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The National High Blood Pressure Education Program (NHBPEP) was launched 20 years ago based on data from population studies and clinical trials that showed high blood pressure (HBP) was a major unsolved--but soluble--mass public health problem. The present review summarizes recent data from US prospective population studies on blood pressure--systolic (SBP), diastolic (DBP)--and cardiovascular risk. The outcome variables include blood pressure-related risks, primarily incidence and mortality from coronary heart disease, stroke, other and all cardiovascular diseases (CVD); also cardiac abnormalities (roentgenographic, electrocardiographic, echocardiographic); also, all-cause mortality and life expectancy. Data accrued during the past 20 years confirm that SBP and DBP have continuous, graded, strong, independent, etiologically significant relationships to the outcome variables. These relationships are documented for young, middle-aged, and older men and for middle-aged and older women of varying socioeconomic backgrounds and ethnicity. Among persons aged 35 years or more, most have SBP/DBP above optimal (120/80 mm Hg); hence, they are at increased CVD risk, ie, the blood pressure problem involves most of the population, not only the substantial minority with clinical HBP. For middle-aged and older persons, SBP relates even more strongly to risk than DBP; at every DBP level, higher SBP results in greater CVD risk and curtailment of life expectancy. A great potential exists for improved health and increased longevity through control of the blood pressure problem. Its realization requires a strategy combining population wide and high-risk approaches, the former to prevent rise of blood pressure with age and to achieve primary prevention of HBP by nutritional-hygienic means; the latter to enhance detection, treatment, and control of HBP. The newly expanded goals of the NHBPEP, aimed at implementing this broader strategy for the solution of the blood pressure problem, merit active support from physicians and all health professionals.

Health care costs are generally highest in the year before death, and much attention has been directed toward reducing costs for end-of-life care. However, it is unknown whether cardiovascular risk profile earlier in life influences health care costs in the last year of life. This study addresses this question.Prospective cohort of adults from the Chicago Heart Association Detection Project in Industry included 6582 participants (40% women), aged 33 to 64 years at baseline examination (1967-1973), who died at ages 66 to 99 years. Medicare billing records (1984-2002) were used to obtain cardiovascular disease-related and total charges (adjusted to year 2002 dollars) for inpatient and outpatient services during the last year of life. Participants were classified as having favorable levels of all major cardiovascular risk factors (low risk), that is, serum cholesterol level lower than 200 mg/dL (5.2 mmol/L), blood pressure 120/80 mm Hg or lower and no antihypertensive medication, body mass index (calculated as weight in kilograms divided by the square of height in meters) lower than 25, no current smoking, no diabetes, and no electrocardiographic abnormalities, or unfavorable levels of any 1 only, any 2 only, any 3 only, or 4 or more of these risk factors.In the last year of life, average Medicare charges were lowest for low-risk persons. For example, cardiovascular disease-related and total charges were lower by 10,367 dollars and 15,318 dollars compared with those with 4 or more unfavorable risk factors; the fewer the unfavorable risk factors, the lower the Medicare charges (P for trends.001). Analyses by sex showed similar patterns.Favorable cardiovascular risk profile earlier in life is associated with lower Medicare charges at the end of life.

The magnitude of coronary mortality risk associated with diabetes or prior myocardial infarction (MI) is debatable. Modulating effects of age, risk factors, and duration of follow-up may explain discrepancies in previous research. Associations with noncardiovascular mortality are little explored.To compare mortality patterns in men with a history of diabetes or MI and to assess modulating effects on mortality of age, cardiovascular risk factors, and follow-up duration.We compared the 25-year mortality of 4809 men with diabetes only and 4625 men with MI only (all men aged 35-57 years).The adjusted hazard ratio (HR) for all-cause mortality for those with MI only vs those with diabetes only was 0.97 (95% confidence interval, 0.92-1.03; P =.32). The pattern of deaths was different: higher coronary mortality (HR = 1.37; P.001) and lower mortality from noncardiovascular causes (HR = 0.66; P.001) in those with MI only compared with those with diabetes only. This finding prevailed across all ages and levels of cardiovascular risk factors. Hazard ratios for coronary mortality significantly declined over follow-up (2.7, 1.7, 1.2, 1.1, and 1.0 foror =5, 6-10, 11-15, 16-20, and20 years of follow-up, respectively), whereas HRs for noncardiovascular mortality remained relatively constant.Overall, diabetes and MI were similarly strong predictors of total mortality. Higher mortality from noncardiovascular causes was observed in those with diabetes only, whereas prior MI was more strongly predictive of coronary mortality than diabetes at any age and level of cardiovascular risk factors. The difference in coronary mortality between the 2 groups was most evident in the first 10 years of follow-up.

Background It remains unclear whether hypertriglyceridemia is an independent risk factor for coronary heart disease (CHD), and whether fasting and nonfasting triglyceride (TG) levels are equally predictive. Methods A total of 2809 (of 12 866) men randomized during 1973 through 1975 into the Multiple Risk Factor Intervention Trial with fasting and nonfasting TG levels measured at baseline were followed up for CHD incidence and death. Proportional hazards regression models were used to assess associations of fasting and nonfasting TG levels with CHD. Results Average fasting and nonfasting TG levels were 187 and 284 mg/dL (2.11 and 3.21 mmol/L), respectively. Prevalence of hypertriglyceridemia (200 mg/dL [2.26 mmol/L] or more) was 31% for fasting and 61% for nonfasting. There were 175 nonfatal or fatal CHD events during 8 years and 328 CHD deaths during 25 years. Compared with TG levels less than 200 mg/dL, risk factor–adjusted hazard ratios for CHD mortality for hypertriglyceridemia were 1.24 (P= .09) for fasting and 1.26 (P= .07) for nonfasting. For nonfatal or fatal CHD, fasting and nonfasting TG levels were similarly predictive with hazard ratios of 1.64 (P= .004) for fasting and 1.46 (P= .03) for nonfasting. These associations for fasting TG levels were assessed to be underestimated by 56% because of regression dilution bias, with attenuation likely greater for nonfasting TG levels. Conclusions Greater ease of obtaining nonfasting than fasting measurements, greater prevalence of hypertriglyceridemia with nonfasting than fasting values, and similarly increased risk with each indicate that nonfasting TG levels may be more useful than fasting ones for risk stratification.

The appropriateness of current cardiovascular disease (CVD) risk factor guidelines in women continues to be debated.To present new data on the appropriateness of current CVD risk factor guidelines, for women and men, from long-term follow-up of a large population sample.Cardiovascular disease risk factor status according to current clinical guidelines and long-term impact on mortality were determined in 8686 women and 10503 men aged 40 to 64 years at baseline from the Chicago Heart Association Detection Project in Industry; average follow-up was 22 years.At baseline, only 6.6% of women and 4.8% of men had desirable levels for all 3 major risk factors (cholesterol level,5.20 mmol/L [200 mg/dL]; systolic and diastolic blood pressure,120 and80 mm Hg, respectively; and nonsmoking). With control for age, race, and other risk factors, each major risk factor considered separately was associated with increased risk of death for women and men. In analyses of combinations of major risk factors, risk increased with number of risk factors. Relative risks (RRs) associated with any 2 or all 3 risk factors were similar: for coronary heart disease mortality in women, RR= 5.72 (95% confidence interval [CI], 2.35-13.93), and in men, RR = 5.51 (95% CI, 3.10-9.77); for CVD mortality in women, RR = 4.54 (95% CI, 2.33-8.84), and in men, RR = 4.12 (95% CI, 2.56-6.37); and for all-cause mortality in women, RR = 2.34 (95% CI, 1.73-3.15), and in men, RR = 3.20 (95% CI, 2.47-4.14). Absolute excess risks were high in women and men with any 2 or all 3 major risk factors.Combinations of major CVD risk factors place women and men at high relative, absolute, and absolute excess risk of coronary heart disease, CVD, and all-cause mortality. These findings support the value of (1) measurement of major CVD risk factors, especially in combination, for assessing long-term mortality risk and (2) current advice to match treatment intensity to the level of CVD risk in both women and men.

BACKGROUND: Findings from epidemiological studies suggest an inverse relationship between individuals’ protein intake and their blood pressure. METHODS: Cross-sectional epidemiological study of 4680 persons, aged 40 to 59 years, from 4 countries. Systolic and diastolic blood pressure was measured 8 times at 4 visits. Dietary intake based on 24-hour dietary recalls was recorded 4 times. Information on dietary supplements was noted. Two 24-hour urine samples were obtained per person. RESULTS: There was a significant inverse relationship between vegetable protein intake and blood pressure. After adjusting for confounders, blood pressure differences associated with higher vegetable protein intake of 2.8% kilocalories were −2.14 mm Hg systolic and −1.35 mm Hg diastolic (P

Background The magnitude of coronary mortality risk associated with diabetes or prior myocardial infarction (MI) is debatable. Modulating effects of age, risk factors, and duration of follow-up may explain discrepancies in previous research. Associations with noncardiovascular mortality are little explored. Objectives To compare mortality patterns in men with a history of diabetes or MI and to assess modulating effects on mortality of age, cardiovascular risk factors, and follow-up duration. Methods We compared the 25-year mortality of 4809 men with diabetes only and 4625 men with MI only (all men aged 35-57 years). Results The adjusted hazard ratio (HR) for all-cause mortality for those with MI only vs those with diabetes only was 0.97 (95% confidence interval, 0.92-1.03; P = .32). The pattern of deaths was different: higher coronary mortality (HR = 1.37; P P 20 years of follow-up, respectively), whereas HRs for noncardiovascular mortality remained relatively constant. Conclusions Overall, diabetes and MI were similarly strong predictors of total mortality. Higher mortality from noncardiovascular causes was observed in those with diabetes only, whereas prior MI was more strongly predictive of coronary mortality than diabetes at any age and level of cardiovascular risk factors. The difference in coronary mortality between the 2 groups was most evident in the first 10 years of follow-up.

Background Life expectancy is greater for people with favorable midlife cardiovascular risk profiles (ie, low risk). However, some speculate that increased longevity may lead to large numbers of ill, disabled, older persons with lower quality of life. Few data exist on this important issue. This study evaluates the relationship of midlife low-risk status to quality of life and illness in older age. Methods Cohort of middle-aged adults from the Chicago Heart Association Detection Project in Industry (2692 women and 3650 men; baseline ages, 36-64 years [average age, 73.2 years in 1996]) without baseline (1967-1973) major electrocardiographic abnormalities or history of diabetes or myocardial infarction. Quality of life (12-item Health Status Questionnaire [HSQ-12] on physical, mental, and social well-being) and self-reported diseases were assessed after 26 years of follow-up. Baseline risk strata included low risk (favorable blood pressure and serum cholesterol levels, no smoking, and no minor electrocardiographic abnormalities); 0 risk factors (ie, no high risk factors but ≥1 risk factors not at favorable levels); or any 1, any 2, or 3 or more of the following 4 risk factors: high blood pressure, high serum cholesterol level, smoking, and minor electrocardiographic abnormalities. The HSQ-12 scores and disease outcomes for low risk were compared with other strata. Results Adjusted scores for physical, mental, social functioning, and disease-free outcomes were highest for low-risk individuals and decreased significantly with number of risk factors (eg, 58% of low-risk women had excellent/very good health compared with 28% of women with ≥3 risk factors). Conclusions Favorable cardiovascular risk profile in middle age is associated with better quality of life and lower risk of diseases in older age. Moreover, the fewer the risk factors, the higher the quality of life.

Overweight and obesity are associated with higher morbidity and shorter life expectancy, but the effect of body mass index (BMI) (calculated as weight in kilograms divided by the square of height in meters) ascertained during middle age on subsequent quality of life among older survivors is unknown. This study evaluates whether BMI in middle age is related to health-related quality of life in older age.This prospective cohort of adults from the Chicago Heart Association Detection Project in Industry included 6766 middle-aged men and women, aged 36 to 64 years, without diabetes mellitus or myocardial infarction at baseline (November 7, 1967-January 8, 1973), who completed a 26-year follow-up questionnaire in 1996 when they were 65 years and older. Relationships of baseline BMI (categories: normal weight, overweight, and obese) to mean 26-year follow-up Health Status Questionnaire 12 scores (measuring physical, mental, and social well-being) were assessed.For men and women, BMI had significant inverse-graded associations with all Health Status Questionnaire 12 scores (P.01 for trend for all). Scores (adjusted for baseline cardiovascular disease risk factors and 1996 age) were highest (best) in normal-weight individuals (BMI, 18.5-25.0) and decreased significantly (P range,.006-.001 for trend) with higher BMI, with worst outcomes for obese persons (BMI,or=30.0). A higher multivariate-adjusted percentage of normal-weight persons reported excellent or very good health compared with overweight and obese persons: for women, 46.8% vs 37.9% and 24.3%; and for men, 53.8% vs 49.1% and 36.5% (P.001 for trend).A higher BMI in middle age is associated with a poorer quality of life in older age. Preventive measures may lessen the burden of disease and impaired quality of life associated with excess weight.

Background: Data are limited on blood pressure (BP) in young adults and long-term mortality. Moreover, screening and hypertension treatment guidelines have been based mainly on findings for middle-aged and older populations. This study assesses relationships of BP measured in young adult men to long-term mortality due to coronary heart disease (CHD), cardiovascular diseases (CVD), and all causes. Methods: This cohort from the Chicago Heart Association Detection Project in Industry included 10 874 men aged 18 to 39 years at baseline (1967-1973), not receiving antihypertensive drugs, and without CHD or diabetes. Relationship of baseline BP to 25-year CHD, CVD, and all-cause mortality was assessed. Results: Age-adjusted association of systolic BP to CHD mortality was continuous and graded. Multivariateadjusted CHD hazard ratios (HRs) for 1 SD higher systolic BP (15 mm Hg) and diastolic BP (10 mm Hg) were 1.26 (95% confidence interval [CI], 1.11-1.44) and 1.17 (95% CI, 1.01-1.35), respectively. Compared with the Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure stratum with normal BP (and lowest mortality rates), the large strata with high-normal BP and stage 1 hypertension had 25-year absolute risks for death of 63 and 72 per 1000, respectively, and absolute excess risks of 10 and 20 per 1000, respectively; accounted for 59.8% of all excess CHD, CVD, and all-cause mortality; and were estimated to have life expectancy shortened by 2.2 and 4.1 years, respectively. Conclusions: In young adult men, BP above normal was significantly related to increased long-term mortality due to CHD, CVD, and all causes. Population-wide primary prevention, early detection, and control of higher BP are indicated from young adulthood on. Arch Intern Med. 2001;161:1501-1508

Background There are scant data on the effect of body mass index (BMI) (calculated as weight in kilograms divided by the square of height in meters) on cardiovascular events and death in older patients with hypertension. Objective To determine if low body mass in older patients with hypertension confers an increased risk of death or stroke. Patients Participants were 3975 men and women (mean age, 71 years) enrolled in 17 US centers in the Systolic Hypertension in the Elderly Program trial, a randomized, double-blind, placebo-controlled clinical trial of low-dose antihypertensive therapy, with follow-up for 5 years. Main Outcome Measures Five-year adjusted mortality and stroke rates from Cox proportional hazards analyses. Results There was no statistically significant relation of death or stroke with BMI in the placebo group ( P = .47), and there was a U- or J-shaped relation in the treatment group. The J-shaped relation of death with BMI in the treated group ( P = .03) showed that the lowest probability of death for men was associated with a BMI of 26.0 and for women with a BMI of 29.6; the curve was quite flat for women across a wide range of BMIs. For stroke, men and women did not differ, and the BMI nadir for both sexes combined was 29, with risk increasing steeply at BMIs below 24. Those in active treatment, however, had lower death and stroke rates compared with those taking placebo. Conclusions Among older patients with hypertension, a wide range of BMIs was associated with a similar risk of death and stroke; a low BMI was associated with increased risk. Lean, older patients with hypertension in treatment should be monitored carefully for additional risk factors.

Background Evidence exists that cardiovascular risk factors influence progression toward end-stage renal failure. We tested the hypothesis that in nondiabetic middle-aged adults without macroalbuminuria, cardiovascular risk factors are related to urinary albumin excretion and prevalence of microalbuminuria, a sign of early nephropathy. Methods Cross-sectional analysis of data for 1567 participants in The Gubbio Population Study (677 men and 890 women), aged 45 to 64 years, without macroalbuminuria, without diabetes mellitus, and with fasting plasma glucose levels of less than 7.8 mmol/L (140 mg/dL). Data collection included albumin and creatinine excretion in timed overnight urine collection; levels of fasting plasma cholesterol, glucose, triglycerides, creatinine, and uric acid; creatinine clearance; red blood cell sodium-lithium countertransport; blood pressure; weight; height; medical history; smoking status; and alcohol intake. Urinary albumin excretion and prevalence of microalbuminuria were the dependent variables. Results Blood pressure, plasma cholesterol levels, smoking, and body mass index significantly related to urinary albumin excretion and prevalence of microalbuminuria. In analyses with control for multiple variables, relative risk for microalbuminuria (urinary albumin excretion, 20-199 µg/min) in men and women was 2.51 and 1.62, respectively, with 18 mm Hg higher (1 SD) systolic blood pressure; 2.25 and 2.10, respectively, with 1.0-mmol/L (40 mg/dL) higher plasma cholesterol level; 1.99 and 1.91, respectively, for smokers vs nonsmokers; and 1.83 and 1.33, respectively, with 4 kg/m 2 higher body mass index. Findings were similar for microalbuminuria defined as urinary albumin excretion of at least 25 µg/dL glomerular filtration rate. Conclusion Major cardiovascular risk factors are independent correlates of microalbuminuria in nondiabetic middle-aged adults.

Popkin calls attention to recent adverse trends of diet and physical activity in China and Japan. These should be of more than casual interest to American health practitioners, Continued on page 2253 Continued from page 2249 researchers, and policy makers. In addition to our appropriate general concern for international health, we need to comprehend that these adverse trends have their origins in part in the United States. In the modern era of rapid and extensive communication on a global scale, American culture affects the populations of all countries, influencing them to adopt multiple components of the American lifestyle, some worthwhile and some, unfortunately, deleterious. This happens in many ways—often subtle, but also obtrusive, eg, the impact of our movies, TV programs, advertising, exported fast-food emporia, as well as direct governmental pressures to accept products (such efforts for the US cigarette industry are especially shameful). In these circumstances, all of us

Our article 1 did not address the relationship between cholesterol lowering and risk of noncardiovascular death. We studied the relationship of a single cholesterol measurement to specific causes of death. It is likely that the association that we observed between the very low serum cholesterol level (

SUSTAINED CALORIC imbalance with consequent overweight has become the behavioral norm for the American population. This phenomenon is documented in the data from the US National Health and Examination Survey of 1976 through 1980 (NHANES-II), displayed in the article by Denke et al in this issue of theArchives. 1 Of the white men aged 20 to 74 years described there, an absolute majority had a body mass index (BMI) greater than 25.0 kg/m 2 , equivalent to more than 12% above desirable weight. 2 ("Normal" BMI has been described as between 20.0 and 25.0 kg/m 2 ). 3 This pattern of overweight was the consistent NHANES-II finding for white men aged 35 to 44 years on up, and similar results were recorded for black men. 4 While median BMI levels were slightly lower for younger white women, they exceeded 25.0 for those aged 55 to 74 years, and among black women

Background.— With increased efforts to lower serum cholesterol levels, it is important to quantify associations between serum cholesterol level and causes of death other than coronary heart disease, for which an etiologic relationship has been established. Methods.— For an average of 12 years, 350 977 men aged 35 to 57 years who had been screened for the Multiple Risk Factor Intervention Trial were followed up following a single standardized measurement of serum cholesterol level and other coronary heart disease risk factors; 21 499 deaths were identified. Results.— A strong, positive, graded relationship was evident between serum cholesterol level measured at initial screening and death from coronary heart disease. This relationship persisted over the 12-year follow-up period. No association was noted between serum cholesterol level and stroke. The absence of an association overall was due to different relationships of serum cholesterol level with intracranial hemorrhage and nonhemorrhagic stroke. For the latter, a positive, graded association with serum cholesterol level was evident. For intracranial hemorrhage, cholesterol levels less than 4.14 mmol/L ( Conclusions.— The association of serum cholesterol with specific causes of death varies in direction, strength, gradation, and persistence. Further research on the determinants of low serum cholesterol level in populations and long-term follow-up of participants in clinical trials are necessary to assess whether inverse associations with noncardiovascular disease causes of death are consequences of noncardiovascular disease, whether serum cholesterol level and noncardiovascular disease are both consequences of other factors, or whether these associations are causal. ( Arch Intern Med . 1992;152:1490-1500)

Introduction Many clinicopathologic studies have been performed which report the presence at autopsy of myocardial infarctions unsuspected during life. 2-5 From these studies the concept has evolved of painless, silent, occult, or asymptomatic myocardial infarction. In contrast to the wealth of necropsy material on painless myocardial infarction, there is a paucity of clinical reports describing totally asymptomatic myocardial infarction diagnosed during life. 6 This report presents three such cases, and offers an estimate of the incidence rate of totally asymptomatic myocardial infarction in our urban, white, middle-aged male population. Methods A comprehensive study was made of the case records of the medical department of a Chicago utility corporation for the four-year period 1954-1957. 7 During this period 756 male employees (737 white, 19 nonwhite) in the age group 50-59 as of Jan. 1, 1954, underwent a voluntary yearly medical review consisting of a complete history and physical examination, 14×17 roentgenogram

• A randomized controlled trial demonstrated the ability of nutritional intervention in place of antihypertensive drugs to maintain blood pressure at normal levels for four years in 39% of less severely hypertensive patients whose blood pressure was previously well controlled by pharmacologic treatment. However, average blood pressures during the trial for patients in the intervention group were higher than those for a comparison group that continued to receive drug therapy throughout the study. Holter monitoring, echocardiography, roentgenography, and electrocardiography done at four years to determine whether blood pressure differences between groups were associated with differences in cardiac status did not indicate any differences in cardiac status favorable to one group compared with the other. Further investigation in larger samples is needed to assess any long-term differences in cardiac status based on such alternate therapies. ( Arch Intern Med 1989;149:661-665)