Snoring and obstructive sleep apnoea syndrome among hypertensive Nigerians: Prevalence and clinical correlates
Adeseye Abiodun Akintunde1, Oluyomi Oluseun Okunola1, Rotimi Oluyombo1, Yussuf Olatunji Oladosu1, Oladimeji George Opadijo1
1Department of Medicine, Lautech Teaching Hospital, Osogbo, Nigeria
AA Akintunde, Department of Medicine, Lautech Teaching Hospital, P.O. Box 3238, Osogbo, Nigeria
Obstructive sleep apnoea syndrome (OSAS) is a common disorder in the community . Association between hypertension and sleep apnoea/snoring has been described among many population [2,3]. The association between sleep related breathing disorders and cardiovascular disease is further stressed by reports of a high prevalence of sleep apnoea among patients with hypertension .
Obstructive sleep apnoea syndrome is associated with increased morbidity and mortality. It is characterized by partial or complete collapse of the upper airways during sleep leading to impaired gas exchange and recurrent arousal from sleep. The consequences of OSAS include excessive daytime sleepiness, cognitive dysfunction, impaired work performance, and impairment in health-related quality of life. Observational and experimental evidence suggests that obstructive sleep apnea may contribute to the development of systemic hypertension, [4
] cardiovasculardisease, [5
] and abnormalities in glucose metabolism [6
]. Obstructive sleep apnea is insidious and patients are often unaware of the associated symptoms. Cardinal manifestations include loud snoring, witnessed breathing pauses during sleep, fitful sleep quality, and excessive daytime sleepiness. Early recognition and appropriate therapy can ameliorate the neurobehavioral consequences and may also have favorable effects on cardiovascular health [7
]. Habitual snoring is associated with hypertension, cerebrovascular disease and coronary heart disease [8
]. The prevalence of snoring among adults varies from different part of the world from 5 to 44% [8
]. In a report from Abuja, Nigeria , overall prevalence of snoring among adults was 31% while the prevalence of clinically Suspected Obstructive Sleep Apneas (CSOSA) was 1%, (1.9% in males, 0.5% in females) [11
There is dearth of information on the pattern of snoring and sleep apnoea among Nigerians with hypertension. The study aimed at describing the frequency of occurrence of snoring and risk of obstructive sleep apnoea among hypertensive subjects and their associated clinical correlates.
This was a cross sectional study. It was carried out at the Cardiology unit of the Ladoke Akintola University Teaching Hospital, Osogbo. Osun State Nigeria. One hundred patients being managed for hypertension were recruited consecutively for this study. Hypertension was diagnosed by either a persistent blood pressure >140/90mmHg or the use of antihypertensive medications. Demographic variables such as age, body weight in kilograms, height in meters, waist circumference hip circumference and gender of each participant were documented. Informed consent was taken from each participant. Ethical approval was obtained from the Institutional Ethical Review Board.
The Epworth Sleepiness Scale (ESS) was used to determine excessive day time sleepiness. It is an eight item self administered questionnaire. Possible score ranges were from 0 to 24. For this study, an ESS score of more than 11 was taken to mean Excessive day time sleepiness EDS. The Berlin Questionnaire was used to identify the risk of having clinical obstructive sleep apnoea. The questionnaire consists of 3 categories related to the risk of having sleep apnea. Patients can be classified into High Risk or Low Risk based on their responses to the individual items and their overall scores in the symptom categories. Subjects were categorized as high risk for having OSA if there were 2 or more Categories where the score was positive and low risk if there was only 1 or no Categories where the score was positive [12
]. The Berlin questionnaire has been documented to be clinically sensitive and correlates significantly with the presence of OSA among various population. Clinically Suspected Obstructive Sleep Apneas (CSOSA) was defined in accordance with the 2001 International Classification of Sleep Disorders [13
Statistical analysis was done using the Statistical Package for Social Sciences SPSS 16.0 (Chicago Ill.) Numerical data were summarized using means and standard deviation while categorical data were summarized using frequencies and percentages. Comparism between groups was done using t-test and Chi square.
One hundred consecutive hypertensive subjects were recruited for the study. It consisted of 40 males (40.0%) and 60 females (60.0%). The age range was between 39 and 90 years. The mean age was 58.4±11.9 years. There was no significant difference between the mean age of males compared to female participants (57.1±10.8 vs. 59.2±12.6 years, p>0.05 respectively). Similarly systolic blood pressure, diastolic blood pressure, fasting blood sugar and waist-hip-ratio were similar between male and female participants (Table 1). The mean body mass index was significantly higher among females than male hypertensives (28.3±5.5 vs. 24.0±3.9, p<0.05 respectively). The proportion of those with abnormal Epworth sleepiness scale was similar between the male and the female participants. Snoring was commoner among male hypertensive subjects than female hypertensive subjects (55.0% vs. 46.7%, p<0.05 respectively). 96% of snorers reported excessive daytime somnolence as predicted by the ESS score compared to 4% of non snorers.
shows the demographic parameters between hypertensive subjects with reported history of snoring and non-snorers. The mean age of snorers was significantly higher than non-snorers (59.4±12.1vs. 56.1±11.9, p< 0.05 respectively). Likewise, systolic blood pressure and fasting blood sugar were significantly higher among snorers than non snorers (141.9±21.2, 5.90±1.0 vs. 134.9±14.1, 4.9±1.8, p<0.05 respectively). Mean Epworth sleepiness scale was significantly higher among snorers than non-snorers (8.74±3.9 vs. 7.1±4.7, p<0.05 respectively) reflecting an increased daytime somnolence among snorers. Almost all snorers were found to have a high risk of OSA using the Berlin score compared to only 4% of non snorers.
The prevalence of snoring based on age group is shown in Table 3
. The highest prevalence of snoring was found in the sixth decade followed by those more than 70 years. Snoring was also found to be commoner among overweight and obese hypertensive subjects as shown in Table 3
The study revealed that the prevalence of snoring among hypertensive Nigerians in this study was 50%. It also revealed that almost all the hypertensive snorers reported excessive daytime somnolence as predicted using the Epworth sleepiness scale. Male hypertensive subjects had a significantly higher frequency of snoring than their female counterparts. In men the frequency of snoring was 55% while it was 46.7% among female participants in the study. This is similar to what has been reported among other hypertensive population . The prevalence of snoring among these hypertensive subjects was however greater than that reported among non-hypertensive Nigerians . Also, about 52% of hypertensive subjects were found to be at high risk for having obstructive sleep apnoea in this study. Hypertension is a well documented risk for developing sleep related difficulties such as sleep apnoea, hypopnoea and snoring [2,3,5,7].
Individuals with OSA have been shown to have heightened sympathetic activity due to activation of chemoreceptors leading to peripheral vasoconstriction [15
]. OSA also results in the production of important neurohumoral mediators of cardiac and vascular disease [16
]. Individuals with OSA have increased production of the potent vasoconstrictor endothelin and impaired endothelial function, which affect vasomotion. OSA has also been associated with systemic inflammation, reflected by increases in C-reactive protein and serum amyloid A levels, which may advance atherosclerosis and is associated with increased cardiovascular risk. Perhaps through its effects on sympathetic activity or because of sleep deprivation, OSA may increase insulin resistance, which promotes cardiovascular risk via multiple pathways [17
]. Also, OSA is associated with increased levels of leptin, a hormone secreted by fat cells that is also associated with cardiovascular events.
This study also revealed that hypertensive subjects with positive history of snoring were significantly older than those without history of snoring. Furthermore, body mass index and fasting blood sugar were significantly higher among hypertensive subjects with history of snoring than those without it. This highlights the fact that hypertensive subjects with OSA likely have increased cardiovascular risk. The prevalence of snoring increased with increasing age group with the highest incidence among those in the sixth decade and the very elderly group (>70 years).This agrees with other studies have shown that obstructive sleep apnoea and snoring are directly related to age. With advancing age, sleep-related difficulties become increasingly common and often manifest as subjective complaints of difficulty falling asleep, reduced duration of night-time awakenings, and the amount of night-time sleep obtained [18
]. Mechanisms proposed for the age-related increase inprevalence include increased deposition of fat in the parapharyngeal area, lengthening of the softpalate, and changes in body structures surrounding the pharynx [20
Several epidemiologic studies have described the higher incidence of snoring and sleep apnoea among men compared to their female counterparts. Several explanation account for this: first, women may be less likely to report classical symptoms such as loud snoring, apnoea, nocturnal sorting or gasping [22
]. Secondly, differential response of the bedpartner to the symptoms of obstructive breathing during sleep may also contribute to the clinical underrecognition of the disorder in women.
This study shows that hypertensive who were overweight or obese were more likely to be having sleep related disorders including snoring than those with normal body mass index. Similarly, a higher percentage of overweight and obese subjects were found to be at a high risk of obstructive sleep apnoea using the Berlin questionnaire. Epidemiologic studies from around the world have consistently shown body weight as the strongest risk factor for obstructive sleep apnea. In the Wisconsin Sleep Cohort study, a one standard deviation difference in body mass index (BMI) was associated with a 4-fold increase in disease prevalence [24
]. Other population- and community-based studies conducted in the United States and other countries have confirmed that excess body weight is uniformly associated with a graded increase in prevalence of obstructive sleep apnea [25-27
This study therefore shows that snoring is a commonly prevalent associated condition among hypertensive subjects in Osogbo, Nigeria. Similarly many of them were found to be at a high risk of OSA. Snoring and clinically suspected OSA were associated with increasing age, body mass index, fasting blood sugar and systolic blood pressure. Hypertensive subjects with sleep related disorders may therefore have increased cardiovascular risk compared to those without sleep related disorders. Therefore, early identification and management of sleep related disorders such as snoring and obstructive sleep apnoea can further reduce the cardiovascular risk of hypertensive Nigerian subjects.
The authors declared no competing interests.
AA: design, data collection, statistical analysis, writing and editing of manuscript. OG: design, writing and editing of manuscript; OO: design, writing and editing of manuscript. RO: design, data collection, editing of manuscript.
YO: data collection, writing and editing of manuscript.
Table 1: Clinical and demographic characteristics of study participants based on gender
Table 2: Clinical and demographic characteristics of snorers compared to non-snorers
Table 3: Prevalence of snoring based on age group and body mass index among study participants
- Punjabi NM. The Epidemiology of adult Obstructive sleep apnoea.Proc Am Thorac Soc. 2008 Feb 15;5(2):136-43. This article on PubMed
- Bixler EO, Vgontzas AN, Lin HM, et al. Association of hypertension and sleep-disordered breathing. Arch Intern Med. 2000 Aug 14-28;160(15):2289-95. This article on PubMed
- Worsnop CJ, Naughton MT, Barter CE, et al. The prevalence of obstructive sleep apnea in hypertensives. Am J Respir Crit Care Med. 1998 Jan;157(1):111-5. This article on PubMed
- Peppard PE, Young T, Palta M, Skatrud J. Prospective study of the association between sleep-disordered breathing and hypertension. N Engl J Med. 2000 May 11;342(19):1378-84. This article on PubMed
- Peker Y, Carlson J, Hedner J. Increased incidence of coronary artery disease in sleep apnoea: a long-term follow-up. Eur Respir J. 2006 Sep;28(3):596-602. This article on PubMed
- Punjabi NM, Polotsky VY. Disorders of glucose metabolism in sleep apnea. J Appl Physiol. 2005 Nov;99(5):1998-2007. This article on PubMed
- Marin JM, Carrizo SJ, Vicente E, Agusti AG. Long-term cardiovascular outcomes in men with obstructive sleep apnoea-hypopnoea with or without treatment with continuous positive airway pressure: an observational study. Lancet. 2005 Mar 19-25;365(9464):1046-53. This article on PubMed
- Jenna P, Sol A. Snoring, sleep apnea and cardiovascular risk factors: the MONICA II Study. Int J Epidemiol. 1993 Jun;22(3):439-44. This article on PubMed
- Zielinski J, Zgierska A, Podlodowski M, et al. Snoring and excessive daytime somnolence among Polish middle-aged adults.Eur Respir J. 1999 Oct;14(4):946-50. This article on PubMed
- Olson LG, King MT, Hensley MJ, et al. A community study of snoring and sleep-disordered breathing. Prevalence. Am J Respir Crit Care Med. 1995 Aug;152(2):711-6. This article on PubMed
- Adewole OO, Adeyemo H, Ayeni F, Anteyi EA, Ajuwon ZO, Erhabor GE, Adewole TT. Prevalence and correlates of snoring among adults in Nigeria.Afr Health Sci. 2008 Jun;8(2):108-13. This article on PubMed
- American Sleep Disorders Association, author, editor. The International Classification of Sleep Disorders, Revised: Diagnostics and Coding Manual. Rochester, MN: American Sleep Disorders Association; 2001. Obstructive sleep apnea syndrome
- Netzer NC, Stoohs RA, Netzer CM, Clark K,Strohl KP. Using the Berlin Questionnaire to identify patients at risk for the sleep apnea syndrome. Ann Intern Med. 1999;131(7):485-491. This article on PubMed
- Narkiewicz K, Wolf J, Lopez-Jimenez F, Somers VK. Obstructive sleep apnea and hypertension. Curr Cardiol Rep. 2005; 7:435. This article on PubMed
- Shamsuzzaman AS, Gersh BJ, Somers VK. Obstructive sleep apnea: Implications for cardiac and vascular disease. JAMA. 2003; 290:1906. This article on PubMed
- Wolk R, Gami AS, Garcia-Touchard A, Somers VK. Sleep and cardiovascular disease. Curr Probl Cardiol. 2005; 30:625. This article on PubMed
- Svatikova A, Wolk R, Gami AS, et al. Interactions between obstructive sleep apnea and the metabolic syndrome. Curr Diab Rep. 2005; 5:53. This article on PubMed
- Ford DE, Kamerow DB. Epidemiologic study of sleep disturbances and psychiatric disorders: an opportunity for prevention? JAMA. 1989 Sep 15;262(11):1479-84. This article on PubMed
- Gislason T, Reynisdottir H, Kristbjarnarson H, Benediktsdottir B. Sleep habits and sleep disturbances among the elderly?an epidemiological survey. J Intern Med. 1993 Jul;234(1):31-9. This article on PubMed
- Eikermann M, Jordan AS, Chamberlin NL, Gautam S, Wellman A, Lo YL, White DP, Malhotra A. The influence of aging on pharyngeal collapsibility during sleep. Chest. 2007 Jun;131(6):1702-9. This article on PubMed
- Malhotra A, Huang Y, Fogel R, Lazic S, Pillar G, Jakab M, Kikinis R, White DP. Aging influences on pharyngeal anatomy and physiology: the predisposition to pharyngeal collapse. Am J Med. 2006;119:72. This article on PubMed
- Bixler EO, Vgontzas AN, Lin HM, Ten Have T, Rein J, Vela-Bueno A, Kales A. Prevalence of sleep-disordered breathing in women: effects of gender. Am J Respir Crit Care Med. 2001 Mar;163(3 Pt 1):608-13.. This article on PubMed
- Duran J, Esnaola S, Rubio R, Iztueta A. Obstructive sleep apneahypopnea and related clinical features in a population-based sample of subjects aged 30 to 70 yr. Am J Respir Crit Care Med. 2001 Mar;163(3 Pt 1):685-9. This article on PubMed
- Young T, Palta M, Dempsey J, Skatrud J, Weber S, Badr S. The occurrence of sleep-disordered breathing among middle-aged adults. N Engl J Med. 1993 Apr 29;328(17):1230-5. This article on PubMed
- Bearpark H, Elliott L, Grunstein R, Cullen S, Schneider H, Althaus W, Sullivan C. Snoring and sleep apnea: a population study in Australian men.Am J Respir Crit Care Med. 1995 May;151(5):1459-65. . This article on PubMed
- Ip MS, Lam B, Lauder IJ, Tsang KW, Chung KF, Mok YW, Lam WK. A community study of sleep-disordered breathing in middle-aged Chinese men in Hong Kong. Chest. 2001 Jan;119(1):62-9. This article on PubMed
- Ng TP, Seow A, Tan W. Prevalence of snoring and sleep breathing-related disorders in Chinese, Malay and Indian adults in Singapore. Eur Respir J. 1998 Jul;12(1):198-203. This article on PubMed