ABSTRACT 1.

Background Sleep-disordered breathing is preva-lent in the general population and has been linked to

2. chronically elevated blood pressure in cross-section-al epidemiologic studies. We performed a prospective, 3. population-based study of the association between 4. objectively measured sleep-disordered breathing and 5. hypertension defined as a laboratory-measured blood !. pressure of at least "4#$%# mm &g or the use of an-tihypertensive medications'. (. )ethods We analy*ed data on sleep-disordered +. breathing, blood pressure, habitus, and health histo-ry at base line and after four years of follow-up in %. (#% participants of the Wisconsin ,leep -ohort ,tudy "#. and after eight years of follow-up in the case of "+4 "". of these participants'. .articipants were assessed over-night by "+-channel polysomnography for sleep-dis-ordered breathing, as defined by the apnea/ hypopnea "2. inde0 the number of episodes of apnea and hypop-nea per hour of sleep'. 1he odds ratios for the pres-ence of hypertension at the four-year follow-up study "3. according to the apnea/hypopnea inde0 at base line "4. were estimated after adjustment for base-line hyper-tension status, body-mass inde0, nec2 and waist cir-cumference, age, se0, and wee2ly use of alcohol and "5. cigarettes. 16. Results Relative to the reference category of an 17. apneahypopnea index of 0 events per hour at base 18. line, the odds ratios for the presence of hypertension 19. at follo !up ere 1."# $9% percent confidence inter!val, 1.1& to 1.78' ith an apneahypopnea index of a. to ".9 events per hour at base line as co(pared #. ith none, #.0& $9% percent confidence interval, 1.#9

&. to &.17' ith an apneahypopnea index of %.0 to 1".9 ". events per hour, and #.89 $9% percent confidence in!terval, 1."6 to %.6"' ith an apneahypopnea index %. of 1%.0 or (ore events per hour. 6. )onclusions *e found a doseresponse associa!tion bet een sleep!disordered breathing at base line 7. and the presence of hypertension four years later 8. that as independent of +no n confounding factors. 9. ,he findings suggest that sleep!disordered breath!ing is li+ely to be a ris+ factor for hypertension and 10. conse-uent cardiovascular (orbidity in the general 11. population. $. /ngl 0 1ed #0002&"#31&78!8".' 1#. )R//.4.5 studies in the 6nited 7tates, 1&. /urope, and 8ustralia have sho n that a sub! 1". stantial proportion of the adult population 1%. has (ild!to!(oderate sleep!disordered breath! 16. ing, a condition characteri9ed by repeated episodes 17. of apnea and hypopnea during sleep.1!6 18. 8pnea and hy! 19. popnea cause te(porary elevations in blood pressure #0. in association ith blood oxygen desaturation, arous! #1. al, and sy(pathetic activation and (ay cause elevat! ##. ed blood pressure during the dayti(e and, ulti(ate! #&. ly, sustained hypertension. #". 7Recent revie s :udged #%. the epide(iologic evidence relating sleep!disordered #6. breathing to hypertension to be inconclusive, but #7. they noted that study designs ere inappropriate, that

#8. there as inade-uate control for confounding fac! #9. tors such as obesity, and that there as a dearth of &0. prospective studies.8,97ince sleep!disordered breathing &1. is prevalent and treatable and the (orbidity and costs &#. of hypertension are profound, a rigorous assess(ent &&. of the relation bet een the t o conditions re(ains &". a priority. &%. *e assessed the association bet een sleep!disor! &6. dered breathing and hypertension in a prospective &7. analysis of data fro( the *isconsin 7leep )ohort &8. 7tudy. ,he 7leep )ohort 7tudy is a population!based, &9. longitudinal study of the natural history of sleep!dis! "0. ordered breathing in adults. ;articipants co(plete "1. overnight sleep studies at four!year intervals. ,hese "#. studies include assess(ent of sleep!disordered breath! "&. ing $by (onitored polyso(nography', blood pres! "". sure, and (any potential confounding factors. "%. 1/,<=>7 "6. 1989, a subgroup of e(ployees of four *isconsin state agencies "7. as (ailed a four!page -uestionnaire on sleep habits, health his!tory, and de(ographic infor(ation. 8 stratified rando( sa(ple "8. of respondents as invited to participate in the study. ;articipants "9. co(pleted a base!line overnight protocol that included assess(ents %0. of the physiologic characteristics of sleep by polyso(nography, %1. blood pressure, habitus, health history, and other infor(ation. %#. 8pproxi(ately every four years thereafter, participants have been %&. invited for follo !up studies.

%". /xclusion criteria included pregnancy, unstable or deco(pen!sated cardiopul(onary disease, air ay cancers, and recent surgery %%. of the upper respiratory tract. ?or this report, participants ere %6. also excluded if they had sleep studies ith unusable physiologic %7. (easure(ents, an inade-uate period of sleep $less than four hours', %8. no episodes of rapid!eye!(ove(ent sleep, or a history of physi!cian!diagnosed stro+e or cardiovascular disease, or if they ere re!ceiving (edical treat(ent for sleep!disordered breathing. %9. ;articipants 60. 8s of 7epte(ber 1999, a total of 1189 participants had co(!pleted a base!line sleep study and 9%7 of these participants had 61. been invited for four!year follo !up studies. =f those invited, 709 6#. $7" percent' participated in a follo !up study, #&& $#" percent' 6&. declined, and 1% $# percent' could not be contacted $because 6". they had (oved or died'. =f the 709 ho co(pleted four!year 6%. follo !up studies, #19 had been invited for eight!year follo !up 66. studies at the ti(e of our analysis. =f these, 18" $8" percent' 67. co(pleted the second follo !up study, &0 $1" percent' declined, 68. and % $# percent' could not be contacted. ,able 1 co(pares +ey 69. base!line variables a(ong the participants ho co(pleted the base!line sleep study, those ho co(pleted the four!year follo !up study, 70. and those ho co(pleted the eight!year follo !up study. ,here 71. ere no substantial differences a(ong the three groups, although 7#. the percentage of fe(ale participants as slightly lo er in the 7&. subgroup that co(pleted t 7". readings of systolic and diastolic $phase @' blood pressure ere 7%. obtained at %!(inute intervals ith the use of conventional (er!cury sphyg(o(ano(etry according to the reco((endations of 76. the 8(erican 7ociety of <ypertension. 77. 10<abitus as assessed

78. ith the use of standard procedures11 79. and included (easure(ents 80. of height $in (eters' and eight $in +ilogra(s'2 aist, hip, and 81. nec+ circu(ference $in centi(eters'2 s+in!fold thic+ness $in (il!li(eters' of the biceps, triceps, and subscapular and suprailiac ar!eas ith use of a caliper2 and body!(ass index, hich as calcu!lated as the eight in +ilogra(s divided by the s-uare of the 8#. height in (eters. 8&. 8fter the assess(ent of blood pressure and habitus, technicians 8". affixed polyso(nography leads to each participant and perfor(ed 8%. calibrations. 8n 18!channel polyso(nographic recording syste( 86. $(odel 78, 5rass 4nstru(ents, Auincy, 1ass.' as used to assess 87. sleep state and respiratory and cardiac variables. 7leep state as 88. (easured ith electroencephalography, electrooculography, and 89. chin electro(yography. ,hese signals ere used to deter(ine the 90. sleep stage for each &0!second interval of the polyso(nographic 91. record, according to conventional criteria. 9#. 1# 9&. 8rterial oxyhe(oglo!bin saturation, oral and nasal airflo , nasal air pressure, and rib!cage and abdo(inal respiratory (otion ere used to assess epi!sodes of sleep! disordered breathing. =xyhe(oglobin saturation 9". as continuously recorded ith a pulse oxi(eter $(odel &7"0, 9%. =h(eda, /ngle ood, )olo.'. 7tal+!(ounted ther(ocouples $;ro!,ec, <endersonville, ,enn.' detected oral and nasal airflo . 8 96. pressure transducer $@alidyne /ngineering, .orthridge, )alif.' 97. (easured air pressure at the nares. Respiratory inductance pleth!ys(ography $Respitrace, 8(bulatory 1onitoring, 8rdsley, ..B.' 98. recorded rib!cage and abdo(inal excursions. 7leep stage and res!piratory events ere assessed by trained sleep technicians and re!vie ed by an expert polyso(nographer. /ach &0!second interval

99. of the polyso(nographic record as inspected visually for epi!sodes of abnor(al breathing. )essation of airflo for at least 10 100. seconds as defined as an episode of apnea. 8 discernible reduc!tion in the su( a(plitude of the rib!cage plus the abdo(inal ex!cursions on respiratory inductance plethys(ography that lasted at 101. 10#. 10&. 10". 10%. 106. 107. 108. least 10 seconds and that as associated ith a reduction in the oxyhe(oglobin saturation of at least " percent as defined as an episode of hypopnea. ,he apneahypopnea index as defined as the average nu(ber of episodes of apnea and hypopnea per hour of ob:ectively (easured sleep and as the su((ary (easure(ent of the occurrence of sleep!disordered breathing. 7tatistical 8nalysis ,he pri(ary goal of the study as to esti(ate the association

109. of sleep!disordered breathing at base line ith the presence of hy! pertension four years later. *ith this approach, an interpretation 110. of a positive association (ight be that greater initial degrees of

111. sleep!disordered breathing accelerate the develop(ent of hyper!tension. 8ctual changes in blood!pressure levels ere not (od!eled, because the prevalent use of antihypertensive (edication in 11#. 11&. 11". the cohort obscures underlying blood!pressure levels in those ho use (edications, possibly biasing associations.1& ;articipants hose

11%. blood pressure exceeded a specified cutoff point or ho used an! tihypertensive (edication at the ti(e of their studies ere classi!fied as being hypertensive. 4n defining hypertension, e exa(ined 116. 117. 118. cutoff points for blood pressure ranging fro( 1&0C8% to 180C110 (( <g. ,he cutoff point of pri(ary interest as 1"0C90 (( <g, hich as defined as stage 1 hypertension by the sixth report of

119. the 0oint .ational )o((ittee on ;revention, >etection, /valua!tion, and ,reat(ent of <igh Dlood ;ressure. 1#0. 1"

1#1.

=ther cutoff points

1##. ere also exa(ined to deter(ine hether the associations de!pended on the choice of cutoff point. 1#&. 1#". 8(ong 709 participants ho co(pleted base!line and four!year follo !up sleep studies, 18" also co(pleted eight!year follo !up

1#%. studies, yielding data on 89& sets of four!year sleep studies for analy!sis. *e used logistic!regression analysis ith the 787 5/.1=> 1#6. procedure1%

1#7. to esti(ate the odds ratios for the presence of hyper!tension at follo !up according to the level of sleep

128. breathing at base line. We used the generalized-estimating-equa-tions approach

1#9.

16,17

1&0. to incorporate correlations bet een observa!tions resulting fro( the inclusion of the 18" participants assessed 1&1. 1&#. at all three ti(es. ,he significance of logistic!regression coefficients as deter(ined ith t o!sided ; values ith use of an alevel of

1&&. 0.0% for (ain effects and of 0.01 for interactions bet een the co!variates and the apneahypopnea index. 1&". 1&%. 1&6. 1&7. 1&8. ,he degree of sleep!disordered breathing as characteri9ed by the apneahypopnea index. *e exa(ined hether untransfor(ed values for the apneahypopnea index at base line, log!transfor(ed values $apneahypopnea indexE1', the s-uare of the values, and categori9ation of values $0, 0.1 to ".9, %.0 to 1".9, and 1%.0 or

1&9. (ore events per hour' ere predictors of the presence of hyper!tension at follo !up. ,he category of 0 events per hour as in!cluded because a substantial proportion of the participants had 1"0. no episodes of apnea or hypopnea at base line. ,he cutoff points

1"1. of %.0 and 1%.0 events per hour have been used in previous epi!de(iologic studies of sleep!disordered breathing. ?urther subdi!vision of the highest category as i(practical because fe partic!ipants had (ore than 1%.0 events per hour. 1"#. 1"&. Decause of variability ithin sub:ects and (easure(ent error in assessing blood pressure, so(e (isclassification of hypertension

1"". status as inevitable. ,hus, e could not precisely identify a co!hort of participants ho ere free of hypertension at base line to 1"%. follo for a deter(ination of the incidence of hypertension. 4n!stead, in all (odels, e controlled for hypertension status at base 1"6. line. ,his approach allo ed us si(ultaneously to exa(ine the as!sociation bet een sleep!disordered breathing at base line and hy!pertension at follo !up in participants classified as nor(otensive 1"7. at base line and the association bet een sleep!disordered breath!ing and persistent hypertension in participants classified as hyper!tensive at base line. *e used an interaction ter( to assess hether 1"8. these t o associations ere different. 8s a chec+ for a possible

1"9. bias resulting fro( the (isclassification of hypertension, e per!for(ed 1onte )arlo si(ulations in hich a rando( error as 1%0. added to the (easure(ent of participantsF blood pressure. 6sing

1%1. conservative $larger than li+ely' esti(ates of the error in blood!pressure (easure(ents calculated fro( the variability bet een 1%#. participantsF base!line and follo !up (easure(ents, e deter!(ined that the (isclassification of hypertension (ight lead to 1%&. slight underesti(ates of the odds ratios for the li+elihood of hy!pertension at follo !up. 1%". 1%%. *e exa(ined the follo ing base!line variables as covariates3 age, sex, body!(ass index, nec+ circu(ference, aist circu(ference,

1%6. aist!to!hip ratio, s+in!fold (easure(ents, s(o+ing status $cur!rent s(o+er, for(er s(o+er, or no history of s(o+ing2 the nu(!ber of pac+!years2 and the current nu(ber of pac+s s(o+ed per 1%7. ee+', extent of alcohol use $based on the participantFs usual ee+!ly consu(ption', hours of regular exercise per ee+, and (eno!pausal status. Dase! line covariates that substantially altered regres!sion coefficients for the apnea hypopnea index at base line ere

1%8. 1%9. 160. 161.

included in the final (odels. 4nteractions bet een the covariates and the apneahypopnea index ere tested for statistical significance. R/76G,7 ,able # presents +ey characteristics at base line

16#. and follo !up according to the apneahypopnea in!dex at base line. *hen data on all 89& follo !up stud!ies ere analy9ed, there as a decrease in (ean blood 16&. 16". 16%. 166. pressure fro( base line to follo !up $fro( 1#%C8# (( <g to 1#&C79 (( <g' and an increase in the prevalence of stage 1 or orse hypertension $fro( #8 percent to &1 percent'. ,hese changes ere due,

167. in part, to a net increase in the use of antihyperten!sive (edications $fro( 10 percent to 17 percent'. 168. 169. 170. =dds ratios for the presence of hypertension at follo !up according to the apneahypopnea index at base line are given in ,able &. Results fro( four

171.

models are presented. The first model adjusted for

17#.

hypertension status at base line, the second controlled

17&. for this variable as ell as for age and sex $non(od!ifiable ris+ factors', the third controlled for all these 17". variables as ell as for habitus, and the fourth con!trolled for all the preceding variables as ell as for 17%. ee+ly alcohol consu(ption and cigarette use. *ith!in each (odel there as a linear increase in the log!arith( of the odds ratios for successively higher stra!ta of the apneahypopnea index. ,hese (odels fit better than alternative (odels that used continuous

176.

177. (easures of the apneahypopnea index. .o higher!order ter(s $e.g., linear s-uared or cubed' for the 178. strata of the apneahypopnea index ere statistically

179.

significant.

180. ,able & reveals that age and sex (ini(ally con!founded the association bet een sleep!disordered 181. 18#. 18&. breathing and hypertension3 the odds ratios re(ained essentially unchanged after ad:ust(ent for age and sex. 8d:ust(ent for habitus variables did reduce the

18". odds ratios, but further ad:ust(ent for alcohol and cig!arette use did not. =ther variables exa(ined did not 18%. appreciably alter the odds ratios. .o interaction ter(s

186. for sleep!disordered breathing and the covariates ex!a(ined, including base!line hypertension status, ere 187. significant.

188. =dds ratios obtained ith the use of a (ore con!servative definition of hypertension $blood pressure 189. 190. of at least 160C100 (( <g or the use of antihyper!tensive (edications' ere si(ilar to those in ,able &. 8fter ad:ust(ent for base!line hypertension status,

191. age, sex, body!(ass index, aist and nec+ circu(fer!ence, and ee+ly alcohol and cigarette use, the odds 19#. 19&. 19". 19%. 196. 197. 198. ratio associated ith an apneahypopnea index of 0.1 to ".9 events per hour as co(pared ith none as 1.&9 $9% percent confidence interval, 1.0" to 1.8"', the odds ratio associated ith an apneahypopnea index of %.0 to 1".9 events per hour as 1.9# $9% percent confidence interval, 1.09 to &.&9', and the odds ratio associated ith an apneahypopnea index

199. of 1%.0 or (ore events per hour as #.66 $9% per!cent confidence interval, 1.1& to 6.#%'. =dds ratios #00. based on other cutoff points for blood pressure $rang!ing fro( 1&0C8% to 180C110 (( <g' ere si(ilar. #01. 8s a chec+ for possible bias resulting fro( the

#0#. #0&. #0". #0%. #06. #07.

dropout of participants fro( the study, e analy9ed data after excluding all eight!year follo !up data and ad:usting for base!line hypertension status, age, sex, body!(ass index, aist and nec+ circu(ference, and ee+ly alcohol and cigarette use. ,he resulting odds ratios for the presence of hypertension at the four!year follo !up study ere 1."0 $9% percent confidence

#08. interval, 1.09 to 1.81' ith an apneahypopnea in!dex of 0.1 to ".9 events per hour at base line, 1.97 #09. #10. #11. #1#. $9% percent confidence interval, 1.19 to &.#7' ith an apneahypopnea index of %.0 to 1".9 events per hour at base line, and #.77 $9% percent confidence interval, 1.&0 to %.9#' ith an apneahypopnea in!

213.

de of 1!." or more e#ents per hour at base line. $n

#1". each case the reference category as an apneahypop!nea index of 0 events per hour. ,hese odds ratios #1%. #16. #17. ere si(ilar to those in ,able &. >47)6774=. *e found a relation bet een sleep!disordered

#18. breathing and hypertension, (easured over a four!year period, after ad:ust(ent for habitus, age, sex, #19. and cigarette and alcohol use. ;ersons ith fe ep!isodes of apnea or hypopnea $0.1 to ".9 events per ##0. ##1. ###. ##&. ##". hour' at base line had "# percent greater odds of having hypertension at follo !up than did persons ith no episodes. ;ersons ith (ild sleep!disordered breathing $as defined by an apneahypopnea index of %.0 to 1".9 events per hour' and those ith (ore

##%. ##6.

severe sleep!disordered breathing $as defined by an apneahypopnea index of 1%.0 or (ore events per

##7. hour' had approxi(ately t o and three ti(es, re!spectively, the odds of having hypertension at fol!lo !up of those ith no episodes of apnea or hypop! nea. =ur findings, if accurate and reflective of a ##8. ##9. #&0. causal relation, are particularly i(portant because of the high prevalences of sleep!disordered breathing and hypertension.

#&1. >ropout of participants, the possibility of con!founding, and error in assessing +ey study factors are #&#. i(portant features of our study that (ay be relevant

#&&. to the accuracy of our results. 8(ong the partici!pants ho ere invited for the four!year and eight

23%.

&ear follo'-up studies( 7% percent and 8% percent(

#&%. #&6. #&7.

respectively, co(pleted the studies. ,he odds ratios for hypertension at follo !up that ere calculated fro( base!line and all follo !up data ere si(ilar to

#&8. those that excluded eight!year follo !up data, indi!cating that factors influencing participation in the #&9. eight!year follo !up studies did not lead to biased

#"0. associations. 4f si(ilar factors influenced participa!tion in the four!year follo !up studies, then it ould #"1. #"#. be unli+ely that an i(portant bias related to dropout affected the findings.

#"&. ,he associations bet een sleep!disordered breath!ing and hypertension (ay be confounded by vari!ables that cause both sleep!disordered breathing and #"". hypertension. *e (easured and controlled for es!tablished confounding factors $age, sex, and habitus'

#"%. #"6.

as ell as several additional variables. 4n our sa(ple, (easures of habitus, but not age or sex, ere strong

#"7. confounding variables. ;revious cross!sectional stud!ies of sleep! disordered breathing and hypertension #"8. #"9. #%0. #%1. #%#. #%&. #%". have been faulted for not ad:usting for s(o+ing or alcohol use. 8 *e found no evidence that these fac!tors ere i(portant confounders. 1easure(ent error in assessing sleep!disordered breathing, blood pressure, or other covariates (ay have reduced the accuracy of our findings. Rando(

#%%. error in (easuring sleep!disordered breathing is li+e!ly to produce a bias to ard the absence of an asso!ciation. #%6. #%7. #%8. #%9. #60. #61. 18 =ur 1onte )arlo si(ulations indicated that a rando( error in blood!pressure (easure(ent (ight also produce a bias to ard a reduced association. 4f the accuracy of the classification of hypertension as related to the degree of sleep!disordered breathing or

#6#. to i(portant covariates such as obesity, then under!esti(ates or overesti(ates of association could occur. #6&. 4nco(plete control of confounding due to, for exa(!ple, (easure(ent error in assessing habitus (ay pro!duce a bias to ard an overesti(ate of associations be!t een sleep!disordered breathing and hypertension. #6". 18

#6%. ,he fact that our study as prospective lends sup!port to the evidence of a causal role of sleep!disor!dered breathing in hypertension. *e found that the #66. presence of sleep!disordered breathing as predic!tive of the presence of hypertension four years later.

#67. ,his finding (ay indicate that sleep!disordered breath!ing accelerates the progression of blood!pressure lev!els co((only present in (iddle!aged adults in the #68. #69. #70. #71. 6nited 7tates. <o ever, our findings do not offer co(prehensive insight into the natural history of the association. 7leep!disordered breathing changes blood pressures acutely.19!##

#7#. .octurnal exposure to sleep!disordered breathing (ay lead to elevations in blood #7&. #7". #7%. #76. #77. #78. #79. #80. #81. #8#. pressure that last throughout the (orning or the en!tire day. #& 8 dayti(e pressor response that outlasts experi(entally induced nocturnal hypoxia has been de(onstrated in hu(ans.#" 4t has also been hypoth!esi9ed that sleep!disordered breathing could cause per(anent changes in blood pressure by re(odeling the syste(ic vasculature. #% *e did not have data that could be used to (odel

#8&. the dyna(ic relation bet een sleep!disordered breath!ing, habitus, and hypertension. ?or exa(ple, although #8". #8%. #86. #87. #88. there have been fe relevant studies, there has been speculation that sleep!disordered breathing has a causal role in obesity. #6 4f this is the case, then our

#89. efforts to control for confounding by including (eas!ures of obesity in our (odels (ay have led to a par!tial overad:ust(ent of the association bet een sleep!

290.

disordered breathing and hypertension and thus to

291.

an underestimate of the association.

292. We found no evidence of a threshold of the ap-neahypopnea index below which hypertension was 293. not related to sleep-disordered breathing. ven per-sons with minimal sleep-disordered breathing !as de-fined by an apneahypopnea index of ".1 to #.9 events 29#. 29%. 29'. 29(. per hour$ had higher odds of hypertension than those with no episodes of sleep-disordered breathing. &f even those with minimal sleep-disordered breathing are at higher ris) for hypertension* then the proportion of

29+. cases of hypertension that are attributable to this fac-tor may be substantial. 299. 3"". ,revious epidemiologic studies of sleep-disordered breathing and hypertension that focused on sub-ects

3"1. from the general population and patients from sleep-disorders clinics have reached conflicting conclusions* 3"2. 3"3. although none have precluded the existence of a moderate association.9

3"#. .tudies that involved cross-sectional samples from sleep-disorders clinics 3"%. 3"'. 2'-3# have

3"(. typically used high-/uality methods to assess sleep-disordered breathing !multichannel polysomnogra-phy$. 0owever* un)nown factors that influence re-ferral to a sleep-disorders clinic may have made these 3"+. 3"9. 31". 311. studies incapable of accurately assessing the relations. 1onversely* most cross-sectional population-based studies %*3%-#3

312. have used samples that were epidemio-logically more rigorous but used instruments with 313. poor or un)nown validity to assess sleep-disordered

31#. breathing. 2wo recent population-based cross-section-al analyses from the Wisconsin .leep 1ohort .tudy 31%. 31'. 31(. ## and the .leep 0eart 0ealth .tudy* #%

31+. which used poly-somnography to assess sleep-disordered breathing* re-ported moderate* statistically significant associations 319. 32". 321. 322. between sleep-disordered breathing and hypertension. &n a recent prospective study* 0u and colleagues #' assessed a large number of normotensive women and

323. found that snoring* a cardinal !but nonspecific$ symp-tom of sleepdisordered breathing* significantly in-creased the ris) of hypertension. 3s compared with 32#. 32%. 32'. the ris) in nonsnorers* the ris) of hypertension was increased by 29 percent in occasional snorers and by %% percent in those who snored regularly.

32(. 3s evidence builds of a causal role of sleep-disor-dered breathing in hypertension and other health out-comes* there is a growing need to understand the 32+. natural history of and ris) factors for sleep-disor-dered breathing. 1ontinued development and re-finement of medical treatments for sleepdisordered 329. breathing are also priorities. 3vailable treatments* such

33". as continuous positive airway pressure* can be effec-tive. 0owever* these therapies may be overly burden-some for the treatment of mild cases of asymptomat-ic sleep-disordered breathing. 4ittle is )nown about 331. the effectiveness of ris)-factor intervention for mild-to-moderate sleep-disordered breathing* and this is

332. 333.

an important area for future research. &n this prospective analysis* we found an association

Taranlate

8D7,R8H 1. Gatar Dela+ang 7leep!gangguan pernapasan preva!dipin:a(+an pada populasi u(u( dan telah di+ait+an dengan #. +ronis te+anan darah tinggi di pena(pang!al studi epide(iologi. Ha(i (ela+u+an prospe+tif, &. berdasar+an populasi studi hubungan antara ". obye+tif diu+ur tidur!gangguan pernapasan dan %. hipertensi $didefinisi+an sebagai darah laboratoriu(!diu+ur 6. ,e+anan (ini(al 1"0C90 (( <g atau penggunaan obat!tihypertensive'. 7. 1etode Ha(i (enganalisis data pada tidur!gangguan 8. pernapasan, te+anan darah, habitus, dan +esehatan histo!ry di garis dasar dan setelah e(pat tahun (asa tinda+ lan:ut dala( 9. 709 peserta studi *isconsin 7leep )ohort 10. $>an setelah delapan tahun (asa tinda+ lan:ut dala( +asus 18" 11. dari peserta'. ;eserta dinilai over!(ala( oleh 18!channel polyso(nography untu+ tidur!dis!(e(erintah+an pernapasan, seperti yang didefinisi+an oleh apnea!<ypopnea 1#. 4nde+s $:u(lah episode apnea dan hypop!nea per :a( tidur'. Rasio gan:il untu+ ence pres!hipertensi pada studi e(pat tahun tinda+ lan:ut 1&. (enurut inde+s apnea!<ypopnea di garis dasar 1". diper+ira+an setelah penyesuaian untu+ basis!line hiper!+etegangan, leher 7tatus inde+s (assa tubuh, dan pinggang )4R!cu(ference, usia, :enis +ela(in, dan penggunaan al+ohol dan (ingguan 1%. ro+o+. 16. 7ehubungan dengan +ategori referensi dari hasil 17. apnea!<ypopnea inde+s 0 +e:adian per :a( di pang+alan 18. line, odds ratio untu+ +ehadiran hipertensi 19. di follo !up adalah 1,"# $9% persen +epercayaan antar!val, 1,1&!1,78' dengan inde+s apnea!<ypopnea dari a. (en:adi ",9 peristi a per :a( pada garis dasar dibanding+an #0. dengan tida+ ada, #,0& $9% persen interval +epercayaan, 1,#9 #1. (en:adi &,17' dengan inde+s apnea!<ypopnea dari %,0!1",9 ##. +e:adian per :a(, dan #,89 $9% persen +eya+inan!terval, 1,"6!%,6"' dengan inde+s apnea!<ypopnea #&. dari 1%,0 atau lebih peristi a per :a(. #". Hesi(pulan Ha(i (ene(u+an dosis!respons asosiasi!tion antara tidur!gangguan pernapasan pada garis dasar #%. dan adanya hipertensi e(pat tahun +e(udian #6. yang independen dari fa+tor perancu di+etahui.

#7. ,e(uan (enun:u++an bah a tidur!gangguan napas!ing +e(ung+inan (en:adi fa+tor risi+o hipertensi dan #8. +onse+uen +ardiovas+ular (orbiditas pada u(u(nya #9. populasi. $. /ngl 0 1ed #0002. &"#31&78!8"' &0. )R//.4.5 studi di 8(eri+a 7eri+at, &1. /ropa, dan 8ustralia telah (enun:u++an bah a sub! &#. stantial proporsi populasi orang de asa &&. (e(ili+i ringan sa(pai sedang tidur!gangguan napas! &". ing, suatu +ondisi yang ditandai dengan episode berulang &%. apnea dan hypopnea sela(a sleep.1!6 &6. 8pnea dan hy! &7. popnea (enyebab+an pening+atan se(entara te+anan darah &8. dala( hubungan dengan desaturation o+sigen darah, 8rous! &9. al, dan a+tivasi si(pati+ dan dapat (enyebab+an elevat! "0. ed te+anan darah pada siang hari dan, a+hir! "1. ly, hipertensi ber+elan:utan. "#. 6lasan 7Recent dinilai "&. epide(iologi bu+ti yang ber+aitan dengan tidur!gangguan "". bernapas hipertensi (en:adi tida+ (eya+in+an, na(un "%. (ere+a (encatat bah a desain penelitian adalah tida+ pantas, bah a "6. ada +ontrol yang tida+ (e(adai untu+ pe(baur fa+tor! "7. tor seperti obesitas, dan bah a ada +elang+aan "8. calon studies.8, 97ince tidur!gangguan pernapasan "9. adalah la9i( dan dapat diobati dan (orbiditas dan biaya %0. hipertensi yang (endala(, penilaian yang +etat %1. tentang hubungan antara dua +ondisi tetap %#. prioritas. %&. Ha(i (enilai hubungan antara tidur!disor! %". dered pernapasan dan hipertensi dala( prospe+tif %%. analisis data dari *isconsin 7leep )ohort %6. 7tudi. )ohort 7tudy ,idur adalah berbasis populasi, %7. (e(bu:ur studi se:arah ala( tidur!dis! %8. (e(erintah+an bernapas pada orang de asa. Geng+ap ;eserta %9. se(ala( tidur studi di e(pat tahun interval. 4ni 60. ;enelitian (eliputi penilaian tidur!gangguan napas! 61. ing $oleh polyso(nography dipantau', pres!darah 6#. ya+in, dan banya+ fa+tor perancu potensial. 6&. 1/,=>/ 6". 1989, sub+elo(po+ +arya an dari e(pat le(baga negara *isconsin 6%. telah di+iri(+an +uesioner e(pat!hala(an pada +ebiasaan tidur, +esehatannya!tory, dan infor(asi de(ografis. 7ebuah sa(pel aca+ berting+at 66. responden diundang untu+ berpartisipasi dala( penelitian ini. ;eserta 67. (enyelesai+an proto+ol dasar!line se(ala( yang ter(asu+ penilaian 68. dari +ara+teristi+ fisiologis tidur dengan polyso(nography, 69. te+anan darah, habitus, ri ayat +esehatan, dan infor(asi lainnya. 70. Hira!+ira setiap e(pat tahun sesudahnya, para peserta telah

71. diundang untu+ tinda+ lan:ut penelitian. 7#. Hriteria e+s+lusi (eliputi +eha(ilan, tida+ stabil atau deco(pen!:enuh penya+it cardiopul(onary, +an+er saluran napas, dan operasi baru!baru ini 7&. dari saluran pernapasan bagian atas. 6ntu+ laporan ini, peserta 7". :uga di+ecuali+an :i+a (ere+a telah tidur dengan studi fisiologis tida+ dapat diguna+an 7%. pengu+uran, suatu periode yang tida+ (e(adai tidur $+urang dari e(pat :a(', 76. tida+ ada episode rapid!eye!(ove(ent tidur, atau ri ayat physi!udi!didiagnosis penya+it stro+e atau :antung, atau :i+a (ere+a +e(bali ceiving pera atan (edis untu+ gangguan napas saat tidur. 77. ;eserta 78. ;er 7epte(ber 1999, total 1189 peserta telah co(!pleted basis!line tidur studi dan 9%7 peserta ini (e(ili+i 79. diundang untu+ e(pat tahun tinda+ lan:ut studi. >ari (ere+a diundang, 709 80. $7" persen' berpartisipasi dala( studi lan:utan, #&& $#" persen' 81. (enurun, dan 1% $# persen' tida+ bisa dihubungi $+arena 8#. (ere+a telah pindah atau (eninggal'. >ari 709 yang (enyelesai+an e(pat tahun 8&. tinda+ lan:ut studi, #19 telah diundang untu+ delapan tahun tinda+ lan:ut 8". 7tudi pada saat analisis +a(i. >ari :u(lah tersebut, 18" $8" persen' 8%. (enyelesai+an studi tinda+ lan:ut +edua, &0 $1" persen' (enurun, 86. dan % $# persen' tida+ bisa dihubungi. ,abel 1 (e(banding+an +unci 87. dasar!line variabel antara peserta yang (enyelesai+an studi tidur dasar!line, (ere+a yang (enyelesai+an e(pat tahun tinda+ lan:ut studi, 88. dan (ere+a yang (enyelesai+an delapan tahun tinda+ lan:ut studi. 7ana 89. ada perbedaan substansial antara tiga +elo(po+, (es+ipun 90. persentase peserta pere(puan sedi+it lebih rendah di 91. sub+elo(po+ yang (enyelesai+an t 9#. pe(bacaan sistoli+ dan diastoli+ $fase @' te+anan darah yang 9&. diperoleh pada % (enit interval dengan penggunaan +onvensional (er!cury sphyg(o(ano(etry sesuai dengan re+o(endasi dari 9". 8(erican 7ociety of <ypertension. 9%. 10<abitus dinilai 96. dengan (engguna+an standar procedures11 97. dan ter(asu+ pengu+uran 98. tinggi badan $dala( (eter' dan berat badan $dala( +ilogra(', pinggang, pinggul, dan 99. ling+ar leher $dala( c(', +ulit!+ali lipat +etebalan $dala( :uta!li(eters' dari otot bisep, trisep, dan subs+apularis dan suprailiac ar!/87 dengan penggunaan caliper, dan inde+s (assa tubuh, yang calcu!lated sebagai berat dala( +ilogra( dibagi dengan +uadrat dari 100. tinggi dala( (eter. 101. 7etelah penilaian te+anan darah dan habitus, te+nisi 10#. polyso(nography dite(pel+an (engarah +e (asing!(asing peserta dan dila+u+an 10&. +alibrasi. 7ebuah 18!channel polyso(nographic siste( pencatatan 10". $1odel 78, Ru(put 4nstru(en, Auincy, 1ass' diguna+an untu+ (enilai 10%. tidur negara dan pernapasan dan variabel :antung. Headaan tidur adalah 106. diu+ur dengan electroencephalography, electrooculography, dan

107. dagu ele+tro(iografi. 7inyal!sinyal ini diguna+an untu+ (enentu+an 108. tidur panggung untu+ setiap interval &0 deti+ dari polyso(nographic 109. (ere+a(, (enurut +riteria +onvensional. 110. 1# 111. 8rteri oxyhe(oglo!bin saturasi, (ulut dan hidung aliran udara, te+anan udara hidung, dan tulang rusu+!+andang dan gera+ pernapasan perut yang diguna+an untu+ (enilai epi!sodes tidur!gangguan pernapasan. =+sihe(oglobin saturasi 11#. terus (enerus dire+a( dengan o+si(eter pulsa $(odel &7"0, 11&. =h(eda, /ngle ood, )olo'. Datang!(ount ter(o+opel $;ro!,ec, <endersonville, ,ennessee' terdete+si aliran udara oral dan hidung. 8 11". transduser te+anan $@alidyne ,e+ni+, .orthridge, )alifornia' 11%. diu+ur te+anan udara di nares. ;ernapasan indu+tansi ;G/,<!ys(ography $Respitrace, ;e(antauan 8(bulatory, 8rdsley, .B' 116. (encatat rusu+!+andang dan +un:ungan perut. ,idur panggung dan res!peristi a pernapasan dinilai oleh te+nisi terlatih dan tidur +e(bali dilihat oleh polyso(nographer ahli. 7etiap interval &0 deti+ 117. dari catatan polyso(nographic diperi+sa secara visual untu+ epi!sodes dari pernapasan abnor(al. ;enghentian aliran udara sela(a setida+nya 10 118. deti+ didefinisi+an sebagai episode apnea. 7ebuah pengurangan!tion dilihat dala( a(plitudo :u(lah tulang rusu+!plus perut (antan cursions pada plethys(ography indu+tansi pernapasan yang berlangsung di 119. setida+nya 10 deti+ dan itu di+ait+an dengan penurunan 1#0. o+sihe(oglobin saturasi (ini(al " persen didefinisi+an sebagai 1#1. episode <ypopnea. 4nde+s apnea!<ypopnea didefinisi+an sebagai 1##. rata!rata :u(lah episode apnea dan <ypopnea per :a( 1#&. dari obye+tif diu+ur tidur dan pengu+uran ring+asan 1#". dari ter:adinya gangguan napas saat tidur. 1#%. 8nalisis statisti+ 1#6. ,u:uan uta(a dari penelitian ini adalah untu+ (e(per+ira+an asosiasi 1#7. tidur!gangguan pernapasan pada garis dasar dengan +ehadiran hy!pertension e(pat tahun +e(udian. >engan pende+atan ini, interpretasi 1#8. asosiasi positif (ung+in bah a dera:at a al yang lebih besar dari 1#9. tidur!gangguan pernapasan (e(percepat penge(bangan hiper!+etegangan. ;erubahan a+tual dala( te+anan darah ting+at tida+ (od!eG/>, +arena penggunaan u(u( dari obat antihipertensi dala( 1&0. +ohort (engabur+an (endasari te+anan darah pada (ere+a yang ting+at 1&1. (engguna+an obat!obatan, +e(ung+inan biasing associations.1& 1&#. ;eserta yang 1&&. te+anan darah (elebihi titi+ cutoff ditentu+an atau yang (engguna+an sebuah! tihypertensive obat pada saat studi (ere+a yang di+lasifi+asi+an sebagai hipertensi. >ala( (endefinisi+an hipertensi, +a(i diperi+sa 1&". cutoff poin untu+ te+anan darah (ulai dari 1&0C8% sa(pai 180C110 1&%. (( <g. ,iti+ cutoff (inat uta(a adalah <g 1"0C90 ((, 1&6. yang didefinisi+an sebagai tahap 1 hipertensi oleh laporan +eena( 1&7. Ho(ite .asional Dersa(a ;encegahan, >ete+si, evaluasi!tion, dan ;enanganan ,e+anan >arah ,inggi.

1&8. 1" 1&9. Gainnya cutoff poin 1"0. :uga diperi+sa untu+ (enentu+an apa+ah asosiasi de!pended pada pilihan titi+ cutoff. 1"1. >i antara 709 peserta yang (enyelesai+an dasar!line dan e(pat tahun 1"#. tinda+ lan:ut studi tidur, 18" :uga (enyelesai+an delapan tahun tinda+ lan:ut 1"&. ;enelitian, yang (enghasil+an data (engenai 89& set e(pat tahun studi tidur untu+ analisi!sis. Ha(i (engguna+an analisis regresi logisti+ dengan 5/.1=> 787 1"". procedure1% 1"%. untu+ (e(per+ira+an odds ratio untu+ +eberadaan hiper!+etegangan di follo !up sesuai dengan ting+at tidur 1"6. bernapas di garis dasar. Ha(i (engguna+an pende+atan u(u(!(e(per+ira+an! persa(aan!tions 1"7. 16,17 1"8. untu+ (e(asu++an +orelasi antara observasi!tions a+ibat (asu+nya 18" peserta dinilai 1"9. di se(ua tiga +ali. ;entingnya logisti+!+oefisien regresi 1%0. ditentu+an dengan dua sisi nilai ; dengan penggunaan alevel dari 1%1. 0,0% untu+ efe+ uta(a dan dari 0,01 untu+ intera+si antara co!variates dan inde+s apnea!hypopnea. 1%#. ,ing+at gangguan napas saat tidur ditandai oleh 1%&. inde+s apnea!hypopnea. Ha(i (e(eri+sa apa+ah untransfor(ed 1%". nilai untu+ inde+s apnea!<ypopnea di garis dasar, log!berubah 1%%. nilai $apnea!hypopnea index E1', +uadrat dari nilai!nilai, dan 1%6. +ategorisasi nilai $0, 0,1!",9, %,0!1",9, dan 1%,0 atau 1%7. peristi a lebih per :a(' adalah predi+tor adanya hiper!+etegangan di follo !up. Hategori 0 +e:adian per :a( berada di!cluded +arena sebagian besar peserta (e(ili+i 1%8. tida+ ada episode apnea atau <ypopnea di garis dasar. ;oin cutoff 1%9. dari %,0 dan 1%,0 peristi a per :a( telah diguna+an dala( sebelu(nya epi! de(iologic studi tidur!gangguan pernapasan. 7elan:utnya subdi!visi dari +ategori tertinggi adalah tida+ pra+tis +arena beberapa partic!ipants (e(ili+i lebih dari 1%,0 peristi a per :a(. 160. Harena variabilitas dala( subye+ dan +esalahan pengu+uran di 161. (enilai te+anan darah, beberapa +esalahan +lasifi+asi hipertensi 16#. 7tatus ta+ terela++an. >engan de(i+ian, +ita tida+ bisa secara tepat (engidentifi+asi co!hort peserta yang bebas dari hipertensi pada baris dasar untu+ 16&. i+uti untu+ penentuan +e:adian hipertensi. >i!stead, di se(ua (odel, +a(i (engontrol untu+ status hipertensi di dasar 16". line. ;ende+atan ini (e(ung+in+an +a(i untu+ (e(eri+sa secara bersa(aan sebagai!apapun antara tidur!gangguan pernapasan pada garis dasar dan hy!pertension di follo !up pada peserta di+lasifi+asi+an sebagai nor(otensive 16%. pada garis dasar dan hubungan antara tidur!gangguan napas!ing dan hipertensi terus! (enerus dala( peserta di+lasifi+asi+an sebagai hiper!bersayap di garis dasar. Ha(i (engguna+an istilah intera+si untu+ (enilai apa+ah 166. dua asosiasi yang berbeda. 7ebagai ce+ untu+ +e(ung+inan

167. Dias a+ibat +esalahan +lasifi+asi hipertensi, +ita per!terbentu+ si(ulasi 1onte )arlo di (ana +esalahan aca+ adalah 168. dita(bah+an +e pengu+uran te+anan darah peserta I. 1engguna+an 169. +onservatif $lebih besar dari +e(ung+inan' per+iraan +esalahan dala( pengu+uran te+anan darah dihitung dari variabilitas antara 170. Ipeserta dasar!line dan tinda+ lan:ut pengu+uran, +ita (enghalangi!dita(bang bah a +esalahan +lasifi+asi hipertensi dapat (enga+ibat+an 171. sedi+it (ere(eh+an dari odds ratio untu+ +e(ung+inan hy!pertension di follo !up. 17#. Ha(i (e(eri+sa dasar!line variabel beri+ut sebagai +ovariat3 usia, 17&. sex, inde+s (assa tubuh, ling+ar leher, ling+ar pinggang, 17". pinggang!pinggul rasio, +ulit +ali lipat pengu+uran, status (ero+o+ $s+r!se a pero+o+, (antan pero+o+, atau tida+ ada ri ayat (ero+o+, sedang+an nu(!ber pa+! tahun, dan saat ini :u(lah pa+et yang dihisap per 17%. (inggu', ting+at penggunaan al+ohol $berdasar+an biasanya +onsu(si peserta (inggu!ly', :a( olahraga teratur per (inggu, dan (eno!pausal status. Dasis!line +ovariat yang secara substansial (engubah +oefisien regresi untu+ inde+s apnea!<ypopnea di garis dasar yang 176. ter(asu+ dala( (odel a+hir. 4ntera+si antara +ovariat dan 177. inde+s apnea!<ypopnea diu:i untu+ signifi+ansi statisti+. 178. <874G 179. ,abel # (enya:i+an +ara+teristi+ +unci pada garis dasar 180. dan tinda+ lan:ut sesuai dengan apnea!<ypopnea di!dex di base line. Heti+a data pada se(ua 89& tinda+ lan:ut penelitian!penelitian dianalisis, ada penurunan dala( darah rata!rata 181. te+anan dari garis dasar untu+ (eninda+lan:uti $dari 1#%C8# 18#. (( <g untu+ 1#&C79 (( <g' dan pening+atan 18&. prevalensi hipertensi stadiu( 1 atau buru+ $dari 18". #8 persen (en:adi &1 persen'. ;erubahan ini adalah +arena, 18%. sebagian, +enai+an bersih dala( penggunaan antihyperten!sive obat $dari 10 persen (en:adi 17 persen'. 186. =dds rasio untu+ +ehadiran hipertensi di 187. tinda+ lan:ut (enurut inde+s apnea!<ypopnea 188. pada garis dasar yang diberi+an dala( ,abel &. <asil dari e(pat 189. (odel disa:i+an. 1odel perta(a disesuai+an 190. hipertensi status di garis dasar, yang di+endali+an +edua 191. untu+ variabel ini serta untu+ usia dan :enis +ela(in $non(od!ifiable fa+tor risi+o', +etiga di+ontrol untu+ se(ua 19#. variabel serta untu+ habitus, dan +ee(pat di+ontrol untu+ se(ua variabel sebelu(nya serta untu+ 19&. al+ohol (ingguan +onsu(si dan penggunaan ro+o+. >engan!in (asing!(asing (odel ada pening+atan linear di arith( log!dari odds ratio untu+ berturut!turut lebih tinggi stra!ta dari inde+s apnea!hypopnea. 1odel ini coco+ 19". lebih bai+ daripada (odel!(odel alternatif yang diguna+an terus (enerus 19%. u+uran inde+s apnea!hypopnea. ,ida+ ada istilah ting+at tinggi $(isalnya, persegi atau potong dadu linier' untu+

196. strata inde+s apnea!<ypopnea secara statisti+ 197. signifi+an. 198. ,abel & (engung+ap+an bah a usia dan :enis +ela(in (ini(al con!(endiri+an hubungan antara tidur!gangguan 199. pernapasan dan hipertensi3 odds ratio tetap #00. dasarnya tida+ berubah setelah penyesuaian untu+ usia dan #01. se+s. ;enyesuaian untu+ variabel habitus tida+ (engurangi #0#. odds rasio, na(un penyesuaian lebih lan:ut untu+ al+ohol dan cig!8rette penggunaan tida+. @ariabel lain diperi+sa tida+ #0&. lu(ayan (engubah odds ratio. ,ida+ ada istilah intera+si #0". untu+ tidur!gangguan pernapasan dan +ovariat (antan a(ined, ter(asu+ basis!baris status hipertensi, adalah #0%. signifi+an. #06. =dds rasio yang diperoleh dengan (engguna+an definisi yang lebih +onservatif hipertensi $te+anan darah #07. (ini(al 160C100 (( <g atau penggunaan antihyper!bersayap obat' adalah serupa dengan yang ada di ,abel &. #08. 7etelah penyesuaian untu+ dasar!baris status hipertensi, #09. usia, :enis +ela(in, inde+s (assa tubuh, pinggang dan leher circu(fer!ence, dan (ingguan al+ohol dan penggunaan ro+o+, +e(ung+inan #10. rasio yang berhubungan dengan inde+s apnea!<ypopnea dari 0,1 #11. (en:adi ",9 +e:adian per :a( dibanding+an dengan tida+ ada yang #1#. 1,&9 $9% persen interval +epercayaan, 1,0" sa(pai 1,8"', #1&. rasio odds yang ter+ait dengan apnea!<ypopnea #1". inde+s %,0!1",9 +e:adian per :a( adalah 1,9# $9% #1%. persen interval +epercayaan, 1,09!&,&9', dan #16. odds ratio yang berhubungan dengan inde+s apnea!<ypopnea #17. dari 1%,0 atau lebih peristi a per :a( adalah #,66 $9% persen interval +epercayaan, 1,1&!6,#%'. =dds rasio #18. berdasar+an poin cutoff lain untu+ te+anan darah $berdering!ing dari 1&0C8% sa(pai 180C110 (( <g' adalah serupa. #19. 7ebagai ce+ untu+ +e(ung+inan bias yang dihasil+an dari ##0. putus se+olah peserta dari penelitian, +a(i (enganalisis ##1. data setelah tida+ ter(asu+ se(ua delapan!tahun tinda+!up data dan ###. disesuai+an dengan dasar!baris status hipertensi, usia, :enis +ela(in, ##&. inde+s (assa tubuh, ling+ar pinggang dan leher, dan ##". (ingguan al+ohol dan penggunaan ro+o+. Bang dihasil+an +e(ung+inan ##%. rasio untu+ +ehadiran hipertensi pada studi e(pat!tahun tinda+ lan:ut adalah 1,"0 $9% persen confidence ##6. interval, 1,09!1,81' dengan apnea!<ypopnea di!dex dari 0,1!",9 +e:adian per :a( pada garis dasar, 1,97 ##7. $9% persen interval +epercayaan, 1,19!&,#7' dengan ##8. inde+s apnea!<ypopnea dari %,0!1",9 +e:adian per ##9. :a( pada garis dasar, dan #,77 $9% persen confidence #&0. interval, 1,&0!%,9#' dengan apnea!<ypopnea di!

#&1. dex dari 1%,0 atau lebih peristi a per :a( pada garis dasar. >i #&#. setiap +asus +ategori referensi adalah inde+s apnea!hypop!nea dari 0 +e:adian per :a(. 4ni odds ratio #&&. adalah serupa dengan yang di ,abel &. #&". ;/1D8<878. #&%. Ha(i (ene(u+an hubungan antara tidur!gangguan #&6. pernapasan dan hipertensi, diu+ur sela(a periode e(pat tahun, setelah penyesuaian untu+ se+s habitus, usia,, #&7. dan ro+o+ dan penggunaan al+ohol. =rang dengan beberapa ep!isodes apnea atau <ypopnea $0,1!",9 +e:adian per #&8. :a(' pada garis dasar (e(ili+i +e(ung+inan "# persen lebih besar dari #&9. (e(ili+i hipertensi pada tinda+ lan:ut daripada orang #"0. tanpa episode. =rang dengan ringan tidur!gangguan #"1. bernapas $seperti yang didefinisi+an oleh inde+s apnea!<ypopnea #"#. dari %,0!1",9 +e:adian per :a(' dan (ere+a dengan lebih #"&. parah gangguan napas saat tidur $seperti yang didefinisi+an oleh #"". apnea!<ypopnea inde+s 1%,0 atau lebih +e:adian per #"%. :a(' (e(ili+i +urang lebih dua dan tiga +ali, +e(bali!spectively, +e(ung+inan (e(ili+i hipertensi di fol!lo !up dari (ere+a yang tida+ (e(ili+i episode apnea atau hypop!nea. ,e(uan +a(i, :i+a a+urat dan refle+tif dari #"6. hubungan +ausal, sangat penting +arena #"7. tinggi prevalensi gangguan napas saat tidur #"8. dan hipertensi. #"9. >ropout peserta, +e(ung+inan con!pendiri +esalahan, dan dala( (enilai fa+tor penelitian +unci #%0. fitur penting dari penelitian +a(i yang (ung+in relevan #%1. untu+ +ea+uratan hasil +a(i. >i antara peserta yang diundang untu+ e(pat tahun dan delapan #%#. tahun tinda+ lan:ut studi, 7" persen dan 8" persen, #%&. (asing, (enyelesai+an studi. He(ung+inan rasio #%". untu+ hipertensi di follo !up yang dihitung #%%. dari dasar!line dan se(ua tinda+!up data yang (irip dengan #%6. (ere+a yang di+ecuali+an delapan tahun tinda+!up data, indi+ator!cating bah a fa+tor!fa+tor yang (e(pengaruhi partisipasi dala( #%7. delapan tahun tinda+ lan:ut studi tida+ (eni(bul+an bias #%8. asosiasi. 0i+a fa+tor!fa+tor yang sa(a (e(pengaruhi partisipasi tion dala( e(pat tahun tinda+ lan:ut studi, (a+a a+an #%9. tida+ (ung+in bah a bias penting ter+ait putus se+olah #60. (e(pengaruhi te(uan. #61. <ubungan antara tidur!gangguan napas!ing dan hipertensi dapat di+acau+an oleh variabel!variabel yang (enyebab+an bai+ pernapasan tidur!teratur dan #6#. hipertensi. Ha(i diu+ur dan di+endali+an untu+ es!tablished fa+tor pe(baur $usia, :enis +ela(in, dan habitus' #6&. serta variabel ta(bahan beberapa. >ala( contoh +ita,

#6". u+uran habitus, tetapi tida+ usia atau :enis +ela(in, yang +uat #6%. perancu variabel. 7ebelu(nya cross!sectional pe:antan!ies tidur!gangguan pernapasan dan hipertensi #66. telah (enyalah+an +arena tida+ (enyesuai+an untu+ (ero+o+ atau #67. penggunaan al+ohol. #68. 8 #69. Ha(i tida+ (ene(u+an bu+ti bah a fa+tor!fa+tor pe(baur yang penting. #70. ;engu+uran +esalahan dala( (enilai tidur!gangguan #71. pernapasan, te+anan darah, atau (ung+in +ovariat #7#. telah (engurangi a+urasi te(uan +a(i. 8ca+ #7&. +esalahan dala( (engu+ur tidur!gangguan pernapasan seperti!ly untu+ (enghasil+an bias terhadap tida+ adanya ciation 8sso!. #7". 18 #7%. Ha(i 1onte )arlo si(ulasi (enun:u++an bah a #76. +esalahan aca+ dala( te+anan darah pengu+uran (ung+in #77. :uga (enghasil+an bias terhadap hubungan ber+urang. 0i+a #78. +ea+uratan +lasifi+asi hipertensi #79. ter+ait dengan ting+at gangguan napas saat tidur atau #80. untu+ +ovariat penting seperti obesitas, +e(udian di ba ah!per+iraan atau overesti(ates asosiasi bisa ter:adi. #81. Hendali penuh dari pengganggu +arena, sebagai contoh, +esalahan pengu+uran dala( (enilai habitus (ung+in pro!>uce bias terhadap suatu (elebih!lebih+an asosiasi (en:adi!t een tidur!gangguan pernapasan dan hipertensi. #8#. 18 #8&. ?a+ta bah a studi +a(i adalah calon (e(in:a(+an du+ungan!port +e bu+ti peran +ausal tidur!disor!tanya bernapas dala( hipertensi. Ha(i (ene(u+an bah a #8". adanya gangguan napas saat tidur adalah predi+si!tive +ehadiran hipertensi e(pat tahun +e(udian. #8%. ,e(uan ini (ung+in (enun:u++an bah a tidur!gangguan napas!ing (e(percepat per+e(bangan te+anan darah lev!els biasa hadir di tengah!usia de asa di #86. 8(eri+a 7eri+at. .a(un, te(uan +a(i tida+ (ena ar+an #87. +o(prehensif a asan se:arah ala( dari #88. asosiasi. ,idur!gangguan pernapasan perubahan darah #89. te+anan acutely.19!## #90. ;aparan .octurnal untu+ tidur!gangguan pernapasan dapat (enyebab+an pening+atan dala( darah #91. ,e+anan yang berlangsung sepan:ang pagi atau hari en!ban. #9#. #& #9&. 7ebuah respon pressor siang hari yang outlasts #9". hipo+sia no+turnal e+speri(en diindu+si telah #9%. ditun:u++an dala( hu(ans.#" #96. 4a :uga telah hypoth!esi9ed bah a tidur!gangguan pernapasan dapat (enyebab+an #97. per(anen perubahan te+anan darah dengan renovasi #98. pe(buluh darah siste(i+. #99. #% &00. Ha(i tida+ (e(ili+i data yang dapat diguna+an untu+ (e(odel+an

&01. hubungan dina(is antara tidur!gangguan ing napas!, habitus, dan hipertensi. 7ebagai contoh, (es+ipun &0#. ada beberapa studi relevan, telah ada &0&. spe+ulasi bah a gangguan napas saat tidur (e(ili+i &0". +ausal peran dala( obesitas. &0%. #6 &06. 0i+a hal ini ter:adi, (a+a +a(i &07. 6paya untu+ (engendali+an terhadap fa+tor pe(baur ter(asu+ lang+ah!ures obesitas dala( (odel +a(i (ung+in telah (enyebab+an =verad:ust(ent par!esensial dari hubungan antara tidur! &08. gangguan pernapasan dan hipertensi dan dengan de(i+ian untu+ &09. (ere(eh+an asosiasi. &10. Ha(i tida+ (ene(u+an bu+ti dari a(bang inde+s ap!nea!<ypopnea di ba ah ini yang hipertensi &11. tida+ ber+aitan dengan tidur!gangguan pernapasan. Dah+an per!ana+ dengan (ini(al gangguan napas saat tidur $seperti de!didenda oleh inde+s apnea!<ypopnea dari 0,1!",9 peristi a &1#. per :a(' (e(ili+i +e(ung+inan lebih tinggi hipertensi dibanding+an &1&. tanpa episode tidur!gangguan pernapasan. 0i+a bah+an &1". (ere+a yang (ini( gangguan napas saat tidur berada di &1%. tinggi risi+o untu+ hipertensi, (a+a proporsi &16. +asus hipertensi yang dapat diatribusi+an ini fa+tor!tor (ung+in substansial. &17. 7ebelu(nya studi epide(iologi dari tidur!gangguan &18. pernapasan dan hipertensi yang berfo+us pada subye+ &19. dari populasi u(u( dan pasien dari tidur!gangguan +lini+ telah (encapai +esi(pulan yang bertentangan, &#0. (es+ipun ta+ ada satupun yang (enghalangi adanya &#1. (oderat association.9 &##. 7tudi yang (elibat+an cross!sectional sa(pel dari tidur!gangguan +lini+ &#&. #6!&" &#". (e(ili+i &#%. biasanya diguna+an ber+ualitas tinggi (etode untu+ (enilai gangguan napas saat tidur $(ultichannel polyso(nogra!phy'. .a(un, fa+tor yang tida+ di+etahui yang (e(pengaruhi re!ferral +e +lini+ tidur!gangguan ini (ung+in telah (e(buat &#6. 7tudi tida+ (a(pu secara a+urat (enilai hubungan. &#7. 7ebali+nya, sebagian besar cross!sectional berdasar+an populasi &#8. studi &#9. %,&%!"& &&0. telah (engguna+an sa(pel yang epide(io!logis yang lebih +etat tetapi diguna+an instru(en dengan &&1. (is+in atau tida+ di+etahui validitas untu+ (enilai tidur!gangguan &&#. pernapasan. >ua baru!baru ini berbasis populasi pena(pang!al analisis dari *isconsin 7leep )ohort 7tudy &&&. "" &&". dan 7leep <eart <ealth 7tudy,

&&%. "% &&6. yang diguna+an poli!so(nography untu+ (enilai tidur!gangguan pernapasan, +e(bali porting (oderat, asosiasi yang signifi+an secara statisti+ &&7. antara tidur!gangguan pernapasan dan hipertensi. &&8. >ala( sebuah penelitian prospe+tif baru!baru ini, <u dan re+an &&9. "6 &"0. dinilai se:u(lah besar anita nor(otensif dan &"1. (ene(u+an bah a (endeng+ur, $tapi nonspesifi+' Hardinal ge:ala!to( tidur! gangguan pernapasan, secara signifi+an di!ber+erut risi+o hipertensi. >ibanding+an dengan &"#. risi+o dala( nonsnorers, risi+o hipertensi &"&. (ening+at sebesar #9 persen pada pendeng+ur sese+ali dan dengan &"". %% persen pada (ere+a yang (endeng+ur teratur. &"%. 7ebagai bu+ti (e(bangun dari peran +ausal tidur!disor!tanya (enghirup hipertensi dan +esehatan lainnya +eluar!datang, ada +ebutuhan yang ber+e(bang untu+ (e(aha(i &"6. ala(i se:arah dan fa+tor risi+o untu+ tidur!disor!tanya pernapasan. Gan:utan pe(bangunan dan re!fine(ent pera atan (edis untu+ tidur!gangguan &"7. pernapasan :uga prioritas. ;era atan yang tersedia, seperti &"8. sebagai continuous positive air ay pressure, bisa efe+tif. .a(un, terapi ini (ung+in terlalu (e(bebani!sebagian untu+ pengobatan +asus!+asus ringan asy(pto(at!ic tidur! gangguan pernapasan. 7edi+it yang di+etahui tentang &"9. efe+tivitas intervensi fa+tor risi+o untu+ ringan sa(pai sedang tidur!gangguan pernapasan, dan ini adalah &%0. daerah penting untu+ penelitian (asa depan. &%1. >ala( analisis prospe+tif, +a(i (ene(u+an sebuah asosiasi