Modern Environment as New Secondary Cause of Hypertension: Comparison
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The most important risk factor for cardiovascular disease, the leading cause of death worldwide, is hypertension. Although most cases of hypertension are thought to be essential, the multifactorial associations of the environmental influence on blood pressure seem to play an important role and should be more closely investigated. 

  • hypertension
  • environment
  • noise pollution
  • seasonal variability
  • temperature
  • obesity

1. Introduction

Cardiovascular disease (CVD) is the top cause of death worldwide and, despite the scientific attempts, hypertension still remains one of the main cardiovascular risk factors [1]. According to the World Health Organization, 1.13 billion people worldwide have hypertension, and the numbers are expected to become higher in the following years [2]. In the United States, nearly half of adults (47%) have hypertension, defined either as abnormal values of blood pressure (BP) or as the use of antihypertension treatment [3]. In Europe, the prevalence is lower but still remarkable, coming close to 25% [4]. The control rates of the hypertensive population seem also to be dramatic; the condition of 25% of that population is reported to be uncontrolled and almost half of them live with BP values higher than 140/90 mmHg [3]. According to the May Measurement Month 2017, which is an annual initiative launched by the International Society of Hypertension as a way to tackle the widespread lack of awareness regarding hypertension, more than 1.2 million individuals from 80 different countries were enrolled and subjected to analysis, with nearly one-third of them being identified as hypertensive.
Hypertension, a medical condition characterized by systolic BP values equal to or exceeding 140 mmHg and/or diastolic BP values equal to or exceeding 90 mmHg, has been rigorously defined through extensive research, drawing upon evidence gathered from numerous randomized controlled trials. This body of research unequivocally demonstrates the substantial benefits derived from treating patients whose BP falls within or surpasses these specified values when managed in a clinical setting [6][5]. Blood pressure results from the interplay of cardiac output and systemic vascular resistance. Consequently, individuals suffering from arterial hypertension can experience elevated cardiac output, increased systemic vascular resistance, or a combination of both factors. Various growth factors, such as angiotensin and endothelins, induce an increase in vascular smooth muscle mass, a process known as vascular remodeling. The renin–angiotensin–aldosterone system significantly contributes to the regulation of arterial pressure and sodium balance within the body. Substantial evidence suggests that the resetting of pressure natriuresis significantly contributes to the onset of hypertension [7][6].
An acknowledgement of novel elements—further than the well-known, previously reported ones—that influence the development and management of hypertension seems, nowadays, to be more than crucial. Evidence suggests that environmental factors play a key role not only in the onset of hypertension but also in the success of the treatment. Specifically, components like climate change, air pollution, traffic noise, and socioeconomic status seem to have direct effects that lead to high BP [9][7]. 

2. Seasonal Variation and Hypertension

It is known that hypertension exhibits seasonal variation. BP seems to be higher in the colder months of the year than in the summer [10][8]. These changes happen through vasoconstriction and a rise in peripheral resistance resulting from exposure to low outdoor temperatures [11][9]. As such, the activation of the sympathetic nervous system as well as the renin–angiotensin–aldosterone index in the seasonality of hypertension is of major importance [12][10]. There is, of course, a multi-factorial background to these changes in BP levels. Elements like the restriction in physical activity, the increased food intake, and inadequate home heating can be responsible for these alternations during the winter. Patients well treated for high blood pressure can experience a deregulation during periods of low ambient temperature [13][11]. Furthermore, this observation agrees with the rise of cardiovascular events during the same time period, bearing in mind that one of the main risk factors for cardiovascular diseases is hypertension [14][12]. This concerns both men and women of all ages, as well as individuals being treated or not for hypertension. The relationship between hypertension’s seasonality and age was examined in another study based on routine measurements of blood pressure in primary care health system. Older patients (aged 81 or older) presented a greater effect in the elevation of systolic blood pressure regarding the decrease in outdoor temperature than younger patients. No other differences in systolic blood pressure were found when other characteristics like BMI were examined. In general, thise study showed that seasonality does exist for all hypertensive patients but was greater in older individuals [16][13]. Data show that weather changes can even impact the number of hospital admissions for hypertension. Specifically, a decline of 5 °C can lead to a 3% increase in risk for hospital admissions, with short-term changes in temperature shown to not affect the number of admissions, which is opposed to the effects of long-term decreases in temperature. Thise study was in accordance with other reports, showing that higher temperatures during summertime did not lead to an increase in hospital admissions for hypertension [17,18,19][14][15][16]. Seasonal variability in the onset of essential hypertension was evaluated in another retrospective observational study, not only by office measurements but also by the use of 24 h ambulatory blood pressure measurement in patients admitted for first-diagnosed primary hypertension [20][17]. Hence, controlling the increase in BP during winter is of major importance, and techniques such as changing the indoor temperature or the antihypertensive treatment may help. Indeed, the effects of the adjustment of indoor temperature and antihypertensive medication on the reduction in the winter surge have been studied during the latest years [21][18]. The rise in indoor temperature by 1 °C could lead to a reduction in systolic BP of up to 0.37 mmHg in the morning and 0.45 mmHg in the evening, as revealed by home monitoring. The effect of outdoor ambient temperature was weaker compared to indoor temperature [22][19]. The probability of having an abnormal value of BP is lower when the indoor temperature is higher than 12 °C for men >60 years old, 19 °C for men >70 years old, and 24 °C for men >80 years old, while for women the decrease seems to occur at lower temperatures; 11 °C for >70 years old and 16 °C for >80 years old [23][20].  Another interesting point was made in a cross-sectional study with more than 4000 participants by Narita et al. that used the database of the J-HOP study about the role of seasonal variation in hypertension in target organ damage [25][21]. The urine albumin–creatinine ratio (UACR) and serum B-type natriuretic peptide (BNP) level were used to quantify the effect of the increased BP during wintertime on target organs. First of all, it was confirmed that morning home BP was found to be higher in winter, and that this effect was stronger than in the evening home blood pressure and office blood pressure.  The seasonal variability in hypertension in patients undergoing hemodialysis was also examined [26][22]. Consistent with observations regarding changes in BP throughout the year in the general population, this research revealed an elevation in BP during the winter season also in patients undergoing hemodialysis. December, one of the coldest months, exhibited the highest mean pre-dialysis systolic (148 ± 23 mmHg) and diastolic BP (87 ± 17 mmHg), whereas June recorded the lowest pre-dialysis systolic BP (144 ± 23 mmHg) and July the lowest pre-dialysis diastolic BP (85 ± 16 mmHg).

3. Hypertension, Noise, and Air Pollution

There is a strong relationship between noise pollution and cardiovascular events. As claimed by the WHO, 1.6 billion healthy life years are lost every year in Western Europe because of transportation noise [31][23]. Traffic noise can cause oxidative stress in the vasculature, promoting hypertension and, therefore, increasing the risk of cardiovascular illness. Also, the activation of the hypothalamic–pituitary–adrenal axis, which can cause the release of stress hormones (like cortisol) and the deregulation of glucose adjustment and blood pressure, may offer another possible explanation. Additionally, noise pollution can cause sleep disturbances and alternations in the circadian rhythm leading to the release of stress hormones and endothelial dysfunction, which can result in hypertension [32][24]. The effect of noise on hypertension has been examined and proved to be both short- and long-term. In 2018, Shih-Yi Lu et al. investigated the adverse effects of high-frequency noise on BP in a group of thirty participants without a history of hypertension. During the study, participants were exposed to three distinct noise levels (<55, 75, and 90 dB) for 20 min, and their BP measurement as well as cardiac rhythm were recorded before and after the noise exposure. All participants successfully completed the task. As anticipated, different noise frequencies had varying impacts on BP levels. Notably, a significant increase in both systolic and diastolic BP was observed when participants were exposed to 90 dB noise. The association between occupational noise and hypertension in workers in a local aircraft manufacturing enterprise in Xi’an, China was investigated in a cross-sectional study [36][25]. Results showed that exposure to high noise (>85 dB(A)) caused a 30% higher risk for hypertension compared to lower exposure, while in young adults, the odds were 70%. The most crucial point is the long-term effect of noise on hypertension, as well as if this could be a possible answer to high rates of uncontrolled hypertension. A 4-year follow-up with more than 6000 participants revealed that an increase of 1.2 mmHg in systolic and 1.1 mmHg in diastolic blood pressure was associated with a 10 dB(A) higher noise level. Most importantly, this increase in noise was found to be associated with 20% increased odds of apparent treatment-resistant hypertension [43][26]. Beyond noise pollution, air pollution seems also to be an important environmental factor of hypertension [44][27]. Air pollution is a blend of particles, characterized by variations in their physical and chemical makeup, source, and harmful effects across different locations and times. Solid-phase air pollutants are typically categorized based on their size, with PM2.5 standing for particulate matter (PM) with a diameter of less than 2.5 μm, PM10 being particles with a diameter of less than 10 μm, PMcoarse encompassing particles between 2.5 and 10 μm in size, and ultrafine particles (UFP) indicating those with a diameter of less than 0.1 μm [45][28].

4. Hypertension and Socioeconomic Status

The importance of socioeconomic status, lifestyle preferences, and dietary practices should be researched extensively due to the close relationships between these factors and the onset, but also regulation, of hypertension. Mental health issues are also strongly associated with the above-mentioned factors and act as determinants of hypertension [52][29]. Conditions such as depression and anxiety disorders show a rapid increase nowadays and are affecting more than 300 million people worldwide [53][30]. Profound interconnections between these factors and hypertension are recognized. The activation of the sympathetic nervous system, the surge in cortisone, and the ongoing inflammation in stressful situations can cause hypertension through many different pathways [53,54,55][30][31][32]. These associations were researched in a recent study that assessed the responses provided by participants who had completed questionnaires regarding hypertension and disability. These questionnaires were administered during the 2017–2018 cycle of the National Health and Nutrition Examination Survey (NHANES). In the sphere of socioeconomic status and lifestyle choices, the persistent issue of obesity is also rooted. Obesity is one of the most prominent risk factors for hypertension and both constitute major risk factors for cardiovascular disease [57,58][33][34]. The Framingham study was one of the first big data population studies to analyze in detail the relationship between hypertension and obesity, showing that a BMI ≥ 25 was responsible for 26% of the cases of hypertension in men and 28% in women [59][35]. Also, the economic extenders of food insecurity can lead to individuals preferring to spend money on food rather than on medication (e.g., antihypertensive drugs) [71,72][36][37]. The psychological effect of food insecurity should not be ignored as it increases stress and causes anxiety and depression [73,74][38][39]. Furthermore, advertisement is all around, mostly promoting unhealthy food and almost never fruits or vegetables and creating behaviors. 

5. Conclusions

Most cases of hypertension are classified as essential. Environmental factors like socioeconomic conditions, climate change, and lifestyle choices influence hypertension. A revision in the categorization of hypertension could be important, as even in the case of essential, primary hypertension, the environment could be found to constitute it as secondary. In real clinical practice, the hypertensive population should be assessed and managed by—in addition to the common lifestyle modifications and pharmacological treatment—the identification of socioeconomic and environmental risk factors and their modifications in collaboration with community programs.

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