Arterial Hypertension as a Modulator of Cognitive Response to CPAP Therapy in Moderate-to-Severe Obstructive Sleep Apnea

Background and Objectives: Cognitive deficits are common in obstructive sleep apnea (OSA), and both intermittent hypoxemia and cardiovascular comorbidity may contribute to poorer outcomes. Arterial hypertension (HTN) has been suggested as a potential modifier of cognitive function in OSA, but findings remain inconsistent. This study examined whether HTN influences baseline cognition or cognitive improvement after continuous positive airway pressure (CPAP) therapy in moderate-to-severe OSA and identified predictors of poorer post-treatment cognitive status. Materials and Methods: This prospective study involved 71 adults with newly diagnosed moderate-to-severe OSA (AHI ≥ 15). Participants underwent baseline polysomnography, Montreal Cognitive Assessment (MoCA) testing, and P300 assessments. Cognitive impairment was defined as MoCA < 26 and HTN by antihypertensive therapy, documented diagnosis, or repeatedly elevated blood pressure. All participants initiated auto-adjusting CPAP and were reassessed after three months for adherence, residual respiratory indices, MoCA, and P300 parameters. Multivariate logistic regression and receiver operating characteristic (ROC) analyses were used to identify independent predictors of poorer cognitive outcomes. Results: CPAP therapy significantly improved apnea severity, daytime sleepiness, global cognition, and P300 latency, while P300 amplitude did not change significantly. After three months, hypertensive and normotensive patients showed similar MoCA scores, respiratory outcomes, and P300 amplitude; P300 latency remained marginally longer in hypertensive individuals. Across multivariate models, lower mean nocturnal oxygen saturation and reduced CPAP adherence independently predicted poorer cognitive outcome at follow-up. CPAP adherence demonstrated greater discriminative ability than mean nocturnal oxygenation. Conclusions: In adequately treated moderate-to-severe OSA, HTN did not significantly affect baseline cognition or short-term cognitive recovery with CPAP. Although P300 latency remained slightly prolonged in hypertensive individuals, this difference was marginal and not accompanied by cognitive deficits. Nocturnal oxygenation and CPAP adherence emerged as the strongest predictors of post-treatment cognitive status, underscoring the importance of sustained and effective therapy. These findings suggest that effective CPAP adherence and improved nocturnal oxygenation are crucial for cognitive recovery in OSA patients, regardless of hypertensive status.