Excessive Daytime Sleepiness Plus Prolonged Sleep-Onset Latency Triples Hypertension Risk

Excessive daytime sleepiness (EDS) combined with objectively prolonged sleep-onset latency on polysomnography was associated with more than a threefold increase in the odds of developing incident hypertension over 7.5 years of follow-up, according to research from Penn State College of Medicine presented at SLEEP 2026 in Baltimore, Maryland, and published in an online supplement of the journal Sleep.¹

Complaints of daytime sleepiness are common and most often attributed to insufficient sleep, obesity, or obstructive sleep apnea (OSA). The present findings suggest that a subset of these patients — those who are sleepy during the day but also have difficulty falling asleep at night — may carry a significantly elevated cardiovascular risk that warrants more specific evaluation and intervention.

“Adults with excessive daytime sleepiness and prolonged sleep-onset latency appeared to represent a distinct subgroup with significantly greater cardiovascular risk,” lead author Alexandros Vgontzas, MD, a professor of psychiatry and director of the Sleep Research and Treatment Center at Penn State College of Medicine, said in a statement. “Neither excessive daytime sleepiness on its own, nor prolonged sleep latency on its own, showed the same increased risk of hypertension.”

The study drew from the Penn State Adult Cohort, and included 1741 adults at baseline; the incident hypertension analysis followed 786 participants without hypertension at baseline for a mean of 7.5 years. All participants underwent overnight 8-hour polysomnography. EDS was defined by self-report of moderate-to-severe daytime sleepiness, drowsiness, or irresistible sleep attacks. Prolonged sleep-onset latency (SOL ≥30 minutes) on polysomnography served as an objective index of sleep disturbance and physiological hyperarousal.

Participants were categorized into 4 mutually exclusive groups using these 2 variables, with no EDS and SOL <30 minutes as the reference. Hypertension was defined by systolic BP ≥140 mmHg or diastolic BP ≥90 mmHg, or antihypertensive treatment use.

Analyses were adjusted for sex, age, BMI, race and ethnicity, smoking, caffeine use, alcohol use, diabetes, depression, apnea-hypopnea index, total sleep time, and wake time after sleep onset.¹

Results showed EDS alone was associated with 52% greater odds of prevalent hypertension (odds ratio [OR], 1.52; 95% CI, 1.01–2.27; P = .044) and 74% greater odds of incident hypertension (OR, 1.74; 95% CI, 1.05–2.87; P = .030) compared with normal controls.¹ When EDS was accompanied by prolonged SOL ≥30 minutes, odds of prevalent hypertension more than doubled (OR, 2.34; 95% CI, 1.18–4.63; P = .015) and odds of incident hypertension more than tripled (OR, 3.43; 95% CI, 1.58–7.41; P = .002). Of note, neither EDS alone nor prolonged SOL alone conferred the same degree of risk.

The mechanistic underpinning is physiological hyperarousal: a state of sustained central nervous system activation that prevents normal sleep initiation despite perceived fatigue, and which drives elevated sympathetic tone and vascular resistance over time.

Prior research from this group demonstrated that the insomnia phenotype characterized by physiological hyperarousal, measured objectively by the Multiple Sleep Latency Test, is independently associated with hypertension, with the hypothesized mechanism involving persistent stress-response activation. Prolonged SOL on polysomnography reflects the same underlying biology. Studies have reported high sympathetic activity and nocturnal non-dipping blood pressure profiles in patients with severe insomnia associated with hyperarousal, both established contributors to sustained BP elevation and end-organ risk.

“These findings suggest that evaluating excessive daytime sleepiness should extend beyond screening for sleep apnea alone,” Vgontzas said. “Assessing nighttime sleep difficulties and objective sleep measures such as prolonged sleep-onset latency may help identify patients with elevated cardiovascular risk and support more targeted treatment approaches.”

References

1. Associated Professional Sleep Societies. Sleepy days and restless nights are a dangerous combination for blood pressure. Published June 10, 2026. Accessed June 15, 2026. https://www.sleepmeeting.org/sleepy-days-and-restless-nights-are-a-dangerous-combination-for-blood-pressure/

2. Pejovic S, Vgontzas A, Athanasiou N, et al. Excessive daytime sleepiness and prevalent and incident hypertension: the modifying effect of objective sleep disturbance [abstract 0985]. Sleep. 2026;49(Suppl 1). https://doi.org/10.1093/sleep/zsag091.0984

3. Li Y, Vgontzas AN, Fernandez-Mendoza J, et al. Insomnia with physiological hyperarousal is associated with hypertension. Hypertension. 2015;65:644–650.