Robbins, Terry Young and Thomas G. Pickering
Donald C. Haas, Gregory L. Foster, F. Javier Nieto, Susan Redline, Helaine E. Resnick, John A.
Systolic Hypertension in the Sleep Heart Health Study
Importance of Discriminating Between Systolic/Diastolic Hypertension and Isolated
Age-Dependent Associations Between Sleep-Disordered Breathing and Hypertension :
Print ISSN: 0009-7322. Online ISSN: 1524-4539
Copyright © 2005 American Heart Association, Inc. All rights reserved.
is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231
World Wide Web at:
The online version of this article, along with updated information and services, is located on the
is online at:
Information about subscribing to
Information about reprints can be found online at:
document. Permissions and Rights Question and Answer this process is available in the
click Request Permissions in the middle column of the Web page under Services. Further information about
Office. Once the online version of the published article for which permission is being requested is located,
can be obtained via RightsLink, a service of the Copyright Clearance Center, not the Editorial
Requests for permissions to reproduce figures, tables, or portions of articles originally published
by guest on June 13, 2013http://circ.ahajournals.org/Downloaded from
Age-Dependent Associations Between Sleep-Disordered
Breathing and Hypertension
Importance of Discriminating Between Systolic/Diastolic Hypertension and
Isolated Systolic Hypertension in the Sleep Heart Health Study
Donald C. Haas, MD, MPH; Gregory L. Foster, MA; F. Javier Nieto, MD, PhD;
Susan Redline, MD, MPH; Helaine E. Resnick, PhD, MPH; John A. Robbins, MD, MHS;
Terry Young, PhD; Thomas G. Pickering, MD, DPhil
Background—Sleep-disordered breathing (SDB) is associated with hypertension in the middle-aged. The association is
less clear in older persons. Most middle-aged hypertensives have systolic/diastolic hypertension, whereas isolated
systolic hypertension (ISH) is common among persons over 60 years. Mechanistically, only systolic/diastolic
hypertension is expected to be associated with SDB, but few studies of SDB and hypertension distinguish
systolic/diastolic hypertension from ISH. Prior investigations may have underestimated an association between SDB and
systolic/diastolic hypertension in the elderly by categorizing individuals with ISH as simply hypertensive.
Methods and Results—We conducted cross-sectional analyses of 6120 participants in the Sleep Heart Health Study,
stratified by age: 40 to 59 (n?2477) and ?60 years. Outcome measures included apnea-hypopnea index (AHI; average
number of apneas plus hypopneas per hour of sleep), systolic/diastolic hypertension (?140 and ?90 mm Hg), and ISH
(?140 and ?90 mm Hg). With adjustment for covariates, ISH was not associated with SDB in either age category. In
those aged?60 years, AHI was significantly associated with higher odds of systolic/diastolic hypertension (AHI 15 to
29.9, OR?2.38 [95% CI 1.30 to 4.38]; AHI ?30, OR?2.24 [95% CI 1.10 to 4.54]). Among those aged ?60 years, no
adjusted association between AHI and systolic/diastolic hypertension was found.
Conclusions—SDB is associated with systolic/diastolic hypertension in those aged ?60 years. No association was found
between SDB and systolic/diastolic hypertension in those aged ?60 years or between SDB and ISH in either age
category. These findings have implications for SDB screening and treatment. Distinguishing between hypertensive
subtypes reveals a stronger association between SDB and hypertension for those aged ?60 years than previously
reported. (Circulation. 2005;111:614-621.)
Key Words: epidemiology ? hypertension ? risk factors ? sleep apnea syndromes
strate SDB to be an independent risk for future hypertension.4
Although the link between SDB and hypertension is clear, the
majority of evidence has been obtained in middle-aged popula-
tions. Less certainty exists about the risk of SDB for hyperten-
sion in the elderly, although both hypertension and SDB are
more common in the elderly than in the middle-aged.3,5–9
The combination of systolic and diastolic hypertension is
common in middle-aged hypertensive patients, whereas isolated
systolic hypertension (ISH) is predominately a disease of elderly
hypertensives.10It is estimated that ISH accounts for nearly 60%
leep-disordered breathing (SDB) is strongly associated with
hypertension.1–3More recently, prospective data demon-
of hypertension in older populations, and its treatment results in
as much as a 35% reduction in cardiovascular events.11,12
Although both systolic/diastolic hypertension and ISH predict
adverse cardiovascular events, each reflects different underlying
pathophysiological processes. Systolic/diastolic hypertension
represents multiple etiologic factors, with evidence to suggest
that the sympathetic nervous system is an important mediator.13
ISH results from the age-dependent loss of arterial compliance,
manifested clinically by a widened pulse pressure.14
Activation of the sympathetic nervous system is an impor-
tant mechanism linking SDB to hypertension; the loss of
arterial compliance has not been implicated mechanistical-
Received May 21, 2004; revision received October 21, 2004; accepted October 29, 2004.
From Mount Sinai School of Medicine (D.C.H.), New York, NY; Johns Hopkins University (G.L.F.), SHHS Coordinating Center, Baltimore, Md;
University of Wisconsin Medical School (F.J.N., T.Y.), Madison, Wis; Case Western Reserve University and Rainbow Babies and Children’s Hospital
(S.R.), Cleveland, Ohio; MedStar Research Institute (H.E.R.), Hyattsville, Md; University of California at Davis (J.A.R.), Sacramento, Calif; and
Columbia University (T.G.P.), College of Physicians and Surgeons, Department of Medicine, New York, NY.
These data were presented in part at the Elizabeth Barrett-Connor Young Investigator Award competition at the 76th Scientific Sessions of the
American Heart Association, Orlando, Fla, November 9–12, 2003, and published in abstract form (Circulation. 2003;108[suppl IV]:IV-766).
Correspondence to Thomas G. Pickering, MD, DPhil, Columbia University, College of Physicians and Surgeons, Department of Medicine, 622 W
168th St, PH9-946, New York, NY 10032. E-mail email@example.com
© 2005 American Heart Association, Inc.
Circulation is available at http://www.circulationaha.orgDOI: 10.1161/01.CIR.0000154540.62381.CF
by guest on June 13, 2013http://circ.ahajournals.org/Downloaded from
cohort, however; the older group is distinguished by not
having succumbed to a disease at a younger age. The
comparison of the 2 age groups is thus a comparison of 2
distinct and different groups. It is not a longitudinal compar-
ison of an aging population, and hence we cannot exclude the
possibility that the reason we failed to observe any associa-
tion between SDB and hypertension in the elderly was
because those affected did not survive.
This work was supported by National Heart, Lung, and Blood
Institute cooperative agreements U01HL53940 (University of Wash-
ington), U01HL53941 (Boston University), U01HL53938 (Univer-
sity of Arizona), U01HL53916 (University of California, Davis),
U01HL53934 (University of Minnesota), U01HL53931 (New York
University), U01HL53937 and U01HL64360 (Johns Hopkins Uni-
versity), U01HL63463 (Case Western Reserve University), and
U01HL63429 (Missouri Breaks Research). The SHHS acknowl-
edges the Atherosclerosis Risk in Communities Study (ARIC), the
Cardiovascular Health Study (CHS), the Framingham Heart Study
(FHS), the Cornell/Mt. Sinai Worksite and Hypertension Studies, the
Strong Heart Study (SHS), the Tucson Epidemiologic Study of
Airways Obstructive Diseases (TES) and the Tucson Health and
Environment Study (H&E) for allowing their cohort members to be
part of the SHHS and for permitting data acquired by them to be used
in the study. SHHS is particularly grateful to the members of these
cohorts who agreed to participate in SHHS as well. SHHS further
recognizes all of the investigators and staff who have contributed to its
success. A list of SHHS investigators, staff, and their participating
institutions is available on the SHHS Web site at www.jhsph.edu/shhs.
1. Nieto FJ, Young TB, Lind BK, Shahar E, Samet JM, Redline S,
D’Agostino RB, Newman AB, Lebowitz MD, Pickering TG. Association
of sleep-disordered breathing, sleep apnea, and hypertension in a large
community-based study. JAMA. 2000;283:1829–1836.
2. Young T, Peppard P, Palta M, Hla KM, Finn L, Morgan B, Skatrud J.
Population-based study of sleep-disordered breathing as a risk factor for
hypertension. Arch Intern Med 1997;1746–1752.
3. Duran J, Esnaola S, Rubio R, Iztueta A. Obstructive sleep apnea-
hypopnea and related clinical features in a population-based sample of
subjects aged 30 to 70 yr. Am J Respir Crit Care Med. 2001;163:
4. Peppard PE, Young T, Palta M, Skatrud J. Prospective study of the
association between sleep-disordered breathing and hypertension. N Engl
J Med. 2000;342:1378–1384.
5. Bixler EO, Vgontzas AN, Ten Have T, Tyson K, Kales A. Effects of age
on sleep apnea in men, I: prevalence and severity. Am J Respir Crit Care
6. Bixler EO, Vgontzas AN, Lin HM, Ten Have T, Leiby BE, Vela-Bueno
A, Kales A. Association of hypertension and sleep-disordered breathing.
Arch of Intern Med. 2000;160:2289–2295.
7. Enright PL, Newman AB, Wahl PW, Manolio TA, Haponik EF, Boyle PJ.
Prevalence and correlates of snoring and observed apneas in 5,201 older
adults. Sleep. 1996;19:531–538.
8. Burt VL, Cutler JA, Higgins M, Horan MJ, Labarthe D, Whelton P,
Brown C, Roccella EJ. Trends in the prevalence, awareness, treatment,
and control of hypertension in the adult US population: data from the
Health Examination Surveys, 1960 to 1991. Hypertension. 1995;26:
9. Ancoli-Israel S, Kripke DF, Klauber MR, Mason WJ, Fell R, Kaplan O.
Sleep-disordered breathing in community dwelling elderly. Sleep. 1991;
10. National High Blood Pressure Education Program Working Group.
National High Blood Pressure Education Program Working Group Report
on Hypertension in the Elderly. Hypertension 1994;23:275–285.
11. Kannel WB. Blood pressure as a cardiovascular risk factor: prevention
and treatment. JAMA. 1996;275:1571–1576.
12. MRC Working Party. Medical Research Council trial of treatment of
hypertension in older adults: principle results. BMJ 1992;304:405–412.
13. Esler M, Rumantir M, Kaye D, Jennings G, Hastings J, Socratous F,
Lambert G. Sympathetic nerve biology in essential hypertension. Clin
Exp Pharmacol Physiol. 2001;28:986–989.
14. Lakatta EG, Levy D. Arterial and cardiac aging: major shareholders in
cardiovascular disease enterprises: part I: aging arteries: a “set up” for
vascular disease. Circulation. 2003;107:139–146.
15. Fletcher EC. Sympathetic overactivity in the etiology of hypertension of
obstructive sleep apnea. Sleep. 2003;26:15–19.
16. Narkiewicz K, Somers VK. The sympathetic nervous system and
obstructive sleep apnea: implications for hypertension. J Hypertens.
17. Quan SF, Howard BV, Iber C, Kiley JP, Nieto FJ, O’Connor GT,
Rapoport DM, Redline S, Robbins J, Samet JM, Wahl PW. The Sleep
Heart Health Study: design, rationale, and methods. Sleep. 1997;20:
18. Lind BK, Goodwin JL, Hill JG, Ali T, Redline S, Quan SF. Recruitment
of healthy adults into a study of overnight sleep monitoring in the home:
experience of the Sleep Heart Health Study. Sleep Breath. 2003;7:13–24.
19. Redline S, Sanders MH, Lind BK, Quan SF, Iber C, Gottlieb DJ, Bonekat
WH, Rapoport DM, Smith PL, Kiley JP, for the Sleep Heart Health
Research Group. Methods for obtaining and analyzing unattended poly-
somnography data for a multicenter study. Sleep. 1998;21:759–767.
20. Psaty BM, Lee M, Savage PJ, Rutan GH, German PS, Lyles M, for the
Cardiovascular Health Study Collaborative Research Group. Assessing
the use of medications in the elderly: methods and initial experience in the
Cardiovascular Health Study. J Clin Epidemiol. 1992;45:683–692.
21. Callaway CW, Chumlea WC, Bouchard C, Himes JH, Lohman TG,
Martin AD, Mitchell CD, Mueller WH, Roche AF, Seefeldt VD. Circum-
ferences. In: Lohman TG, Roche AF, Martorell R, eds. Anthropometric
Standardization Reference Manual. Champaign, Ill: Human Kinetics;
22. Quan SF, Griswold ME, Iber C, Nieto FJ, Rapoport DM, Redline S,
Sanders M, Young T. Short-term variability of respiration and sleep
during unattended polysomnography: the Sleep Heart Health Study.
23. Whitney CW, Gottlieb DJ, Redline S, Norman RG, Dodge RR, Shahar E,
Surovec S, Nieto FJ. Reliability of scoring disturbance indices and sleep
staging. Sleep. 1998;21:749–757.
24. Franklin SS, Gustin W IV, Wong ND, Larson MG, Weber MA, Kannel
WB, Levy D. Hemodynamic patterns of age-related changes in blood
pressure: the Framingham Heart Study. Circulation. 1997;96:308–315.
25. Systolic Hypertension in the Elderly Program (SHEP) Cooperative
Research Group. Prevention of stroke by antihypertensive drug treatment
in older persons with isolated systolic hypertension: final results of the
Systolic Hypertension in the Elderly Program (SHEP). JAMA 1991;265:
26. Staessen JA, Fagard R, Thijs L, Celis H, Arabidze GG, Birkenhager WH,
Bulpitt CJ, de Leeuw PW, Dollery CT, Fletcher AE, Forette F, Leonetti
G, Nachev C, O’Brien ET, Rosenfeld J, Rodicio JL, Tuomilehto J,
Zanchetti A. Randomised double-blind comparison of placebo and active
treatment for older patients with isolated systolic hypertension. Lancet
27. Coope J, Warrender TS. Randomised trial of treatment of hypertension in
elderly patients in primary care. BMJ. 1986;29:1145–1151.
28. Young T, Evans L, Finn L, Palta M. Estimation of the clinically
diagnosed proportion of sleep apnea syndrome in middle-aged men and
women. Sleep. 1997;20:705–706.
29. Young T, Peppard PE, Gottlieb DJ. Epidemiology of obstructive sleep
apnea. Am J Respir Crit Care Med. 2002;165:1217–1239.
30. Ancoli-Israel S, Kripke DF, Klauber MR, Parker L, Stepnowsky C,
Kullen A, Fell R. Natural history of sleep disordered breathing in com-
munity dwelling elderly. Sleep. 1993;16:S25–S29.
31. Young T, Shahar E, Nieto FJ, Redline S, Newman AB, Gottlieb DJ,
Walsleben JA, Finn L, Enright P, Samet JM. Predictors of sleep-
disordered breathing in community-dwelling adults. Arch Intern Med.
32. Sjostrom C, Lindberg E, Elmasry A, Hagg A, Svardsudd K, Janson C.
Prevalence of sleep apnea and snoring in hypertensive men: a population
based study. Thorax. 2002;57:602–607.
Haas et al Sleep-Disordered Breathing and Hypertension
by guest on June 13, 2013http://circ.ahajournals.org/Downloaded from