Obstructive sleep apnea (OSA)-related hypertension is a complex clinical syndrome involving multisystem damage throughout the body. It is characterized by repeated upper airway obstruction during sleep, leading to apnea, hypopnea, and/or respiratory effort-related microarousals. These events result in chronic intermittent hypoxia, carbon dioxide retention, sympathetic nervous system activation, sleep fragmentation, which in turn contribute to chronic hypoxia and elevated blood pressure. The typical manifestations are refractory hypertension, nocturnal hypertension, and elevated morning blood pressure, presenting a non-dipper or reverse-dipper blood pressure rhythm. OSA-related hypertension can be classified into hypoxic burden type, high-arousal type, high-loop-gain type, upper airway collapse type, high-aldosterone type, mixed type, and other types. Currently, clinical management and treatment goal setting of OSA-related hypertension overly rely on the apnea-hypopnea index (AHI). In clinical practice, there are issues including insufficient consideration of patient heterogeneity and pathophysiological classification, inadequate consideration of comorbidities and confounding factors, poor adherence to continuous positive airway pressure (CPAP), and insufficient effective therapeutic dosage, all of which pose new challenges to disease diagnosis, treatment, and patient management. In addition, OSA-related hypertension often coexists with obesity, tumors, primary aldosteronism, metabolic syndrome, insulin resistance, chronic kidney disease, and other conditions, particularly in elderly patients. Therefore, based on precise heterogeneity and pathophysiological classification, a multidimensional assessment and treatment strategy for OSA-related hypertension centered on AHI and hypoxic burden—combined with lifestyle interventions, effective hypoxic burden reduction, weight loss and sleep management, pharmacotherapy, CPAP therapy, catheter-based renal denervation, surgical intervention, device therapy, technological innovations such as artificial intelligence, policy support, health insurance policies, and patient engagement—should be adopted to establish a new lifelong management and treatment system.
