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Sleep Disorders

Lack of Sleep/High Blood Pressure

06/21/2010

Question:

For a long time I get nights where I am unable to sleep until about 4 am for maybe three nights in a row. Then I sleep fairley well for four or five nights. This has gone on for quite a few years. I then was treated for a thyroid problem but that has not changed anything (under active). I have been treated for high blood pressure and don`t seem to respond. This has been going on for five years. I am now on 160mg of Diovan-Valsartan. Last night when I took my BP it was 200 over 107. Is this keeping me awake? I can hear my heart thumping loudly. Can you throw any light on this problem? I would indeed be most grateful.

Answer:

You describe two problems that are not necessary related, though could be: namely insomnia and hypertension. Let’s address the blood pressure issue first.

While your blood pressure appears difficult to control, it is not necessarily untreatable (or “refractory”). Refractory hypertension has specific definition including the need for multiple anti-hypertensive medications simultaneously. Insomnia has not been reported to be a as a cause of refractory hypertension or “difficult to control” hypertension. However, insomnia has been associated with medical and mood disorders, some of which may worsen blood pressure control. For instance, cardiac and kidney disorders may be associated with both insomnia and hypertension. Importantly, mood disorders such as anxiety disorder and depression can be associated with insomnia. Simultaneously, depression and anxiety disorders may be associated with autonomic imbalance and can affect blood pressure control.

You describe a sense of hearing your heart beating at night. This may be simply due to hearing heart beats being transmitted through the mattress and bedding. It can also be a manifestation of arrhythmia or a fast heart rate. In some cases, certain types of heart arrhythmias have been associated with insomnia. Additionally, some endocrine disorders characterized by increased production of norepinephrine (adrenaline), a hormone that is associated with stress response, can cause both hypertension and insomnia.

Another sleep disorder that has been associated with both of hypertension and insomnia is obstructive sleep apnea, a condition characterized by narrowing or closure of the airway during sleep. This condition may be associated with snoring as well. It is currently recommended that patients who have hypertension that is difficult to control undergo evaluation of sleep apnea.

It’s certainly possible that your episodic insomnia may not be at all related to your high blood pressure. Insomnia has multiple underlying causes. Identifying the underlying factors that are contributing to insomnia is extremely important to ensure appropriate treatment. Factors affecting one’s ability to fall asleep at the start of the night, as you describe, are quite varied and may include one or more of the following; a poor sleep environment (i.e. the bedroom is too noisy, too bright or too warm), learned poor sleep habits (i.e. watching TV to fall asleep), excessive use of stimulants (both medications and common substances such as caffeine and nicotine), certain medications, stress or anxiety, pain, medical conditions that may make it uncomfortable or difficult to breath well when lying down, heartburn, restless legs syndrome (an irresistible need to move the legs when awake at night) and circadian rhythm disturbances (when the body’s biologic rhythms are out of synchrony or delayed). Occasionally some individuals will not have any of these underlying causes contributing to their insomnia and their condition is often labeled as “idiopathic insomnia” or insomnia for which a cause can not be found.

I recommend that you see a sleep physician to help sort out your problems. The evaluation for sleep apnea is part of the standard of care for evaluation of this type of hypertension. The sleep physician can also help with the management of your insomnia.

More importantly, your blood pressure should be brought under better control soon. A primary care physician, or a physician specialized in hypertension will be able to initiate some evaluation for the blood pressure. In some cases, evaluation of kidney function and perfusion, along with screening for some endocrine disorders is in order. You may then need to be on a combination of blood pressure medications. Do not give up on your blood pressure control, it is very serious!

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Response by:

Rami N Khayat, MD Rami N Khayat, MD
Clinical Assistant Professor of Pulmonary, Allergy, Critical Care & Sleep
College of Medicine
The Ohio State University