Ambulatory Blood Pressure and Cardiovascular Outcome in Relation to Perceived Sleep Deprivation

Abstract

Abstract-Sleep deprivation induced by cuff inflations during overnight blood pressure (BP) monitoring might interfere with the prognostic significance of nighttime BP. In 2934 initially untreated hypertensive subjects, we assessed the perceived quantity of sleep during overnight BP monitoring. Overall, 58.7%, 27.7%, 9.7%, and 4.0% of subjects reported a sleep duration perceived as usual (group A), Ͻ2 hours less than usual (group B), 2 to 4 hours less than usual (group C), and Ͼ4 hours less than usual (group D). Daytime BP did not differ across the groups (all Ps not significant). Nighttime BP increased from group A to D (124/75, 126/76, 128/77, and 129/79 mm Hg, respectively; all Ps for trend Ͻ0.01). Over a median follow-up period of 7 years there were 356 major cardiovascular events and 176 all-cause deaths. Incidence of total cardiovascular events and deaths was higher in the subjects with a night/day ratio in systolic BP Ͼ10% compared with those with a greater day-night BP drop in the group with perceived sleep duration as usual or Ͻ2 hours less than usual (both PϽ0.01), not in the group with duration of sleep Ն2 hours less than usual (all Ps not significant). In a Cox model, the independent prognostic value of nighttime BP for total cardiovascular end points and all-cause mortality disappeared in the subjects with perceived sleep deprivation Ն2 hours. In conclusion, nighttime BP rises and loses its prognostic significance in the hypertensive subjects who perceive a sleep deprivation by Ն2 hours during overnight monitoring. Key Words: hypertension Ⅲ dippers Ⅲ nondippers Ⅲ blood pressure monitoring Ⅲ sleep Ⅲ stroke Ⅲ myocardial infarction Ⅲ epidemiology D espite the growing body of evidence supporting the prognostic value of nighttime blood pressure (BP), 1-6 it is unclear to what extent the compressive, tactile, and sonorous stimuli produced by repeated cuff inflations during 24-hour ambulatory BP (ABP) monitoring interfere with nighttime BP measurements, possibly through sleep disturbance or deprivation. In a study, intra-arterial ABP did not differ during day and night in the presence versus absence of concomitant noninvasive ABP monitoring. 7 Studies carried out in sleep laboratories produced conflicting results in showing no changes 8 and an increase 9,10 in the number of nocturnal awakenings during overnight monitoring. The picture is complicated by the finding that hypertensive subjects with a blunted day-night fall in BP ("non-dippers") 11 present more frequent microarousals 12 and apneic snoring 13 as compared with subjects with normal day-night BP fall, but evidence is controversial. 14 Overall, available studies suggest that nighttime BP could be altered by the sleep noise induced by repeated cuff inflations but do not clarify the prevalence of this phenomenon or, more importantly, its prognostic significance. The clinical impact of this issue is relevant because of the growing reliance on nighttime BP when interpreting results of ABP monitoring. Thus, the aim of the present study was to determine t...

Nocturnal blood pressure and cardiovascular disease: a review of recent advances

“…13,14 As sleep deprivation resulting from the repeated cuff-inflame during overnight BP monitoring leads to BP elevation, the clinical implications of high nocturnal BP levels obtained in such cases should be interpreted with caution. In fact, Verdecchia et al 15 suggested that the nocturnal BP of patients who perceived sleep deprivation of at least 2 h of lost sleep lost its prognostic significance with at least 7 years of follow-up for mortality and also in terms of composite cardiovascular risk. Moreover, Hensken et al 16 also reported that the association between nocturnal BP levels and cardiac hypertrophy tended to be weaker when sleep was subjectively disturbed during overnight BP monitoring.…”

Home Blood Pressure Measurements Will Not Replace 24-Hour Ambulatory Blood Pressure Monitoring

“…If sleep is perceived as "poor" during overnight BP monitoring (duration of sleep Ͻ2 hours less than usual), nighttime BP rises, and its prognostic significance appears to be no longer reliable. 52 An objective consideration is that 24-hour ABP monitoring is the only reasonable and established way to measure nighttime BP and the day-night BP changes. Indeed, some modern instruments for home BP measurements could be set to take some occasional BP measurements even during the night, 53 but their clinical use to refine organ damage prediction and risk stratification should be further investigated.…”

Increased low-grade inflammation and plasminogen-activator inhibitor-1 level in nondippers with sleep apnea syndrome

“…There may be 2 types of non-dippers (with and without other risk factors such as SAS and/or diabetes), and the risks of non-dipper status may be partly explained by the subjects' backgrounds that lead to non-dipper status. Verdecchia, et al [23] reported that non-dippers with sleep deprivation induced by cuff inflations during nighttime ABPM did not have increased cardiovascular mortality. Some of the mechanisms by which SAS may increase blood pressure include the reninangiotensin-aldosterone system [24,25], sympathetic nerve activation [26], endothelial dysfunction [27], endothelin [28], and oxidative stress [29].…”