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Revista da Escola de Enfermagem da USP

Print version ISSN 0080-6234On-line version ISSN 1980-220X

Rev. esc. enferm. USP vol.50 no.2 São Paulo Mar./Apr. 2016 


Poor sleep quality in patients with resistant hypertension: is there an association?

Má qualidade do sono em pacientes com hipertensão resistente: existe uma associação?

Baja calidad de sueño en pacientes con hipertensión arterial resistente ¿existe asociación?

Eddy López-Huamanrayme1 

Noé Atamari-Anahui1 

César Johan Pereira-Victorio2 

1Universidad Nacional San Antonio Abad del Cusco. Facultad de Medicina, Cusco, Perú.

2Pan American Health Organization, Special Program of Sustainable Development and Health Equity, Washington, DC, USA.

Dear Editor,

We read with great interest the article published in your journal by Hanus et al.1, about sleep characteristics in hypertensive patients. Thus, we offer the following discussion for your consideration.

The survey results shows that about 50% (133/280) of patients received four or more antihypertensive drugs; therefore, these patients would be considered resistant hypertensive2. The study did not show blood pressure (BP) levels in the patients studied and it is not possible to know which of them were adequately controlling their hypertension. Furthermore, the study did not mentioned if the hypertensive individuals were randomized chosen1.

Resistant hypertension is a serious condition associated with increased cardiovascular risk and poor prognosis3. It is defined as the failure to control blood pressure with three or more antihypertensive drugs, including a diuretic, or using four drugs to control BP2-4.

In recent years, many studies have found a relationship between poor sleep quality and/or short sleep duration with high incidence and prevalence of hypertension. Pathophysiological mechanisms include the over activation of the autonomic nervous system and renin-angiotensin-aldosterone system, increased pro-inflammatory molecules and higher endothelial dysfunction3-4.

In a cohort of patients it was possible to establish an association between poor sleep quality and resistant hypertension, with predominance in females3. Moreover, Friedman et al.4 found an association between resistant hypertension and sleep disorders (short duration and low efficiency); the studies show a clear relationship between the quality of sleep and the risk of developing resistant hypertension. We think it is important to mention the quality of sleep in relation to the number of antihypertensive drugs, especially in those patients who taken four or more drugs, noted as an important group in the study of Hanus et al., and to consider wheter patients who did not use medication to sleep, probably had better quality of sleep compared to patients who used medication1. These aforementioned differences could be explained.

Finally, considering that the treatment of resistant hypertension is also based on lifestyle modification2, it is important to investigate sleep disorders in these patients, especially in primary care. This approach has proven to have a positive effect on patients and it improves adherence to medical treatment, making the prognosis most favorable. It has even been suggested that "sleep" be considered as a vital sign in a medical consultation5.


1 Hanus JS, Amboni G, Inês da Rosa M, Ceretta LB, Tuon L. The quality and characteristics of sleep of hypertensive patients. Rev Esc Enferm USP [Internet]. 2015 [cited 2015 Oct 20];49(4):596-602. Available from: Available from: ]

2 Ghofrani H, Weaver FA, Nadim MK. Resistant Hypertension: Medical management and alternative therapies. Cardiol Clin. 2015;33(1):75-87. [ Links ]

3 Bruno RM, Palagini L, Gemignani A, Virdis A, Di Giulio A, Ghiadoni L, et al. Poor sleep quality and resistant hypertension. Sleep Med. 2013;14(11):1157-63. [ Links ]

4 Friedman O, Bradley TD, Ruttanaumpawan P, Logan AG. Independent association of drug-resistant hypertension to reduced sleep duration and efficiency. Am J Hypertens. 2010;23(2):174-9. [ Links ]

5 Grandner MA, Malhotra A. Sleep as a vital sign: why medical practitioners need to routinely ask their patients about sleep. Sleep Health. 2015;1(1):11-2. [ Links ]

Correspondence autor: Eddy López Huamanrayme. Universidad Nacional San Antonio Abad del Cusco. Av. La Cultura 733 - Cusco, Perú.

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