Sleep and hypertension: A two-way street of risks
Click Here to Manage Email Alerts
Key takeaways:
- There is a bidirectional relationship between disrupted sleep and hypertension.
- Some BP medications can interfere with sleep, complicating treatment.
BOSTON — Data show sleep abnormalities are associated with hypertension; however, antihypertensive medications can in turn disrupt sleep, complicating treatment for patients, according to a speaker.
“Disrupted sleep, including insufficient sleep and obstructive sleep apnea, may contribute to daytime hypertension,” Virend K. Somers, MD, PhD, the Alice Sheets Marriott Professor and director of the cardiovascular and sleep facilities at the Mayo Clinic’s Center for Clinical and Translational Science in Rochester, Minnesota, told Healio. “However, treatment of hypertension, including with diuretics, beta-blockers or other drugs, also has the potential to disrupt sleep.”
Less sleep, more hypertension risk
Recent guidance from the American Heart Association highlights sleep as an important component of overall health and CV health, Somers said during a presentation at the Cardiometabolic Health Congress. The American Academy of Sleep Medicine and the Sleep Research Society jointly recommend adults get 7 to 9 hours of sleep per night, yet CDC data suggest one in three Americans sleeps fewer than 7 hours per night.
“If you look at the relationship between sleep insufficiency and obesity and hypertension geographically ... there is a clear geographic predisposition to less sleep, more hypertension and more obesity in certain states,” Somers said. “[National Health and Nutrition Examination Survey] data show that people who sleep 5 hours or less have a twofold greater risk for developing new-onset or incident hypertension.”
During sleep, there are structured changes in rates of autonomic tone, BP and heart rate across different sleep stages, Somers said. For most people, BP falls or “dips” during sleep; so-called “non-dippers” will have the same daytime BP without a fall in BP during sleep.
“The implications of being a ‘non-dipper’ is you have increased CV risk, well proven and independent of your daytime BP,” Somers said. “The absence of a fall in nighttime BP is going to predict an increased likelihood of left ventricular hypertrophy, stroke, MI and HF.”
People with hypertension are also much more likely to have comorbid sleep apnea, Somers said.
“You have heard about resistant hypertension — 80% of people with drug-resistant hypertension have a high likelihood of sleep apnea,” Somers said. “But I caution you: Sleep apnea is common. Hypertension is common. Just because they exist in the same patient does not mean that sleep apnea is causing hypertension. The trick is finding those people with sleep apnea that is significantly contributing to the presence of hypertension.”
Weigh risks, benefits of treatments
For adults with hypertension, following recommended sleep guidance can be difficult when taking medications that may interfere with sleep. Likewise, some sleep medications have been associated with increases in BP, Somers said.
“In a post hoc analysis of a randomized controlled crossover trial of 4 hours vs. 8 hours of sleep per night, over 10 nights, in healthy young subjects, restricted sleep was accompanied by increases in BP that were especially evident in men rather than women,” Somers told Healio.
Somers said common antihypertensive medications, such as beta-blockers, can reduce melatonin, a driver of sleep, and are also associated with nighttime awakenings and nightmares. Clonidine can suppress REM sleep and lead to daytime fatigue and drowsiness; alpha-blockers can also interfere with REM sleep. Diuretics can disrupt sleep due to a need to urinate at night, whereas ACE inhibitors can cause nocturnal cough and muscle aches, Somers said.
For patients with serious sleep disorders like narcolepsy, characterized by excessive daytime sleepiness and cataplexy, the widely used treatment sodium oxybate has 1,100 mg to 1,600 mg of sodium in a typical dose, Somers said.
“This is a huge dose of salt given to these patients already at high risk for future hypertension,” Somers said. “Data show that 6 months after getting sodium oxybate, the narcoleptic patients either had a new diagnosis of hypertension or were given an antihypertensive drug.”
Emerging data also suggest that renal denervation, an interventional procedure used to treat resistant hypertension, may be associated with a reduction in apnea-hypopnea index among patients with obstructive sleep apnea who underwent the procedure. Researchers continue to explore the association, Somers said.
“We do not know what [reduction] means,” Somers said. “[Renal denervation] is not a way to treat sleep apnea. It is a curious finding that when you denervate the renal sympathetic nerves, you may improve the severity of sleep apnea. How that relates to a future reduction in BP, we do not know.”
With the many risks and benefit nuances of treatment, Somers said a combination of interventions may ultimately prove successful in adults with elevated BP.
“If we can lower BP on a population-wide basis, whether it is through interventions like better sleep, less salt, more exercise, and change the systolic BP distribution of the population by even 2 mm Hg, you will reduce stroke by 6%,” Somers said. “If you can reduce systolic BP by 3 mm Hg, you reduce stroke by 8%. Reduce systolic BP by 5 mm Hg across the population, you reduce risk for stroke by 14%. By putting multiple interventions together, you can get a substantial fall in BP.”
Collapse
Somers V. Sleep and hypertension: A two-way street. Presented at: Cardiometabolic Health Congress; Oct. 18-21, 2023; Boston.
Read more about
Click Here to Manage Email Alerts