"Environmental hypertensionology" the effects of environmental factors on blood pressure in clinical practice and research

The Association between Indoor Air Quality and Adult Blood Pressure Levels in a High-Income Setting

Background: Indoor air pollution is still considered one of the leading causes of morbidity and mortality worldwide. We aimed to investigate the potential association between indoor particulate matter (PM) and fasting clinic blood pressure in adult Australians. Methods: Sixty-three participants residing within the Perth metropolitan area were studied. Participants were aged between 18 and 65 years and free of major medical conditions. We conducted 24-h monitoring of residential PM concentrations, including the size fractions PM1, PM2.5, PM4, and PM10. All participants attended a clinical assessment at Curtin University following a 10–12 h overnight fast. Results: In this study we found that PM1 and PM2.5 were significantly associated with heart rate: a one interquartile range (IQR) increase in PM1 or PM2.5 was associated with a 4–6 beats per minute (bpm) increase in heart rate. Both PM10 and total PM exposure had a significant impact on systolic blood pressure (SBP): a one IQR increase in PM10 and total PM were associated with a 10 mmHg (95% CI: 0.77–20.05) and 12 mmHg (2.28–22.43 mmHg) increase in SBP, respectively. Conclusion: The study findings provide additional support to the thesis that indoor air pollution is an important modifiable factor in the risk of hypertension.

Gender differences in factors associated with prehypertension and hypertension in Nepal: A nationwide survey

BACKGROUND

Nepal has one of the highest prevalence of hypertension in South Asia. However, no national studies have examined the gender differences in the determinants of prehypertension and hypertension in the country to inform targeted interventions. This study aimed to investigate gender differences in factors associated with prehypertension and hypertension in Nepal using the 2016 Nepal Demographic and Health Survey (NDHS).

METHODS

Sociodemographic, behavioural, anthropometric and health status data and information on hypertension were obtained from 14,857 (males: 6,245 and females: 8,612) individuals aged 15 years or above from the biomarker sample of the 2016 NDHS. Factors associated with prehypertension and hypertension by gender were investigated using generalized linear latent and mixed models (GLLAM) with the mlogit link and binomial family that adjusted for clustering and sampling weights.

RESULTS

The overall prevalence of prehypertension and hypertension was 26.9% [95% confidence interval (CI): 25.7, 28.1] and 17.2% (95% CI 16.1, 18.3), respectively. Prehypertension was present in 30.4% (95%CI: 28.7, 32.2) of males and 24.3% (95% CI: 23.1, 25.6) of females, while hypertension was present in 20.4%, (95% CI 18.9, 22.0) of males and 14.8% (95% CI: 13.7, 16.0) of females. Key modifiable factors that were strongly associated with prehypertension and hypertension in both genders included overweight and obesity, caffeine intake, tobacco use, no schooling, previously informed of hypertension in a health facility, and alcohol consumption (for males). Other significant factors associated with prehypertension and hypertension included increasing age (> 30 years), ecological zone (Hill), Developmental zone (Western) and being married.

CONCLUSION

Our results suggest that prehypertension and hypertension were higher in males compared to females. Interventions to improve awareness, screening, treatment and control of prehypertension and hypertension in Nepal are warranted and should target key modifiable factors, as well as people aged 30 years and above.

Household air pollution and measures of blood pressure, arterial stiffness and central haemodynamics

Objective

We evaluated the exposure–response associations between personal exposure to air pollution from biomass stoves and multiple vascular and haemodynamic parameters in rural Chinese women.

Methods

We analysed the baseline information from a longitudinal study in southwestern China. Women’s brachial and central blood pressure and pulse pressure, carotid-femoral pulse wave velocity and augmentation index, and their 48-hour personal exposures to fine particulate matter (PM2.5) and black carbon were measured in summer and winter. We evaluated the associations between exposure to air pollution and haemodynamic parameters using mixed-effects regression models adjusted for known cardiovascular risk factors.

Results

Women’s (n=205, ages 27–86 years) exposures to PM2.5 and black carbon ranged from 14 µg/m3 to 1405 µg/m3 and 0.1–121.8 µg/m3, respectively. Among women aged ≥50 years, increased PM2.5 exposure was associated with higher systolic (brachial: 3.5 mm Hg (P=0.05); central: 4.4 mm Hg (P=0.005)) and diastolic blood pressure (central: 1.3 mm Hg (P=0.10)), higher pulse pressure (peripheral: 2.5 mm Hg (P=0.05); central: 2.9 mm Hg (P=0.008)) and lower peripheral–central pulse pressure amplification (−0.007 (P=0.04)). Among younger women, the associations were inconsistent in the direction of effect and not statistically significant. Increased PM2.5 exposure was associated with no difference in pulse wave velocity and modestly higher augmentation index though the CI included zero (1.1%; 95% CI −0.2% to 2.4%). Similar associations were found for black carbon exposure.

Conclusions

Exposure to household air pollution was associated with higher blood pressure and central haemodynamics in older Chinese women, with no associations observed with pulse wave velocity.

The influence of proximity to city parks and major roads on the development of arterial hypertension

AIMS

The aim of this study was to examine the relation between residential distance from major roads and city parks and the development of arterial hypertension.

METHODS

In this study, we used data of the population included in the MONICA survey (Lithuania). In total, 739 participants without arterial hypertension were selected for the present study. Poisson regression with robust variance estimation was used to evaluate the associations between distances from a major road and a city park expressed as categorical variables and the incidence of arterial hypertension, adjusting for individual risk factors.

RESULTS

For persons living at a distance of 151-300 m and > 300 m from city parks, relative risks were 1.49 (95% CI 1.03-2.15) and 1.51 (95% CI 1.10-2.07) respectively, as compared to a ≤ 150 m distance from city parks. For persons living further than 200 m away from a major road, the relative risk for the residential distance from city parks > 150 m was 2.36 ( p = 0.029) times higher, as compared to a ≤ 150 m distance from city parks. We found that an increased risk of arterial hypertension was associated with the distance from a city park > 350 m and the distance to a major road < 200 m (RR = 1.48, 95% CI 1.03-2.12) as compared to living ≤ 350 m to a city park and ≥ 200 m away from a major road.

CONCLUSIONS

An increase in the incidence of arterial hypertension was associated with a shorter distance to a major road and a greater distance to a city park. The effect modification of a shorter distance to a major road on the association between a greater distance to city parks and the incidence of arterial hypertension was identified.

Differential Expression of Hypertensive Phenotypes in BXD Mouse Strains in Response to Angiotensin II

BACKGROUND

Besides environmental risk factors, genetic factors play a crucial role in the pathogenesis of primary hypertension. The current study is to unravel whether hypertensive phenotypes vary in mice with different genetic background.

METHODS

Hypertension was induced in C57BL/6J (B6), DBA/2J (D2), and 25 BXD strains by administrating angiotensin (Ang)II (2.5 mg/kg/day infused by osmotic minipump) for 4 weeks. Systolic blood pressure was monitored before (baseline) and after 4 weeks of AngII treatment by tail cuff. Cardiac and renal fibrosis was evaluated by picrosirius red staining and collagen volume fraction (CVF) was quantitated using imaging analyzing system; cardiac transforming growth factor (TGF)-β gene expression was monitored by RT-PCR, and inflammatory response was detected by immunohistochemical ED-1 staining.

RESULTS

AngII infusion caused hypertension in all strains. However, blood pressure elevation was more evident in the D2 strain than the B6 group, while it was widely variable among BXD strains. Furthermore, chronic AngII treatment lead to development of hypertensive cardiac and renal diseases. Cardiac and renal CVF levels in the D2 strain was significantly higher than the B6 cohort, whereas these varied vastly across BXD strains. Moreover, cardiac TGF-β mRNA levels were markedly diverse among various mouse strains.

CONCLUSION

Our study unequivocally demonstrates that in response to AngII, BXDs with different genetic background expressed hypertension phenotypes with varied degree in severity. It implicates that genomics contribute to pathogenesis of primary hypertension. Building upon the genotype and hypertensive phenotypes, the BXD cohort can be further exploited experimentally to identify genes that influence blood pressure.

Air Pollution and Cardiometabolic Disease: An Update and Call for Clinical Trials

Fine particulate matter <2.5 µm (PM2.5) air pollution is a leading cause of global morbidity and mortality. The largest portion of deaths is now known to be due to cardiovascular disorders. Several air pollutants can trigger acute events (e.g., myocardial infarctions, strokes, heart failure). However, mounting evidence additionally supports that longer-term exposures pose a greater magnified risk to cardiovascular health. One explanation may be that PM2.5 has proven capable of promoting the development of chronic cardiometabolic conditions including atherosclerosis, hypertension, and diabetes mellitus. Here, we provide an updated overview of recent major studies regarding the impact of PM2.5 on cardiometabolic health and outline key remaining scientific questions. We discuss the relevance of emerging trials evaluating personal-level strategies (e.g., facemasks) to prevent the harmful effects of PM2.5, and close with a call for large-scale outcome trials to allow for the promulgation of formal evidence-base recommendations regarding their appropriate usage in the global battle against air pollution.

Personal-level exposure to environmental temperature is a superior predictor of endothelial-dependent vasodilatation than outdoor-ambient level

Environmental temperatures influence cardiovascular physiology. However, the majority of time is spent indoors, making outdoor-ambient temperatures inaccurate estimates of true exposures encountered by most individuals. We evaluated in 50 healthy adults the associations between previous 7-day outdoor-ambient (four occasions) and prior 24-hour personal-level (two occasions) environmental temperature exposures with blood pressure, heart rate variability, sleep parameters, and endothelial-dependent vasodilatation (brachial flow-mediated dilatation [FMD]) using generalized estimating equations. Participants (34 females; age, 32.1 ± 9.6 years) had normal blood pressures (107.8 ± 13.3/70.2 ± 9.4 mm Hg), FMD (7.4 ± 2.8%), as well as sleep and heart rate variability parameters. Mean 7-day outdoor-ambient (4.6 ± 9.7°C) differed from personal-level temperature exposures (22.0 ± 3.0°C). Colder outdoor-ambient temperatures (per -10°C) over the previous 1-6 days (rolling averages) were associated with decreases in FMD: -0.57% (95% confidence interval [CI]: -1.14% to 0.01%, P = .055) to -0.62% (95% CI: -1.07% to -0.18%, P = .006). However, a 10°C decrease in personal-level temperature during the prior 24 hours was associated with a greater decrement in FMD: -2.44% (95% CI: -4.74% to -0.13%, P = .038). Both were also linearly related to FMD during all seasons and without a threshold temperature. Other end points were not significantly related to either temperature level in this study. Short-term exposures to colder environmental temperatures reduced endothelial-dependent vasodilatation, supporting the epidemiologic associations with heightened cardiovascular risk. We show here for the first time that temperature exposures characterized at the personal level may be more robust predictors of endothelial function than outdoor-ambient levels.

Air pollution and arterial hypertension. A new risk factor is in the air

Air pollution is one of the greatest environmental threats and has been implicated for several adverse cardiovascular effects including arterial hypertension (HTN). However, the exact relationship between air pollution exposure and HTN is still unclear. Air contamination provokes oxidative stress, systemic inflammation, and autonomic nervous system imbalance that subsequently induce endothelial dysfunction and vasoconstriction leading to increased blood pressure. The aim of this review was to describe the potential mechanisms by which air pollution contributes to HTN and to summarize the consequences of short- and long-term exposure.

Carotid and aortic stiffness in essential hypertension and their relation with target organ damage: the CATOD study

OBJECTIVE

The objective of the study is to investigate in the hypertensive population the possible differential association between increased aortic and/or carotid stiffness and organ damage in multiple districts, such as the kidney, the vessels, and the heart.

METHODS

In 314 essential hypertensive patients, carotid-femoral pulse wave velocity (cfPWV, by applanation tonometry) and carotid stiffness (from ultrasound images analysis), together with left ventricular hypertrophy, carotid intima-media thickness, urinary albumin-creatinin ratio, and glomerular filtration rate were measured. Increased cfPWV and carotid stiffness were defined according to either international reference values or the 90th percentile of a local control group (110 age and sex-matched healthy individuals).

RESULTS

When considering the 90th percentile of a local control group, increased cfPWV was associated with reduced glomerular filtration rate, either when carotid stiffness was increased [odds ratio (OR) 13.27 (confidence limits (CL) 95% 3.86-45.58)] or not [OR 7.39 (CL95% 2.25-24.28)], whereas increased carotid stiffness was associated with left ventricular hypertrophy, either when cfPWV was increased [OR 2.86 (CL95% 1.15-7.09)] or not [OR 2.81 (CL95% 1.13-6.97)]. No association between increased cfPWV or carotid stiffness and target organ damage was found when cutoffs obtained by international reference values were used. The concomitance of both increased cfPWV and carotid stiffness did not have an additive effect on organ damage.

CONCLUSION

Aortic and carotid stiffness are differentially associated with target organ damage in hypertensive patients. Regional arterial stiffness as assessed by cfPWV is associated with renal organ damage and local carotid stiffness with cardiac organ damage.

Activation of Transient Receptor Potential Melastatin Subtype 8 Attenuates Cold-Induced Hypertension Through Ameliorating Vascular Mitochondrial Dysfunction

Background

Environmental cold‐induced hypertension is common, but how to treat cold‐induced hypertension remains an obstacle. Transient receptor potential melastatin subtype 8 (TRPM8) is a mild cold‐sensing nonselective cation channel that is activated by menthol. Little is known about the effect of TRPM8 activation by menthol on mitochondrial Ca²⁺ homeostasis and the vascular function in cold‐induced hypertension.

Methods and Results

Primary vascular smooth muscle cells from wild‐type or Trpm8^−/− mice were cultured. In vitro, we confirmed that sarcoplasmic reticulum–resident TRPM8 participated in the regulation of cellular and mitochondrial Ca²⁺ homeostasis in the vascular smooth muscle cells. TRPM8 activation by menthol antagonized angiotensin II induced mitochondrial respiratory dysfunction and excess reactive oxygen species generation by preserving pyruvate dehydrogenase activity, which hindered reactive oxygen species–triggered Ca²⁺ influx and the activation of RhoA/Rho kinase pathway. In vivo, long‐term noxious cold stimulation dramatically increased vasoconstriction and blood pressure. The activation of TRPM8 by dietary menthol inhibited vascular reactive oxygen species generation, vasoconstriction, and lowered blood pressure through attenuating excessive mitochondrial reactive oxygen species mediated the activation of RhoA/Rho kinase in a TRPM8‐dependent manner. These effects of menthol were further validated in angiotensin II–induced hypertensive mice.

Conclusions

Long‐term dietary menthol treatment targeting and preserving mitochondrial function may represent a nonpharmaceutical measure for environmental noxious cold–induced hypertension.

Environmental ambient temperature and blood pressure in adults: A systematic review and meta-analysis

OBJECTIVE

Although many individual studies have examined the association between temperature and blood pressure (BP), they used different methods and also their results were somewhat inconsistent. The aims of this study are to quantitatively summarize previous studies and to systematically assess the methodological issues to make recommendations for future research.

METHODS

We searched relevant empirical studies published before January 2016 concerning temperature and BP among adults using the MEDLINE, Embase and PubMed databases. Mean changes in systolic (SBP) and diastolic blood pressure (DBP) per 1°C reduction in temperature were pooled using a random-effects meta-analysis.

RESULTS

Of 23 studies included, 14 were used for meta-analysis. Consistent, statistically significant, inverse associations were observed between ambient temperature (mean, maximum, minimum outdoor temperature and indoor temperature) and BP. An 1°C decrease in mean daily outdoor temperature was associated with an increase in SBP and DBP of 0.26mmHg (95% CI: 0.18-0.33) and 0.13 (95% CI: 0.11-0.16), respectively. The increase was greater in people with conditions related to cardiovascular disease. An 1°C decrease in indoor temperature was associated with 0.38mmHg (0.18-0.58) increase in SBP, while the effects on DBP were not estimated due to limited studies. Among the previous studies on temperature-BP relationship, temperature and BP measurements are not accurate enough and statistical methods need to be improved.

CONCLUSIONS

Lower ambient temperatures seem to increase adults' BP and people with conditions related to cardiovascular disease are more susceptible to drops in temperature. Indoor temperature appeared to have a stronger effect on BP than outdoor temperature. To understand temperature-BP relationship well, a study combining repeated personal temperature exposure and ambulatory BP monitoring, applying improved statistical methods to examine potential non-linear relationship is warranted.

Hospitalizations from Hypertensive Diseases, Diabetes, and Arrhythmia in Relation to Low and High Temperatures: Population-Based Study

Little is known about the extent to which ambient temperatures contribute to the burden of hospitalizations from hypertensive diseases, diabetes, and arrhythmia. To fill this knowledge gap, we conducted a time-series study comprising entire population of Ontario, Canada during 1996–2013. A distributed lag non-linear model was developed to estimate the cumulative effect of temperatures over a 21-day lag period. We computed the burden of hospitalizations attributable to cold and heat. Furthermore, we separated the burden into components related to mild and extreme temperatures. Compared to the temperature with minimum risk of morbidity, cold temperatures (1^st percentile) were associated with a 37% (95% confidence interval: 5%, 78%) increase in hypertension-related hospitalizations whereas no significant association with hot temperatures (99^th percentile) was observed. Cold and hot temperatures were also associated with a 12% (1%, 24%) and a 30% (6%, 58%) increase in diabetes-related hospitalizations, respectively. Arrhythmia was not linked to temperatures. These estimates translate into ~10% of hypertension-related hospitalizations attributable to total cold, and ~9% from mild cold. Similarly, ~11% of diabetes-related hospitalizations were due to total heat, virtually all of which were from mild heat. In conclusion, ambient temperatures, especially in moderate ranges, contribute to excess hospitalizations from hypertension and diabetes.

Particulate matter air pollution and ambient temperature: opposing effects on blood pressure in high-risk cardiac patients

OBJECTIVE

Fine particulate matter air pollution (PM2.5) and extreme temperatures have both been associated with alterations in blood pressure (BP). However, few studies have evaluated their joint haemodynamic actions among individuals at high risk for cardiovascular events.

METHODS

We assessed the effects of short-term exposures during the prior week to ambient PM2.5 and outdoor temperature levels on resting seated BP among 2078 patients enrolling into a cardiac rehabilitation programme at the University of Michigan (from 2003 to 2011) using multiple linear regression analyses adjusting for age, sex, BMI, ozone and the same-day alternate environmental factor (i.e. PM2.5 or temperature).

RESULTS

Mean PM2.5 and temperature levels were 12.6 ± 8.2 μg/m and 10.3 ± 10.4°C, respectively. Each standard deviation elevation in PM2.5 concentration during lag days 4-6 was associated with significant increases in SBP (2.1-3.5 mmHg) and DBP (1.7-1.8 mmHg). Conversely, higher temperature levels (per 10.4°C) during lag days 4-6 were associated with reductions in both SBP (-3.6 to -2.3 mmHg) and DBP (-2.5 to -1.8 mmHg). There was little evidence for consistent effect modification by other covariates (e.g. demographics, seasons, medication usage).

CONCLUSION

Short-term exposures to PM2.5, even at low concentrations within current air quality standards, are associated with significant increases in BP. Contrarily, higher ambient temperatures prompt the opposite haemodynamic effect. These findings demonstrate that both ubiquitous environmental exposures have clinically meaningful effects on resting BP among high-risk cardiac patients.

An Update on Inpatient Hypertension Management

Hypertension is highly prevalent affecting nearly one third of the US adult population. Though generally approached as an outpatient disorder, elevated blood pressure is observed in a majority of hospitalized patients. The spectrum of hypertensive disease ranges from patients with hypertensive emergency including markedly elevated blood pressure and associated end-organ damage to asymptomatic patients with minimally elevated pressures of unclear significance. It is important to note that current evidence-based hypertension guidelines do not specifically address inpatient hypertension. This narrative review focuses primarily on best practices for diagnosing and managing nonemergent hypertension in the inpatient setting. We describe examples of common hypertensive syndromes, provide suggestions for optimal post-acute management, and point to evidence-based or consensus guidelines where available. In addition, we describe a practical approach to managing asymptomatic elevated blood pressure observed in the inpatient setting. Finally, arranging effective care transitions to ensure optimal ongoing hypertension management is appropriate in all cases.

A panel study of the acute effects of personal exposure to household air pollution on ambulatory blood pressure in rural Indian women

BACKGROUND

Almost half the world's population is exposed to household air pollution from biomass and coal combustion. The acute effects of household air pollution on the cardiovascular system are poorly characterized. We conducted a panel study of rural Indian women to assess whether personal exposures to black carbon during cooking were associated with acute changes in blood pressure.

METHODS

We enrolled 45 women (ages 25-66 years) who cooked with biomass fuels. During cooking sessions in winter and summer, we simultaneously measured their personal real-time exposure to black carbon and conducted ambulatory blood pressure measurements every 10min. We recorded ambient temperature and participants' activities while cooking. We assessed body mass index, socioeconomic status, and salt intake. Multivariate mixed effects regression models with random intercepts were used to estimate the associations between blood pressure and black carbon exposure, e.g., average exposure in the minutes preceding blood pressure measurement, and average exposure over an entire cooking session.

RESULTS

Women's geometric mean (GM) exposure to black carbon during cooking sessions was lower in winter (GM: 40μg/m(3); 95% CI: 30, 53) than in summer (GM: 56μg/m(3); 95% CI: 42, 76). Interquartile range increases in black carbon were associated with changes in systolic blood pressure from -0.4mm Hg (95% CI: -2.3, 1.5) to 1.9mm Hg (95% CI: -0.8, 4.7), with associations increasing in magnitude as black carbon values were assessed over greater time periods preceding blood pressure measurement. Interquartile range increases in black carbon were associated with small decreases in diastolic blood pressure from -0.9mm Hg (95% CI: -1.7, -0.1) to -0.4mm Hg (95% CI: -1.6, 0.8). Associations of a similar magnitude were estimated for cooking session-averaged values.

CONCLUSIONS

We found some evidence of an association between exposure to black carbon and acute increases in systolic blood pressure in Indian women cooking with biomass fuels, which may have implications for the development of cardiovascular diseases.

Seasonal Variation in Blood Pressure in 162,135 Patients With Type 1 or Type 2 Diabetes Mellitus

Seasonal variation in blood pressure (BP) has been observed in different populations. However, only few studies have focused on BP seasonality in diabetic patients. This study examined the seasonal patterns in BP in 62,589 patients with type 1 diabetes mellitus (T1DM) and in 99,546 patients with type 2 diabetes mellitus (T2DM) from the German/Austrian Diabetes Follow-up Registry. Adjusted mean BP values revealed seasonal cycles of 12 months, with higher BP in colder months. Using harmonic regression models, the estimated systolic BP difference throughout the year was 2.28/2.48 mm Hg in T1DM/T2DM (both P<.001). Interestingly, seasonal variation in diastolic BP was larger in T1DM than in T2DM (1.24/0.64 mm Hg, P<.001). A sex difference was observed in T1DM only, while age differences occurred in both types of diabetes. Correlations between BP and potentially related factors such as outdoor temperature indicated that reasons underlying BP seasonality are likely to be complex and vary by subgroup.

Association of Carbon Monoxide exposure with blood pressure among pregnant women in rural Ghana: Evidence from GRAPHS

BACKGROUND AND OBJECTIVE

The Ghana Randomized Air Pollution and Health Study (GRAPHS) is a community-level randomized-controlled trial of cookstove interventions for pregnant women and their newborns in rural Ghana. Given that household air pollution from biomass burning may be implicated in adverse cardiovascular outcomes, we sought to determine whether exposure to carbon monoxide (CO) from woodsmoke was associated with blood pressure (BP) among 817 adult women.

METHODS

Multivariate linear regression models were used to evaluate the association between CO exposure, determined with 72 hour personal monitoring at study enrollment, and BP, also measured at study enrollment. At the time of these assessments, women were in the first or second trimester of pregnancy.

RESULTS

A significant positive association was found between CO exposure and diastolic blood pressure (DBP): on average, each 1 ppm increase in exposure to CO was associated with 0.43 mmHg higher DBP [0.01, 0.86]. A non-significant positive trend was also observed for systolic blood pressure (SBP).

CONCLUSION

This study is one of very few to have examined the relationship between household air pollution and blood pressure among pregnant women, who are at particular risk for hypertensive complications. The results of this cross-sectional study suggest that household air pollution from wood-burning fires is associated with higher blood pressure, particularly DBP, in pregnant women at early to mid-gestation. The clinical implications of the observed association toward the eventual development of chronic hypertension and/or hypertensive complications of pregnancy remain uncertain, as few of the women were overtly hypertensive at this point in their pregnancies.

Altitudes of residential areas affect salt intake in a rural area in Japan: a Shimane CoHRE Study

There is increasing evidence of an association between residential environments and hypertension. As shown in our previous study, the inconvenience of the locations of residential areas may be one of the factors influencing the blood pressures of inhabitants. Salt intake is one of the likely mediators between inconvenience and hypertension. Therefore, in this study, we evaluated the association between the altitudes of residential areas and salt intake in a rural Japanese region because altitude may be one of the proxies for inconvenience. In this cross-sectional study, 1016 participants living in a mountainous region in Japan were recruited during health examinations. The altitude of each participant's residence was estimated using a geographic information system. Subjects were divided into quartile groups according to the altitudes of their residences. To evaluate salt intake, we employed the 24-h salt intake estimation of Kawano et al. (e24-h salt intake) and the urinary sodium-to-potassium ratio (uNa/K). Linear regression analyses indicated that altitude was an independent factor influencing both e24-h salt intake and uNa/K after adjustments for age, sex, body mass index, physical activity, alcohol consumption, triglycerides and county of residence. The same result was observed when the subjects who did not take antihypertensive medications were analyzed (N=633). The present study indicated that altitude of residence had a significant positive influence on salt intake in a rural area of Japan.

Visit-to-Visit Variability and Seasonal Variation in Blood Pressure With Single-Pill Fixed-Dose Combinations of Angiotensin II Receptor Blocker/Calcium Channel Blocker and Angiotensin II Receptor Blocker/Diuretic in Hypertensive Patients

BACKGROUND

The visit-to-visit variability in blood pressure (BP) has been shown to be a strong predictor of cardiovascular events. It is not known whether anti-hypertensive therapy using a single-pill fixed-dose combination of angiotensin II receptor blocker (ARB)/calcium channel blocker (CCB) or ARB/diuretic (DI) in hypertensive patients affects the visit-to-visit variability and seasonal variation of BP.

METHODS

We enrolled 47 hypertensive patients who had received a single-pill fixed-dose combination of either ARB/CCB (n = 30) or ARB/DI (n = 17) for 15 months. Beginning 3 months after the start of ARB/CCB or ARB/DI treatment, we determined the visit-to-visit variability in BP expressed as the standard deviation (SD) of average BP and the seasonal variation in BP expressed as the SD of average BP in each season (spring, summer, fall and winter were defined as lasting from March to May, June to August, September to November and December to February, respectively) for a year.

RESULTS

There were no significant differences in baseline patient characteristics except for the prevalence of coronary artery disease and the percentage of CCB excluding amlodipine in the ARB/CCB group between the ARB/CCB and ARB/DI groups. There were no significant differences in the 1-year time course of systolic and diastolic BP (SBP and DBP) between the groups, although there were significant differences in SBP in August and November and DBP in December. Interestingly, the visit-to-visit variability and seasonal variation of BP in the ARB/CCB group were similar to those in the ARB/DI group.

CONCLUSION

Single-pill fixed-dose combinations of ARB/CCB and ARB/DI had similar effects on visit-to-visit variability and seasonal variation in BP in hypertensive patients.

Elevated relative risk of aneurysmal subarachnoid hemorrhage with colder weather in the mid-Atlantic region

We have previously reported an increase of 0.6% in the relative risk of aneurysmal subarachnoid hemorrhage (aSAH) in response to every 1°F decrease in the maximum daily temperature (Tmax) in colder seasons from patients presenting to our regional tertiary care center. We hypothesized that this relationship would also be observed in the warmer summer months with ambient temperatures greater than 70°F. From prospectively collected incidence data for aSAH patients, we investigated absolute Tmax, average daily temperatures, intraday temperature ranges, and the variation of daily Tmax relative to 70°F to assess associations with aSAH incidence for patients admitted to our institution between 1991 and 2009 during the hottest months and days on which Tmax>70°F. For all days treated as a group, the mean Tmax (± standard deviation) was lower when aSAH occurred than when it did not (64.4±18.2°F versus 65.8±18.3°F; p=0.016). During summer months, the odds ratio (OR) of aSAH incidence increased with lower mean Tmax (OR 1.019; 95% confidence interval 1.001-1.037; p=0.043). The proportion of days with aSAH admissions was lower on hotter days than the proportion of days with no aSAH (96% versus 98%; p=0.006). aSAH were more likely to occur during the summer and on days with a temperature fluctuation less than 10°F (8% versus 4%; p=0.002). During the hottest months of the year in the mid-Atlantic region, colder maximum daily temperatures, a smaller heat burden above 70°F, and smaller intraday temperature fluctuations are associated with increased aSAH admissions in a similar manner to colder months. These findings support the hypothesis that aSAH incidence is more likely with drops in temperature, even in the warmer months.

Effects of weather and heliophysical conditions on emergency ambulance calls for elevated arterial blood pressure

We hypothesized that weather and space weather conditions were associated with the exacerbation of essential hypertension. The study was conducted during 2009-2010 in the city of Kaunas, Lithuania. We analyzed 13,475 cards from emergency ambulance calls (EACs), in which the conditions for the emergency calls were made coded I.10-I.15. The Kaunas Weather Station provided daily records of air temperature (T), wind speed (WS), relative humidity, and barometric pressure (BP). We evaluated the associations between daily weather variables and daily number of EACs by applying a multivariate Poisson regression. Unfavorable heliophysical conditions (two days after the active-stormy geomagnetic field or the days with solar WS>600 km/s) increased the daily number of elevated arterial blood pressure (EABP) by 12% (RR=1.12; 95% confidence interval (CI) 1.04-1.21); and WS≥3.5 knots during days of T<1.5 °C and T≥12.5 °C by 8% (RR=1.08; CI 1.04-1.12). An increase of T by 10 °C and an elevation of BP two days after by 10 hPa were associated with a decrease in RR by 3%. An additional effect of T was detected during days of T≥17.5 °C only in females. Women and patients with grade III arterial hypertension at the time of the ambulance call were more sensitive to weather conditions. These results may help in the understanding of the population's sensitivity to different weather conditions.

The impact of decreases in air temperature and increases in ozone on markers of endothelial function in individuals having type-2 diabetes

Several studies have reported an association between air pollution and endothelial dysfunction, especially in individuals having diabetes. However, very few studies have examined the impact of air temperature on endothelial function. The objective of this analysis was to investigate short-term effects of temperature and ozone on endothelial function in individuals having diabetes. Moreover, we investigated interactive effects between air temperature and air pollution on markers of endothelial function. Between November 2004 and December 2005 flow-mediated dilatation (FMD), nitroglycerin-mediated dilatation (NTGMD) and several blood markers representing endothelial function were measured using brachial artery ultrasound on four consecutive days in 22 individuals with type-2 diabetes mellitus in Chapel Hill, North Carolina (USA). Daily measurements of meteorological parameters, ozone and particulate matter with an aerodynamic diameter ≤2.5 µm (PM2.5) were obtained from fixed monitoring sites. We used additive mixed-models adjusting for time trend, day of the week, relative humidity and barometric pressure to assess temperature and ozone associations with endothelial function. A 1 °C decrease in the 24-h temperature average was associated with a decrease in mean FMD on the same day (-2.2% (95%-confidence interval:[-4.7;0.3%])) and with a delay of one and four days. A temperature decrement also led to an immediate (-1.7%[-3.3;-0.04]) decrease in NTGMD. Moreover, we observed an immediate (-14.6%[-26.3;-2.9%]) and a one day delayed (-13.5%[-27.0; 0.04%]) decrease in FMD in association with a 0.01 ppm increase in the maximum 8-h moving average of ozone. Temperature effects on FMD strengthened when PM2.5 and ozone concentrations were high. The associations were similar during winter and summer. We detected an association between temperature decreases and ozone increases on endothelial dysfunction in individuals having diabetes. We conclude that endothelial dysfunction might be a possible mechanism explaining cardiovascular events in association with environmental stimuli.

Air pollution associated hypertension and increased blood pressure may be reduced by breastfeeding in Chinese children: the Seven Northeastern Cities Chinese Children's Study

BACKGROUND

Little is known about the association between air pollution and hypertension among children, and no studies report whether breastfeeding modifies this association in children.

METHODS

Nine thousand three hundred fifty-four Chinese children, ages 5-17 years old, from 24 elementary schools and 24 middle schools in the Seven Northeastern Cities during 2012-2013 were evaluated. The weight, height, and BP were measured. Four-year average concentrations of particles with an aerodynamic diameter of ≤10 μm (PM10), sulfur dioxide (SO2), nitrogen dioxides (NO2), ozone (O3), and carbon monoxide (CO) were calculated from monitoring stations. Two-level regression analysis was used to examine the effects, controlling for covariates.

RESULTS

The results showed that associations existed between hypertension and pollutants. The odds ratios for hypertension ranged from 1.12 per 46.3 μg/m3 increase for O3 (95% confidence interval [CI], 1.10-1.13) to 1.68 per 30.6 μg/m3 increase for PM10 (95% CI, 1.53-1.86). The increases in mean diastolic BP ranged from 0.58 mm Hg per 46.3 μg/m3 increase for O3 (95% CI, 0.52-0.63 mm Hg) to 2.89 mm Hg per 563.4 μg/m3 increase for CO (95% CI: 2.53-3.24 mm Hg). The increase in systolic BP ranged from 0.50 mm Hg per 46.3 μg/m3 increase for O3 (95% CI: 0.43-0.57 mm Hg) to 2.10 mm Hg per 30.6 μg/m3 increase for PM10 (95% CI, 1.73-2.47 mm Hg). Compared with children who had been breastfed, non-breastfed children exhibited consistently stronger effects.

CONCLUSION

Study findings indicate that high levels of PM10, SO2, NO2, O3, and CO are associated with increased arterial BP and hypertension among the children. Breastfeeding may reduce the risk.

Derivation and validation of BOREAS, a risk score identifying candidates to develop cold-induced hypertension

INTRODUCTION

Blood pressure increases in cold periods, but its implications on prevalence of hypertension and on individual progression to hypertension remain unclear. Our aim was to develop a pre-screening test for identifying candidates to suffer hypertension only in cold months among non-hypertensive subjects.

METHODS

We included 95,277 subjects registered on a primary care database from Girona (Catalonia, Spain), with ≥ 3 blood pressure measures recorded between 2003 and 2009 and distributed in both cold (October-March) and warm (April-September) periods. We defined four blood pressure patterns depending on the presence of hypertension through these periods. A Cox model determined the risk to develop vascular events associated with blood pressure patterns. A logistic regression distinguished those nonhypertensive individuals who are more prone to suffer cold-induced hypertension. Validity was assessed on the basis of calibration (using Brier score) and discrimination (using the area under the receiver operating characteristics).

RESULTS

In cold months, the mean systolic blood pressure increased by 3.3 ± 0.1 mmHg and prevalence of hypertension increased by 8.2%. Cold-induced hypertension patients were at higher vascular events risk (Hazard ratio=1.44 [95% Confidence interval 1.15-1.81]), than nonhypertensive individuals. We identified age, diabetes, body mass index and prehypertension as the major contributing factors to cold-induced hypertension onset.

DISCUSSION

Hypertension follows a seasonal pattern in some individuals. We recommend screening for hypertension during the cold months, at least in those nonhypertensive individuals identified as cold-induced hypertensive by this assessment tool.

Analysis of differentially expressed genes in cold-exposed mice to investigate the potential causes of cold-induced hypertension

Cold exposure is considered to be an important contributing factor to the high morbidity of hypertension. In order to elucidate the cause and mechanism of cold-induced hypertension (CIH), gene expression analysis was performed on microarray data for two groups of cold-exposed mice (4°C for 1 week and 4°C for 5 weeks, three replicates per group) and their respective control groups maintained at 30°C. Analysis results indicated that the differentially expressed genes with the most significance were associated with adaptive thermogenesis, fatty acid metabolism and energy metabolism. The expected marked increase in metabolism during cold exposure caused tissue hypoxia. Genes involved in the hypoxia-inducible factor signaling pathway were activated. In addition, genes associated with oxidative stress were significantly upregulated, including superoxide dismutase 2 (SOD2) and epoxide hydrolase 2 (EPHX2). The majority of genes involved in inflammation-associated pathways were shown to be downregulated in the 4°C 5-week group. Therefore, the results of the present study indicate that tissue hypoxia and increased oxidative stress may play important roles in the process of CIH.

Short-term effects of air temperature on blood pressure and pulse pressure in potentially susceptible individuals

BACKGROUND

Only few epidemiological studies have investigated the association between air temperature and blood pressure (BP) or pulse pressure (PP), with inconsistent findings. We examined whether short-term changes in air temperature were associated with changes in BP or PP in three different populations.

METHODS

Between March 2007 and December 2008, 371 systolic and diastolic BP measurements were collected in 30 individuals with type-2 diabetes mellitus (T2D), 30 persons with impaired glucose tolerance and 42 healthy individuals without a metabolic disorder from Augsburg, Germany. Hourly means of ambient meteorological data were obtained from a fixed measurement station. Personal temperature measurements were conducted using data loggers. Temperature effects were evaluated using additive mixed models adjusting for time trend and relative humidity.

RESULTS

Decreases in air temperature were associated with an increase in systolic BP, diastolic BP and PP in individuals with T2D. For example, a 1°C decrease in ambient temperature was associated with an immediate increase in systolic BP of 1.0 mmHg (95%-confidence interval: [0.5;1.4]mmHg). Effects of personally measured air temperature were similar. Temperature effects were modified by age, body mass index, gender, antihypertensive medication and whereabouts, such as being indoors.

CONCLUSIONS

We observed associations between decreases in air temperature and increases in BP as well as PP in persons with T2D indicating that these people might be potentially more susceptible to changes in air temperature. Our findings may provide a hypothesis for a mechanism between air temperature decreases and short-term increases of cardiovascular events.

Short-term changes in ambient temperature and risk of ischemic stroke

Background

Despite consistent evidence of a higher short-term risk of cardiovascular mortality associated with ambient temperature, there have been discrepant findings on the association between temperature and ischemic stroke. Moreover, few studies have considered potential confounding by ambient fine particulate matter air pollution <2.5 μm in diameter (PM_2.5) and none have examined the impact of temperature changes on stroke in the subsequent hours rather than days. The aim of this study was to evaluate whether changes in temperature trigger an ischemic stroke in the following hours and days and whether humid days are particularly harmful.

Methods

We reviewed the medical records of 1,705 patients residing in the metropolitan region of Boston, Mass., USA, who were hospitalized with neurologist-confirmed ischemic stroke, and we abstracted data on the time of symptom onset and clinical characteristics. We obtained hourly meteorological data from the National Weather Service station and hourly PM_2.5 data from the Harvard ambient monitoring station. We used the time-stratified case-crossover design to assess the association between ischemic stroke and apparent temperature averaged over 1-7 days prior to stroke onset adjusting for PM_2.5. We assessed whether differences in apparent temperature trigger a stroke within shorter time periods by examining the association between stroke onset and apparent temperature levels averaged in 2-hour increments prior to stroke onset (0-2 h through 36-38 h). We tested whether the association varied by health characteristics or by PM_2.5, ozone or relative humidity.

Results

The incidence rate ratio of ischemic stroke was 1.09 (95% confidence interval 1.01-1.18) following a 5°C decrement in average apparent temperature over the 2 days preceding symptom onset. The higher risk associated with cooler temperatures peaked in the first 14-34 h. There was no statistically significant difference in the association between temperature and ischemic stroke across seasons. The risk of ischemic stroke was not meaningfully different across subgroups of patients defined by health characteristics. The association between ischemic stroke and ambient temperature was stronger on days with higher levels of relative humidity.

Conclusions

Lower temperatures are associated with a higher risk of ischemic stroke onset in both warm and cool seasons, and the risk is higher on days with higher levels of relative humidity. Based on this study and the body of literature on ambient temperature and cardiovascular events, identifying methods for mitigating cardiovascular risk may be warranted.

Personal black carbon exposure influences ambulatory blood pressure: air pollution and cardiometabolic disease (AIRCMD-China) study

Few prospective studies have assessed the blood pressure effect of extremely high air pollution encountered in Asia's megacities. The objective of this study was to evaluate the association between combustion-related air pollution with ambulatory blood pressure and autonomic function. During February to July 2012, personal black carbon was determined for 5 consecutive days using microaethalometers in patients with metabolic syndrome in Beijing, China. Simultaneous ambient fine particulate matter concentration was obtained from the Beijing Municipal Environmental Monitoring Center and the US Embassy. Twenty-four-hour ambulatory blood pressure and heart rate variability were measured from day 4. Arterial stiffness and endothelial function were obtained at the end of day 5. For statistical analysis, we used generalized additive mixed models for repeated outcomes and generalized linear models for single/summary outcomes. Mean (SD) of personal black carbon and fine particulate matter during 24 hours was 4.66 (2.89) and 64.2 (36.9) μg/m(3). Exposure to high levels of black carbon in the preceding hours was associated significantly with adverse cardiovascular responses. A unit increase in personal black carbon during the previous 10 hours was associated with an increase in systolic blood pressure of 0.53 mm Hg and diastolic blood pressure of 0.37 mm Hg (95% confidence interval, 0.17-0.89 and 0.10-0.65 mm Hg, respectively), a percentage change in low frequency to high frequency ratio of 5.11 and mean interbeat interval of -0.06 (95% confidence interval, 0.62-9.60 and -0.11 to -0.01, respectively). These findings highlight the public health effect of air pollution and the importance of reducing air pollution.

The associations between traffic-related air pollution and noise with blood pressure in children: results from the GINIplus and LISAplus studies

Although traffic emits both air pollution and noise, studies jointly examining the effects of both of these exposures on blood pressure (BP) in children are scarce. We investigated associations between land-use regression modeled long-term traffic-related air pollution and BP in 2368 children aged 10 years from Germany (1454 from Munich and 914 from Wesel). We also studied this association with adjustment of long-term noise exposure (defined as day-evening-night noise indicator "Lden" and night noise indicator "Lnight") in a subgroup of 605 children from Munich inner city. In the overall analysis including 2368 children, NO2, PM2.5 mass (particles with aerodynamic diameters below 2.5μm), PM10 mass (particles with aerodynamic diameters below 10μm) and PM2.5 absorbance were not associated with BP. When restricting the analysis to the subgroup of children with noise information (N=605), a significant association between NO2 and diastolic BP was observed (-0.88 (95% confidence interval: -1.67, -0.08)). However, upon adjusting the models for noise exposure, only noise remained independently and significantly positively associated with diastolic BP. Diastolic BP increased by 0.50 (-0.03, 1.02), 0.59 (0.05, 1.13), 0.55 (0.03, 1.07), and 0.58 (0.05, 1.11)mmHg for every five decibel increase in Lden and by 0.59 (-0.05, 1.22), 0.69 (0.04, 1.33), 0.64 (0.02, 1.27), and 0.68 (0.05, 1.32)mmHg for every five decibel increase in Lnight, in different models of NO2, PM2.5 mass, PM10 mass and PM2.5 absorbance as the main exposure, respectively. In conclusion, air pollution was not consistently associated with BP with adjustment for noise, noise was independently and positively associated with BP in children.

Season, temperature and blood pressure: a complex interaction

An increase in blood pressure values measured during winter either in the office, at home, or at ambulatory blood pressure monitoring was consistently observed. Besides potentially contributing to increase the risk for cardiovascular events during the cold season, long term blood pressure variations can influence results of clinical trials, epidemiological surveys, and require personalized management of antihypertensive medications in the single patient. Those variations are often considered as an effect of climate, due to the close correlation observed in various countries and in different settings between temperature and blood pressure among children, adults, and specially the elderly. However, obtaining true measurements of exposition is a main problem when investigating the effects of climate on human health especially when the aim is to disentangle the effects of climate from those of seasonality. The aim of the present note is not to provide a complete review of the literature demonstrating the implications of seasonal blood pressure changes in the clinical and experimental setting; rather it is to consider methodological aspects useful to investigate the interaction between seasonality and temperature on blood pressure and to make health care providers aware of the implications of environmental factors on blood pressure in clinical and research settings.

Blood pressure response to patterns of weather fluctuations and effect on mortality

Very few studies have looked at longitudinal intraindividual blood pressure responses to weather conditions. There are no data to suggest that specific response to changes in weather will have an impact on survival. We analyzed >169 000 clinic visits of 16 010 Glasgow Blood Pressure Clinic patients with hypertension. Each clinic visit was mapped to the mean West of Scotland monthly weather (temperature, sunshine, rainfall) data. Percentage change in blood pressure was calculated between pairs of consecutive clinic visits, where the weather alternated between 2 extreme quartiles (Q(1)-Q(4) or Q(4)-Q(1)) or remained in the same quartile (Q(n)-Q(n)) of each weather parameter. Subjects were also categorized into 2 groups depending on whether their blood pressure response in Q(1)-Q(4) or Q(4)-Q(1) were concordant or discordant to Q(n)-Q(n). Generalized estimating equations and Cox proportional hazards model were used to model the effect on longitudinal blood pressure and mortality, respectively. Q(n)-Q(n) showed a mean 2% drop in blood pressure consistently, whereas Q(4)-Q(1) showed a mean 2.1% and 1.6% rise in systolic and diastolic blood pressure, respectively. However, Q(1)-Q(4) did not show significant changes in blood pressure. Temperature-sensitive subjects had significantly higher mortality (1.35 [95% confidence interval, 1.06-1.71]; P=0.01) and higher follow-up systolic blood pressure (1.85 [95% confidence interval, 0.24-3.46]; P=0.02) compared with temperature-nonsensitive subjects. Blood pressure response to temperature may be one of the underlying mechanisms that determine long-term blood pressure variability. Knowing a patient's blood pressure response to weather can help reduce unnecessary antihypertensive treatment modification, which may in turn increase blood pressure variability and, thus, risk.

Seasonal blood pressure changes: an independent relationship with temperature and daylight hours

Seasonal blood pressure (BP) changes have been found to be related to either outdoor or indoor temperature. No information regarding the independent effects of temperature measured proximally to the patient, the personal-level environmental temperature (PET), is available. Inclusion of daylight hours in multivariate analysis might allow exploring the independent interaction of BP with seasonality. To investigate whether ambulatory BP monitoring is affected by PET or by seasonality, 1897 patients referred to our hypertension units underwent ambulatory BP monitoring with a battery-powered temperature data logger fitted to the carrying pouch of the monitor. Predictors of 24-hour daytime and nighttime BP and of morning BP surge were investigated with a multivariate stepwise regression model, including age, sex, body mass index, antihypertensive treatment, office BP, ambulatory heart rate, PET, relative humidity, atmospheric pressure, and daylight hours as independent variables. At adjusted regression analysis, daytime systolic BP was negatively related to PET (-0.14; 95% confidence interval, -0.25 to -0.02); nighttime BP was positively related to daylight hours (0.63; 0.37-0.90); and morning BP surge was negatively related to daylight hours (-0.54; -0.87 to -0.21). These results provide new evidence that PET and seasonality (daylight hours) are 2 independent predictors of ambulatory BP monitoring.

Uric Acid Reduction Rectifies Prehypertension in Obese Adolescents

Epidemiologic studies, animal models, and preliminary clinical trials in children implicate uric acid in the development of essential hypertension. Controversy remains as to whether the observations indicate a general mechanism or a surrogate phenomenon. We sought to determine whether uric acid is a causative mediator of increased blood pressure (BP) and impaired vascular compliance. We report a randomized, double-blinded, placebo-controlled trial comparing 2 mechanisms of urate reduction with placebo in prehypertensive, obese, adolescents, aged 11 to 17 years. Subjects were randomized to the xanthine oxidase inhibitor, allopurinol, uricosuric, probenecid, or placebo. Subjects treated with urate-lowering therapy experienced a highly significant reduction in BP. In clinic systolic BP fell 10.2 mm Hg and diastolic BP fell 9.0 mm Hg in treated patients compared with a rise of 1.7 mm Hg and 1.6 mm Hg systolic and diastolic BP, respectively in patients on placebo. Urate-lowering therapy also resulted in significant reduction in systemic vascular resistance. These data indicate that, at least in adolescents with prehypertension, uric acid causes increased BP that can be mitigated by urate lowering therapy.

Within-subject blood pressure level--not variability--predicts fatal and nonfatal outcomes in a general population

To assess the prognostic significance of blood pressure (BP) variability, we followed health outcomes in a family-based random population sample representative of the general population (n=2944; mean age: 44.9 years; 50.7% women). At baseline, BP was measured 5 times consecutively at each of 2 home visits 2 to 4 weeks apart. We assessed within-subject overall (10 readings), within- and between-visit systolic BP variability from variability independent of the mean, the difference between maximum and minimum BP, and average real variability. Over a median follow-up of 12 years, 401 deaths occurred and 311 participants experienced a fatal or nonfatal cardiovascular event. Overall systolic BP variability averaged (SD) 5.45 (2.82) units, 15.87 (8.36) mmHg, and 4.08 (2.05) mmHg for variability independent of the mean, difference between maximum and minimum BP, and average real variability, respectively. Female sex, older age, higher-mean systolic BP, lower body mass index, a history of peripheral arterial disease, and use of β-blockers were the main correlates of systolic BP variability. In multivariable-adjusted analyses, overall and within- and between-visit BP variability did not predict total or cardiovascular mortality or the composite of any fatal plus nonfatal cardiovascular end point. For instance, the hazard ratios for all cardiovascular events combined in relation to overall variability independent of the mean, difference between maximum and minimum BP, and average real variability were 1.05 (0.96-1.15), 1.06 (0.96-1.16), and 1.08 (0.98-1.19), respectively. By contrast, mean systolic BP was a significant predictor of all end points under study, independent of BP variability. In conclusion, in an unbiased population sample, BP variability did not contribute to risk stratification over and beyond mean systolic BP.