The impact of elevated blood pressure upon 10-year mortality among Japanese men in Hawaii: the Honolulu Heart Program

Significance of blood pressure variability in normotensive individuals as a risk factor of developing hypertension

PURPOSE

Visit-to-visit blood pressure variability is a strong predictor of the incidence of cardiovascular events and target organ damage due to hypertension. The present study investigated whether year-to-year blood pressure variability predicts the risk of hypertension in the Japanese general population.

MATERIALS AND METHODS

This study analysed 2806 normotensive individuals who participated in our physical check-up program for five years in a row from 2008 to 2013. The average, standard deviation, coefficient of variation, average real variability, and highest value of systolic blood pressure in the five consecutive visits were determined and used as baseline data. The participants were followed up for the next 6 years with the development of 'high blood pressure', an average blood pressure level of ≥140/90 mmHg or the use of antihypertensive medications, as the endpoint.

RESULT

During follow-up, 'high blood pressure' developed in 389 participants (13.9%, 29.5 per 1 000 person-years). The incidence increased across the quartiles of standard deviation and average real variability, while the average and highest systolic blood pressure had the most prominent impact on the development of 'high blood pressure'. Multivariate logistic regression analysis adjusted for possible risk factors indicated that the average, standard deviation, average real variability, and highest blood pressure, but not the coefficient of variation of systolic blood pressure, were significant predictors of 'high blood pressure'.

CONCLUSION

Increased year-to-year blood pressure variability predicts the risk of hypertension in the general normotensive population. The highest blood pressure in the preceding years may also be a strong predictor of the risk of hypertension.

The directed acyclic graph helped identify confounders in the association between coronary heart disease and pesticide exposure among greenhouse vegetable farmers

To explore the causal pathways associated with coronary heart disease (CHD) and pesticide exposure using a directed acyclic graph (DAG) analysis and to investigate the potential benefits of DAG by comparing it with logistic regression. This cross-sectional study enrolled 1368 participants from April 2015 to May 2017. Trained research investigators interviewed farmers using a self-administered questionnaire. Logistic regression and DAG models were used to identify the associations between CHD and chronic pesticide exposure. A total of 150 (11.0%) of the 1368 participants are characterized as having CHD. High pesticide exposure (odds ratio = 2.852, 95% confidence intervals: 1.951-4.171) is associated with CHD when compare with low pesticide exposure by both DAG and logistic analyses. After adjusting for the additional potential influence of factors identified by the DAG analysis, there is no significant association, such as the results in logistic regression: ethnicity, education level, settlement time, and mixed pesticide status. Specifically, age, meal frequency, and consumption of fresh fruit, according to the DAG analysis, are independent factors for CHD. High pesticide exposure is a risk factor for CHD as indicated by both DAG and logistic regression analyses. DAG can be a preferable improvement over traditional regression methods to identify sources of bias and causal inference in observational studies, especially for complex research questions.

Association Between Occupational Exposure to Pesticides and Cardiovascular Disease Incidence: The Kuakini Honolulu Heart Program

Background

Previously, Kuakini Honolulu Heart Program researchers reported that occupational exposure to pesticides was significantly associated with total mortality. The current study examines occupational exposure to pesticides in relation to incident cardiovascular disease, defined as coronary heart disease or cerebrovascular accident.

Methods and Results

With the Occupational Safety Health Administration exposure scale used as an estimate of exposure, statistical analyses were performed on a cohort of 7557 Japanese‐American men from the Kuakini Honolulu Heart Program. Hazard ratios for cardiovascular disease incidence were calculated for various levels of pesticide exposure using Cox proportional hazards models. In the first 10 years of follow‐up, a positive association was observed between age‐adjusted cardiovascular disease incidence and high levels of pesticide exposure (hazard ratio=1.46, 95% CI=1.10‐1.95, P=0.009). This relationship remained significant after adjustment for other cardiovascular disease risk factors (hazard ratio=1.42, 95% CI=1.05‐1.92, P=0.021). No significant association for coronary heart disease or cerebrovascular accident incidence with pesticide exposure was observed when examined separately, possibly due to a smaller number of events.

Conclusions

These findings suggest that occupational exposure to pesticides may play a role in the development of cardiovascular diseases. The results are novel, as the association between occupational exposure to pesticides and cardiovascular disease incidence has not been examined previously in this unique cohort.

Carotid intima-media thickness is a novel predictor of new onset of hypertension in normotensive subjects

Increased carotid intima-media thickness (IMT) in individuals without hypertension might indicate other factors promoting the atherosclerotic process that are often simultaneously clustered in individuals. The present study tested the hypothesis that carotid IMT predicts new onset of hypertension in the normotensive subjects.A total of 867 participants were enrolled from our yearly physical checkup program and their carotid IMT was measured. After a baseline examination, the subjects were followed up for a median of 1091 days with the endpoint being the development of hypertension.At baseline, the carotid IMT value was 0.75 ± 0.16 mm. Hypertension developed in 184 subjects during the follow-up (76.9/1000 person-years). The incidence of hypertension was increased across the tertiles of the carotid IMT value (39.6, 70.0, and 134.5/1000 person-years in the first, second, and third tertiles, respectively, P < .001 by log-rank test). Multivariate Cox-hazard analysis after adjustment identified carotid IMT, taken as a continuous variable, as a significant predictor of new-onset hypertension (hazard ratio = 7.08, 95% confidence interval = 3.06-15.39). Furthermore, multivariate linear regression analyses indicated a significant correlation between the carotid IMT at baseline and yearly increases in systolic blood pressure during the follow-up period (β = 0.189, P < .001).Carotid IMT is an independent predictor of hypertension onset in normotensive subjects. The findings also suggested a close association between increased carotid IMT and blood pressure.

The health benefits and challenges of exercise training in persons living with schizophrenia: a pilot study

BACKGROUND

In addition to the hallmark cognitive and functional impairments mounting evidence indicates that schizophrenia is also associated with an increased risk for the development of secondary complications, in particular cardio-metabolic disease. This is thought to be the result of various factors including physical inactivity and the metabolic side effects of psychotropic medications. Therefore, non-pharmacological approaches to improving brain health, physical health, and overall well-being have been promoted increasingly.

METHODS

We report on the health-related physical fitness (body composition, blood pressure, heart rate, and aerobic fitness) and lipid profile of persons living with schizophrenia and effective means to address the challenges of exercise training in this population.

RESULTS

There was a markedly increased risk for cardio-metabolic disease in 13 persons living with schizophrenia (Age = 31 ± 7 years) including low aerobic fitness (76% ± 34% of predicted), reduced HDL (60% of cohort), elevated resting heart rate (80% of cohort), hypertension (40% of cohort), overweight and obesity (69% of cohort), and abdominal obesity (54% of cohort). Individualized exercise prescription (3 times/week) was well tolerated, with no incidence of adverse exercise-related events. The exercise adherence rate was 81% ± 21% (Range 48%-100%), and 69% of the participants were able to complete the entire exercise training program. Exercise training resulted in clinically important changes in physical activity, aerobic fitness, exercise tolerance, blood pressure, and body composition.

CONCLUSION

Persons living with schizophrenia appear to be at an increased risk for cardio-metabolic disease. An individualized exercise program has shown early promise for the treatment of schizophrenia and the various cognitive, functional, and physiological impairments that ultimately affect health and well-being.

Application of leukocyte transcriptomes to assess systemic consequences of risk factors for cardiovascular disease

Prevention of cardiovascular disease (CVD) remains a major health issue in the Western world. The diagnostic and therapeutic approach is currently based on risk factor assessment and treatment, which adequately predicts CVD at population level, but not at the level of a single individual. This may arise from the fact that the stage and activity of complex disease states are not likely to be captured by a single parameter or a small set of markers and thus may need a more complex representation. The aim of this review is to explore the possibility of pursuing the use of high-throughput gene expression profiling as a way to improve diagnosis, prognosis and monitoring of the disease. Novel chip-based techniques such as oligo- and cDNA microarrays can measure the abundance of thousands of mRNA transcripts in parallel and thus provide a comprehensive picture of the cell phenotype. Circulating white blood cells (WBCs), which are exposed to the systemic environment (including the risk factors) and are directly involved in the low-grade chronic inflammation related to CVD, have the potential to be used in this context to improve phenotyping of the patient. The paper reviews conceptual limitations in the use of risk factors and biomarkers, and shows the rationale beyond the possible use of circulating WBCs or subpopulations as representative cells to monitor systemic consequences of CVD. Methodological issues in performing microarray analysis of WBCs are also addressed, including controversies related to the choice of adequate cell populations and reference samples. Reproducibility and challenges occurring in the definition of a disease-specific gene panel are also discussed. The available proofs of principle from the literature presented in the last section of the review further support exploration of the application of circulating cell transcriptomics in CVD.

Treatment of systolic hypertension: spotlight on recent studies with angiotensin II antagonists

Systolic blood pressure has a continuous, graded, strong, independent, and aetiologically significant relationship to mortality from coronary heart disease, stroke, and all cardiovascular diseases, as well as to all-cause mortality and life expectancy. Angiotensin II (AII) may be intimately involved in the pathogenesis of systolic hypertension through multiple mechanisms, including decreasing the elastin content and increasing the collagen content of the arterial wall, thickening and fibrotic remodelling of the vascular intima, and proliferating smooth muscle cells in the arterial wall, resulting in increased thickness, stiffening, and partial loss of contractility. AII antagonists may therefore offer hitherto unrecognized benefits (independent of blood pressure) on age-related vascular damage and provide particular benefits in patients with systolic hypertension. Recent evidence has demonstrated that losartan offers cardiovascular outcomes benefits in isolated systolic hypertension (ISH) associated with an excellent tolerability profile. This, in patients with ISH, AII antagonists more facilitate systolic BP control, providing cardiovascular protection and offering an excellent risk-benefit profile.

Impact of elevated blood pressure on mortality from all causes, cardiovascular diseases, heart disease and stroke among Japanese: 14 year follow-up of randomly selected population from Japanese — Nippon data 80

The objectives of the study were to clarify the relationship between blood pressure and mortality from stroke, heart disease, cardiovascular diseases and all causes of death among representative population of Japanese and to estimate category-specific excess mortality from stroke due to blood pressure (BP) level. The study design comprised a retrospective cohort study using the 1980 National Survey on Cardiovascular Diseases and identification of underlying causes of death using national vital statistics data. In 1994, a 14-year follow-up cohort study was conducted among participants of the National Survey on Cardiovascular Diseases in 1980, randomly selected from the Japanese population. With a collaboration of 300 public health centres, which had conducted the original survey in 1980, 91.4% of the participants of the original survey could be followed up. Total observed person-years were 53948 for men and 70932 for women. During follow-up, 1327 deaths were observed. BP levels were significantly related to mortality from strokes, cardiovascular diseases and all causes of death for both sexes (P<0.001). Heart disease mortality was significantly related to BP levels among men (P<0.05) while not among women. Estimated excess mortality was 130% for men and 42% for women and chiefly observed among moderate hypertensives (48% for men and 16% for women). In conclusion, high blood pressure was a risk factor for mortality from all causes as well as those from cardiovascular diseases, stroke and heart disease among Japanese. Since the major part of excess mortality was due to mild hypertension, a population strategy to reduce blood pressure should be encouraged.

Antihypertensive therapy and cancer risk

The aim of this article is to provide an overview of the available data linking antihypertensive drug therapy to cancer risk. In recent years, a number of mainly retrospective studies have reached different conclusions on the risk of cancer in patients with hypertension being treated with different antihypertensive drugs. At some point or another nearly all antihypertensive drugs have been suggested to increase the risk of cancer. Some studies have even found an association between hypertension itself and increased carcinogenesis. For calcium channel antagonists, beta-blockers and alpha-blockers, the available evidence seems to favour a neutral effect on cancer development and death rate. For ACE inhibitors, the overall data suggest a similar neutral effect on cancer or, possibly, a small protective effect. Perhaps the strongest evidence in favour of a link, although probably weak, between cancer and antihypertensive drugs is with the diuretics. Until further solid data are available from prospective clinical trials, we suggest that the management of hypertension should continue according to current treatment guidelines with little fear of any substantial cancer risk.

Is drug treatment of hypertension in clinical practice as effective as in randomized controlled trials with regard to the reduction of the incidence of stroke?

The results from several nonexperimental studies suggest that drug treatment of hypertension in daily clinical practice may not be as effective as in randomized controlled trials. These nonexperimental studies had limitations with regard to the selection of an appropriate control group. The objective of our study was to assess the effect of drug treatment of hypertension under circumstances of everyday medical practice on the incidence of stroke by using a prognostically comparable untreated reference group. Within two prospective, population-based cohort studies among 45,000 men and women 20 years of age and older in the Netherlands, we selected a cohort of 2,301 hypertensive subjects who either received drug treatment for hypertension (N = 1,318) or were untreated for hypertension but were determined to be "candidates" for drug treatment on the basis of their level of blood pressure and the presence of other cardiovascular risk factors (N = 983). Follow-up averaged 4.6 years and was complete for 91% of the hypertensives. Compared with untreated hypertensive subjects who were "candidates" for drug treatment, subjects who received drug treatment for hypertension had, after adjustment for potential confounders, a 39% [95% confidence interval (CI) = 3-61%] reduced risk of stroke. About 46 (95% CI = 29-599) hypertensive patients need to be treated with antihypertensive drugs for 5 years to prevent one stroke in the general Dutch population. When a prognostically comparable reference group is used, the drug treatment of hypertension under circumstances of everyday medical practice appears to be effective in the reduction of the incidence of stroke. The relative risk reduction that we found was similar to those found in randomized controlled trials.

Excess mortality associated with increased pulse pressure among middle-aged men and women is explained by high systolic blood pressure

OBJECTIVE

To assess the risk of death from coronary heart disease, stroke, all cardiovascular diseases and all-cause mortality associated with pulse pressure among the middle-aged population.

METHODS AND DESIGN

A prospective 15-year follow-up cohort study was conducted of two independent cross-sectional random samples of the population who participated in baseline surveys in 1972 or 1977. Each survey included a self-administered questionnaire with questions on smoking and antihypertensive drug treatment, measurements of height, weight and blood pressure and the determination of the serum cholesterol concentration. Multivariate analyses were performed by using Cox proportional hazard models.

SETTING

The provinces of North Karelia and Kuopio in eastern Finland

PARTICIPANTS

Men and women aged 45-64 years with no history of myocardial infarction or stroke at the time of the baseline survey were selected. In total 4333 men and 5270 women took part in this follow-up study.

RESULTS

The relative risk of coronary heart disease, stroke, cardiovascular disease and all-cause mortality increased with the increasing pulse pressure in individuals aged 45-64 years independent of the diastolic blood pressure level. Only in women with diastolic blood pressure > or = 95 mmHg was the relative risk of fatal stroke not statistically significant. After adjustment for systolic blood pressure, the positive association between mortality and increasing pulse pressure disappeared.

CONCLUSION

Increasing pulse pressure is a predictor of death from coronary heart disease, stroke, cardiovascular disease and all causes in men and women aged 45-64 years, but the increase in risk is entirely associated with the increase in systolic blood pressure.

Elevated systolic blood pressure as a cardiovascular risk factor

This paper reviews the evolution of attitudes toward the treatment and diagnosis of hypertension. In particular, there is a growing realization that elevated systolic pressure may be a more valuable measurement in evaluating and controlling hypertension than is generally acknowledged. A large number of epidemiologic studies in a wide variety of populations have revealed that systolic blood pressure exerts a stronger influence than diastolic blood pressure. The largest of these, the Framingham Heart Study, showed that in subjects with systolic hypertension, diastolic blood pressure was only weakly related to the risk of cardiovascular events, but in those with diastolic hypertension, the risk of these events was strongly influenced by the level of systolic pressure. Furthermore, cardiovascular event rates were found to increase steeply with systolic pressure and were higher in cases of isolated systolic hypertension than diastolic hypertension. Clinical trials produced similar results, again suggesting that a greater reliance should be placed on systolic pressure in evaluating the risk of cardiovascular problems. This review concludes that the health community needs to be reeducated to consider the importance of systolic and diastolic blood pressure in assessing appropriate management strategies for hypertensive patients.

Midlife blood pressure and dementia: the Honolulu-Asia aging study

We studied the association of mid-life blood pressure to late age dementia, specifically Alzheimer's disease and vascular dementia. Data are from the cohort of 3703 Japanese-American men who were followed in the Honolulu Heart Program (HHP;1965-1971), and subsequently re-examined in 1991 for dementia. We assessed the risk (odds ratio (95% CI)) for dementia associated with categories of systolic (SBP) and diastolic blood pressure (DBP), stratified by never/ever treatment with anti-hypertensive medications, and adjusting for age, education, apolipoprotein epsilon allele, smoking and alcohol intake. Among those never treated (57% sample), the risk for dementia was OR 95% CI 3.8 (1.6-8.7) for DBP of 90-94 mm Hg, and 4. 3 (1.7-10.8) for DBP of 95 mmHg and over compared to those with DBP of 80 to 89 mm Hg. Compared to those with SBP of 110 to 139 mm Hg, the risk for dementia was 4.8 (2.0-11.0) in those with SBP 160 mm Hg and higher. Blood pressure was not associated with the risk for dementia in treated men. These results were consistent for Alzheimer's disease and vascular dementia. This study suggests elevated levels of blood pressure in middle age can increase the risk for late age dementia in men never treated with anti-hypertensive medication.

Excess stroke among hypertensive men and women attributable to undertreatment of hypertension

BACKGROUND AND PURPOSE

Most population-based studies indicate that a considerable proportion of hypertensive subjects are undertreated and that undertreatment is more prevalent among hypertensive men than among hypertensive women. The aim of our study was to investigate the consequences of undertreatment of hypertension for women and men in terms of stroke occurrence.

METHODS

Approximately 45 000 men and women aged >/=20 years were examined in 2 population-based studies in the Netherlands. A cohort of 2616 hypertensive subjects (pharmacologically treated hypertensives and untreated hypertensives who needed pharmacological treatment according to the severity of their hypertension and the coexistence of additional cardiovascular risk factors) was selected for a follow-up study. Follow-up (mean duration, 4.6 years) was complete for 2369 (91%) of the enrolled hypertensive subjects.

RESULTS

Compared with treated and controlled hypertensives, the relative risks of stroke for treated and uncontrolled hypertensives and for untreated hypertensives who needed treatment were 1.30 (95% CI, 0.70 to 2.44) and 1.76 (95% CI, 1.05 to 2.94), respectively. These relative risks and the prevalence of (undertreated) hypertension in the total population of 45 000 subjects were used to estimate the number of strokes in the Netherlands attributable to undertreatment. Among hypertensive men and women aged >/=20 years in the Netherlands, the proportions of strokes attributable to treated but uncontrolled blood pressure were 3.1% (95% CI, -5.2% to 18.7%) and 4.1% (95% CI, -7.2% to 20.7%), respectively. For untreated hypertensive men and women who should have been treated, these proportions were 22.8% (95% CI, 0.8% to 38.4%) and 25.4% (95% CI, 0. 5% to 42.5%), respectively.

CONCLUSIONS

Increasing the detection of hypertension and improving adherence to current guidelines might prevent a considerable proportion of the incident strokes among hypertensives. The potential impact of achieving control of blood pressure in patients already being treated on the reduction of strokes requires further investigation.

Variation between studies in reported relative risks associated with hypertension: time trends and other explanatory variables

OBJECTIVES

This study examined the variation in reported relative risks of coronary heart disease and stroke associated with hypertension and determined reasons for the interstudy variation.

METHODS

Studies published since 1970 were examined that reported the absolute number of events and person-years for men by age and hypertensive status. The data were pooled in Poisson regression models with the coronary heart disease or stroke rate as the dependent variable. Independent variables were hypertensive status, age at entry, age of study, duration of follow-up, diastolic blood pressure cut-off point, and interactions of all these variables with hypertensive status.

RESULTS

The reported relative risks associated with hypertension ranged from 1.45 to 2.77 for coronary heart disease and from 1.86 to 5.78 for stroke. Smaller relative risks were found in more recent studies, in studies with long follow-up, and in studies using a lower cut-off point to define hypertension.

CONCLUSIONS

Part of the interstudy variation in relative risks associated with hypertension can be attributed to differences in duration of follow-up, blood pressure cutoff point, and time at which blood pressure was measured, suggesting declining relative risks over time.

Association of body mass index with blood pressure in elderly Japanese American men. The Honolulu Heart Program

Few data are available on the association between body mass index (BMI) and blood pressure in elderly individuals, particularly among minority groups. We studied the cross-sectional association of BMI with systolic and diastolic pressures in 1378 Japanese American men 60 to 82 years of age who were participants in the population-based Third Lipoprotein Examination of the Honolulu Heart Program conducted between 1980 and 1982. When the subjects were divided into 5-year age groups, mean BMI decreased linearly with increasing age. Mean systolic pressure rose from 134.8 mm Hg in the first quintile of BMI to 138 in the second and 141.8 in the third quintiles, with levels of 139.2 and 142 in the fourth and fifth quintiles, respectively (test for trend, P = .083). Mean diastolic pressure rose from 78.1 mm Hg in the lowest quintile of BMI to 83.9 in the highest (test for trend, P = .008). We performed multiple regression analysis, controlling for factors known to influence blood pressure values, including age, physical activity index, alcohol intake, current smoking status, and diabetes mellitus. The association between BMI and both systolic and diastolic pressures remained highly statistically significant in these analyses. These results show that obesity and high blood pressure continue to be highly correlated even in old age and suggest that it may be possible to modify rates of hypertension by changes in body weight.

Incidence of myocardial infarction in elderly men being treated with antihypertensive drugs: population based cohort study

OBJECTIVE

To analyse the association between use of antihypertensive treatment, diastolic blood pressure, and long term incidence of ischaemic cardiac events in elderly men.

DESIGN

Population based cohort study. Baseline examination in 1982-3 and follow up for up to 10 years.

SETTING

Malmŏ, Sweden.

SUBJECTS

484 randomly selected men born in 1914 and living in Malmŏ during 1982.

MAIN OUTCOME MEASURES

Observational comparisons of incidence rates and rate and hazard ratios of ischaemic cardiac events (myocardial infarction or death due to chronic ischaemic cardiac disease).

RESULTS

The crude incidence rate of ischaemic cardiac events was higher in those subjects who were taking antihypertensive drugs than in those who were not (rate ratio 2.6 (95% confidence interval 1.7 to 3.9)). After adjustment for potential confounders (differences in baseline smoking habits, blood pressure, time since diagnosis of hypertension, ischaemic or other cardiovascular disease, hypercholesterolaemia, hypertriglyceridaemia, diabetes mellitus, obesity, and raised serum creatinine concentration) this rate was reduced but still raised (hazard ratio 1.9 (1.0 to 3.7)). In men with diastolic blood pressure > 90 mm Hg, antihypertensive treatment was associated with a twofold increase in the incidence of ischaemic cardiac events (rate ratio 2.0 (1.1 to 3.6)), which vanished after adjustment for potential confounders (hazard ratio 1.1 (0.5 to 2.6)). In those subjects with diastolic blood pressure < or = 90 mm Hg, antihypertensive treatment was associated with fourfold increase in incidence (rate ratio 3.9 (2.1 to 7.1)), which remained after adjustment for potential confounders (hazard ratio 3.8 (1.3 to 11.0)).

CONCLUSION

Antihypertensive treatment may increase the risk of myocardial infarction in elderly men with treated diastolic blood pressures < or = 90 mm Hg.

Outcomes of black and white hypertensive individuals after 30 years of follow-up

Outcomes of a 30-year follow-up for the participants of the Charleston Heart Study were studied with elevated blood pressure assessed using various classifications. The traditional categories of > or = 140/90 mmHg, > or = 160/95 mmHg and isolated systolic hypertension, as well as high normal and the four stages of high blood pressure were utilized in analyses. Prevalence rates of hypertension were, in general, higher among blacks compared to whites. Blacks had higher prevalence rates of hypertension and greater prevalence of high blood pressure at younger ages. Risk ratios were higher for black and white hypertensives than their normotensive counterparts. Blacks were found to have substantially higher population attributable risk proportions, particularly at the higher blood pressure categories. The results suggest that the standard clinical classifications of hypertension as related to mortality are appropriate for blacks and white.

Mortality from stroke, coronary heart disease and all causes related to blood pressure and length of follow-up

Measurements of blood pressure in 52,064 men and women in the city of Bergen, Norway, who were 30 to 89 years in 1963, have been related to mortality occurring in different intervals of the follow-up period from 1963 throughout 1983. Blood pressure measurements obtained on one occasion were highly predictive of both coronary heart disease, stroke and all-cause mortality several years after measurements. The relative risk of stroke mortality associated with blood pressure varied little in the first ten to fifteen years, but the predictive power was clearly lower in the last five years of follow-up. The relative risk of death from coronary heart disease was stable in the whole period of follow-up. The risk curves relating coronary heart disease mortality to diastolic blood pressure in men and women aged 60-79 years at screening had the same shape in the first five years as in the rest of the follow-up. No J-shaped association was seen in either time interval.

Echocardiographic correlates of left ventricular structure among 844 mildly hypertensive men and women in the Treatment of Mild Hypertension Study (TOMHS)

BACKGROUND

Echocardiography provides a noninvasive means of assessing left ventricular (LV) structure and evidence of LV wall remodeling in hypertensive persons. The relation of demographic, biological, and other factors with LV structure can be assessed.

METHODS AND RESULTS

LV structure was assessed by M-mode echocardiograms for 511 men and 333 women with mild hypertension (average blood pressure, 140/91 mm Hg). Measurements of LV wall thicknesses and internal dimensions were made, and estimates of LV mass indexes and other derivations of structure were calculated. LV hypertrophy criteria were based on previously reported echocardiographic population studies of normal subjects. These measures were compared by age, sex, race, body mass index, systolic blood pressure, antihypertensive drug use, physical activity, alcohol intake, cigarette smoking, and urinary sodium excretion. Despite virtual absence of ECG-determined LV hypertrophy, 13% of men and 20% of women had echocardiographically determined LV hypertrophy indexed by body surface area (g/m2), and 24% of men and 45% of women had LV hypertrophy indexed by height (g/m). Black participants had slightly higher mean levels of wall thickness than nonblack participants but similar LV mass. Systolic blood pressure and urinary sodium excretion were significantly and independently associated with LV mass index and LV hypertrophy using both g/m2 and g/m. Body mass index was significantly related to LV mass index and LV hypertrophy using g/m. Smoking was significantly associated with LV mass index, i.e., using continuous measurement but not using the dichotomy for LV hypertrophy.

CONCLUSIONS

This study of a large population of men and women with mild primary hypertension, largely without ECG evidence of LV hypertrophy, showed a substantial percentage of participants with echocardiographically determined LV hypertrophy. LV mass indexes correlated positively with systolic blood pressure, body mass index, urinary sodium excretion, and smoking.

Cardiovascular risk factors, premature heart disease, and all-cause mortality in a cohort of northern California women

Large prospective studies and intervention trials have identified major risk factors for premature heart disease in men, while the Framingham Heart Disease Study has provided the leading evidence of predictors of cardiovascular disease in women. We evaluated the role of these risk factors in a 13-year follow-up study of 8935 premenopausal and 2716 postmenopausal women in the Walnut Creek Contraceptive Drug Study cohort in Northern California. Elevated cholesterol levels, high blood pressure, smoking, obesity, family history of heart disease, and diabetes were investigated for their contribution to premature death due to all causes and due to cardiovascular disease. In addition, risk factor profiles were developed separately for users and nonusers of Premarin (conjugated estrogen) in the postmenopausal cohort. The results show that the strongest predictors of cardiovascular mortality among premenopausal women were smoking, high blood pressure, and diabetes, with relative risks of 2.8, 10.5, and 11.6, respectively. A disparity between high cardiovascular risk factor prevalence and low rates of premature heart disease indicates that the high relative risks will not be accompanied by large attributable risks. Nevertheless, the study reconfirms the need for screening women for heart disease risk because life-style changes can improve cardiovascular risk factors and can potentially reduce the chance of premature death even further.

Mortality associated with diastolic hypertension and isolated systolic hypertension among men screened for the Multiple Risk Factor Intervention Trial

The large cohort of white men (317,871) 35 to 57 years old at initial screening for possible enrollment into the Multiple Risk Factor Intervention Trial (MRFIT) was examined with regard to initial blood pressure levels and subsequent coronary heart disease (CHD), stroke, and all-cause mortality. The overall prevalence of isolated systolic hypertension (ISH), defined as systolic blood pressure (SBP) greater than or equal to 160 mm Hg and diastolic blood pressure (DBP) less than 90 mm Hg, was 0.67% among white men screened for MRFIT and increased with age (0.31% among 35- to 39-year-olds to 1.7% among 55- to 57-year-olds). The 6 year CHD and all-cause mortality rates in men over 50 were highest in those with ISH compared with both subjects with diastolic hypertension and those with normal pressure. The relative risk of death from stroke in those with ISH, compared with that in those with SBP less than 160 mm Hg and those with DBP less than 90 mm Hg, was 3.0 (95% confidence interval 1.3 to 6.8). In addition, at any level of DBP, the level of SBP appeared to be the major determinant of all-cause and CHD mortality. The determinants of ISH in individuals under 60 years of age as well as the possible efficacy of its treatment should be evaluated further.

Use of non-drug therapy in treating hypertension

The high degree of risk for cardiovascular disease and the failure of medication to provide adequate protection are the chief considerations in the use of nondrug therapy of hypertension. We shall examine the effects of weight reduction, sodium restriction, exercise, and other such alternatives to blood pressure-lowering medication. If nondrug therapies can lower blood pressure, they will remove the need for drug therapy in some patients and minimize the amount of drugs needed for others.