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Progress in the battle against hypertension. Changes in blood pressure levels in the United States from 1960 to 1980
Abstract
Intensive efforts by practicing physicians and public health workers to identify and treat persons with hypertension have been underway for many years. In this report, changes in blood pressure levels in the United States are assessed based on nationally representative health (and nutrition) examination surveys conducted by the National Center for Health Statistics in 1960 to 1962, 1971 to 1974, and 1976 to 1980. Analysis of age-adjusted data for adults aged 18 to 74 years (including those on antihypertensive medication) indicates that between the first and third surveys for whites and blacks, respectively, mean systolic blood pressure declined 5 and 10 mm Hg; the proportion of persons with systolic blood pressure of 140 mm Hg or higher fell 18 and 31%; the proportion with undiagnosed hypertension decreased 17 and 59%; and the proportion taking antihypertensive medications rose 71 and 31%. These differences between the first and third surveys were all statistically significant (p less than 0.05 or better). Changes in diastolic blood pressure levels were generally not significant among race-sex groups. The proportion of persons with definite hypertension (i.e., systolic blood pressure greater than or equal to 160 mm Hg, and/or diastolic blood pressure greater than or equal to 95 mm Hg, and/or taking antihypertensive medication) declined among blacks but rose slightly among whites. Study results are consistent with the recent decline in cardiovascular disease mortality.
... Since the early 1960s, Americans have made substantial improvements in the levels of a number of coronary heart disease (CHD) risk factors (1)(2)(3)(4)(5)(6). For example, the mean serum cholesterol level in US adults decreased 15 mg/dl from the 1960-1962 National Health and Examination Survey I to the 1988-1992 National Health and Nutrition Examination Survey HI (7). ...
... For example, the mean serum cholesterol level in US adults decreased 15 mg/dl from the 1960-1962 National Health and Examination Survey I to the 1988-1992 National Health and Nutrition Examination Survey HI (7). The number of Americans who reported better diagnosis and treatment of elevated blood pressure has also increased (2,3). Finally, lower prevalence rates of cigarette smoking have been reported in many subgroups of the population, with the one exception being adolescent and young adult females (8). ...
The objective of this research was to investigate the long-term relation between body mass index (BMI) and mortality from all causes and from specific causes in the general population. A 29-year follow-up study was conducted in a random sample of white men (n = 611) and women (n = 697) aged 20-96 years who were residents of Buffalo, New York, in 1960. At baseline, height and weight were determined by self-report. BMI was calculated as weight (kg)/height (m2). During the follow-up period, 295 (48.3 percent) men and 281 (40.3 percent) women died. With the Cox proportional hazards model and adjustment for age, education, and cigarette smoking, a significant linear association was found between BMI and all-cause mortality in men less than age 65 years at baseline (relative risk (RR) = 1.06, 95 percent confidence interval 1.02-1.09), but not in women (RR = 1.02, 95 percent confidence interval 0.99-1.05). In men age 65 years and older, the relation was quadratic in form (p = 0.02), with the lowest risks appearing in the BMI range of 23-27. BMI was most strongly related to cardiovascular disease (CVD) and coronary heart disease mortality in women and younger men. No such associations were observed in older men. BMI was not related to an increased risk of death from non-CVD or cancer in either sex. These findings illustrate the importance of BMI as a risk factor for CVD and coronary heart disease mortality in certain gender-age groups and indicate that the majority of the impact of BMI on overall mortality is due to the strong relation between relative weight and these specific causes of death.
... 63 These programs are aimed at working with the food industry and restaurants as well as establishing policies to reduce salt in the prepared and processed food, encouraging the consumption of more fresh fruits and vegetables, increasing community parti cipation in physical activity, detecting and tracking high BP at churches, worksites and community events and public education campaigns. 64,65 This population-based approach complements the clinical hypertension treatment and management. Primary prevention strategies are implemented to reduce the BP levels in the population. ...
... This approach serves to decrease blood pressure levels in the general population by relatively modest amounts but in large populations has the potential to substantially reduce stroke morbidity and mortality and delay the onset of hypertension. 188 Stamler 189 estimated 2 decades ago that a 5-mm Hg reduction of SBP in the adult population would result in a 14% overall reduction in mortality caused by stroke. As presented in Figures 1 and 2 and the Table, the reduction in SBP is consistent with the decline in stroke mortality and corresponds to the predicted lower stroke mortality rates. ...
Stroke mortality has been declining since the early 20th century. The reasons for this are not completely understood, although the decline is welcome. As a result of recent striking and more accelerated decreases in stroke mortality, stroke has fallen from the third to the fourth leading cause of death in the United States. This has prompted a detailed assessment of the factors associated with the change in stroke risk and mortality. This statement considers the evidence for factors that have contributed to the decline and how they can be used in the design of future interventions for this major public health burden.
Writing group members were nominated by the committee chair and co-chair on the basis of their previous work in relevant topic areas and were approved by the American Heart Association Stroke Council's Scientific Statements Oversight Committee and the American Heart Association Manuscript Oversight Committee. The writers used systematic literature reviews, references to published clinical and epidemiological studies, morbidity and mortality reports, clinical and public health guidelines, authoritative statements, personal files, and expert opinion to summarize evidence and to indicate gaps in current knowledge. All members of the writing group had the opportunity to comment on this document and approved the final version. The document underwent extensive American Heart Association internal peer review, Stroke Council leadership review, and Scientific Statements Oversight Committee review before consideration and approval by the American Heart Association Science Advisory and Coordinating Committee.
The decline in stroke mortality over the past decades represents a major improvement in population health and is observed for both sexes and for all racial/ethnic and age groups. In addition to the overall impact on fewer lives lost to stroke, the major decline in stroke mortality seen among people <65 years of age represents a reduction in years of potential life lost. The decline in mortality results from reduced incidence of stroke and lower case-fatality rates. These significant improvements in stroke outcomes are concurrent with cardiovascular risk factor control interventions. Although it is difficult to calculate specific attributable risk estimates, efforts in hypertension control initiated in the 1970s appear to have had the most substantial influence on the accelerated decline in stroke mortality. Although implemented later, diabetes mellitus and dyslipidemia control and smoking cessation programs, particularly in combination with treatment of hypertension, also appear to have contributed to the decline in stroke mortality. The potential effects of telemedicine and stroke systems of care appear to be strong but have not been in place long enough to indicate their influence on the decline. Other factors had probable effects, but additional studies are needed to determine their contributions.
The decline in stroke mortality is real and represents a major public health and clinical medicine success story. The repositioning of stroke from third to fourth leading cause of death is the result of true mortality decline and not an increase in mortality from chronic lung disease, which is now the third leading cause of death in the United States. There is strong evidence that the decline can be attributed to a combination of interventions and programs based on scientific findings and implemented with the purpose of reducing stroke risks, the most likely being improved control of hypertension. Thus, research studies and the application of their findings in developing intervention programs have improved the health of the population. The continued application of aggressive evidence-based public health programs and clinical interventions is expected to result in further declines in stroke mortality.
... Human primary hypertension is one of the most common chronic diseases (1). It shows a significant degree of heritability (2)(3)(4) and is commonly recognized as a complex, polygenic disorder, with the exception of rare monogenetic forms (5,6). ...
We have previously identified a locus on rat chromosome 10 as carrying a major hypertension gene, BP/SP-1. The 100:1 odds support interval for this gene extended over a 35-centimorgan (cM) region of the chromosome that included the angiotensin I-converting enzyme (ACE) locus as demonstrated in a cross between the stroke-prone spontaneously hypertensive rat (SHRSPHD) and the normotensive Wistar-Kyoto (WKY-0HD) rat. Here we report on the further characterization of BP/SP-1, using a congenic strain, WKY-1HD. WKY-1HD animals carry a 6-cM chromosomal fragment genotypically identical with SHRSPHD on chromosome 10, 26 cM away from the ACE locus. Higher blood pressures in the WKY-1HD strain compared with the WKY-0HD strain, as well as absence of linkage of the chromosome 10 region to blood pressure in an F2 (WKY-1HD x SHRSPHD) population suggested the existence of a quantitative trait locus, termed BP/SP-1a, that lies within the SHRSP-congenic region in WKY-1HD. Linkage analysis in the F2 (WKY-0HD x SHRSPHD) cross revealed that BP/SP-1a is linked to basal blood pressure, whereas a second locus on chromosome 10, termed BP/SP-1b, that maps closer to the ACE locus cosegregates predominantly with blood pressure after exposure to excess dietary NaCl. Thus, we hypothesize that the previously reported effect of BP/SP-1 represents a composite phenotype that can be dissected into at least two specific components on the basis of linkage data and congenic experimentation. One of the loci identified, BP/SP-1a, represents the most precisely mapped locus affecting blood pressure that has so far been characterized by random-marker genome screening.
... The rat provides an informative animal model for the study of hypertension, the most common of all human diseases (1). To identify the quantitative trait loci (QTL)' controlling blood pressure, we have been utilizing a candidate gene approach (2)(3)(4)(5)(6)(7)(8)(9). ...
The endothelin system, consisting of a series of potent vasoconstrictor peptides and their receptors, is potentially important in the control of blood pressure. We found that the gene coding for endothelin-2 (ET2), also known as vasoctive intestine peptide, cosegregated strongly with systolic blood pressure in a F2 population [F2(S x LEW)] derived from a cross of the Dahl salt-sensitive (S) rat and the Lewis (LEW/NCrlBR) (LEW) rat. The ET2 locus was assigned to rat chromosome 5. The testis-specific histone (HITH) locus also strongly cosegregated with blood pressure in the F2(S x LEW) population and was assigned to rat chromosome 17. Genetic maps of the regions containing the quantitative trait loci (QTL) for blood pressure on chromosomes 5 and 17 were constructed and the QTL were localized using the MAPMAKER/QTL program. The rat genes for endothelin-1, endothelin-3, and endothelin receptor A did not cosegregate with blood pressure in several F2 populations tested and were assigned to rat chromosomes 17, 3, and 19, respectively. Endothelin receptor B cosegregated weakly with blood pressure and was provisionally assigned to rat chromosome 15. We conclude that, in the rat, one new blood pressure QTL is located on chromosome 5 marked by the ET2 locus and another new QTL is located on chromosome 17 near the HITH locus.
... In 1984, the Joint National Committee (1988) redefined the criteria for diagnosing hypertension as SBP greater than 139 or DBF greater than 89. However, the NAS continues, as do other long-term studies such as Framingham (Kannel & Gordon, 1978), National Health and Nutrition Examination Survey (NHANES; Dannenberg et al., 1987), and NHANES Epidemiologic Follow-up Study (Cornoni-Huntley et al., 1989;Ford & Cooper, 1991), to maintain for sake of continuity the original definition of hypertension as blood pressure exceeding 159/94. ...
Personality predictors of hypertension incidence were studied in 838 community-residing men from the Normative Aging Study. They were followed over a mean of 17 years during which time 38% developed hypertension. Stepwise proportional hazards regression was used to identify scales from the Cattell 16 Personality Factor Questionnaire that predicted hypertension incidence, controlling for biomedical, social, and behavioral risk factors. There was a significant negative relation between the personality trait of emotional stability and the incidence of hypertension, controlling for baseline blood pressure, education, and alcohol consumption. These results support those who argue that personality characteristics predict the development of hypertension.
Atherosclerotic cardiovascular disease (ASCVD) accounts for 50% of deaths in industrialized societies. Numerous large-scale community-based longitudinal studies of individuals initially free of clinically overt ASCVD indicate that the main risk factors associated with development of ASCVD are hypertension, hypercholesterolemia, especially when accompanied by reduced high-density lipoprotein (HDL) levels, and smoking [1–3].
The incidence of hypertension (HTN) and diabetes mellitus (DM) appear to be increasing in the Eastern Mediterranean (EM) region. To initiate efforts to establish national or regional programs for the prevention and control of cardiovascular diseases (CVD) in EM countries, policy makers need more epidemiological data on HTN and DM. This study was undertaken to assess the current extent of HTN and DM prevalence and to identify the degree of awareness, treatment and control of HTN and DM.
These data were collected from most studies conducted since 1970 on the prevalence, awareness, treatment or control rates of HTN or DM in Iran and other EM countries. We searched for papers published in medical journals by using the MEDLINE database since 1970. The prevalence of HTN ranges between 7.7% and 31% in different cities in Iran and has been reported up to 33.6% in some urban areas in the EM region. The frequency of awareness of HTN ranges from 62% in Iran down to 23.5% in Saudi Arabia. On the contrary the treatment and control of HTN was better in Saudi Arabia of 76% and 20%, respectively compared to Egypt at 24% and 8%, respectively
While it is estimated that 2 million Iranians have diabetes now, the prevalence of DM in different populations in the EM region varied between 0.1% in Sudan to as high as 25.5% in Bahrain.
While most of the surveys in the EM region showed that over 50% of diabetics are undiagnosed, high rates of DM awareness from Iran (70%) and Egypt (50%) were reported. The wide range obtained from these studies may be explained by the lack of standardization of the blood pressure or plasma glucose measurements, varied definitions, different age groups or sample size of the studied population and finally different dates of the studies. In summary, our analysis indicates that although there are many reports from EM countries and Iran concerning the epidemiological views of HTN and DM, it is obvious that still there is more need to conduct a national or regional surveys using highly standardized methodology in the EM region.
Objectives-This study aimed at evaluating the trends in hypertension prevalence and control during the last decade. Methods-We drew upon four independent cross-sectional population surveys conducted in 1992, 1996, 1999 and 2001 in Isfahan, Iran. Results-The prevalence of hypertension had a downward trend from 31.8% in 1992 to 17.5% in 2001. The mean systolic (SBP) and diastolic blood pressure (DBP) decreased in both sexes. The mean SBP decreased from 142.24 to 116.8 mmHg in men and from 143.07 to 113.7 mmHg in women. Regarding DBP, this decrease was from 92.5 to 73.8 mmHg in men and from 92.2 to 72.8mmHg in women (P<0.05). The proportion of hypertensives who were aware of their condition increased from 46.2% to 50.1% (P<0.05), and the proportion of hypertensive subjects with adequately controlled blood pressure increased from 2.8% to 12% (P<0.05). Conclusion-Hypertension care has improved significantly during the last decade, which is probably the result of the implementation of different population-based national plans (Iranian Heart Journal 2004; 5(1,2):33-38).
The National Center for Health Statistics makes available data from three national health evaluation surveys that it has conducted since 1960: NHES I (1960-1962), NHANES I (1971-1975), and NHANES II (1976-1980). There has been considerable interest in using these data to assess secular trends in cardiovascular risk factors such as blood pressure (BP). Unfortunately, underlying trends in BP are confounded with trends in physician treatment of hypertension over the same period; in the early 1960s it was rare to treat hypertension, whereas by the late 1970s it had become quite common. Our approach to estimating the underlying trends is to take untreated BP to be the variable of interest and to consider it missing in those subjects who are under treatment. We then use a multiple-imputation scheme to construct estimates of trend parameters that adjust for the incompleteness of the original data. Because our imputations depend on certain model features that the data cannot address, we form estimates under different models and compare the results. Our analyses suggest that trend estimates are sensitive to the assumed model, and naive estimates that do not adjust for treatment trends appear to be overly optimistic.
This study examined associations between blood pressure (BP) and dispositional variables pertaining to anger and hostility. Black and White 25-to 44-year old male and female normotensives and unmedicated mild to moderate hypertensives completed four reliable self-report scales—the Cook-Medley Hostility (Ho) Scale, the Trait Anger subscale of the State-Trait Anger Scale (STAS-T), and the Cognitive Anger and Somatic Anger subscales of the Cognitive-Somatic Anger Scale—plus the Framingham Anger Scale and the Harburg Anger Scale. They also engaged in three laboratory tasks—Type A Structured Interview (SI), a video game, and a cold pressor task—that elicit cardiovascular reactivity. Ambulatory BP readings at home and at work were also obtained from most subjects. Blacks had significantly higher Ho and lower STAS-T scores than did Whites. Women reported higher levels of somatic anger than did men. White women showed significant positive correlations between STAS-T and systolic BP (SBP) and diastolic BP (DBP) both at rest in the laboratory and during the SI. Black women revealed significant positive relationships between STAS-T and SBP and DBP at rest in the laboratory and at work as well as with DBP during the cold pressor test. For Black men, cognitive anger and DBP at rest were positively related. In contrast, White men revealed significant negative correlations between Ho scores and SBP at rest and during the video game; these men also showed significant negative relationships between somatic anger and SBP and DBP reactivity during the cold pressor test. Women, but not men, showed significant positive relationships between all four anger measures and ambulatory BP at work. Whereas main effects relating anger and cardiovascular measures were not apparent as a function of race, Blacks demonstrated significantly greater SBP and DBP reactivity than Whites during the cold pressor test, with the converse occurring during the SI. Men demonstrated significantly greater DBP reactivity than women during the video game. The present findings indicate that self-reports on anger/hostility measures and cardiovascular responses to behavioral tasks differ as a function of race but that relationships between anger and BP regulation need to take into account possible race-sex interactions and selection of anger/hostility measures.
Key words: blood pressure (BP), anger proneness, hostility, sex, race, reactivity, ambulatory blood pressure
In order to determine the adequacy of blood pressure treatment in black and white elderly men and women, the authors performed a cross-sectional population survey in Central North Carolina in 1986–1987. Participants included a random sample of noninstitutionalized individuals age 65 years or older. Blacks were oversampled. A health questionnaire was administered, and blood pressure was measured. Of 5,223 eligible persons, 4,162 (80%) participated. Fifty-four percent of subjects were black and 65% were women. Sixteen percent of the study subjects were white men, 30% white women, 19% black men, and 35% black women. The mean age was 73 years. Fifty-three percent had hypertension. Among hypertensives, 80.8% were taking blood pressure medication. Among treated hypertensives, blood pressure was adequately controlled, (measured diastolic blood pressure of 90 mm Hg or lower) in 85.6%. Women were 52% more likely than men and blacks were 40% less likely than whites to exhibit adequate blood pressure control. Older age and smoking were also associated with better blood pressure control. The authors conclude that hypertension is more likely to be controlled in elderly women than men and less likely to be well-controlled in elderly blacks than whites. The choice of antihypertensive agent may also be important. Further investigation is needed into the mechanisms accounting for the observed sex and race differences.
Objective: To assess the prevalence, awareness, treatment and control of hypertension for men and women living in three French regions.
Design: A cross-sectional population survey.
Setting: Subjects in the World Health Organization Monitoring Trends and Determinants in Cardiovascular Disease population surveys of Bas-Rhin, the urban community of Lille and Haute-Garonne, France.
Subjects: We studied 1924 men and 1874 women aged 35-64 years.
Main outcome measures: Hypertension was defined as a systolic blood pressure ≥ 160 mmHg, a diastolic blood pressure ≥ 95 mmHg, being administered antihypertensive drug treatment or any combination of the foregoing. Treated hypertensive subjects were considered controlled if their systolic blood pressure was < 160 mmHg and their diastolic blood pressure was < 95 mmHg.
Results: The prevalence of hypertension was 40.2, 43.8 and 27.7% among men in Lille, Bas-Rhin and Haute-Garonne, respectively. For women, the corresponding values were 31.5, 33.8 and 18.9%. Among hypertensive men, 51.8% were aware of their condition, 30.0% were being administered drug treatment and 9.2% were controlled; the respective values for hypertensive women were 69.8, 51.2 and 25.3% (P <0.001). Awareness of hypertension was associated with antihypertensive treatment more commonly in Haute-Garonne (81.0% for men and 84.7% for women). The percentages of treated subjects in whom adequate control of the blood pressure had been achieved were only 30.7% for men and 49.4% for women.
Conclusion: Women have a better awareness of hypertension than do men and their hypertension is controlled better but the low rate of control for both sexes calls for further improvements.
Objectives: The SA-gene shows markedly higher levels of expression in the kidneys of spontaneously hypertensive rats (SHR) than in their non-hypertensive reference strain, the Wistar-Kyoto (WKY) rat. Based on the important role of the kidney in blood pressure regulation, the possibility has been raised that this gene, the translational product of which remains unknown, may participate in the pathogenesis of primary hypertension. The present study was conducted to test this hypothesis and to ascertain the chromosomal localization of the SA-gene.
Design: A cosegregation study was performed using an F2 intercross between strokeprone SHR (SHRSP) and WKY rats, and a previously described restriction fragment length polymorphism of the SA-gene for characterization of genotype. Mapping of the SA-gene was accomplished by screening a somatic cell-hybrid panel and by linkage group analysis.
Results: A statistically significant difference in systolic blood pressure was found after sodium loading, but not under basal conditions between groups of rats defined by zygosity at the SA locus, consistent with a hypertensive effect of the SHRSP allele. No effect of SA genotype on diastolic blood pressure was observed. The SA-gene was localized on rat chromosome 1.
Conclusions: This study establishes the SA locus on chromosome 1 as a region in which a gene or genes contributing to blood pressure regulation in this model are localized, and provides further evidence for a possible role of the SA-gene in the pathogenesis of hypertension.
(C) Lippincott-Raven Publishers.
A cross-sectional population survey using a random, stratified sample into phases was conducted in order to assess the prevalence, awareness, treatment, and control of hypertension in Albacete (a south-eastern province in Spain) with 248000 inhabitants over 18 years of age. The sample size was of 1322 people. Both systolic and diastolic BP were higher in men than in women and showed an increasing trend with age independently of gender. Assuming a cut-off for hypertension of <140/90 mm Hg and <160/95 mm Hg, we found a prevalence of hypertension of 32.7% and 23.1%, respectively. Overall, 56.5% of hypertensive subjects were aware of their condition. The degree of this awareness was significantly higher in women and in the elderly. The percentage of patients who were receiving antihypertensive treatment was 49.1%. This proportion was also higher among women, elderly people, and subjects living in urban areas. High BP was successfully controlled in 10.9% of the total hypertensive population which accounted for 24.4% of the treated patients. The corresponding figures for the <160/95 mm Hg cut-off were 38.5% and 60.6%, respectively. In the logistic regression model, male gender and size of the local community were significantly associated with a better pharmacological control of hypertension. We found a high prevalence of hypertension with low degree of awareness and control, despite the general progress made in the diagnosis and treatment of hypertension in Spain. Specific intervention programs are necessary to increase the extent of control of hypertension in our country.
In the past decade several new antihypertensives have been marketed. Some, like the new beta blockers, are related to pre-1977 drugs, while others, the angiotensin-converting enzyme inhibitors, alpha blockers, and calcium channel blockers, are entirely new classes. While the newer agents have definite advantages, the extent of these benefits must be weighed against their cost. Drug costs for a two-drug regimen of captopril and diltiazem are 25 times those of hydrochlorothiazide and propranolol. The new beta blockers seem to have modest overall advantages: angiotensin-converting enzyme inhibitors are useful for patients who cannot accept a diminution in exercise tolerance; calcium channel blockers are useful for elderly hypertensives who have a contraindication for thiazides. Hypertension is being increasingly better controlled, with a concomitant reduction in cardiovascular mortality. The challenge for the next decade will be to achieve reductions in atherosclerotic, as well as hypertensive, complications without interfering with the users' quality of life. In this paper the authors review the new drugs and indicate what groups of patients might be benefited by them.
Between 1975 and 1988, demographic data, weight and height measurements, and blood pressure readings were obtained for 77 890 residents of Saskatchewan (about 7.6% of the population). High readings were present in 7.8% of those surveyed, but prevalence fell over the lifetime of the survey. Subjects whose drug therapy was modified had a larger fall in blood pressure than those whose medical regimen was unchanged.
The spontaneously hypertensive rat and the stroke-prone spontaneously hypertensive rat are useful models for human hypertension. In these strains hypertension is a polygenic trait, in which both autosomal and sex-linked genes can influence blood pressure. Linkage studies in crosses between the stroke-prone spontaneously hypertensive rat and the normotensive control strain Wistar-Kyoto have led to the localization of two genes, BP/SP-1 and BP/SP-2, that contribute significantly to blood pressure variation in the F2 population. BP/SP-1 and BP/SP-2 were assigned to rat chromosomes 10 and X, respectively. Comparison of the human and rat genetic maps indicates that BP/SP-1 could reside on human chromosome 17q in a region that also contains the angiotensin I-converting enzyme gene (ACE). This encodes a key enzyme of the renin-angiotensin system, and is therefore a candidate gene in primary hypertension. A rat microsatellite marker of ACE was mapped to rat chromosome 10 within the region containing BP/SP-1.
Hypertensive heart disease is a frequent complication in hypertensive African-Americans because of inadequate high blood pressure control. Moreover, African-Americans may be predisposed to develop LVH earlier in life and more readily than Caucasians, and it may be more malignant. The appearance of both LVH and congestive heart failure are ominous developments in individual patients, and early detection of LVH is mandatory for adequate management and reversal of this complication, if possible. Additional research is needed, and new, sensitive tools for detecting LVH will accelerate such studies. Further investigations are also needed on the reversibility of LVH, preferred antihypertensive agents for accomplishing reversal, and whether expected benefits result.
Hypertension is a major contributor to cardiovascular morbidity and mortality, increasing risk threefold. It predisposes to every clinical manifestation of coronary heart disease, now the most common and lethal outcome. It is as relevant a risk factor in the elderly as in the young. Risk is proportional to the degree of blood pressure elevation without a discernible critical value. Cardiovascular sequelae do not derive chiefly from the diastolic component, and isolated systolic hypertension confers increased risk at all ages. Hypertension tends to cluster with other cardiovascular risk factors, which must be taken into account in evaluating the risk and in choosing treatment. The excess cardiovascular risk in hypertension is concentrated in those with an increased total/high density lipoprotein cholesterol ratio, glucose intolerance, cigarette smoking, elevated fibrinogen, and electrocardiogram abnormalities. Left ventricular hypertrophy (LVH) is a common feature of hypertension and an ominous harbinger of cardiovascular sequellae. Electrocardiographic evidence of LVH, when manifested by repolarization abnormalities and voltage elevations, is particularly hazardous, reflecting not only anatomical hypertrophy but also ischemia. Electrocardiogram-LVH adds to cardiovascular risk associated with X ray or echocardiographic evidence of anatomical LVH. Because of a tendency to ventricular ectopy, LVH is associated with increased risk of sudden death. Electrocardiogram-LVH can be corrected or avoided by control of hypertension and weight reduction. The efficacy of correcting LVH remains to be demonstrated but benefits seem likely.
We analyzed the records of all residents of Jefferson County, Alabama, accepted for renal replacement therapy between 1982 and 1987 and compared them with those accepted between 1974 and 1978 to determine any changes in the distribution and frequency of end-stage renal disease (ESRD) due to hypertension (H-ESRD). H-ESRD increased from 6.4 to 9.6 per 100,000 in blacks and from 0.36 to 0.62 per 100,000 in whites. Smoothed age- and race-specific yearly H-ESRD rates decreased in blacks under age 50. Peak incidence of H-ESRD shifted from age 40 to 49 in 1974 through 1978 to age 50 to 59 in 1982 through 1987 (P less than 0.0001). Blacks were referred for care with significantly higher blood pressure levels and serum creatinine concentrations than whites, and had more severe retinal vascular disease. Factors significantly associated with a shorter time from referral to renal replacement therapy were black race, female gender, blood urea nitrogen and serum creatinine concentrations, carbohydrate intolerance, and the use of alpha-agonist and/or angiotensin-converting enzyme (ACE) inhibitor. We conclude that racial distribution and risk for H-ESRD have not changed. Peak rates of H-ESRD have been delayed nearly a decade, suggesting a possible effect of better awareness and treatment of hypertension.
Since large-scale health surveys usually have complicated sampling schemes, there is often a question as to whether the sampling design must be considered in the analysis of the data. A recent disagreement concerning the analysis of a body iron stores-cancer association found in the first National Health and Nutrition Examination Survey and its follow-up is used to highlight the issues.
We explain and illustrate the importance of two aspects of the sampling design: clustering and weighting of observations. The body iron stores-cancer data are reanalyzed by utilizing or ignoring various aspects of the sampling design. Simple formulas are given to describe how using the sampling design of a survey in the analysis will affect the conclusions of that analysis.
The different analyses of the body iron stores-cancer data lead to very different conclusions. Application of the simple formulas suggests that utilization of the sample clustering in the analysis is appropriate, but that a standard utilization of the sample weights leads to an uninformative analysis. The recommended analysis incorporates the sampling weights in a nonstandard way and the sample clustering in the standard way.
Which particular aspects of the sampling design to use in the analysis of complex survey data and how to use them depend on certain features of the design. We give some guidelines for when to use the sample clustering and sample weights in the analysis.
To provide information on the incidence of coronary heart disease (CHD) in the offspring of the original cohort from the Framingham Heart Study.
From 1972 to 1974, offspring of the original participants in the Framingham Heart Study underwent a baseline examination for standard cardiovascular risk factors. At entry into the study, these offspring were 30 to 59 years old and free of CHD. They were followed for 12 years, during which time 156 of 1,663 men and 55 of 1,714 women developed CHD.
In a multivariate proportional hazards model, CHD was significantly associated with age, lower high-density lipoprotein cholesterol (HDL-C) levels, and number of cigarettes smoked. Fasting glucose levels and low-density lipoprotein cholesterol (LDL-C) were highly associated with CHD in men, but borderline in women, while triglycerides and very-low-density lipoprotein cholesterol were not significantly associated with CHD after adjustment for HDL-C and glucose. Blood pressure medication was used in half of the hypertensive individuals, and systolic pressure was associated with CHD in women only.
This study confirms the importance of the common CHD risk factors of cigarette smoking and LDL-C, and extends the prognostic role of HDL-C in a middle-aged cohort. The impact of blood pressure, with or without use of hypertensive medications, was reduced in this study, and the data suggest that this attenuation was due to successful treatment.
Hypertensive end-stage renal disease is about 10-fold more common nationwide in African-Americans than in Caucasians and 17-fold higher in some sections of the United States. These figures are alarming and require a much greater effort in understanding the causes of this disparity and improving blood pressure control in this population to prevent catastrophic renal damage. More information is also needed about the renovascular status of other minorities. Financial obstacles to antihypertensive care appear to be an important contributing factor to the disparities of end-stage renal disease in African-Americans and perhaps other minorities.
Heart disease is the leading cause of death for Asian-Americans and Pacific-Islanders, Hispanic-Americans, and Native Americans. Generally, heart disease death rates are lower in these population groups than in Caucasians, with the notable exception of Native Americans under the age of 35. Of particular interest are data for southwestern US Native Americans and Mexican-Americans, which indicate low CHD prevalence rates despite high rates of obesity, diabetes mellitus, increasing hypertension, and low socioeconomic status. Much more research is needed to explain these and other observations. Intervention in those risk factors already identified is necessary, particularly in prevention of obesity and diabetes.
Contrary to opinions generally accepted in the past, CHD is very common in both African-American men and women, with incidence rates approaching those of US Caucasians. Higher prevalence of hypertension, diabetes, cigarette smoking, and obesity all contribute to the high level of CHD in African-Americans. Additional research is needed about the interrelations and management of various risk factors for CHD in African-Americans outside of the sudden death of African-Americans outside of the hospital is urgent, and special attention should be given to accessibility and use of health services by minority populations.
Stroke in Asian and Pacific-Islander populations remains the principal cause of death among adults, but its incidence in the United States approximates that of Caucasians. Although controversial, uncontrolled hypertension in certain population groups (e.g., northern Japanese) and high dietary saturated fat in others (e.g, Pacific-Islanders) are believed to be responsible for the high stroke incidence rates. The recent reduction in stroke frequency rates in these areas is thought to be the result of better hypertension control. In the Ni-Hon-San Study, the level of hypertension and its frequency were similar in Hawaii and Japan, but ischemic infarction and intracerebral hemorrhage were less frequent in Hawaii. Reduced meat and fat intake may contribute to small vessel disease in Japan. Stroke is the third major cause of death among Hispanic-Americans and Native Americans, yet there is a paucity of information, especially about stroke, in subgroups of these populations. There is also considerable ignorance and controversy about risk factors for stroke in these populations. The need for additional research is urgent.
Hypertension is the most important risk factor for stroke, especially in African-Americans. Improved control of high blood pressure nationwide is a key factor in the recent dramatic decline in stroke frequency, most notably in African-American women. Hypertension control programs must be adequately funded and expanded. African-Americans have a disproportionately high incidence of risk factors for stroke, including hypertension. There is evidence that the cerebral vessels involved in ischemic stroke in African-Americans may differ from those of Caucasians. There is an urgent need for more research on stroke in general, risk factor relations in particular, and mechanisms in the pathogenesis of stroke in African-Americans.
There is a paucity of information about hypertension and its risk factors, prevalence, morbidity, and mortality in many racial minorities in the United States. Most of the population groups discussed in this section are composed of several subgroups that differ culturally, socioeconomically, educationally, and ethnically. This fact, however, does not lessen the need for more information about the extent of hypertension and risk factors in these groups. Moreover, a bonus from expanded research in these areas will be new information useful to the general population.
The prevention of cardiovascular disease antedates our current preoccupation with risk factors for coronary heart disease and hypertension. Indeed, earlier preventive efforts have in part been so successful that many people have forgotten that they existed. The almost forgotten entity, beriberi heart disease, was first prevented in 1883 by Takaki of Japan. With diphtheria, it was the identification of the causative bacillus by Klebs in 1883, leading finally to the development of diphtheria toxoid by Ramon in 1923, which resulted in the disappearance of diphtheritic heart disease. Success in the attack on syphilitic heart and vascular disease began with Bordet and Gengou in 1901 with the discovery of the phenomenon of complement fixation, and with the formulation of Salvarsan by Ehrlich in 1907. The story of the prevention of rheumatic fever has a large cast of characters, but special recognition must be given to Coburn for his observations confirming the role of the hemolytic streptococcus published in 1931 and showing the prophylactic value of sulfanilamide published in 1939. The important association of maternal rubella with congenital heart malformations was revealed by Gregg in 1941. Alcoholic heart disease was identified particularly by Brigden and Evans in 1957 and 1959, respectively. In relation to coronary and hypertensive heart disease, the names of Anitschkow (1933), Leary (1935), and Keys (1948) in relation to diet, of Freis (1967) in the field of hypertension treatment, of White (1927) in relation to physical exercise, and of English, Willius, and Berkson (1940) and Hammond and Horn (1954) in the role of cigarette smoking, deserve special recognition.
The contribution of obesity to cardiovascular risk has not been adequately appreciated because of a failure to recognize the involvement of upper-body predominance of body weight with hypertension, diabetes, and hypertriglyceridemia even in the absence of significant overall obesity. This article examines the evidence that upper-body obesity, as usually induced by caloric excess in the presence of androgens, mediates these problems by way of hyperinsulinemia. Because of these interrelationships, there is a need to identify and prevent upper-body obesity or, failing that, to provide therapies that will control the associated problems without aggravating hyperinsulinemia.
The classical World Health Organization (WHO) definition of hypertension has recently been questioned. The criteria of the distribution curve, as well as the risk-related definition of hypertension, are being replaced by a more pragmatic definition based on the benefits of intervention, as demonstrated in recent large scale therapeutic trials. Variability of blood pressure and the ‘doctor’s effect’ also reduce the value of casual blood pressure measurement in the detection of hypertension, which might in the future be based on ambulatory blood pressure monitoring. Although systematic screening for hypertension is not particularly useful in developed countries, periodic surveys of the population will be needed to assess the situation of the detection and control of hypertension. Early detection by the search for markers of hypertensive heredity remains a field where progress is slow.
Incidence and trends in incidence of definite hypertension were analyzed based on 30 years follow-up of 5,209 subjects in the Framingham Heart Study cohort. Based on pooling of 15 two-year periods, hypertension incidence per biennium increased with age in men from 3.3 per cent at ages 30-39 to 6.2 per cent at ages 70-79, and in women from 1.5 per cent at ages 30-39 to 8.6 per cent at ages 70-79. No consistent trend in incidence rates was evident for either sex from the 1950s through the 1970s. The proportion of hypertensive subjects receiving antihypertensive medication has increased since 1954-58 and exceeded 80 per cent for both men and women ages 60-89 years in 1979-81. Incidence data presented in this report may serve as a baseline for assessing the impact of future public health efforts in the primary prevention of hypertension.
The Framingham Heart Study has been the foundation upon which several national policies regarding risk factors for coronary heart disease mortality are based. The NHANES I Epidemiologic Followup Study is the first national cohort study based upon a comprehensive medical examination of a probability sample of United States adults. The average follow-up time was 10 years. This study afforded an opportunity to evaluate the generalizability of the Framingham risk model, using systolic blood pressure, total cholesterol, and cigarette smoking, to the U.S. population with respect to predicting death from coronary heart disease. The Framingham model predicts remarkably well for this national sample. The major risk factors for coronary heart disease mortality described in previous Framingham analyses are applicable to the United States white adult population.
The objective of this study was to describe secular trends in the distribution of blood pressure and prevalence of hypertension in US adults and changes in rates of awareness, treatment, and control of hypertension. The study design comprised nationally representative cross-sectional surveys with both an in-person interview and a medical examination that included blood pressure measurement. Between 6530 and 13,645 adults, aged 18 through 74 years, were examined in each of four separate national surveys during 1960-1962, 1971-1974, 1976-1980, and 1988-1991. Protocols for blood pressure measurement varied significantly across the surveys and are presented in detail. Between the first (1971-1974) and second (1976-1980) National Health and Nutrition Examination Surveys (NHANES I and NHANES II, respectively), age-adjusted prevalence of hypertension at > or = 160/95 mm Hg remained stable at approximately 20%. In NHANES III (1988-1991), it was 14.2%. Age-adjusted prevalence at > or = 140/90 mm Hg peaked at 36.3% in NHANES I and declined to 20.4% in NHANES III. Age-specific prevalence rates have decreased for every age-sex-race subgroup except for black men aged 50 and older. Age-adjusted mean systolic pressures declined progressively from 131 mm Hg at the NHANES I examination to 119 mm Hg at the NHANES III examination. The mean systolic and diastolic pressures of every sex-race subgroup declined between NHANES II and III (3 to 6 mm Hg systolic, 6 to 9 mm Hg diastolic). During the interval between NHANES II and III, the threshold for defining hypertension was changed from 160/95 to 140/90 mm Hg.(ABSTRACT TRUNCATED AT 250 WORDS)
The purpose of this study was to estimate the current prevalence and distribution of hypertension and to determine the status of hypertension awareness, treatment, and control in the US adult population. The study used a cross-sectional survey of the civilian, noninstitutionalized population of the United States, including an in-home interview and a clinic examination, each of which included measurement of blood pressure. Data for 9901 participants 18 years of age and older from phase 1 of the third National Health and Nutrition Examination Survey, collected from 1988 through 1991, were used. Twenty-four percent of the US adult population representing 43,186,000 persons had hypertension. The age-adjusted prevalence in the non-Hispanic black, non-Hispanic white, and Mexican American populations was 32.4%, 23.3%, and 22.6%, respectively. Overall, two thirds of the population with hypertension were aware of their diagnosis (69%), and a majority were taking prescribed medication (53%). Only one third of Mexican Americans with hypertension were being treated (35%), and only 14% achieved control in contrast to 25% and 24% of the non-Hispanic black and non-Hispanic white populations with hypertension, respectively. Almost 13 million adults classified as being normotensive reported being told on one or more occasions that they had hypertension; 51% of this group reported current adherence to lifestyle changes to control their hypertension. Hypertension continues to be a common finding in the general population. Awareness, treatment, and control of hypertension have improved substantially since the 1976-1980 National Health and Nutrition Examination Survey but continue to be suboptimal, especially in Mexican Americans.(ABSTRACT TRUNCATED AT 250 WORDS)
The purpose of the study was to identify the determinants of awareness, treatment, and control of hypertension in a population with full access to medical care.
Unionized New York City health care workers (n = 1394) with comprehensive medical insurance were screened for hypertension. Union records documenting all physician visits and prescription medications for the year before screening provided the opportunity to relate patterns of treatment to blood pressure outcomes.
Of the 409 employees found to have hypertension, 289 (71%) were aware of their condition and 201 (49%) had been treated, but only 51 (12%) had their blood pressure controlled at the recommended level (< 140/90 mm Hg). In a logistic regression model, the only variable of treatment associated with control was days of antihypertensive medication. The total number of physician visits was not associated with control.
These findings demonstrate that in conventional community settings, even in the absence of financial barriers, treatment for hypertension continues to be characterized by poor outcomes. Improving access to primary care, without changes in the nature of that care, may not substantially improve blood pressure control.
Trends in hypertension prevalence are difficult to assess because of a massive increase in the prevalence of antihypertensive treatment. Over the past three decades mean blood pressure levels among the 5209 members of the Framingham Study cohort have declined, and elevated blood pressure is only one third as prevalent. However, if those receiving treatment who have normalized blood pressures are defined as hypertensive, in addition to those with elevated blood pressure, the prevalence of hypertension has increased. No consistent secular trend in the incidence of hypertension was noted over three decades, but high blood pressure eventually developed in two thirds of the study cohort. To determine whether untreated blood pressure levels are changing over time, trends in mean blood pressure were examined in normotensive subjects over three decades. Only a 1 mm Hg decline in mean systolic and diastolic pressure over each 10-year interval was noted (p < 0.001). Thus blood pressure in the normotensive segment of the population has been quite stable. Because the incidence of hypertension is very high and future hypertension arises from the upper end of the normal blood pressure distribution, there is an urgent need for primary prevention. Preventive measures such as exercise, avoidance of salt and alcohol, and especially weight control deserve a high priority.
To describe the epidemiology of hypertension in U.S. African American women and to highlight priority areas for future research, data from the nationwide surveys of the U.S. National Center for Health Statistics, from selected multicenter studies of the U.S. National Heart, Lung, and Blood Institute, as well as from selected other population-based studies, were reviewed. In 1988 through 1991, an estimated 3 million African American women aged 18 and older had hypertension. Compared with that in U.S. whites, hypertension in black women is characterized by higher incidence, earlier onset, longer duration, higher prevalence, and higher rates of hypertension-related mortality and morbidity. Risk factors for hypertension incidence in black women include obesity and weight gain. The effectiveness of drug therapy of hypertension has been established in black women, and important gains in rates of treatment and control have been accomplished. Nevertheless, rates of hypertension-related mortality for black women remain among the highest in the industrialized nations. Further research on causes and prevention of hypertension in black women is needed. Goals related to prevention and control of hypertension in African Americans for the year 2000 have been established and must be vigorously pursued.
The importance of hypertension in the pediatric population has not been as well-appreciated as in adults. This may be due in part to the much lower prevalence of hypertension in children. Nevertheless, hypertension is an important clinical problem in pediatrics, and the approach to its management differs from that in adults in several major respects. Compared with adults, a much greater percentage of hypertension in children is caused by secondary, potentially correctable, disease states. Elevated blood pressure in children may also represent the early expression of primary or essential hypertension. In addition, the technique of blood pressure measurement, the definitions of high blood pressure, and the classifications of blood pressure values in children are different than in adults. These factors dictate a pediatric approach to detection, evaluation, and management of hypertension in children and adolescents.
Factors that exacerbate the risk of atherosclerotic plaque formation include cigarette smoking, hypertension, hypercholesterolaemia, sedentary lifestyle, and oestrogen deficiency. The potentially important role of oestrogen deficiency in this process is evidenced by the significant increase in cardiovascular risk observed in women after menopause, and in the marked reduction in cardiovascular events observed in women who take hormone replacement therapy. Oestrogen replacement therapy, through an effect on the blood vessel wall and on serum lipids, also appears to stabilize existing atherosclerotic plaques. The combination of oestrogen and progesterone reduces risk of endometrial cancer while possibly delivering the same benefits as oestrogen alone. Other measures, such as antithrombotic therapy, exercise, and smoking cessation, also contribute to reduced risk of cardiovascular disease in older women.
Decline in stroke mortality in recent decades has been well documented in the United States and other countries. This study, based on a well-defined population with comprehensive medical records available for research purposes, seeks to explain decline in stroke mortality among older persons between 1967 and 1985. The study specifically explores the competing explanatory mechanisms of decreased incidence of stroke versus decreased case-fatality rate.
We conducted a retrospective analysis of three successive period cohorts (1967 through 1971, 1974 through 1978, and 1981 through 1985) of persons > or = 65 years of age enrolled in a large group model HMO in a metropolitan community. All new hospitalized and a sample of nonhospitalized strokes were ascertained, and samples of first-ever strokes were studied. Incidence, case-fatality rates, survival times, and comorbidities were compared across cohorts.
There was no significant change in stroke incidence over time; however, 1-month case fatality declined dramatically from 33% in 1967 through 1971 to 18% in 1981 through 1985 (P < .01); median survival increased from 213 to 1092 days. Indices of reduced severity included declines in coma from 27% to 12% (P < .01) and in wheelchair- or bed-bound status from 40% to 30% (P = .067). Cases with and without CT scan in 1981 to 1985, when this procedure became widely available in the health plan, were similar in severity, thereby reducing the possibility of ascertainment bias.
In this well-defined older population, stroke has become a less lethal and disabling though no less common disease. This finding fails to support the "compression of morbidity" hypothesis while supporting a model of delayed progression for stroke in this age group.
1. We have determined the optimal polymerase chain reaction (PCR) conditions for the amplification and detection of mRNA for a new vascular growth factor—vascular endothelial growth factor (VEGF)–-and determined its size and tissue distribution in genetically normotensive and hypertensive rats.
2. Multiple VEGF mRNA subtypes were obtained which were 625, 520 and 480 base pairs in length.
3. All three species of VEGF mRNA were found in heart, kidney, aorta, adrenal and brainstem and the size and tissue distribution of VEGF mRNA subtypes were not different between spontaneously hypertensive rats (SHR) of the Okamoto strain and normotensive Wistar-Kyoto (WKY) controls.
4. Thus multiple forms of VEGF mRNA can be readily detected by PCR in a variety of tissues. While these preliminary results suggest no difference in size and tissue distribution between SHR and WKY, sequencing and quantitative studies will be required to confirm this.
1. To determine biochemically the incipient timing of cerebral stroke in stroke-prone spontaneously hypertensive rats (SHRSP) the relation between the glutathione peroxidase (GSH-Px) activity in erythrocytes and the extent of stroke lesion was investigated.
2. When the blood pressure of SHRSP was maintained over 250 mmHg, the GSH-Px activity was lowered and the body-weight also decreased. In the SHRSP where the GSH-Px activity in erythrocytes dropped below 23 units/mL blood, the incidence of cerebral stroke was 98% (n= 88/90).
3. The haemoglobin and haematocrit level were unchanged even after the GSH-Px activity dropped to 23 units/mL blood.
4. Lowering of GSH-Px activity in erythrocytes observed during continued hypertension was found to be due to decreased GSH-Px protein, but not to an inactivation of enzymes, as evidenced from immunochemical titration.
5. Lowering of GSH-Px activity in erythrocytes was found to be closely related with the incidence of cerebral stroke in SHRSP. These findings suggest that tracing of the GSH-Px activity in erythrocytes in SHRSP may serve as an indicator for prediction and prognosis of stroke lesion.
The association between employment status and high blood pressure in women was examined at two time periods to determine if associations between employment status and high blood pressure varied by time period or by age, race, education, marital status, or parental status.
Women participants from the National Health Examination Survey (1960) and the Second National Health and Nutrition Survey (1976-1980) between the ages of 25 and 64 and currently employed or keeping house were included. Logistic regression analysis was used to examine the cross-sectional association between employment status and high blood pressure in each survey, taking into account potential effect modifiers and covariates.
In 1960 employment was associated with a slight, but not statistically significant, elevation in odds of high blood pressure. In 1976-1980, it was associated with a modest but significant reduction in odds of high blood pressure. Variations in associations occurred by marital status (protective associations were limited to unmarried women) and race (associations were of stronger magnitude among African-American women).
The employment status-high blood pressure relationship shifted across surveys. Changes in the composition of the employed and nonemployed groups account for at least part of the varying relationships.
One of the cornerstones of the primary prevention of cardiovascular disease has been screening and early antihypertensive drug treatment of patients with high blood pressure (BP). Nevertheless, recent population studies have shown that awareness and management of high BP levels are far from optimal. In this study, we performed a search for publications providing frequencies of hypertension awareness, treatment and control in different populations. In men, the frequencies of awareness, antihypertensive drug treatment and BP control among all hypertensive patients varied between 23% and 93%, 5% and 89% and 5% and 87%, respectively. In women, the frequencies ranged between 28% and 97%, 6% and 97%, and 0% and 97%, respectively. The percentage of aware hypertensives who were under antihypertensive drug treatment varied between 47% and 95% in men and between 50% and 100% in women. The percentage of hypertensives who were under antihypertensive drug treatment varied between 47% and 95% in men and between 50% and 100% in women. The percentage of treated hypertensives achieving an adequate BP control varied between 29% and 95% in men and between 0% and 100% in women. Overall, women had a better awareness, treatment and control status for hypertension than men, and worse in developing countries than in industrialised countries. Hypertension awareness, treatment and control improved with time, together with the proportion of diagnosed hypertensive patients under treatment and the proportion of well controlled among treated hypertensive patients. We conclude that although the 'rule of halves' no longer applies for screening and treatment of hypertension in industrialised countries, it might still be valid for developing countries and for the effectiveness of antihypertensive drug treatment in all countries.
This observational study was performed in order to determine the hypertension awareness, treatment, and control rates for the country of Korea.
Rates were determined in conjunction with a national blood pressure survey in Korea in 1990. Through cluster sampling, individuals aged > 30 in 190/146,944 districts were selected for study. Among 25,567 eligible individuals, 21,242 had measurement of blood pressure (BP) and answered a standard questionnaire. BP was recorded as the mean of two measurements with a standard mercury manometer. Hypertension was defined either as BP > or = 160/95 mm Hg or on treatment (n = 2628), or as BP > or = 140/90 mm Hg or on treatment (n = 4219). Treatment was defined as any method of BP treatment, including dietary, traditional, or medication.
Rates for BP > or = 160/95 mm Hg or on treatment: aware 1057 (40%), treated 696 (27%), controlled 367 (14%). Rates for BP > or = 140/90 mm Hg or on treatment: aware 1069 (25%), treated 696 (16%), controlled 221 (5%).
Hypertension awareness, treatment, and control rates are relatively low in Korea. Blood-pressure control programs, including detection strategies, are needed here and worldwide.
Three hundred and eighty male hypertensive patients with diastolic blood pressures averaging 90 to 114 mm Hg were randomly assigned to either active antihypertensive agents or placebos. The estimated risk of developing a morbid event over a five-year period was reduced from 55% to 18% by treatment. Terminating morbid events occurred in 35 patients of the control group as compared to 9 patients in the treated group. Nineteen deaths related to hypertension or atherosclerosis occurred in the control group and 8 in the actively treated group. In addition to morbid events, 20 control patients developed persistent diastolic levels of 125 mm Hg or higher. Treatment was more effective in preventing congestive heart failure and stroke than in preventing the complications of coronary artery disease. The degree of benefit was related to the level of prerandomization blood pressure.
Since publication of the 1980 Report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure,1 several events have occurred that affect successful management of hypertension: publication of major clinical trial results, introduction of new antihypertensive agents, evidence concerning effectiveness of nonpharmacologic treatment, and further analysis of the epidemiologic data-base relating BPs with the risk of premature morbidity and mortality. These events led the director of the National Heart, Lung, and Blood Institute (NHLBI), as chairman of the National High Blood Pressure Education Program Coordinating Committee, to establish a new Joint National Committee to revise earlier recommendations.This report includes recommendations on the following topics: (1) screening and referral procedures, (2) classification according to BPs, (3) use of nonpharmacologic therapies, (4) revised stepped-care approach, (5) management of mild hypertension, (6) patient-professional interaction, and (7) management of BP in special groups, including blacks, children, and pregnant
The measurement of a patient's blood pressure is a routine procedure when a person visits a physician or health facility. We carry out this test because elevated blood pressure is an etiologic factor for the development of stroke, coronary heart disease, congestive heart failure, and renal failure. In recent years, many different drugs have become available to reduce blood pressure. Normalization of elevated blood pressure decreases the risk of the various complications, and vigorous therapy for hypertension is recommended by many authorities. Since the condition is common, millions of individuals are labeled as hypertensives and many are given antihypertensive drugs to lower their blood pressure.
Our current policies raise many questions. While we define hypertension as a blood pressure of more than 160/90 mm Hg or thereabouts, this definition is arbitrary. The distribution of blood pressure in the normal population is continuous, with no "cutoff" pressure at which a person
The authors examine reasons for the decline in ischemic heart disease mortality rates in the United States between 1968 and 1976. They estimate that more than half of the decline over this period was related to changes in life-style specifically reductions in serum cholesterol levels and cigarette smoking. "In comparison about 40% of the decline can be directly attributed to specific medical interventions with coronary care units and the medical treatment of clinical ischemic heart disease and hypertension being the leading estimated contributors." (EXCERPT)
A comparison of the contribution of systolic versus diastolic blood pressure to risk of coronary heart disease and the role of mean arterial pulse pressure and systolic lability have been examined prospectively in 5,127 men and women during 14 years of biennial follow-up studies.Similar gradients of risk of subsequent coronary heart disease were observed whether persons were classified by their systolic or diastolic pressure, and no “safe” or critical level could be identified. Assessment of the net effect of each, employing discriminant analysis, indicated a stronger association of systolic than diastolic pressure with risk of coronary heart disease. Neither the systolic and diastolic pressure measurements in combination nor the pulse pressure and the mean arterial pressure measurements alone discriminated better than the systolic measurement alone. Systolic lability did not predict incidence of coronary heart disease independently of the associated level of blood pressure.There was a trend of declining relative importance of diastolic and a corresponding increase in the importance of systolic pressure with advancing age. Only in those under 45 was diastolic pressure predominant. The level of casually obtained blood pressure was a good predictor of coronary heart disease. The current practice of assessing the importance of blood pressure at all ages largely on the basis of diastolic pressure and the commonly held view concerning the innocuous nature of an elevated level of systolic pressure in the elderly requires reevaluation.
Throughout the 1960's repeated findings indicated a poor state of management for hypertension in widely diverse communities across the United States. In the early years of the 1970's similarly derived findings showed a substantial improvement in hypertension management. These trends are confirmed in two random samples of a black urban population studied in 1971 and in 1973 indicating more than a twofold improvement in blood pressure control over that period. This improvement was noticeable in all subgroups of the population at risk although young black males continue to have a less favorable status of detection and control of hypertension.
In the Spring and Summer of 1982 the Second Connecticut Blood Pressure Survey (CBPS-II) was completed. This survey is independent of, but essentially identical in design and implementation to the First Connecticut Blood Pressure Survey reported on by Freeman et al. [1]. This paper compares the results of the two surveys using the same analytic techniques as reported previously [2]. In addition, a model for analyzing the components of hypertension control is utilized in the analysis. Finally, the implications of the survey comparison are discussed in the context of the Connecticut High Blood Pressure Program (CHBP) [3].
A representative population sample of 5192 men and women was followed for 16 years, during which overt congestive heart failure (CHF) developed in 142. In the age range from 30 to 62 years the dominant etiologic precursor was hypertension, which preceded CHF in 75 per cent of the cases. Six times more CHF developed in hypertensive than in normotensive persons. Examination of the association of myocardial hypertrophy on x-ray or electrocardiographic study with systolic versus diastolic pressure revealed little to suggest a greater role for diastolic pressure. Systolic and diastolic pressure together, mean arterial pressure, pulse pressure, and tension-time index discriminated potential hypertrophy and CHF no better than systolic pressure alone. Examination of the correlation of heart weight and left ventricular thickness at autopsy with premorbid systolic versus diastolic pressure revealed a better correlation with systolic than with diastolic pressure. CHF was a lethal phenomenon, with only 50 pe...
Control of hypertension, labile or fixed, systolic or diastolic, at any age, in either sex appears to be central to prevention of atherothrombotic brain infarction (ABI). Prospectively, hypertension proved the most common and potent precursor of ABI's. Its contribution was direct and could not be attributed to factors related both to stroke and hypertension. Asymptomatic, causal "hypertension" was associated with a risk of ABI about four times that of normotensives. The probability of occurrence of an ABI was predicted no better with both blood pressure measurements or the mean arterial pressure than with systolic alone. Since there was no diminishing impact of systolic pressure with advancing age, the concept that systolic elevations are, even in the aged, innocuous is premature. Comparing normotensives and hypertensives in each sex, women did not tolerate hypertension better than men.
A comparison of the contribution of systolic versus diastolic blood pressure to risk of coronary heart disease and the role of mean arterial pulse pressure and systolic lability have been examined prospectively in 5,127 men and women during 14 years of biennial follow-up studies. Similar gradients of risk of subsequent coronary heart disease were observed whether persons were classified by their systolic or diastolic pressure, and no "safe" or critical level could be identified. Assessment of the net effect of each, employing discriminant analysis, indicated a stronger association of systolic than diastolic pressure with risk of coronary heart disease. Neither the systolic and diastolic pressure measurements in combination nor the pulse pressure and the mean arterial pressure measurements alone discriminated better than the systolic measurement alone. Systolic lability did not predict incidence of coronary heart disease independently of the associated level of blood pressure. There was a trend of declining relative importance of diastolic and a corresponding increase in the importance of systolic pressure with advancing age. Only in those under 45 was diastolic pressure predominant. The level of casually obtained blood pressure was a good predictor of coronary heart disease. The current practice of assessing the importance of blood pressure at all ages largely on the basis of diastolic pressure and the commonly held view concerning the innocuous nature of an elevated level of systolic pressure in the elderly requires reevaluation.
An association between hypertension and coronary heart disease is well established. However, many misconceptions have arisen concerning the nature of this relationship. This report has explored prospectively in some detail the relation of antecedent blood pressure status to the risk of subsequent clinical manifestations of CHD over 14 years in a cohort of 5,127 men and women in Framingham, Massachusetts.
Risk of every manifestation of CHD including angina, coronary insufficiency, myocardial infarction and sudden death was distinctly and impressively related to the antecedent level of both systolic and diastolic blood pressure. Risk was related not solely to "hypertension" but was proportional to the level of the blood pressure—even at non-hypertensive pressures—from the lowest to the highest recorded. Also, risk appeared to be related to casual as well as to more basal pressures.
Gradients of rick of each manifestation of CHD were similar whether subjects were classified according to their systolic or diastolic pressure. More detailed analysis is required to determine the net contribution to risk of systolic versus diastolic pressure at specified ages in each sex. The clinical dictum that the cardiovascular consequences of "hypertension" derive principally from the diastolic pressure and that isolated systolic elevation is innocuous requires re-evaluation.
As regards CHD, women were found to tolerate hypertension no better than did men. While absolute incidence was greater in men, the same increment of relative risk was observed comparing normotensives with hypertensives in each sex.
There was no evidence to suggest a lack of a potent effect of elevated blood pressure on risk of CHD beyond age 50. Even elevated systolic pressures beyond age 50 carried a substantial increase in risk of CHD.
Casual blood pressure determinations are useful in determining risk of CHD. Labile blood pressure elevations may contribute to risk as well as fixed hypertension. The contribution of lability to risk at specified levels of blood pressure deserves further study.
Blood pressure appears to contribute to risk of CHD even in the absence of other conditions presumed to be associated with both hypertension and increased propensity to CHD. The seriousness of a "hypertensive" blood pressure, however, is markedly influenced by the coexisting blood lipid content and ECG abnormalities.
Hypertension is a common and a major contributor to CHD morbidity and mortality which is readily controlled by hygienic and pharmacologic measures. There is good rationale for advocating early, vigorous and sustained control of elevated pressure, labile or fixed, whether systolic or diastolic, at any age, in both sexes. There is good reason to expect that this should result in a substantial reduction in CHD morbidity and mortality.
Blood pressures from a 1980-1981 survey of 1,656 adults in Minneapolis-St Paul were compared with BPs from a similar community survey of 3,475 adults conducted in 1973-1974. Mean age-adjusted BPs in 1980-1981 were 3 mm Hg lower for men and 2 mm Hg lower for women than in 1973-1974. Hypertension prevalence, defined as diastolic BP of 95 mm Hg or greater and/or use of antihypertensive medication, was essentially unchanged. In 1973-1974, however, only 40.4% of hypertensive persons had adequately controlled BPs, 13.7% were treated but had conditions that were uncontrolled, 20.4% had known hypertension but were untreated, and 25.5% had previously undetected hypertension. In 1980-1981, the respective percentages were 76.1%, 8.5%, 8.8% and 6.6%. These impressive changes in hypertension detection and control may have contributed to the recent decline in cardiovascular disease mortality in this community.
(JAMA 1983;250:916-921)
The National High Blood Pressure Education Program recently celebrated its tenth anniversary. It is timely and appropriate to assess progress toward the realization of its mission and to examine the critical elements of this large-scale, community-based intervention program. This article describes the origin of the National Program, the planning process and models used in undertaking this national health education effort, the application of theoretical models, and approaches used to evaluate the effort. The lessons learned and the application of the National Program as a model for health education interventions are offered.
The topic of hypertension is one that has received an enormous amount of attention during the past 50 years. The pathology has been extensively described and investigated, and the role of the kidney, including the thousands of studies on the renin-angiotensin system, has been of continuing intense interest. The contributions of neurohumoral influences on hypertension have also been vigorously studied, and the clinical and epidemiologic features have been subject to intense scrutiny—to mention only some of the areas of concern. Great expectations for an early cure of hypertension when the Goldblatt kidney preparation (1934) and renin (1939) were first described were not realized with the passage of time. The mosaic theory of Page1 emphasized the complexity of the problem and the existence and the interrelations of multiple forces leading to a common event—raised arterial BP. Forms of treatment existing in the 1930s and 1940s were not satisfactory, including the
Of 177,692 persons screened in 1977 as part of an ongoing City-Wide Hypertension Screening Program in Chicago, 14,988 (8.4%) had diastolic blood pressure (BP) greater than or equal to 95 mm Hg as compared to 13.2% of a similar population in 1976. Only 7% (3,910) of the hypertensive population (diastolic BP greater than or equal to 95 mm Hg or presently on antipressor drugs) had previously undetected hypertension in contrast to 11.9% (4,184) the year before and 48.7% in the same community in 1972. Conversely, 73.2% (40,738) had adequately controlled blood pressure as contrasted to 59.3% (20,897) the previous year and 20.6% in 1972. Of the remaining hypertensives, 7.5% (4,201) were known but not treated and 12.3% (6,824) were under treatment but not controlled in contrast to 12.1% (4,251) and 16.8% (5,905) respectively the year before. This upward trend in controlled hypertension was present in all strata of the population.
To determine whether the immense multifocal efforts in the United States over the past 7 years to detect and treat high blood pressure (BP), had affected the status of hypertension, data from a national household survey in 1973-74 were compared with data obtained in 1977-78 from a second non-overlapping population in the same three communities. The impact of hypertension programs was measured by assessing change over the 5-year period in BP distribution, degree of awareness, and level of treatment in the population. Our data show that a substantial improvement in the status of high BP detection, treatment, and control has occurred since the early 1970s for all age, sex, and race groups studied.
Control of hypertension, labile or fixed, systolic or diastolic, at any age, in either sex appears to be central to prevention of atherothrombotic brain infarction (ABI). Prospectively, hypertension proved the most common and potent precursor of ABI's. Its contribution was direct and could not be attributed to factors related both to stroke and hypertension. Asymptomatic, causal "hypertension" was associated with a risk of ABI about four times that of normotensives. The probability of occurrence of an ABI was predicted no better with both blood pressure measurements or the mean arterial pressure than with systolic alone. Since there was no diminishing impact of systolic pressure with advancing age, the concept that systolic elevations are, even in the aged, innocuous is premature. Comparing normotensives and hypertensives in each sex, women did not tolerate hypertension better than men.
The medical examination of the population of a complete natural community, Tecumseh, Michigan, has provided a basis for investigation of factors possibly relating to predisposition to chronic disease.The following are reported: 1.1. Parameters for distributions of blood pressure and cholesterol values for the entire population, including young children.2.2. Correlations between parents and children within specific age groups and by age-sex adjusted scores; these are relatively low, but consistently positive, being considerably greater for cholesterol than for blood pressure. Thus, there was a distinct resemblance in values between parents and children but the force of similarity was essentially equal over the entire range of distributions of blood pressure and cholesterol. Children resembled mothers and fathers equally in regard to blood pressure, but had some tendency to be more like their mothers in their cholesterol values.3.3. Correlations between siblings, while somewhat greater, were found to be within the same general range of magnitude as the parent-child comparisons.4.4. Spouse comparisons, as noted by most other investigators, showed a lack of significant correlations for either variable when all couples are viewed in the aggregate. No gradient of increasing conformity between spouses was demonstrable for either blood pressure or cholesterol when viewed by length of marriage, a rough index of the number of years of a shared environment.5.5. Comparisons with other studies were presented and types of possible genetic control and environmental interaction was discussed. The present findings are compatible with the concept of a multifactorial genetic and environmental interplay for both blood pressure and cholesterol.
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