Alcohol consumption and the incidence of hypertension: The Atherosclerosis Risk in Communities Study

Food preference questionnaire as a screening tool for assessing dietary risk of cardiovascular disease within health risk appraisals

OBJECTIVE

Nutrition components of health risk appraisals (HRAs) aim to rapidly and accurately assess dietary behaviors that increase disease risk. Because cognitive research suggests that recalling food likes/dislikes may be simpler and more accurate than recalling intake, we tested whether a preference measure was predictive of cardiovascular disease risk factors within an HRA.

METHODS

HRA participants (422 primarily non-Hispanic white men, mean age 46+/-10 years) from a manufacturing company completed surveys to assess fat and sweet food/beverage preference; frequency of consuming fat and sweet foods/beverages, alcoholic beverages, fiber-rich foods (whole grains, fruits, and vegetables); and physical activity. Per measured risk factors, 34% had central obesity (waist circumference>or=102 cm), 32% had hypertension (>or=140 and/or>or=90 mm Hg), 52% had prehypertension (>or=120 to 139 and/or>or=80 to 89 mm Hg), and 52% had an elevated total cholesterol level (>or=200 mg/dL [5.2 mmol/L]).

STATISTICAL ANALYSES

Multiple linear regression models explaining variability in waist circumference, blood pressure, and serum lipids were tested.

RESULTS

Although preference and intake pairs for fat and sweets were significantly correlated, intake of fat and sweets failed to associate significantly with any risk factor. Significant variance in waist circumference was explained by age, fat preference, fiber intake, and physical activity. Those with greater circumferences liked fat more, consumed less fiber, and exercised less. Waist circumference in turn contributed significantly to models predicting serum lipid levels and blood pressure. Alcohol intake explained variability in serum lipid levels-higher intakes were associated with higher high-density lipoprotein cholesterol levels. The models predicting risk were generally more explanatory in younger (<50 years) than in older men.

CONCLUSIONS

Including a preference measure within an HRA appears to enhance cardiovascular disease risk factor assessment. Fat preference, intake of fiber-rich foods, and alcohol proved the best dietary determinants of cardiovascular disease risk factors.

ALCOHOL IS BAD FOR BLOOD PRESSURE

1. The regular consumption of alcohol elevates blood pressure, with global estimates that the attributable risk for hypertensive disease from alcohol is 16%. 2. The increase in blood pressure is approximately 1 mmHg for each 10 g alcohol consumed and is largely reversible within 2-4 weeks of abstinence or a substantial reduction in alcohol intake. 3. This increase in blood pressure occurs irrespective of the type of alcoholic beverage. In particular, the postulated effects of vasodilator flavonoid components of red wine to lessen or reverse alcohol-related hypertension have not been borne out in intervention studies. 4. Heavy drinking, especially a binge pattern of drinking, is linked to a higher incidence of cerebral thrombosis, cerebral haemorrhage and coronary artery disease deaths, although a role for alcohol-related hypertension in the causal pathway is not well defined. 5. In contrast, the light to moderate intake of alcohol has been consistently linked to a reduced risk of atherosclerotic vascular disease end-points. Such a protective effect may also extend to hypertensive subjects. 6. However, the magnitude of any protective effect appears to have been exaggerated because of unmeasured confounders, especially diet, lifestyle and patterns of drinking. Furthermore, a decrease in overall mortality with drinking appears confined to older subjects and to populations with a high background cardiovascular risk profile. 7. Any putative cardiovascular benefits from drinking need to be carefully considered against the effects of alcohol to elevate blood pressure, together with many other adverse health consequences from drinking. Maximum cardiovascular benefit occurs at relatively low levels of consumption (i.e. one to two standard drinks a day in men (10-20 g alcohol) and up to one a day in women (10 g alcohol)). In hypertensive subjects, consumption beyond these levels would be unwise.

Incidence of hypertension by alcohol consumption: is it modified by race?

OBJECTIVE

To investigate the influence of race, binge drinking and alcohol addiction on the association between consumption of alcoholic beverages and incidence of hypertension.

METHODS

In a population-based cohort study, 1089 adults were interviewed and had blood pressure and anthropometric measurements carried out at home. Their alcohol consumption was ascertained by an amount-frequency questionnaire. Binge drinking was defined as consumption of five or more drinks on one occasion for men or four drinks for women, and abuse of alcohol as consumption of 30 g/day or more in men or 15 g/day or more in women. Incident cases of hypertension were characterized by blood pressure > or = 140/90 mmHg or use of hypertension medication.

RESULTS

Among 589 normotensive individuals in the baseline visit, 127 incident cases of hypertension were identified, after a follow-up of 5.6 +/- 1.1 years. Binge drinking and alcohol dependency were not associated with the incidence of hypertension. Adjusted (age, education) risk ratios for the incidence of hypertension (95% confidence interval) were significant only for non-white abusers of ethanol: 11.8 (1.6-86.9). Systolic blood pressure of black abusers increased by 16.1 +/- 3.5 mmHg, in comparison with 4.9 +/- 1.5 mmHg among white abusers (P = 0.004).

CONCLUSION

Individuals with an African ancestry, who consumed larger amounts of ethanol, are at higher risk of developing hypertension. This risk is not explained by a binge drinking pattern or addiction to alcohol.

Serum uric acid and risk of ischemic stroke: The ARIC Study

AIMS

Since serum uric acid (UA) is strongly associated with cardiovascular risk factors, it has been debated whether serum UA is a stroke risk factor or whether UA may be simply "marking" subjects with other, causal risk factors. We therefore investigated the relation between UA and ischemic stroke in the Atherosclerosis Risk in Communities (ARIC) Study.

METHODS AND RESULTS

Of 15,792 ARIC participants, 13,413 who were free of recognized stroke or coronary heart disease (CHD) at baseline and had a baseline UA measurement were included in the analysis. We followed the participants for ischemic stroke incidence (N=381) over 12.6 years. Although serum UA was independently and positively related to ischemic stroke incidence when we adjusted for age, sex, race, and education, the positive relation was weakened when additionally adjusted for possible confounding variables. The positive multivariate-adjusted association between serum UA and ischemic stroke was observed among subjects not using diuretics (adjusted relative hazard in the highest quartile versus the lowest: relative hazard (RH)=1.49; 95% confidence interval (CI): 1.00-2.23) (P for trend: 0.02), but not among diuretic users (P for interaction: 0.08).

CONCLUSION

Our findings suggest that UA is an independent predictor of ischemic stroke among subjects not using diuretics, but that elevated UA itself may not cause ischemic stroke.

Effects of alcohol withdrawal on blood pressure in hypertensive heavy drinkers

BACKGROUND

Epidemiological investigations have demonstrated a close association between heavy alcohol consumption and hypertension. The mechanisms of this association, however, remain elusive. We studied the effects of alcohol withdrawal on blood pressure, hormonal parameters, and circulating markers of endothelial activity.

METHODS

In 14 hypertensive heavy alcohol consumers (> 200 g/day) who agreed to participate in a hospital withdrawal programme we monitored, for 30 days, blood pressure, plasma levels of renin, aldosterone, cortisol, endothelin, and plasminogen activator inhibitor 1 (PAI-1), and urinary levels of catecholamines. Patients in the withdrawal group were compared with eight hypertensive heavy drinkers who refused to participate in the programme and maintained regular alcohol consumption and 11 normotensive teetotalers.

RESULTS

By the third day after withdrawal, blood pressure was significantly decreased and the normalization of levels was obtained in 13 of 14 patients by the end of the study. Alcohol withdrawal significantly decreased plasma aldosterone and cortisol levels, but did not affect levels of active renin and fractionated urinary catecholamines. At baseline, plasma endothelin and PAI-1 levels were significantly higher in alcoholic individuals than in teetotalers, and after the cessation of alcohol intake decreased progressively, reaching levels different from baseline within 1 week. A significant correlation was found between changes in endothelin and PAI-1, and blood pressure variations during alcohol abstinence that remained significant only for endothelin with the multivariate approach.

CONCLUSION

Hypertension is rapidly reversible in the majority of heavy drinkers after the withdrawal of alcohol consumption. In these patients, hypertension is associated with an increased release of endothelial factors that might contribute to the increase in blood pressure.

Blood pressure, levels of serum lipids, liver enzymes and blood glucose by aldehyde dehydrogenase 2 and drinking habit in Japanese men

OBJECTIVES

The association of blood pressure and levels of serum lipids, liver enzymes, blood glucose and aldehyde dehydrogenase 2 (ALDH2) with drinking habit was examined in Japanese men.

METHODS

The subjects were 264 men aged 39 to 80 years who were classified into the ALDH2 deficiency or sufficiency group using the ethanol patch test and the Tokyo University ALDH2 Phenotype Screening Test. A self-administered questionnaire including drinking habit was used. Blood pressure and the levels of biochemical markers in groups with ALDH2 sufficiency, ALDH2 deficiency and drinking habit were compared using multiple regression models for adjusting age, smoking habit, physical exercising habit and body mass index.

RESULTS

The levels of serum high-density lipoprotein cholesterol, triglycerides, aspartate aminotransferase (AST) and gamma-glutamyl transpeptidase (γ-GTP) were significantly higher in current drinkers of 20 g of ethanol or more per day than in nondrinkers of the ALDH2 sufficiency group. The levels of serum AST and γ-GTP in current drinkers of 20 g of ethanol or more per day, and fasting blood sugar in current drinkers of less than 20 g of ethanol per day were significantly higher than those in nondrinkers of the ALDH2 deficiency group.

CONCLUSIONS

These results suggest that alcohol consumption increases the levels of serum lipids and liver enzymes in ALDH2-sufficient individuals and liver enzymes and blood glucose levels in ALDH2-deficient individuals.

Relation between benchmark dose and no-observed-adverse-effect level in clinical research: effects of daily alcohol intake on blood pressure in Japanese salesmen

The benchmark dose (BMD) is defined as the dose that corresponds to a specific change in an adverse response compared to the response in unexposed subjects, and the lower 95% confidence limit is termed the benchmark dose level (BMDL). In this study, the threshold of daily ethanol intake affecting blood pressure was calculated by both the BMD approach and multiple logistic regression analysis to clarify the relation between the BMDL and no-observed-adverse-effect level (NOAEL). Systolic and diastolic blood pressures (SBP and DBP) and daily ethanol intake were explored in 1,100 Japanese salesmen. The SBP and DBP were positively related to daily ethanol intake (p < 0.001) when adjusting for possible confounders such as age, body mass index, and smoking status. The adjusted risk for hypertension (SBP >or= 140 mmHg or DBP >or= 90 mmHg) increased significantly when daily ethanol intake exceeded 60 g/day, and the categorical dose of interest was 60.1-90 g/day. The BMDL and BMD of ethanol intake for increased SBP and DBP were estimated to be approximately 60 and 75 g/day, respectively. These findings suggest that the BMDL and BMD correspond to the NOAEL and lowest-observed-adverse-effect level, respectively, if the sample number of clinical data is large enough to confirm the dose-response association.

An evaluation of an intervention to assist primary care physicians in screening and educating older patients who use alcohol

OBJECTIVES

To evaluate whether providing physicians and older patients with personalized reports of drinking risks and benefits and patient education reduces alcohol-related risks and problems.

DESIGN

Prospective comparison study.

SETTING

Community primary care.

PARTICIPANTS

Twenty-three physicians and 665 patients aged 65 and older.

INTERVENTION

Combined report, in which six physicians and 198 [corrected] patients received reports of patients' drinking classifications and patients also received education; patient report, in which 245 patients received reports and education, but their five physicians did not receive reports; and usual care.

MEASUREMENTS

Assessments at baseline and 12 months later to determine patients' nonhazardous (no known risks), hazardous (risks for problems), or harmful (presence of problems) classifications using the Computerized Alcohol-Related Problems Survey (CARPS). The CARPS contains a scanned screening measure and scoring algorithms and automatically produces patient and physician reports and patient education.

RESULTS

At baseline, 21% were harmful drinkers, and 26% were hazardous drinkers. The patient report and combined report interventions were each associated with greater odds of lower-risk drinking at follow-up than usual care (odds ratio=1.59 and 1.23, respectively, P<.05 for each). The patient report intervention significantly reduced harmful drinking at follow-up from an expected 21% in usual care to 16% and increased nonhazardous drinking from 52% expected in usual care to 58%. Patients in the combined report intervention experienced a significantly greater average decrease in quantity and frequency.

CONCLUSION

Older primary care patients can effectively reduce their alcohol consumption and other drinking risks when given personalized information about their drinking and health.

Risk factors for high blood pressure in women attending menopause clinics in Italy

OBJECTIVE

We analysed risk factors for high blood pressure (BP) among women around menopause.

METHODS

Eligible women were consecutively attending first-level outpatient menopause clinics in Italy for general counseling or treatment of menopausal symptoms. During the visit BP was measured three times. The mean of second and third of the three diastolic BP values for women was >90mm of mercury and/or reporting any current pharmacological treatment for high BP were considered hypertensive. Out of 45,204 women who entered the study with information on blood pressure, 12,150 had high BP.

RESULTS

The odds ratios (OR) of high BP increased with age: in comparison with women aged <50 years, the multivariate OR were 1.44 (95% confidence interval (CI), 1.34-1.55), 1.61 (95% CI, 1.50-1.74) and 1.91 (95% CI, 1.77-2.06) in women aged 51-53, 54-57 and > or =58, respectively. Women with high BP were less educated than those without (OR education >12 versus <7 years, 0.79, 95% CI, 0.74-0.84). In comparison with women with a body mass index (BMI) <24, the multivariate ORs were 1.48 (95% CI, 1.39-1.57) and 2.56 (95% CI, 2.41-2.71) for women with BMI 24-26 and >26. In comparison with women reporting no regular physical activity, the multivariate OR of high BP was 0.93 (95% CI, 0.87-0.99) for women reporting regular activity. In comparison with peri-menopausal women, post-menopausal women were at increased risk (OR 1.14, 95% CI, 1.03-1.24) and the risk tended to increase with age at menopause. Current use of hormonal replacement therapy (HRT) was associated with a lower risk of high BP (OR 0.88, 95% CI, 0.84-0.94).

CONCLUSIONS

This large cross-sectional study suggests that, after taking into account the effect of age, post-menopausal women are at greater risk of high BP, but current HRT use slightly lowers the risk. Other determinants of high BP were low level of education, overweight, and low level of physical activity.

Alcohol intake, drinking patterns, and risk of nonfatal acute myocardial infarction in Costa Rica

BACKGROUND

Moderate alcohol consumption is associated with a lower risk of myocardial infarction (MI). Whether alcohol is truly protective or whether the amount, type, or pattern of intake is the most important is still under debate.

OBJECTIVE

The purpose of this study was to determine whether alcohol intake and drinking patterns are associated with plasma lipids and the risk of MI in Costa Ricans, a population with a low intake of wine.

DESIGN

We conducted a study of 2090 cases of a first nonfatal acute MI and 2090 population-based controls matched by age, sex, and residence in Costa Rica, a country with diet and lifestyles different from those of Western countries. Alcohol and dietary intakes were assessed by using validated questionnaires.

RESULTS

In a multivariate conditional regression model that controlled for other cardiovascular disease risk factors, the lowest risk of MI [odds ratio (OR) = 0.44; 95% CI: 0.31, 0.61] was observed for those who drank on average 3 drinks/wk (compared with lifelong abstainers). When we looked at the frequency of consumption, we found that the risk of MI among daily drinkers (OR = 0.64; 95% CI: 0.41, 1.01) was not significantly different (P = 0.23) from that of weekend drinkers (OR = 0.76; 95% CI: 0.59, 0.98) regardless of the amount consumed. HDL cholesterol increased with the amount and frequency of alcohol intake. Similar to a few other populations, apparent protection was observed at very low alcohol intakes.

CONCLUSION

Low to moderate consumption of alcohol 1-2 d/wk is independently associated with a reduced risk of MI.

HYPERTENSION IN EARLY ALCOHOL WITHDRAWAL IN CHRONIC ALCOHOLICS

AIMS

Hypertension is an established risk factor in chronic alcoholics, but little is known about the relationship between blood pressure (BP), severity of their alcohol abuse, and severity of alcohol withdrawal syndrome (AWS).

METHOD

BP was assessed daily for 18 days in a series of chronic alcoholics on early alcohol withdrawal (AW), while also assessing the severity of their AWS on the CIWA-Ar scale.

RESULTS

A sharp and sustained decrease in BP was observed after AW; at T0, BP had increased in 55% of patients, and at T18 in 21%. The variation of BP is partially explained by years of at-risk drinking and AWS severity, but other factors may play a role in hypertension in alcoholics, as a large amount of BP variation was not explained by the alcohol-abuse-related parameters that we studied. BP values were not correlated with cigarette smoking, anxiety, or depression. Hypertension found in 'detoxified' alcoholics (approximately 20%) may be related to alcohol-independent hypertension or to a long-lasting alcohol-induced derangement of the BP regulating mechanisms. Further research is needed in these patients to elucidate the mechanisms of persistent hypertension and to set up a treatment protocol. At present, careful monitoring is advisable, as well as pharmacological treatment for moderate or severe hypertension; often a modification of life-style is needed which includes physical activity and possibly sodium (Na) restriction, since hypertension in detoxified alcoholics seems to be Na sensitive.

CONCLUSION

Complete alcohol abstinence must be recommended to all hypertensive alcoholics, as AW-induced transient hypertension was found to be harmless in all our subjects, and abstinence leads to a complete recovery from hypertension in most cases.

Alcohol consumption and hypertension

Hypertension is a major independent risk factor for cardiovascular disease. In alcohol-consuming populations, the amount of alcohol consumption has significant impact on blood pressure values, the prevalence of hypertension, and cardiovascular as well as all-cause mortality. In this review, we focus on the connection between alcohol consumption and hypertension, and discuss the consequences on cardiovascular risk.

Alcohol consumption, binge drinking, and early coronary calcification: findings from the Coronary Artery Risk Development in Young Adults (CARDIA) Study

It is unclear to what extent the apparently beneficial cardiovascular effects of moderate alcohol consumption are mediated by protection against atherosclerosis. Alcohol consumption, coronary heart disease risk factors, and coronary calcification (a marker of atherosclerosis) were measured during 15 years of follow-up in the Coronary Artery Risk Development in Young Adults (CARDIA) Study (1985-2001). Among 3,037 participants aged 33-45 years after follow-up (55% women, 45% Black), the prevalence of coronary calcification was 8% for consumption of 0 drinks/week (n = 1,435), 9% for 1-6 drinks/week (n = 1,023), 13% for 7-13 drinks/week (n = 341), and 19% for > or = 14 drinks/week (n = 238) (p < 0.001 for trend). Calcification was also more common among binge drinkers (odds ratio = 2.1, 95% confidence interval: 1.6, 2.7). These associations persisted after adjustment for potential confounders (age, gender/ethnicity, income, physical activity, family history, body mass index, smoking) and intermediary factors (lipids, blood pressure, glucose, C-reactive protein, and fibrinogen). Stratification showed the dose-response relation most clearly in Black men; only heavier alcohol consumption (> or = 14 drinks/week) was associated with coronary calcification in other race/sex subgroups. These surprising findings suggest the presence of proatherogenic effects of alcohol in young adults, especially Black men, which may counterbalance high density lipoprotein cholesterol elevation and other possible benefits of alcohol consumption.

Effect of Coffee Intake on Blood Pressure in Male Habitual Alcohol Drinkers

Many cross-sectional epidemiological studies have revealed that alcohol consumption is closely related to an increase in blood pressure, which is known to be associated with an elevated serum gamma-glutamyltransferase (GGT) level, rather than to the volume of alcohol consumed. Since recent studies showed that coffee intake is inversely related to serum GGT, we investigated the effect of coffee on blood pressure in habitual alcohol drinkers. A total of 42 male hypertensive or prehypertensive volunteers who consumed alcohol and coffee daily completed this randomized controlled crossover trial. After a 2-week baseline period, these participants were randomly assigned to either a coffee-drinking group or a non-coffee-drinking group for the first 4 weeks. The situation was then reversed for the next 4 weeks. All participants continued their usual alcohol consumption. Blood pressure was measured once a week and compared between the two groups. After 1 week of coffee intake of more than 3 cups per day, the systolic and diastolic blood pressure began to fall slowly, and cessation of coffee intake raised the blood pressure. Systolic blood pressure was lowered by 7-10 mmHg, and diastolic pressure by 3-7 mmHg in 4 weeks. Alcohol consumption of more than 60 ml per day was maintained and there were no lifestyle changes in the participants of either group throughout the study period. Analyses of urine electrolytes and urea nitrogen indicated that there were no significant dietary changes. In conclusion, coffee intake of more than 3 cups per day in hypertensive and prehypertensive men who regularly consume alcohol lowers blood pressure.

Olive oil, the Mediterranean diet, and arterial blood pressure: the Greek European Prospective Investigation into Cancer and Nutrition (EPIC) study

BACKGROUND

Diet has been reported to influence arterial blood pressure, and evidence indicates that the Mediterranean diet reduces cardiovascular mortality.

OBJECTIVE

The objective was to examine whether the Mediterranean diet, as an entity, and olive oil, in particular, reduce arterial blood pressure.

DESIGN

Arterial blood pressure and several sociodemographic, anthropometric, dietary, physical activity, and clinical variables were recorded at enrollment among participants in the Greek arm of the European Prospective Investigation into Cancer and Nutrition (EPIC) study. Of these participants, 20 343 had never received a diagnosis of hypertension and were included in an analysis in which systolic and diastolic blood pressure were regressed on the indicated possible predictors, including a 10-point score that reflects adherence to the Mediterranean diet and, alternatively, the score's individual components and olive oil.

RESULTS

The Mediterranean diet score was significantly inversely associated with both systolic and diastolic blood pressure. Intakes of olive oil, vegetables, and fruit were significantly inversely associated with both systolic and diastolic blood pressure, whereas cereals, meat and meat products, and ethanol intake were positively associated with arterial blood pressure. Mutual adjustment between olive oil and vegetables, which are frequently consumed together, indicated that olive oil has the dominant beneficial effect on arterial blood pressure in this population.

CONCLUSIONS

Adherence to the Mediterranean diet is inversely associated with arterial blood pressure, even though a beneficial component of the Mediterranean diet score-cereal intake-is positively associated with arterial blood pressure. Olive oil intake, per se, is inversely associated with both systolic and diastolic blood pressure.

One-year hypertension incidence and its predictors in a working population: the IHPAF study

THE AIMS OF OUR STUDY WERE

(i). to estimate the yearly incidence rates based on one vs two visits in a working population and (ii). to identify incident hypertension modifiable risk factors. A total of 21566 normotensive subjects were included in a 1-year cohort study. Blood pressure (BP) levels at inclusion and at the second year screening were measured on the basis of two visits, that is, if BP was over 140/90 mmHg in untreated subjects, they were invited to a control visit 1 month later. Height and weight were measured and behavioural risk factors were collected. Among the 17465 subjects who completed the entire protocol (9691 men and 7774 women), 17026 remained normotensive at a 1-year interval and 439 (325 men and 114 women) became hypertensive. Crude yearly incidence rates based on one visit were 6.21% in men and 3.06% in women, compared with 3.04% in men and 1.34% in women when incidence rates were based on two visits, a more than twofold difference. Age and body mass index at baseline were the two major independent determinants of incident hypertension in both genders. Smoking and alcohol consumption were significant risk factors in men but not in women, and a low educational level only in women. BP measurement on separate occasions is necessary to avoid overestimation of incidence. Weight in both genders and alcohol consumption in men were the main modifiable predictors of hypertension.

Alcohol consumption and cardiovascular risk in hypertensives with left ventricular hypertrophy: the LIFE study

The Losartan Intervention For End point reduction in hypertension (LIFE) study showed superiority of losartan over atenolol for reduction of composite risk of cardiovascular death, stroke, and myocardial infarction in hypertensives with left ventricular hypertrophy. We compared hazard ratios (HR) in 4287 and 685 participants who reported intakes of 1-7 and >8 drinks/week at baseline, respectively, with those in 4216 abstainers, adjusting for gender, age, smoking, exercise, and race. Within categories, clinical baseline characteristics, numbers randomized to losartan and atenolol, and blood pressure (BP) lowering were similar on the drug regimens. Overall BP control (<140/90 mmHg) at end of follow-up was similar in the categories. Composite end point rate was lower with 1-7 (24/1000 years; HR 0.87, P<0.05) and >8 drinks/week (26/1000 years; HR 0.80, NS) than in abstainers (27/1000 years). Myocardial infarction risk was reduced in both drinking categories (HR 0.76, P<0.05 and HR 0.29, P<0.001, respectively), while stroke risk tended to increase with >8 drinks/week (HR 1.21, NS). Composite risk was significantly reduced with losartan compared to atenolol only in abstainers (HR 0.81 95% confidence interval, CI (0.68, 0.96), P<0.05), while benefits for stroke risk reduction were similar among participants consuming 1-7 drinks/week (HR 0.73, P<0.05) and abstainers (HR 0.72, P<0.01). Despite different treatment benefits, alcohol-treatment interactions were nonsignificant. In conclusion, moderate alcohol consumption does not change the marked stroke risk reduction with losartan compared to atenolol in high-risk hypertensives. Alcohol reduces the risk of myocardial infarction, while the risk of stroke tends to increase with high intake.

Primary prevention of essential hypertension

The best approach to the primary prevention of hypertension is a combination of lifestyle changes: weight loss in overweight persons; increased physical activity; moderation of alcohol intake; and consumption of a diet that is higher in fruits, vegetables, and low-fat dairy products and lower in sodium content than the average American diet (Table 3). Recent randomized controlled trials have demonstrated that these lifestyle changes can be sustained over long periods of time (more than 3 years) and can have blood pressure-lowering effects as large as those seen in drug studies. Hypertension is an important preventable risk factor for cardiovascular disease, the leading cause of mortality in the United States. To achieve the Healthy People 2010 goal of reducing the proportion of adults with hypertension from 28% to 16%, concerted efforts must be directed toward primary prevention strategies. Lifestyle modifications including weight loss, increased physical activity, and dietary changes in individuals have been shown to reduce the incidence of hypertension and should be recommended for all persons and especially those with prehypertension. In addition, timely adoption of prevention strategies to reduce the incidence of hypertension and its subsequent complications in the general population may interrupt the costly cycle of hypertension and prevent the reductions in quality of life associated with this chronic disease.

Meeting the challenge to improve the treatment of hypertension in blacks

Hypertension is more prevalent and severe in African descendent populations living outside Africa than in any other population. Given this greater burden of hypertension in blacks, it is increasingly necessary to refine strategies to prevent the disorder as well as improve its treatment and control. This review assesses results from clinical trials on lifestyle and pharmacologic interventions to identify which approaches most effectively prevent adverse hypertension-related outcomes in African descendent populations. The Dietary Approaches to Stop Hypertension (DASH) study provided evidence that a carefully controlled diet rich in fruits, vegetables, low-fat dairy foods, and reduced in saturated fat, total fat, and cholesterol (i.e., the DASH diet) reduces blood pressure in blacks and is well accepted. The combination of the DASH diet with reduction in dietary sodium below 100 mmol/d may provide a reduction in blood pressure beyond that reached by the DASH diet alone. Physical exercise and interventions to reduce psychological stress may also reduce blood pressure in blacks. Strong evidence from numerous studies is a compelling argument for continuing to recommend diuretics and beta blockers as first-line antihypertensive therapy for persons of all races. Some new studies also favor angiotensin-converting enzyme inhibitors as first-line antihypertensive drugs. The African American Study of Kidney Disease and Hypertension provided evidence that an angiotensin-converting enzyme inhibitor-based treatment program is more beneficial than calcium channel blockers and beta blockers in reducing the progression of renal failure in blacks with hypertensive nephropathy. Studies in patients with diabetes have also shown evidence that both angiotensin-converting enzyme inhibitors and angiotensin receptor antagonists are more effective than other classes of antihypertensives in reducing adverse renal events. Studies to evaluate the effects of the new antihypertensives in improving outcomes in blacks living outside the United States are needed.

Cardiovascular manifestations of substance abuse: part 2: alcohol, amphetamines, heroin, cannabis, and caffeine

The abuse of alcohol is associated with chronic cardiomyopathy, hypertension, and arrhythmia. Abstinence or using alcohol in moderation can reverse these cardiovascular problems. Alcohol is also distinguished among the substances of abuse by having possible protective effects against coronary artery disease and stroke when used in moderate amounts. Amphetamines (eg, speed, ice, ecstasy) have many of the cardiovascular toxicities seen with cocaine, including acute and chronic cardiovascular diseases. Heroin and other opiates can cause arrhythmias and noncardiac pulmonary edema, and may reduce cardiac output. Cardiovascular problems are less common with cannabis (marijuana) than with opiates, but major cognitive disorders may be seen with its chronic use. It is still controversial whether caffeine can cause hypertension and coronary artery disease, and questions have been raised about its safety in patients with heart failure and arrhythmia.

Prevention of hypertension

Hypertension is a major risk factor for many cardiovascular diseases including stroke, coronary heart disease, cardiac failure, and endstage renal disease. Therefore, prevention of hypertension becomes an important goal in overall efforts to control blood pressure and reduce the incidence of hypertension-related cardiovascular and renal complications and outcomes. Many risk factors underlying hypertension have been identified including nonmodifiable factors such as age, gender, genetic factors, and race, as well as modifiable factors including overweight, high sodium intake, low potassium intake, alcohol consumption, and reduced physical activity. A number of studies have demonstrated that interventions aimed at changing these modifiable factors might decrease blood pressure and even prevent the development of hypertension. Thus, present national recommendations and guidelines include lifestyle modifications ranging from weight loss in case of obesity, engagement in regular isotonic physical activity, reduced sodium diet (<100 mmol/d), supplementation of potassium, and alcohol moderation (<1 ounce of ethanol or its equivalent per day).

Biobehavioral approaches to the treatment of essential hypertension

Despite recent advances in the medical management of hypertension, chronically elevated blood pressure remains a major health problem in the United States, affecting almost 50 million Americans. It is widely recognized that lifestyle factors contribute to the development and maintenance of elevated blood pressure. This article critically reviews current approaches to the nonpharmacological treatment of high blood pressure and highlights outcome studies of exercise, weight loss and dietary modification, and stress management and relaxation therapies. Methodological issues in the assessment and treatment of hypertension are discussed, along with possible mechanisms by which lifestyle modification may reduce elevated blood pressure.

Misconceptions of older adults with hypertension concerning OTC medications and alcohol

Knowledge and self-efficacy concerning interactions of antihypertensives with over-the-counter (OTC) analgesics and alcohol were assessed in 51 adults aged 60 and older taking antihypertensives and attending a blood pressure clinic. The subjects had low self-efficacy about how to prevent interactions of antihypertensives with OTC analgesics and alcohol. Inspection of knowledge item responses revealed eight general misconceptions about OTC medications. These data guide educating those with hypertension about potential drug interactions arising from self-medication.

Pathogenesis and prevalence of hypertension in acromegaly

Hypertension is an important complication of acromegaly, contributing to the increased morbidity and mortality of this condition. Prevalence of hypertension in acromegalic patients is about 35%, ranging from 18 to 60% in different clinical series, and the incidence is higher than in the general population. The lowering of blood pressure observed concomitantly with the reduction in GH levels after successful therapy for acromegaly suggests a relationship between GH and/or IGF-I excess and hypertension. The exact mechanisms underlying the development of hypertension in acromegaly are still not clear but may include several factors depending on the chronic exposure to GH and/or IGF-I excess. Experimental and clinical studies suggest that the anti-natriuretic action of GH (due to direct renal action of GH or IGF-I and/or to indirect, systemic GH or IGF-I-mediated mechanisms) may play a role in the pathogenesis of hypertension. Acromegaly is frequently associated with insulin resistance and hyperinsulinaemia which may induce hypertension by stimulating renal sodium absorption and sympathetic nervous activity. Whether sympathetic tone is altered in acromegalic hypertensive patients remains a matter of debate. Recent studies indicate that an increased sympathetic tone and/or abnormalities in the circadian activity of sympathetic system could play an important role in development and/or maintenance of elevated blood pressure in acromegaly, and may partially account for the increased risk of cardiovascular complications. Acromegalic cardiomiopathy may also concur to elevate blood pressure and can be aggravated by the coexistence of hypertension. Finally, a role of GH and IGF-I as vascular growth factors cannot be excluded. In conclusion, acromegaly is associated with hypertension, but there is still no real consensus in the literature on the mechanisms behind the development of the high blood pressure.