Journal of Emergencies, Trauma, and Shock
Home About us Editors Ahead of Print Current Issue Archives Search Instructions Subscribe Advertise Login 
Users online:1912   Print this pageEmail this pageSmall font sizeDefault font sizeIncrease font size   


 
 Table of Contents    
ORIGINAL ARTICLE  
Year : 2021  |  Volume : 14  |  Issue : 2  |  Page : 104-107
Prevalence and risk factors of obstructive sleep apnea in hypertensive emergency


1 Department of Medicine, Faculty of Medicine, Sleep Apnea Research Group, Khon Kaen University, Khon Kaen, Thailand
2 Department of Marketing, Faculty of Business Administration and Accountancy, Khon Kaen University, Khon Kaen, Thailand

Click here for correspondence address and email

Date of Submission12-Apr-2020
Date of Acceptance23-Jun-2020
Date of Web Publication27-Apr-2021
 

   Abstract 


Introduction: Obstructive sleep apnea (OSA) is a common factor associated with hypertensive crises. There is limited evidence of prevalence and risk factors of OSA in hypertensive emergency. Methods: This study recruited adult patients who diagnosed as hypertensive emergency and tested for OSA. The study period was between July 2019 and January 2020. The patients were categorized as OSA and non-OSA groups by the evidence from polysomnography. Prevalence and risk factors for OSA were executed. Results: During the study, there were 52 eligible patients. Of those, 30 patients (57.69%) were diagnosed with OSA. The stepwise logistic regression analysis for predicting OSA had two remaining factors: body mass index and diastolic blood pressure. Only body mass index was independently associated with OSA with an adjusted odds ratio of 1.166 (95% confidence interval of 1.033, 1.316). The body mass index of 25.02 kg/m2 gave sensitivity and specificity of 80.00% and 59.09%, respectively. The area under the receiver operating characteristic curve was 70.98%. Conclusion: OSA had high incidence rate in patients with hypertensive emergency. High body mass index was a predictor for OSA associated with hypertensive emergency.

Keywords: Body mass index, hypertensive emergency, obesity, obstructive sleep apnea, prevalence

How to cite this article:
Khamsai S, Kachenchart S, Sawunyavisuth B, Limpawattana P, Chindaprasirt J, Senthong V, Chotmongkol V, Pongkulkiat P, Sawanyawisuth K. Prevalence and risk factors of obstructive sleep apnea in hypertensive emergency. J Emerg Trauma Shock 2021;14:104-7

How to cite this URL:
Khamsai S, Kachenchart S, Sawunyavisuth B, Limpawattana P, Chindaprasirt J, Senthong V, Chotmongkol V, Pongkulkiat P, Sawanyawisuth K. Prevalence and risk factors of obstructive sleep apnea in hypertensive emergency. J Emerg Trauma Shock [serial online] 2021 [cited 2021 Jul 31];14:104-7. Available from: https://www.onlinejets.org/text.asp?2021/14/2/104/314959

FNx01Sittichai Khamsai and Sitthan Kachenchart have contributed equally.





   Introduction Top


Hypertension and obstructive sleep apnea (OSA) are common diseases in clinical practice. The prevalence of hypertension in the Chinese community was high as 64.05% in 2014.[1] While, the prevalence of OSA was found up to 49% of middle-aged men in the United States and Europe.[2] Both diseases are closely related in terms of cause and prevalence. Since 2003, the Joint National Committee on hypertension control (JNC 7) has defined OSA as a secondary cause of hypertension.[3] OSA may be found 30%–50% of hypertensive patients and may be high as 71% in resistant hypertension, 85% in those who have at least one symptom of OSA, and 90% in hypertensive in the young.[4],[5],[6],[7]

Hypertensive crisis particularly hypertensive emergency is an emergency condition with high morbidity and mortality.[8] A 12-month mortality was 38.9% in hypertensive emergency patients. A previous study found that OSA was common in hypertensive crises: up to 70.8%.[9] The study did not report on risk factors of OSA in hypertensive crises. In addition, the prevalence was not specific to hypertensive emergency which is more critical condition. This study, therefore, aimed to study the risk factors of OSA only in hypertensive emergency condition.


   Methods Top


This was a retrospective study and recruited adult patients who diagnosed as hypertensive emergency and admitted to Srinagarind Hospital, a university hospital of Khon Kaen University, Khon Kaen, Thailand. Those who are pregnant or unstable to perform polysomnography were excluded. The diagnosis of hypertensive emergency defined as systolic blood pressure of 180 mmHg or over and/or diastolic blood pressure of 100 mmHg or over plus acute target organ damage.[9] The study period was between July 2019 and January 2020.

The eligible patients were evaluated by the Alice PDx device.[10] OSA was diagnosed if an apnea-hypopnea index (AHI) was five times/hour or over and classified as mild, moderate, and severe with the AHI of 5–14, 15–29, 30, or over, respectively. Baseline characteristics, comorbid diseases, blood pressure, and laboratory tests were studied. The patients were categorized as OSA and non-OSA groups by the evidence from polysomnography.

Statistical analyses

Sample size calculation. Required sample size was calculated using one sample formula with an approximate prevalence of 70%.[9] With a confidence of 95% and an error of 0.12, the required sample size was 57.



The prevalence of OSA in hypertensive emergency patients was calculated. Descriptive statistics were used to evaluate differences between those with and without OSA. Predictors for OSA associated with hypertensive emergency were executed by the stepwise logistic regression analysis. An independent factor was defined by a P < 0.05 in the final logistic regression model. The final model was tested for goodness of fit by the Hosmer–Lemeshow method. The independent predictor for OSA was chosen for the best diagnostic properties if it was numerical variable. Sensitivity, specificity, and area under a receiver operating characteristic (ROC) curve were reported. The statistical analyses were performed by the STATA software (College Station, Texas, USA).


   Results Top


During the study, there were 52 eligible patients. Of those, 30 patients (57.69%) were diagnosed with OSA. The severity of OSA was categorized as follows: mild (12 patients, 40.00%), moderate (13 patients, 43.33%), and severe (5 patients, 16.67%). There were two significant factors between both groups: body mass index and serum blood urea nitrogen level. The OSA group had significantly higher body mass index (23.97 vs. 28.60 kg/m2; P = 0.010) and lower serum blood urea nitrogen level (23.65 vs. 34.5 mg/dL; P 0.039) than the non-OSA group [Table 1] and [Table 2].
Table 1: Baseline characters of patients with hypertensive emergency categorized by the presence of obstructive sleep apnea

Click here to view
Table 2: Laboratory results of patients with hypertensive emergency categorized by the presence of obstructive sleep apnea

Click here to view


The stepwise logistic regression analysis for predicting OSA had two remaining factors: body mass index and diastolic blood pressure [Table 3]. Only body mass index was independently associated with OSA with the adjusted odds ratio of 1.166 (95% confidence interval of 1.033, 1.316). The Hosmer–Lemeshow Chi-square of the final model was 7.21 (P = 0.513). The body mass index of 25.02 kg/m2 gave sensitivity and specificity of 80% and 59.09%, respectively. The area under the ROC curve was 70.98% [Figure 1].
Table 3: Factors predictive of hypertensive emergency caused by obstructive sleep apnea

Click here to view
Figure 1: A receiver operating characteristic curve of body mass index and hypertensive emergency caused by obstructive sleep apnea

Click here to view



   Discussion Top


The incidence of OSA in hypertensive emergency was over 50% (57.69%) which was lower than the previous study (70.8%). However, the incidence rate of OSA in this study is more specific to only hypertensive emergency; not hypertensive crises as in the previous study. The proportions of OSA severity were quite comparable in moderate severity (43.33% vs. 40.35%), while in this study found more mild OSA (40.0% vs. 25.43%) but fewer severe OSA (16.67% vs. 34.21%) than the previous study. Once again, the results of this study were more specific to hypertensive emergency. There are several mechanisms to explain severe hypertensive emergency from OSA. First, blood pressure may be as high as 240/130 mmHg after each apnea episode.[11],[12] In each night, OSA patients may have over several hundred of apneic events depending on the AHI. Second, a meta-analysis found that OSA increased angiotensin II and aldosterone levels significantly compared with controls by 3.39 ng/L and 1.35 ng/mL, respectively.[13] Least but not last, OSA had proportions of a reverse dipper than control on both systolic (73.5% vs. 26.5%) and diastolic (69.6% vs. 30.4%) blood pressures.[14]

Obesity is a major risk factor for OSA. Those with body mass index over 30 kg/m2 had OSA is 63%.[15] A study also found a close relationship between body mass index, OSA, and hypertension.[16] The body mass index had the adjusted coefficient of 0.46 with the blood pressure. These data support the positive correlation of body mass index and the occurrence of hypertensive emergency with a 16% risk per 1 kg/m2 increase in body mass index [Table 3]. Those with a body mass index of 25 kg/m2 increased the risk of OSA with hypertensive emergency (80% sensitivity). The cut point was similar to the obesity criterion for the Asian population.[17]

There are some limitations in this study. First, the cut point of body mass index may not be applicable to other ethnicities. However, the body mass index of 30 kg/m2 may be justified for the non-Asian populations. Second, there was no long-term outcome of the patients in this study. Further studies are needed to evaluate if continuous positive airway pressure treatment for OSA may improve the hypertensive emergency outcome.[18] Finally, some other aspects of OSA or metabolic diseases were not studied.[19],[20],[21],[22],[23],[24]


   Conclusion Top


OSA had a high incidence rate in patients with hypertensive emergency. High body mass index was a predictor for OSA associated with hypertensive emergency.

Acknowledgment

The authors would like to thank Sleep Apnea Research Group, Research center in Back, Neck, Other Joint Pain and Human Performance (BNOJPH), North-Eastern Stroke Research Group, Khon Kaen University, Thailand.

Research quality and ethics statement

This study was approved by the Institutional Review Board / Ethics Committee approval number [HE611131]. The authors followed applicable EQUATOR Network (http:// www.equator-network.org/) guidelines during the conduct of this research project.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Liang X, Zhong H, Xiao L. The effect of community hypertension management on blood pressure control and its determinants in southwest China. Int Health 2020;12:203-12.  Back to cited text no. 1
    
2.
Garvey JF, Pengo MF, Drakatos P, Kent BD. Epidemiological aspects of obstructive sleep apnea. J Thorac Dis 2015;7:920-9.  Back to cited text no. 2
    
3.
Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL Jr., et al. Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension 2003;42:1206-52.  Back to cited text no. 3
    
4.
Jinchai J, Khamsai S, Chattakul P, Limpawattana P, Chindaprasirt J, Chotmongkol V, et al. How common is obstructive sleep apnea in young hypertensive patients? Intern Emerg Med 2020. doi: 10.1007/s11739-019-02273-3.  Back to cited text no. 4
    
5.
Gonçalves SC, Martinez D, Gus M, de Abreu-Silva EO, Bertoluci C, Dutra I, et al. Obstructive sleep apnea and resistant hypertension: A case-control study. Chest 2007;132:1858-62.  Back to cited text no. 5
    
6.
Sawanyawisuth K, Chindaprasirt J, Senthong V, Makarawate P, Limpawattana P, Domthong A, et al. Lower BMI is a predictor of obstructive sleep apnea in elderly Thai hypertensive patients. Sleep Breath 2013;17:1215-9.  Back to cited text no. 6
    
7.
Ahmad M, Makati D, Akbar S. Review of and updates on hypertension in obstructive sleep apnea. Int J Hypertens 2017;2017:1848375.  Back to cited text no. 7
    
8.
Guiga H, Decroux C, Michelet P, Loundou A, Cornand D, Silhol F, et al. Hospital and out-of-hospital mortality in 670 hypertensive emergencies and urgencies. J Clin Hypertens (Greenwich) 2017;19:1137-42.  Back to cited text no. 8
    
9.
Börgel J, Springer S, Ghafoor J, Arndt D, Duchna HW, Barthel A, et al.Unrecognized secondary causes of hypertension in patients with hypertensive urgency/emergency: Prevalence and co-prevalence. Clin Res Cardiol 2010;99:499-506.  Back to cited text no. 9
    
10.
Kahal H, Tahrani AA, Kyrou I, Dimitriadis GK, Kimani PK, Barber TM, et al. The relationship between obstructive sleep apnoea and quality of life in women with polycystic ovary syndrome: A cross-sectional study. Ther Adv Endocrinol Metab 2020;11:2042018820906689.  Back to cited text no. 10
    
11.
Somers VK, Dyken ME, Skinner JL. Autonomic and hemodynamic responses and interactions during the Mueller maneuver in humans. J Auton Nerv Syst 1993;44:253-9.  Back to cited text no. 11
    
12.
Ahmad M, Makati D, Akbar S. Review of and updates on hypertension in obstructive sleep apnea. Int J Hypertens 2017;2017:1848375.  Back to cited text no. 12
    
13.
Jin ZN, Wei YX. Meta-analysis of effects of obstructive sleep apnea on the renin-angiotensin-aldosterone system. J Geriatr Cardiol 2016;13:333-43.  Back to cited text no. 13
    
14.
Genta-Pereira DC, Furlan SF, Omote DQ, Giorgi DMA, Bortolotto LA, Lorenzi-Filho G, et al. Nondipping blood pressure patterns predict obstructive sleep apnea in patients undergoing ambulatory blood pressure monitoring. Hypertension 2018;72:979-85.  Back to cited text no. 14
    
15.
Tufik S, Santos-Silva R, Taddei JA, Bittencourt LR. Obstructive sleep apnea syndrome in the Sao Paulo epidemiologic sleep study. Sleep Med 2010;11:441-6.  Back to cited text no. 15
    
16.
Khan MA, Mathur K, Barraza G, Sin S, Yang CJ, Arens R, et al. The relationship of hypertension with obesity and obstructive sleep apnea in adolescents. Pediatr Pulmonol 2020:1-8.  Back to cited text no. 16
    
17.
WHO Expert Consultation. Appropriate body-mass index for Asian populations and its implications for policy and intervention strategies. Lancet 2004;363:157-63.  Back to cited text no. 17
    
18.
Sawunyavisuth B. What are predictors for a continuous positive airway pressure machine purchasing in obstructive sleep apnea patients? Asia Pac J Sci Technol 2018;23:APST-23-03-10.  Back to cited text no. 18
    
19.
Phtisanuwong C, Ariyanuchitkul S, Chumjan S, Domthong A, Silaruks S, Senthong S. Does hypertensive crisis worsen the quality of life of hypertensive patients with OSA?: A pilot study. Asia Pac J Sci Technol 2017;22(2): APST-22-02-01.  Back to cited text no. 19
    
20.
Abuyassin B, Sharma K, Ayas NT, Laher I. Obstructive sleep apnea and kidney disease: A potential bidirectional relationship? J Clin Sleep Med 2015;11:915-24.  Back to cited text no. 20
    
21.
Kingkaew N, Antadech T. Cardiovascular risk factors and 10-year CV risk scores in adults aged 30-70 years old in Amnat Charoen Province, Thailand. Asia Pac J Sci Technol 2019;24:APST-24-04-04.  Back to cited text no. 21
    
22.
Buttichak A, Leelayuwat N, Bumerraj S, Boonprakob Y. The effects of a yoga training program with fit ball on the physical fitness and body composition of overweight or obese women. Asia Pac J Sci Technol 2019;24:APST-24-02-07.  Back to cited text no. 22
    
23.
Churak P, Praditsorn P, Meenongwah J, Wimonpeerapattana W. Factors associated with nutritional status of elderly in Ubon Ratchathani, Thailand. Asia Pac J Sci Technol 2019;24:APST-24-01-08.  Back to cited text no. 23
    
24.
Senaphan K, Kukongviriyapan U, Pakdeechote P, Kukongviriyapan V, Pannangpetch P. Rat model of a metabolic syndrome induced by a high-carbohydrate, high-fat diet with fructose in drinking water. Asia Pac J Sci Technol 2017;22: APST-22-02-07.  Back to cited text no. 24
    

Top
Correspondence Address:
Kittisak Sawanyawisuth
Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen 40002
Thailand
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JETS.JETS_47_20

Rights and Permissions


    Figures

  [Figure 1]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

Top
  
 
  Search
 
  
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Email Alert *
    Add to My List *
* Registration required (free)  


    Abstract
   Introduction
    Materials and Me...
   Results
   Discussion
   Conclusion
   Methods
    References
    Article Figures
    Article Tables

 Article Access Statistics
    Viewed588    
    Printed7    
    Emailed0    
    PDF Downloaded8    
    Comments [Add]    

Recommend this journal