Genetic variation in bone morphogenetic proteins family members (BMPs 2 and 4) and hypertension risk in middle-aged men: The TAMRISK study

Gene ic a ia ion in bone mo phogene ic p o eins amily membe s (BMPs 2 and 4) and hype ension isk in middle-aged men The TAMRISK s udy Jaakko V.I. Piesanen, MB a , Seppo T. Nikka i, MD, PhD a,b , Ta ja A. Kunnas, PhD a,∗ Abs ac Bone mo phogene ic p o eins (BMPs) a e impo an egula o s o i on me abolism a ec ing hepcidin exp ession. We ha e p e iously shown ha 2 gene ic polymo phisms in di e en genes (his ocompa ibili y complex class I-like ansmemb ane p o ein, hemoju elin) in ol ed in he egula ion o hepcidin exp ession pa hways a e associa ed wi h hype ension. In his s udy, we analyzed gene ic a ia ion si es in BMP2 ( s235756, s235768) and BMP4 ( s4901474) o ge mo e e idence linking i on me abolism o hype ension isk in he Finnish popula ion. The s udy included 321 hype ensi e cases and 463 con ols om he Tampe e Adul Popula ion Ca dio ascula Risk s udy coho . Geno yping o polymo phisms was done by polyme ase chain eac ion using DNAs ex ac ed om buccal swabs. We ound ha men ca ying he GG geno ype o BMP2 s235756 (A>G) polymo phic si e had a 4.09- old isk (confidence in e al [CI] 1.61–10.39, P=.003) o hype ension a he age o 50 yea s compa ed wi h A-allele ca ie s. The isk was significan in he age g oups o 45 and 40 yea s as well. In addi ion, he 15-yea ollow-up pe iod o he same indi iduals showed ha ca ie s o he GG- geno ype had also significan ly highe eadings o bo h sys olic (P<.001) and dias olic (P=.01) blood p essu e du ing he ollow-up ime. No significan associa ion be ween BMP2 s235768 (A>T) and hype ension was ound. BMP4 polymo phic si e s4901474 (T>C) also had an e ec on hype ension. CC geno ype ca ie s had a 1.48- old isk (CI 1.03–2.13, P=.033) o hype ension a he age o 50 yea s when compa ed wi h T-allele ca ie s. In conclusion, BMP2 polymo phic si e s235756 was associa ed wi h hype ension in Finnish men. An e ec o BMP4 polymo phic si e on hype ension was also ound. Abb e ia ions: ANG =angio ensin, ANOVA =analysis o a iance, BMI =body mass index, BMP =bone mo phogene ic p o ein, BP =blood p essu e, CAD =co ona y a e y disease, CI =confidence in e al, HFE =his ocompa ibili y complex class I-like ansmemb ane p o ein, HH =hemoch oma osis, HJV =hemoju elin, OR =odds a io, PCR =polyme ase chain eac ion, PHE =pe iodic heal h examina ion, SNP =single-nucleo ide polymo phism, TAMRISK =Tampe e Adul Popula ion Ca dio ascula Risk s udy. Keywo ds: BMP, gene ic a ian s, hype ension, i on 1. In oduc ion Hype ension is a subs an ial isk ac o o ca dio ascula diseases, including co ona y a e y disease (CAD), s oke, le en icula hype ophy, conges i e hea ailu e, pe iphe al ascula disease, enal ailu e, and ao ic aneu ysms. [1] In conside a ion o he high p e alence o hype ension, i has also a huge impac on public heal h. A be e unde s anding o gene ic ac o s o hype ension will be help ul in he p e en ion and cu ing o he disease. Bone mo phogene ic p o eins (BMPs) a e signaling molecules belonging o ans o ming g ow h ac o -be a supe amily. Apa om many o he unc ions, hey ha e a key ole in i on homeos asis. A ec ing he exp ession o hepcidin, he egula o ho mone o i on homeos asis, mu a ions/gene ic a ia ion in BMPs a e belie ed o lead o i on-deficiency and i on-o e load synd omes. [2] The common single-nucleo ide polymo phism (SNP) a ian s in he BMP genes a e s235756 and s235768 (BMP2) and s490141 (BMP4). We ha e p e iously shown he associa ion be ween he polymo phism o 2 di e en i on egula o p o eins—majo his ocompa ibili y complex class I-like ansmemb ane p o ein (HFE) and hemoju elin (HJV) genes and hype ension. [3,4] Howe e , he associa ion be ween BMP2 and BMP4, and hype ension has no been s udied ea lie . Ins ead, Mile e al [5] es ed associa ion o BMP2 polymo phism wi h se um e i in le els wi h conflic ing esul s in 2 di e en coho sample o C282Y homozygo e hemoch oma osis (HH) pa ien s. Recen - ly, Ji e al [6] ound an associa ion wi h plasma e i in le els and s235756 in he BMP2 gene when hey s udied Aus alian blood dono s. Associa ion was significan , especially in male dono s. Edi o : Leona do Roe e . Funding: Compe i i e esea ch unding o he Pi kanmaa Hospi al Dis ic unded his wo k. The au ho s decla e ha he e is no conflic o in e es . a Depa men o Medical Biochemis y, Facul y o Medicine and Li e Sciences, Uni e si y o Tampe e, b Fimlab Labo a o ies, Tampe e, Finland. ∗ Co espondence: Ta ja A. Kunnas, Facul y o Medicine and Li e Sciences, FI- 33014 Uni e si y o Tampe e, Finland (e-mail: a ja.kunnas@u a.fi). Copy igh ©2017 he Au ho (s). Published by Wol e s Kluwe Heal h, Inc. This is an open access a icle dis ibu ed unde he e ms o he C ea i e Commons A ibu ion-Non Comme cial-No De i a i es License 4.0 (CCBY-NC- ND), whe e i is pe missible o download and sha e he wo k p o ided i is p ope ly ci ed. The wo k canno be changed in any way o used comme cially wi hou pe mission om he jou nal. Medicine (2017) 96:51(e9362) Recei ed: 20 June 2017 / Recei ed in final o m: 16 Oc obe 2017 / Accep ed: 27 No embe 2017 h p://dx.doi.o g/10.1097/MD.0000000000009362 Obse a ional S udy Medicine® OPEN 1 The aim o his s udy was o e alua e whe he polymo phic si es in BMP2 and BMP4 genes a e associa ed wi h hype ension in he Finnish (Tampe e Adul Popula ion Ca dio ascula Risk s udy [TAMRISK]) coho . 2. Me hods 2.1. Pa icipan s The TAMRISK is a p ospec i e, longi udinal popula ion-based heal h su ey s udy in Tampe e, a ci y in sou he n Finland, wi h a popula ion o 230,000. The da a o he TAMRISK was collec ed om he pe iodic heal h examina ions (PHEs) done o 50-yea - old men and women li ing in Tampe e. The PHE included one 60-minu e session wi h a public heal h nu se a he cen e ’s heal h examina ion uni as p e iously desc ibed. [3,7] TAMRISK da a include in o ma ion o isk ac o s o hype ension: blood p essu e (BP), weigh , lipid alues and smoking, alcohol consump ion, diabe es, and amily his o y o ca dio ascula diseases. Cu en and p e ious diseases we e iden ified based on sel - epo o diagnosis by a physician, including hype ension. Cases in his s udy we e he subjec s who had hype ension and/ o CAD a he age o 50 yea s as diagnosed by a physician by no mal heal hca e p ocedu es. Fo mos pa ien s, physicians diagnose hype ension when BP eadings a e consis en ly 140/90 mm Hg o abo e. Fo each case, a leas 1 no mo ensi e con ol wi h he same sex and simila smoking habi s we e chosen om a PHE coho (n=6000). Smoking s a us was e alua ed based on sel - epo ing. Alcohol use was documen ed by indi idual in e iews using a s uc u ed ques ionnai e. Weekly alcohol consump ion was assessed dis inguishing he amoun s o bee , wine, and liquo consumed, and was hen calcula ed as uni /wk. One uni co esponds o 12g o e hanol. Buccal swabs o DNA ex ac ion and a pe mission o m o use PHE da a we e collec ed by mail sepa a ely o he physical examina ion du ing yea s 2006 o 2010. In o med consen was ob ained om all pa icipan s. TheE hicsCommi eeso heTampe e Uni e si y Hospi al and he Ci y o Tampe e app o ed he s udy. 2.2. DNA geno yping DNA was ex ac ed om buccal swabs using a comme cial ki (Qiagen Inc., Valencia, CA). Polyme ase chain eac ion (PCR) was pe o med in a final olume o 5mL con aining 10ng o sample DNA, 0.05mL o cus om SNP-specific Assay mix, and 2.18mL o Taqman Uni e sal PCR Mas e Mix. The Assay mixes used we e C___2513516_10 ( s235756), C___2244893_10 ( s235768), and C___7844917_10 ( s4901417). Amplifica ion p oceeded o 40 cycles o 15seconds a 95°C and 60seconds a 60°C. Geno yping ollowed he Applied Biosys ems (Pleasan on, CA) p o ocol. Au oma ic geno ype call was pe o med a e PCR, by scanning pla es on he 7900 HT Fas Real-Time PCR, which p o ides he SDS2.3 so wa e (Applied Biosys ems). 2.3. S a is ical analysis Ha dy–Weinbe g equilib ium o he geno ypes was calcula ed using online encyclopedia calcula o o gene ic epidemiology s udies. [8] T es and 1-way analysis o a iance (ANOVA) o con inuous a iables (clinical cha ac e is ics), and chi-squa e es o ca ego ical a iables (hype ension, CAD) we e applied o he compa ison o BMP geno ype g oups. Associa ions o he geno yped BMP2 and BMP4 gene a ian s wi h hype ension/ co ona y a e y disease wi h isk ac o s (BMI, sex, smoking [yea s], and alcohol consump ion [uni /wk]) we e analyzed using logis ic eg ession analysis. The ANOVA was used o assess he di e ences in mean BPs be ween geno ypes a he age o 35, 40, 45, and 50 yea s. The model included he main e ec s o g oup ac o and ime, and hei in e ac ion. S a is ical analyses we e assessed using IBM SPSS S a is ics 23, and he s a is ical significance was se o 0.05. 3. Resul s Clinical cha ac e is ics o he middle-aged (50±0 yea s) s udy pa icipan s a e lis ed in Table 1. B iefly, case g oup comp ised 321 hype ensi e cases and con ol g oup 463 no mo ensi e subjec s wi h he same sex dis ibu ion and simila smoking habi s. A o al o 22 subjec s we e ound o ha e CAD a he age o 50 yea s. Geno yping was success ul in 756 subjec s o he BMP2 s235756 (A>G), in 784 subjec s o he s235768 (A>T), and in 766 subjec s o he BMP4 s4901474 (T>C). In he s udy popula ion, geno ype dis ibu ion o he s235756 in he BMP2 gene was 37% AA, 48% AG, and 15% GG, and o he s235768 i was 33% TT, 48% TA, and 19% AA. Geno ype dis ibu ion o BMP4 s4901474 was 31% TT, 50% TC, and 19% CC. The measu ed geno ype equencies we e no significan ly di e en om he expec a ions o Ha dy–Weinbe g equilib ium (x 2 = 0.613 o s235756, x 2 =0.432 o s235768, and x 2 =0.204 o s4901474). In he whole s udy popula ion, a he age o 50 yea s, he BMP2 SNP s235756 (A>G) associa ed significan ly wi h hype ension (P=.035). Mo e de ailed analysis showed ha indi iduals ca ying he GG geno ype had mo e o en hype ension (47%) compa ed wi h he AG o AA geno ype ca ie s (36.9% and 45.1%, espec i ely). S a is ically significan di e ence was ound only be ween GG and AG geno ype ca ie s (P=.047), and when A-allele ca ie s we e combined, only a end o hype ension isk was ound (P=.152). When men and women we e analyzed sepa a ely, we ound ha he isk o hype ension was significan ly highe only among men (P=.035 o geno ype e ec and P=.016 o GG s A-allele). In he la e analysis, Table 1 Clinical cha ac e is ics o cases and con ols o he s udy popula ion. Clinical cha ac e is ics Cases (n=321) Con ols (n=463) P Age, y 50±050±0 BMI, kg/m 2 28.4±5.0 25.2±3.5 <.001 Hemoglobin 146.4±13.2 143.8±12.8 .020 Choles e ol, mmol/L 5.39±0.95 5.40±0.88 .769 T iglyce ides, mmol/L 1.49±1.15 1.17±0.69 <.001 HDL choles e ol, mmol/L 1.58±0.45 1.69±0.44 .002 LDL choles e ol, mmol/L 3.17±0.88 3.19±0.82 .710 Glucose, mmol/L 5.21±1.44 4.83±0.53 <.001 Sys olic blood p essu e, mm Hg 143.0±16.8 129.0±15.3 <.001 Dias olic blood p essu e, mm Hg 92.7±9.0 84.3±9.6 <.001 Hype ension, % 100 0 <.001 Diabe es, % 13.4 0 <.001 Daily smoke s, % 27.1 22.7 .154 Alcohol consump ion, uni /wk 6.8 5.3 .007 Lipid-lowe ing d ugs, % 14.7 3.2 <.001 Family his o y o hype ension, % 73.5 41.1 <.001 Sex (male), % 56.1 53.1 .416 Da a a e p esen ed as mean ±s anda d de ia ion. BMI=body mass index, HDL =high-densi y lipop o ein, LDL =low-densi y lipop o ein. Piesanen e al. Medicine (2017) 96:51 Medicine 2 55.9% o males ca ying he GG geno ype had hype ension compa ed wi h 37.8% o A-allele ca ie s. We also ound a highe suscep ibili y o hype ension incidence al eady when he same men we e 10 yea s younge . A he age o 40 yea s, 19% o he GG geno ype ca ie s had hype ension compa ed wi h 8.1% o he A-allele ca ie s (P=.019, o geno ype e ec P=.006). Mul i a ia e logis ic eg ession wi h A-allele as e e ence (adjus ed wi h BMI, smoking his o y [yea s] and alcohol consump ion [uni /wk]) showed ha a he age o 50 yea s, he isk o hype ension was 4.09- old in GG-geno ype ca ie s (confidence in e al [CI] 1.61–10.39, P=.003), a he age o 45 yea s i was 3.14 (CI 1.03–9.55, P=.043), and a he age o 40 yea s i was 2.55 (CI 1.13–5.72, P=.024). As expec ed, no s a is ically significan associa ion was ound be ween geno ypes and hype ension a he age o 35 yea s due o small amoun o hype ension cases. In women, no s a is ically significan associa ion wi h hype ension a any age g oup was ound. In addi ion, 15-yea ollow-up pe iod (35, 40, 45, and 50 yea s) o he same indi iduals showed ha ca ie s o he GG geno ype had also significan ly highe eadings o bo h sys olic (P<.001) and dias olic (P=.01) BP du ing he ollow-up ime (Table 2, Fig. 1). Finally, we also analyzed associa ion o his polymo phism wi h diagnosed CAD in men. Al hough he e we e only 22 men who had CAD a he age o 50 yea s, hose ca ying he GG geno ype ended o ha e mo e o en CAD han A-allele ca ie s (11.5% s 4.1%, espec i ely; P=.027). Fo he o he polymo phic si e o he BMP2 gene ( s235768), no s a is ically significan associa ion wi h hype ension o CAD was ound (da a no shown). No significan associa ion be ween BMP4 s4901474 (T>C) a ian s and hype ension was ound (P=.092) in he whole s udy popula ion. Howe e , a e combining he T-allele ca ie s, we ound ha 52.1% o he a e geno ype CC ca ie s had hype ension a he age o 50 yea s compa ed wi h 42.3% o he T-allele ca ie s (odds a io [OR] 1.48, CI 1.03–2.13, P=.033). When BMI, smoking his o y (yea s), and alcohol consump ion (uni /wk) we e included in o analyses, isk o hype ension among CC ca ie s was e en highe (OR 2.00, CI 1.21–3.32, P=.007). A he age o 45 yea s, isk o hype ension was s ill significan (OR 1.98, CI 1.02–3.82, P=.043), bu disappea ed a he age o 40 and 35 yea s. No s a is ically significan associa ion wi h CAD was ound o BMP4 gene s4901474. 4. Discussion In he p esen s udy, we ound a significan associa ion be ween hype ension and gene ic a ia ion o he BMP2 gene ( s235756). Fu he mo e, a sligh e ec o BMP4 polymo phic si e ( s4901474) on hype ension was ound. The isk o hype en- sion was significan ly highe wi hin men in age g oups o 40, 45, and 50 yea s o GG geno ype o SNP s235756. Bo h sys olic and dias olic BPs we e also significan ly highe among GG geno ype ca ie s al eady a he age o 35. Bone mo phogene ic p o eins ha e ea lie been ound o ha e ole in human de elopmen and 2 ascula diso de s—pulmo- na y a e ial hype ension and he edi a y hemo hagic elangi- ec asia. [9] Mo eo e , a numbe o BMPs a e up- egula ed a si es o ascula inju y and a he oscle o ic plaques, sugges ing ha BMPs could play a ole in egula ing no mal ascula homeos asis and disease-associa ed ascula pa hology. In addi ion, di e en s udies ha e e ealed majo ole o he BMP amily o ligands and ecep o s in i on homeos asis. BMP signaling in ascula de elopmen and ca dio ascula diseases ha e ecen ly been excellen ly e iewed by Mo el e al, [10] and Lowe y and deCaes ecke . [11] Bone mo phogene ic p o eins a e also in ol ed in i on homeos asis egula ion, and in li e , hey ac as co ecep o s o HJV. Ac i a ion o he HJV-BMP signaling pa hway leads o ansc ip ion o hepcidin, which is he majo known egula o o sys emic i on homeos asis. By educing die a y i on up ake and elease om mac ophages, hepa ocy es, and o he cell ypes, i a ec s he amoun o sys emic i on. [12] In 2003, hepcidin deficiency was e ealed as a cause o i on o e load. HH pa ien s wi h HJV mu a ions also had low le els o se um hepcidin [13] and HH pa ien s wi h HFE mu a ions had lowe exp ession o hepcidin in he li e compa ed wi h con ols. [14] In addi ion o HJV-BMP pa hway, he e a e o he pa hways a ec ing hepcidin exp ession as well. We ha e p e iously ound an associa ion be ween hype ension and 2 i on me abolism egula o p o eins, HFE and HJV. [3,4] The p esen s udy is consis en wi h he ea lie findings. Table 2 Means o sys olic and dias olic blood p essu es a di e en ages acco ding gene ic a ian s. Sys Dias Sys Dias Sys Dias Sys Dias s235756 AA AG GG P Age 50 135.1±17.5 88.4±10.0 133.5±16.2 86.8 ±10.0 139.1±18.8 89.8±10.2 .009 .011 Age 45 132.5±13.6 85.3±9.2 131.3±14.7 84.2 ±9.5 137.4±20.0 86.5±10.6 .002 .084 Age 40 128.9±13.1 83.1±9.9 129.3±12.4 82.9 ±9.6 132.8±15.0 85.5±10.9 .037 .063 Age 35 127.7±12.6 81.5±10.1 127.5±12.8 81.7 ±9.3 132.9±13.9 83.7±10.3 .002 .191 s235768 AA AT TT P Age 50 134.6±18.1 87.9±10.9 134.4±16.8 87.5 ±9.7 135.5±17.3 88.0±10.5 .696 .747 Age 45 132.7±16.4 84.7±10.4 133.0±14.9 85.2 ±9.3 131.7±14.8 84.4±9.5 .587 .647 Age 40 129.8±13.6 83.5±10.9 129.7±13.0 83.4 ±10.0 129.1±12.5 82.9±9.1 .804 .786 Age 35 127.9±12.7 80.7±10.5 128.3±12.8 82.4 ±9.6 128.8±13.5 81.9±9.3 .829 .275 s4901474 TT TC CC P Age 50 134.4±16.3 87.6±9.8 135.2±17.1 87.8 ±9.8 136.5±16.3 89.2±9.6 .481 .260 Age 45 133.1±15.0 84.7±9.3 132.7±14.5 85.4 ±9.3 131.9±13.4 86.1±9.5 .756 .415 Age 40 131.1±13.3 84.1±9.1 130.5±12.5 83.7 ±9.6 131.0±13.4 84.5±13.0 .872 .728 Age 35 129.1±13.6 82.0±8.5 128.8±12.6 82.1 ±9.5 129.7±12.9 84.0±10.0 .839 .181 Da a a e p esen ed as mean ±s anda d de ia ion. Piesanen e al. Medicine (2017) 96:51 www.md-jou nal.com 3 Associa ion wi h BMP2 and BMP4, and hype ension has no been s udied ea lie . Ins ead, he s aigh e ec s o BMPs on i on me abolism ha e been unde in e es . Mu a ions o BMPs a e belie ed o lead o i on deficiency o o e load synd omes. [2] Mile e al. ound ha he polymo phic si e o BMP2 ( s235756) is associa ed wi h highe se um e i in le els in HFE p.C282Y homozygous pa ien s, [5] bu hey we e no able o eplica e he esul s in a la e s udy. [15] They ound ha he highes se um e i in le elswe e among TT (AA) geno ypes, whe eas ou findings sugges ha he highes BPs we eamong GG geno ype ca ie s. The e o e, a link wi h high e i in and BP may no be specula ed in his con ex . Howe e , since hei s udies included only p.C282Y homozygous pa ien s, he esul s o he s udies canno be ully compa ed wi h ou p esen s udy. In Aus alian blood dono s, BMP2 gene a ian s we e also ound o associa e wi h e i in le els, especially in male dono s, bu i was no possible o de e mine he significance o homozygosi y and he e ozygosi y o he a ian allele due o insu ficien s a is ical powe . [6] Ou ecen finding sugges s he possible ole o BMPs in essen ial hype ension, which may be linked wi h i on me abo- lism. Male pa ien s wi h essen ial hype ension ha e been ound o ha e inc eased se um e i in le els when compa ed wi h no mo ensi e indi iduals, and a s ong associa ion be ween hepcidin le els and se um e i in has been obse ed. [16] This unde lines he possible e ec o al e ed i on me abolism on hype ension, al hough o he BMP-media ed mechanisms canno be excluded. A limi a ion o he s udy popula ion is he lack o in o ma ion abou die , which has an impo an ole in i on me abolism. Howe e , since he a e age daily i on in ake o Finnish people is nea he na ional ecommenda ions [17] and ou s udy popula ion is qui e la ge, we belie e ha he e a e no significan di e ences o daily die a y i on among he s udy popula ion. Howe e , i is known ha di e en gene ic polymo phisms a ec i on abso p- ion and i on le els in he body. In Finland, ma ke s o body i on s o es, se um e i in, and ans e in sa u a ion a e no ou inely measu ed, and he e o e a limi a ion o he TAMRISK s udy popula ion is he lack o hese sa u a ion ma ke s. The mechanism be ween i on me abolism and hype ension a e cu en ly unde s udy. Al hough he field o i on me abolism egula ion is a om being unde s ood, hepcidin has been assumed as being he p imo dial egula o o i on homeos asis. The e o e, ou ocus is now o in es iga e he possible ole o hepcidin in egula ion o BP. [3,4] Possible connec ion o he ennin-angio ensin sys em and i on me abolism is suppo ed by he obse a ions ha angio ensin (ANG) II adminis a ion caused 4.7- old inc ease in he amoun o hepcidin mRNA concen a ion in he a kidney, and ha his inc ease could be supp essed by he concomi an adminis a ion o losa an. [18] An opposi e e ec was ound in he hepa ic hepcidin mRNA exp ession and se um hepcidin concen a ion in ANG II- induced hype ensi e mice. [19] Howe e , possible hepcidin- enin-angio ensin sys em in hype ension wa an s u he s udy. 5. Conclusions In conclusion, he e was a significan associa ion in men be ween BMP2 gene ic a ian ( s235756) and hype ension in he gene ically homogeneous Finnish popula ion. Those who ca ied he a e GG geno ype o he gene had highe isk o hype ension al eady a he age o 40 yea s. The e was also an associa ion be ween BMP4 ( s4901417) gene ic a ian s and hype ension. Ou esul s sugges ha gene ic a ia ion in i on me abolism- ela ed genes pa icipa ing in hepcidin exp ession may ha e an e ec on hype ension. The a ea o in es iga ion is impo an , as he e migh be some clinical consequences o he ea men o essen ial hype ension as well. Fo example, he i on in ake o hype ensi e pa ien s would be needed o be assessed mo e ho oughly o achie e op imal i on balance o hese pa ien s. In addi ion, he e migh be a chance o some pha macological applica ions as well. S ill, mo e in es iga ion will be needed o confi m he connec ion be ween i on me abolism and essen ial hype ension. Acknowledgmen s We hank all he pa icipan s o he TAMRISK s udy and Mi ka Pie iläinen, Ulla Saa ijoki, and Nina Pel onen o hei skil ul echnical assis ance. Figu e 1. Di e ences in mean sys olic (P<.001) and dias olic (P=.01) blood p essu e be ween BMP s235756 geno ypes (A>G) du ing 15 yea s o ollow-up in men. P alues a e om epea ed-measu es analysis. Piesanen e al. 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