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Original Article
Cardiovascular
8 (
3
); 187-192
doi:
10.25259/IJCDW_18_2023

Ambulatory Blood Pressure Monitoring and Sleep Quality in Hypertensive Men and Women

Department of Biotechnology, Era University, Lucknow, India
Corresponding author: Ghizal Fatima, Department of Biotechnology, Era University, Lucknow, India. ghizalfatima8@gmail.com
Licence
This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, transform, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.

How to cite this article: Fatima G. Ambulatory Blood Pressure Monitoring and Sleep Quality in Hypertensive Men and Women. Indian J Cardiovasc Dis Women 2023;8:187-92.

Abstract

Objectives:

This study aims to provide major insight in 24-h ambulatory blood pressure monitoring (ABPM), which will describe the 24 h (Circadian rhythm) blood pressure (BP) profile by measuring its impact on the sleep quality.

Materials and Methods:

For the study, 25 men and 25 women were recruited. Sleep quality was assessed by the Pittsburgh Sleep Index. Using wrist actigraphy, sleep-quality was assessed during seven working non-ABPM days (starting point) and the three following 24-h ABPM days.

Results:

During the day, the average AMP was 139.2 10.9/83.4 8.6 mm Hg, while at night, it was 118.9 12.9/68.5 9.7 mm Hg. There were 40 dipper and 10 non-dipper, respectively, on the standard of a systolic BP dip of <10%. Time had no bearing on total sleep time or sleep efficiency between ABPM days and non-ABPM days, indicating that ABPM has no negative effects on sleep quality.

Conclusion:

Both male and female having untreated hypertension were found to have disrupted sleep quality. Importantly, it is now evident that the ABPM has a negative impact on sleep quality for either dippers or non-dippers.

Keywords

Ambulatory blood pressure monitoring
Hypertension
Dipper
Non-dipper
Actigraphy

ABSTRACT IMAGE

INTRODUCTION

Studies on ambulatory blood pressure monitoring (ABPM) had shown the occurrence of distinct circadian rhythm, in which there is a drop in blood pressure (BP) while sleeping overnight. Healthy diurnal BP takes a BP drop of 10% or more during hours of darkness (night). Contrarily, non-dipping diurnal profile of BP, which is commonly defined as reduction in 10% normal BP from the day to night, clearly predicts of higher chance of cardiovascular diseases (CVDs) and death in both hypertensive and non-hypertensive subjects.[1-6] A current meta-analysis showed that the dippers in BP had more positive subjective quality of sleep than non-dippers.[7]

Disturbed sleep quality is directly related to a non-dipping, BP circadian profile, according to objective criteria of sleep quality obtained from actigraphy and polysomnography.[8-12] Concern has been raised about the possibility that cuff levels of inflation during the BP monitoring evaluation stage may interfere with the sleep structure and the monitoring of the BP profile. A sleep laboratory investigation with six healthy individuals revealed that ABPM measures may rouse up an individual from sleep and cause significant, brief rises in recorded BP.[13]

Ten hospitalized patients having 24-h intra-arterial BP recorded, it was found that non-invasive ambulatory BP (ABP) measurements each minute while awake and each thirty min during in the night had no effect on circadian BP profiles.[14] In a second, smaller trial with 44 healthy men, it was shown that ABPM only mild changed circadian BP profiles without significantly altering sleep patterns.[15] However, it has been suggested that because hypertensive individuals require increased peak cuff inflation pressures, the confounding variables effect of cuffs inflation on sleep and night-time BP that might be more severe in hypertensive patients.[16] The previous studies have connected hypertension to poor sleep quality and insomnia.[17] By changing normal sleep cycles, ABPM may have an unclear impact on how much BP drops throughout the nocturnal sleep period.[18,19]

Non-dippers have worse sleep quality than dippers as a result of ABPM. In another study, 823 women and men with the mild-to-severe hypertension had their disruptive effects of ABPM reduced moderately.[20] Degaute et al. conducted the laboratory test of sleep on 44 males and recording of non-invasive BP measures in each 10 min disrupted their sleep.[15] Study done in a sleep laboratory by Van de Borne et al. determined that ABPM was correlated with a slight decrease in fifteen men.[21] A study conducted by Davies et al. made similar observations in six healthy adults who were also investigated in a same condition in sleep laboratory.[13]

Another study showed that BP monitoring in patients with suspected obstructive sleep apnea could promote awakening, and an increase in BP, in a setting of sleep laboratory condition, which they believed could influence dipper and non-dipper classification.[22] Other studies, however, dispute these conclusions. Parati et al.[14] concluded that ABPM had no influence on overnight BP in hospitalized patients. Tropeano et al.[23] examined 70 male and female who had ABPM for the purpose of determining their BP by assessing the caliber of their sleep on the days that followed and after the ABPM assessment. Wrist actigraphy measure the quality of sleep and ABPM had no effect on it. It is challenging to explain these contradictory findings from different investigations. By examining its impacts on sleep quality, the present study will clarify the potential confounding effects of 24-h ABPM, which describe the circadian profile of BP.

MATERIALS AND METHODS

Participants

Patients in age group of 30–50 years were included, 25 men and 25 women. Patients were included based on the 2017 American College of Cardiology Criteria for high BP in the adults. This covers the Stage 1 and 2 of hypertension. The body mass index (BMI) is >35 kg/m2, pacemaker, atrialfibrillation, obstructive sleep-apnea, myocardial-infarction, surgery within 6 months after enrolment, heart failure, and diabetes mellitus were exclusion criteria. Before taking part in the trial, everyone was eligible gave their written and informed consent to participate in the study.

BP screening

Four seated BP readings were collected using a mercury sphygmomanometer and stethoscope. Each reading was taken 2 min apart. The last three measurements were used to calculate systolic BP (SBP) and diastolic BP, and eligibility of each participant was determined by the average office BP reading fulfilled the requirements of inclusion for the research. Age, sex, height (kg), and weight (m) were recorded; BMI was computed as kg)/m.

ABPM

Every participant had their ABP measured every 24-h from Monday through Friday throughout three different terms. Utilizing the previously approved ABP monitor from IEM GmbH Stolberg in Germany.[18,19] Every 30 min throughout the daytime and every 30 min while the subject was sleeping at night, the monitor was set to record the patient BP.

Subjective sleep quality

The subjective quality of sleep was evaluated using the Pittsburgh sleep quality index (PSQI). 19 item questionnaire that is self-rated, called the PSQI, used to assess subjective quality of sleep over the period of a month. A subjective score of sleep quality is provided by the PSQI, reading from 0 to 21, with higher numbers denoting lower quality of sleep. The PSQI was completed by all participants.[20]

Measurement of sleep quality: ABPM and Non-ABPM days using actigraphy

The objective estimations of sleep parameters were determined using Mini-Mitter actigraphs (MiniMitter, Sunriver). Actigraphy offers the exact estimates of sleep parameters that are comparable to those from polysomnography, according to past studies. Actigraphy-measured sleep quality associated to night dipping. Actiwatch has memory storage device which calibrated the accelerometer inside of a case that is shaped and sized like a wristwatch. The time from when study participants decided to go to bed and turned out the lights until the next morning was considered the sleep period, according to their own self-reports in the actigraphy logs kept on each assessment day. Actigraphy log timings were verified using data from the actigraph, and sleep efficiency (SE, time of asleep in the percentage) and total sleep-duration were calculated total sleep time (TST, total hours asleep in the percentage). Disrupted quality of sleep was determined by a SE of 85%.

Statistical analysis

SBP and diastolic BP means for each participant at waking and during sleep were calculated using the subject self-reported sleeping and waking patterns. To create a reliable assessment of each participant’s waking and overnight ABP, values from the three sessions were averaged. By dividing the mean SBP during waking hours by the mean SBP during the night, the dipping rhythm was evaluated. The mean dip value was subtracted from the mean wake value, and the result was multiplied by 100 to get the dip percent. Initial 24-h ABPM assessment, 24 h actigraphy information was collected on seven consecutive non-ABPM days as well as on each of the 3 ABPM days. For every 7 non-ABPM days, parameters of sleep including SE and TST were estimated. In all 3-days that ABP monitoring happened, the same sleep quality measures were calculated independently. They were then calculated to provide total mean for SE and TST throughout total 3 of ABPM days. The demographic data, BP, and assessments of quality of sleep were expressed in mean ± SD. Relative sleep quality change across time and the association in demographic and anthropomorphic characteristics and PSQI scores were assessed using repeat measurement of analyses of covariance, in the control for BMI, age, and PSQI. Significance was set at P = 0.05, the SAS system (SAS 9.2, Cary, NC) was used to assess all statistical analyses.

RESULTS

Table 1 shows the studied sample based on dippers versus non-dippers. The 50 participants were 25 men and 25 women, mean age of 40.8 ± 7.9 years and a screening BP of 139 ± 7/90 ± 5 mmHg. Study cohort’s average ABP: 139.2 ± 10.9/83.4 ± 8.6 mm Hg in the day time: 118.9± 12.9/68.5± 9.7 mm Hg in the night time. 10 were non-dippers (SBP dip = 7.6 ± 2.7%) and 40 were the dippers (SBP dip = 15.8 ± 3.8%).

Table 1: Dipper status.
All (n=50) Nondipper (n=10) Dipper (n=40) P
Age 40.8±7.9 42.5±7.2 43.6±8.9 0.779
BMI 28.2±3.6 28.0±3.1 27.3±3.3 0.044
CSBP in mmHg 139.2±6.0 140.1±7.5 138.8±7.4 0.390
CDBP in mmHg 86.4±5.7 90.2±5.4 84.9±6.2 <0.001
Awake SBP in mm Hg 139.2±10.9 137.4±10.6 137.8±10.9 0.299
Awake DBP in mm Hg 83.4±8.6 84.6±8.8 82.8±8.9 0.186
Sleep SBP in mm Hg 118.9±12.9 127.9±10.9 117.8±10.4 <0.001
Sleep DBP in mm Hg 68.5±9.7 74.8±9.3 67.6±8.9 <0.001
PSQI 6.9±3.7 7.1±3.9 5.6±3.4 0.111

BMI: Body mass index, CDBP: Clinic diastolic blood pressure, CSBP: Clinic systolic blood pressure, SBP: Systolic blood pressure, DBP: Diastolic blood pressure, PSQI: Pittsburgh sleep quality index

Quality of sleep measures during the 24-h ABPM days

Efficiency of sleep

No significant effects for BMI or age in our investigation for the relationships between subject variables and SE. However, the significant effects for sleep quality and dipper status were significant (P ≤ 0.0001) and (P = 0.033). In [Table 2]: The means and standard deviations for SE by sex, dipper status, and sleep quality of subjective. SE was decreased in those who had poor (PSQI score ≥5) in participants with the right quality of sleep in subjective (PSQI ≥5). It is also significant to note that neither non-ABPM nor ABPM days showed any overall impacts of time on SE, indicating that ABPM had no negative effects on SE.

Table 2: Efficiency of sleep and sleep-time in total (mean±SD) in dipper and measure of PSQI for non-ABPM and 24-h ABPM days.
Sleep efficiency in percentage (%)
n In-Baseline ABPM (1) ABPM (2) ABPM (3)
Dippers 40 79±9** 80±8* 82±10* 83±9*
Non-dipper 10 74±10 76±15 79±12 75±14
Male 25 78±9 80±10 81±11 80±10
Female 25 79±8 79±11 80±10 81±10
PSQI<5 20 82±10** 83±8** 84±10 84±11
PSQI≥5 30 77±8 76±12 78±11 79±11
Sleep time (total in hours)
n In-Baseline ABPM (1) ABPM (2) ABPM (3)
Dippers 40 5.9±1.3** 6.1±1.2** 6.2±1.1 6.1±1.1
Non-dippers 10 4.8±1.3 5.5±1.3 5.5±1.1 5.6±1.4
Male 25 5.5±1.1 5.9±1.2 5.9±1.2 5.8±1.2
Females 25 5.7±1.2 6.2±1.3 6.0±1.1 6.2±1.2
PSQI<5 20 5.9±1.4* 6.1±1.3 6.2±1.2 6.1±1.3
PSQI≥5 30 5.2±1.1 5.5±1.3 5.6±1.2 5.7±1.4

P≤0.001, P≤0.05 is significant. PSQI: Pittsburgh sleep quality index, APBM: Ambulatory blood pressure monitoring. **very significant, *significant

DISCUSSION

We did not find any evidence in our study that ABPM have any negative effects on quality of sleep. However, both men and women with untreated hypertension in this study were often indicated by disturbed sleep quality. This data depicts that poor sleep quality as determined by actigraphy is a characteristic that varies from person to person. Nocturnal dipping in BP is a valid physiological aspect of few individuals suffering from hypertension. Our findings provide additional evidence that a non-dipping BP profile and poor sleep quality are related.

Study findings of our work are consistent with the many earlier studies that reported a disturbed circadian variations in BP and the non-dipping of night-time BP profile was amalgamated with disrupted sleep quality.[11,24] Our study findings for quality of sleep, measured by actigraphy in male and female with the untreated hypertension, indicated that SE and TST in assessing ABPM were not different from quality of sleep that is defined by the identical recorded parameters over 1-week time without taking into account the ABPM assessments. Our study, which included both male and female with untreated hypertension, found that sleep quality was poor on ABPM and non-ABPM days, whether measured subjectively or objectively. Many studies have reported that high BP is associated to poor quality of sleep, which has previously been documented.[17] Our results additionally demonstrate that ABPM has a potential confounder’s effect on BP drops during the late night sleep by disturbing normal sleep patterns.[19,25] This study reported that disturbed quality of sleep, noted in non-dippers when compared to the dippers had no effect on the ABPM assessment. There was also no proof that any of those characteristics (such as age, sex, or sleep patterns) recognized a vulnerability to sleep disturbance that is correlated with ABPM.

On an average, study participants slept soundly on ABPM days just as they slept on non-ABPM days. Furthermore, repeating the ABPM on 3 different days, each on a week apart time, did not lead to acclimatization to monitoring or an improvement in sleep quality. This conclusion is consistent with the evidence that in women and men, with moderate-to-severe hypertension, the condition deteriorates of ABPM, were found to be slightly decreased during the second 24-h phase of a 48-h ABPM.[26]

Wrist actigraphy use in place of the polysomnography that is gold standard, to give an objective approach in the assessment of sleep quality is a limitation of our study. Wrist actigraphy, however, is a recognized indicator of quality of sleep, is not very expensive and also is time-consuming in comparison to polysomnography, is a suggested objective indicator of sleep design, and is also not a core component used in research study.[27] However, we found no confirmation that ABPM cause any adverse effect on quality of sleep, although, little effects may have gone missed due to the small study sample size.

According to Verdecchia et al.[28] who also observed no impact of ABPM on sleep quality, reduced BP dropping during night time was amalgamated with a higher risk of CVDs during a 7-year follow-up study. This study was in concordance to our study finding reports. Another limitation of the study was the timing of the 24-h ABPM sessions, which were separated by a 7 days rather than in continuation of 72-h period. The advantage of this study is, the sleep quality assessments among ABPM and non-ABPM days, that were done in the subjects’ own homes.

CONCLUSION

During the day, the average ABP was 139.2 ± 10.9/83.4 ± 8.6 mm Hg, while at night, it was 118.9 ± 12.9/68.5 ± 9.7 mm Hg. There were 40 dippers and 10 non-dippers, respectively, according to the standard of SBP dip of <10%. Time had no bearing on TST or SE in the ABPM days and also the nonABPM days, indicating, ABPM has no negative effects on sleep quality.

No evidence has reported that ABPM have negative effects on quality of sleep. However, both the genders with untreated hypertension in this study were often characterized by poor sleep. This data shows that poor sleep quality as determined by actigraphy is a characteristic that varies from person to person irrespective of confusing consequence of the assessment of ABPM. Furthermore, the findings of our study state that the night time decline in BP (non-dipping) is a valid physiological aspect of few individuals suffering from hypertension. Our findings provide additional evidence that a non-dipping BP profile and poor sleep quality are related. Correlation in perturbed sleep quality and non-dipping BP, along with a sufficient sample size, is required to evaluate the cause, and the effect, and that interventions may enhance sleep-quality which stimulate the recurring theme of nighttime dip of BP which may potentially reduce CVD’s risk.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent.

Conflicts of interest

There are no conflicts of interest.

Audio summary available at

https://doi.org/10.25259/IJCDW_18_2023

Financial support and sponsorship

Nil.

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