Applying recovery biomarkers to calibrate self-report measures of sodium and potassium in the Hispanic Community Health Study/Study of Latinos.

Measurement error in assessment of sodium and potassium intake obscures associations with health outcomes. The level of this error in a diverse US Hispanic/Latino population is unknown. We investigated the measurement error in self-reported dietary intake of sodium and potassium and examined differences by background (Central American, Cuban, Dominican, Mexican, Puerto Rican and South American). In 2010-2012, we studied 447 participants aged 18-74 years from four communities (Miami, Bronx, Chicago and San Diego), obtaining objective 24-h urinary sodium and potassium excretion measures. Self-report was captured from two interviewer-administered 24-h dietary recalls. Twenty percent of the sample repeated the study. We examined bias in self-reported sodium and potassium from diet and the association of mismeasurement with participant characteristics. Linear regression relating self-report with objective measures was used to develop calibration equations. Self-report underestimated sodium intake by 19.8% and 20.8% and potassium intake by 1.3% and 4.6% in men and women, respectively. Sodium intake underestimation varied by Hispanic/Latino background (P<0.05) and was associated with higher body mass index (BMI). Potassium intake underestimation was associated with higher BMI, lower restaurant score (indicating lower consumption of foods prepared away from home and/or eaten outside the home) and supplement use. The R2 was 19.7% and 25.0% for the sodium and potassium calibration models, respectively, increasing to 59.5 and 61.7% after adjusting for within-person variability in each biomarker. These calibration equations, corrected for subject-specific reporting error, have the potential to reduce bias in diet-disease associations within this largest cohort of Hispanics in the United States.

Applying recovery biomarkers to calibrate self-report measures of sodium and potassium in the hispanic community health study/study of latinos.

This corrects the article DOI: 10.1038/jhh.2016.98.

Myocardial infarction in treated hypertensive patients: the paradox of lower incidence but higher mortality in young blacks compared with whites.

BACKGROUND: Despite the impressive decline in coronary heart disease death rates, a mortality differential between blacks and whites persists. Our study objective was to determine whether excess mortality among well-controlled hypertensive black men compared with whites is due to differences in disease incidence or in case fatality. METHODS AND RESULTS: Of 3382 male subjects (1266 blacks and 2116 whites) enrolled between 1973 and 1996 and followed up through 1997 in a work-site hypertension control program, 2343 were followed up until 60 years of age, and 1884 were followed up until >60 years of age (either continuing after 60 years [n=845] or beginning treatment at >/=60 years [n=1039]), with a mean follow-up of 5.2 and 5.5 years, respectively. During follow-up, 186 myocardial infarction (MI) events (including 31 revascularizations) occurred, with 63 in patients <60 years and 123 in patients >/=60 years of age. Age-adjusted MI incidence was nearly twice as high for whites as blacks in younger (6.3 versus 3.4/1000 person-years) and older (14.1 versus 7.5 person-years) subjects. In contrast, the age-adjusted case fatality rate was 3-fold higher for younger blacks than for whites (37.8% versus 12.2%). In older patients, case fatality did not differ significantly between blacks and whites (37.6% versus 50. 3%). In separate Cox regression analyses, among younger blacks but not younger whites, history of diabetes and smoking were significantly associated with both incidence and fatality. CONCLUSIONS: In these treated male hypertensive patients with good blood pressure control (139.6/85.7 mm Hg), young blacks, despite a lower MI incidence, had higher MI mortality than did their white counterparts. Their higher case fatality rate was associated with fewer coronary artery revascularizations and a higher prevalence of diabetes and smoking.

Relation of blood pressure and body build to left ventricular mass in normotensive and hypertensive employed adults.

Left ventricular muscle mass is increased in the presence of large body size, high blood pressure and obesity, but the relative contributions to ventricular mass of these and other factors have not been elucidated. Accordingly, echocardiographic left ventricular mass in unmedicated employed adults (162 normotensive, 145 borderline hypertension and 317 with established essential hypertension) was related to height, weight, lean body mass, body mass index, systolic and diastolic blood pressure, age, gender, race and 24 h urinary sodium and potassium excretion. In the total population, body mass index, systolic blood pressure and height were the most significant (p less than 0.0001) independent correlates of left ventricular mass, whereas gender and age made smaller contributions. In each normotensive and hypertensive subgroup, body mass index and height remained highly significant independent predictors of left ventricular mass, systolic blood pressure became a weaker predictor (0.001 less than p less than 0.02) and only among patients with established hypertension was diastolic blood pressure a weak independent determinant (p less than 0.05) of ventricular mass. The increase in left ventricular mass attributable to obesity was due to eccentric hypertrophy because end-diastolic relative wall thickness was similar in obese and nonobese subjects in each blood pressure group. Thus obesity, as measured by body mass index, is as important a potential determinant of left ventricular muscle mass as is systolic blood pressure and it is of greater statistical significant in an adult employed population than is diastolic blood pressure, height, gender, age or dietary sodium intake.

The prevalence and correlates of echocardiographic left ventricular hypertrophy among employed patients with uncomplicated hypertension.

To determine the prevalence and correlates of echocardiographic left ventricular hypertrophy among subjects in a general population, we studied 621 employed subjects. Patients with uncomplicated essential hypertension in a worksite-based treatment program included 145 with borderline hypertension and 316 with sustained hypertension by World Health Organization criteria. Normotensive subjects were randomly selected from members of the same unions. M-mode echocardiographic left ventricular dimensions were used to calculate left ventricular mass and other indexes of left ventricular anatomy. The specificity of 13 echocardiographic criteria of left ventricular hypertrophy was determined in normotensive individuals, and the prevalence of left ventricular hypertrophy by each criterion was assessed in patients with borderline or sustained essential hypertension. The results suggest that the most suitable reference standard for detection of left ventricular hypertrophy in a heterogeneous urban population utilizes sex-specific cutoff values for left ventricular mass index of 110 g/m2 or greater for women and 134 g/m2 or greater for men. With 97% specificity, the prevalence of left ventricular hypertrophy by these criteria is approximately 12% among patients with borderline hypertension and 20% among patients with relatively mild, uncomplicated sustained essential hypertension. Wall thickness measurements performed slightly less well. At similar levels of blood pressure, black patients were more likely than white patients to exhibit concentric left ventricular hypertrophy, especially among borderline hypertensive patients. Left ventricular hypertrophy occurred in patients with sustained hypertension who also exhibited increased cardiac output, strongly associated with low plasma renin activity.

Left ventricular mass and body size in normotensive children and adults: assessment of allometric relations and impact of overweight.

OBJECTIVES: This study was designed to determine the most appropriate method to normalize left ventricular mass for body size. BACKGROUND: Left ventricular mass has been normalized for body weight, surface area or height in experimental and clinical studies, but it is uncertain which of these approaches is most appropriate. METHODS: Three normotensive population samples--in New York City (127 adults), Naples, Italy (114 adults) and Cincinnati, Ohio (444 infants to young adults)--were studied by echocardiography. Relations of left ventricular mass to body size were similar in all normal weight groups, as assessed by linear and nonlinear regression analysis, and results were pooled (n = 611). RESULTS: Left ventricular mass was related to body weight to the first power (r = 0.88), to body surface area to the 1.5 power (r = 0.88) and to height to the 2.7 power (r = 0.84), consistent with expected allometric (growth) relations between variables with linear (height), second-power (body surface area) and volumetric (left ventricular mass and body weight) dimensions. Strong residual relations of left ventricular mass/body surface area to body surface area (r = 0.54) and of ventricular mass/height to height (r = 0.72) were markedly reduced by normalization of ventricular mass for height2.7 and body surface area1.5. The variability among subjects of ventricular mass was also reduced (p < 0.01 to p < 0.002) by normalization for body weight, body surface area, body surface area1.5 or height2.7 but not for height. In 20% of adults who were overweight, ventricular mass was 14% higher (p < 0.001) than ideal mass predicted from observed height and ideal weight; this increase was identified as 14% by left ventricular mass/height2.7 and 9% by ventricular mass/height, whereas indexation for body surface area, body surface area1.5 and body weight erroneously identified left ventricular mass as reduced in overweight adults. CONCLUSIONS: Normalizations of left ventricular mass for height or body surface area introduce artifactual relations of indexed ventricular mass to body size and errors in estimating the impact of overweight. These problems are avoided and variability among normal subjects is reduced by using left ventricular mass/height2.7. Simple nomograms of the normal relation between height and left ventricular mass allow detection of ventricular hypertrophy in children and adults.

Assessment of left ventricular function by the midwall fractional shortening/end-systolic stress relation in human hypertension.

OBJECTIVES: This study examined left ventricular performance in relatively unselected hypertensive patients by use of physiologically appropriate midwall shortening/end-systolic stress relations. BACKGROUND: Supranormal left ventricular function has been reported in hypertensive patients, possibly due to an artifact of mismatching endocardial rather than midwall fractional shortening to mean left ventricular end-systolic stress. METHODS: Samples of 474 hypertensive patients (150 women, 324 men) and 140 normal subjects (68 women, 72 men) were drawn from a large urban employed population. The inverse relations (p < 0.0001) of both echocardiographic endocardial and midwall fractional shortening to end-systolic stress in normal subjects were used to calculate the ratios of observed to predicted endocardial and midwall fractional shortening in hypertensive patients. Midwall shortening was calculated from an elliptic model, taking into account the epicardial migration of the midwall during systole. RESULTS: Use of midwall fractional shortening in hypertensive patients reduced the proportion of patients with function above the 95th percentile of normal from 22% to 4% (p < 0.0001) and fractional shortening as a percent of predicted from 107% (p < 0.001 vs. 100% in normotensive control subjects) to 95% (p < 0.0001; p < 0.001 vs. 101% in normotensive control subjects). Midwall shortening was below the 5th percentile of normal in 16% of hypertensive patients instead of 2% with endocardial shortening (p < 0.0001): They tended to be older than other hypertensive patients and had concentric left ventricular hypertrophy. Among hypertensive patients, those with concentric left ventricular hypertrophy or remodeling had reduced midwall shortening as a percent of predicted from end-systolic stress (p < 0.0001). CONCLUSIONS: Use of the physiologically more appropriate midwall shortening/end-systolic stress relation 1) markedly reduces the proportion of hypertensive subjects identified as having high endocardial left ventricular function; and 2) identifies a substantial subgroup of patients with reduced left ventricular function who have concentric geometry of the left ventricle, a pattern associated with high cardiovascular risk.

Standardization of M-mode echocardiographic left ventricular anatomic measurements.

To improve standardization of echocardiographic left ventricular anatomic measurements, echographic left ventricular dimensions and mass were related to body size indexes, sex, age and blood pressure. Independent normal populations comprised 92 hospital-based subjects (64 women, 28 men) and 133 subjects from a population sample (55 women, 78 men). All measurements of chamber size, wall thickness and mass differed between men and women in both series (p less than 0.01 to p less than 0.001). Left ventricular mass was related most closely to body surface area among measurements of body size (r = 0.37, p less than 0.01 to r = 0.57, p less than 0.001) in all four groups. Indexation by body surface area eliminated sex differences in wall thicknesses and internal dimension, but a significant sex difference in left ventricular mass index persisted (89 +/- 21 g/m2 in men versus 69 + 19 g/m2 in women in the entire series, p less than 0.0001). The 97th percentile of left ventricular mass index was identical in both groups of men (136 and 132 g/m2) and women (112 and 109 g/m2). A highly significant difference in lean body mass, estimated from 24 hour urine creatine excretion, was observed between men and women (58 +/- 15 versus 40 +/- 13 kg, p less than 0.001) and no sex difference existed in left ventricular mass indexed by lean body mass (3.4 +/- 1.3 versus 3.5 +/- 1.5 g/kg). Weak correlations were observed between left ventricular mass/lean body mass and systolic or diastolic blood pressure (r = 0.25, p less than 0.05 and r = 0.28, p less than 0.01, respectively) but not age (18 to 72 years).(ABSTRACT TRUNCATED AT 250 WORDS)

The potential effect of blood pressure reduction on cardiovascular disease. A cautionary note.

The risk of cardiovascular disease (CVD) at various levels of systolic blood pressure (BP) and the potential benefit of BP reduction have been estimated by constructing probability tables for extended periods based on the Framingham Study data. These estimates demonstrate that systolic BP alone delineates subgroups of persons with widely divergent risk of CVD, depending both on their demographic and clinical characteristic. For example, the disparity in prognosis is such that some persons with a systolic BP of 160 mm Hg are at greater risk of subsequent CVD than others with a systolic BP of 195 mm Hg. The potential benefit to be derived from systolic BP reduction shows similarly wide variation, so initial pressure alone does not precisely predict the gain that might accompany BP reduction. Measures of greater prognostic value are needed to enhance the value of BP determination.

Treatment of hypertension at the university medical clinic.

The treatment of high blood pressure at the general medical clinic of a traditionally oriented university hospital was found to be unsatisfactory for most patients. Charts of all hypertensive patients (diastolic blood pressure, greater than or equal to 105 mm Hg) who made their first clinic visit in 1964 or 1971 were reviewed. Half of all patients were lost to follow-up within the first year, and blood pressure control was achieved by only one third of the patients. New information contained in the Veterans Administration study reports (1967 and 1970) had no effect on workup, compliance, or blood pressure decline. Furthermore, no significant relationship was found between blood pressure reduction and medical process, therapeutic regimens, or patient compliance. These data suggest that, in contrast to experience obtained in programs specifically designed for long-term management of this chronic disease, the present-day general medical clinic cannot satisfy the needs of most hypertensive patients.

Differences in urinary albumin excretion rate between normotensive and hypertensive, white and nonwhite subjects.

Eighty-one normotensive and 61 hypertensive white and nonwhite subjects were studied cross-sectionally to determine the prevalence and determinants of elevated urinary albumin levels. Twenty-four-hour urinary albumin excretion was determined by radioimmunoassay. The prevalence of elevated urinary albumin level (greater than or equal to 15 mg/24 h) was significantly greater in hypertensive than in normotensive subjects (31.1% and 8.6%). Among hypertensive subjects, a much greater proportion of whites than nonwhites had urinary albumin levels of 15 mg/24 h or greater (39.5% and 17.4%). The independent association of blood pressure with urinary albumin level was affirmed by logistic regression analyses for white normotensive and hypertensive subjects combined, and for hypertensive subjects alone. Furthermore, among hypertensive subjects, whites were five times as likely as nonwhites to have elevated urinary albumin levels. Thus, blood pressure and ethnicity were the important determinants of urinary albumin excretion among hypertensive subjects.

Antihypertensive drug therapy withdrawal in a general population.

To determine the fraction of all hypertensives who can be successfully withdrawn from antihypertensive medication, a study was conducted of a patient group originally drawn from a screened population of union members. Of 157 patients, 88 (56.1%) met preestablished blood pressure criteria for drug interruption, and 66 (75%) actually had medication withdrawn. Of these 66 patients, 69.8% and 54.5% followed up for one and two years, respectively, remained normotensive. Patients requiring reintroduction of antihypertensive therapy were distinguished from those remaining drug free by increased systolic blood pressure (141.4 +/- 13.2 vs 131.6 +/- 8.6 mm Hg) after one month. Extrapolation of the finding that 28% of the study population remained normotensive one year after drug therapy withdrawal suggests the possibility that as many as 5 million Americans currently taking antihypertensive drugs could have therapy interrupted for at least one year and thus avoid both the hazards and costs of drug therapy.

Therapeutic benefits of ACE inhibitors and other antihypertensive drugs in patients with type 2 diabetes.

OBJECTIVE: To assess whether ACE inhibitors are superior to alternative agents for the prevention of cardiovascular events in patients with hypertension and type 2 diabetes. RESEARCH DESIGN AND METHODS: This study is a review and meta-analysis of randomized controlled trials that included patients with type 2 diabetes and hypertension who were randomized to an ACE inhibitor or an alternative drug, were followed for > or =2 years, and had adjudicated cardiovascular events. RESULTS: A total of 4 trials were eligible. The Appropriate Blood Pressure Control in Diabetes (ABCD) trial (n = 470) compared enalapril with nisoldipine, the Captopril Prevention Project (CAPPP) (n = 572) compared captopril with diuretics or beta-blockers, the Fosinopril Versus Amlodipine Cardiovascular Events Trial (FACET) (n = 380) compared fosinopril with amlodipine, and the U.K. Prospective Diabetes Study (UKPDS) (n = 758) compared captopril with atenolol. The cumulative results of the first 3 trials showed a significant benefit of ACE inhibitors compared with alternative treatments on the outcomes of acute myocardial infarction (63% reduction, P < 0.001), cardiovascular events (51% reduction, P < 0.001), and all-cause mortality (62% reduction, P = 0.010). These findings were not observed in the UKPDS. The ACE inhibitors did not appear to be superior to other agents for the outcome of stroke in any of the trials. None of the findings were explained by differences in blood pressure control. CONCLUSIONS: Compared with the alternative agents tested, ACE inhibitors may provide a special advantage in addition to blood pressure control. The question of whether atenolol is equivalent to captopril remains open. Conclusive evidence on the comparative effects of antihypertensive treatments will come from large prospective randomized trials.

Increased risk of bacterial pneumonia in HIV-infected intravenous drug users without AIDS.

Although patients with AIDS have been noted to be at risk for bacterial pneumonia as well as opportunistic infections, little is known about the risk of bacterial pneumonia in HIV-infected populations without AIDS. To determine the incidence of bacterial pneumonia in a well defined population of intravenous drug users (IVDUs), and to examine any association with HIV infection, we prospectively studied 433 IVDUs without AIDS, enrolled in a longitudinal study of HIV infection in an out-patient methadone maintenance program. At enrollment, 144 (33.3%) subjects were HIV-seropositive, 289 (66.7%) were seronegative. Over a 12-month period, 14 out of 144 (9.7%) seropositive subjects were hospitalized for community-acquired bacterial pneumonia, compared with six out of 289 (2.1%) seronegative subjects. The cumulative yearly incidence of bacterial pneumonia was 97 out of 1000 for seropositives and 21 out of 1000 for seronegatives (risk ratio = 4.7, P less than 0.001). Eleven out of 14 (78.6%) cases among the seropositive patients were due to either Streptococcus pneumoniae [5] or Hemophilus influenzae [6]. Two out of 14 (14.3%) cases among the seropositives were fatal. Stratifying by level of intravenous drug use indicated that even among subjects not reporting active intravenous drug use at study entry, eight out of 82 (9.8%) seropositives compared with three out of 211 (1.4%) seronegatives were hospitalized for bacterial pneumonia over the study period (risk ratio = 6.9, P less than 0.01). This study shows a markedly increased incidence of bacterial pneumonia associated with HIV infection in IVDUs without AIDS.(ABSTRACT TRUNCATED AT 250 WORDS)

Trend of stroke hospitalization, United States, 1988-1997.

BACKGROUND AND PURPOSE: Age-adjusted stroke mortality in the United States has declined in recent decades. However, the course of stroke incidence is less certain. To address this issue, we determined trends of stroke hospitalization and in-hospital case fatality during 1988-1997. METHODS: Stroke hospitalization was estimated from National Hospital Discharge Survey as numerator and Current Population Survey as denominator. Hospitalization rates were determined and stratified by patient characteristics. Average length of hospital stay was also determined. In-hospital mortality was specified by sex, age, and other patient characteristics. The change in these rates over 10 years and average annual percent changes were calculated. RESULTS: During 1988-1997, age-adjusted stroke hospitalization rate increased 18.6% (from 560 to 664/100 000; P=0.043), while total hospitalization increased from 592 811 to 821 760. This increase was limited to persons aged >/=65 years. Patients in the South had the highest stroke hospitalization rates, and those in the West had the lowest. Overall, 58% of strokes were classified as ischemic, 13% as hemorrhagic, and 29% as other. Over these 10 years, stroke patients having coincident diabetes, hypertension, and congestive heart failure increased 17.4% (P=0.17), 34% (P=0.05), and 31% (P=0.091), respectively. The average length of hospital stay fell from 11.1 to 6.2 days (44.1%; P=0.012). As a result, despite an increase in hospitalizations for stroke, the total person-days in hospital actually decreased by 22% (P=0.06). CONCLUSIONS: The declining age-adjusted stroke mortality in the United States has not been accompanied by a fall in hospitalization over recent years. Thus far, however, decrease in length of stay has more than offset increased admission. At the same time, the sharp drop in hospital case fatality rates suggests that continuing decline in stroke mortality may be due, in large part, to improved survival after acute stroke.

Management of the hypertensive patient: a continuing dilemma.

The proper management of mild and moderate hypertension remains a matter of considerable professional disagreement. Major clinical and population research has largely been designed to define a level of blood pressure (BP) at which treatment should be initiated. This paper reviews studies of the natural history of hypertension and the findings of intervention trials to determine whether the BP level alone is adequate to identify, diagnose, and predict the future course of hypertensive patients. Observational data suggest that patients defined by mild elevation of BP are a heterogeneous group who do not share a common prognosis. Moreover, intervention trials reveal that not all those at risk of cardiovascular disease will benefit from hypotensive therapy. Thus, BP level alone defines neither the group at risk nor those likely to benefit from BP reduction. It is therefore concluded that the management of each patient with hypertension should be determined on the basis of available clinical, biochemical, and behavioral as well as epidemiological data.

Reduction of cardiovascular disease events by worksite hypertension treatment.

A retrospective cohort study of hypertensive employees to evaluate the impact of worksite antihypertensive treatment (WST) on cardiovascular disease (CVD) over 8 1/2 years is reported. In a union-sponsored screening from August 1973 to February 1974, 604 hypertensives (greater than or equal to 160 and/or 95 mm Hg, or on medication) were identified. Of these, standardized criteria were met by 344, of whom 150 chose WST and 194 referred care (RC). The study groups were similar in age and sex composition. Union hospitalization and death records through 1982 revealed that CVD rates were fewer in WST than RC (3.0 vs 5.4/100 person-years; p less than 0.01). By contrast, nonCVD rates were similar (8.1 vs 9.6). All-cause mortality rate in WST (0.89) was significantly (p less than 0.05) lower than that in RC (1.81), as was the standard mortality ratio (55.1), based on U.S. mortality in 1978. CVD mortality was also lower (0.48 vs 1.10; NS). Persons with an initial blood pressure (BP) less than 160/95 mm Hg had CVD event rates that were low and similar in WST and RC (3.6 vs 3.5). However, among those with elevated BP at entry, WST subjects fared significantly better than RC (2.8 vs 6.1; p less than 0.001). Furthermore, in WST, previously treated patients with elevated BP at screening experienced one-third the CVD morbidity of their counterparts in RC (3.1 vs 10.8; p less than 0.01). These results extend previous evidence that WST is an effective method to achieve BP control and demonstrate that this approach to the management of hypertension alters health outcomes favorably and significantly.

Diabetes and cardiovascular events in hypertensive patients.

To determine the relation of self-reported history of diabetes as well as baseline and in-treatment blood sugar to subsequent cardiovascular disease (CVD) in treated hypertensive patients, we assessed the experience of 6886 participants in a systematic treatment program. The presence or absence of a history of diabetes was known for all patients, who were then stratified into 3 groups according to blood sugar at baseline and in treatment (<6.11, 6.11 to 7.74, and >/=7.75 mmol/L). Some 7.4% of all patients reported history of diabetes, and the overall prevalence of blood sugar >/=7. 75 mmol/L was 7.7% and 10.4% at baseline and in treatment, respectively. Patients with a history of diabetes were 10 or 8 times as likely to have blood sugar >/=7.75 mmol/L at baseline (47.2% versus 4.5%) or in treatment (55.0% versus 6.8%), as were patients without history. During an average 6.3 years of follow-up, patients with history of diabetes had a cardiovascular event incidence 2-fold higher than those without history (20.8 versus 8.6/1000 person-years). Age-gender-adjusted CVD incidence rate but not non-CVD was twice as high in the highest compared with the lowest blood sugar stratum (baseline 16.6 versus 8.4/1000 person-years; in treatment 15.2 versus 8.2). Three separate models of Cox multivariate analysis revealed that history of diabetes (with no history as reference) had a greater association with CVD events (hazard ratio 2.37, 95% confidence interval 1.80 to 3.11) than did baseline (1.75, 1.31 to 2.33) or in-treatment blood sugar (1.55, 1. 19 to 2.02). Furthermore, in the presence of history of diabetes (2. 15, 1.58 to 2.92), neither baseline nor in-treatment blood sugar was independently associated with CVD risk. In the elevated (>/=7.75 mmol/L) in-treatment blood sugar group, the age-gender-adjusted rate of CVD events in frequent diuretic users (30.79/1000 person-years) was significantly higher than in moderate (13.34, P=0.004) and rare users (13.25, P=0.008). These data affirm that the coincidence of diabetes and hypertension is common, that evidence of diabetes substantially increases CVD risk, that self-reported history is a more powerful predictor of CVD events than any measure of blood sugar, and that CVD increases in hypertensive diuretic users who develop hyperglycemia even when blood pressure is well controlled.

Profile of hypertensives as a determinant of long-term antihypertensive medication needs.

The experience of 110 hypertensives who participated in a worksite stepped-care treatment program has been examined to draw a patient profile at entry that would determine medication needs on a long-term basis. Patients entered untreated with a blood pressure (BP) level of greater than or equal to 160 mm Hg systolic and/or greater than or equal to 95 mm HG diastolic (DBP) and had a minimum follow-up of 1 year. Treatment was initiated with diuretics, and additional drugs were added as necessary to achieve BP control. Patients were divided into three groups according to initial DBP levels: Group A (33 patients, greater than or equal to 105 mm Hg), Group B (43 patients, 95-104 mm Hg), and Group C (34 patients, less than 95 mm Hg). Using a life table method, we analyzed the therapeutic experience of these patients to obtain 5-year cumulative rates of adding a second drug to diuretics. Within the first 2 years of treatment, the cumulative rates were: 64% in Group A, 33% in Group B, and 23% in Group C. In all three groups the rates after the second year remained stable. This stepped-care approach resulted in BP control (less than 160/95) which ranged from 78% in the first year to 96% in the fifth year. Findings suggest that initial DBP level and age are principal factors in determining medication needs. Furthermore, at higher DBP levels, younger nonwhite and younger white males are most likely to require a second drug within the first year of treatment. The need for a second drug is apparent within the first 2 years.

Relation of pulse pressure and blood pressure reduction to the incidence of myocardial infarction.

The prognostic value of pretreatment pulse pressure as a predictor of myocardial infarction and the relation of pulse pressure and in-treatment diastolic blood pressure reduction to myocardial infarction were investigated in a union-sponsored systematic hypertension control program. In a prospective study, 2207 hypertensive patients with a pretreatment systolic blood pressure greater than or equal to 160 mm Hg and/or diastolic pressure greater than or equal to 95 mm Hg grouped according to tertile of pulse pressure (PP1, < or = 46; PP2, 47 to 62; PP3, > or = 63 mm Hg) were further stratified by the degree of diastolic fall: large (L), > or = 18; moderate (M), 7 to 17; small (S), < or = 6 mm Hg. During an average follow-up of 5 years, 132 cardiovascular events (50 myocardial infarctions, 23 strokes) were observed. Myocardial infarction rates per 1000 person-years were positively related to pulse pressure (PP1, 3.5; PP2, 2.9; PP3, 7.5; PP3 versus PP1, P = .02). Wide pulse pressure was identified as a predictor of myocardial infarction (PP3 versus [PP1 + PP2]: relative risk [RR] = 2.2, 95% confidence interval [CI] = 1.2-4.1), controlling for other known risk factors by Cox regression. A curvilinear relation (resembling a J shape) between diastolic fall and myocardial infarction was observed in patients with the widest pulse pressure, PP3 (L, 9.5; M, 3.9; S, 11.2; L versus M: RR = 2.5, 95% CI = 1.0-6.2; S versus M: RR = 2.9, 95% CI = 1.1-8.0).(ABSTRACT TRUNCATED AT 250 WORDS)