Published ahead of print on September 18, 2003, doi:10.1164/rccm.200304-525OC
© 2003 American Thoracic Society Rhinitis and Blood Pressure in AdultsInstitute of Epidemiology, GSF–National Research Center for Environment and Health, Neuherberg; and Department of Indoor Climatology, Institute of Occupational, Social and Environmental Medicine, University of Jena, Erfurt, Germany Correspondence and requests for reprints should be addressed to Dr. Joachim Heinrich, GSF—Institute of Epidemiology, PO Box 1129, D-85758 Neuherberg, Germany. E-mail: joachim.heinrich{at}gsf.de
Recently, a study of 330 adults reported increased systolic blood pressure and higher hypertension rates in men with rhinitis. We replicated this study using data from a population-based sample of 896 subjects participating in the European Respiratory Health Survey and in a study on "Monitoring of Trends and Determinants of Cardiovascular Diseases" in Erfurt, Germany. Rhinitis was assessed by questionnaire, blood pressure was measured using a standardized method, and subjects were asked about current use of any high blood pressure medication. After adjustment for age, body mass index, and smoking, neither average systolic (p = 0.17) nor diastolic blood pressure (p = 0.60) was statistically significantly different between men with and without rhinitis. The adjusted prevalence rate of hypertension was also not different between males with and without rhinitis (p = 0.25). In addition, no statistically significant associations between rhinitis and blood pressure were seen in women. We could not confirm the conclusion of the previous study that men with rhinitis need special attention for blood pressure control.
Key Words: rhinitis • blood pressure • hypertension • ECRHS • MONICA Sabine Kony and colleagues report that systolic blood pressure (SBP) and rates of hypertension were significantly higher in men with rhinitis than in men without rhinitis (1) in a population-based study of 330 adults aged 28 to 56 years, as part of the European Community Respiratory Health Survey. Although the authors provide a thoughtful explanation of their results, in particular why their main finding was restricted to men and not found in women, the underlying physiopathologic mechanisms remain unknown (1). Because rhinitis symptoms are known to be associated with snoring and obstructive sleep apnea (2–4) and snoring and obstructive sleep apnea are associated with hypertension (5, 6), an association between rhinitis and blood pressure seems to be plausible. Kony and coworkers claim that a low cardiovascular morbidity rate in premenopausal women may explain why the reported association was restricted to men (1). We tried to replicate their results using a similar data set.
In 1991 to 1992, we conducted a study in Erfurt, Germany, with 1,168 subjects aged 20 to 64 years (response rate 56.4%) (7, 8). To ensure the comparability of the findings between both studies, we restricted the analyses to subjects aged 28 to 56 years (n = 896). We used the European Community Respiratory Health Survey study protocol (7, 9) and the MONICA (monitoring of trends and determinants of cardiovascular diseases) protocol (10). Therefore, the definition of rhinitis between both European Community Respiratory Health Survey study centers in Paris and Erfurt was identical. Briefly, subjects who responded "yes" to the question: "Do you have any nasal allergy including ‘hay fever’?" were categorized as subjects who suffer from rhinitis. Those subjects who "got a runny or stuffy nose or started sneeze" when they were exposed to "trees, grass or flowers, or when there are a lot of pollen about" were considered as having seasonal rhinitis. Subjects suffering from rhinitis who had symptoms, while being near "animals, such as cats, dogs or horses, near feathers including pillows, quilts or duvets, or in dusty parts of the house" were assessed as having perennial allergic rhinitis. If symptoms arose with exposure to both scenarios, the subjects were categorized as belonging to the perennial rhinitis group. Blood pressure was measured using a calibrated sphygmomanometer. In accordance with the MONICA protocol, two independent measurements were taken with a 5-minute pause after 5 minutes in an unchanged sitting position. The mean of these two measurements was analyzed in this study (8). Thus, blood pressure measurement in this study was different than in the Kony study with respect to equipment (spygmomanometer vs. digital electronic tensiometer), blood pressure readings (mean of two vs. use of second measurements only), and position of subjects (sitting vs. supine). Hypertension was defined analogously to Kony and coworkers (1) as blood pressure greater than or equal to 140 mm Hg systolic or 90 mm Hg diastolic or the reported use of antihypertensive medication. The data were analyzed separately for men and women. We applied linear and logistic regression models to analyze differences between subjects suffering from rhinitis and nonsufferers. SAS version 8.0 was used for all calculations (SAS Institute, Cary, NC). The Ethics Committee of the Medical School in Erfurt approved the study protocol.
Table 1 shows some characteristics of the European Community Respiratory Health Survey–Erfurt Survey (1991–1992) study population included in this analysis.
Neither average systolic nor diastolic blood pressure was statistically significantly different between men with and without rhinitis (Table 2) . The results for women were also not statistically significant. The adjusted prevalence rates of hypertension assessed as high blood pressure (  140/90 mm Hg) or antihypertensive medication were also not different between men with and without rhinitis in men (adjusted odds ratio, 1.49; 95% confidence interval, 0.755–2.942; p = 0.25) and women with and without rhinitis (adjusted odds ratio, 1.15; 95% confidence interval, 0.582–2.270; p = 0.69). Restricting the data to only the antihypertensive medicated hypertension group did not show any statistically significant differences between rhinitis and nonrhinitis groups of men (14.9 vs. 7.9%, p = 0.11) or of women (7.1 vs. 14.0%, p = 0.20). Moreover, the prevalence rates for systolic hypertension did not differ between rhinitis and nonrhinitis groups of men (44.7 vs. 33.2%, p = 0.12) or women (25.0 vs. 26.4%, p = 0.82). Sensitivity analyses for the seasonal and perennial allergic rhinitis subgroups did not show statistically significantly higher SBP levels compared with the nonrhinitis group in men (mean ± SD: 129.2 ± 17.6 and 140.1 ± 17.8 mm Hg vs. 135.0 ± 17.0 [reference group]) and women (mean ± SD: 131.5 ± 13.3 and 130.4 ± 21.8 mm Hg vs. 132.1 ± 18.6 mm Hg [reference group]). Average diastolic blood pressure levels were not different between these three subgroups for men (85.4 ± 10.5 and 85.2 ± 12.4 mm Hg vs. 87.2 ± 11.6 [reference group]) or for women (84.5 ± 8.8 and 81.7 ± 12.9 mm Hg vs. 83.2 ± 10.4 mm Hg as reference group). Prevalence rates for hypertension antihypertensive medication did not show any meaningful difference between the three subcategories (data not shown). Moreover, if only systolic hypertension (SBP 140 mm Hg) was considered, the prevalence rate was also not statistically significant between seasonal and perennial allergic subgroups and the no rhinitis subgroup (data not shown).
Our findings were consistent with the results of the Paris study showing no association between rhinitis and blood pressure in women, but the results for men were different. In contrast to the Paris data, no increased trend of SBP was seen for the seasonal and perennial allergic subgroups in men. For women, both studies consistently show no statistically significant difference in SBP between the seasonal and perennial allergic subgroup and the no rhinitis group as referent. There are much higher prevalence rates for rhinitis in the Paris center compared with the Erfurt center (38 vs. 10% in men, 44 vs. 13% in women), which are consistent with reported results from the first survey in 1991 to 1993 in both European Community Respiratory Health Survey centers (9). Because participation rates were quite similar between both studies, participation bias is unlikely to cause the difference between these prevalence rates. The different prevalence rates of allergic rhinitis seem to be unrelated to different levels of SBP in men. The prevalence of hypertension defined as blood pressure above 140/90 mm Hg or the use of antihypertensive medication was higher in this study than in Kony's study (44 vs. 23% for men, 30 vs. 15% for women). The absence of observer bias is one advantage of using automated devices, but conventional measurement remains the standard method for assessment of blood pressure (11). Nevertheless, we could not exclude that the different measurement devices used in the two studies affected blood pressure readings and the prevalence of hypertension. In a comparison of blood pressure measurements in sitting and supine positions, slightly higher average blood pressure recordings were found for supine position measurement (2 mm Hg for systolic, 2 mm Hg for diastolic) (12), but this difference does not explain the higher sitting blood pressure levels in Erfurt. Finally, other representative population-based samples within the MONICA study showed higher levels of blood pressure in Germany; specifically in East German populations compared with the French MONICA centers (SBP [men]: 141 mm Hg in the East German center and 125 to 135 mm Hg for the three French centers, SBP [women]: 137 vs. 117–129 mm Hg) (13). We could not exclude that using different equipment for blood pressure measurement, or only the second blood pressure measurement in Paris and the mean between the two measurements in Erfurt, or using the blood pressure data in supine position in Paris and in sitting position in Erfurt, might contribute to the inconsistent findings between rhinitis and blood pressure in men in both studies. Nevertheless, we consider it unlikely, that the different prevalence rates of hypertension and rhinitis in Erfurt and Paris explain the different results but are unable to completely rule out that possibility. A strength of our study is the large sample size, which is nearly three times larger than the Paris study size. Our study has a power of nearly 90% to identify a difference of 4 mm Hg in SBP between men with and without rhinitis as statistically significant.
Conclusions
J.H. has no declared conflict of interest; R.T. has no declared conflict of interest; S.B. has no declared conflict of interest. Received in original form April 15, 2003; accepted in final form September 12, 2003
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