Resistant/Refractory Hypertension and Sleep Apnoea: Current Knowledge and Future Challenges

Hypertension is one of the most frequent cardiovascular risk factors. The population of hypertensive patients includes some phenotypes whose blood pressure levels are particularly difficult to control, thus putting them at greater cardiovascular risk. This is especially true of so-called resistant hypertension (RH) and refractory hypertension (RfH). Recent findings suggest that the former may be due to an alteration in the renin–angiotensin–aldosterone axis, while the latter seems to be more closely related to sympathetic hyper-activation. Both these pathophysiological mechanisms are also activated in patients with obstructive sleep apnoea (OSA). It is not surprising, therefore, that the prevalence of OSA in RH and RfH patients is very high (as reflected in several studies) and that treatment with continuous positive airway pressure (CPAP) manages to reduce blood pressure levels in a clinically significant way in both these groups of hypertensive patients. It is therefore necessary to incorporate into the multidimensional treatment of patients with RH and RfH (changes in lifestyle, control of obesity and drug treatment) a study of the possible existence of OSA, as this is a potentially treatable disease. There are many questions that remain to be answered, especially regarding the ideal combination of treatment in patients with RH/RfH and OSA (drugs, renal denervation, CPAP treatment) and patients’ varying response to CPAP treatment

Nursing students bringing first aid to the community

AimThis study aimed to evaluate the theoretical and practical skills acquired by nursing students and school students after the service-learning project.MethodsThis study promotes nursing students and school students working together to gain awareness and basic theoretical knowledge of first aid. The learning project was conducted with nursing students (n = 67) and school students (n = 131) from April to June 2022. The nursing students gave scores higher than 8 on the aspects linked to expectations, self-perception, overall assessment, and attainment of the goals, and these results are in line with the qualitative analysis.ResultsMoreover, 100% of the school students reported a satisfactory outcome about the service.ConclusionService-learning is a challenging and motivating methodology for nursing students, which results in greater engagement with theory and practice and the development of essential skills for future professionals

Prediabetes Is Associated with Increased Prevalence of Sleep-Disordered Breathing

Type 2 diabetes leads to severe nocturnal hypoxemia, with an increase in apnea events and daytime sleepiness. Hence, we assessed sleep breathing parameters in the prediabetes stage. A cross-sectional study conducted on 966 middle-aged subjects without known pulmonary disease (311 patients with prediabetes and 655 controls with normal glucose metabolism) was conducted. Prediabetes was defined by glycated hemoglobin (HbA1c), and a nonattended overnight home sleep study was performed. Participants with prediabetes (n = 311) displayed a higher apnea-hypopnea index (AHI: 12.7 (6.1;24.3) vs. 9.5 (4.2;19.6) events/h, p < 0.001) and hypopnea index (HI: 8.4 (4.0;14.9) vs. 6.0 (2.7;12.6) events/h, p < 0.001) than controls, without differences in the apnea index. Altogether, the prevalence of obstructive sleep apnea was higher in subjects with prediabetes than in controls (78.1 vs. 69.9%, p = 0.007). Additionally, subjects with prediabetes presented impaired measurements of the median and minimum nocturnal oxygen saturation, the percentage of time spent with oxygen saturations below 90%, and the 4% oxygen desaturation index in comparison with individuals without prediabetes (p < 0.001 for all). After adjusting for age, sex, and the presence of obesity, HbA1c correlated with the HI in the entire population (r = 0.141, p < 0.001), and the presence of prediabetes was independently associated with the AHI (B = 2.20 (0.10 to 4.31), p = 0.040) as well as the HI (B = 1.87 (0.61 to 3.14), p = 0.004) in the multiple linear regression model. We conclude that prediabetes is an independent risk factor for an increased AHI after adjusting for age, sex, and obesity. The enhanced AHI is mainly associated with increments in the hypopnea events

Estudio del efecto del síndrome de apneas-hiponeas del sueño y su tratamiento con CPAP en diferentes fenotipos de presión arterial

La síndrome d'apnees-hipopnees de la son (SAHS) s'ha associat a la presència d'hipertensió arterial (HTA), especialment amb la hipertensió resistent (HR). A més, s'ha descrit que el tractament del SAHS amb pressió positiva contínua en la via aèria (CPAP) aconsegueix reduccions en la pressió arterial (PA), però, hi ha una gran variabilitat en la resposta observada i no hi ha evidència a llarg termini. Per tant, els quatre estudis que composen la present tesi doctoral tenen com a objectiu contribuir al coneixement sobre la relació entre ambdues patologies, i establir l'efecte del tractament del SAHS sobre la PA en diferents fenotips de PA. En aquest sentit, es va desenvolupar i implementar un estudi prospectiu per avaluar l'impacte del SAHS i el seu tractament en el pronòstic cardiovascular en pacients amb HR. En el segon estudi, es va avaluar la prevalença de SAHS en subjectes amb HR, així com l'impacte d'aquesta patologia sobre el control de la PA, observant-se una prevalença de SAHS del 83.5%, i una associació dosi-resposta entre la gravetat del SAHS i els valors de la PA, especialment de la PA nocturna. En el tercer estudi, es va avaluar l'efecte de la CPAP en subjectes normotensos. Els resultats mostren que el patró circadià de la PA o la presència d'hipertensió emmascarada tenen un paper important en l'efecte de la CPAP sobre la PA, sent els pacients amb un patró circadià non-dipper i aquells amb hipertensió emmascarada els que més es beneficien del tractament amb CPAP, en termes de reducció de la PA. A més, en pacients normotensos amb patró circadià dipper, el tractament amb CPAP podria incrementar la PA nocturna, per tant aquests resultats mostren la necessitat de dur a terme un monitoratge de la PA prèviament a la prescripció de CPAP per tal de definir subgrups de resposta al tractament. Finalment, i de continuïtat amb aquest estudi, es va avaluar l'efecte del tractament amb CPAP en pacients amb HTA segons el patró circadià basal, i els resultats mostren de nou, que només els pacients amb tractament amb CPAP i un patró circadià non-dipper redueixen els valors de PA. En definitiva, els resultats exposats en la present tesi doctoral són de rellevància i interès en la pràctica clínica habitual donat que poden ajudar a millorar el maneig i indicació del tractament amb CPAP en pacients amb SAHS i contribuir a establir una indicació més individualitzada i cost-efectiva.El síndrome de apneas-hipopneas del sueño (SAHS) se ha asociado a la presencia de hipertensión arterial (HTA), especialmente con la hipertensión resistente (HR). Además, se ha descrito que el tratamiento del SAHS con presión positiva continua en la vía aérea (CPAP) consigue reducciones en la presión arterial (PA), pero existe una gran variabilidad en la respuesta observada y no hay evidencia a largo plazo. Por lo tanto, los cuatro estudios de esta tesis tienen cómo objetivo contribuir al conocimiento sobre la relación de ambas patologías, y establecer el efecto del tratamiento del SAHS sobre la PA en distintos fenotipos de PA. En este sentido, se desarrolló e implementó un estudio prospectivo para evaluar el impacto del SAHS y su tratamiento en el pronóstico cardiovascular en pacientes con HR. En el segundo estudio, se evaluó la prevalencia de SAHS en sujetos con HR, así cómo el impacto de esta patología sobre el control de la PA, observándose una prevalencia de SAHS del 83.5%, además de, una asociación dosis-respuesta entre la gravedad del SAHS y los valores de la PA, especialmente la PA nocturna. En el tercer estudio, se evaluó el efecto de la CPAP en sujetos normotensos. Los resultados muestran que el patrón circadiano de la PA o la presencia de hipertensión enmascarada tiene un papel importante en el efecto de la CPAP sobre la PA, siendo los sujetos con patrón circadiano non-dipper y aquellos con hipertensión enmascarada los que más se benefician del tratamiento con CPAP, en términos de reducción de la PA. Además, en pacientes normotensos con patrón circadiano dipper, el tratamiento con CPAP podría incrementar la PA nocturna, por lo que estos resultados muestran la necesidad de llevar a cabo una monitorización de la PA previamente a la prescripción de CPAP con el fin de definir subgrupos de respuesta al tratamiento. Finalmente, y de continuidad con este estudio, se evaluó el efecto del tratamiento con CPAP en pacientes con HTA según el patrón circadiano basal, y los resultados muestran de nuevo que sólo los pacientes en tratamiento con CPAP y con un patrón circadiano non-dipper reducen los valores de PA. En definitiva, los resultados expuestos en la presente tesis doctoral son de relevancia e interés en la práctica clínica habitual dado que pueden ayudar a mejorar el manejo e indicación del tratamiento con CPAP en pacientes con SAHS y contribuir a establecer una indicación más individualizada y coste-efectiva.Obstructive sleep apnea syndrome (OSAs) has been associated with arterial hypertension (HTN), especially with resistant hypertension (RH). In addition, it has been described that the treatment of OSAs with continuous positive airway pressure (CPAP) produces reductions in blood pressure (BP), nevertheless there is a great variability in the BP response and there is no evidence at long-term. Despite the relation between both pathologies, some aspects remain unclear due to the limited available evidence and the controversy in the published studies. Therefore, the four studies that shape this doctoral thesis aim to contribute to the knowledge about the relation between both pathologies, and to determine the effect of CPAP treatment on BP in different BP phenotypes. In this sense, a prospective study was carried out and implemented to evaluate the impact of OSAs and its treatment on cardiovascular prognosis in patients with RH. In the second study, we evaluate the prevalence of OSAs and its impact on BP in subjects with RH, and a prevalence of 83.5% was found. Moreover, we found a dose-response association between OSAs’ severity and BP values, especially with nocturnal BP. In the third study, the effect of CPAP on normotensive subjects was evaluated. The results show that the circadian BP pattern or the presence of masked hypertension could determine the effect of CPAP on BP. It was observed that patients with a non-dipper circadian pattern and those with masked hypertension benefited the most from CPAP treatment, in terms of BP reduction. Moreover, an increase in nocturnal BP with CPAP treatment was observed in normotensive subjects with a dipper circadian pattern. These results show the necessity to perform a BP monitoring prior to CPAP prescription in order to define subgroups of treatment response. Finally, we evaluated if there is a differential effect of CPAP treatment on BP in patients with HTN according to the baseline circadian BP pattern. The results of this study showed again that only patients with CPAP treatment and non-dipper circadian pattern reduce BP. In conclusion, the results presented in this doctoral thesis could be of relevance and interest in the clinical practice because they can help to improve the management and indication of CPAP treatment in patients with OSAs and contribute to establishing a more individualized and cost-effective indication of the CPAP treatment