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Effect of continuous positive airway pressure in patients with true refractory hypertension and sleep apnea

a post-hoc intention-to-treat analysis of the HIPARCO randomized clinical trial

Navarro-Soriano, Cristinaa; Martínez-García, Miguel-Angela; Torres, Gerardb; Barbé, Ferránc,q; Caballero-Eraso, Candelad,q; Lloberes, Patriciae; Diaz Cambriles, Trinidadf; Somoza, Maríag; Masa, Juan F.h; González, Mónicai; Mañas, Evaj; de la Peña, Mónicak; García-Río, Franciscol,q; Montserrat, Josep M.m,q; Muriel, Alfonson,q; Oscullo, Gracea; Feced Olmos, Lauraa; García-Ortega, Albertoa; Calhoun, Davido; Campos-Rodriguez, Franciscop,q on behalf the Spanish Sleep Network

doi: 10.1097/HJH.0000000000002053

Rationale: Continuous positive airway pressure (CPAP) can significantly reduce blood pressure (BP) levels in patients with resistant hypertension and sleep apnea (OSA); however, the effect on patients with refractory hypertension (RfH) is not known. This study seeks to evaluate the effect of CPAP treatment on BP levels in patients with OSA and RfH, compared with those with OSA and resistant hypertension.

Methods: Post-hoc analysis of the HIPARCO randomized clinical trial on the effect of CPAP treatment on BP levels in patients with resistant hypertension. Those patients with uncontrolled 24-h ambulatory BP monitoring readings (>130 and/or >80 mmHg) in SBP or DBP were considered to have resistant hypertension (if they were taking three or four antihypertensive drugs) or RfH (if they were taking at least five drugs). OSA patients were randomized to receive CPAP or usual care for 3 months. They underwent a second 24-h ambulatory BP monitoring study to establish the effect of CPAP treatment on BP levels in both groups.

Results: A total of 98 patients were randomized to CPAP (19 RfH/79 resistant hypertension) and 96 to usual care (21 RfH/75 resistant hypertension). BP readings dropped more marked in patients with RfH than resistant hypertension, in both 24-h SBP (−9 vs. −1.6 mmHg, P = 0.021) and 24-h DBP (−7.3 vs. −2.3 mmHg, P = 0.074), especially at night (−11.3 vs. −3.8, P = 0.121 and −8.8 vs. −2.2, P = 0.054) respectively. Adjusted difference between groups was statistically significant in 24-h SBP levels (−7.4 mmHg, P = 0.021).

Conclusion: CPAP lowers BP levels in both resistant hypertension and RfH patients although the degree of this reduction is higher in those with RfH especially during the night.

aPneumology Department, Hospital Universitario y Politécnico La Fe, Valencia

bInternal Medicine Service, Hospital Universitari de Santa María

cInstitut de Recerca Biomédica, IRB Lleida, Lleida

dRespiratory Department, Hospital Universitario Virgen del Rocío, Institute of Biomedicine of Seville (IBiS), Seville

eRespiratory Department, Hospital Universitario Vall Hebrón, Barcelona

fRespiratory Department, Hospital Universitario 12 de Octubre, Madrid

gRespiratory Department, Consorcio Sanitario de Terrassa, Barcelona

hRespiratory Department, Hospital Universitario San Pedro de Alcántara, Cáceres

iRespiratory Department, Hospital Universitario Marqués de Valdecilla, IDIVAL, Santander

jRespiratory Department, Hospital Universitario Ramón y Cajal, Madrid

kRespiratory Department, Hospital Universitario Son Espases, Palma de Mallorca

lRespiratory Department, Hospital Universitario La Paz, IdiPAZ, Madrid

mRespiratory Department, Hospital Clinic-IDIBAPS, Barcelona

nBiostatistic Unit, Hospital Universitario Ramón y Cajal, Madrid, Spain

oVascular Biology and Hypertension Program, University of Alabama at Birmingham, Birmingham, Alabama, USA

pRespiratory Department, Hospital Universitario ValmE, Institute of Biomedicine of Seville (IBiS), Seville

qCIBERes, CIBER de enfermedades Respiratorias, Madrid, Spain

Correspondence to Miguel-Angel Martínez-García, Pneumology Department, Hospital Universitario y Politécnico La Fe, Bulevar Sur s/n, 46012 Valencia, Spain. Tel: +34 609865934; e-mail:

Abbreviations: ABPM, ambulatory blood pressure monitoring; AHI, apnea-hypopnea index; BP, blood pressure; CPAP, continuous positive airway pressure; OSA, obstructive sleep apnea; RfH, refractory hypertension

Received 26 September, 2018

Revised 11 December, 2018

Accepted 2 January, 2019

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