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Temperature, cardiovascular mortality, and the role of hypertension and renin–angiotensin–aldosterone axis in seasonal adversity: a narrative review

Journal of Human Hypertension volume 36, pages 1035–1047 (2022)Cite this article

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Abstract

Environmental temperature is now well known to have a U-shaped relationship with cardiovascular (CV) and all-cause mortality. Both heat and cold above and below an optimum temperature, respectively, are associated with adverse outcomes. However, cold in general and moderate cold specifically is predominantly responsible for much of temperature-attributable adversity. Importantly, hypertension—the most important CV risk factor—has seasonal variation such that BP is significantly higher in winter. Besides worsening BP control in established hypertensives, cold-induced BP increase also contributes to long-term BP variability among normotensive and pre-hypertensive patients, also a known CV risk factor. Disappointingly, despite the now well-stablished impact of temperature on BP and on CV mortality separately, direct linkage between seasonal BP change and CV outcomes remains preliminary. Proving or disproving this link is of immense clinical and public health importance because if seasonal BP variation contributes to seasonal adversity, this should be a modifiable risk. Mechanistically, existing evidence strongly suggests a central role of the sympathetic nervous system (SNS), and secondarily, the renin–angiotensin–aldosterone axis (RAAS) in mediating cold-induced BP increase. Though numerous other inflammatory, metabolic, and vascular perturbations likely also contribute, these may also well be secondary to cold-induced SNS/RAAS activation. This review aims to summarize the current evidence linking temperature, BP and CV outcomes. We also examine underlying mechanisms especially in regard to the SNS/RAAS axis, and highlight possible mitigation measures for clinicians.

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Fig. 1: Putative mechanisms driving cold-induced blood pressure increase and CV mortality, based on human epidemiologic studies, in vitro experiments, and animal experiments.

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All data used to prepare this review are available upon request from the authors

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Authors and Affiliations

  1. Department of Internal Medicine, St. Luke’s University Health Network, Bethlehem, PA, USA

    Harsh Goel, Kashyap Shah & John T. Hippen

  2. Lewis Katz School of Medicine, Temple University, Philadelphia, PA, USA

    Harsh Goel & John T. Hippen

  3. Department of Medicine, Wellspan York Hospital, York, PA, USA

    Ashish Kumar

  4. Department of Medicine, Sultan Qaboos University Hospital, Muscat, Oman

    Sunil K. Nadar

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Goel, H., Shah, K., Kumar, A. et al. Temperature, cardiovascular mortality, and the role of hypertension and renin–angiotensin–aldosterone axis in seasonal adversity: a narrative review. J Hum Hypertens 36, 1035–1047 (2022). https://doi.org/10.1038/s41371-022-00707-8

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