Driving and subsidiary behavior of taxi drivers working alternate-day shifts.

A field study on taxi drivers working alternate-day shifts of prescribed duration of 16 hr of work revealed that most of them actually worked longer for 16 hr 50 min on the average, starting from 7:00 and ending later than 2:00. The mean hourly income greatly increased in hours later than 22:00 due to the increased fare per hire and higher speed, so that these hours were regarded by the drivers as the most important period of the day. This resulted in retarded mean bedtime of 5:31 after the shift end and in reduced sleep. The total rate of subsidiary activities of the drivers decreased during the middle of the day, but increased towards the shift end. Those activities having a relatively low rate at the beginning, such as subsidiary lower limb movements, shoulder-neck movements, and yawning, remarkably increased in the late evening and midnight hours. These activities increased even during frequent driving operations and tended to relate with each other, often recurring in bursts especially while feeling drowsy. The incentive wage system of the drivers thus accounts not only for the extraordinarily long working hours but also for intensified night work.     

One night of partial sleep deprivation affects biomarkers of cardiac damage,but not cardiovascular and lipid profiles,in young athletes

Sleep loss is among the most common yet frequently overlooked problems. This disruptive influence is associated with an adverse lipid profile (LP) and consequently results in an increased risk of cardiovascular disease. Furthermore, it has been well established that athletes are increasingly confronted with sleep problems. The aim of this study was to explore the effect of one night of partial sleep deprivation (PSD) on the cardiovascular profile and LP in young, trained athletes. Ten male Taekwondo athletes were randomized for three sleep conditions in a counterbalanced order: (i) following a baseline sleep night (BN), (ii) following PSD at the beginning of the night (PSDBN), and (iii) following PSD at the end of the night (PSDEN). Basal cardiovascular physiological measures were recorded, and blood samples were taken in the fasted state following each sleep session (i.e., in the morning at 07:00 h). The results showed that myoglobin and creatine phosphokinase increased significantly after PSDEN but not after PSDBN. By contrast, no alteration was observed in the LP and physiological parameters following the two types of PSD. In conclusion, these results show that PSDEN increases cardiac damage biomarkers significantly, even though they do not reach clinical significance. Thus, one night of PSD does not affect the physiological responses and biomarkers of LP in Taekwondo athletes.     

Chronophysiology of the cardiovascular system

The development of ambulatory blood pressure monitoring devices and the beat-by-beat measurement of heart rate have enabled it to be established that there are circadian rhythms in heart rate and blood pressure in subjects living normally. Investigations of these variables have led to quantification of their fall at night, and rapid rise on awakening and becoming active in the morning. These changes are of particular interest insofar as abnormalities in them are associated with cardiovascular problems and morbidity in patients and also act as risk factors in otherwise healthy individuals. It has also been shown that there are many other variables of the cardiovascular system. The causes of the circadian rhythms in heart rate and blood pressure are outlined, with particular stress upon the role of the autonomic nervous system, as assessed from low- and high-frequency components of the variation in heart rate measured beat-by-beat. Activity increases blood pressure, but there is evidence that this “reactivity” varies with time of day, and this also might be related to cardiovascular morbidity. Based upon data from several sources, including night work, resting subjects and bed-ridden patients, it is concluded that the contribution of the “body clock” to producing the circadian rhythm in heart rate and blood pressure is relatively small. A bias towards an exogenous cause applies also to most other circadian rhythms in the cardiovascular system. Knowledge of circadian rhythmicity in cardiovascular system, together with an understanding of its causes, provides a rationale for advice to reduce cardiovascular risk and to assess the efficacy of therapies.     

Blood pressure dipping and salivary cortisol as markers of fatigue and sleep deprivation in staff anesthesiologists

Anesthesiologists often work extended duty shifts that result in acute and chronic sleep loss and circadian disruption. Stress caused by sleep deprivation, together with excessive workload could contribute to acute increases in blood pressure (BP) and sympathetic nervous system activity. Non-dipping pattern of BP is considered an additional risk factor for cardiovascular events and target organ damage. We hypothesized that there would be significant changes of cardiovascular parameters when comparing work on call during the 24-hour in-hospital shift (24-HD) versus ordinary working day (8-HD) combined with changes of dipping pattern and altered diurnal cortisol secretion, measured by salivary cortisol (SC). Following local Medical Ethics Committee approval, 12 out of 36 staff anesthesiologists (8 male, 4 female), 33-61 years old, participated in this study. Ambulatory BP monitor was used for noninvasive 24-hour ambulatory BP and heart rate (HR) monitoring. Each participant was monitored continuously during the 8-HD, as well as during the 24-HD. Saliva for analysis of cortisol levels was collected six times a day (at 8 am, 11 am, 2 pm, 5pm, 8pm, and 11 pm) both during 8-HD and on 24-HD. There was a significant decrease in number of diastolic dippers on call vs. diastolic dippers on ordinary working day (4/12 vs. 10/12, p=0.036), and non significant decrease of systolic dippers (3/12 vs. 7/12, p =0.214). There were no significant differences in SC values between 8-HD and 24-HD at all observed time points. However, the SC values measured during the night were markedly elevated on both days compared with reference values and the shapes of SC curves were altered. The lack of diastolic BP dipping could be more sensitive indicator of stress among staff anesthesiologists than systolic BP dipping. The shape of SC diurnal curve in terms of elevated night values could be another indicator of their chronic fatigue.     

Effects of obstructive sleep apnea on endogenous circadian rhythms assessed during relaxed wakefulness; an exploratory analysis

ABSTRACT

Obstructive sleep apnea (OSA) is associated with hypertension, cardiovascular disease, and a change in the 24 h pattern of adverse cardiovascular events and mortality. Adverse cardiovascular events occur more frequently in the middle of the night in people with OSA, earlier than the morning prevalence of these events in the general population. It is unknown if these changes are associated with a change in the underlying circadian rhythms, independent of behaviors such as sleep, physical activity, and meal intake. In this exploratory analysis, we studied the endogenous circadian rhythms of blood pressure, heart rate, melatonin and cortisol in 11 participants (48 ± 4 years; seven with OSA) throughout a 5 day study that was originally designed to examine circadian characteristics of obstructive apnea events. After a baseline night, participants completed 10 recurring 5 h 20 min behavioral cycles divided evenly into standardized sleep and wake periods. Blood pressure and heart rate were recorded in a relaxed semirecumbent posture 15 minutes after each scheduled wake time. Salivary melatonin and cortisol concentrations were measured at 1–1.5 h intervals during wakefulness. Mixed-model cosinor analyses were performed to determine the rhythmicity of all variables with respect to external time and separately to circadian phases (aligned to the dim light melatonin onset, DLMO). The circadian rhythm of blood pressure peaked much later in OSA compared to control participants (group × circadian phase, p < .05); there was also a trend toward a slightly delayed cortisol rhythm in the OSA group. Rhythms of heart rate and melatonin did not differ between the groups. In this exploratory analysis, OSA appears to be associated with a phase change (relative to DLMO) in the endogenous circadian rhythm of blood pressure during relaxed wakefulness, independent of common daily behaviors.     

Intervention for regulating sleep–wake rhythms to prevent sleepiness in Japanese train drivers

Sleep and Biological Rhythms - The nocturnal sleep of train drivers is apt to be short and their lifestyle become irregular because they drive at midnight and early in the morning. As a result,...     

Metabolic Syndrome in Permanent Night Workers

Night and shift work might be risk factors for metabolic and cardiovascular disorders due to interference with diet, circadian metabolic rhythms, and lifestyle. The relationship between permanent night work and metabolic and cardiovascular risk factors was explored in a retrospective longitudinal study of workers employed in a large municipal enterprise in charge of street cleaning and domestic waste collection. All subjects who had worked night shifts between 1976 and 2007 as hand sweepers, motor sweepers, and delivery tricar drivers were compared with subjects who always worked the same jobs but on day shifts. From the periodical medical surveillance files, we identified 488 male workers who had been examined on average five times (minimum 2, maximum 14) during the study period, for a total of 2,328 medical examinations; 157 always had worked day shifts, 12 always the night shift, and 319 both (initially day and subsequently night shifts). Their age ranged from 22 to 62 yrs, and work experience varied from 1 to 28 yrs. Lifestyle habits (smoking, alcohol consumption), body mass index, serum glucose, total cholesterol, tryglicerides, hepatic enzymes, blood pressure, resting electrocardiogram, diabetes, coronary heart disease, hypertension, and related drugs were taken into consideration for the analysis. We used generalized estimating equations (GEE) models (exchangeable correlation matrix) to analyze the relationship between night work and health effects while accounting for within‐subject correlations and adjusting for study period, job, age, and lifestyle variables. As a whole, night workers smoked more and had significantly higher BMI, serum total cholesterol, and triglycerides than day workers. Both the inter‐individual comparison between day and night workers and the intra‐individual comparison among the workers, who were day workers at the beginning of their employment and later became night workers, showed a significant increase in BMI, total cholesterol, and tryglicerides associated with night work. No consistent effect was seen on fasting glucose, hepatic enzymes, and blood pressure, whereas a higher incidence of coronary heart disease was recorded in night workers.     

Metabolic syndrome in permanent night workers

Night and shift work might be risk factors for metabolic and cardiovascular disorders due to interference with diet, circadian metabolic rhythms, and lifestyle. The relationship between permanent night work and metabolic and cardiovascular risk factors was explored in a retrospective longitudinal study of workers employed in a large municipal enterprise in charge of street cleaning and domestic waste collection. All subjects who had worked night shifts between 1976 and 2007 as hand sweepers, motor sweepers, and delivery tricar drivers were compared with subjects who always worked the same jobs but on day shifts. From the periodical medical surveillance files, we identified 488 male workers who had been examined on average five times (minimum 2, maximum 14) during the study period, for a total of 2,328 medical examinations; 157 always had worked day shifts, 12 always the night shift, and 319 both (initially day and subsequently night shifts). Their age ranged from 22 to 62 yrs, and work experience varied from 1 to 28 yrs. Lifestyle habits (smoking, alcohol consumption), body mass index, serum glucose, total cholesterol, tryglicerides, hepatic enzymes, blood pressure, resting electrocardiogram, diabetes, coronary heart disease, hypertension, and related drugs were taken into consideration for the analysis. We used generalized estimating equations (GEE) models (exchangeable correlation matrix) to analyze the relationship between night work and health effects while accounting for within-subject correlations and adjusting for study period, job, age, and lifestyle variables. As a whole, night workers smoked more and had significantly higher BMI, serum total cholesterol, and triglycerides than day workers. Both the inter-individual comparison between day and night workers and the intra-individual comparison among the workers, who were day workers at the beginning of their employment and later became night workers, showed a significant increase in BMI, total cholesterol, and tryglicerides associated with night work. No consistent effect was seen on fasting glucose, hepatic enzymes, and blood pressure, whereas a higher incidence of coronary heart disease was recorded in night workers.     

Behavioural state influences the cardiovascular response to haemorrhage in lambs

We investigated the effect of behavioural state on the cardiovascular response to an acute venous haemorrhage in 7 lambs aged 13 to 19 days. Each lamb had previously been anaesthetized and instrumented for measurements of electrocorticogram, electro-oculogram, nuchal and diaphragm electromyograms, pulmonary blood flow (electromagnetic flow transducer), aortic and right atrial blood pressures. The lambs were allowed to recover from surgery at least three days before they were studied. Measurements were made during a 1-minute control period and during a 1-minute experimental period that followed a 10 ml/kg body weight haemorrhage during quiet wakefulness, quiet sleep and active sleep; the haemorrhage took approximately 30s. Haemorrhage produced similar decreases in right atrial pressure and pulmonary blood flow during the three behavioural states. However, mean aortic pressure decreased more following haemorrhage during active sleep than during quiet sleep or quiet wakefulness. These results provide evidence that reflex control of the peripheral circulation is altered during active sleep compared to quiet sleep and quiet wakefulness in lambs.     

Effects of exhaustive submaximal exercise on cardiovascular function during sleep

The influence of an afternoon bout of exhaustive submaximal exercise on cardiovascular function and catecholamine excretion during sleep was examined in five female and four male subjects. Subjects walked on a treadmill for successive 50-min periods at 50, 60, and 70% maximal O2 consumption, separated by 10-min rest periods. Exercise terminated with volitional exhaustion. Following an adaptation night, electroencephalographic and impedance cardiographic measures were obtained during three successive nights of sleep, with exercise preceding night 3. Relative to the base-line night (night 2), exhaustive exercise resulted in a sustained elevation of heart rate and cardiac output throughout the entire night's sleep. The magnitude of these elevations was unaffected by sleep stage but decreased over the night. The typical pattern of circadian decline in cardiac output was unaltered. However, the decline in heart rate with sleep onset was greater on the exercise night. Changes in impedance dZ/dt and R-Z interval suggested an enhanced myocardial contractility during the first 3 h of sleep postexercise. Analysis of morning urine samples revealed that in seven of nine subjects norepinephrine excretion increased, epinephrine excretion decreased, and dopamine excretion was unchanged during sleep on the exercise night. It is suggested that these cardiac changes reflect a sustained increase in myocardial beta-receptor activity.     

Blood sugar control in diabetic patients bearing microinfusors: the importance of the dawn phenomenon

Significant early morning hyperglycemia (the so-called "dawn phenomenon") has been observed in insulin-dependent diabetics who were otherwise well controlled. This phenomenon, if present, could lead to errors in adapting the basal insulin infusion in CSII treated diabetic patients, because a normal glucose level in the morning could be associated with asymptomatic hypoglycemic values in the night. In order to observe the occurrence and to quantify the magnitude of this phenomenon 14 well controlled CSII-treated type I diabetics were hospitalized for 1 night and samples for the determination of blood glucose (14 patients) and serum cortisol, free insulin and NEFA (8 patients) were drawn at 24.00, 02.00, 04.00, 06.00, 08.00 h. Blood glucose values were slightly but significantly higher at 06.00 than at 02.00 (106 +/- 7.92 v.s. 88.57 +/- 7.02 mg/dl, p less than 0.025, paired Student t test) while serum free insulin values decreased from midnight to 02.00 and then they remained stable. It is concluded that the small increase of blood glucose values in the morning is not a major clinical problem in CSII treated diabetic patients.     

Sleep processes exert a predominant influence on the 24-h profile of heart rate variability

Adverse cardiovascular events are known to exhibit 24-h variations with a peak incidence in the morning hours and a nonuniform distribution during the night. The authors examined whether these 24-h variations could be related to circadian or sleep-related changes in heart rate (HR) and in HR variability (HRV). To differentiate the effect of circadian and sleep-related influences, independent of posture and of meal ingestion, seven normal subjects were studied over 24 h, once with nocturnal sleep from 2300 to 0700 h and once after a night of sleep deprivation followed by 8 h of daytime sleep from 0700 to 1500 h. The subjects were submitted to constant conditions (continuous enteral nutrition and bed rest). HRV was calculated every 5 min using two indexes: the standard deviation of normal R-R intervals (SDNN) and the ratio of low-frequency to low-frequency plus high-frequency power. Sleep processes exerted a predominant influence on the 24-h profiles of HR and HRV, with lowest HRV levels during slow wave sleep, high levels during REM sleep and intrasleep awakenings, and abrupt increases in HR at each transition from deeper sleep to lighter sleep or awakenings. The circadian influence was smaller, except for SDNN, which displayed a nocturnal increase of 140% whether the subjects slept or not. This study demonstrates that 24-h variations in HR and HRV are little influenced by the circadian clock andare mainly sleep-stage dependent. The results suggest an important role for exogenous factors in the morning increase in cardiovascular events. During sleep, the sudden rises in HR at each transition from deeper sleep to lighter sleep or awakenings might precipitate the adverse cardiac events.     

The effects of nocturnal life on endocrine circadian patterns in healthy adults

We observed the 24-hour patterns of endocrine in medical students who lived either a diurnal life or nocturnal life. Nocturnal life was designed by skipping their breakfast but consuming much (>50% of their daily food intake) in the evening and at night with the sleep from 0130 h to 0830 h the next morning. After 3 weeks in the experimental life, the 24-hour plasma concentrations of melatonin, leptin, glucose and insulin were measured every three hours. Both plasma melatonin and leptin showed peaks at 0300 h in the diurnal lifestyle group, and the night peaks decreased in the nocturnal lifestyle group. The changes in the patterns of melatonin and leptin were highly consistent with that of night-eating syndrome (NES). Plasma glucose increased after all meals in both groups. Its concentration maintained a high level in the nocturnal lifestyle group between midnight and early morning while insulin secretion decreased markedly during this period. Furthermore, the strong association between glucose and insulin in the diurnal lifestyle group after meals was damaged in the nocturnal lifestyle group. It was suggested that nocturnal life leads to the impairment of insulin response to glucose. Taking these results together, nocturnal life is likely to be one of the risk factors to health of modern people, including NES, obesity and diabetes.     

The impact of sleep timing and bright light exposure on attentional impairment during night work

The prevalence of hazardous incidents induced by attentional impairment during night work and ensuing commute times is attributable to circadian misalignment and increased sleep pressure. In a 10-day shift work simulation protocol (4 day shifts and 3 night shifts), the efficacies of 2 countermeasures against nighttime (2300 to 0700 h) attentional impairment were compared: (1) Morning Sleep (0800 to 1600 h; n = 18) in conjunction with a phase-delaying light exposure (2300 to 0300 h), and (2) Evening Sleep (1400 to 2200 h; n = 17) in conjunction with a phase-advancing light exposure (0300 to 0700 h). Analysis of the dim light salivary melatonin onset indicated a modest but significant circadian realignment in both sleep groups (evening sleep: 2.27 +/- 0.6 h phase advance, p < 0.01; morning sleep: 4.98 +/- 0.43 h phase delay, p < 0.01). Daytime sleep efficiency and total sleep time did not differ between them or from their respective baseline sleep (2200 to 0600 h; p > 0.05). However, on the final night shift, the evening sleep subjects had 37% fewer episodes of attentional impairment (long response times: 22 +/- 4 vs. 35 +/- 4; p = 0.02) and quicker responses (p < 0.01) on the Psychomotor Vigilance Task than their morning sleep counterparts. Their response speed recovered to near daytime levels (p = 0.47), whereas those of the morning sleep subjects continued to be slower than their daytime levels (p = 0.008). It is concluded that partial circadian realignment to night work in combination with reduced homeostatic pressure contributed to the greater efficacy of a schedule of Evening Sleep with a phase-advancing light exposure as a countermeasure against attentional impairment, over a schedule of Morning Sleep with a phase-delaying light exposure. These results have important implications for managing patients with shift work disorder.     

Twenty-four-hour rhythms of plasma glucose and insulin secretion rate in regular night workers

To determine whether the ultradian and circadian rhythms of glucose and insulin secretion rate (ISR) are adapted to their permanent nocturnal schedule, eight night workers were studied during their usual 24-h cycle with continuous enteral nutrition and a 10-min blood sampling procedure and were compared with 8 day-active subjects studied once with nocturnal sleep and once with an acute 8-h-shifted sleep. The mean 24-h glucose and ISR levels were similar in the three experiments. The duration and the number of the ultradian oscillations were influenced neither by the time of day nor by the sleep condition or its shift, but their mean amplitude increased during sleep whenever it occurred. In day-active subjects, glucose and ISR levels were high during nighttime sleep and then decreased to a minimum in the afternoon. After the acute sleep shift, the glucose and ISR rhythms were split in a biphasic pattern with a slight increase during the night of deprivation and another during daytime sleep. In night workers, the glucose and ISR peak levels exhibited an 8-h shift in accordance with the sleep shift, but the onset of the glucose rise underwent a shift of only 6 h and the sleep-related amplification of the glucose and ISR oscillations did not occur simultaneously. These results demonstrate that despite a predominant influence of sleep, the 24-h glucose and ISR rhythms are only partially adapted in permanent night workers.     

Glycated hemoglobin as a marker of cardiovascular risk

PURPOSE OF REVIEW: Diabetes mellitus is an established risk factor for cardiovascular disease. This review examines glycated hemoglobin, an indicator of long-term average blood glucose concentrations, in risk prediction for cardiovascular disease. RECENT FINDINGS: Glycated hemoglobin concentrations predict cardiovascular disease risk in people with diabetes, and trial data suggest that good blood glucose control is associated with reduction in cardiovascular disease. Elevated glycated hemoglobin levels below the thresholds accepted for diabetes are also associated with increasing cardiovascular disease risk independent of classical risk factors in a continuous relationship across the whole normal distribution. A 1% increase in absolute concentrations of glycated hemoglobin is associated with about 10-20% increase in cardiovascular disease risk. The continuous relationship is most evident for coronary heart disease in men; the shape of the risk curve is less clear for women and for other cardiovascular endpoints such as stroke or peripheral vascular disease. SUMMARY: Glycated hemoglobin concentration predicts cardiovascular risk both in people with diabetes and in the general population, and may help identify individuals at higher risk of cardiovascular disease for targeted interventions, including blood pressure or cholesterol reduction. Understanding the nature of this relationship may inform new preventive and therapeutic interventions.     

Twenty-four-hour pattern of angina pectoris, acute myocardial infarction and sudden cardiac death: Role of blood pressure, heart rate and rate-pressure product circadian rhythms

Population-based epidemiology and clinical case studies document a prominent 24-hour pattern in the occurrence of silent and non-silent angina pectoris (AP), acute myocardial infarction (AMI), and sudden cardiac death (SCD). When the data are summarized per 3 - 6 hour intervals of the 24 hours, the temporal pattern of these ischemic heart disease (IHD) events shows a single morning peak between 06:00 and 12:00 h in incidence. However, when the occurrence of such events is examined according to the hour of their occurrence, several studies reveal a second late-afternoon/early-evening minor peak. The true day - night pattern in AP, AMI, and SCD is unknown because the data represent nothing more than the recorded “time of day” of the events. It has been postulated that the day - night pattern in IHD events is at least in part dependent on endogenous circadian rhythms, which are synchronized by the daily routine of sleep in darkness/activity in light. Approximately 20% of the working population is involved in night and rotating shift employment; thus, “time of day” studies are not likely to accurately represent the actual “chronorisk” of vulnerable individuals to IHD events. Moreover, it is likely that the events in the persons comprising the population and clinical case studies were influenced by ongoing treatment with antihypertensive, anticoagulant, and antianginal medications. Details regarding the class, dose, and schedule of such medications are rarely if ever reported in accounts of IHD events. Many of the investigations were conducted decades ago, when short-acting antihypertensive and cardiovascular medications required twice or thrice-a-day dosing, and thus the observed day - night variations could be significantly affected by such multiple treatment timings each day. Thus, the magnitude and nature (single versus multiple peaks) of the reported day - night patterns in AP, AMI, and SCD are suspect, as are their geneses. Presently, it is hypothesized that multiple cyclic exogenous triggers (e.g. posture, physical exertion, emotional stress, and medication scheduling) superimposed upon an endogenous 24-hour susceptibility-resistance pattern that arises from circadian rhythms in heart rate, blood pressure, rate-pressure product, and haemostasis, are major contributory factors.     

Heart rate variability during long truck driving work

We recorded ambulatory electrocardiograms of 6 long distance truck drivers during their work period in order to observe the affect of autonomic nervous function and symptoms while doing their work. We also recorded their work patterns every minute. The RR50 value and the LFP/HFP ratio were calculated every two minutes based on R-R interval data. RR50 was significantly higher during taking naps than during other periods of work shifts, while, the LFP/HFP ratio showed significantly lower during taking naps than during other periods of work shifts. RR50 in the morning was significantly higher than that in the afternoon. On the contrary, the LFP/HFP ratio showed opposite tendency. Only on the times of driving, RR50 was significantly higher in the morning than that in the afternoon. On the other hand, the LFP/HFP ratio showed an opposite tendency. These results show that the parasympathetic nervous activities were more dominant than sympathetic nervous activities in the morning during the subjects were doing long distance truck driving including midnight work. Driving while in high parasympathetic nervous activity levels may add to cardiovascular stress and lead to drowsiness. And this may result in disrupted attention. It is necessary to decrease work time and improve working conditions of truck drivers working long-hour shifts.     

Using thresholds based on risk of cardiovascular disease to target treatment for hypertension: modelling events averted and number treated

ObjectiveTo estimate the impact of using thresholds based on absolute risk of cardiovascular disease to target drug treatment to lower blood pressure in the community.DesignModelling of three thresholds of treatment for hypertension based on the absolute risk of cardiovascular disease. 5 year risk of disease was estimated for each participant using an equation to predict risk. Net predicted impact of the thresholds on the number of people treated and the number of disease events averted over 5 years was calculated assuming a relative treatment benefit of one quarter.SettingAuckland, New Zealand.Participants2158 men and women aged 35-79 years randomly sampled from the general electoral rolls.Results46 374 (12%) Auckland residents aged 35-79 receive drug treatment to lower their blood pressure, averting an estimated 1689 disease events over 5 years. Restricting treatment to individuals with blood pressure ⩾170/100 mm Hg and those with blood pressure between 150/90-169/99 mm Hg who have a predicted 5 year risk of disease ⩾10% would increase the net number for whom treatment would be recommended by 19 401. This 42% relative increase is predicted to avert 1139/1689 (68%) additional disease events overall over 5 years compared with current treatment. If the threshold for 5 year risk of disease is set at 15% the number recommended for treatment increases by <10% but about 620/1689 (37%) additional events can be averted. A 20% threshold decreases the net number of patients recommended for treatment by about 10% but averts 204/1689 (12%) more disease events than current treatment.ConclusionsImplementing treatment guidelines that use treatment thresholds based on absolute risk could significantly improve the efficiency of drug treatment to lower blood pressure in primary care.