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Original Investigation
June 23, 2021

Association of Pediatric Obstructive Sleep Apnea With Elevated Blood Pressure and Orthostatic Hypertension in Adolescence

Author Affiliations
  • 1Sleep Research and Treatment Center, Department of Psychiatry and Behavioral Health, College of Medicine, Penn State University, Hershey, Pennsylvania
  • 2Department of Public Health Sciences, College of Medicine, Penn State University, Hershey, Pennsylvania
JAMA Cardiol. Published online June 23, 2021. doi:10.1001/jamacardio.2021.2003
Key Points

Question  Is childhood sleep apnea associated with elevated blood pressure in adolescence?

Findings  In this population-based cohort study of 421 children, persistent sleep apnea was associated with nearly 3-fold increased odds of elevated blood pressure in adolescence. The severity of adolescent sleep apnea was associated with elevated blood pressure and orthostatic hypertension in a dose-response manner.

Meaning  The results of this study suggest that sleep apnea is a risk factor for hypertension in youth and that early sleep apnea interventions may help prevent long-term cardiovascular consequences.


Importance  Although pediatric guidelines have delineated updated thresholds for elevated blood pressure (eBP) in youth and adult guidelines have recognized obstructive sleep apnea (OSA) as an established risk factor for eBP, the relative association of pediatric OSA with adolescent eBP remains unexplored.

Objective  To assess the association of pediatric OSA with eBP and its orthostatic reactivity in adolescence.

Design, Setting, and Participants  At baseline of this population-based cohort study (Penn State Child Cohort) in 2000-2005, a random sample of 700 children aged 5 to 12 years from the general population was studied. A total of 421 participants (60.1%) were followed up in 2010-2013 after 7.4 years as adolescents (ages, 12-23 years). Data analyses were conducted from July 6 to October 29, 2020.

Main Outcomes and Measures  Outcomes were the apnea-hypopnea index (AHI) score, ascertained via polysomnography conducted in a laboratory; eBP measured in the seated position identified using guideline-recommended pediatric criteria; orthostatic hyperreactivity identified with BP assessed in the supine and standing positions; and visceral adipose tissue assessed via dual-energy x-ray absorptiometry.

Results  Among the 421 participants (mean [SD] age at follow-up, 16.5 [2.3] years), 227 (53.9%) were male and 92 (21.9%) were racial/ethnic minorities. A persistent AHI of 2 or more since childhood was longitudinally associated with adolescent eBP (odds ratio [OR], 2.9; 95% CI 1.1-7.5), while a remitted AHI of 2 or more was not (OR, 0.9; 95% CI 0.3-2.6). Adolescent OSA was associated with eBP in a dose-response manner; however, the association of an AHI of 2 to less than 5 among adolescents was nonsignificant (OR, 1.5; 95% CI, 0.9-2.6) and that of an AHI of 5 or more was approximately 2-fold (OR, 2.3; 95% CI, 1.1-4.9) after adjusting for visceral adipose tissue. An AHI of 5 or more (OR, 3.1; 95% CI, 1.2-8.5), but not between 2 and less than 5 (OR, 1.3; 95% CI, 0.6-3.0), was associated with orthostatic hyperreactivity among adolescents even after adjusting for visceral adipose tissue. Childhood OSA was not associated with adolescent eBP in female participants, while the risk of OSA and eBP was greater in male participants.

Conclusions and Relevance  The results of this cohort study suggest that childhood OSA is associated with adolescent hypertension only if it persists during this developmental period. Visceral adiposity explains a large extent of, but not all, the risk of hypertension associated with adolescent OSA, which is greater in male individuals.

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