Prognostic implications of heart failure stages among Chinese community populations: insight from a nationwide population-based study.

Background: In light of high burden of heart failure (HF) in China, studies of prognostic implication of HF stages are important. We aimed to evaluate the relationship between HF stages and mortality risk in Chinese community populations. Methods: Nationwide representative populations aged ≥35 years (n = 23,284, mean age 56.9 years, women 53.2%) were enrolled from 2012 to 2016. According to the international HF guidelines, participants were divided into stage A, B and C, and those who did not qualify these stages were categorized as apparently-healthy group. Association between HF stages and all-cause, cardiovascular [CV] and non-CV death was evaluated using multivariable-adjusted Cox proportional regression analysis. Findings: During a median follow-up of 4.7 years (109,902.8 person-years), 1314 deaths occurred. Age-adjusted incidence rate of all-cause death was 5.3 in apparently-healthy, 7.8 in stage A, 8.6 in stage B and 24.6 in stage C groups per 1000 person-years. In reference to apparently-healthy group, adjusted hazard ratio for all-cause death was 1.90 (95% CI: 1.47-2.45), 2.43 (95% CI: 1.89-3.13) and 6.40 (95% CI: 4.56-8.99) for stage A, B and C. Advancing HF stages were associated with increasing risks for all-cause, CV and non-CV death (P-trend <0.05). For all-cause death, population attributable fraction due to stage A, B and C were 21.2%, 33.4% and 4.9%, accounting for 1,933,385, 3,045,993 and 446,867 deaths in China in 2018. Interpretation: Advancing HF stages were associated with increasing risk mortality. Development and implementation of early screening and targeted interventions are urgently needed to reduce HF burdens in China. Funding: This work was supported by the Chinese Academy of Medical Sciences Innovation Fund for Medical Sciences (grant 2017-I2M-1-004), the Projects in the Chinese National Science & Technology Pillar Program during the Twelfth Five-year Plan Period (No.: 2011BAI11B01), and the Project Entrusted by the National Health Commission of the People's Republic of China (NHC2020-609).

Association Between the Improvement of Knowledge, Attitude and Practice of Hypertension Prevention and Blood Pressure Control-A Cluster Randomized Controlled Study.

BACKGROUND: Hypertension-related knowledge, attitude and practice (KAP) of hypertensive patients can affect the awareness, treatment and control of hypertension. However, little attention has been paid to the association between the change of hypertension preventive KAP and blood pressure (BP) control in occupational population using longitudinal data. We assess the effectiveness of a workplace-based multicomponent hypertension intervention program on improving the level of KAP of hypertension prevention, and the association between improvement in KAP and BP control during intervention. METHODS: From January 2013 to December 2014, workplaces across 20 urban regions in China were randomized to either the intervention group (n = 40) or control group (n = 20) using a cluster randomized control method. All employees in each workplace were asked to complete a cross-sectional survey to screen for hypertension patients. Hypertension patients in the intervention group were given a 2-year workplace-based multicomponent hypertension intervention for BP control. The level of hypertension prevention KAP and BP were assessed before and after intervention in the two groups. RESULTS: Overall, 3331 participants (2658 in the intervention group and 673 in the control group) were included (mean [standard deviation] age, 46.2 [7.7] years; 2723 men [81.7%]). After 2-year intervention, the KAP qualified rate was 63.2% in the intervention groups and 50.1% in the control groups (odds ratio = 1.65, 95% CI, 1.36∼2.00, P < .001). Compared with the control group decreased in the qualified rate of each item of hypertension preventive KAP questionnaire, all the items in the intervention group increased to different degrees. The increase of KAP score was associated with the decrease of BP level after intervention. For 1 point increase in KAP score, systolic blood pressure (SBP) decreased by .28 mmHg and diastolic blood pressure (DBP) decreased by .14 mmHg [SBP: ß = -.28, 95%CI: -.48∼-.09, P = .004; DBP: ß = -.14, 95%CI: -.26∼-.02, P = .024]. SBP and DBP was significantly in manual labor workers (SBP: ß = -.34, 95%CI: -.59∼-.09, P = .008; DBP: ß = -.23, 95%CI: -.38∼-.08, P = .003), workers from private enterprise, state-owned enterprise (SOE) (SBP: ß = -.40, 95%CI: -.64∼-.16, P = .001; DBP: ß = -.21, 95%CI: -.36∼-.06, P = .005) and a workplace with an affiliated hospital (SBP: ß = -.31, 95%CI: -.52∼-.11, P = .003; DBP: ß = -.16, 95%CI: -.28∼-.03, P = .016). The improvement of knowledge (SBP: ß = -.29, 95%CI: -.56∼-.02, P = .038; DBP: ß = -.12, 95%CI: -.29∼.05, P = .160), as well as attitude (SBP: ß = -.71, 95%CI: -1.25∼-.18, P = .009; DBP: ß = .18, 95%CI: -.23∼.59, P = .385) and behavior (SBP: ß = -.73, 95%CI: -1.22∼-.23, P = .004; DBP: ß = -.65, 95%CI: -.97∼-.33, P < .001) was gradually strengthened in relation to BP control. CONCLUSION: This study found that workplace-based multicomponent hypertension intervention can effectively improve the level of hypertension preventive KAP among employees, and the improvement of KAP levels were significantly associated with BP control. TRIAL REGISTRATION: Chinese Clinical Trial Registry No. ChiCTR-ECS-14004641.

Effects of loneliness and isolation on cardiovascular diseases: a two sample Mendelian Randomization Study.

BACKGROUND: Loneliness and isolation are associated with multiple cardiovascular diseases (CVDs), but there is a lack of research on whether they were causally linked. We conducted a Mendelian Randomization (MR) study to explore causal relationships between loneliness and isolation and multiple CVDs. METHODS: Single nucleotide polymorphisms associated with loneliness and isolation were identified from a genome-wide association study (GWAS) of 455,364 individuals of European ancestry in the IEU GWAS database. Summary data for 15 CVDs were also obtained from the IEU GWAS database. We used three MR methods including inverse variance weighting, MR-Egger, and weighted median estimation to assess the causal effect of exposure on outcomes. Cochran's Q test and MR-Egger intercept test were used to evaluate the heterogeneity and pleiotropy. RESULTS: MR analysis showed that loneliness and isolation were significantly associated with essential hypertension (OR = 1.07, 95% CI: 1.03-1.12), atherosclerotic heart disease (OR = 1.04; 95% CI: 1.02-1.06), myocardial infarction (OR = 1.02; 95% CI: 1-1.04) and angina (OR = 1.04; 95% CI =1.02-1.06). No heterogeneity and pleiotropy effects were found in this study. CONCLUSIONS: Causal relationship of loneliness and isolation with CVDs were found in this study.

Cardiovascular disease and all-cause mortality associated with individual and combined cardiometabolic risk factors.

BACKGROUND: Previous studies have investigated the association between cardiometabolic risk factors and cardiovascular disease (CVD), but evidence of the attributable burden of individual and combined cardiometabolic risk factors for CVD and mortality is limited. We aimed to investigate and quantify the associations and population attributable fraction (PAF) of cardiometabolic risk factors on CVD and all-cause mortality, and calculate the loss of CVD-free years and years of life lost in relation to the presence of cardiometabolic risk factors. METHODS: Twenty-two thousand five hundred ninety-six participants aged ≥ 35 without CVD at baseline were included between October 2012 and December 2015. The outcomes were the composite of fatal and nonfatal CVD events and all-cause mortality, which were followed up in 2018 and 2019 and ascertained by hospital records and death certificates. Cox regression was applied to evaluate the association of individual and combined cardiometabolic risk factors (including hypertension, diabetes and high low-density lipoprotein cholesterol (LDL-C)) with CVD risk and all-cause mortality. We also described the PAF for CVD and reductions in CVD-free years and life expectancy associated with different combination of cardiometabolic conditions. RESULTS: During the 4.92 years of follow-up, we detected 991 CVD events and 1126 deaths. Hazard ratio were 1.59 (95% confidential interval (CI) 1.37-1.85), 1.82 (95%CI 1.49-2.24) and 2.97 (95%CI 1.85-4.75) for CVD and 1.38 (95%CI 1.20-1.58), 1.66 (95%CI 1.37-2.02) and 2.97 (95%CI 1.88-4.69) for all-cause mortality, respectively, in participants with one, two or three cardiometabolic risk factors compared with participants without diabetes, hypertension, and high LDL-C. 21.48% of CVD and 15.38% of all-cause mortality were attributable to the combined effect of diabetes and hypertension. Participants aged between 40 and 60 years old, with three cardiometabolic disorders, had approximately 4.3-year reductions life expectancy compared with participants without any abnormalities of cardiometabolic disorders. CONCLUSIONS: Cardiometabolic risk factors were associated with a multiplicative risk of CVD incidence and all-cause mortality, highlighting the importance of comprehensive management for hypertension, diabetes and dyslipidemia in the prevention of CVD.

Air pollution is associated with abnormal left ventricular diastolic function: a nationwide population-based study.

BACKGROUND: Air pollution is a growing public health concern of global significance. Till date, few studies have explored the associations between air pollutants and cardiac imaging phenotypes. In this study, we aim to explore the association of ambient air pollution and abnormal left ventricular diastolic function (ALVDF) among a large-scale free-living population. METHODS: The participants were from a national representative large-scale cross-sectional study, i.e., the China Hypertension Survey (CHS), 2012-15. After exclusion, 25,983 participants from 14 provinces and 30 districts in China were included for the final analysis. The annual average ambient PM2.5, PM10 and NO2 concentrations were obtained from the chemical data assimilation system (ChemDAS). The clinical evaluation of left ventricular function was conducted in the survey field which was based on echocardiography. Grading diastolic dysfunction was based on Recommendations for the evaluation of left ventricular diastolic function by echocardiography (2009). RESULTS: The mean age of 25,983 participants was 56.8 years, 46.5% were male, and the crude prevalence of GradeI-III ALVDF were 48.1%, 1.6% and 1.1%, respectively. The ORs (95% CI) for ALVDF in the fully adjusted model were 1.31 (1.11-1.56), 1.11 (1.01-1.21) and 1.18 (0.90-1.54) for an increase of 10 µg/m3 of PM2.5, PM10 and NO2, respectively. And for different grades of ALVDF, elevated concentration of PM2.5 and PM10 exposures significantly increased the risk of gradeIinstead of gradeII ~ III ALVDF. There was a positive linear and "J" shape concentration-response association between annual average ambient PM2.5 and NO2 and the ALVDF risk assessed by the restricted cubic spline. The exposure level of most participants to PM10 was less than 130 µg/m3, and the risk of ALVDF increased significantly with the concentration rise. CONCLUSIONS: This large-scale nationwide population study demonstrated a significantly positive association between ambient PM2.5, PM10 and NO2 with ALVDF, especially for mild ALVDF. The functional abnormality may partially explain the enhanced cardiovascular morbidity and mortality associated with air pollution, which highlights the importance of appropriate interventions to reduce ambient air pollution in China.

Socioeconomic inequalities in dementia burden related to high body mass index, 2005-2018: findings from 1.25 million Chinese adults.

Background: Dementia has become a major public health concern worldwide, but comprehensive assessments of dementia burden attributable to high body mass index (BMI) in China have not been done. Methods: We used a temporal-spatial Bayesian hierarchical model to estimated BMI levels based on 1.25 million Chinese. We estimated dementia burden attributable to high BMI by age, sex, year, and socioeconomic development in terms of deaths and years of life lost (YLLs) and assessed the effect of population ageing. Findings: The average age-standardised BMI was 24.58 kg/m2 and 24.15 kg/m2 for men and women in 2018, respectively. 12,901 (95% UI, 10,617-15,420) dementia deaths were attributable to high BMI in China in 2018, with 5417 deaths from man and 7421 deaths from woman. The attributable age-standardised YLL rates for dementia increased 27% from 2005 to 2018. The attributable age-standardised mortality rates increased with human development index. People aged 80 years and older had the highest attributable mortality rate, and the rate decreased with decreasing age. Population ageing was an important component of the increase in dementia death. Interpretation: The rapid increase and large inequality highlighted the urgent need for evidence-based policies and interventions. We therefore call for establishing stronger anti-dementia strategies to promote the healthy ageing. Funding: China National Key Research and Development Program, China National Science & Technology Pillar Program, and National Health Commission of the People's Republic of China.

Workplace-based primary prevention intervention reduces incidence of hypertension: a post hoc analysis of cluster randomized controlled study.

BACKGROUND: A workplace-based primary prevention intervention be an effective approach to reducing the incidence of hypertension (HTN). However, few studies to date have addressed the effect among the Chinese working population. We assessed the effect of a workplace-based multicomponent prevention interventions program for cardiovascular disease on reducing the occurrence of HTN through encouraging employees to adopt a healthy lifestyle. METHODS: In this post hoc analysis of cluster randomized controlled study, 60 workplaces across 20 urban regions in China were randomized to either the intervention group (n = 40) or control group (n = 20). All employees in each workplace were asked to complete a baseline survey after randomization for obtaining sociodemographic information, health status, lifestyle, etc. Employees in the intervention group were given a 2-year workplace-based primary prevention intervention program for improving their cardiovascular health, including (1) cardiovascular health education, (2) a reasonable diet, (3) tobacco cessation, (4) physical environment promotion, (5) physical activity, (6) stress management, and (7) health screening. The primary outcome was the incidence of HTN, and the secondary outcomes were improvements of blood pressure (BP) levels and lifestyle factors from baseline to 24 months. A mix effect model was used to assess the intervention effect at the end of the intervention in the two groups. RESULTS: Overall, 24,396 participants (18,170 in the intervention group and 6,226 in the control group) were included (mean [standard deviation] age, 39.3 [9.1] years; 14,727 men [60.4%]). After 24 months of the intervention, the incidence of HTN was 8.0% in the intervention groups and 9.6% in the control groups [relative risk (RR) = 0.66, 95% CI, 0.58 ~ 0.76, P < 0.001]. The intervention effect was significant on systolic BP (SBP) level (ß = - 0.7 mm Hg, 95% CI, - 1.06 ~ - 0.35; P < 0.001) and on diastolic BP (DBP) level (ß = - 1.0 mm Hg, 95% CI, - 1.31 ~ - 0.76; P < 0.001). Moreover, greater improvements were reported in the rates of regular exercise [odd ratio (OR) = 1.39, 95% CI, 1.28 ~ 1.50; P < 0.001], excessive intake of fatty food (OR = 0.54, 95% CI, 0.50 ~ 0.59; P < 0.001), and restrictive use of salt (OR = 1.22, 95% CI, 1.09 ~ 1.36; P = 0.001) in intervention groups. People with a deteriorating lifestyle had higher rates of developing HTN than those with the same or improved lifestyle. Subgroup analysis showed that the intervention effect of BP on employees with educational attainment of high school above (SBP: ß = - 1.38/ - 0.76 mm Hg, P < 0.05; DBP: ß = - 2.26/ - 0.75 mm Hg, P < 0.001), manual labor workers and administrative worker (SBP: ß = - 1.04/ - 1.66 mm Hg, P < 0.05; DBP: ß = - 1.85/ - 0.40 mm Hg, P < 0.05), and employees from a workplace with an affiliated hospital (SBP: ß = - 2.63 mm Hg, P < 0.001; DBP: ß = - 1.93 mm Hg, P < 0.001) were significantly in the intervention group. CONCLUSIONS: This post hoc analysis found that workplace-based primary prevention interventions program for cardiovascular disease were effective in promoting healthy lifestyle and reducing the incidence of HTN among employees. TRIAL REGISTRATION: Chinese Clinical Trial Registry No. ChiCTR-ECS-14004641.

Rapid increasing burden of diabetes and cardiovascular disease caused by high body mass index in 1.25 million Chinese adults, 2005-2018.

BACKGROUND: Temporal trends and geographical variations in disease burden for diabetes mellitus (DM) and cardiovascular disease (CVD) attributable to high body mass index (BMI) in China have not been fully elucidated. METHODS: We estimated deaths and years of life lost (YLLs) for DM and CVD attributable to high BMI by age, sex, year, and region from 2005 to 2018 based on pooled data of 1.25 million adults. FINDINGS: Approximately 497,430 (95% uncertainty interval [UI], 470,520-525,720) deaths for DM and CVD were attributable to high BMI in China in 2018, with 453,750 deaths from CVD and 43,700 deaths from DM. Between 2005 and 2018, there was a 17.35% increase in age-standardized mortality rate for DM and CVD attributable to high BMI. The high BMI-related DM and CVD YLL rates increased from 127.46 (95% UI 108.70-148.62) per 100,000 people aged 20-24 years to 5,735.54 (95% UI 4,844.16-6,713.53) per 100,000 people aged ≥80 years, respectively. The highest age-standardized mortality rate for high BMI-related DM and CVD in northeast, northwest, and circum-Bohai Sea regions of China. CONCLUSION: The disease burden for DM and CVD attributable to high BMI increased substantially between 2005 and 2018. Urgent measures are required at both national and regional levels for resource mobilization to slow the growing burden. FUNDING: The work was supported by the National Key Research and Development Program of China, China National Science & Technology Pillar Program, and National Health Commission of the People's Republic of China.

Effect of a Multicomponent Intervention Delivered on a Web-Based Platform on Hypertension Control: A Cluster Randomized Clinical Trial.

Importance: The prevalence of hypertension is high and still increasing across the world, while the control rate remains low in many countries. Emerging technology, such as telemedicine, may offer additional support to change the unsatisfactory situation. Objective: To establish a multicomponent intervention delivered on a web-based telemedicine platform and oriented with the Chinese hypertension management guidelines and to evaluate the effect of the intervention on blood pressure (BP) control for patients with hypertension. Design, Setting, and Participants: This cluster randomized clinical trial of a hypertension management program was conducted at 66 community health centers in China from October 1, 2018, to May 31, 2020, with a 12-month follow-up. Patients with hypertension were blinded to randomization and were randomized to either the intervention group or control group. Hypertension was diagnosed at mean systolic BP (SBP) and diastolic BP (DBP) readings higher than 140 and 90 mm Hg or with use of antihypertensive medication. Evaluation of the intervention effect was based on the principle of modified intention to treat. Interventions: Multicomponent intervention was delivered on a web-based platform and consisted of a primary prevention program for cardiovascular disease and standardized management for hypertension. Main Outcomes and Measures: The primary outcome was the change in BP control rate (SBP and DBP levels <140 and 90 mm Hg, or <130 and 80 mm Hg for patients with diabetes) from baseline to the 12-month follow-up among patients with hypertension in the intervention and control groups. Results: A total of 4118 patients (mean [SD] age, 61.6 [9.4] years; 2265 women [55.0%]) were included in the analysis, with 2985 in the intervention group and 1133 in the control group. The BP control rate at baseline was 22.8% in the intervention group and 22.5% in the control group. After 12 months of the intervention, the BP control rate for the intervention group compared with the control group was significantly higher (47.4% vs 30.2%; odds ratio, 1.18; 95% CI, 1.13-1.24; P < .001). The intervention effect on SBP level was -10.1 mm Hg (95% CI, -11.7 to -8.5 mm Hg; P < .001) and on DBP level was -1.8 mm Hg (95% CI, -2.8 to -0.8 mm Hg; P < .001). Conclusions and Relevance: Results of this trial showed that a multicomponent intervention delivered on a web-based platform improved BP control rate and lowered BP level more than usual care alone. Such a telemedicine program may provide a new, effective way to treat patients with hypertension in the community and may generate public health benefits across diverse populations. Trial Registration: Chinese Clinical Trial Registry Identifier: ChiCTR1800017791.

Long-Term Impacts of Diurnal Temperature Range on Mortality and Cardiovascular Disease: A Nationwide Prospective Cohort Study.

Previous studies have documented the associations between short-term diurnal temperature range (DTR) exposure and cardiovascular disease (CVD) via time-series analyses. However, the long-term impacts of DTR through a population-based prospective cohort have not been elucidated thoroughly. This study aimed to quantify the longitudinal association of DTR exposure with all-cause mortality and CVD in a nationwide prospective cohort and, by extension, project future DTR changes across China under climate change. We included 22,702 adults (median age 56.1 years, 53.7% women) free of CVD at baseline from a nationwide cross-sectional study in China during 2012-2015, and examined three health outcomes during a follow-up survey in 2018-2019. We estimated the chronic DTR exposure as baseline annual mean daily maximum minus minimum temperature. The Cox proportional hazards regression was adopted to assess the multivariable-adjusted hazard ratio and its corresponding 95% confidence interval (95% CI). We employed 31 downscaled global climate models under two shared socioeconomic pathways for future projection. During the median follow-up period of ~5 years, 1096 subjects died due to all causes while 993 and 597 individuals developed fatal or nonfatal CVD and fatal or nonfatal stroke, respectively. The cumulative incidence rates of all-cause mortality, CVD, and stroke were 10.49, 9.45, and 5.64 per 1000 person-years, respectively. In the fully adjusted models, the risks for all-cause mortality, CVD, and stroke would increase by 13% (95% CI: 8-18%), 12% (95% CI: 7-18%), and 9% (95% CI: 2-16%) per 1 °C increment in DTR, respectively. Moreover, linear positive associations for the concentration-response curves between DTR and mortality and CVD were observed. We also found significantly greater DTR-related mortality risks among rural residents than their urban counterparts. The DTR changes featured a dipole pattern across China under a warming climate. The southern (northern) China would experience increased (decreased) DTR exposure by the end of 21st century. The present study indicates that chronic DTR exposure can exert long-term impacts on mortality and CVD risks, which may inform future public health policies on DTR-related susceptible population and regions.

Age at Menarche and Menopause, Reproductive Lifespan, and Risk of Cardiovascular Events Among Chinese Postmenopausal Women: Results From a Large National Representative Cohort Study.

Background: At present, the association between age at menarche and menopause, reproductive lifespan, and cardiovascular disease (CVD) risk among Chinese postmenopausal women is not clear, and some related researches are contradictory. Methods: A total of 6,198 Chinese postmenopausal women with a mean age of 63.6 years were enrolled at baseline in 2012-2015 and followed up for 5 years. A standardized questionnaire was used to collect relevant information by well-trained interviewers. Physical examination of the participants was performed by trained medical staff. CVD events were observed during follow-up. Cox proportional hazards models were used to estimate hazard ratios between reproductive characteristics and CVD events. Results: Age at menarche was positively associated with CVD events (HR, 1.106; 95%CI, 1.047-1.167). There was a negative association between age at menopause and CVD risk in postmenopausal women with comorbidity (HR, 0.952; 95%CI, 0.909-0.996). Reproductive lifespan was negatively associated with CVD events (HR, 0.938; 95%CI, 0.880-0.999). The CVD risk increased by 10.6% for every 1-year increase in age at menarche. The CVD risk reduced by 6.2% for every 1-year increase in age at menopause in women with comorbidity. The CVD risk reduced by 3.8% for every 1-year increase in reproductive lifespan. Conclusions: Based on the large prospective study with a nationally representative sample, Chinese postmenopausal women with late age at menarche and shorter reproductive lifespan have higher risk of CVD events.

Reproductive lifespan in association with risk of hypertension among Chinese postmenopausal women: Results from a large representative nationwide population.

Background: The association between reproductive lifespan and risk of hypertension among postmenopausal women is unclear. Methods: A total of 94,141 postmenopausal women with a mean age of 64.8 years from the China Hypertension Survey were enrolled at baseline from 2012 to 2015. A standardized questionnaire was used to collect relevant information by well-trained interviewers. Blood pressure and physical examination of the participants were performed by trained medical staff. Logistic regression was used to estimate the odds ratios for hypertension by years of reproductive lifespan. Results: The average years of reproductive lifespan in Chinese women was 34.0 years. Women who were longer in reproductive lifespan were more likely to have older age at recruitment, higher body mass index, larger waist circumference, lower mean systolic blood pressure, and higher mean diastolic blood pressure (p < 0.05). After adjustments, odds ratios (95% confidence interval) for hypertension were 1.035 (0.988-1.085), 1.007 (0.966-1.048), 1.000 (reference), 0.932 (0.899-0.967), and 0.953 (0.909-0.997) for those with reproductive lifespan at ≤ 28, 29-31, 32-34 (reference), 35-37, and ≥ 38 years, respectively, with a significantly inverse association was seen in those with reproductive lifespan at 35-37 and ≥ 38 years. The overall risk of hypertension declined with the increase in reproductive lifespan, and the risk of hypertension was reduced by 1.1% for every 1-year increase in the reproductive lifespan (odds ratio, 0.989; 95% confidence interval, 0985-0.994) per year. The negative association between reproductive lifespan and hypertension was evident among age at recruitment groups, body mass index categories, and education levels, with the strongest association among women aged ≥ 70 years. Positive associations between reproductive lifespan and risk of hypertension were evident among women aged < 60 years, and this association was stronger among current alcohol drinkers. Conclusion: Based on the large nationally representative sample, Chinese postmenopausal women with a shorter reproductive lifespan have a higher risk of hypertension.