Excessive daytime sleepiness, but not sleep apnea, sleep duration or insomnia, was associated with poor adherence to anti-hypertensive treatment: The ELSA-Brasil study

Sleep Med. 2023 Apr:104:113-120. doi: 10.1016/j.sleep.2023.02.025. Epub 2023 Mar 7.


Hypertension is the leading risk factor for cardiovascular mortality. Poor adherence may partially explain this scenario. Beyond traditional factors, it is conceivable that sleep conditions such as Obstructive Sleep Apnea (OSA), Sleep Duration (SDUR), sleepiness and insomnia may contribute to impair adherence but the evidence is scanty. Consecutive participants with hypertension from the ELSA-Brasil study performed a home sleep monitoring and 7-days actigraphy to determine OSA (apnea-hypopnea index ≥15 events/hour) and SDUR, respectively. Excessive daytime sleepiness (EDS) and insomnia were evaluated by Epworth Sleepiness Scale (ESS) and Clinical Interview Scheduled Revised (CIS-R), respectively. The 4-itens Morisky questionnaire was used to evaluate adherence to anti-hypertensive therapy. A total of 411 patients were including in the analysis (mean age: 54 ± 8 years, 47% men). Medium/low adherence to anti-hypertensive therapy was observed in 62%. Compared to the high adherence group, the participants with medium/low adherence had lower frequencies of Whites (64.1 vs. 47.8%), high-degree education (50.6 vs. 40%), and monthly per-capita income ($1021.90 vs. $805.20). In contrast, we observed higher frequency of EDS (35.9 vs. 46.1%). No differences were observed for OSA, short SDUR (<6 h) and insomnia. Logistic regression analysis showed that race other than White (OR: 1.80; 95% IC:1.15-2.82), lower monthly income (OR: 1.74; 95% IC:1.01-3.0) and EDS (OR: 1.63; 95% IC:1.05-2.53) were independently associated with medium/low adherence to the anti-hypertensive treatment. Interestingly, EDS mediated the abdominal obesity-adherence outcome. In conclusion, among sleep-related parameters, EDS, but not OSA, short SDUR or insomnia, were associated to impaired adherence to anti-hypertensive therapy.

Keywords: Hypertension; Medication adherence; Sleep apnea; Sleep duration.

MeSH terms

  • Antihypertensive Agents / therapeutic use
  • Disorders of Excessive Somnolence* / drug therapy
  • Female
  • Humans
  • Hypertension* / drug therapy
  • Male
  • Middle Aged
  • Sleep Apnea Syndromes*
  • Sleep Apnea, Obstructive* / drug therapy
  • Sleep Duration
  • Sleep Initiation and Maintenance Disorders* / drug therapy
  • Sleep Wake Disorders*
  • Sleepiness


  • Antihypertensive Agents