Sleep

Obstructive sleep apnea comorbid with insomnia symptoms and objective short sleep duration is associated with incident hypertension.

Athanasiou N, Pejovic S, et al. • Journal of clinical sleep medicine : JCSM : official publication of the American Academy of Sleep Medicine • 2026

PubMed 41677976 DOI 10.1007/s44470-025-00027-x

TL;DR

The highest risk of incident hypertension was in the COMISA with insomnia short sleep duration phenotype (OR=4.25), and the additive effect of COMISA on hypertension risk is associated with the ISSD phenotype, the most severe biological phenotype of insomnia.

Key Findings

Results

COMISA with insomnia short sleep duration (ISSD) phenotype was associated with the highest risk of incident hypertension compared to good sleepers.

OR = 4.25, 95% CI = 1.52–11.90 compared to good sleepers
This was the highest odds ratio among all sleep disorder groups examined
ISSD was defined as objective sleep duration < 6 hours measured by in-laboratory polysomnography
COMISA was defined as the co-occurrence of insomnia symptoms and OSA (AHI ≥ 5 events/h)

Results

OSA alone was associated with a significantly increased risk of incident hypertension.

OR = 3.31, 95% CI = 1.85–5.92 compared to good sleepers
OSA was defined as an obstructive apnea/hypopnea index ≥ 5 events/h measured by 8-hour in-laboratory polysomnography
This was the second highest risk group after COMISA with ISSD

Results

Insomnia with short sleep duration (ISSD) alone was associated with a significantly increased risk of incident hypertension.

OR = 2.27, 95% CI = 1.29–4.00 compared to good sleepers
ISSD was defined as insomnia symptoms combined with objective sleep duration < 6 hours
This represented the third highest risk group overall

Results

Insomnia with normal sleep duration, either alone or combined with OSA (COMISA without ISSD), was not significantly associated with incident hypertension.

Neither the insomnia-normal sleep duration phenotype alone nor combined with OSA reached statistical significance for incident hypertension
This finding indicates that the biological severity marker of short objective sleep duration drives the elevated hypertension risk in COMISA
Normal sleep duration was defined as ≥ 6 hours of objective sleep

Methods

The study followed participants from the Penn State Adult Cohort over approximately 7.5 years to assess incident hypertension.

1741 total participants in the Penn State Adult Cohort; 1395 were followed up after 7.5 years
786 participants did not have hypertension at baseline and formed the analytic sample for incident hypertension
Mean age was 47.5 ± 12.7 years and 51.3% were women
Hypertension was determined by self-report of receiving treatment for high blood pressure
All subjects underwent 8-hour in-laboratory polysomnography at baseline

Discussion

This was identified as the first longitudinal study based on a large random general population sample showing that increased hypertension risk in COMISA patients is driven by the ISSD phenotype.

The study used a random general population sample rather than a clinical sample
Insomnia symptoms were defined as chronic insomnia lasting ≥ 1 year or complaints of difficulty falling asleep, staying asleep, nonrestorative sleep, or early morning awakening
The authors emphasize this supports obtaining objective sleep duration in addition to AHI and oxygen saturation indices for more accurate COMISA diagnosis

What This Means

This research suggests that people who have both obstructive sleep apnea (OSA) and insomnia—a condition called COMISA—face a particularly high risk of developing high blood pressure (hypertension), but only when their insomnia is accompanied by objectively short sleep (less than 6 hours measured in a sleep lab). The study followed nearly 800 adults from the general population who did not have hypertension at the start, tracking them over about 7.5 years. People with COMISA and short sleep duration had over four times the odds of developing hypertension compared to good sleepers, a higher risk than those with sleep apnea alone (about 3.3 times the odds) or insomnia with short sleep alone (about 2.3 times the odds). Notably, people with insomnia who slept a normal amount of time—whether or not they also had sleep apnea—did not have a statistically significant increase in hypertension risk. This research suggests that not all insomnia is the same when it comes to cardiovascular health. The type of insomnia that is biologically 'severe'—meaning the person actually sleeps less than 6 hours when measured objectively—appears to be the key driver of increased heart and blood pressure risks in people who also have sleep apnea. Simply reporting insomnia symptoms without also measuring how much a person actually sleeps may miss important health risk information. The practical implication of these findings is that objective measurement of sleep duration—through tools like polysomnography (a sleep study) or actigraphy—may be valuable in assessing and treating people with combined sleep apnea and insomnia. This could help clinicians better identify who is at the greatest risk for developing hypertension and potentially tailor treatments more precisely, which aligns with goals of personalized medicine.

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Citation

Athanasiou N, Pejovic S, Vgontzas A, Fernandez-Mendoza J, Li Y, Karataraki M, et al.. (2026). Obstructive sleep apnea comorbid with insomnia symptoms and objective short sleep duration is associated with incident hypertension.. Journal of clinical sleep medicine : JCSM : official publication of the American Academy of Sleep Medicine. https://doi.org/10.1007/s44470-025-00027-x

Key Findings

What This Means

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