published: Mar 1, 1991

References