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Jin L, Conklin DJ. A novel evaluation of endothelial dysfunction ex vivo: "Teaching an Old Drug a New Trick". Physiol Rep 2021; 9:e15120. [PMID: 34755498 PMCID: PMC8579072 DOI: 10.14814/phy2.15120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 10/29/2021] [Indexed: 11/24/2022] Open
Abstract
Cardiovascular disease (CVD) is the leading cause of morbidity and mortality worldwide. Many CVDs begin with endothelium dysfunction (ED), including hypertension, thrombosis, and atherosclerosis. Our assay evaluated ED in isolated murine aorta by quantifying phenylephrine-induced contractions (PE) in the presence of L-NAME, which blocked acetylcholine-induced relaxation (ACh %; >99%). The "L-NAME PE Contraction Ratio" (PECR) was defined as: "PE Tension post-L-NAME" divided by "PE Tension pre-L-NAME." We hypothesized that our novel PE Contraction Ratio would strongly correlate with alterations in endothelium function. Validation 1: PECR and ACh % values of naïve aortas were strongly and positively correlated (PECR vs. ACh %, r2 = 0.91, n = 7). Validation 2: Retrospective analyses of published aortic PECR and ACh % data of female mice exposed to filtered air, propylene glycol:vegetable glycerin (PG:VG), formaldehyde (FA), or acetaldehyde (AA) for 4d showed that the PECR in air-exposed mice (PECR = 1.43 ± 0.05, n = 16) correlated positively with the ACh % (r2 = 0.40) as seen in naïve aortas. Similarly, PECR values were significantly decreased in aortas with ED yet retained positive regression coefficients with ACh % (PG:VG r2 = 0.54; FA r2 = 0.55). Unlike other toxicants, inhaled AA significantly increased both PECR and ACh % values yet diminished their correlation (r2 = 0.09). Validation 3: To assess species-specific dependence, we tested PECR in rat aorta, and found PECR correlated with ACh % relaxation albeit less well in this aged and dyslipidemic model. Because the PECR reflects NOS function directly, it is a robust measure of both ED and vascular dysfunction. Therefore, it is a complementary index of existing tests of ED that also provides insight into mechanisms of vascular toxicity.
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Affiliation(s)
- Lexiao Jin
- American Heart Association‐Tobacco Regulation and Addiction CenterUniversity of LouisvilleLouisvilleKentuckyUSA
- Christina Lee Brown Envirome InstituteUniversity of LouisvilleLouisvilleKentuckyUSA
| | - Daniel J. Conklin
- American Heart Association‐Tobacco Regulation and Addiction CenterUniversity of LouisvilleLouisvilleKentuckyUSA
- Christina Lee Brown Envirome InstituteUniversity of LouisvilleLouisvilleKentuckyUSA
- Superfund Research CenterUniversity of LouisvilleLouisvilleKentuckyUSA
- Diabetes and Obesity CenterUniversity of LouisvilleLouisvilleKentuckyUSA
- Division of Environmental MedicineDepartment of MedicineUniversity of LouisvilleLouisvilleKentuckyUSA
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Chen X, Chen W, Wang Y, Han Y, Zhu T. Responses of healthy young males to fine-particle exposure are modified by exercise habits: a panel study. Environ Health 2018; 17:88. [PMID: 30545423 PMCID: PMC6293663 DOI: 10.1186/s12940-018-0437-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2018] [Accepted: 12/04/2018] [Indexed: 05/21/2023]
Abstract
BACKGROUND Aerobic exercise benefits health but increases inhalation of fine particles (PM2.5) in ambient air. Acute cardiopulmonary responses to PM2.5 exposure in individuals with different exercise habits, especially in areas with severe air pollution, are not well understood. METHODS To examine acute cardiopulmonary responses to PM2.5 exposure modified by exercise habits, a panel of 20 healthy non-smoking male subjects, recruited in Beijing, China, completed seven visits. The exercise frequency per week and preferred exercise place were recorded using a baseline questionnaire to describe exercise habits. Fractional exhaled nitric oxide (FeNO), cytokines in exhaled breath condensate, blood pressure, and pulse-wave analysis (PWA) indices were measured during each visit as biomarkers of acute cardiopulmonary responses. The hourly average mass concentration of PM2.5 and black carbon (BC), and the number concentrations of ultrafine particles (UFP) and accumulation mode particles (AMP) were monitored throughout the follow-up period at an outdoor fixed monitoring station beginning 14 days prior to each visit. Linear mixed-effects models were used to evaluate the associations between acute changes in biomarker levels and exposure to PM2.5 and its constituents. The primary aim was to assess the modification of long-term exercise habits on these associations. RESULTS FeNO concentration, systolic blood pressure, ejection duration, aortic augmentation pressure, and aortic pressure index were positively associated with exposure to PM2.5 and its constituents. However, no associations with cytokine levels or diastolic blood pressure were observed. In a stratified analysis, we found that acute cardiopulmonary responses were modified by exercise habit. Specifically, the interquartile ranges (IQR) of increases in the 6-12-h moving average (MA) PM2.5 and AMP exposure were associated with 19-21% and 24-26% increases in FeNO, respectively, in subjects with high exercise frequency; these associations were significantly stronger than those in subjects with low exercise frequency. An IQR increase in 3-11-d MA AMP exposure was associated with a 10-26% increase in aortic augmentation pressure in subjects with low exercise frequency; this association was significantly stronger than that in subjects with high exercise frequency. An IQR increase in 9-13-d MA UFP exposure was associated with a 13-17% increase in aortic augmentation pressure in subjects who preferred outdoor exercise; this association was stronger than that in subjects who preferred indoor exercise. CONCLUSIONS In highly polluted areas, frequent exercise might protect against PM2.5-associated arterial stiffness but exacerbate airway inflammation.
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Affiliation(s)
- Xi Chen
- State Key Joint Laboratory for Environmental Simulation and Pollution Control, College of Environmental Sciences and Engineering, Peking University, Beijing, 100871 China
- Center of Research and Innovation, Shenzhen Institute of Building Research Co., Ltd., Shenzhen, 518049 China
| | - Wu Chen
- State Key Joint Laboratory for Environmental Simulation and Pollution Control, College of Environmental Sciences and Engineering, Peking University, Beijing, 100871 China
| | - Yanwen Wang
- State Key Joint Laboratory for Environmental Simulation and Pollution Control, College of Environmental Sciences and Engineering, Peking University, Beijing, 100871 China
| | - Yiqun Han
- State Key Joint Laboratory for Environmental Simulation and Pollution Control, College of Environmental Sciences and Engineering, Peking University, Beijing, 100871 China
| | - Tong Zhu
- State Key Joint Laboratory for Environmental Simulation and Pollution Control, College of Environmental Sciences and Engineering, Peking University, Beijing, 100871 China
- The Beijing Innovation Center for Engineering Science and Advanced Technology, Peking University, Beijing, 100871 China
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Sanip Z, Hanaffi SHM, Ahmad I, Yusoff SSM, Rasool AHG, Yusoff HM. The effects of Secondhand Smoke (SHS) exposure on microvascular endothelial function among healthy women. Tob Induc Dis 2015; 13:32. [PMID: 26346914 PMCID: PMC4559930 DOI: 10.1186/s12971-015-0052-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2014] [Accepted: 08/20/2015] [Indexed: 11/10/2022] Open
Abstract
Background Studies have demonstrated that secondhand smoke (SHS) exposure could impair endothelial function. However, the effect of SHS exposure specifically on microvascular endothelial function is not well understood. This study aimed to determine the effects of SHS exposure on microvascular endothelial function among non-smoking, generally healthy women. Findings We studied 127 women; and based on their hair nicotine levels measured using gas chromatography-mass spectrometry, 25 of them were categorized as having higher hair nicotine levels, 25 were grouped as having lower hair nicotine and 77 women were grouped into the non-detected group. The non-detected group did not have detectable levels of hair nicotine. Anthropometry, blood pressure (BP), lipid profile and high-sensitivity C-reactive protein (hsCRP) were measured accordingly. Microvascular endothelial function was assessed non-invasively using laser Doppler fluximetry and the process of iontophoresis involving acetylcholine and sodium nitroprusside as endothelium-dependent and endothelium-independent vasodilators respectively. The mean hair nicotine levels for higher and lower hair nicotine groups were 0.74 (1.04) and 0.05 (0.01) ng/mg respectively. There were no significant differences in anthropometry, BP, lipid profile and hsCRP between these groups. There were also no significant differences in the microvascular perfusion and endothelial function between these groups. Conclusion In this study, generally healthy non-smoking women who have higher, lower and non-detected hair nicotine levels did not show significant differences in their microvascular endothelial function. Low levels of SHS exposure among generally healthy non-smoking women may not significantly impair their microvascular endothelial function.
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Affiliation(s)
- Zulkefli Sanip
- Central Research Laboratory, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Kelantan Malaysia
| | - Siti Hajar Mohd Hanaffi
- Department of Family Medicine, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Kelantan Malaysia
| | - Imran Ahmad
- Department of Family Medicine, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Kelantan Malaysia
| | - Siti Suhaila Mohd Yusoff
- Department of Family Medicine, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Kelantan Malaysia
| | - Aida Hanum Ghulam Rasool
- Department of Pharmacology, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Kelantan Malaysia
| | - Harmy Mohamed Yusoff
- Department of Family Medicine, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Kelantan Malaysia ; Faculty of Medicine, Universiti Sultan Zainal Abidin, City Campus, 20400 Kuala Terengganu, Terengganu Malaysia
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Del Bo' C, Porrini M, Fracassetti D, Campolo J, Klimis-Zacas D, Riso P. A single serving of blueberry (V. corymbosum) modulates peripheral arterial dysfunction induced by acute cigarette smoking in young volunteers: a randomized-controlled trial. Food Funct 2015; 5:3107-16. [PMID: 25263326 DOI: 10.1039/c4fo00570h] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Cigarette smoking causes oxidative stress, hypertension and endothelial dysfunction. Polyphenol-rich foods may prevent these conditions. We investigated the effect of a single serving of fresh-frozen blueberry intake on peripheral arterial function and arterial stiffness in young smokers. Sixteen male smokers were recruited for a 3-armed randomized-controlled study with the following experimental conditions: smoking treatment (one cigarette); blueberry treatment (300 g of blueberry) + smoking; control treatment (300 mL of water with sugar) + smoking. Each treatment was separated by one week of wash-out period. The blood pressure, heart rate, peripheral arterial function (reactive hyperemia and Framingham reactive hyperemia), and arterial stiffness (digital augmentation index, digital augmentation index normalized for a heart rate of 75 bpm) were measured before and 20 min after smoking with Endo-PAT2000. Smoking impaired the blood pressure, heart rate and peripheral arterial function, but did not affect the arterial stiffness. Blueberry consumption counteracted the impairment of the reactive hyperemia index induced by smoking (-4.4 ± 0.8% blueberry treatment vs. -22.0 ± 1.1% smoking treatment, p < 0.01) and Framingham reactive hyperemia (+28.3 ± 19.2% blueberry treatment vs. -42.8 ± 20.0% smoking treatment, p < 0.0001), and the increase of systolic blood pressure (+8.4 ± 0.02% blueberry treatment vs. +13.1 ± 0.02% smoking treatment, mmHg, p < 0.05) after cigarette smoking. No effect was observed for arterial stiffness and other vital signs. In conclusion, data obtained suggest a protective role of blueberry on reactive hyperemia, Framingham reactive hyperemia, and systolic blood pressure in subjects exposed to smoke of one cigarette. Future studies are necessary to elucidate the mechanisms involved.
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Affiliation(s)
- Cristian Del Bo'
- Università degli Studi di Milano, Department of Food, Environmental and Nutritional Sciences, Division of Human Nutrition, Milano, Italy.
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Henriksson P, Lu Q, Diczfalusy U, Freyschuss A. Immediate effect of passive smoking on microcirculatory flow. Microcirculation 2015; 21:587-92. [PMID: 24698527 DOI: 10.1111/micc.12137] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2014] [Accepted: 03/31/2014] [Indexed: 01/02/2023]
Abstract
OBJECTIVE Exposure to SHS, as by passive smoking, seems to increase the incidence of cardiovascular events. It has been shown that active smoking of a single cigarette causes an immediate and significant decrease in microcirculatory blood flow velocity, whereas the acute effects of exposure to SHS on microcirculatory flow have as yet not been demonstrated. METHODS Healthy nonsmoking volunteers of both genders were studied during acute exposure to SHS of two cigarettes burning up to 10 minutes. Microvessels were examined by in vivo vital capillaroscopy (Capiflow(®)), allowing continuous assessment of CBV. RESULTS CBV decreased from 514 mm/sec (CI 383-646) at baseline to 306 mm/sec (CI 191-420) at end of SHS exposure with a further decrease to a nadir of 240 mm/sec (CI 155-325) four minutes after the end of this exposure (p < 0.0001; ANOVA). CONCLUSIONS The result of this study shows that passive inhalation of secondhand cigarette smoke induces an immediate and prolonged marked reduction in CBV in nonsmoking healthy volunteers.
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Affiliation(s)
- Peter Henriksson
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
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Wu JP, Hsieh CH, Ho TJ, Kuo WW, Yeh YL, Lin CC, Kuo CH, Huang CY. Secondhand smoke exposure toxicity accelerates age-related cardiac disease in old hamsters. BMC Cardiovasc Disord 2014; 14:195. [PMID: 25524239 PMCID: PMC4349676 DOI: 10.1186/1471-2261-14-195] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2014] [Accepted: 12/11/2014] [Indexed: 11/10/2022] Open
Abstract
Background Aging is associated with physiological or pathological left ventricular hypertrophy (LVH) cardiac changes. Secondhand smoke (SHS) exposure is associated with pathological LVH. The action mechanism in cardiac concentric hypertrophy from SHS exposure is understood, but the transition contributed from SHS exposure is not. To determine whether exposure to SHS has an impact on age-induced LVH we examined young and old hamsters that underwent SHS exposure in a chamber for 30 mins. Methods Morphological and histological studies were then conducted using hematoxylin and eosin (H&E) and Masson’s trichrome staining. Echocardiographic analysis was used to determine left ventricular wall thickness and function. LVH related protein expression levels were detected by western blot analysis. Results The results showed that both young and aged hamsters exposed to SHS exhibited increased heart weights and left ventricular weights, left ventricular posterior wall thickness and intraventricular septum systolic and diastolic pressure also increased. However, left ventricular function systolic and diastolic pressure deteriorated. H&E and Masson’s trichrome staining results showed LV papillary muscles were ruptured, resulting in lower cardiac function at the myocardial level. LV muscle fiber arrangement was disordered and collagen accumulation occurred. Concentric LVH related protein molecular markers increased only in young hamsters exposed to SHS. However, this declined with hamster age. By contrast, eccentric LVH related proteins increased in aging hamsters exposed the SHS. Pro-inflammatory proteins, IL-6, TNF-α, JAK1, STAT3, and SIRTI expression increased in aging hamsters exposed to SHS. Conclusions We suggest that SHS exposure induces a pro-inflammatory response that results in concentric transition to aging eccentric LVH.
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Affiliation(s)
| | | | | | | | | | | | | | - Chih-Yang Huang
- Graduate Institute of Basic Medical Science, China Medical University, Taichung, Taiwan.
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Wilker EH, Ljungman PL, Rice MB, Kloog I, Schwartz J, Gold DR, Koutrakis P, Vita JA, Mitchell GF, Vasan RS, Benjamin EJ, Hamburg NM, Mittleman MA. Relation of long-term exposure to air pollution to brachial artery flow-mediated dilation and reactive hyperemia. Am J Cardiol 2014; 113:2057-63. [PMID: 24793676 DOI: 10.1016/j.amjcard.2014.03.048] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2013] [Revised: 03/20/2014] [Accepted: 03/20/2014] [Indexed: 11/15/2022]
Abstract
Long-term exposure to ambient air pollution has been associated with cardiovascular morbidity and mortality. Impaired vascular responses may, in part, explain these findings, but the association of such long-term exposure with measures of both conduit artery and microvascular function has not been widely reported. We evaluated the association between residential proximity to a major roadway (primary or secondary highway) and spatially resolved average fine particulate matter (PM2.5) and baseline brachial artery diameter and mean flow velocity, flow-mediated dilation%, and hyperemic flow velocity, in the Framingham Offspring and Third Generation Cohorts. We examined 5,112 participants (2,731 [53%] women, mean age 49 ± 14 years). Spatially resolved average PM2.5 was associated with lower flow-mediated dilation% and hyperemic flow velocity. An interquartile range difference in PM2.5 (1.99 μg/m(3)) was associated with -0.16% (95% confidence interval [CI] -0.27%, -0.05%) lower flow-mediated dilation% and -0.72 (95% CI -1.38, -0.06) cm/s lower hyperemic flow velocity%. Residential proximity to a major roadway was negatively associated with flow-mediated dilation%. Compared with living ≥400 m away, living <50 m from a major roadway was associated with 0.32% lower flow-mediated dilation (95% CI -0.58%, -0.06%), but results for hyperemic flow velocity had wide confidence intervals -0.68 cm/s (95% CI -2.29, 0.93). In conclusion, residential proximity to a major roadway and higher levels of spatially resolved estimates of PM2.5 at participant residences are associated with impaired conduit artery and microvascular function in this large community-based cohort of middle-aged and elderly adults.
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Affiliation(s)
- Elissa H Wilker
- Cardiovascular Epidemiology Research Unit, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts; Department of Environmental Health, Harvard School of Public Health, Boston, Massachusetts.
| | - Petter L Ljungman
- Cardiovascular Epidemiology Research Unit, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts; Institute of Environmental Medicine, Karolinska Institute, Stockholm, Sweden
| | - Mary B Rice
- Cardiovascular Epidemiology Research Unit, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts; Pulmonary and Critical Care Unit, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Itai Kloog
- Department of Geography and Environmental Development, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Joel Schwartz
- Department of Environmental Health, Harvard School of Public Health, Boston, Massachusetts
| | - Diane R Gold
- Department of Environmental Health, Harvard School of Public Health, Boston, Massachusetts
| | - Petros Koutrakis
- Department of Environmental Health, Harvard School of Public Health, Boston, Massachusetts
| | - Joseph A Vita
- NHLBI and Boston University's Framingham Heart Study, Framingham, Massachusetts; Whitaker Cardiovascular Institute, Boston University School of Medicine, Boston, Massachusetts
| | | | - Ramachandran S Vasan
- NHLBI and Boston University's Framingham Heart Study, Framingham, Massachusetts; Whitaker Cardiovascular Institute, Boston University School of Medicine, Boston, Massachusetts; Sections of Preventive Medicine and Epidemiology and Cardiology, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts
| | - Emelia J Benjamin
- NHLBI and Boston University's Framingham Heart Study, Framingham, Massachusetts; Whitaker Cardiovascular Institute, Boston University School of Medicine, Boston, Massachusetts
| | - Naomi M Hamburg
- NHLBI and Boston University's Framingham Heart Study, Framingham, Massachusetts; Whitaker Cardiovascular Institute, Boston University School of Medicine, Boston, Massachusetts
| | - Murray A Mittleman
- Cardiovascular Epidemiology Research Unit, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts; Department of Environmental Health, Harvard School of Public Health, Boston, Massachusetts
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Noguchi M, Fujikawa R, Kimura A. Smoking as a confounding factor on the influence of cold therapy on the vascular endothelium function of young men. J Phys Ther Sci 2013; 25:1285-8. [PMID: 24259776 PMCID: PMC3820185 DOI: 10.1589/jpts.25.1285] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2013] [Accepted: 05/20/2013] [Indexed: 11/30/2022] Open
Abstract
[Purpose] This study was designed to determine whether smoking affects endothelium
function after cold therapy in young men. [Subjects] The final cohort included 27 healthy
men (age, 20–21 years). Because an impact on vascular endothelium function was anticipated
to be caused by smoking, the study enrolled 14 participants in a smoking group and 13 in a
non-smoking group. [Methods] Vascular endothelial function was assessed by determining the
reactive hyperemia index (RHI), using finger-tonometry. RHI was measured twice, at rest
(baseline) and after a cold stimulus. The forearm was cooled with an ice bag for 10 min as
the cold stimulus. Comparisons between the RHI at baseline and after cold treatment, and
between the smoking and non-smoking groups, were performed using the paired and unpaired
t-tests, respectively. [Results] There was a significant difference in baseline RHI values
between the smoking and non-smoking groups, but there was no significant difference
between the baseline and post-treatment RHI values in either group. [Conclusion] These
results suggest that cigarette smoking damages the endothelial cells in young men with a
short history of smoking. However, cold therapy did not have a significant impact on the
RHI in either group.
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Brook RD, Weder AB, Rajagopalan S. "Environmental hypertensionology" the effects of environmental factors on blood pressure in clinical practice and research. J Clin Hypertens (Greenwich) 2011; 13:836-42. [PMID: 22051429 DOI: 10.1111/j.1751-7176.2011.00543.x] [Citation(s) in RCA: 93] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Blood pressure (BP) is affected by many environmental factors including ambient temperature, altitude, latitude, noise, and air pollutants. Given their pervasiveness, it is plausible that such factors may also have an impact on hypertension prevalence and control rates. Health care providers should be aware that the environment can play a significant role in altering BP. Although not among the established modifiable risk factors (eg, obesity) for hypertension, reducing exposures when pertinent should be considered to prevent or control hypertension. The authors provide a concise review of the evidence linking diverse environmental factors with BP and suggest an approach for incorporating this knowledge into clinical practice. The authors propose using the term environmental hypertensionology to refer to the study of the effects of environmental factors on BP in clinical and research settings.
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Affiliation(s)
- Robert D Brook
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, MI 48188, USA.
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