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

Intra-neighborhood associations between residential greenness and blood pressure

INTRODUCTION

Previous investigations have reported that individuals living in greener neighborhoods have better cardiovascular health. It is unclear whether the effects reported at large geographic scales persist when examined at an intra-neighborhood level. The effects of greenness have not been thoroughly examined using high-resolution metrics of greenness exposure, and how they vary with spatial scales of assessment or participant characteristics.

METHODS

We conducted a cross-sectional assessment of associations between blood pressure and multiple high-resolution measures of residential area greenness in spatially concentrated HEAL Study cohort of the Green Heart Project. We employed generalized linear models, accounting for individual-level covariates, to examine associations between different high-resolution measures of greenness and blood pressure among 667 participants in a 4 sq. mile contiguous neighborhood area in Louisville, KY.

RESULTS

In adjusted models, we observed significant inverse associations between residential greenness, measured by leaf area index (LAI), and systolic blood pressure (SBP) within 150-250 m and 500 m of homes, but not for Normalized Difference Vegetation Index (NDVI) or grass cover. Weaker associations were also found with diastolic blood pressure (DBP). Significant positive associations were observed between LAI and SBP among participants who reported being female, White, without obesity, non-exercisers, non-smokers, younger age, of lower income, and who had high nearby roadway traffic. We found few significant associations between grass cover and SBP, but an inverse association in those with obesity, but positive associations for those without obesity.

CONCLUSIONS

We found that leaf surface area of trees around participants home is strongly associated with lower blood pressure, with little association with grass cover. These effects varied with participant characteristics and spatial scales. More research is needed to test causative links between greenspace types and cardiovascular health and to develop population-, typology-, and place-based evidence to inform greening interventions.

Associations of prenatal blood pressure trajectory and variability with child neurodevelopment at 2 years old

BACKGROUND

The patterns of blood pressure (BP) change throughout the pregnancy were related to adverse birth outcomes. However, little is known about the long-term effect of BP change patterns on child neurodevelopment. This study aimed to explore the relationship between the BP trajectory and BP variability during pregnancy and early childhood neurodevelopment.

METHOD

A total of 2797 mother-newborn pairs were derived from the Wuhan Healthy Baby Cohort Study. BP was measured during each antenatal visit, and Mental and Psychomotor Development Indexes (MDI and PDI) were assessed using the Bayley Scales of Infant Development (BSID) when the children were 2 years old. Delayed neurodevelopment was defined as scores of PDI or MDI less than - 1SD relative to the mean score of the study population. A group-based multi-trajectory model was adopted to identify multi-trajectories of systolic blood pressure (SBP) and diastolic blood pressure (DBP). Visit-to-visit BP variability was assessed by the coefficient of variation (CV), standard deviation (SD), and average real variability (ARV). Generalized linear models and multivariate logistic regressions were used to assess the associations of BP trajectories and variability with BSID scores and delayed neurodevelopment, respectively.

RESULTS

Five distinct trajectories for SBP and DBP were identified, namely, "Low-increasing," "Low-stable," "Moderate-decreasing," "Moderate-increasing," and "High-stable" groups. Compared with the "Low-stable" group, the children whose mothers' BP fell into the other four groups had lower PDI scores, and mothers in the "Low-increasing," "Moderate-increasing," and "Moderate-decreasing" groups had 43% (OR: 1.43, 95% CI: 1.01, 2.03), 48% (OR: 1.48, 95% CI: 1.05, 2.08) and 45% (OR:1.45, 95% CI: 1.03, 2.04) higher risk of having offspring with delayed psychomotor neurodevelopment, respectively. High DBP variability was associated with lower BSID scores, and delayed psychomotor neurodevelopment (OR = 1.46, 95% CI: 1.10, 1.92 for DBP-SD; OR = 1.53, 95% CI: 1.16, 2.02 for DBP-CV).

CONCLUSION

Our findings suggest that BP change patterns assessed by multi-trajectory and visit-to-visit variability were associated with lower BSID scores and delayed neurodevelopment. Health professionals should be aware of the influence of BP level and its oscillations during pregnancy on the risk of delayed neurodevelopment.

Angiotensin II participates in mitochondrial thermogenic functions via the activation of glycolysis in chemically induced human brown adipocytes

Brown adipocytes are potential therapeutic targets for the prevention of obesity-associated metabolic diseases because they consume circulating glucose and fatty acids for heat production. Angiotensin II (Ang II) peptide is involved in the pathogenesis of obesity- and cold-induced hypertension; however, the mechanism underlying the direct effects of Ang II on human brown adipocytes remains unclear. Our transcriptome analysis of chemical compound-induced brown adipocytes (ciBAs) showed that the Ang II type 1 receptor (AGTR1), but not AGTR2 and MAS1 receptors, was expressed. The Ang II/AGTR1 axis downregulated the expression of mitochondrial uncoupling protein 1 (UCP1). The simultaneous treatment with β-adrenergic receptor agonists and Ang II attenuated UCP1 expression, triglyceride lipolysis, and cAMP levels, although cAMP response element-binding protein (CREB) phosphorylation was enhanced by Ang II mainly through the protein kinase C pathway. Despite reduced lipolysis, both coupled and uncoupled mitochondrial respiration was enhanced in Ang II-treated ciBAs. Instead, glycolysis and glucose uptake were robustly activated upon treatment with Ang II without a comprehensive transcriptional change in glucose metabolic genes. Elevated mitochondrial energy status induced by Ang II was likely associated with UCP1 repression. Our findings suggest that the Ang II/AGTR1 axis participates in mitochondrial thermogenic functions via glycolysis.

Susceptibility of hypertensive individuals to acute blood pressure increases in response to personal-level environmental temperature decrease

BACKGROUND

Environmental temperature is negatively associated with blood pressure (BP), and hypertension may exacerbate this association. The aim of this study is to investigate whether hypertensive individuals are more susceptible to acute BP increases following temperature decrease than non-hypertensive individuals.

METHODS

The study panel consisted of 126 hypertensive and 125 non-hypertensive (n = 251) elderly participants who completed 940 clinical visits during the winter of 2016 and summer of 2017 in Beijing, China. Personal-level environmental temperature (PET) was continuously monitored for each participant with a portable sensor platform. We associated systolic BP (SBP) and diastolic BP (DBP) with the average PET over 24 h before clinical visits using linear mixed-effects models and explored hourly lag patterns for the associations using distributed lag models.

RESULTS

We found that per 1 °C decrease in PET, hypertensive individuals showed an average (95 % confidence interval) increase of 0.96 (0.72, 1.19) and 0.28 (0.13, 0.42) mmHg for SBP and DBP, respectively; and non-hypertensive participants showed significantly smaller increases of 0.28 (0.03, 0.53) mmHg SBP and 0.14 (-0.01, 0.30) mmHg DBP. A lag pattern analysis showed that for hypertensive individuals, the increases in SBP and DBP were greatest following lag 1 h PET decrease and gradually attenuated up to lag 10 h exposure. No significant BP change was observed in non-hypertensive individuals associated with lag 1-24 h PET exposure. The enhanced increase in PET-associated BP in hypertensive participants (i.e., susceptibility) was more significant in winter than in summer.

CONCLUSIONS

We found that a decrease in environmental temperature was associated with acute BP increases and these associations diminished over time, disappearing after approximately 10 hours. This implies that any intervention measures to prevent BP increases due to temperature drop should be implemented as soon as possible. Such timely interventions are particularly needed for hypertensive individuals especially during the cold season due to their increased susceptibility.

Study on the dynamic effects of plateau hypoxic and cold environment on the thermal adaptation of short-term sojourners in Xizang

The plateau hypoxic environment can affect the thermoregulation process of the human body, and due to the different acclimatization ability to the hypoxic environment, the thermal requirements among the people who enter Xizang at different times may be different. Accordingly, this study aims to clarify how plateau hypoxic environments influence the physiological and subjective responses of people entering Xizang at different times. And field experiments were conducted in Xi'an and Lhasa, respectively, to compare the thermal responses and oxygen responses of the subjects under different temperature conditions on the plain, the first day of entering Xizang and the 15th day of entering Xizang. The results showed that under the hypoxic environment, the thermal sensation of the subjects decreased. With the extension of the time entering Xizang, the influence of the hypoxic environment on thermal comfort was gradually weakened, but under the low temperature environment, the effect of hypoxia on thermal response was not significantly reduced. The results of this study can help to reveal how plateau hypoxic environments affect human thermal comfort and provide a theoretical basis for the design of indoor thermal environment parameters suitable for sojourners entering Xizang at different times.

Hypertension among adolescents in sub-Saharan Africa: a systematic review

Introduction

Hypertension (HTN) among adolescents is common in high-income countries, and leads to increased premature cardiovascular diseases (CVD). In sub-Saharan Africa (SSA), the prevalence of HTN among adolescents, associated risk factors and CVD complications are not well-described. Such data is needed for planning public health programs to prevent premature CVD in SSA.

Methods

We systematically searched 5 databases (MEDLINE, Embase, Google Scholar, Web of Science, and African Index Medicus) from their establishment to December 2021. Key search terms were: adolescent, arterial hypertension, and names of the 48 countries in SSA. We used Covidence® to manage the search results. The review was registered in the Open Science Framework (OSF) https://osf.io/p5sbt/.

Results

We identified 4,008 articles out of which we screened 3,088 abstracts, and reviewed 583 full-text articles. We finally included 92 articles that were published between 1968 to December 2021. The majority were cross-sectional studies (80%) and conducted in school settings (78%). The risk of bias was low for 59 studies (64.1%), moderate for 29 studies (31.5%), and high for 4 studies (4.3%). Overall, the prevalence of HTN varied widely from 0.18% to 34.0% with a median (IQR) of 5.5% (3.1%, 11.1%). It was relatively higher in studies using automated blood pressure (BP) devices, and in studies defining HTN using thresholds based on percentile BP distribution for one's height, age, and sex. In addition, the prevalence of HTN was significantly higher in studies from Southern Africa region of SSA and positively correlated with the year of publication. Across studies, traditional risk factors such as age, sex, body mass index, and physical inactivity, were commonly found to be associated with HTN. In contrast, non-traditional risk factors related to poverty and tropical diseases were rarely assessed. Only three studies investigated the CVD complications related to HTN in the study population.

Conclusion

The prevalence of HTN among adolescents in SSA is high indicating that this is a major health problem. Data on non-traditional risk factors and complications are scarce. Longitudinal studies are needed to clearly define the rates, causes, and complications of HTN.

Systematic Review Registration

https://osf.io/p5sbt/, identifier (10.17605/OSF.IO/P5SBT).

Cigarette smoking and air pollution exposure and their effects on cardiovascular diseases

Cardiovascular disease (CVD) has no socioeconomic, topographical, or sex limitations as reported by the World Health Organization (WHO). The significant drivers of CVD are cardio-metabolic, behavioral, environmental, and social risk factors. However, some significant risk factors for CVD (e.g., a pitiable diet, tobacco smoking, and a lack of physical activities), have also been linked to an elevated risk of cardiovascular disease. Lifestyles and environmental factors are known key variables in cardiovascular disease. The familiarity with smoke goes along with the contact with the environment: air pollution is considered a source of toxins that contribute to the CVD burden. The incidence of myocardial infarction increases in males and females and may lead to fatal coronary artery disease, as confirmed by epidemiological studies. Lipid modification, inflammation, and vasomotor dysfunction are integral components of atherosclerosis development and advancement. These aspects are essential for the identification of atherosclerosis in clinical investigations. This article aims to show the findings on the influence of CVD on the health of individuals and human populations, as well as possible pathology and their involvement in smoking-related cardiovascular diseases. This review also explains lifestyle and environmental factors that are known to contribute to CVD, with indications suggesting an affiliation between cigarette smoking, air pollution, and CVD.

Effects of weather conditions on endovascular treatment case volume for patients with ischemic stroke

BACKGROUND

Weather conditions have been shown to influence the occurrence of cardiovascular events. We tested the hypothesis that weather parameters may be associated with variations of case volume of endovascular treatment (EVT) for acute ischemic stroke.

METHODS

Individual data from the ETIS (Endovascular Treatment in Ischemic Stroke) French national registry were matched to local weather stations. Meteorological parameters (rainfall, humidity, atmospheric pressure, air temperature) were gathered from national online resources. Weather readings and EVT case volumes were annually standardized per weather station and EVT center, and their associations tested with non-parametric univariable and generalized linear statistical models.

RESULTS

Between 2015 and 2021, 9913 EVT procedures addressed by 135 primary stroke units were matched to weather conditions. The mean daily case volume per center was 0.41 [StDev 0.33], and there was a median of 0.84 procedures daily linked to a weather station [StDev 0.47]. We found lower atmospheric pressure (β estimate -0.04; 95%CI[-0.07;-0.03], p<0.001), higher humidity (β estimate 0.07; 95%CI [0.05;0.09], p<0.001) and lower temperatures (β estimate -0.08; 95%CI[-0.10;-0.06], p<0.001) to be associated with higher standardized EVT daily case volumes. These associations were stable when testing them across strata of binned EVT standardized case volumes.

CONCLUSIONS

Our study suggests that lower ambient temperature, lower atmospheric pressure, and higher air humidity are associated with significantly more daily EVT cases in a European temperate country. These results may provide insight into both system of care optimization at times of climate change and intracranial LVO pathophysiology. REGISTRATION-URL: https://clinicaltrials.gov/ct2/show/NCT03776877.

Seasonal variation in blood pressure: what is still missing?

Seasonal variation of blood pressure (BP) is a topic in cardiology that has gained more attention throughout the years. Although it is extensively documented that BP increases in seasons coupled with lower temperatures, there are still many gaps in this knowledge field that need to be explored. Notably, seasonal variation of BP phenotypes, such as masked and white coat hypertension, and the impact of air pollution, latitude, and altitude on seasonal variation of BP are still poorly described in the literature, and the levels of the existing evidence are low. Therefore, further investigations on these topics are needed to provide robust evidence that can be used in clinical practice.

Associations of air pollution mixtures with ambulatory blood pressure: The MobiliSense sensor-based study

Air pollution is acknowledged as a determinant of blood pressure (BP), supporting the hypothesis that air pollution, via hypertension and other mechanisms, has detrimental effects on human health. Previous studies evaluating the associations between air pollution exposure and BP did not consider the effect that air pollutant mixtures may have on BP. We investigated the effect of exposure to single species or their synergistic effects as air pollution mixture on ambulatory BP. Using portable sensors, we measured personal concentrations of black carbon (BC), nitrogen dioxide (NO2), nitrogen monoxide (NO), carbon monoxide (CO), ozone (O3), and particles with aerodynamic diameters below 2.5 μm (PM2.5). We simultaneously collected ambulatory BP measurements (30-min intervals, N = 3319) of 221 participants over one day of their lives. Air pollution concentrations were averaged over 5 min to 1 h before each BP measurement, and inhaled doses were estimated across the same exposure windows using estimated ventilation rates. Fixed-effect linear models as well as quantile G-computation techniques were applied to associate air pollutants' individual and combined effects with BP, adjusting for potential confounders. In mixture models, a quartile increase in air pollutant concentrations (BC, NO2, NO, CO, and O3) in the previous 5 min was associated with a 1.92 mmHg (95% CI: 0.63, 3.20) higher systolic BP (SBP), while 30-min and 1-h exposures were not associated with SBP. However, the effects on diastolic BP (DBP) were inconsistent across exposure windows. Unlike concentration mixtures, inhalation mixtures in the previous 5 min to 1 h were associated with increased SBP. Out-of-home BC and O3 concentrations were more strongly associated with ambulatory BP outcomes than in-home concentrations. In contrast, only the in-home concentration of CO reduced DBP in stratified analyses. This study shows that exposure to a mixture of air pollutants (concentration and inhalation) was associated with elevated SBP.

Seasonal variation in blood pressure control across US health systems

OBJECTIVE

We aimed to characterize seasonal variation in US population-based blood pressure (BP) control and BP-related metrics and evaluate the association between outdoor temperature and BP control variation.

METHODS

We queried electronic health records (EHRs) from 26 health systems, representing 21 states, to summarize BP metrics by quarters of 12-month periods from January 2017 to March 2020. Patients with at least one ambulatory visit during the measurement period and a hypertension diagnosis during the first 6 months or prior to the measurement period were included. Changes in BP control, BP improvement, medication intensification, average SBP reduction after medication intensification across quarters and association with outdoor temperature were analyzed using weighted generalized linear models with repeated measures.

RESULTS

Among 1 818 041 people with hypertension, the majority were more than 65 years of age (52.2%), female (52.1%), white non-Hispanic (69.8%) and had stage 1/2 hypertension (64.8%). Overall, BP control and process metrics were highest in quarters 2 and 3, and lowest in quarters 1 and 4. Quarter 2 had the highest percentage of improved BP (31.95 ± 0.90%) and average SBP reduction after medication intensification (16 ± 0.23 mmHg). Quarter 3 had the highest percentage of BP controlled (62.25 ± 2.55%) and lowest with medication intensification (9.73 ± 0.60%). Results were largely consistent in adjusted models. Average temperature was associated with BP control metrics in unadjusted models, but associations were attenuated following adjustment.

CONCLUSION

In this large, national, EHR-based study, BP control and BP-related process metrics improved during spring/summer months, but outdoor temperature was not associated with performance following adjustment for potential confounders.

A systematic review and meta-analysis of cold exposure and cardiovascular disease outcomes

Background

Cold exposure has been considered an essential risk factor for the global disease burden, while its role in cardiovascular diseases is still underappreciated. The increase in frequency and duration of extreme cold weather events like cold spells makes it an urgent task to evaluate the effects of ambient cold on different types of cardiovascular disease and to understand the factors contributing to the population's vulnerability.

Methods

In the present systematic review and meta-analysis, we searched PubMed, Scopus, and Cochrane. We included original research that explored the association between cold exposure (low temperature and cold spell) and cardiovascular disease outcomes (mortality and morbidity). We did a random-effects meta-analysis to pool the relative risk (RR) of the association between a 1°C decrease in temperature or cold spells and cardiovascular disease outcomes.

Results

In total, we included 159 studies in the meta-analysis. As a result, every 1°C decrease in temperature increased cardiovascular disease-related mortality by 1.6% (RR 1.016; [95% CI 1.015–1.018]) and morbidity by 1.2% (RR 1.012; [95% CI 1.010–1.014]). The most pronounced effects of low temperatures were observed in the mortality of coronary heart disease (RR 1.015; [95% CI 1.011–1.019]) and the morbidity of aortic aneurysm and dissection (RR 1.026; [95% CI 1.021–1.031]), while the effects were not significant in hypertensive disease outcomes. Notably, we identified climate zone, country income level and age as crucial influential factors in the impact of ambient cold exposure on cardiovascular disease. Moreover, the impact of cold spells on cardiovascular disease outcomes is significant, which increased mortality by 32.4% (RR 1.324; [95% CI 1.2341.421]) and morbidity by 13.8% (RR 1.138; [95% CI 1.015–1.276]).

Conclusion

Cold exposure could be a critical risk factor for cardiovascular diseases, and the cold effect varies between disease types and climate zones.

Systematic Review Registration

https://www.crd.york.ac.uk/PROSPERO, identifier: CRD42022347247.

Ambient temperature and ambulatory blood pressure: An hourly-level, longitudinal panel study

BACKGROUND

Variations of blood pressure (BP) related to air temperature have been reported previously; however, no evidence is available regarding the association of hourly ambient temperature with ambulatory blood pressure.

METHODS

We conducted a longitudinal panel study among 1895 patients from an outpatient department who received repeated ambulatory blood pressure monitoring in Urumqi, China between July 2020 and December 2021. We obtained hourly ambient temperature from the nearest monitoring station to the residential address, and measured 4 ambulatory blood pressure indicators. Linear mixed-effect model combined with distributed lag models were applied to investigate the cumulative associations of hourly temperature with BP.

RESULTS

A total of 97,466 valid blood pressure measurements were evaluated. We observed almost linear and monotonically decreasing relationships between temperature and blood pressure. The effects occurred in the same hour, attenuated thereafter and became insignificant approximately 36 h. A 10 °C decrease in temperature was significantly associated with increments of 0.84 mmHg in systolic blood pressure, 0.56 mmHg in diastolic blood pressure, 1.38 mmHg in mean arterial pressure, and 0.66 mmHg in pulse pressure over lag 0 to 36 h. Stronger associations were found among patients of female sex, age between 18 and 65 years, overweight or obesity, minority, less education or in the cold season, as well as those without hypertension or with coronary heart disease, or did not take anti-hypertension medication.

CONCLUSION

Our study provides robust evidence that hourly ambient temperature is inversely associated with ambulatory blood pressure. It also highlights a linear relationship between decreased ambient temperature and elevated BP, which may have implications for the prevention and management of hypertension in susceptible populations.

Cumulative effects of temperature on blood pressure during pregnancy: A cohort study of differing effects in three trimesters

BACKGROUND

Little is known about the non-linear cumulative effects of temperature on blood pressure (BP) during pregnancy. We investigated the differing effects of daily ambient temperature on BP for up to 30 days in three trimesters.

METHODS

The first, second, and third trimester analyses included 2547, 2299, and 2011 pregnant women, respectively, from a prospective cohort in Nanjing from January 2017 to January 2020. BP was measured at each follow-up visit. The individual daily temperature exposures were calculated for 30 days prior to the follow-up date. The Distributed Lag Non-linear Model was used to investigate the relationship between temperature and BP in each trimester.

RESULTS

Temperatures under 15 °C elevate systolic, diastolic BP, and mean arterial pressure (SBP, DBP, and MAP) in the first trimester, while temperatures above 15 °C reduce SBP in the second and third trimesters. By using Distributed Lag Linear Models, we estimated that with a 1 °C decrease in daily temperature, the SBP and DBP increased by 0.32 (95 % CI: 0.12, 0.52) and 0.23 (95 % CI: 0.07, 0.39) mmHg, respectively, in the first trimester with a 20-day cumulative lag, while with a 1 °C increase in daily temperature, the SBP decreased by 0.23 (0.35, 0.10) mmHg in the third trimester with a 30-day cumulative lag. The significant effects of temperature mainly manifested between 2 and 4 weeks of exposure.

CONCLUSIONS

Temperature has different effects on BP over three trimesters. Protective measures to reduce cold-related BP rise will help reduce the risk of hypertensive disorders of pregnancy.

Association of blood pressure variability during acute care hospitalization and incident dementia

Background and objectives

Recognized as a potential risk factor for Alzheimer's disease and related dementias (ADRD), blood pressure variability (BPV) could be leveraged to facilitate identification of at-risk individuals at a population level. Granular BPV data are available during acute care hospitalization periods for potentially high-risk patients, but the incident ADRD risk association with BPV measured in this setting is unknown. Our objective was to evaluate the relation of BPV, measured during acute care hospitalization, and incidence of ADRD.

Methods

We retrospectively studied adults, without a prior ADRD diagnosis, who were admitted to a large quaternary care medical center in Southern California between January 1, 2013 and December 31, 2019. For all patients, determined BPV, calculated as variability independent of the mean (VIM), using blood pressure readings obtained as part of routine clinical care. We used multivariable Cox proportional hazards regression to examine the association between BP VIM during hospitalization and the development of incident dementia, determined by new ICD-9/10 coding or the new prescription of dementia medication, occurring at least 2 years after the index hospitalization.

Results

Of 81,892 adults hospitalized without a prior ADRD diagnosis, 2,442 (2.98%) went on to develop ADRD (2.6 to 5.2 years after hospitalization). In multivariable-adjusted Cox models, both systolic (HR 1.05, 95% CI 1.00-1.09) and diastolic (1.06, 1.02-1.10) VIM were associated with incident ADRD. In pre-specified stratified analyses, the VIM associations with incident ADRD were most pronounced in individuals over age 60 years and among those with renal disease or hypertension. Results were similar when repeated to include incident ADRD diagnoses made at least 1 or 3 years after index hospitalization.

Discussion

We found that measurements of BPV from acute care hospitalizations can be used to identify individuals at risk for developing a diagnosis of ADRD within approximately 5 years. Use of the readily accessible BPV measure may allow healthcare systems to risk stratify patients during periods of intense patient-provider interaction and, in turn, facilitate engagement in ADRD screening programs.

Effect of Leventhal's self-regulatory intervention on the hypertensive patients' illness perception and lifestyle: a randomized controlled trial

BACKGROUND

The perception of illness may lead to improving the hypertensive patients' lifestyle, but no study was found in this regard. Therefore, this study was conducted to determine the effect of intervention based on Leventhal's self-regulatory model on the illness perception and lifestyle of patients with hypertension.

METHODS

In the present randomized controlled trial study, ninety eligible patients with primary hypertension were randomly assigned to one of the two groups of intervention and control. Patients in the intervention group received five sessions of Leventhal's self-regulatory intervention, each of 60 min and weekly. However the control group received routine care. The outcomes were illness perception and lifestyle of the patients with hypertension. The Revised Illness Perception Questionnaire and the Lifestyle Questionnaire were administered to assess illness perception and lifestyle before the treatment to establish a baseline and subsequently 12 weeks after the intervention. The collected data were analyzed using statistical IMB SPSS software, version 21. Qualitative data were analyzed using Chi-Square test or Fisher's Exact test, and the Independent Sample t- test and Paired Sample t- test were used for analyzing quantitative data.

RESULTS

Leventhal's self-regulatory intervention improved subscales of illness perception (p < 0.05) except for emotional representations and consequences. The global mean scores of the hypertensive patients ̓ lifestyle in the intervention group significantly increased from 102.8 ± 2.3 at the baseline to 112.1 ± 3 post-intervention.

CONCLUSIONS

Interventions based on Leventhal's self-regulatory model could improve the illness perception and lifestyle of patients with hypertension. Trial registration The present randomized controlled trial study was registered on the Iranian Registry of Clinical Trials Website (IRCT); ID: IRCT20141222020401N6 on 8/5/2019.

Haze and inbound tourism: Empirical evidence from China

The impact of climate change on tourism has always been an important topic for research in the field of international tourism, and haze has been widely recognized as the primary negative factor affecting the development of inbound tourism in China. In this study, we first conduct a theoretical analysis of the mechanism through which haze influences the tourism industry, and then we empirically analyze the impact on China's inbound tourism using surface particulate matter (PM2.5) concentrations as a proxy for haze, based on provincial panel data from 1998 to 2016. The empirical results show that haze not only has an inhibitory effect on inbound tourism, but also significantly reduces the average length of stay of international tourists. In addition, while there are significant regional differences in the crowding-out effect of haze pollution on inbound tourism, the effect varies depending on the origin of inbound tourists, exhibiting the greatest negative impact on inbound tourism from Taiwan and the smallest from foreign countries. Our research highlights that haze pollution can led to the change of human tourism behavior which enrich the literature on tourism and haze.

Ambient Temperature and Cardiac Biomarkers: A Meta-Analysis

This study quantified the effect of cold or heat exposure of ambient temperature on the alteration of well-known cardiac markers. A meta-analysis was performed using the PRISMA guidelines. Peer-reviewed studies on ambient temperature and cardiac biomarkers were retrieved from MEDLINE, ScienceDirect and Google Scholar from January 2000 to February 2022. The pooled effect sizes of ambient temperature on cardiac biomarkers c-reactive protein, soluble-cell adhesion-molecule-1, soluble-intercellular-adhesion-molecule-1, total cholesterol, low-densitylipoprotein, interleukin-6, B-type-Natriuretic-Peptide; systolic/diastolic blood pressure were quantified using a random-effects meta-analysis. A total of 26 articles were included in the metaanalysis after screening the titles, abstracts and full texts. The pooled results for a 1°C decrease of ambient temperature showed an increase of 0.31% (95% CI= 0.26 to 0.38) in cardiac biomarkers (p=0.00; I-squared=99.2%; Cochran's Q=5636.8). In contrast, the pooled results for a 1°C increase in ambient temperature showed an increase of 2.03% (95% CI= 1.08 to 3.82) in cardiac biomarkers (p=0.00; I-squared=95.7%; Cochran's Q=235.2). In the cardiovascular (CV) population, the percent increase in cardiac biomarkers levels due to a decrease/increase in ambient temperature was greater. This study showed the decrease/increase in ambient temperature has a direct correlation with the alterations in cardiac biomarkers. These findings are useful for managing temperatureassociated cardiovascular mortality.

Role of blood-borne factors in sympathoexcitation-mediated hypertension: Potential neurally mediated hypertension in preeclampsia

Hypertension remains a threat for society due to its unknown causes, preventing proper management, for the growing number of patients, for its state as a high-risk factor for stroke, cardiac and renal complication and as cause of disability. Data from clinical and animal researches have suggested the important role of many soluble factors in the pathophysiology of hypertension through their neuro-stimulating effects. Central targets of these factors are of molecular, cellular and structural nature. Preeclampsia (PE) is characterized by high level of soluble factors with strong pro-hypertensive activity and includes immune factors such as proinflammatory cytokines (PICs). The potential neural effect of those factors in PE is still poorly understood. Shedding light into the potential central effect of the soluble factors in PE may advance our current comprehension of the pathophysiology of hypertension in PE, which will contribute to better management of the disease. In this paper, we summarized existing data in respect of hypothesis of this review, that is, the existence of the neural component in the pathophysiology of the hypertension in PE. Future studies would address this hypothesis to broaden our understanding of the pathophysiology of hypertension in PE.

Is there an ex-ante moral hazard on Indonesia's health insurance? An impact analysis on household waste management behavior

The presence of ex-ante moral hazard could undermine the potential gain from expanding health insurance coverage in developing nations. To test the proposition, this study utilizes a nationally representative longitudinal survey with Indonesia's health insurance for poor policy in 2014 as the quasi-experimental case study. The country represents developing nations that undergo a massive and rapid expansion of health insurance coverage. The empirical approach combines a matching and difference-in-differences method to obviate potential bias of the selectivity nature of health insurance provision and time-invariant unobserved factors. The findings suggest the presence of ex-ante moral hazard in the form of the less people using trash cans associated with the introduction of the subsidized health insurance premium. The results add empirical findings of a negative side effect of expanding health insurance coverage in developing nations.

Acute ambulatory blood pressure response to short-term black carbon exposure: The MobiliSense sensor-based study

Documented relationships between black carbon (BC) exposure and blood pressure (BP) have been inconsistent. Very few studies measured both BC exposure and ambulatory BP across the multiple daily environments visited in the general population, and none adjusted for personal noise exposure, a major confounder. Our study addresses these gaps by considering 245 adults living in the Grand Paris region. Personal exposure to BC was monitored for 2 days using AE51 microaethalometers. Ambulatory BP was measured every 30 min after waking up using Arteriograph 24 monitors (n = 6772). Mixed effect models with a random intercept at the individual level and time-autocorrelation structure adjusted for personal noise exposure were used to evaluate the associations between BC exposure (averaged from 5 min to 1 h before each BP measurement) and BP. To increase the robustness of findings, we eliminated confounding by unmeasured time-invariant personal variables, by modelling the associations with fixed-effect models. All models were adjusted for potential confounders and short-term time trends. Results from mixed models show that a 1-μg/m³ increase in 5-minute averaged BC exposure was associated with an increase of 0.57 mmHg in ambulatory systolic blood pressure (SBP) (95 % CI: 0.30, 0.83) and with an increase of 0.36 mmHg in diastolic blood pressure (DBP) (95 % CI: 0.14, 0.58). The slope of the exposure-response relationship gradually decreased for both SBP and DBP with the increase in the averaging period of BC exposure from 5 min to 1 h preceding each BP measurement. Findings from the fixed-effect models were consistent with these results. There was no effect modification by noise in the associations, across all exposure windows. We found evidence of a relationship between BC exposure and acute increase in ambulatory SBP and DBP after adjustment for personal noise exposure, with potential implications for the development of adverse cardiovascular outcomes.

Influence of depression on the association between colder indoor temperature and higher blood pressure

OBJECTIVES

Cold exposure accounts for more than 7% of all-cause mortality worldwide, and cold-induced blood pressure (BP) elevation and consequent cardiovascular events are partially responsible. For prevention, it is important to identify risk factors for exaggerated temperature-sensitivity of BP but this is not fully understood. This study investigated whether depressive symptoms affect the relationship between indoor temperature and BP.

METHODS

We conducted a cross-sectional analysis of 1076 community-based individuals who were at least 60 years of age. Depressive symptoms were assessed using the 15-item Geriatric Depression Scale at a cutoff point of 4/5. We performed ambulatory BP monitoring and indoor temperature measurement on two consecutive days during the cold season in Nara, Japan.

RESULTS

When using daytime SBP as a dependent variable, multilevel linear regression analyses showed that lower daytime indoor temperature was significantly associated with higher daytime SBP in the depressive group (n = 216, β = -0.804, P < 0.001) but not in the nondepressive group (n = 860, β = -0.173, P = 0.120); moreover, a significant interaction between depression and daytime indoor temperature was observed (P = 0.014). These relationships were independent of potential confounders including age, gender, BMI, medications, and physical activity. Similar results were obtained for morning SBP, nocturnal SBP dipping, and morning BP surge.

CONCLUSION

The results suggest that depressive participants are more likely to have cold-induced BP elevation than nondepressive participants. Further longitudinal studies are warranted to determine whether people with depressive symptoms are at a high risk for cold-related cardiovascular events.

Short- and medium-term air pollution exposure, plasmatic protein levels and blood pressure in children

Exposure to air pollution influences children's health, however, the biological mechanisms underlying these effects are not completely elucidated. We investigated the association between short- and medium-term outdoor air pollution exposure with protein profiles and their link with blood pressure in 1170 HELIX children aged 6-11 years. Different air pollutants (NO₂, PM₁₀, PM_2.5, and PM_2.5abs) were estimated based on residential and school addresses at three different windows of exposure (1-day, 1-week, and 1-year before clinical and molecular assessment). Thirty-six proteins, including adipokines, cytokines, or apolipoproteins, were measured in children's plasma using Luminex. Systolic and diastolic blood pressure (SBP and DBP) were measured following a standardized protocol. We performed an association study for each air pollutant at each location and time window and each outcome, adjusting for potential confounders. After correcting for multiple-testing, hepatocyte growth factor (HGF) and interleukin 8 (IL8) levels were positively associated with 1-week home exposure to some of the pollutants (NO₂, PM₁₀, or PM_2.5). NO₂ 1-week home exposure was also related to higher SBP. The mediation study suggested that HGF could explain 19% of the short-term effect of NO₂ on blood pressure, but other study designs are needed to prove the causal directionality between HGF and blood pressure.

Association between personal exposure to household air pollution and gestational blood pressure among women using solid cooking fuels in rural Tamil Nadu, India

BACKGROUND

The Household Air Pollution Intervention Network (HAPIN) trial is an ongoing multi-center randomized controlled trial assessing the impact of a liquified petroleum gas (LPG) cookstove and fuel intervention on health. Given the potential impacts of household air pollution (HAP) exposure from burning solid fuels on cardiovascular health during pregnancy, we sought to determine whether baseline exposures to particulate matter with an aerodynamic diameter ≤2.5 μm (PM2.5), black carbon (BC) and carbon monoxide (CO) were associated with blood pressure among 799 pregnant women in Tamil Nadu, India, one of the HAPIN trial centers.

METHODS

Multivariable linear regression models were used to examine the association between 24-h personal exposure to PM2.5/BC/CO and systolic and diastolic blood pressure, controlling for maternal age, body mass index (BMI), mother's education, household wealth, gestational age, and season. At the time of measurement, women were between 9- and 20-weeks of gestation.

RESULTS

We found that systolic blood pressure (SBP) and diastolic blood pressure (DBP) were higher in pregnant women exposed to higher levels of HAP, though only the result for CO and DBP reached conventional statistical significance (p < 0.05). We observed a positive association between CO and DBP among the entire study cohort: a 1-log μg/m3 increase in CO exposure was associated with 0.36 mmHg higher DBP (95% confidence interval [CI]: 0.02 to 0.70). The effect was stronger in pregnant women with higher CO exposures (in the 3rd [≥ 0.9 and < 2.1 ppm] and 4th quartiles [≥ 2.1 and ≤ 46.9 ppm]). We also found that pregnant women with PM2.5 exposures in the highest quartile (≥ 129.9 and ≤ 2100 μg/m3) had a borderline significant association (p = 0.054) with DBP compared to those who had PM2.5 exposures in the lowest quartile (≥ 9.4 and < 47.7 μg/m3). No evidence of association was observed for BC exposure and blood pressure.

CONCLUSION

This study contributes to limited evidence regarding the relationship between HAP exposure and blood pressure among women during pregnancy, a critical window for both mother and child's life-course health. Results from this cross-sectional study suggest that exposures to PM2.5 and CO from solid fuel use are associated with higher blood pressure in pregnant women during their first or second trimester.

Seasonal variation of blood pressure in children

Seasonal blood pressure (BP) variation is mostly found between the summer and winter months. Guidelines for diagnosis and treatment of hypertension in children have not considered this variation until recently. This review aims to present an overview of seasonal BP variation in childhood along with potential underlying pathophysiological mechanisms and long-term implications as well as conclusions for future studies. In pediatric cohorts, seven studies investigated seasonal changes in BP. These changes amount to 3.4-5.9 mmHg (or 0.5-1.5 mmHg per - 1 °C difference in environmental temperature) in systolic BP with a peak in fall or winter. Potential mechanisms and mediators of seasonal BP variation include sympathetic activation of the nervous system with an increase of urinary and plasma norepinephrine levels in the winter season. Additionally, the physical activity among children and adolescents was inversely correlated with BP levels. Temperature sensitivity of BP and pediatric BP levels predict future systolic BP and target-organ damage. Therefore, cardiovascular events may even be long-term complications of seasonal BP variation in pediatric hypertensive patients. Overall, these data strongly suggest an important effect of ambient temperature on BP in children. Additional studies in pediatric cohorts are needed to define how best to incorporate such variation into clinical practice.

Exposure to Air Pollution in Rural Malawi: Impact of Cooking Methods on Blood Pressure and Peak Expiratory Flow

We made static and personal PM2.5 measurements with a miniature monitor (RTI MicroPEM) to characterise the exposure of women cooking with wood and charcoal in indoor and outdoor locations in rural Malawi, together with measurements of blood pressure and peak expiratory flow rate (PEFR). Mean PM2.5 concentrations of 1338 and 31 µg/m3 were observed 1 m from cookstove locations during cooking with wood and charcoal, respectively. Similarly, mean personal PM2.5 exposures of 706 and 94 µg/m3 were observed during cooking with wood and charcoal, respectively. Personal exposures to PM2.5 in indoor locations were 3.3 and 1.7 times greater than exposures observed in equivalent outdoor locations for wood and charcoal, respectively. Prior to the measured exposure, six out of eight participants had PEFR observations below 80% of their expected (age and height) standardised PEFR. We observed reductions in PEFR for participants cooking with wood in indoor locations. Five out of eight participants reported breathing difficulties, coughing, and eye irritation when cooking with wood but reported that symptoms were less severe when cooking with charcoal. In conclusion, we observed that exposure to PM2.5 was substantially reduced by cooking outdoor with charcoal. As both wood and charcoal fuels are associated with negative environmental and health impacts, the adoption of high-efficiency cookstoves and less polluting sources of energy will be highly beneficial. Cooking outside whenever possible, and minimising the time spent in close proximity to stoves, may be simple interventions that could reduce the risks of exacerbation and progression of respiratory and cardiovascular diseases in Malawi.

The Impact on Blood Pressure of a Short-Term Change in Indoor Temperature

Objective

The aim of this study is to evaluate the impact on blood pressure (BP) of a 10°C change in room temperature (between 18°C and 28°C).

Methods

A total of 112 volunteers, 56 males and 56 females, 55 with and 57 without hypertension, were enrolled in the study. First, the participants were placed in a 25°C room. Second, they were randomly assigned to either a 28°C (group A) or an 18°C room (group B). Finally, they were moved from the 28°C to the 18°C room, or vice versa. They stayed in each room for 20 minutes. Seated BP was measured at the 17th and 19th minute in each room, and the average was used. The difference in the subject's BP between the second two rooms was recorded as delta BP.

Results

The baseline systolic BP (SBP), age, gender distribution, and incidence of hypertension were similar between the two groups. In group A, the decrease in room temperature of 10°C induced a mean rise in SBP of 4.1 mmHg. In group B, the increase of 10°C caused SBP to decrease by 4.0 mmHg. When compared with the group without hypertension, the group with hypertension had a significantly higher rise in mean SBP (6.8 vs 1.2 mmHg) as a result of the decrease in temperature and a significantly higher drop in SBP (7.3 vs 1.2 mmHg) as a result of the increase in temperature. The participants in the group with hypertension were older.

Conclusion

A 10°C change in room temperature, from 18°C to 28°C, for 20 min can cause a significant change in SBP. The extent of this change is more obvious in the older group.

Environmental Contaminant Body Burdens and the Relationship with Blood Pressure Measures Among Indigenous Adults

Supplemental Digital Content is available in the text.

Blood pressure (BP) increase cardiovascular disease (CVD) risk. Indigenous Canadians experience slightly higher CVD compared with nonIndigenous Canadians. This study examined the role of polychlorinated biphenyls (PCBs), other organic compound concentrations (OCs), and toxic metals on blood pressure measures among Indigenous Canadians.

Impact of short- and long-term exposure to air pollution on blood pressure: A two-decade population-based study in Tehran

Plenty of recent studies on the impact of air pollution on blood pressure (BP) exist; however, there is a lack of data for the highly polluted Eastern Mediterranean region. We evaluated the associations of short-term exposure to air pollutants with systolic BP (SBP) and diastolic BP (DBP) and the long-term impact of air pollutants on incident hypertension, among Tehranian adults. In the Tehran Lipid and Glucose Study, 4580 nonhypertensive participants aged 20-69 years (41.6% male) were followed from 2001 to 2018 through 3-year follow-ups and 4-5 examinations of them were recorded. The air pollutants included particulate matter with a diameter ≤10 μm (PM₁₀), carbon monoxide (CO), ozone (O₃), nitrogen dioxide (NO₂), and sulfur dioxide (SO₂). The mixed-effects transition model estimated the air pollution impact on BP. The proportional hazards Weibull model measured the long-term effects of air pollutants on the multivariate hazard of incident hypertension. The air pollutants were put in the models in the form of mean annual level, applying three versions of 1, 2, and 3 years before the follow-ups. During a median follow-up of 12.3 years, 1618 cases of hypertension were found. In the short-term, increase in CO did not affect SBP but decreased DBP with a delay effect lasting for 14 days; increase in NO₂ raised SBP with a 14-day lag, however did not change DBP; increase in O₃ reduced SBP with a 14-day lag but made slight non-significant increase in DBP; rise in PM₁₀ concentrations led to increased SBP (lag 0-3 days) and DBP with lags of 0-3 days and 12-14 days and increase in SO₂ made the largest increases in DBP with lags lasting for 14 days, but did not affect SBP. Regarding incident hypertension in the long-term, the increase in CO had no significant effect; increase in NO₂ decreased the risk over the 2- and 3-year time spans; rise in O₃, PM₁₀, and SO₂ levels increased the risk in all time spans; the largest hazard ratio [1.96 (95% CI: 1.48, 2.62)] for incident hypertension was attributable to PM₁₀ in 3 years. Considering the major effects of air pollutants including O₃, SO₂, and especially PM₁₀ on incident hypertension, urgent public health policies should be implemented to reduce the burden of air pollution in metropolitan city of Tehran.

Influence of altitude on hypertension phenotypes and responses to antihypertensive therapy: Review of the literature and design of the INTERVENCION trial

Systemic arterial hypertension constitutes the leading cause of mortality worldwide, and affects people living at different altitudes above sea level (AASL). AASL has a major impact on cardiovascular function and various biologic pathways that regulate blood pressure-related phenotypes, but whether it affects the clinical response to antihypertensive therapy is unknown. The hemodynamic adaptations observed among lowlanders acutely exposed to high altitude (HA) is distinct from those observed among HA dwellers. However, the phenotypic patterns of hypertension and the response to standard antihypertensive agents among adults chronically exposed to different AASL are poorly understood. The authors describe the protocol for the INTERVENCION trial, a randomized clinical trial designed to assess the effects of three first-line antihypertensive monotherapies (a thiazide diuretic, an angiotensin receptor blocker, and a calcium channel blocker) on peripheral and central blood pressure, in-office blood pressure, and ambulatory blood pressure hemodynamics of hypertensive patients living at different AASL (low altitude, intermediate altitude, and high altitude). The primary end point is the reduction in 24-hour brachial systolic blood pressure. The INTERVENCION trial will provide the first clinical trial data regarding the influence of AASL on the response to antihypertensive monotherapy, as well as the hemodynamic characteristics of arterial hypertension at different AASL.

Urinary Sodium Excretion and Blood Pressure Relationship across Methods of Evaluating the Completeness of 24-h Urine Collections

We compared the sodium intake and systolic blood pressure (SBP) relationship from complete 24-h urine samples determined by several methods: self-reported no-missed urine, creatinine index ≥0.7, measured 24-h urine creatinine (mCER) within 25% and 15% of Kawasaki predicted urine creatinine, and sex-specific mCER ranges (mCER 15-25 mg/kg/24-h for men; 10-20 mg/kg/24-h for women). We pooled 10,031 BP and 24-h urine sodium data from 2143 participants. We implemented multilevel linear models to illustrate the shape of the sodium-BP relationship using the restricted cubic spline (RCS) plots, and to assess the difference in mean SBP for a 100 mmol increase in 24-h urine sodium. The RCS plot illustrated an initial steep positive sodium-SBP relationship for all methods, followed by a less steep positive relationship for self-reported no-missed urine, creatinine index ≥0.7, and sex-specific mCER ranges; and a plateaued relationship for the two Kawasaki methods. Each 100 mmol/24-h increase in urinary sodium was associated with 0.64 (95% CI: 0.34, 0.94) mmHg higher SBP for self-reported no-missed urine, 0.68 (95% CI: 0.27, 1.08) mmHg higher SBP for creatinine index ≥0.7, 0.87 (95% CI: 0.07, 1.67) mmHg higher SBP for mCER within 25% Kawasaki predicted urine creatinine, 0.98 (95% CI: -0.07, 2.02) mmHg change in SBP for mCER within 15% Kawasaki predicted urine creatinine, and 1.96 (95% CI: 0.93, 2.99) mmHg higher SBP for sex-specific mCER ranges. Studies examining 24-h urine sodium in relation to health outcomes will have different results based on how urine collections are deemed as complete.

Past Sodium Intake, Contemporary Sodium Intake, and Cardiometabolic Health in Southwest Coastal Bangladesh

Background We compared the relationship of past and contemporary sodium (Na) intake with cardiometabolic biomarkers. Methods and Results A total of 1191 participants' data from a randomized controlled trial in coastal Bangladesh were analyzed. Participants provided 24-hour urine Na (24UNa) data for 5 monthly visits. Their fasting blood glucose, total cholesterol, triglycerides, high-density lipoprotein, blood pressure, and 24-hour urine protein were measured at the fifth visit. Participants' mean 24UNa over the first 4 visits was the past Na, and 24UNa of the fifth visit was the contemporary Na intake. We estimated the prevalence ratios of elevated cardiometabolic biomarkers and metabolic syndrome across 24UNa tertiles by multilevel logistic regression using participant-, household-, and community-level random intercepts. Models were adjusted for age, sex, body mass index, smoking, physical activity, alcohol consumption, sleep hours, religion, and household wealth. Compared with participants in tertile 1 of past urine Na, those in tertile 3 had 1.46 (95% CI, 1.08-1.99) times higher prevalence of prediabetes or diabetes mellitus, 5.49 (95% CI, 2.73-11.01) times higher prevalence of large waist circumference, and 1.60 (95% CI, 1.04-2.46) times higher prevalence of metabolic syndrome. Compared with participants in tertile 1 of contemporary urine Na, those in tertile 3 had 1.93 (95% CI, 1.24-3.00) times higher prevalence of prediabetes or diabetes mellitus, 3.14 (95% CI, 1.45-6.83) times higher prevalence of proteinuria, and 2.23 (95% CI, 1.34-3.71) times higher prevalence of large waist circumference. Conclusions Both past and contemporary Na intakes were associated with higher cardiometabolic disease risk.

Blood Pressure in Andean Adults Living Permanently at Different Altitudes

Vinueza Veloz, Andrés Fernando, Aymaru Kailli Yaulema Riss, Chris I. De Zeeuw, Tannia Valeria Carpio Arias, and María Fernanda Vinueza Veloz. Blood pressure in Andean adults living permanently at different altitudes. High Alt Med Biol. 21:360-369, 2020. Aims: To estimate the association between blood pressure (BP) and chronic exposure to altitude in nonhypertensive Andean adults, while taking ethnicity into consideration. Materials and Methods: Sample included 10,041 nonhypertensive adults with indigenous or mixed ethnic background (the latter also referred to as mestizos), who permanently lived at different altitudes. BP was measured following international recommendations. Altitude was measured in meters above the sea level (masl) using a global positioning system. Data were analyzed through linear regression models with restricted cubic splines. Results: A significant nonlinear relation between altitude and systolic blood pressure (SBP) as well as diastolic blood pressure (DBP) was found (both p < 0.001). BP described a j-shaped curve, where the minimum was observed between 750 and 1250 masl, from where both SBP and DBP rose as altitude increased. These associations were independent from sex, age, index of economic wellbeing, body mass index, and years of education. Interestingly, at all altitudes indigenous people had lower SBP and DBP in comparison to mestizos (both p < 0.001). Conclusions: Living permanently at altitudes ≥750 masl is associated with higher SBP and DBP in Andean dwellers and this association is modulated by their ethnic background.

Effect of an Informative Video on Anxiety and Hemodynamic Parameters in Patients Requiring Mandibular Third Molar Extraction: A Randomized Clinical Trial

PURPOSE

The purpose was to determine the effect of watching an informative video about mandibular third molar (M3M) removal on patient anxiety and hemodynamic parameters.

PATIENTS AND METHODS

A randomized controlled clinical trial was carried out in healthy patients (aged between 18 and 40 years) requiring M3M extraction under local anesthesia. Patients with previous tooth extractions, psychiatric disorders, or cardiac problems or patients undergoing anxiolytic or antidepressant drug treatment were excluded. Participants were randomized into 2 groups according to whether they watched an informative video about the surgical procedure (video group) or not (control group). The primary outcome variable was the difference between groups regarding patient anxiety assessed with the State-Trait Anxiety Inventory (STAI) and the Modified Dental Anxiety Scale (MDAS). The secondary outcome variables were hemodynamic parameters recorded during different moments of the surgical procedure. Descriptive, bivariate, and multivariate analyses were performed, and a repeated-measures mixed model was generated. Statistical significance was considered for P < .05.

RESULTS

Fifty patients referred for M3M extraction met the inclusion criteria. The final data analysis was based on 47 patients: 25 from the video group and 22 controls. The bivariate analysis showed the video group to have a significant decrease in anxiety as measured by the MDAS (P = .006; 95% confidence interval [CI], -4.1 to -0.7) and STAI-State (P = .003; 95% CI, -13.7 to -0.7). A significantly lower heart rate was likewise found in the video group (χ² = 4.30, df = 1, P = .038). The linear regression analysis adjusting for the STAI-Trait also showed lower dental anxiety measured by the MDAS in the video group (P = .023; 95% CI, 0.32 to 4.14).

CONCLUSIONS

Providing preoperative information through an informative video about M3M removal significantly reduces patient anxiety and heart rate during the surgical procedure.

Early-Life Environmental Exposures and Blood Pressure in Children

BACKGROUND

Growing evidence exists about the fetal and environmental origins of hypertension, but mainly limited to single-exposure studies. The exposome has been proposed as a more holistic approach by studying many exposures simultaneously.

OBJECTIVES

This study aims to evaluate the association between a wide range of prenatal and postnatal exposures and blood pressure (BP) in children.

METHODS

Systolic and diastolic BP were measured among 1,277 children from the European HELIX (Human Early-Life Exposome) cohort aged 6 to 11 years. Prenatal (n = 89) and postnatal (n = 128) exposures include air pollution, built environment, meteorology, natural spaces, traffic, noise, chemicals, and lifestyles. Two methods adjusted for confounders were applied: an exposome-wide association study considering the exposures independently, and the deletion-substitution-addition algorithm considering all the exposures simultaneously.

RESULTS

Decreases in systolic BP were observed with facility density (β change for an interquartile-range increase in exposure: -1.7 mm Hg [95% confidence interval (CI): -2.5 to -0.8 mm Hg]), maternal concentrations of polychlorinated biphenyl 118 (-1.4 mm Hg [95% CI: -2.6 to -0.2 mm Hg]) and child concentrations of dichlorodiphenyldichloroethylene (DDE: -1.6 mm Hg [95% CI: -2.4 to -0.7 mm Hg]), hexachlorobenzene (-1.5 mm Hg [95% CI: -2.4 to -0.6 mm Hg]), and mono-benzyl phthalate (-0.7 mm Hg [95% CI: -1.3 to -0.1 mm Hg]), whereas increases in systolic BP were observed with outdoor temperature during pregnancy (1.6 mm Hg [95% CI: 0.2 to 2.9 mm Hg]), high fish intake during pregnancy (2.0 mm Hg [95% CI: 0.4 to 3.5 mm Hg]), maternal cotinine concentrations (1.2 mm Hg [95% CI: -0.3 to 2.8 mm Hg]), and child perfluorooctanoate concentrations (0.9 mm Hg [95% CI: 0.1 to 1.6 mm Hg]). Decreases in diastolic BP were observed with outdoor temperature at examination (-1.4 mm Hg [95% CI: -2.3 to -0.5 mm Hg]) and child DDE concentrations (-1.1 mm Hg [95% CI: -1.9 to -0.3 mm Hg]), whereas increases in diastolic BP were observed with maternal bisphenol-A concentrations (0.7 mm Hg [95% CI: 0.1 to 1.4 mm Hg]), high fish intake during pregnancy (1.2 mm Hg [95% CI: -0.2 to 2.7 mm Hg]), and child copper concentrations (0.9 mm Hg [95% CI: 0.3 to 1.6 mm Hg]).

CONCLUSIONS

This study suggests that early-life exposure to several chemicals, as well as built environment and meteorological factors, may affect BP in children.

'My blood pressure is low today, do you have the heating on?' The association between indoor temperature and blood pressure

OBJECTIVES

The independent association of indoor temperature with blood pressure (BP) is poorly understood and is not routinely considered in hypertension diagnosis or research. Questions remain as to whether the effect of indoor temperature on BP is confounded or modified by other factors.

METHODS

This study used data from the Health Survey for England 2014, consisting of 4659 community-dwelling adults aged 16 years and over, interviewed from January to December. Multivariable regression models were used to determine whether indoor temperature was related to levels of BP, and whether these relationships were confounded by other factors, including mean monthly outdoor temperature.

RESULTS

After controlling for confounding variables, a 1°C decrease in indoor temperature was associated with rises of 0.48 mmHg (95% confidence interval: -0.72 to -0.25) in SBP and 0.45 mmHg (95% confidence interval: -0.63 to -0.27) in DBP. The magnitude of association of indoor temperature with DBP and SBP was modified by physical activity. The indoor temperature-BP relationship was stronger in people who do not take physical activity regularly than people who exercise regularly.

CONCLUSION

The size of the independent association between indoor temperature and BP suggests it should be considered in the clinical management of hypertension and in hypertension research. Room temperature should also be considered as a modifiable risk factor in hypertension-related mortality and morbidity.

The influence of the North Atlantic Oscillation index on arterial blood pressure

AIM

to detect the complex association between arterial blood pressure (BP) and air temperature, atmospheric pressure, relative humidity, wind speed, and North Atlantic oscillation (NAO) indices.

METHODS

Data were obtained from the survey performed in the framework of the international Health, Alcohol and Psychosocial Factors in Eastern Europe study. The number of individuals used in the models or other analysed groups was 7077. The association between environmental variables and SBP and DBP were evaluated by applying the multiple regression analysis, adjusting for health-related and weather variables.

RESULTS

More than one-half (58.7%) of the respondents had high BP, and 39.4% of the respondents had taken drugs for high BP during the last 2 weeks. Among the respondents, the mean SBP and DBP were 141.6 ± 22.2 and 90.4 ± 12.5 mmHg, respectively. An increase in SBP was associated with the presence of a lower relative humidity, and a higher wind speed and extreme atmospheric pressure with a lag of 2 days. During the period of spring-autumn, continuous NAO indices on the same day and a positive NAO on the same and on 2 previous days were negatively associated with the SBP value. A positive NAO was associated (P = 0.001) with a decrease in SBP by 1.7 mmHg in all participants, by 2.30 mmHg in physically active participants, and by 3.62 mmHg in the elderly, as compared with a negative NAO.

CONCLUSION

These results provided new evidence that the NAO index may be affect the value of SBP and DBP in the elderly during the period of spring-autumn.

Productivity and physiological responses during exposure to varying air temperatures and clothing conditions

This study assessed the effects of clothing and air temperature combinations on workplace productivity and physiological response. Ten male Japanese subjects were exposed to six combinations of clothing (0.3 clo and 0.9 clo) and air temperature (16°C, 26°C, and 36°C) during which cognitive performance (Bourdon and calculation tests), manual motor performance (finger-tapping test), and physiological responses (heart rate, blood pressure, and skin and oral temperatures) were measured. Both cold exposure and lower clothing levels likely increased the Bourdon test performance. Calculation test performance tended to be affected by exposure to cold or neutral temperatures at the beginning of the test. Cold exposure undermined manual motor performance (especially when combined with fewer clothing items) while heat exposure significantly increased heart rate. Both cold exposure and higher clothing level during heat exposure increased blood pressure. Body temperature, particularly mean skin temperature, increased with higher air temperature and was significantly influenced by clothing insulation during cold exposure. These results provide novel evidence for the effects of clothing and air temperature (particularly cold) on human productivity and physiological responses in humans.

Ambient air pollution as a mediator in the pathway linking race/ethnicity to blood pressure elevation: The multi-ethnic study of atherosclerosis (MESA)

BACKGROUND

Racial/ethnic disparities in blood pressure and hypertension have been evident in previous studies, as were associations between race/ethnicity with ambient air pollution and those between air pollution with hypertension. The role of air pollution exposure to racial/ethnic differences in hypertension has not been explored.

OBJECTIVE

To assess the potential mediating effects of ambient air pollution on the association between race/ethnicity and blood pressure levels.

METHODS

We studied 6,463 White, Black, Hispanic and Chinese adults enrolled across 6 US cities. Systolic (SBP) and diastolic blood pressure (DBP) were measured at Exam 1 (2000-2002) and Exam 2 (2002-2004). Household-level annual average concentrations of fine particulate matter (PM_2.5), oxides of nitrogen (NO_X), and ozone (O₃) for the year 2000 were estimated for participants.

RESULTS

The difference in SBP levels by race/ethnicity that was related to higher PM_2.5 concentrations compared with White men ("indirect associations") was 0.3 (95% CI: 0.1, 0.6) mmHg for Black men, 0.3 (95% CI: 0.1, 0.6) mmHg for Hispanic men and 1.0 (95% CI: 0.2, 1.8) mmHg for Chinese men. Findings were similar although not statistically significant for women. PM_2.5 did not mediate racial/ethnic differences in DBP. Indirect associations were significant for O₃ for SBP among women and men and for DBP among men. In contrast, racial/ethnic disparities were attenuated due to exposure to NO_X.

CONCLUSION

Racial disparities in blood pressure were reduced after accounting for PM_2.5 and ozone while increased after accounting for NO_X.

Short-term effects of air pollution on blood pressure

Elevated blood pressure (BP) has been proposed as a possible pathophysiological mechanism linking exposure to ambient air pollution and the increased risk of cardiovascular mortality and morbidity. In this study, we investigated the hourly relationship between ambient air pollutants and BP. BP measurements were extracted from the electronic health record database of the Seoul National University Bundang Hospital from February 2015 to June 2017. A total of 98,577 individual BP measurements were matched to the hourly levels of air pollutants. A generalized additive model was constructed for hour lags of 0–8 of air pollutants adjusting for age, sex, meteorological variables, and time trend. Systolic BP was shown to be significantly lower at 2–4 hours and 3–5 hours after increased levels of SO₂ and CO, respectively (0.24 mmHg and 0.26 mmHg for an interquartile range, respectively). In contrast, O₃ and NO₂ were associated with significantly increased systolic BP at 3–5 lag hours and at 0–2 lag hours, respectively. BP elevation in association with O₃ and NO₂ was shown to be significantly greater in hypertensive patients than normotensive subjects. Our findings suggest that short-term exposure to air pollution may be associated with elevated BP.

Conditional prescriptions of oral antihypertensive drugs for the management of hypertension urgencies in the inpatient setting: An observational study

WHAT IS KNOWN AND OBJECTIVES

The management of hypertension urgencies during hospitalization may generally not necessitate urgent care. However, physicians frequently prescribe 'as needed' antihypertensive drugs for which administration is triggered by blood pressure thresholds. The lack of rationale for this hospital practice led us to study oral conditional antihypertensive (OCA) prescriptions. We aimed to estimate the prevalence of OCA prescriptions and to establish their characteristics.

METHODS

In our institution, prescriptions are computerized. The study was retrospectively performed using a hospital clinical data warehouse over a 5-year period.

RESULTS AND DISCUSSION

The prevalence of OCA prescriptions was 6.9% among subjects treated with an antihypertensive drug. The median duration of these prescriptions was 4 days, until the day of the patient discharge in 78.8% stays. The calcium channel inhibitors were the main (79.9%) pharmacological class prescribed, with mostly prescriptions of nicardipine. OCA prescriptions were associated with another antihypertensive medication in 58.8% of the prescriptions; for 19.3%, it was a medication belonging to the same pharmacological class than the OCA drug prescribed. Regarding the computerized drafting, 39.6% of the conditional prescriptions were considered uninterpretable. At least one administration by nurses concerned 65.1% of the OCA prescriptions. The mean SBP and DBP before the initiation of an OCA drug was 142.9 ± 28.2 and 75.8 ± 24.5 mm Hg, respectively, relative to 143.0 ± 24.9 and 77.6 ± 19.9 mm Hg after the initiation (P = .8 for SBP and P = .06 for DBP).

WHAT IS NEW AND CONCLUSION

The originality of this study lies in the use of a clinical data warehouse to evaluate OCA prescriptions in hospital. These prescriptions are current, often uninterpretable and mostly ordered until patient discharge. Such drug orders could be associated with an increased risk of iatrogenic events and/or administration errors. This underlies the need for developing decision support tools and computerized protocols to manage hypertension urgencies.

Associations Between Sub-Clinical Markers of Cardiometabolic Risk and Exposure to Residential Indoor Air Pollutants in Healthy Adults in Perth, Western Australia: A Study Protocol

BACKGROUND

A growing body of epidemiological and clinical evidence has implicated air pollution as an emerging risk factor for cardiometabolic disease. Whilst individuals spend up to two-thirds of daily time in their domestic residential environment, very few studies have been designed to objectively measure the sub-clinical markers of cardiometabolic risk with exposure to domestic indoor air pollutants. This cross-sectional study aims to investigate associations between the components of domestic indoor air quality and selected sub-clinical cardiometabolic risk factors in a cohort of healthy adults living in Perth, Western Australia.

METHODS

One hundred and eleven non-smoking adults (65% female) living in non-smoking households who were aged between 35-69 years were recruited for the project. Study subjects were invited to participate in all sections of the study, which included: Domestic indoor air monitoring along with the concurrent 24 h ambulatory monitoring of peripheral and central blood pressure and measures of central hemodynamic indices, standardized questionnaires on aspects relating to current health status and the domestic environment, a 24 h time-activity diary during the monitoring period, and clinic-based health assessment involving collection of blood and urine biomarkers for lipid and glucose profiles, as well as measures of renal function and an analysis of central pulse wave and pulse wave velocity.

RESULTS

This study provides a standardized approach to the study of sub-clinical cardiometabolic health effects that are related to the exposure to indoor air pollution.

CONCLUSION

The findings of this study may provide direction for future research that will further contribute to our understanding of the relationship that exists between indoor air pollution and sub-clinical markers of cardiometabolic risk.

Air Pollution and Cardiovascular Disease: JACC State-of-the-Art Review

Fine particulate matter <2.5 μm (PM_2.5) air pollution is the most important environmental risk factor contributing to global cardiovascular (CV) mortality and disability. Short-term elevations in PM_2.5 increase the relative risk of acute CV events by 1% to 3% within a few days. Longer-term exposures over several years increase this risk by a larger magnitude (∼10%), which is partially attributable to the development of cardiometabolic conditions (e.g., hypertension and diabetes mellitus). As such, ambient PM_2.5 poses a major threat to global public health. In this review, the authors provide an overview of air pollution and health, including assessment of exposure, impact on CV outcomes, mechanistic underpinnings, and impact of air pollution reduction strategies to mitigate CV risk. The review concludes with future challenges, including the inextricable link between air pollution and climate change, and calls for large-scale trials to allow the promulgation of formal evidence-based recommendations to lower air pollution-induced health risks.

The state of hypertension care in 44 low-income and middle-income countries: a cross-sectional study of nationally representative individual-level data from 1·1 million adults

BACKGROUND

Evidence from nationally representative studies in low-income and middle-income countries (LMICs) on where in the hypertension care continuum patients are lost to care is sparse. This information, however, is essential for effective targeting of interventions by health services and monitoring progress in improving hypertension care. We aimed to determine the cascade of hypertension care in 44 LMICs-and its variation between countries and population groups-by dividing the progression in the care process, from need of care to successful treatment, into discrete stages and measuring the losses at each stage.

METHODS

In this cross-sectional study, we pooled individual-level population-based data from 44 LMICs. We first searched for nationally representative datasets from the WHO Stepwise Approach to Surveillance (STEPS) from 2005 or later. If a STEPS dataset was not available for a LMIC (or we could not gain access to it), we conducted a systematic search for survey datasets; the inclusion criteria in these searches were that the survey was done in 2005 or later, was nationally representative for at least three 10-year age groups older than 15 years, included measured blood pressure data, and contained data on at least two hypertension care cascade steps. Hypertension was defined as a systolic blood pressure of at least 140 mm Hg, diastolic blood pressure of at least 90 mm Hg, or reported use of medication for hypertension. Among those with hypertension, we calculated the proportion of individuals who had ever had their blood pressure measured; had been diagnosed with hypertension; had been treated for hypertension; and had achieved control of their hypertension. We weighted countries proportionally to their population size when determining this hypertension care cascade at the global and regional level. We disaggregated the hypertension care cascade by age, sex, education, household wealth quintile, body-mass index, smoking status, country, and region. We used linear regression to predict, separately for each cascade step, a country's performance based on gross domestic product (GDP) per capita, allowing us to identify countries whose performance fell outside of the 95% prediction interval.

FINDINGS

Our pooled dataset included 1 100 507 participants, of whom 192 441 (17·5%) had hypertension. Among those with hypertension, 73·6% of participants (95% CI 72·9-74·3) had ever had their blood pressure measured, 39·2% of participants (38·2-40·3) had been diagnosed with hypertension, 29·9% of participants (28·6-31·3) received treatment, and 10·3% of participants (9·6-11·0) achieved control of their hypertension. Countries in Latin America and the Caribbean generally achieved the best performance relative to their predicted performance based on GDP per capita, whereas countries in sub-Saharan Africa performed worst. Bangladesh, Brazil, Costa Rica, Ecuador, Kyrgyzstan, and Peru performed significantly better on all care cascade steps than predicted based on GDP per capita. Being a woman, older, more educated, wealthier, and not being a current smoker were all positively associated with attaining each of the four steps of the care cascade.

INTERPRETATION

Our study provides important evidence for the design and targeting of health policies and service interventions for hypertension in LMICs. We show at what steps and for whom there are gaps in the hypertension care process in each of the 44 countries in our study. We also identified countries in each world region that perform better than expected from their economic development, which can direct policy makers to important policy lessons. Given the high disease burden caused by hypertension in LMICs, nationally representative hypertension care cascades, as constructed in this study, are an important measure of progress towards achieving universal health coverage.

FUNDING

Harvard McLennan Family Fund, Alexander von Humboldt Foundation.

Ambient Particulate Air Pollution and Blood Pressure in Peri-urban India

BACKGROUND

Evidence linking long-term exposure to particulate air pollution to blood pressure (BP) in high-income countries may not be transportable to low- and middle-income countries. We examined cross-sectional associations between ambient fine particulate matter (PM2.5) and black carbon (BC) with BP (systolic [SBP] and diastolic [DBP]) and prevalent hypertension in adults from 28 peri-urban villages near Hyderabad, India.

METHODS

We studied 5531 participants from the Andhra Pradesh Children and Parents Study (18-84 years, 54% men). We measured BP (2010-2012) in the right arm and defined hypertension as SBP ≥130 mmHg and/or DBP ≥80 mmHg. We used land-use regression models to estimate annual average PM2.5 and BC at participant's residence. We applied linear and logistic nested mixed-effect models stratified by sex and adjusted by cooking fuel type to estimate associations between within-village PM2.5 or BC and health.

RESULTS

Mean (SD) PM2.5 was 33 µg/m (2.7) and BC was 2.5 µg/m (0.23). In women, a 1 µg/m increase in PM2.5 was associated with 1.4 mmHg higher SBP (95% confidence interval [CI]: 0.12, 2.7), 0.87 mmHg higher DBP (95% CI: -0.18, 1.9), and 4% higher odds of hypertension (95% CI: 0%, 9%). In men, associations with SBP (0.52 mmHg; 95% CI: -0.82, 1.8), DBP (0.41 mmHg; 95% CI: -0.69, 1.5), and hypertension (2% higher odds; 95% CI: -2%, 6%) were weaker. No associations were observed with BC.

CONCLUSION

We observed a positive association between ambient PM2.5 and BP and hypertension in women. Longitudinal studies in this region are needed to corroborate our findings.

Resistant Hypertension: Detection, Evaluation, and Management: A Scientific Statement From the American Heart Association

Resistant hypertension (RH) is defined as above-goal elevated blood pressure (BP) in a patient despite the concurrent use of 3 antihypertensive drug classes, commonly including a long-acting calcium channel blocker, a blocker of the renin-angiotensin system (angiotensin-converting enzyme inhibitor or angiotensin receptor blocker), and a diuretic. The antihypertensive drugs should be administered at maximum or maximally tolerated daily doses. RH also includes patients whose BP achieves target values on ≥4 antihypertensive medications. The diagnosis of RH requires assurance of antihypertensive medication adherence and exclusion of the "white-coat effect" (office BP above goal but out-of-office BP at or below target). The importance of RH is underscored by the associated risk of adverse outcomes compared with non-RH. This article is an updated American Heart Association scientific statement on the detection, evaluation, and management of RH. Once antihypertensive medication adherence is confirmed and out-of-office BP recordings exclude a white-coat effect, evaluation includes identification of contributing lifestyle issues, detection of drugs interfering with antihypertensive medication effectiveness, screening for secondary hypertension, and assessment of target organ damage. Management of RH includes maximization of lifestyle interventions, use of long-acting thiazide-like diuretics (chlorthalidone or indapamide), addition of a mineralocorticoid receptor antagonist (spironolactone or eplerenone), and, if BP remains elevated, stepwise addition of antihypertensive drugs with complementary mechanisms of action to lower BP. If BP remains uncontrolled, referral to a hypertension specialist is advised.

Acute effects of temperature exposure on blood pressure: An hourly level panel study

BACKGROUND

Several epidemiological studies have shown that blood pressure changes with temperature based on the daily temperature and linear relationship assumption. However, little is known about the true curve shape of the relationship between temperature and blood pressure.

OBJECTIVES

The objective of this study was to investigate the non-linear relationship between hourly temperature and blood pressure.

METHODS

This is a prospective panel study comprising 100 participants in Suzhou, China. The blood pressure of each participant was measured >50 times between October 2013 and January 2016. Hourly temperature data were derived from the nearest monitoring station owned by the China Meteorological Administration. A Distributed Lag Nonlinear Model (DLNM) was used to investigate the relationship between hourly temperature and blood pressure.

RESULTS

We found that the relationship between hourly temperature and blood pressure was parabolic. Short-term exposure to hourly temperatures had significant cold and heat effects on systolic blood pressure (SBP), diastolic blood pressure (DBP), pulse pressure (PP), and mean arterial pressure (MAP). The hourly temperature had a significant lag effect on blood pressure, with a lag time of 0-5 h. Alcohol users were more sensitive to the cold effects of hourly temperature, and the diabetic population was more sensitive to the heat effects of hourly temperature on PP.

CONCLUSION

Temperature imparts short-term effects on blood pressure. Therefore, timely protective measures during cold waves or cold weather are beneficial to maintain stable blood pressure levels to reduce the risk of blood pressure related diseases.

Obesity and season as determinants of high blood pressure in a school-based screening study

This school-based screening study assessed the prevalence of high blood pressure (BP) levels according to the European Society of Hypertension (ESH) 2016 guidelines. Moreover, risk factors for BP elevation, and the effect of geographic and seasonal factors on BP screening were investigated. BP and anthropometric measurements were obtained from 2832 children and adolescents, aged 6-18 years, during the period 2013-2016. Three BP measurements were performed using a mercury sphygmomanometer, and the mean of the last two was used for the analysis. Obesity was defined according to the International Obesity Task Force (IOTF) criteria. The prevalence of high-normal BP/hypertension and overweight/obesity was 3.7%/0.9%, and 22.9%/8.5%, respectively. The majority of the participants presenting high BP (≥90th percentile) were overweight or obese. Increased prevalence of high BP was observed during spring (5.5%) and winter (5%) compared with 2.5% in autumn (P<0.05). SBP z scores were higher in males, during spring and summer, and in urban areas. In conclusion, a low rate of high-normal and hypertensive BP levels was found despite the high prevalence of overweight and obesity. Overweight and obesity were associated with higher BP levels, but there was also a seasonal difference in the prevalence of high BP levels.