The treatment for obstructive sleep apnoea (OSA) with continuous positive airway pressure (CPAP) or mandibular advancement devices (MADs) is associated with blood pressure (BP) reduction; however, the overall effect is modest. The aim of this systematic review and meta-analysis of randomised controlled trials (RCTs) comparing the effect of such treatments on BP was to identify subgroups of patients who respond best to treatment.The article search was performed in three different databases with specific search terms and selection criteria. From 2289 articles, we included 68 RCTs that compared CPAP or MADs with either passive or active treatment. When all the studies were pooled together, CPAP and MADs were associated with a mean BP reduction of −2.09 (95% CI −2.78– −1.40) mmHg for systolic BP and −1.92 (95% CI −2.40– −1.43) mmHg for diastolic BP and −1.27 (95% CI −2.34– −0.20) mmHg for systolic BP and −1.11 (95% CI −1.82– −0.41) mmHg for diastolic BP, respectively. The subgroups of patients who showed a greater response were those aged <60 years (systolic BP −2.93 mmHg), with uncontrolled BP at baseline (systolic BP −4.14 mmHg) and with severe oxygen desaturations (minimum arterial oxygen saturation measured by pulse oximetry <77%) at baseline (24-h systolic BP −7.57 mmHg).Although this meta-analysis shows that the expected reduction of BP by CPAP/MADs is modest, it identifies specific characteristics that may predict a pronounced benefit from CPAP in terms of BP control. These findings should be interpreted with caution; however, they are particularly important in identifying potential phenotypes associated with BP reduction in patients treated for OSA.

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There is consistent epidemiological evidence that sleep disordered breathing and systemic arterial hypertension are deeply associated, being linked through a bidirectional complex interaction among multiple mechanisms including autonomic nervous system alterations, inflammation, hormonal and hemodynamic components, sleep alterations. However there are several unanswered questions not only from a pathophysiological perspective, but also regarding the effects of obstructive sleep apnea (OSA) treatment on arterial blood pressure values. At present, while many studies have supported the possibility to obtain at least a small blood pressure reduction with OSA treatment, in particular in hypertensive patients, large trials have not clearly confirmed a significant anti-hypertensive effect, nor a beneficial effect of this intervention on cardiovascular endpoints including cardiovascular mortality. Aim of the present review article is to address the relationship between OSA and hypertension in the light of the latest evidence in the field. Moreover we will discuss research topics which need to be investigated in the future, in order to better clarify still pending issues with the aim of obtaining an early diagnosis, a more suitable phenotyping including comorbidities, and better strategies to improve patients' compliance and adherence to treatment.

Hypertension is a major contributor to fatal/nonfatal cardiovascular diseases, and timely identification and appropriate management of factors affecting hypertension and its control are mandatory public health issues. By inducing neurohormonal alterations and metabolic impairment, sleep disorders have an impact on a variety of cardiovascular risk factors, including hypertension, and ultimately increase the risk of cardiovascular events. There is evidence that qualitative and quantitative sleep disorders are associated with resistant hypertension and with impaired circadian blood pressure variations. However, sleep disturbances are often unrecognized, or heterogeneity exists in their management by non-specialists in the field. This document by the Italian Society of Hypertension summarizes the updated evidence linking sleep disorders to hypertension and cardiovascular diseases, the major underlying mechanisms, and the possible management strategies. A simplified, evidence-based diagnostic and therapeutic algorithm for comorbid hypertension and common sleep disorders, namely obstructive sleep apnoea and insomnia, is proposed.