Is hypertension changing? Blood pressure development in cohorts of 50-year-old men between 1963 and 1993

Results of renal artery revascularization in the post-ASTRAL era with 4 years mean follow-up

Purpose: To investigate contemporary results of percutaneous transluminal renal angioplasty (PTRA).Materials and Methods: A multicentre retrospective study analysing all patients treated with PTRA for primary symptomatic renal artery stenosis (RAS) between 2010 and 2013 at four tertiary centres. Procedures during the preceding four years were counted to evaluate for change in PTRA frequency.Results: The number of PTRA procedures decreased by approximately 50% from 2006 to 2013. Patients treated in the post-ASTRAL period (n = 224) had a significant reduction in mean systolic pressure (168 to 146 mmHg, p < 0.01), diastolic pressure (84 to 76 mmHg, p < 0.01), number of anti-hypertensive drugs (3.54 to 3.05, p < 0.01), and anti-hypertensive treatment index (21.75 to 16.92, p < 0.01) compared to before PTRA. These improvements were maintained at one year and at the last clinical evaluation after a mean follow-up of 4.31 years. Renal function increased transiently without sustained improvement, or deterioration, during later follow-up. Thirteen patients (5.8%) eventually required dialysis, nine of these had eGFR <20 ml/min/1.73 m² before PTRA. There was no difference in outcomes between subgroups differentiated by different indications for PTRA.Conclusion: The frequency of PTRA has decreased, indicating a higher threshold for invasive treatment of RAS in recent years. The reduction in blood pressures, the reduced need for anti-hypertensive medication, and stabilization of renal function over time suggest a clinical benefit for most patients who are now being treated with PTRA.

Obesity and trends in cardiovascular risk factors over 40 years in Swedish men aged 50

OBJECTIVE

To study trends over 40 years in cardiovascular risk factors in normal weight, overweight and obese men, all aged 50 when examined. Design. Cross-sectional studies of five successive cohorts of men aged 50.

SETTING

City of Göteborg, Sweden.

SUBJECTS

Random population samples of altogether 3251 urban Swedish men born in 1913, 1923, 1933, 1943 and 1953.

MAIN OUTCOME MEASURES

Anthropometry, cardiovascular risk factors, rates of nonsmoking, normotension and serum cholesterol <5 mmol L(-1) over four decades.

RESULTS

Over 40 years, there was a net increase in body mass index (BMI) from 24.8 (SD = 3.2) to 26.4 (3.7) kg m(-2) (P < 0.0001), with an increase in the prevalence of obesity (BMI >or= 30 kg m(-2)) from 6.0% in 1963 to 13.8% in 2003. Favourable trends with respect to smoking, blood pressure and serum cholesterol were observed similarly amongst normal weight, overweight and obese men. In 1963, 24% of obese men were normotensive compared to 45% in 2003, and 6% had serum cholesterol <5 mmol L(-1) compared to 34% in 2003. Compared with obese men in 1963, men who were obese in 2003 had an odds ratio (OR) of 3.39 being a nonsmoker [95% confidence interval (CI): 1.56 to 7.36], 2.67 of being normotensive (1.23 to 5.83) and having serum cholesterol <5 mmol L(-1) of 8.30 (2.37 to 29.0). However, optimal risk factor status - no smoking, normotension and total serum cholesterol <5 mmol L(-1)- was still present in less than one in six men in 2003, similar across BMI categories.

CONCLUSIONS

Obese Swedish men who are now in their fifties have much lower levels of other risk factors compared with obese men 40 years ago. This could contribute to explain why coronary heart disease death rates still are falling despite increasing rates of obesity.

Hazard function and secular trends in the risk of recurrent acute myocardial infarction: 30 years of follow-up of more than 775,000 incidents

BACKGROUND

The incidence of a first acute myocardial infarction (AMI) has fallen considerably during the last decades. However, no previous studies have analyzed the underlying hazards function of experiencing a recurrent AMI, and none has analyzed the change of risk for a recurrent AMI over the last 3 decades.

METHODS AND RESULTS

The study was based on the Swedish national myocardial infarction register. The register contained more than 1 million AMI events. After exclusion of events occurring in subjects younger than 20 or older than 84 years and events with uncertain first AMI status, 775 901 events occurring between 1972 and 2001 remained for analysis. During the study period, the risk of a new event among survivors of a previous AMI decreased sharply during the first 2 years after the previous event, had its minimum after 5 years, and then increased slowly again. The risk for a recurrent AMI during the first year after a previous event was fairly stable over the years until the late 1970s and then decreased by 36% in women and 40% in men until the late 1990s, irrespective of age and AMI number, mirroring the incidence decrease over the years for primary events.

CONCLUSIONS

The risk of a recurrent AMI event was highly dependent on time from the previous event, a novel finding which may affect risk scoring. There were strong secular trends toward diminishing risk for a recurrent AMI in recent years, even when other outcome affecting variables were taken into account.

Secular trends in cardiovascular risk factors with a 36-year perspective: observations from 38- and 50-year-olds in the Population Study of Women in Gothenburg

OBJECTIVES

To study secular trends in cardiovascular risk factors in four different cohorts of women examined in 1968-1969, 1980-1981, 1992-1993 and 2004-2005.

DESIGN

Comparison of four representative cohorts of 38- and 50-year-old women over a period of 36 years.

SETTING

Gothenburg, Sweden with approximately 450,000 inhabitants.

SUBJECTS

Four representative samples of 38- and 50-year-old women were invited to free health examinations (participation rate 59-90%, n =1901).

MAIN OUTCOME MEASURES

Body mass index (BMI), systolic and diastolic blood pressure (SBP, DBP), leisure time exercise, use of antihypertensive medication, smoking, levels of haemoglobin, b-glucose, s-cholesterol, s-triglycerides and HDL-cholesterol.

RESULTS

There was no significant difference in mean BMI from 1968-1969 versus 2004-2005. Mean leisure time exercise was significantly higher in later born cohorts; in 1968, around 15% were physically active compared with 40% in 2004. SBP and DBP, mean s-cholesterol and s-triglyceride levels were significantly lower in both 38- and 50-year-old cohorts in 2004-2005 versus 1968-1969. HDL-cholesterol (not measured until 1992-1993), showed a significantly higher mean level in 2004-2005. Reduction of risk factors was apparent in women with a high as well as low level of physical activity. Smoking declined most in women with high levels of physical activity.

CONCLUSIONS

Several cardiovascular risk factors related to lifestyle have improved in middle-aged women from the 1960s until today. Most of the positive trends are observed in women with both low and high physical activity.

Trends in the prevalence, awareness, treatment and control of hypertension: the WHO MONICA Project

OBJECTIVE

To describe the secular changes in the prevalence, awareness, treatment and control of hypertension.

DESIGN

Two independent cross-sectional population surveys using standardized methods conducted between the early 1980s and mid-1990s.

SETTING

Twenty-four geographically defined populations of the WHO MONICA Project.

PARTICIPANTS

Randomly selected men and women aged 35-64 years. The total number of participants was 69 907.

MAIN OUTCOME MEASURES

Two definitions of hypertension were used: 160/95 mmHg or above and 140/90 mmHg or above for systolic or diastolic blood pressure. Subjects on antihypertensive drug treatment were considered to be hypertensive regardless of their blood pressure. Treated subjects whose measured blood pressure level was less than 160/95 or 140/90 mmHg according to the two definitions, respectively, were considered to be adequately treated.

RESULTS

The age-adjusted prevalence of hypertension decreased in most and increased in only a few populations. For both definitions of hypertension, the proportion of hypertensive subjects who were aware of their condition increased in three-quarters of the male populations and in two-thirds of the female populations. Furthermore, the proportion of hypertensive individuals on antihypertensive drug treatment increased in three-quarters of the populations. In the final survey, hypertension tended to be better treated and controlled in women than in men. Nevertheless, a large proportion of patients receiving antihypertensive drug therapy still had inadequately controlled blood pressure levels.

CONCLUSION

Although awareness and treatment of hypertension according to the data obtained during the late 1980s to the mid-1990s increased in several populations, the effectiveness of antihypertensive treatment showed the continuing need for improvements.

Secular decrease in blood pressure and reduction in mortality from cardiovascular disease in Israeli workers

The reasons for the dramatic reduction in age-adjusted mortality from cardiovascular disease (CVD) since the 1970s in developed countries remain uncertain. In the following study we compare the cardiovascular and all-cause mortality rates over an 11-year period in two well-defined employed male cohorts aged 40-69 years old recruited 24 years apart. Blood pressure and other risk markers for CVD were assessed at the time of inception (1963 for 10 048 male civil servants and 1985-1987 for 2237 male industrial workers). Compared to the 1987 cohort, the 1963 cohort show an increase of 8.7 mmHg in the mean systolic blood pressure (SBP) (95% confidence interval (CI): 7.7, 9.6) and a concomitant hazard ratio for CVD mortality of 1.47 (95% CI: 1.16, 1.87). After adding SBP to the analysis, the hazard ratio for CVD mortality in the 1963 cohort decreased to 1.18 (95% CI: 0.88, 1.43). Adding the other risk modifiers to the analysis did not modify the hazard ratio to the same extent. Similar results were obtained for all-cause mortality. We conclude that declining blood pressure values are a major factor in explaining the secular decrease in CVD mortality over a period of 24 years in Israel.

Serum lipids in fathers and sons at middle age: the study of sons to men born in 1913

OBJECTIVE

To relate lipid levels in middle-aged men to that of their fathers at 50 years of age measured 30 years earlier.

DESIGN AND SUBJECTS

In 1963, 855 men born in 1913 took part in a cardiovascular risk factor survey when they were at 50 years of age. In 1993, 475 sons to these men, aged 44-56, were invited to another examination; 263 of these men were examined (response rate: 56%) and compared with their 217 fathers when they were examined at 50 years of age in 1963. In the 1993 survey, 798 men aged 50, were also examined, from a general population sample of men born in 1943 (response rate: 55%).

SETTING

City of Göteborg, Sweden.

MAIN OUTCOME MEASURES

Serum lipids in sons as a function of lipids in their fathers.

RESULTS

Compared with the men born in 1913, both sons and men born in 1943 had lower mean serum cholesterol, but higher body mass index (BMI) and serum triglycerides. There was a significant relation between serum cholesterol in sons and their fathers (r = 0.25; P < 0.0001). Amongst sons to fathers in the highest cholesterol quartile (>6.9 mmol x L(-1)), 37% had serum cholesterol above 6.5 mmol x L(-1), compared with 16% amongst sons to fathers in the lowest quartile (<5.7 mmol x L(-1)) [adjusted odds ratio 3.73 (1.52-9.12)]. Sons to fathers with the highest serum cholesterol levels had slightly lower BMI; otherwise there was no relation between serum cholesterol in the father and any other lifestyle or biological risk factor in the sons. Serum triglyceride concentration in the father was unrelated to any variable in the son.

CONCLUSIONS

There was a moderately strong association between serum cholesterol concentration in fathers and sons at middle age. However, secular trends were also important in determining serum cholesterol concentrations in those born at a later period, indicating a major role of environmental factors.

Hypertension in diabetes: trends in clinical control in repeated large-scale national surveys from Sweden

Hypertension in diabetes is an important and treatable cardiovascular risk factor. Treatment targets from guidelines cannot always be achieved in everyday clinical practice. It is therefore of great importance to monitor trends in hypertension control in defined populations. Patients with type I diabetes (range 6685-10,100; treated hypertension 21-29%) or with type II diabetes (range 15,935-22,605; treated hypertension 47-56%) were included in four national samples between 1996 and 1999. This screening was part of the procedures for the National Diabetes Register in Sweden, which monitors trends in clinical practice and risk factors for patients with diabetes, recruited both in primary health care and at the hospital level. A favourable trend in mean and median blood pressure levels was noticed during the 4-year study period, based either on data from repeated surveys or on repeated measures in the same individual, both for type I diabetes (mean: -2/-2 mmHg; P < 0.01) and for type II diabetes (mean: -5/-3 mmHg; P < 0.001). Correspondingly, the proportion of hypertensive patients in acceptable control of blood pressure (< or =140/85 mmHg) increased (P < 0.001) both in type I diabetes (52.0-57.9%) and in type II diabetes (22.4-33.3%). It was concluded that hypertension is a widespread cardiovascular risk factor in patients with diabetes, especially systolic hypertension. A trend for a better systolic blood pressure control during the late 1990s in hypertensive patients with type II diabetes in Sweden could translate into substantial (estimated) clinical benefits in cardiovascular and diabetes-related morbidity. The National Diabetes Register makes a quality assessment of the hypertension treatment possible.

Evaluation of "Live for Life", a health promotion programme in the County of Skaraborg, Sweden

STUDY OBJECTIVE

To evaluate a health promotion programme, combining a population and individual based strategy, in the County of Skaraborg, Sweden, with special attention to outcome.

DESIGN

The evaluation was subdivided into structure, process and outcome. The evaluation procedure as a total is described here, but the results presented refer only to outcome. In order to study the potential effect of the individually based health examination, 35 year old subjects who had participated five years previously were in 1994-1996 compared with 35 year old subjects who had not participated before, and compared with their own values five years earlier. The results during 1995-1996 were compared with those of 1989-1990 for corresponding ages in order to study the effect of, particularly, the population based strategy.

SETTING

The County of Skaraborg in the south western part of Sweden with about 270 000 inhabitants. In addition to population strategy, involving the total county, men and women aged 30 and 35 years were invited to an individually based examination.

MAIN RESULTS

Factors related to body weight increased during the study period, while other factors mostly changed in the direction wanted. As a whole the changes were rather modest. There were favourable changes in lifestyle variables, for example, concerning smoking and dietary habits.

CONCLUSIONS

There were beneficial effects from the health promotion programme, but there is a need for continuous improvement of methods of intervention referred to lifestyle.

Hypertension: an important precursor of heart failure

Hypertension is an important risk factor for cardiovascular morbidity and mortality. Hypertension is associated with the development of congestive heart failure by way of left ventricular hypertrophy, with left ventricular dilatation and through myocardial ischemia and left ventricular damage. Reports on the natural history of untreated hypertension indicate that at least 50% of affected subjects develop congestive heart failure. Hypertension is an important precursor of heart failure, and still the most common risk factor for congestive heart failure in the population. In clinical trials, particularly in elderly patients, a reduction in the incidence of congestive heart failure has been observed. Despite increments in the use of antihypertensive drugs, mortality from congestive heart failure among the elderly is increasing. Moreover, several patients with hypertension are unaware, untreated and uncontrolled for the most important risk factor for congestive heart failure. For the primary prevention of heart failure, improvements in blood pressure control are of vast importance.

Secular changes in cardiovascular risk factors over 30 years in Swedish men aged 50: the study of men born in 1913, 1923, 1933 and 1943

OBJECTIVES

To study secular trends in cardiovascular risk factors in men aged 50 over a period of 30 years.

DESIGN

Cross-sectional studies of successive cohorts of men from 1963 to 1993.

SETTING

City of Göteborg, Sweden.

SUBJECTS

Four random population samples of men born in 1913, 1923, 1933 and 1943, aged 50 when they were examined in 1963, 1973, 1983, and 1993 (n = 855, 226, 776, and 798, respectively).

MAIN OUTCOME MEASURES

Anthropometric measurements, blood pressure, serum cholesterol and triglycerides and smoking habits over three decades.

RESULTS

Over 30 years, men increased in weight from a mean (SD) of 75.9 (11.0) kg to 82.8 (12.1) kg and gained 3.4 cm in height, with a net increase in body mass index from 24.8 (3.2) to 26.0 (3.4) kg m-2 (P < 0.0001), and a concomitant increase in waist circumference. The proportion of men who were overweight but not obese (BMI = 25-30 kg m-2) increased from 38 to 47%, whereas the prevalence of frank obesity (more than 30 kg m-2) increased from 6% in 1963 to 11% in 1993. Despite the increase in weight, mean systolic blood pressure fell by almost 10 mmHg (P < 0.0001). Mean serum cholesterol concentration decreased from 6.42 (1.12) to 5.88 (1.04) (P < 0.0001). Serum triglycerides increased from 1.26 (0.77) to 1.69 (1.04) mmol L-1 (P = 0.001). The proportion of men who smoked decreased from 56% in 1963 to 30% in 1993 (P < 0.0001). This was due more to an increase in smoking cessation rates than to an increase in the proportion of men who had never smoked. In particular, smokers and former smokers are now more obese than the corresponding categories 30 years ago and smokers are no longer leaner than men who have never smoked.

CONCLUSIONS

Over a period of 30 years, serum cholesterol as well as systolic blood pressure and the prevalence of smoking decreased. This favourable decline in coronary risk factors was offset by an appreciable increase in body mass index and waist circumference.

Hypertension-induced congestive heart failure

Arterial hypertension used to be the most common cause of congestive left ventricular failure. With the availability and common use of antihypertensive treatment the incidence and prevalence of hypertension-induced left ventricular failure has gradually declined. Today congestive heart failure due to underlying coronary heart disease is by far more common than the hypertension-induced variety. The effect of treatment of left ventricular failure in recent years, in particular with angiotensin converting enzyme inhibitors and carvedilol, has been impressive.

Underestimation of the true benefits of antihypertensive treatment: an assessment of some important sources of error

The treatment of arterial hypertension is based on results from several large prospective randomized intervention trials that demonstrated significant benefits from antihypertensive therapy in terms of reduced cardiovascular morbidity and mortality, mainly from strokes, but also from myocardial infarction, congestive heart failure and other vascular or renal complications. Nonetheless, it is obvious that such studies, for a number of reasons, underestimate the true benefit of lowering elevated arterial pressure. Active treatment given to patients allocated randomly to be administered placebo is an important factor, particularly since active treatment is given preferentially to the placebo patients with the highest risk. Recruitment of low-risk patients into studies is another reason for the underestimation of benefit. Moreover, significant loss of patients to follow-up plays a role. Two recent epidemiological surveys, in Framingham and Göteborg, showed markedly beneficial blood pressure-related changes in those populations, suggesting that the long-term effects of antihypertensive therapy may in fact have been underestimated by intervention studies