help button home button
AJRCCM
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
Published ahead of print on November 21, 2002, doi:10.1164/rccm.200208-851OC
This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow All Versions of this Article:
200208-851OCv1
167/4/538    most recent
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Right arrow reprints & permissions
Citing Articles
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Kony, S.
Right arrow Articles by Neukirch, F.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Kony, S.
Right arrow Articles by Neukirch, F.
American Journal of Respiratory and Critical Care Medicine Vol 167. pp. 538-543, (2003)
© 2003 American Thoracic Society

Original Article

Rhinitis Is Associated with Increased Systolic Blood Pressure in Men

A Population-based Study

Sabine Kony, Mahmoud Zureik, Catherine Neukirch, Bénédicte Leynaert, Daniel Vervloet and Françoise Neukirch

Unit 408, Respiratory Diseases Epidemiology, National Institute of Health and Medical Research (INSERM), Paris, and Unit 258, Cardiovascular Epidemiology, INSERM, Villejuif; and Pneumo-Allergology Service, Respiratory Diseases Department, Sainte-Marguerite Teaching Hospital, Marseille, France

Correspondence and requests for reprints should be addressed to Mahmoud Zureik, M.D., Ph.D., INSERM U408, Epidémiologie des Maladies Respiratoires, Faculté Xavier Bichat, 16 rue Henri Huchard, 75018 Paris, France. E-mail: zureik{at}vjf.inserm.fr


   ABSTRACT
TOP
 ABSTRACT
METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
An association between impaired lower respiratory function and cardiovascular risk factors, such as hypertension, is often reported but it is unknown whether there is a relationship between upper airway disorders and cardiovascular risk factors, despite evidence that upper and lower respiratory tract disorders are closely linked. Our objective was to assess whether rhinitis is associated with arterial blood pressure and hypertension. In a population-based study of 330 adults aged 28–56 years, as part of the European Community Respiratory Health Survey, rhinitis was assessed by means of a questionnaire, and cardiovascular data were obtained using a questionnaire and by measuring blood pressure. Systolic blood pressure (SBP) was higher in men with rhinitis than in men without rhinitis (130.6 ± 12.7 mm Hg versus 123.5 ± 13.9 mm Hg; p = 0.002), and it was still the case after adjustment for cardiovascular and respiratory confounding factors. Hypertension was more frequent in men with rhinitis than in men without rhinitis, even after multivariate adjustment (odds ratio = 2.6, 95% confidence interval = [1.14–5.91]). The observation of SBP levels according to whether men have no rhinitis, seasonal rhinitis, or perennial rhinitis was compatible with a dose–response relationship (p for trend = 0.02). In conclusion, rhinitis is strongly associated with SBP and hypertension in men. Blood pressure should be regularly checked in men with rhinitis.

Key Words: rhinitis • blood pressure • hypertension

Numerous epidemiologic studies have suggested that impaired lower respiratory function (expressed by the FEV1 and/or the peak expiratory flow) is associated with some cardiovascular risk factors (1) and with atherosclerosis (2), arterial stiffness (3), cardiovascular diseases, and mortality (4, 5). However, the physiopathologic mechanisms underlying these associations are not known.

In contrast, no studies have assessed the association between upper airway disorders, such as rhinitis, and cardiovascular alterations, although many epidemiologic studies have shown that lower and upper airway disorders are associated (6–8).

In addition, rhinitis might be related to cardiovascular risk factors, particularly hypertension (9), as rhinitis is associated with snoring and obstructive sleep apnea (OSA) (8–12) and as snoring and OSA are associated with hypertension (13–16).

The high prevalence of both rhinitis and hypertension—approximately 25% of the population living in industrialized countries (17, 18)—intensifies the interest to know whether there is actually an association between rhinitis and arterial blood pressure. The present study was performed with this purpose.


   METHODS
TOP
 ABSTRACT
 METHODS
RESULTS
 DISCUSSION
 REFERENCES
 
Study Participants
Data were collected in Hôpital Bichat (Paris, France), between October 1999 and May 2001, as part of the follow-up phase of the European Community Respiratory Health Survey (ECRHS-II). The methods used in this study have been described elsewhere (19). Briefly, 660 subjects aged 20–44 years were randomly selected from the electoral rolls of the 18th district of Paris. These subjects were examined at the hospital between 1992 and 1993 (ECRHS-I). Three hundred and thirty subjects could be contacted again and accepted to be examined a second time between 1999 and 2001 for ECRHS-II.

Study Protocol
During the second examination, each subject answered a standardized questionnaire administered by trained interviewers and underwent lung function tests. Subjects who answered "yes" to the question: "Do you have any nasal allergies including ‘hay fever’?" were considered to suffer from rhinitis (6, 20, 21). Subjects with rhinitis who reported that they "got a runny or stuffy nose or started to sneeze" when they were "near trees, grass or flowers, or when there is a lot of pollen about" were considered to have seasonal nasal symptoms. Rhinitic subjects who reported that they "got a runny or stuffy nose or started to sneeze" when they were "near animals, such as cats, dogs or horses, near feathers, including pillows, quilts or duvets, or in a dusty part of the house" were considered to have perennial nasal symptoms (6, 22–24). Subjects with both perennial and seasonal symptoms were grouped with the subjects with perennial symptoms. Subjects who answered "yes" to both "Have you ever had asthma?" and "Was it confirmed by a doctor?" were considered to suffer from asthma. Smoking status was defined by the cumulative smoking exposure. It was assessed as pack-years (number of packs smoked per day multiplied by the number of years of smoking).

FVC and FEV1 were measured with a water-sealed bell spirometer (Biomedin, Padova, Italy). Lung function was assessed by FEV1 %pred and FEV1 %FVC. Predicted FEV1 values were calculated according to sex, height, and age (25).

In addition to the general ECRHS-II protocol, the participants were asked to complete a standardized questionnaire on conventional cardiovascular risk factors, and their arterial pressure was measured. Both systolic and diastolic blood pressures (SBP and DBP) were measured with a digital electronic tensiometer (Model CP750, Omron Electronics SARL, Fontenay sous Bois, France). Two independent measurements were taken with a 5-minute interval, with the subjects in a lying position. We used the second values for the statistical analyses. Subjects were classified as being hypertensive when their SBP was at least 140 mm Hg, and/or their DBP was at least 90 mm Hg, and/or they reported using an antihypertensive treatment (26). Patients were considered to have hypercholesterolemia if they answered "yes" to at least one of the following questions: "Have you ever been told your cholesterol level was too high?" and "Do you currently use any lipid-lowering drugs?" Body mass index (BMI) was calculated as weight in kilograms divided by the square of height in meters. Nonfasting total serum cholesterol levels were determined using standard methods.

The protocol was approved by the French Ethics Committee for Human Research and by the National Committee for Data Processing and Freedom. Written informed consent was obtained from each subject before inclusion in the study.

Statistical Analysis
Respiratory and/or cardiovascular data were not available for 14 of the 330 subjects who attended the follow-up assessment. Consequently, the study population consisted of 316 subjects, 146 men and 170 women. The characteristics of the excluded subjects (n = 14) were similar to those of the subjects in the study sample, in particular with regard to FEV1 %pred, rhinitis, asthma, SBP, DBP, and smoking status.

Data were analyzed with version 8.1 of SAS (SAS Institute, Cary, NC). All analyses were performed in men and in women separately. In univariate analyses, with rhinitis or hypertension as the dependent variable, chi-square tests and t tests were used to compare qualitative and quantitative variables, respectively. The relationships between SBP or DBP and quantitative variables were assessed with Pearson's correlation coefficient (r). In multivariate analyses, where all potential confounding factors were taken into account, the mean arterial blood pressures (± SD) of subjects with and without rhinitis were compared using analysis of covariance. Univariate and multivariate logistic regressions were used to analyze the relationship between rhinitis and hypertension. p Values below 0.05 were considered to be significant.


   RESULTS
TOP
 ABSTRACT
 METHODS
 RESULTS
DISCUSSION
 REFERENCES
 
Study Population
Table 1 shows the characteristics of the study population according to sex. BMI was higher among men than among women. Asthma and rhinitis tended to be less frequent in men than in women. SBP and DBP were higher in men, and hypertension was more frequent.


View this table:
[in this window]
[in a new window]
  		TABLE 1. Characteristics of the subjects included in the analysis in 2000–2001 sorted by sex

 
Associations between Blood Pressure and Demographic, Respiratory, and Cardiovascular Risk Factors, by Sex
Age was significantly associated with SBP in women (r = 0.27, p < 0.001) and tended to be so in men (r = 0.14; p = 0.08). SBP was positively associated with BMI in both men and women (r = 0.32, p < 0.001 and r = 0.33, p < 0.001, respectively) and with total serum cholesterol level (r = 0.20, p = 0.02 and r = 0.24, p = 0.002, respectively). SBP was not associated with cumulative smoking exposure (in pack-years) among men (p = 0.8) but tended to be negatively so among women (p = 0.07). SBP was higher in men with asthma than in men without asthma (133.4 ± 11.9 mm Hg versus 125.3 ± 13.9 mm Hg; p = 0.03). SBP was not associated with either FEV1 %pred or FEV1 %FVC in men (r = -0.009, p = 0.90 and r = -0.10, p = 0.20). In women, SBP tended to be negatively associated with FEV1 %pred (r = -0.13, p = 0.08) but was not associated with FEV1 %FVC (r = 0.05, p = 0.50). Similar patterns of results were observed for DBP and for hypertension.

Associations between Rhinitis and Demographic, Respiratory, and Cardiovascular Risk Factors, by Sex
Associations between rhinitis and potential confounding factors are shown in Table 2 . There was no association between rhinitis and age, cumulative smoking exposure, FEV1 %pred, FEV1 %FVC, or cholesterol either in men or in women. An association between rhinitis and BMI was observed in women. As expected, rhinitis was significantly associated with asthma both in men and women.


View this table:
[in this window]
[in a new window]
  		TABLE 2. Associations between rhinitis and demographic, respiratory, and cardiovascular risk factors, by sex

 
Associations between Rhinitis and Arterial Blood Pressure, by Sex
Men with rhinitis had a higher SBP than did men without rhinitis (130.6 ± 12.7 versus 123.5 ± 13.9 mm Hg, p = 0.002) (Table 3) . This result remained similar when common potential confounding factors (age, BMI, hypercholesterolemia, and smoking status) were taken into account (129.9 ± 13.2 versus 123.6 ± 13.3 mm Hg, p = 0.006). Additional adjustment for asthma and/or FEV1 (FEV1 %pred or FEV1 %FVC) did not alter this result. In the models including asthma and rhinitis simultaneously, the association between SBP and asthma observed in the univariate analysis disappeared. No association was found between rhinitis and SBP in women either before or after adjustment for common potential confounding factors (Table 3). Rhinitis was not associated with DBP in men or in women (Table 3).


View this table:
[in this window]
[in a new window]
  		TABLE 3. Association between rhinitis and sbp and dbp, by sex

 
When the analysis was performed in men without asthma alone, SBP was still higher among subjects with rhinitis than among ones without rhinitis (129.2 ± 13.0 versus 123.5 ± 14.0 mm Hg, p = 0.03). This result remained similar after adjustment for the potential confounding factors (128.2 ± 13.1 versus 123.6 ± 13.0 mm Hg, p = 0.07).

Furthermore, when men were stratified according to their smoking status, SBP was always higher in men with rhinitis than in men without rhinitis in each stratum, before and after multivariate adjustment, although statistical significance was not always reached (Table 4) .


View this table:
[in this window]
[in a new window]
  		TABLE 4. Association between rhinitis and sbp, in men, according to smoking status

 
Treatment was also taken into account. Eighteen of the men had used corticoids in the last 12 months (10 subjects used steroid nasal sprays alone, 5 used inhaled steroids alone, 2 used nasal sprays plus inhaled steroids, and 1 used nasal sprays plus oral steroids). In the 127 men who had not been treated with steroids, a higher SBP was still observed among men with rhinitis than among men without rhinitis (129.8 ± 12.8 versus 123.9 ± 14.0 mm Hg, p = 0.02). This result remained similar after adjustment for the potential confounding factors (128.8 ± 12.6 versus 124.1 ± 12.6 mm Hg, p = 0.05).

Lastly, we studied SBP according to whether the men had seasonal or perennial rhinitis (Figure 1) . SBP was higher as symptoms of rhinitis were more frequent (p for trend = 0.02 in univariate analysis and 0.03 after adjustment for confounding factors).



View larger version (39K):
[in this window]
[in a new window]
  		Figure 1. SBP values (mm Hg; mean [SD]) of men with no rhinitis, seasonal rhinitis, or perennial rhinitis (p for trend = 0.02). Categories of rhinitis were assessed for 45 of 56 men with rhinitis. SBP = systolic blood pressure.

 
Hypertension
Hypertension was more frequent in men with rhinitis than in men without rhinitis (35.7 versus 15.6%, p = 0.005; odds ratio = 3.0, 95% confidence interval = [1.37–6.64]), and this was still the case after adjustment for the potential confounding factors (odds ratio = 2.6, 95% confidence interval = 1.14–5.91). A similar trend was observed among men without asthma, after stratification according to smoking status, and in men who had not received steroids.

There was also a positive association between the frequency of hypertension and the frequency of symptoms of rhinitis: hypertension was present in 15.6% of the men without rhinitis, 30.8% of the men with rhinitis with seasonal symptoms, and 34.4% of the men with rhinitis with perennial symptoms (p for trend = 0.02).


   DISCUSSION
TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
REFERENCES
 
Main Findings
We found that SBP was higher in men with rhinitis than in men without rhinitis, even after adjustment for major known confounding factors. Furthermore, SBP was higher in men with rhinitis than in men without rhinitis in the subgroup of men without asthma and in men who had not received steroids, and tended to be higher in each stratum of cumulative smoking exposure. Hypertension was more frequent in men with rhinitis than in men without rhinitis.

Data Validity
The validity of our results is supported by the quality of the data collected in the ECRHS (19, 27). Rhinitis was defined as in several other population-based studies (20–24). The epidemiologic definition of ECRHS is also referenced in the latest recommendations from "Allergic Rhinitis and its Impact on Asthma" and the World Health Organization (28). Of the 131 patients who reported that they had rhinitis, all except 23 (11 men and 12 women) also reported that they got seasonal or perennial symptoms of rhinitis (see the definition in METHODS). There was a strong association between the self-reported rhinitis of ECRHS-II and those of ECRHS-I (p < 0.0001). Moreover, atopy (assessed by means of skin prick tests and IgE levels) was strongly associated with self-reported rhinitis in ECRHS-I (6).

Finally, the factors we found to be associated with rhinitis are usually reported to be so in the literature (6, 7, 29). We also found that arterial blood pressure (SBP, DBP, and hypertension) was associated with the expected cardiovascular risk factors such as sex, age, BMI, and cholesterol (30).

We did not find any relationship between cumulative smoking exposure and blood pressure. This result is consistent with previously published studies that showed that smoking is not a cause of persistent hypertension. This relationship is indeed much debated: some authors reported a positive association between smoking and hypertension whereas others reported a lower arterial blood pressure in current smokers than in nonsmokers or found a higher rate of hypertension in former smokers—rather than current smokers—compared with nonsmokers (31, 32).

Strength of the Relationship between Rhinitis and SBP and Hypertension
The association between rhinitis and SBP in men appeared to be strong. The magnitude of the difference between men with rhinitis and men without rhinitis, approximately 7 mm Hg—more than half the difference between men and women—is clinically relevant. In fact, recent meta-analyses of clinical trials comparing treatments in patients with hypertension have reported tight differences in SBP, often smaller than in our study, and pointed out that reductions in blood pressure, rather than baseline values of blood pressure, accounted largely and independently for most differences in the outcome of cardiovascular events (33, 34).

We also found that rhinitis was associated with hypertension, even after multivariate adjustment. This finding emphasizes the potential clinical relevance of our study as hypertension identifies a category of patients with a high cardiovascular risk profile.

We checked the association between rhinitis and blood pressure among men without asthma, as asthma was associated with both rhinitis—in our study and in the literature (6, 7)—and blood pressure. Associations between asthma and cardiovascular diseases (35), SBP (36), and hypertension (36, 37) have previously been suggested in some studies. The fact that in our study the association between asthma and SBP disappeared only when rhinitis was taken into account suggests that this association could be partly explained by rhinitis.

We also analyzed men who had not received steroids because corticosteroids may increase blood pressure (38). In the different subgroups (i.e., subjects without asthma and men who had not been treated with steroids), SBP was still higher in men with rhinitis than in men without rhinitis. In each smoking stratum, SBP was also higher in men with rhinitis than in men without rhinitis, but statistical significance was not always reached, probably because of the small number of subjects.

The results of our additional analysis of SBP level according to whether rhinitis was seasonal or perennial are consistent with the possibility of a dose–response relationship.

Possible Mechanisms
To our knowledge, no studies have ever been performed on the relationship between rhinitis and blood pressure. The mechanisms of this relationship are thus completely unknown. It is possible that rhinitis is associated with an increased blood pressure partly due to snoring or OSA. This hypothesis has been evoked in a previous review of all potential and known complications of rhinitis (9).

Rhinitis has previously been shown to be associated with both the main symptoms of OSA (snoring and daytime sleepiness) and OSA itself (10, 12). This is probably due to partial or complete nasal obstruction being inherent in rhinitis (11). In turn, OSA and surrogate markers, like snoring, are associated with arterial blood pressure and/or hypertension (13, 15, 16), and there is strong evidence that the mechanisms of blood pressure regulation are severely affected by OSA and consequent hypoxia (14).

Rhinitis was found to be associated with SBP but not with DBP. It is well known that measurement errors and intra-individual variability are greater for DBP than for SBP. In addition, SBP and DBP do not depend on the same hemodynamic mechanisms. In contrast to DBP, which is primarily due to the vascular resistance of small peripheral arteries, SBP may increase due to three main factors: an increase in the velocity of ventricular ejection and/or stroke volume, a reduction in the viscoelastic properties of the large arteries, and a modification in the timing of the reflected waves within the arterial tree (39). Thus, elevated SBP is not systematically combined with elevated DBP (40). In addition, it has been shown that SBP is a stronger predictor of adverse cardiovascular events and total mortality than is DBP (41). Nevertheless, the mechanisms that might explain the differential association of SBP and DBP with rhinitis are unknown. Further studies are thus needed to investigate the nature of the association between rhinitis and arterial blood pressure.

Why in Men and Not in Women?
The association between rhinitis and SBP or hypertension was not found in women. This may be partly due to the fact that women are protected from cardiovascular morbidity before menopause (42). Furthermore, after menopause, SBP increases slowly, approaching that in men by 60 to 80 years age (43, 44). This increase in blood pressure takes on average 5 to 20 years to develop (44). The women in our study sample were rather young (median age 45 years, range 28–55 years) and still have relatively low blood pressures (i.e., compared with men and with the threshold used to define hypertension).

In addition, if OSA is actually implicated in the association between rhinitis and hypertension, this is consistent with the absence of this association in the women in our sample. Indeed, before menopause, women are protected from OSA. A recent study, performed on a large random sample of the general population, reported that the prevalence of OSA is quite low in premenopausal women compared with that in men and postmenopausal women (45).

Conclusion
Rhinitis was strongly associated with SBP and hypertension among men in our population-based study. The high prevalence of both rhinitis and hypertension emphasizes the importance of such results. These findings open up a field of investigations and may have easy-to-implement repercussions in clinical practice. To begin with, men with rhinitis, both with seasonal and perennial symptoms, should have regular blood pressure checks.


   Acknowledgments
 
The authors thank the Center of Clinical Investigations (CIC) staff of the Bichat Teaching Hospital for its valuable contributions to the data collection, and especially Isabelle Poirier for her reliable and continuous technical assistance.


   FOOTNOTES
 
Supported by UCB Pharma-France (for the data collection of the European Community Respiratory Health Survey follow-up phase [CRHS-II] in Paris).

Received in original form August 12, 2002; accepted in final form November 18, 2002


   REFERENCES
TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 

  1. Griffith KA, Sherrill DL, Siegel EM, Manolio TA, Bonekat HW, Enright PL. Predictors of loss of lung function in the elderly: the Cardiovascular Health Study. Am J Respir Crit Care Med 2001;163:61–68.[Abstract/Free Full Text]
  2. Zureik M, Kauffmann F, Touboul P-J, Courbon D, Ducimetière P. Association between peak expiratory flow and the development of carotid atherosclerotic plaques. Arch Intern Med 2001;161:1669–1676.[Abstract/Free Full Text]
  3. Zureik M, Benetos A, Neukirch C, Courbon D, Bean K, Thomas F, Ducimetière P. Reduced pulmonary function is associated with central arterial stiffness in men. Am J Respir Crit Care Med 2001;164:2181–2185.[Abstract/Free Full Text]
  4. Weiss ST, Segal MR, Sparrow D, Wager C. Relation of FEV1 and peripheral blood leukocyte count to total mortality: the Normative Aging Study. Am J Epidemiol 1995;142:493–498.[Abstract/Free Full Text]
  5. Hole DJ, Watt GC, Davey-Smith G, Hart CL, Gillis CR, Hawthorne VM. Impaired lung function and mortality risk in men and women: findings from the Renfrew and Paisley prospective population study. BMJ 1996;313:711–715.[Abstract/Free Full Text]
  6. Leynaert B, Bousquet J, Neukirch C, Korobaeff M, Liard R, Neukirch F. Perennial rhinitis: an independent risk factor for asthma in nonatopic subjects. Results from the European Community Respiratory Health Survey. J Allergy Clin Immunol 1999;104:301–304.[CrossRef][Medline]
  7. Leynaert B, Neukirch F, Demoly P, Bousquet J. Epidemiologic evidence for asthma and rhinitis comorbidity. J Allergy Clin Immunol 2000;106:201–205.[Medline]
  8. Passalacqua G, Canonica GW. Impact of rhinitis on airway inflammation: biological and therapeutic implications. Respir Res 2001;2:320–323.[CrossRef][Medline]
  9. Settipane RA. Complications of allergic rhinitis. Allergy Asthma Proc 1999;20:209–213.[Medline]
  10. Young T, Finn L, Kim H for the University of Wisconsin Sleep and Respiratory Research Group. Nasal obstruction as a risk factor for sleep-disordered breathing. J Allergy Clin Immunol 1997;99:757–762.[CrossRef][Medline]
  11. Kushida CA, Guileminault C, Clerk AA, Dement WC. Nasal obstruction and obstructive sleep apnea: a review. Allergy Asthma Proc 1997;18:69–71.[CrossRef][Medline]
  12. Larsson LG, Lindberg A, Franklin KA, Lundback B. Symptoms related to obstructive sleep apnea are common in subjects with asthma, chronic bronchitis and rhinitis in a general population. Respir Med 2001;95:423–429.[CrossRef][Medline]
  13. Lindberg E, Janson C, Gislason T, Svärdsudd K, Hetta J, Boman G. Snoring and hypertension: a 10 year follow-up. Eur Respir J 1998;11:884–889.[Abstract]
  14. Hedner J, Grote L. Cardiovascular consequences of obstructive sleep apnea. In: McNicholas WT, editor. Respiratory disorders during sleep. Sheffield: European Respiratory Society Journals Ltd; 1998. p. 227–265.
  15. Nieto FJ, Young TB, Lind BK, Shahar E, Samet J, Redline S, D'Agostino RB, Newman AB, Lebowitz MD, Pickering TG. Association of sleep-disordered breathing, sleep apnea, and hypertension in a large community-based study (Sleep Heart Health Study). JAMA 2000;283:1829–1836.[Abstract/Free Full Text]
  16. Peppard PE, Young T, Palta M, Skatrud J. Prospective study of the association between sleep-disordered breathing and hypertension. N Engl J Med 2000;342:1378–1384.[Abstract/Free Full Text]
  17. European Community Respiratory Health Survey. Variations in the prevalence of respiratory symptoms, self-reported asthma attacks, and use of asthma medication in the European Community Respiratory Health Survey (ECRHS). Eur Respir J 1996;9:687–695.[Abstract]
  18. Hansson L, Lloyd A, Anderson P, Kopp Z. Excess morbidity and cost of failure to achieve targets for blood pressure control in Europe. Blood Press 2002;11:35–45.[CrossRef][Medline]
  19. Burney PGJ, Luczynska C, Chinn S, Jarvis D for the European Community Respiratory Health Survey. The European Community Respiratory Health Survey. Eur Respir J 1994;7:954–960.[Abstract]
  20. Jogi R, Janson C, Björnsson E, Boman G, Björksten B. The prevalence of asthmatic respiratory symptoms among adults in Estonian and Swedish university cities. Allergy 1996;51:331–336.[Medline]
  21. Plaschke PP, Janson C, Norrman E, Björnsson E, Ellbjär, Järvhom B. Onset and remission of allergic rhinitis and asthma and the relationship with atopic sensitization and smoking. Am J Respir Crit Care Med 2000;162:920–924.[Abstract/Free Full Text]
  22. Droste JHJ, Kerkhof M, De Monchy JGR, Schouten JP, Rijcken B, and the Dutch ECRHS group. Association of skin test reactivity, specific IgE, total IgE, and eosinophils with nasal symptoms in a community-based population study. J Allergy Clin Immunol 1996;97:922–932.[CrossRef][Medline]
  23. Leynaert B, Neukirch C, Liard R, Bousquet J, Neukirch F. Quality of life in allergic rhinitis and asthma: a population-based study of young adults. Am J Respir Crit Care Med 2000;162:1391–1396.[Abstract/Free Full Text]
  24. Leynaert B, Neukirch C, Jarvis D, Chinn S, Burney P, Neukirch F. Does living on a farm during childhood protect against asthma, allergic rhinitis and atopy in adulthood? Am J Respir Crit Care Med 2001;164:1829–1834.[Abstract/Free Full Text]
  25. Quanjer PH, Tammeling GJ, Cotes JE, Pedersen OF, Peslin R, Yernault J-C. Lung volumes and forced ventilatory flows. Eur Respir J Suppl 1993;6:5–40.
  26. The sixth report of the Joint National Committee on prevention, detection, evaluation, and treatment of high blood pressure. Arch Intern Med 1997;157:2413–2446.[Abstract]
  27. Janson C, Anto P, Burney P, Chinn S, de Marco R, Heinrich J, Jarvis D, Kuenzli N, Leynaert B, Luczynska C, et al. The European Community Respiratory Health Survey: what are the main results so far? Eur Respir J 2001;18:598–611.[Abstract/Free Full Text]
  28. Bousquet J, Van Cauwenberge P, Khaltaev N. ARIA Workshop Group; World Health Organization: allergic rhinitis and its impact on asthma. J Allergy Clin Immunol 2001;108 (Suppl. 5):S147–S334.[CrossRef][Medline]
  29. Huang SL, Shiao G, Chou P. Association between body mass index and allergy in teenage girls in Taiwan. Clin Exp Allergy 1999;29:323–329.[CrossRef][Medline]
  30. Lindholm LH. Cardiovascular risk factors and their interactions in hypertensives. J Hypertens Suppl 1991;9:3–6.
  31. Goldbourt U, Medalie J. Characteristics of smokers, non-smokers and ex-smokers among 10 000 adults males in Israel. Am J Epidemiol 1977;105:75–86.[Abstract/Free Full Text]
  32. Halimi J-M, Giraudeau B, Vol S, Cacès E, Nivet H, Tichet J. The risk of hypertension in men: direct and indirect effects of chronic smoking. J Hypertens 2002;20:187–193.[CrossRef][Medline]
  33. Staessen JA, Gasowski J, Wang JG, Thijs L, Hond ED, Boissel J-P, Coope J, Ekbom T, Gueyffier F, Liu L, et al. Risks of untreated and treated isolated systolic hypertension in the elderly: meta-analysis of outcome trials. Lancet 2000;355:865–872.[CrossRef][Medline]
  34. Staessen JA, Wang JG, Thijs L. Cardiovascular protection and blood pressure reduction: a meta-analysis. Lancet 2001;358:1305–1315.[CrossRef][Medline]
  35. Robinette CD, Fraumeni JF. Asthma and subsequent mortality in World War II veterans. J Chronic Dis 1978;31:619–624.[CrossRef][Medline]
  36. Stebbings JH Jr. The relationship of allergies to hypertension and other chronic diseases: some methodologic considerations. Am J Epidemiol 1974;100:161–164.[Free Full Text]
  37. Salako BL, Ajayi SO. Bronchial asthma: a risk factor for hypertension? Afr J Med Med Sci 2000;29:47–50.[Medline]
  38. Maxwell SRJ, Moots RJ, Kendall MJ. Corticosteroids: do they damage the cardiovascular system? Postgrad Med J 1994;70:863–870.[Abstract]
  39. Smulyan H, Safar ME. The diastolic blood pressure in systolic hypertension. Ann Intern Med 2000;132:233–237.[Abstract/Free Full Text]
  40. Cushman WC. The clinical significance of systolic hypertension. Am J Hypertens 1998;11(Suppl. 1):182–185.
  41. Kannel W, Sorlie P, Gordon T. Labile hypertension: a faulty concept? The Framingham Study. Circulation 1980;61:1183–1187.[Abstract/Free Full Text]
  42. Reckelhoff JF. Gender differences in the regulation of blood pressure. Hypertension 2001;37:1199–1208.[Abstract/Free Full Text]
  43. Wiinber N, Hoegholm A, Christensen HR, Bang LE, Mikkelsen KL, Nielsen PE, Svendsen TL, Kampmann JP, Madsen NH, Bentzon MW. 24-h ambulatory blood pressure in 352 normal Danish subjects, related to age and gender. Am J Hypertens 1995;8:978–986.[CrossRef][Medline]
  44. Burl VL, Whelton P, Roccella EJ, Brown C, Culter JA, Higgins M, Horan MJ, Labarthe D. Prevalence of hypertension in the US adult population: results from the Third National Health and Nutrition Examination Survey. 1988–1991. Hypertension 1995;25:305–313.[Abstract/Free Full Text]
  45. Bixler EO, Vgontzas AN, Lin HM, Ten Have T, Rein J, Vela-Bueno A, Kales A. Prevalence of sleep disordered breathing in women: effects of gender. Am J Respir Crit Care Med 2001;163:608–613.[Abstract/Free Full Text]




This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow All Versions of this Article:
200208-851OCv1
167/4/538    most recent
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Right arrow reprints & permissions
Citing Articles
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Kony, S.
Right arrow Articles by Neukirch, F.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Kony, S.
Right arrow Articles by Neukirch, F.

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
Proc. Am. Thorac. Soc. Am. J. Respir. Cell Mol. Biol.
Copyright © 2003 American Thoracic Society