Sleep Apnea and Hypertension Control among Hispanic/Latino Adults in the United States: Results from the Hispanic Community Health Study / Study of Latinos (HCHS/SOL)

Sleep Apnea and Hypertension Control among Hispanic/Latino Adults in the United States: Results from the Hispanic Community Health Study / Study of Latinos (HCHS/SOL) | medRxiv /* */ /* */ <!-- <!-- /*! * yepnope1.5.4 * (c) WTFPL, GPLv2 */ (function(a,b,c){function d(a){return"[object Function]"==o.call(a)}function e(a){return"string"==typeof a}function f(){}function g(a){return!a||"loaded"==a||"complete"==a||"uninitialized"==a}function h(){var a=p.shift();q=1,a?a.t?m(function(){("c"==a.t?B.injectCss:B.injectJs)(a.s,0,a.a,a.x,a.e,1)},0):(a(),h()):q=0}function i(a,c,d,e,f,i,j){function k(b){if(!o&&g(l.readyState)&&(u.r=o=1,!q&&h(),l.onload=l.onreadystatechange=null,b)){"img"!=a&&m(function(){t.removeChild(l)},50);for(var d in y[c])y[c].hasOwnProperty(d)&&y[c][d].onload()}}var j=j||B.errorTimeout,l=b.createElement(a),o=0,r=0,u={t:d,s:c,e:f,a:i,x:j};1===y[c]&&(r=1,y[c]=[]),"object"==a?l.data=c:(l.src=c,l.type=a),l.width=l.height="0",l.onerror=l.onload=l.onreadystatechange=function(){k.call(this,r)},p.splice(e,0,u),"img"!=a&&(r||2===y[c]?(t.insertBefore(l,s?null:n),m(k,j)):y[c].push(l))}function j(a,b,c,d,f){return q=0,b=b||"j",e(a)?i("c"==b?v:u,a,b,this.i++,c,d,f):(p.splice(this.i++,0,a),1==p.length&&h()),this}function k(){var a=B;return a.loader={load:j,i:0},a}var l=b.documentElement,m=a.setTimeout,n=b.getElementsByTagName("script")[0],o={}.toString,p=[],q=0,r="MozAppearance"in l.style,s=r&&!!b.createRange().compareNode,t=s?l:n.parentNode,l=a.opera&&"[object Opera]"==o.call(a.opera),l=!!b.attachEvent&&!l,u=r?"object":l?"script":"img",v=l?"script":u,w=Array.isArray||function(a){return"[object Array]"==o.call(a)},x=[],y={},z={timeout:function(a,b){return b.length&&(a.timeout=b[0]),a}},A,B;B=function(a){function b(a){var a=a.split("!"),b=x.length,c=a.pop(),d=a.length,c={url:c,origUrl:c,prefixes:a},e,f,g;for(f=0;f<d;f++)g=a[f].split("="),(e=z[g.shift()])&&(c=e(c,g));for(f=0;f<b;f++)c=x[f](c);return c}function g(a,e,f,g,h){var i=b(a),j=i.autoCallback;i.url.split(".").pop().split("?").shift(),i.bypass||(e&&(e=d(e)?e:e[a]||e[g]||e[a.split("/").pop().split("?")[0]]),i.instead?i.instead(a,e,f,g,h):(y[i.url]?i.noexec=!0:y[i.url]=1,f.load(i.url,i.forceCSS||!i.forceJS&&"css"==i.url.split(".").pop().split("?").shift()?"c":c,i.noexec,i.attrs,i.timeout),(d(e)||d(j))&&f.load(function(){k(),e&&e(i.origUrl,h,g),j&&j(i.origUrl,h,g),y[i.url]=2})))}function h(a,b){function c(a,c){if(a){if(e(a))c||(j=function(){var a=[].slice.call(arguments);k.apply(this,a),l()}),g(a,j,b,0,h);else if(Object(a)===a)for(n in m=function(){var b=0,c;for(c in a)a.hasOwnProperty(c)&&b++;return b}(),a)a.hasOwnProperty(n)&&(!c&&!--m&&(d(j)?j=function(){var a=[].slice.call(arguments);k.apply(this,a),l()}:j[n]=function(a){return function(){var b=[].slice.call(arguments);a&&a.apply(this,b),l()}}(k[n])),g(a[n],j,b,n,h))}else!c&&l()}var h=!!a.test,i=a.load||a.both,j=a.callback||f,k=j,l=a.complete||f,m,n;c(h?a.yep:a.nope,!!i),i&&c(i)}var i,j,l=this.yepnope.loader;if(e(a))g(a,0,l,0);else if(w(a))for(i=0;i (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0];var j=d.createElement(s);var dl=l!='dataLayer'?'&l='+l:'';j.src='//www.googletagmanager.com/gtm.js?id='+i+dl;j.type='text/javascript';j.async=true;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-P4HH5NV'); Skip to main content Home About Submit ALERTS / RSS Search for this keyword Advanced Search Sleep Apnea and Hypertension Control among Hispanic/Latino Adults in the United States: Results from the Hispanic Community Health Study / Study of Latinos (HCHS/SOL) View ORCID Profile Cecilia Castro-Diehl , Amber Pirzada , View ORCID Profile Lisa de las Fuentes , Daniela Sotres-Alvarez , View ORCID Profile Carmen R. Isasi , Ramon A Durazo-Arvizu , View ORCID Profile Nour Makarem , View ORCID Profile Krista M. Perreira , View ORCID Profile Alberto R. Ramos , Sylvia Wassertheil-Smoller , Katie Stamatakis , Ariana M. Stickel , View ORCID Profile Susan Redline , View ORCID Profile Martha L. Daviglus doi: https://doi.org/10.1101/2024.05.13.24307315 Cecilia Castro-Diehl a Division of Sleep and Circadian Disorders, Department of Medicine, Brigham and Women’s Hospital , Boston, Massachusetts, USA ; b Division of Sleep Medicine, Harvard Medical School , Boston, Massachusetts, USA Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Cecilia Castro-Diehl For correspondence: ocastro-diehl{at}bwh.harvard.edu kspotts{at}bwh.harvard.edu Amber Pirzada c Institute for Minority Health Research, University of Illinois Chicago , Chicago, IL Find this author on Google Scholar Find this author on PubMed Search for this author on this site Lisa de las Fuentes d Cardiovascular Division, Department of Medicine and the Division of Biostatistics, Washington University School of Medicine , St. Louis, MO Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Lisa de las Fuentes Daniela Sotres-Alvarez e Department of Biostatistics, University of North Carolina , Chapel Hill, NC Find this author on Google Scholar Find this author on PubMed Search for this author on this site Carmen R. Isasi f Department of Epidemiology & Population Health, Albert Einstein College of Medicine , New York, NY Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Carmen R. Isasi Ramon A Durazo-Arvizu c Institute for Minority Health Research, University of Illinois Chicago , Chicago, IL Find this author on Google Scholar Find this author on PubMed Search for this author on this site Nour Makarem g Department of Epidemiology, Mailman School of Public Health, Columbia University Irving Medical Center , New York, NY Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Nour Makarem Krista M. Perreira h Department of Social Medicine, UNC School of Medicine , Chapel Hill, NC Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Krista M. Perreira Alberto R. Ramos i Department of Neurology, University of Miami, Miller School of Medicine , Miami, FL Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Alberto R. Ramos Sylvia Wassertheil-Smoller f Department of Epidemiology & Population Health, Albert Einstein College of Medicine , New York, NY Find this author on Google Scholar Find this author on PubMed Search for this author on this site Katie Stamatakis j Department of Epidemiology and Biostatistics, Saint Louis University College for Public Health & Social Justice , St Louis, MO Find this author on Google Scholar Find this author on PubMed Search for this author on this site Ariana M. Stickel k Department of Neurosciences and Shiley-Marcos Alzheimer’s Disease Research Center, University of California , San Diego, La Jolla, CA Find this author on Google Scholar Find this author on PubMed Search for this author on this site Susan Redline b Division of Sleep Medicine, Harvard Medical School , Boston, Massachusetts, USA l Harvard T.H. Chan School of Public Health , Boston, Massach us etts, USA Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Susan Redline Martha L. Daviglus c Institute for Minority Health Research, University of Illinois Chicago , Chicago, IL Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Martha L. Daviglus Abstract Full Text Info/History Metrics Data/Code Preview PDF Abstract Objectives Hispanic/Latino adults have a high prevalence of uncontrolled hypertension predisposing them to CVD. We hypothesize that sleep apnea severity is associated with uncontrolled blood pressure (BP) and resistant hypertension in Hispanic/Latino adults. Methods This was a cross-sectional study of 2,849 Hispanic Community Health Study/Study of Latinos participants with hypertension (i.e., systolic BP ≥130 mm Hg, or diastolic BP ≥80 mm Hg or self-reported antihypertensive medication use) who were taking at least one class of antihypertensive medication. Participants were categorized as having controlled (BP < 130/80 mmHg among those on hypertension treatment) , uncontrolled (BP ≥ 130/80 mmHg using one or two classes of antihypertensive medications), or resistant hypertension (BP ≥ 130/80 mmHg while on ≥ 3 classes of antihypertensive medications or the use of ≥ 4 classes of antihypertensive medications regardless of BP control). Sleep apnea was classified based on the respiratory event index (REI; events/h) as mild (REI ≥ 5 and < 15), moderate-to-severe (REI ≥ 15), or no sleep apnea (REI < 5). Results In multinomial logistic regression, moderate-to-severe sleep apnea (vs. no sleep apnea) was associated with higher odds of resistant hypertension (Odds Ratio [OR], 2.15; 95% CI, 1.36-3.39 at 4% desaturation and OR 1.68; 95% CI, 1.05-2.67 at 3% desaturation). Neither mild nor moderate-to-severe sleep apnea was associated with uncontrolled hypertension. Conclusion Among diverse Hispanic/Latino persons, moderate-to-severe but not mild sleep apnea was associated with resistant hypertension. Identification and management of sleep apnea in this population may improve BP control and subsequently prevent adverse cardiovascular outcomes. Introduction In the United States (US), racial and ethnic disparities in hypertension treatment and control persist and drive CVD inequities [ 1 ]. Although Hispanic/Latino adults have similar hypertension rates to non-Hispanic/Latino white adults per NHANES 2015-2018 data [ 2 ], they have a higher prevalence of uncontrolled hypertension, placing them at increased risk of future cardiovascular disease (CVD) [ 3 ]. Between 2008-18, the number of deaths attributable to high blood pressure (BP) increased by 106% in Hispanic/Latino adults [ 4 ]. Further, the Hispanic Community Health Study / Study of Latinos (HCHS/SOL), the largest cohort of Hispanic/Latino adults from diverse backgrounds in the US, has shown that the prevalence of hypertension varies substantially by Hispanic/Latino background, ranging from 17% among individuals of South American background to 34% among those of Dominican background [ 5 ]. In fact, Hispanic/Latino adults of Caribbean descent, a population with greater African ancestry genetic admixture, have similar hypertension prevalence and incidence rates to non-Hispanic/Latino Black adults, the group with the highest hypertension burden nationwide [ 4 ] [ 6 ]. Untreated sleep apnea is a known risk factor for hypertension [ 7 , 8 ]. Mounting evidence suggests that sleep apnea may also be linked with poor BP control in those with treated hypertension [ 9 ]. Several studies have reported an association between sleep apnea and resistant hypertension, a particularly severe form of hypertension in which BP remains uncontrolled despite the use of at least three different classes of antihypertensive medications [ 10 , 11 ]. However, previous studies are limited by modest sample sizes [ 10 ], study populations from clinical settings [ 12 ], and have focused on predominantly non-Hispanic Black and White adults [ 13 ]. To date, there are no population-based studies of sleep apnea severity in relation to resistant and uncontrolled hypertension in a population-based sample of Hispanic/Latino adults. This study examined the association between overnight objectively recorded sleep apnea and uncontrolled or resistant hypertension among diverse Hispanic/Latino individuals with treated high blood pressure. We hypothesized that sleep apnea is associated with uncontrolled hypertension and that more severe sleep apnea would be associated with poorer BP control and greater odds of resistant hypertension. METHODS Study Sample From 2008-2011, the HCHS/SOL enrolled 16,415 Hispanic/Latino men and women, aged 18–74 years from 4 communities in the United States (Bronx, NY; Chicago, IL; Miami, FL; San Diego, CA). Participants self-identified as Cuban, Puerto Rican, Dominican, Mexican, Central or South American, or other Hispanic/Latino origin. The study used a two-stage area probability sample of households with stratification by Hispanic/Latino concentration and proportion of high/low socio-economic status and over-sampling of individuals ages 45 years and older. Participants underwent a clinical examination and laboratory tests and completed questionnaires about their medical history and health behaviors. Participants were asked to bring all prescription and nonprescription medications taken in the past 4 weeks; medication names and dosages were noted on an inventory. Institutional review boards approved the study at all participating institutions, and all participants gave written informed consent. The current study includes individuals with complete data on measures of sleep apnea and seated resting BP at Visit 1 (baseline exam) who took at least one class of hypertensive medication based on a review and inventory of medications by the study staff. Of the 16,415 individuals, 7,283 had hypertension (defined by the 2017 ACC/AHA BP guidelines [ 15 ], i.e., SBP ≥ 130 mmHg or DBP ≥ 80 mmHg or self-reported use of antihypertensive medications), and of these, 3,464 had treated hypertension (including self-reported antihypertensive medication use), and comprised our study population of interest. After excluding those who did not have objective data of sleep apnea or did not use at least one class of antihypertensive medication: angiotensin-converting enzyme inhibitors, angiotensin II receptor antagonists, beta- blockers, calcium channel blockers, or diuretics, 2,849 individuals were included in this analysis ( Supplementary Figure 1). Ascertainment of Sleep Apnea Severity Data on sleep apnea [ 14 ] was obtained using a home sleep apnea testing (HSAT) monitor (Apnea Risk Evaluation System [ARES], Unicorder, Advanced Brain Imaging, Carlsbad, CA). Using correlation analysis (r), others have shown excellent agreement with sleep apnea classification using this monitor and polysomnography (r=0.96 for in-laboratory ARES and r=0.88 for in-home ARES).[ 15 ] The monitor collected measures of overnight oxygen saturation, nasal airflow, snoring sounds, and head position and movement. Certified polysomnologists identified respiratory events, defined as a 50% or greater reduction in airflow lasting at least 10 seconds and associated with a ≥3% oxyhemoglobin desaturation after annotating artifacts and identifying probably sleep/wake epochs as described elsewhere. [ 16 ] Sleep apnea was assessed by using the respiratory event index (REI), which was calculated as the sum of the number of apneas and hypopneas associated with 3% (REI3%) or 4% (REI4%) oxygen desaturation divided by the total sleep time [events/h]). Presence/severity of sleep apnea was categorized as no sleep apnea (REI < 5 events/h; reference group), mild (REI ≥ 5 and < 15), and moderate-to- severe (REI ≥ 15). We considered sleep apnea associated with 4% (REI4%) and with ≥3% desaturation (REI3%) oxyhemoglobin desaturation. Measurement of Blood Pressure and Definition of Uncontrolled and Resistant Hypertension Seated BP was measured using a standard protocol after 5 minutes of rest. Three measurements were obtained one minute apart, and the average of the three measures was used. Hypertension treatment was defined as the use of at least one antihypertensive medication during the 4 weeks before the clinic examination, based on an inventory of medications brought by the participant. Hypertension was defined based on the 2017 American College of Cardiology/American Heart Association (ACC/AHA) guidelines. [ 17 ] Controlled hypertension was defined as having SBP < 130 and DBP < 80 mmHg among those on hypertension treatment. Uncontrolled hypertension was defined as having SBP ≥ 130 or DBP ≥ 80 using one or two classes of antihypertensive medications (angiotensin-converting enzyme inhibitors, angiotensin II receptor antagonists, beta-blockers, calcium channel blockers, or diuretics). Resistant hypertension was defined as having SBP ≥ 130 or DBP ≥ 80 while on ≥ 3 classes of antihypertensive medications, with one class being a diuretic or the use of ≥ 4 classes of antihypertensive medications regardless of BP control. In an extended analysis, we also defined hypertension based on the Seventh Report of the Joint National Committee (JNC 7) of high blood pressure guidelines [ 18 ] as average SBP ≥ 140 mm Hg or average DBP ≥ 90 mm Hg or use of antihypertensive medication. Only participants who were taking antihypertensive medications in the 4 weeks prior to their clinic visit based on medication inventory were included (n = 2884). Controlled hypertension was defined as SBP < 140 mmHg and DBP < 90 mmHg among those taking hypertension medication. Uncontrolled hypertension was defined as SBP ≥ 140 or DBP ≥ 90 and the use of one or two classes of antihypertensive medications. Resistant hypertension was defined as SBP ≥ 140 or DBP ≥ 90 while on ≥ 3 classes of antihypertensive medications, with one class being a diuretic or the use of ≥ 4 classes of antihypertensive medications regardless of BP control. Assessment of Covariates Participants’ age, sex, Hispanic/Latino background, site, health insurance status (yes, no), and education were ascertained by self-report. Education was categorized as less than high school, high school, or general equivalency diploma and greater than high school or GED (bachelor or higher). Smoking status was categorized as current, former, or never. We also included clinical parameters: Body mass index (BMI, kg/m 2 ) was calculated as measured weight in kilograms divided by the square of height in meters, and obesity was defined as a body mass index ≥ 30 kg/m 2 . Diabetes was defined based on the American Diabetes Association criteria [ 19 ], i.e., fasting glucose ≥ 126 mg/dL if fasting time > 8h or fasting glucose ≥ 200 mg/dL if fasting time ≤ 8h or post-OGTT test≥ 200 mg/dL or A1C≥ 6.5% or self-report of physician-diagnosed diabetes. Prediabetes was defined as having fasting glucose 100-125 mg/dL (if fasting time >8h) or post- OGTT test 140-199 mg/dL or 5.7%≤A1C<6.5%. Insomnia symptoms were derived from the Women’s Health Initiative Insomnia Rating Scale (WHIIRS). [ 20 ] Statistical Analysis All analyses accounted for HCHS/SOL complex survey design (stratification, clustering, and sampling weights) using survey procedures in SAS 9.4. Among individuals with hypertension and receiving antihypertensive medications, we described baseline demographic, socioeconomic, clinical, and behavioral characteristics within each sleep apnea category. T-test and Chi-squared tests or Wilcoxon rank sum or Kruskal Wallis tests were conducted to evaluate differences in the continuous and categorical variables distribution across the sleep apnea groups. Multinomial logistic regression was used to examine the association of sleep apnea (mild and moderate-to-severe sleep apnea vs. none [referent category]) with uncontrolled hypertension or resistant hypertension vs. controlled [referent category]) among persons with hypertension and receiving antihypertensive medication. The odds ratio (OR) and 95% confidence interval (OR and 95% CI) were computed. We used a hierarchical approach to adjust our models. Model 0 was an unadjusted model. Model 1 was adjusted for age and site. Model 2 included covariates in model 1 plus sex, Hispanic/Latino background, education, health insurance, and smoking status. Model 3 was adjusted for covariates included in model 2 plus BMI. RESULTS Sleep Apnea and Hypertension Prevalence Table 1 describes baseline characteristics of 2849 Hispanic/Latino individuals with treated hypertension by sleep apnea severity. About 23% of individuals had mild sleep apnea, 14% had moderate-to-severe sleep apnea, and 63% did not have sleep apnea as defined by REI <5. View this table: View inline View popup Table 1. Sociodemographic, Behavior and Health Characteristics, by Sleep Apnea Severity (n=2959), HCHS/SOL (2008-2011) Sleep apnea prevalence was higher in older vs. younger individuals. Men were more likely than women to have greater sleep apnea severity. Similarly, former and current smokers were more likely than never smokers to have moderate-to-severe sleep apnea. Sleep apnea severity increased with higher BMI. There were no differences in sleep apnea severity by Hispanic/Latino background or health insurance. A very small percentage of the study individuals (∼1%) reported a physician diagnosis of sleep apnea ( data not shown ). Overall, our study population included 34%, 55%, and 11% individuals with controlled, uncontrolled, and resistant hypertension, respectively. Figure 1 shows the prevalence of controlled, uncontrolled, and resistant hypertension by sex and age group. Download figure Open in new tab Figure 1. Prevalence of Controlled, Uncontrolled and Resistant Hypertension among Individuals with Treated Hypertension, HCHS/SOL (2008-2011). Association of Sleep Apnea Severity with Uncontrolled and Resistant Hypertension using the definition of Hypertension by the 2017 ACC/AHA In multinomial logistic regression analyses, moderate-to-severe, but not mild, sleep apnea (based on respiratory events requiring a minimum of 4% desaturation, REI4%) was associated with higher odds of resistant hypertension relative to no sleep apnea (OR, 2.15; 95% CI, 1.36- 3.39; p=0.001) ( Table 2 ) after full covariates adjustment. Effect estimates were attenuated but remained statistically significant when sleep apnea was defined based on respiratory events requiring a minimum of 3% desaturation. Moderate-to-severe sleep apnea (based on REI3% desaturation) was associated with higher odds of resistant hypertension relative to no sleep apnea (OR, 1.68; 95% CI, 1.05-2.67; p = 0.03) ( Table 3 ). Neither mild nor moderate-to-severe sleep apnea was associated with uncontrolled hypertension in any models with apnea based on 4% or 3% desaturation events. View this table: View inline View popup Download powerpoint Table 2. Odds Ratios (OR [95% Confidence Intervals, CI])) for Associations of Mild and Moderate-to-Severe Sleep Apnea defined by 4% desaturation with Uncontrolled or Resistant Hypertension by 2017 ACC/AHA Definition vs. Controlled Hypertension, HCHS/SOL (2008-2011). View this table: View inline View popup Download powerpoint Table 3. Odds Ratios (OR [95% Confidence Intervals, CI]) for Associations of Mild and Moderate-to-Severe Sleep Apnea defined by 3% desaturation with Uncontrolled or Resistant Hypertension by 2017 ACC/AHA Definition vs. Controlled Hypertension, HCHS/SOL (2008-2011). Association of Sleep Apnea Severity with Uncontrolled and Resistant Hypertension using the definition of Hypertension by the JNC 7 Guidelines When we examined these associations using hypertension defined per the JNC 7 guidelines, moderate-to-severe, but not mild, sleep apnea (based on REI4% desaturation) was associated with higher odds of resistant hypertension relative to no sleep apnea (OR, 1.94; 95% CI, 1.18- 3.17; p=0.01) ( Table S1 ) after full covariates adjustment. Sleep apnea based on REI3% desaturation was not associated with resistant or uncontrolled hypertension (Table S2) . DISCUSSION In the current study of Hispanic/Latino adults of diverse backgrounds with treated hypertension, the prevalence of mild and moderate-to-severe sleep apnea was 23% and 14%, respectively, which is within the range of the general adult population [ 21 ]. Uncontrolled and resistant hypertension among individuals with treated hypertension was present in 55% and 11% of the study population, respectively. Moderate-to-severe sleep apnea was associated with up to two- fold higher odds of resistant hypertension but not uncontrolled hypertension. These results underscore the importance of treating sleep apnea for prevention of resistant hypertension and its downstream influence on future CVD risk. The population-based Wisconsin Study conducted more than two decades ago in a non- Hispanic White population showed a dose-response relationship between untreated sleep- disordered breathing and hypertension independent of age, sex, and adiposity. [ 22 ]. Since then, other epidemiological studies in white populations have replicated these findings [ 23 – 25 ]. Previous studies have also reported that the prevalence of sleep apnea in persons with resistant hypertension was high, ranging from 72% [ 26 ] to more than 80% [ 27 – 30 ], and suggested that more severe sleep apnea was associated with a lower likelihood of BP control even with greater antihypertensive medication use [ 10 , 23 , 25 ]. However, these studies had relatively small sample sizes (n=41 to 422 participants) [ 30 ], were conducted in predominantly non-Hispanic/Latino Whites in specific settings (clinical vs. epidemiological studies), and used differing criteria to define sleep apnea severity, which limits the comparability of findings across studies. In addition to the use of nonstandard criteria to define sleep apnea, the definition of hypertension, uncontrolled, and resistant hypertension has also varied across studies and has changed with time. Our findings are consistent with a retrospective cohort study of a racially, ethnically, and socioeconomically diverse population from California [ 31 , 32 ] in showing a higher rate of sleep apnea among individuals with resistant hypertension than among those without resistant hypertension (9.6% vs. 6.8%) and greater odds of sleep apnea with resistant hypertension vs. non-resistant hypertension (OR 1.16 [95% CI 1.12, 1.19]). However, that study did not specifically focus on Hispanic/Latino populations, and our findings reported herein highlight that these associations may be stronger in these population groups than previously reported. In fact, we report a similar effect size to that observed among Black adults in the Jackson Heart Study [ 13 ]. Although the prevalence of resistant hypertension (15%) was higher in the Jackson Heart study than the current study (11%) [ 17 ] those with moderate-to-severe sleep apnea also had two times higher odds of resistant hypertension (OR, 2.00; 95% CI,1.14-3.67) compared to those without sleep apnea [ 13 ]. Mechanisms that may explain the association between sleep apnea and hypertension include intermittent hypoxia [ 33 ], frequent intermittent sympathetic stimulation, a blunted baroreflex, oxidative stress, metabolic abnormalities, arterial stiffness, endothelial dysfunction [ 34 ], which also may explain the association between sleep apnea and poorly controlled hypertension. Non- dipping BP is particularly common in sleep apnea and often coexists in patients with resistant hypertension. Indeed, there is a significant association between resistant hypertension, non- dipping BP, and endothelial dysfunction [ 34 ]. Aldosterone excess is common in persons with resistant hypertension and contributes to the severity of sleep apnea. Aldosterone will induce fluid retention, leading to parapharyngeal edema and increase upper airway resistance [ 35 , 36 ]. Obesity is linked with more severe hypertension and lack of control of hypertension besides an increasing number of antihypertensive medications [ 37 ]. This relation may be explained by impaired sodium excretion and activation of the renin-angiotensin-aldosterone system [ 37 ] [ 38 ]. Obesity is also a recognized risk factor for sleep apnea [ 33 ]. In the current study, the association between sleep apnea and resistant hypertension was attenuated but remained significant with adjustment for BMI. The null association between sleep apnea and uncontrolled hypertension may be explained by the definition used for uncontrolled hypertension, which presents a challenge in its interpretation. Some persons with uncontrolled hypertension may not have been identified, because they remained undiagnosed and untreated [ 39 ]. Persons with resistant hypertension, which is determined by more strict definitions, are a subset of a larger, less well-defined group of persons with uncontrolled hypertension that may additionally include those with poor medication adherence and/or poor medical management [ 40 ]. In addition, both uncontrolled and resistant hypertension could also be affected by masked hypertension, the effect of having normal BP in-office visits but high BP at home. Our study, similar to other studies [ 12 , 13 ], did not find an association between sleep apnea and uncontrolled hypertension. Nonetheless, our study has several potential limitations. First, these analyses were cross- sectional, which limited our ability to establish temporality and infer causality. Second, the sleep study device used allowed us to define sleep-disordered breathing but not to differentiate obstructive sleep apnea from central sleep apnea; however, in this relatively young, community- based cohort the prevalence of central sleep apnea is likely very low. Third, other studies have used ambulatory BP devices to define or confirm resistant hypertension, whereas our study used three measurements of office BP taking during a single examination visit, which is more prone to the effects of white-coat or masked hypertension. Because of our sample size, we had limited power to compare differences in associations across Hispanic/Latino groups. Finally, we defined resistant hypertension based on the 2017 ACC/AHA guidelines in a population who attended their study examination when the JNC 7 guidelines were still in place. This could inflate our prevalence estimates of resistant hypertension since physicians would be trying to target BP control at a cut-off of 140/90 mmHg instead of a lower cut/off (130/80 mmHg). However, our study also has several strengths. First, this is the first study of the association of sleep apnea and resistant hypertension in a population-based cohort of diverse Hispanic/Latino adults in the US. Second, we used home sleep testing to assess sleep-disordered breathing objectively. Third, participants brought the bottles of medications they were using during the four weeks prior to their visit for scanning and inclusion in the participant record. Fourth, HCHS/SOL collected comprehensive measures of lifestyle, social, and medical factors that allowed us to adjust our analyses for several confounders. Finally, we examined the relationship between sleep apnea and uncontrolled elevated BP using both 130/80 and 140/90 mmHg thresholds, which enhances comparability of our results to previous and more recent studies. Conclusions In conclusion, among diverse Hispanic/Latino adults, moderate-to-severe sleep apnea compared to no sleep apnea was associated with prevalent resistant hypertension, defined as uncontrolled hypertension despite aggressive medication use. These findings suggest that moderate-to-severe sleep apnea may play a role in poor hypertension control among persons receiving intensive antihypertensive treatment. Our findings warrant confirmation prospectively to determine the influence of sleep apnea on the incidence of uncontrolled and resistant hypertension in the US Hispanic/Latino population. Given the increased cardiovascular risks posed by sleep apnea and considering our study’s findings on the relation with resistant hypertension, diagnosis, and management of sleep apnea may be an important target for enhanced BP control and improving cardiovascular outcomes in this population. Data Availability The Hispanic Community Health Study / Study of Latinos (HCHS/SOL) data used to support the findings of this study are available at the HCHS/SOL Coordinating Center at request after following procedures. HCHS/SOL Website https://sites.cscc.unc.edu/hchs/ Sources of Funding The Hispanic Community Health Study/Study of Latinos was performed as a collaborative study supported by contracts from the National Heart, Lung, and Blood Institute (NHLBI) to the University of North Carolina (HHSN268201300001I / N01-HC-65233), University of Miami (HHSN268201300004I / N01-HC-65234), Albert Einstein College of Medicine (HHSN268201300002I / N01-HC-65235), University of Illinois at Chicago (HHSN268201300003I / N01-HC-65236 Northwestern Univ), and San Diego State University (HHSN268201300005I / N01-HC-65237). The following Institutes/Centers/Offices have contributed to the HCHS/SOL through a transfer of funds to the NHLBI: National Institute on Minority Health and Health Disparities, National Institute on Deafness and Other Communication Disorders, National Institute of Dental and Craniofacial Research, National Institute of Diabetes and Digestive and Kidney Diseases, National Institute of Neurological Disorders and Stroke, NIH Institution-Office of Dietary Supplements. This study was partly supported by NHLBI grant R25 HL105400 to DC Rao and Victor G. Davila-Roman. National Institute on Aging: K08 AG075351, L30 AG074401, P30 AG059299, and RF1 AG054548 (Ariana Stickel) Disclosures The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Acknowledgments The authors thank the staff and participants of HCHS/SOL for their important contributions. A complete list of staff and investigators has been provided by Sorlie P., et al. in Ann Epidemiol. 2010 Aug;20: 642-649 and is also available on the study website http://www.cscc.unc.edu/hchs/ References 1. ↵ Ullah , M.I. and S. Tamanna , Racial disparity in cardiovascular morbidity and mortality associated with obstructive sleep apnea: The sleep heart health study . Sleep Med , 2023 . 101 : p. 528 – 534 . OpenUrl 2. ↵ Tsao , C.W. , et al. , Heart Disease and Stroke Statistics—2022 Update: A Report From the American Heart Association . Circulation , 2022 . 145 (8): p. e153-e639. 3. ↵ Thomas , I.C. and M.A. Allison , Hypertension in Hispanics/Latinos: Epidemiology and Considerations for Management . Curr Hypertens Rep , 2019 . 21 ( 6 ): p. 43 . OpenUrl 4. ↵ Virani , S.S. , et al. , Heart Disease and Stroke Statistics-2021 Update: A Report From the American Heart Association . Circulation , 2021 . 143 ( 8 ): p. e254-e743. 5. ↵ Sorlie , P.D. , et al. , Prevalence of hypertension, awareness, treatment, and control in the Hispanic Community Health Study/Study of Latinos . Am J Hypertens , 2014 . 27 ( 6 ): p. 793 – 800 . OpenUrl CrossRef PubMed 6. ↵ Elfassy , T. , et al. , Incidence of Hypertension Among US Hispanics/Latinos: The Hispanic Community Health Study/Study of Latinos , 2008 to 2017 . J Am Heart Assoc , 2020 . 9 ( 12 ): p. e015031. 7. ↵ Guillot , M. , et al. , Association between severe obstructive sleep apnea and incident arterial hypertension in the older people population . Sleep Med , 2013 . 14 ( 9 ): p. 838 – 42 . OpenUrl CrossRef PubMed 8. ↵ Vgontzas , A.N. , et al. , Mild-to-moderate sleep apnea is associated with incident hypertension: age effect . Sleep , 2019 . 42 ( 4 ). 9. ↵ Calhoun , D.A. , et al. , Resistant hypertension: diagnosis, evaluation, and treatment. A scientific statement from the American Heart Association Professional Education Committee of the Council for High Blood Pressure Research . Hypertension , 2008 . 51 ( 6 ): p. 1403 – 19 . OpenUrl CrossRef 10. ↵ Lavie , P. and V. Hoffstein , Sleep apnea syndrome: a possible contributing factor to resistant . Sleep , 2001 . 24 ( 6 ): p. 721 – 5 . OpenUrl PubMed Web of Science 11. ↵ Carey , R.M. , et al. , Resistant Hypertension: Detection, Evaluation, and Management: A Scientific Statement From the American Heart Association . Hypertension , 2018 . 72 ( 5 ): p. e53 – e90 . OpenUrl CrossRef PubMed 12. ↵ Walia , H.K. , et al. , Association of Severe Obstructive Sleep Apnea and Elevated Blood Pressure Despite Antihypertensive Medication Use . Journal of Clinical Sleep Medicine , 2014 . 10 ( 8 ): p. 835 – 843 . OpenUrl 13. ↵ Johnson , D.A. , et al. , Association Between Sleep Apnea and Blood Pressure Control Among Blacks . Circulation , 2019 . 139 ( 10 ): p. 1275 – 1284 . OpenUrl 14. ↵ Malhotra , A. , et al. , Metrics of sleep apnea severity: beyond the apnea-hypopnea index . Sleep , 2021 . 44 ( 7 ). 15. ↵ Westbrook , P.R. , et al. , Description and validation of the apnea risk evaluation system: a novel method to diagnose sleep apnea-hypopnea in the home . Chest , 2005 . 128 ( 4 ): p. 2166 – 75 . OpenUrl CrossRef PubMed Web of Science 16. ↵ Redline , S. , et al. , Sleep-disordered breathing in Hispanic/Latino individuals of diverse backgrounds. The Hispanic Community Health Study/Study of Latinos . Am J Respir Crit Care Med , 2014 . 189 ( 3 ): p. 335 – 44 . OpenUrl CrossRef PubMed Web of Science 17. ↵ Whelton , P.K. , et al. , 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines . Hypertension , 2018 . 71 (6): p. e13-e115. OpenUrl CrossRef 18. ↵ Chobanian , A.V. , et al. , The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report . JAMA , 2003 . 289 ( 19 ): p. 2560-72. 19. ↵ American Diabetes, A. , Diagnosis and classification of diabetes mellitus . Diabetes Care , 2010 . 33 Suppl 1 : p. S62 – 9 . OpenUrl FREE Full Text 20. ↵ Levine DW , et al. , Validation of the Women’s Health Initiative Insomnia Rating Scale in a multicenter controlled clinical trial . Psychosomatic medicine , 2005 . 67 ( 1 ): p. 98 – 104 . OpenUrl Abstract / FREE Full Text 21. ↵ Senaratna , C.V. , et al. , Prevalence of obstructive sleep apnea in the general population: A systematic review . Sleep Medicine Reviews , 2017 . 34 : p. 70 – 81 . OpenUrl CrossRef PubMed 22. ↵ Young , T. , et al. , Population-based study of sleep-disordered breathing as a risk factor for hypertension . Arch Intern Med , 1997 . 157 ( 15 ): p. 1746 – 52 . OpenUrl CrossRef PubMed Web of Science 23. ↵ Grote , L. , J. Hedner , and J.H. Peter , Sleep-related breathing disorder is an independent risk factor for uncontrolled hypertension . J Hypertens , 2000 . 18 ( 6 ): p. 679 – 85 . OpenUrl CrossRef PubMed Web of Science 24. Peppard , P.E. , et al. , Prospective Study of the Association between Sleep-Disordered Breathing and Hypertension . The New England Journal of Medicine , 2000 . 342 ( 19 ). 25. ↵ Grote , L. , et al. , Sleep-related breathing disorder is an independent risk factor for systemic hypertension . Am J Respir Crit Care Med , 1999 . 160 ( 6 ): p. 1875 – 82 . OpenUrl CrossRef PubMed Web of Science 26. ↵ Florczak , E. , et al. , Clinical characteristics of patients with resistant hypertension: the RESIST-POL study . J Hum Hypertens , 2013 . 27 ( 11 ): p. 678 – 85 . OpenUrl CrossRef PubMed 27. ↵ Sapina-Beltran , E. , et al. , Prevalence, Characteristics, and Association of Obstructive Sleep Apnea with Blood Pressure Control in Patients with Resistant Hypertension . Annals of the American Thoracic Society , 2019 . 16 ( 11 ): p. 1414 – 1421 . OpenUrl 28. Logan , A.G. , et al. , High prevalence of unrecognized sleep apnoea in drug-resistant hypertension . J Hypertens , 2001 . 19 ( 12 ): p. 2271 – 7 . OpenUrl CrossRef PubMed Web of Science 29. Muxfeldt , E.S. , et al. , Prevalence and associated factors of obstructive sleep apnea in patients with resistant hypertension . Am J Hypertens , 2014 . 27 ( 8 ): p. 1069 – 78 . OpenUrl CrossRef PubMed 30. ↵ Ruttanaumpawan , P. , et al. , Association between refractory hypertension and obstructive sleep apnea . J Hypertens , 2009 . 27 ( 7 ): p. 1439 – 45 . OpenUrl CrossRef PubMed Web of Science 31. ↵ Sim , J.J. , et al. , Characteristics of Resistant Hypertension in a Large, Ethnically Diverse Hypertension Population of an Integrated Health System . Mayo Clinic Proceedings , 2013 . 88 ( 10 ): p. 1099 – 1107 . OpenUrl CrossRef PubMed 32. ↵ Bhandari , S.K. , et al. , Comparisons of sleep apnoea rate and outcomes among patients with resistant and non-resistant hypertension . Respirology , 2016 . 21 ( 8 ): p. 1486 – 1492 . OpenUrl 33. ↵ Wolk , R. , A.S.M. Shamsuzzaman , and V.K. Somers , Obesity, Sleep Apnea, and Hypertension . Hypertension , 2003 . 42 ( 6 ): p. 1067 – 1074 . OpenUrl CrossRef PubMed 34. ↵ Quinaglia , T. , et al. , Non-dipping pattern relates to endothelial dysfunction in patients with uncontrolled resistant hypertension . J Hum Hypertens , 2011 . 25 ( 11 ): p. 656 – 64 . OpenUrl CrossRef PubMed 35. ↵ Parati , G. , et al. , Obstructive sleep apnea syndrome as a cause of resistant hypertension . Hypertension Research , 2014 . 37 ( 7 ): p. 601 – 613 . OpenUrl 36. ↵ Dudenbostel , T. and D.A. Calhoun , Resistant hypertension, obstructive sleep apnoea and aldosterone . J Hum Hypertens , 2012 . 26 ( 5 ): p. 281 – 7 . OpenUrl CrossRef PubMed 37. ↵ Sarafidis Pantelis , A. and L . Bakris George , Resistant Hypertension . Journal of the American College of Cardiology , 2008 . 52 ( 22 ): p. 1749 – 1757 . OpenUrl FREE Full Text 38. ↵ Bramlage , P. , et al. , Hypertension in overweight and obese primary care patients is highly prevalent and poorly controlled . Am J Hypertens , 2004 . 17 ( 10 ): p. 904 – 10 . OpenUrl CrossRef PubMed 39. ↵ Parati , G. , et al. , Current challenges for hypertension management: From better hypertension diagnosis to improved patients’ adherence and blood pressure control . Int J Cardiol , 2021 . 331 : p. 262 – 269 . OpenUrl 40. ↵ Wang , T.J. and R.S. Vasan , Epidemiology of uncontrolled hypertension in the United States . Circulation , 2005 . 112 ( 11 ): p. 1651 – 62 . OpenUrl FREE Full Text View the discussion thread. Back to top Previous Next Posted May 14, 2024. Download PDF Data/Code Email Thank you for your interest in spreading the word about medRxiv. NOTE: Your email address is requested solely to identify you as the sender of this article. Your Email * Your Name * Send To * Enter multiple addresses on separate lines or separate them with commas. You are going to email the following Sleep Apnea and Hypertension Control among Hispanic/Latino Adults in the United States: Results from the Hispanic Community Health Study / Study of Latinos (HCHS/SOL) Message Subject (Your Name) has forwarded a page to you from medRxiv Message Body (Your Name) thought you would like to see this page from the medRxiv website. Your Personal Message CAPTCHA This question is for testing whether or not you are a human visitor and to prevent automated spam submissions. Share Sleep Apnea and Hypertension Control among Hispanic/Latino Adults in the United States: Results from the Hispanic Community Health Study / Study of Latinos (HCHS/SOL) Cecilia Castro-Diehl , Amber Pirzada , Lisa de las Fuentes , Daniela Sotres-Alvarez , Carmen R. Isasi , Ramon A Durazo-Arvizu , Nour Makarem , Krista M. Perreira , Alberto R. Ramos , Sylvia Wassertheil-Smoller , Katie Stamatakis , Ariana M. Stickel , Susan Redline , Martha L. Daviglus medRxiv 2024.05.13.24307315; doi: https://doi.org/10.1101/2024.05.13.24307315 Share This Article: Copy Citation Tools Sleep Apnea and Hypertension Control among Hispanic/Latino Adults in the United States: Results from the Hispanic Community Health Study / Study of Latinos (HCHS/SOL) Cecilia Castro-Diehl , Amber Pirzada , Lisa de las Fuentes , Daniela Sotres-Alvarez , Carmen R. Isasi , Ramon A Durazo-Arvizu , Nour Makarem , Krista M. Perreira , Alberto R. Ramos , Sylvia Wassertheil-Smoller , Katie Stamatakis , Ariana M. Stickel , Susan Redline , Martha L. Daviglus medRxiv 2024.05.13.24307315; doi: https://doi.org/10.1101/2024.05.13.24307315 Citation Manager Formats BibTeX Bookends EasyBib EndNote (tagged) EndNote 8 (xml) Medlars Mendeley Papers RefWorks Tagged Ref Manager RIS Zotero Tweet Widget Facebook Like Google Plus One Subject Area Epidemiology Subject Areas All Articles Addiction Medicine (573) Allergy and Immunology (865) Anesthesia (304) Cardiovascular Medicine (4457) Dentistry and Oral Medicine (445) Dermatology (383) Emergency Medicine (610) Endocrinology (including Diabetes Mellitus and Metabolic Disease) (1517) Epidemiology (15244) Forensic Medicine (30) Gastroenterology (1132) Genetic and Genomic Medicine (6621) Geriatric Medicine (669) Health Economics (1002) Health Informatics (4557) Health Policy (1372) Health Systems and Quality Improvement (1615) Hematology (543) HIV/AIDS (1272) Infectious Diseases (except HIV/AIDS) (15936) Intensive Care and Critical Care Medicine (1106) Medical Education (624) Medical Ethics (147) Nephrology (670) Neurology (6635) Nursing (346) Nutrition (999) Obstetrics and Gynecology (1148) Occupational and Environmental Health (957) Oncology (3348) Ophthalmology (980) Orthopedics (369) Otolaryngology (421) Pain Medicine (436) Palliative Medicine (130) Pathology (665) Pediatrics (1696) Pharmacology and Therapeutics (693) Primary Care Research (714) Psychiatry and Clinical Psychology (5463) Public and Global Health (9257) Radiology and Imaging (2210) Rehabilitation Medicine and Physical Therapy (1371) Respiratory Medicine (1198) Rheumatology (598) Sexual and Reproductive Health (716) Sports Medicine (532) Surgery (714) Toxicology (100) Transplantation (289) Urology (265) (function(){function c(){var b=a.contentDocument||a.contentWindow.document;if(b){var d=b.createElement('script');d.innerHTML="window.__CF$cv$params={r:'a0381ef47fcb1b23',t:'MTc4MDA4NTIwMA=='};var a=document.createElement('script');a.src='/cdn-cgi/challenge-platform/scripts/jsd/main.js';document.getElementsByTagName('head')[0].appendChild(a);";b.getElementsByTagName('head')[0].appendChild(d)}}if(document.body){var a=document.createElement('iframe');a.height=1;a.width=1;a.style.position='absolute';a.style.top=0;a.style.left=0;a.style.border='none';a.style.visibility='hidden';document.body.appendChild(a);if('loading'!==document.readyState)c();else if(window.addEventListener)document.addEventListener('DOMContentLoaded',c);else{var e=document.onreadystatechange||function(){};document.onreadystatechange=function(b){e(b);'loading'!==document.readyState&&(document.onreadystatechange=e,c())}}}})();