Pretreatment blood pressure as a predictor of 21-year mortality
ABSTRACT Our objective was to evaluate pretreatment predictors of longevity, particularly blood pressure, in a large cohort of hypertensive men. During 1974 to 1976, 10,367 male hypertensive veterans (47% black) were identified at screening and subsequently characterized in 32 special Veterans Administration (VA) hypertension clinics. Their mean age was 52 years and mean blood pressure (BP) 154/100 mm Hg. During an average of 21 years of follow-up, 61% died. Risk ratios for all-cause mortality as functions of BP and other risk factors are presented for each variable alone; for each variable controlling for age, race, and BP; and for a multivariate model. We observed that when the entire cohort was divided into deciles by systolic blood pressure (SBP) and by diastolic blood pressure (DBP), the risk ratios for 21-year mortality increased from lowest to highest decile by 178% for SBP and 16% for DBP. When the deciles were computed separately by age group, increases from lowest to highest decile for those less than 40 years of age were 138% for SBP and 263% for DBP. For those over 60 years, the increases were 154% and -10%, respectively. Although blacks were younger and had more severe diastolic hypertension than whites, the risk ratios were similar within each race group. Risk patterns for mean arterial pressure and pulse pressure resembled those for SBP but had smaller gradients. Survival curves for BP groups suggested constant mortality rates during follow-up. Other significant observations included decreasing mortality with increasing body mass index and increased mortality in the Stroke Belt. We concluded that pretreatment SBP strongly predicted all-cause mortality during 21-year follow-up. For the young, both SBP and DBP were strong predictors; for the elderly, only SBP was predictive.
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ABSTRACT: A major invitational hypertension meeting was hosted by the Department of Veterans Affairs (VA) in Washington, DC, on May 26 to 28, 1999. It followed a report that only 25% of hypertensive veterans had adequate levels of treated blood pressure and focused on how control of hypertension could be improved both immediately and in the future. After the presentation of brief outlines of 5 unresolved basic science questions, 2 general topics were considered: (1) 30 years of change in hypertension and its treatment and (2) current healthcare delivery mechanisms and how to improve them. Since 1970, the severity of hypertension has decreased, malignant hypertension has disappeared, and the prognostic roles of systolic and diastolic blood pressure have been reversed as hypertension became milder. Five VA Cooperative Studies have provided important data: the 1970 Freis Trial report demonstrated the value of treatment, 2 trials showed that some controlled patients can decrease or even discontinue pharmacological treatment without recrudescent hypertension, a blinded trial was performed on the efficacy of different antihypertensive drugs, and an unblinded trial showed that diuretics and beta-blockers are the most effective agents when caregivers choose the agent and dose. Two healthcare models were considered: (1) the patient-friendly VA Hypertension Screening and Treatment Program that was introduced in 1972, which controls 80% of patients at the goal of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure with diuretics and keeps patients in the program an average of 7.5 years, and (2) the newer primary care health maintenance organization-like model in the VA and throughout the United States. Choosing a regimen and monitoring control of blood pressure and compliance with therapy were discussed. The meeting was closed with 6 general recommendations for improving the care of hypertensive patients.Hypertension 05/2000; 35(4):853-7. DOI:10.1161/01.HYP.35.4.853 · 7.63 Impact Factor
- American Journal of Hypertension 07/2000; 13(6 Pt 1):736-8. DOI:10.1016/S0895-7061(99)00276-9 · 3.40 Impact Factor
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ABSTRACT: Clinical trials for comparison of antihypertensive agents seem to greatly differ from clinical practice. One limitation of clinical trials is the absence of a random distribution of target organ damage that can determine differences in the response to a given therapy. This study was designed to evaluate, within the conditions of daily clinical practice, the capacity of four different antihypertensive drugs to control blood pressure in essential hypertensive patients randomly distributed according to an assessment of target organ damage. A group of 200 mild essential hypertensives (44.4±12.5 years old; 50.3% male) sent to our unit for routine evaluation and therapy of their hypertension were included in the study. They were randomly allocated to four different therapeutic agents (atenolol, lisinopril, nisoldipine, or losartan). There were 50 patients in each group. After a 4-week washout of previous antihypertensive therapy, or without it if previously untreated (43 %), patients received one of the four medications in an open fashion. A random distribution was performed for sex, age, and the presence of target organ damage, including left ventricular hypertrophy determined by echocardiography, alterations (plaque or thickening) on carotid Doppler ultrasonograms, and/or the presence of microalbuminuria (>30 mg/24 h). Efficacy and tolerability were evaluated after 12 weeks of therapy. Left ventricular hypertrophy was detected in 32% of patients, diastolic dysfunction in 30.1%, and systolic dysfunction in 1.9%. Carotid plaques were detected in 41.5% of subjects, but only 10.4% had more than one plaque. Medial/intimal thickness of >1.00 mm was present in 41.5% of patients. Finally, 27% exhibited microalbuminuria. The expected correlations among the different components of target organ damage were found. After 12 weeks of therapy, blood pressure reductions were similar in all groups, and the expected goal of control (diastolic pressure of <90 mm Hg) was attained in 64.6% of atenolol patients, 68.8% on lisinopril, 62.2% on nisoldipine, and 60.8% on losartan. No severe adverse events were observed, and the withdrawal rates were 20% with atenolol, 10% with lisinopril and nisoldipine, and 8% with losartan. In conclusion, the four antihypertensive agents showed equal antihypertensive efficacy in patients with a similar degree of target organ damage. The β blocker exhibited the lowest tolerability. These results are in agreement with those obtained in prospective clinical trials.Journal of Clinical Hypertension 05/2001; 3(3):139-44. DOI:10.1111/j.1524-6175.2001.00448.x · 2.96 Impact Factor