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The 356 222 men aged 35 to 57 years, who were free of a history of hospitalization for myocardial infarction, screened by the Multiple Risk Factor Intervention Trial (MRFIT) in its recruitment effort, constitute the largest cohort with standardized serum cholesterol measurements and long-term mortality follow-up. For each five-year age group, the relationship between serum cholesterol and coronary heart disease (CHD) death rate was continuous, graded, and strong. For the entire group aged 35 to 57 years at entry, the age-adjusted risks of CHD death in cholesterol quintiles 2 through 5 (182 to 202, 203 to 220, 221 to 244, and ≥245 mg/dL [4.71 to 5.22, 5.25 to 5.69, 5.72 to 6.31, and ≥6.34 mmol/L]) relative to the lowest quintile were 1.29, 1.73, 2.21, and 3.42. Of all CHD deaths, 46% were estimated to be excess deaths attributable to serum cholesterol levels 180 mg/dL or greater (≥4.65 mmol/L), with almost half the excess deaths in serum cholesterol quintiles 2 through 4. The pattern of a continuous, graded, strong relationship between serum cholesterol and six-year age-adjusted CHD death rate prevailed for nonhypertensive nonsmokers, nonhypertensive smokers, hypertensive nonsmokers, and hypertensive smokers. These data of high precision show that the relationship between serum cholesterol and CHD is not a threshold one, with increased risk confined to the two highest quintiles, but rather is a continuously graded one that powerfully affects risk for the great majority of middle-aged American men.See PDF for full text of the original JAMA article.

ContextAbundant evidence links overweight and obesity with impaired health. However, controversies persist as to whether overweight and obesity have additional impact on cardiovascular outcomes independent of their strong associations with established coronary risk factors, eg, high blood pressure and high cholesterol level.ObjectiveTo assess the relation of midlife body mass index with morbidity and mortality outcomes in older age among individuals without and with other major risk factors at baseline.DesignChicago Heart Association Detection Project in Industry study, a prospective study with baseline (1967-1973) cardiovascular risk classified as low risk (blood pressure ≤120/≤80 mm Hg, serum total cholesterol level

Increasing prevalence of overweight/obesity and rapid aging of the US population have raised concerns of increasing health care costs, with important implications for Medicare. However, little is known about the impact of body mass index (BMI) earlier in life on Medicare expenditures (cardiovascular disease [CVD]-related, diabetes-related, and total) in older age.To examine relationships of BMI in young adulthood and middle age to subsequent health care expenditures at ages 65 years and older.Medicare data (1984-2002) were linked with baseline data from the Chicago Heart Association Detection Project in Industry (CHA) (1967-1973) for 9978 men (mean age, 46.0 years) and 7623 women (mean age, 48.4 years) (baseline overall age range, 33 to 64 years) who were free of coronary heart disease, diabetes, and major electrocardiographic abnormalities, were not underweight (BMI18.5), and were Medicare-eligible (or =65 years) for at least 2 years during 1984-2002. Participants were classified by their baseline BMI as nonoverweight (BMI, 18.5-24.9), overweight (25.0-29.9), obese (30.0-34.9), and severely obese (or =35.0).Cardiovascular disease-related, diabetes-related, and total average annual Medicare charges, and cumulative Medicare charges from age 65 years to death or to age 83 years.In multivariate analyses, average annual and cumulative Medicare charges (CVD-related, diabetes-related, and total) were significantly higher by higher baseline BMI for both men and women. Thus, with adjustment for baseline age, race, education, and smoking, total average annual charges for nonoverweight, overweight, obese, and severely obese women were, respectively, 6224 dollars, 7653 dollars, 9612 dollars, and 12,342 dollars (P.001 for trend); corresponding total cumulative charges were 76, 866 dollars, 100,959 dollars, 125,470 dollars, and 174,752 dollars (P.001 for trend). For nonoverweight, overweight, obese, and severely obese men, total average annual charges were, respectively, 7205 dollars, 8390 dollars, 10,128 dollars, and 13,674 dollars (P.001 for trend). Corresponding total cumulative charges were 100,431 dollars, 109,098 dollars, 119,318 dollars, and 176,947 dollars (P.001 for trend).Overweight/obesity in young adulthood and middle age has long-term adverse consequences for health care costs in older age.

Reducing the continued high burden of cardiovascular disease (CVD) morbidity, disability, mortality, disparities, and costs remains a paramount public health goal for communities and countries. Accelerating favorable population trends in cardiovascular health behaviors and factors and reversing adverse trends can be expected to extend further the reduction of recent decades in overall CVD mortality.1 Effective community-wide interventions can be replicated and scaled up to maximize their population health benefit. From this perspective, the report from Record and colleagues2 in this issue of JAMA is an important contribution, describing 4 decades of experience in CVD prevention in Franklin County, Maine.2

ContextThe sixth Joint National Committee (JNC-VI) classification system of blood pressure emphasizes both systolic blood pressure (SBP) and diastolic blood pressure (DBP) for cardiovascular disease risk assessment. Pulse pressure may also be a valuable risk assessment tool.ObjectiveTo compare relationships of SBP, DBP, and pulse pressure, separately and jointly, with cardiovascular disease-related mortality in men.Design and SettingData from the Multiple Risk Factor Intervention Trial (MRFIT), which screened men aged 35 to 57 years from 1973 through 1975 at 22 US centers, was used to assess cardiovascular disease-related mortality through 1996.ParticipantsA total of 342 815 men without diabetes or a history of myocardial infarction were divided into 2 groups based on their age at MRFIT screening (35- to 44-year-olds and 45- to 57-year olds). Participant blood pressure levels were classified into a JNC-VI blood pressure category based on SBP and DBP (optimal, normal but not optimal, high normal, stage 1 hypertension, stage 2-3 hypertension), and pulse pressure was calculated.Main Outcome MeasureCardiovascular disease-related mortality.ResultsThere were 25 721 cardiovascular disease-related deaths. Levels of SBP and DBP were more strongly related to cardiovascular disease than pulse pressure. Relationships of SBP, DBP, and pulse pressure to cardiovascular disease-related mortality varied within JNC-VI category. Concordant elevations of SBP and DBP were associated with a greater risk of cardiovascular disease-related mortality for both age groups of men. Among men aged 45 to 57 years, higher SBP and lower DBP (discordant elevations) also yielded a greater risk of cardiovascular disease-related mortality.ConclusionIn both age groups, cardiovascular disease risk assessment was improved by considering both SBP and DBP, not just SBP, DBP, or pulse pressure separately.

ContextThree major coronary risk factors—serum cholesterol level, blood pressure, and smoking—increase incidence of coronary heart disease (CHD) and related end points. In previous investigations, risks for low-risk reference groups were estimated statistically because samples contained too few such people to measure risk.ObjectiveTo measure long-term mortality rates for individuals with favorable levels for all 3 major risk factors, compared with others.DesignTwo prospective studies, involving 5 cohorts based on age and sex, that enrolled persons with a range of risk factors. Low risk was defined as serum cholesterol level less than 5.17 mmol/L (

Results Age-standardized prevalence of CVD risk factors varied by Hispanic/Latino background; obesity and current smoking rates were highest among Puerto Rican participants (for men, 40.9% and 34.7%; for women, 51.4% and 31.7%, respectively); hypercholesterolemia prevalence was highest among Central American men (54.9%) and Puerto Rican women (41.0%). Large proportions of participants (80% of men, 71% of women) had at least 1 risk factor. Age- and sex-adjusted prevalence of 3 or more risk factors was highest in Puerto Rican participants (25.0%) and significantly higher (P.001) among participants with less education (16.1%), those who were US-born (18.5%), those who had lived in the United States 10 years or longer (15.7%), and those who preferred English (17.9%). Overall, self-reported CHD and stroke prevalence were low (4.2% and 2.0% in men; 2.4% and 1.2% in women, respectively). In multivariate-adjusted models, hypertension and smoking were directly associated with CHD in both sexes as were hypercholesterolemia and obesity in women and diabetes in men (odds ratios [ORs], 1.5-2.2). For stroke, associations were positive with hypertension in both sexes, diabetes in men, and smoking in women (ORs, 1.7-2.6). Conclusion Among US Hispanic/Latino adults of diverse backgrounds, a sizeable proportion of men and women had adverse major risk factors; prevalence of adverse CVD risk profiles was higher among participants with Puerto Rican background, lower SES, and higher levels of acculturation.

ContextFor women, impact of cardiovascular risk factors measured in young adulthood, particularly favorable (low-risk) profile, on mortality has been difficult to assess due to low short-term death rates.ObjectiveTo assess the relationship of baseline coronary risk factor status to mortality from coronary heart disease (CHD), cardiovascular diseases (CVDs), and all causes in young women.DesignProspective cohort study.Setting and ParticipantsA total of 7302 women aged 18 to 39 years without prior CHD or major electrocardiographic abnormalities screened between 1967 and 1973 for the Chicago Heart Association Detection Project in Industry. Risk groups were defined using national guidelines for values of systolic and diastolic blood pressure, serum cholesterol level, body mass index, presence of diabetes, and smoking status. Participants were divided into 4 groups: low risk, 0 risk factors high but 1 or more unfavorable, 1 only risk factor high, and 2 or more risk factors high.Main Outcome MeasuresAll-cause mortality, CHD mortality, and CVD mortality; hazard ratio of outcome measures comparing low-risk group with other groups.ResultsOnly 20% met low-risk criteria; 59% had high levels of 1 or more risk factors. During an average follow-up of 31 years, there were 47 CHD deaths, 94 CVD deaths, and 469 deaths from all causes. The age-adjusted CVD death rate per 10 000 person-years was lowest for low-risk women and increased with the number of risk factors, ie, 1.5, 1.7, 5.0, and 9.1 for low-risk; 0, 1, and 2 or more risk factors high, respectively. Multivariate-adjusted CVD mortality hazard ratio for low-risk women was 0.19 (95% confidence interval, 0.08-0.45) compared with women with 2 or more risk factors high. Similar patterns were observed for CHD and all-cause mortality and for both blacks and whites.ConclusionFor women with favorable levels for all 5 major risk factors at younger ages, CHD and CVD are rare; long-term and all-cause mortality are much lower compared with others.

ContextA frequently cited concept is that individual major risk factors for coronary heart disease (CHD) are absent in many patients (perhaps >50%) with CHD. However, prior studies have not systematically evaluated the extent to which CHD patients have previous exposure to at least 1 risk factor, including diabetes, cigarette smoking, or clinically elevated levels of cholesterol or blood pressure.ObjectiveTo determine the frequency of exposure to major CHD risk factors.Design, Setting, and ParticipantsThree prospective cohort studies were included: the Chicago Heart Association Detection Project in Industry, with a population sample of 35 642 employed men and women aged 18 to 59 years; screenees for the Multiple Risk Factor Intervention Trial, including 347 978 men aged 35 to 57 years; and a population-based sample of 3295 men and women aged 34 to 59 years from the Framingham Heart Study (FHS). Follow-up lasted 21 to 30 years across the studies.Main Outcome MeasuresFatal CHD in all cohorts and nonfatal myocardial infarction (MI) in the FHS, compared by exposure to major CHD risk factors, defined as total cholesterol of at least 240 mg/dL (≥6.22 mmol/L), systolic blood pressure of at least 140 mm Hg, diastolic blood pressure of at least 90 mm Hg, cigarette smoking, and diabetes. Participants were stratified by sex and age (18-39 vs 40-59 years).ResultsFor fatal CHD (n = 20 995), exposure to at least 1 clinically elevated major risk factor ranged from 87% to 100%. Among those aged 40 to 59 years at baseline with fatal CHD (n = 19 263), exposure to at least 1 major risk factor ranged from 87% to 94%. For nonfatal MI, prior exposure was documented in 92% (95% CI, 87%-96%) (n = 167) of men aged 40 to 59 years at baseline and in 87% (95% CI, 80%-94%) (n = 94) of women in this age group.ConclusionsAntecedent major CHD risk factor exposures were very common among those who developed CHD, emphasizing the importance of considering all major risk factors in determining CHD risk estimation and in attempting to prevent clinical CHD. These results challenge claims that CHD events commonly occur in persons without exposure to at least 1 major CHD risk factor.

Results A total of 85 and 132 participants in the active treatment and placebo groups, respectively, had ischemic strokes (adjusted relative risk [RR], 0.63; 95% confidence interval [CI], 0.48-0.82); 9 and 19 had hemorrhagic strokes (adjusted RR, 0.46; 95% CI, 0.21-1.02); and 9 and 8 had strokes of unknown type (adjusted RR, 1.05; 95% CI, 0.40-2.73), respectively. Four subtypes of ischemic stroke were observed in active treatment and placebo group participants, respectively, as follows: for lacunar, n=23 and n=43 (adjusted RR, 0.53; 95% CI, 0.32-0.88); for embolic, n=9 and n=16 (adjusted RR, 0.56; 95% CI, 0.25-1.27); for atherosclerotic, n=13 and n=13 (adjusted RR, 0.99; 95% CI, 0.46-2.15); and for unknown subtype, n=40 and n=60 (adjusted RR, 0.64; 95% CI, 0.43-0.96). Treatment effect was observed within 1 year for hemorrhagic strokes but was not seen until the second year for ischemic strokes. Stroke incidence significantly decreased in participants attaining study-specific systolic blood pressure goals. Conclusions In this study, antihypertensive drug treatment reduced the incidence of both hemorrhagic and ischemic (including lacunar) strokes. Reduction in stroke incidence occurred when specific systolic blood pressure goals were attained.

ContextBased on observational and interventional data for middle-aged cohorts (aged 40-64 years), serum cholesterol level is known to be an established major risk factor for coronary heart disease (CHD). However, findings for younger people are limited, and the value of detecting and treating hypercholesterolemia in younger adults is debated.ObjectiveTo evaluate the long-term impact of unfavorable serum cholesterol levels on risk of death from CHD, cardiovascular disease (CVD), and all causes.Design, Setting, and ParticipantsThree prospective studies, from which were selected 3 cohorts of younger men with baseline serum cholesterol level measurements and no history of diabetes mellitus or myocardial infarction. A total of 11,017 men aged 18 through 39 years screened in 1967-1973 for the Chicago Heart Association Detection Project in Industry (CHA); 1266 men aged 25 through 39 years examined in 1959-1963 in the Peoples Gas Company Study (PG); and 69,205 men aged 35 through 39 years screened in 1973-1975 for the Multiple Risk Factor Intervention Trial (MRFIT).Main Outcome MeasuresCause-specific mortality during 25 (CHA), 34 (PG), and 16 (MRFIT) years of follow-up; mortality risks; and estimated life expectancy in relation to baseline serum cholesterol levels.ResultsDeath due to CHD accounted for 26%, 34%, and 28% of all deaths in the CHA, PG, and MRFIT cohorts, respectively; and CVD death for 34%, 42%, and 39% of deaths in the same cohorts, respectively. Men in all 3 cohorts with unfavorable serum cholesterol levels (200-239 mg/dL [5.17-6.18 mmol/L] and ≥240 mg/dL [≥6.21 mmol/L]) had strong gradients of relative mortality risk. For men with serum cholesterol levels of 240 mg/dL or greater (≥6.21 mmol/L) vs favorable levels (

ContextMinor electrocardiographic (ECG) ST-T abnormalities are common, but their prognostic importance has not been fully determined.ObjectiveTo examine associations of single (1 time only) and multiple (2 times only and ≥3 times) nonspecific minor ST-T abnormalities in 5 years with long-term mortality due to myocardial infarction (MI), coronary heart disease (CHD), cardiovascular disease (CVD), and all causes in middle-aged men.DesignProspective cohort study (29-year follow-up after 5 annual examinations).Setting and ParticipantsA total of 1673 men employed at the Western Electric Company in Chicago, Ill, aged 40 to 55 years at entry, with no evidence of CHD and no major ECG abnormalities throughout the first 5-year period.Main Outcome MeasuresMinor ST-T abnormalities identified from annual resting ECGs and mortality ascertained from death certificates.ResultsOf the 1673 men, 173 had evidence of isolated nonspecific minor ST-T segment abnormalities. During the follow-up period, there were 234 deaths due to MI, 352 deaths due to CHD, 463 deaths due to CVD, and 889 deaths due to all causes. For men with 3 or more annual recordings of minor ST-T abnormalities, risk of death due to MI, CHD, CVD, and all causes was significantly greater than for those with normal ECG findings. For men with 3 or more ECGs with minor ST-T abnormalities, relative risks (and 95% confidence intervals) adjusted for cardiovascular and other risk factors were 2.28 (1.16-4.49), 2.39 (1.39-4.12), 2.30 (1.44-3.68), and 1.60 (1.06-2.42), respectively, with a graded relationship between frequency of occurrence of ST-T abnormalities and mortality risk (linear trend, P≤.007).ConclusionsPersistent, minor, nonspecific ST-T abnormalities are associated with increased long-term risk of mortality due to MI, CHD, CVD, and all causes; the higher the frequency of occurrence of minor ST-T abnormalities, the greater the risk. These data underscore the potential value of including nonspecific ECG findings in the overall assessment of cardiovascular risk.

Context. —Diabetes is a frequent cause of end-stage renal disease (ESRD). However, the degree of risk is uncertain. Objective. —To determine the relative risk (RR) of ESRD related to diabetes in the United States. Design. —Nonconcurrent prospective cohort study. Participants. —A total of 332 544 men aged 35 to 57 years from 18 US cities screened in 1973 to 1975 for participation in the Multiple Risk Factor Intervention Trial (MRFIT). Main Exposure. —Diabetes mellitus defined by self-reported use of medication for diabetes at baseline. Main Outcome. —Incident ESRD through 1990 assessed from a national ESRD registry and by surveillance for death from renal disease. Results. —Over an average follow-up of 16 years, there were 136 cases of ESRD in 5147 diabetic men and 678 cases in 327 397 nondiabetic men. Age-adjusted incidence of all-cause ESRD in the diabetic men was 199.8 per 100 000 person-years compared with 13.7 per 100 000 person years in their nondiabetic counterparts (RR, 12.7; 95% confidence interval [Cl], 10.5-15.4). Diabetic men were also at higher risk for ESRD ascribed to causes other than diabetes (RR=4.3; 95% Cl, 3.2-5.9). With simultaneous adjustment for age, ethnicity, income, blood pressure, serum cholesterol level, and history of myocardial infarction, diabetic men remained at higher risk for all-cause ESRD (RR, 9.0; 95% Cl, 7.4-11.0), ESRD ascribed to diabetes (RR, 92.3; 95% Cl, 64.6-131.9), and ESRD ascribed to nondiabetic causes (RR, 3.0; 95% Cl, 2.2-4.1). Conclusions. —Diabetes mellitus is a strong independent risk factor for ESRD, even for ESRD ascribed to causes other than diabetes. Improvements in the prevention and control of diabetes should produce substantial reductions in ESRD incidence.

Objective. —To determine reasons for the 4-fold higher incidence of treated end-stage renal disease (ESRD) in African-American men compared with white men. Design. —Prospective study. Setting. —Men screened in 1973 through 1975 for entry into the Multiple Risk Factor Intervention Trial (MRFIT). Participants. —A total of 332 544 men (300 645 white, 20 222 African American, and 11 677 other ethnic groups) aged 35 to 57 years. Main Outcome Measures. —Incidence of ESRD assessed through 1990 using the Health Care Financing Administration national ESRD treatment registry and by surveillance for death from renal disease from data of the National Death Index and the Social Security Administration. Results. —Over a mean follow-up of 16 years, age-adjusted ESRD incidence was 13.90 per 100 000 person-years in white men and 44.22 per 100 000 person-years in African-American men. Higher blood pressure and lower socioeconomic status were associated with higher incidence of ESRD in both ethnic groups. With adjustment for baseline age, systolic blood pressure, number of cigarettes smoked, previous myocardial infarction, diabetes, income, and serum cholesterol level, relative risk of ESRD in African-American men compared with white men was reduced from 3.20 to 1.87 (95% confidence interval, 1.47-2.39). Both higher systolic blood pressure and lower income in African-American men as compared with white men were particularly related to this reduced relative risk. Results were similar when hypertensive ESRD was used as the outcome. Conclusion. —Both higher blood pressure and lower income are associated with a higher incidence of ESRD in both white and African-American men. Disparities in blood pressure and socioeconomic status relate importantly to the excess risk of ESRD in African-American men compared with white men.

Objective. —To compare six antihypertensive interventions for the treatment of mild hypertension. Design. —Randomized, double-blind, placebo-controlled clinical trial. Setting. —Four hypertension screening and treatment centers in the United States. Participants. —Hypertensive men and women, aged 45 to 69 years, with diastolic blood pressure less than 100 mm Hg. Intervention. —Sustained nutritional-hygienic advice to all participants to reduce weight, dietary sodium intake, and alcohol intake, and increase physical activity. Participants were randomly allocated to take (1) placebo (n=234); (2) chlorthalidone (n=136); (3) acebutolol (n=132); (4) doxazosin mesylate (n=134); (5) amlodipine maleate (n=131); or (6) enalapril maleate (n=135). Main Outcome Measures. —Blood pressure, quality of life, side effects, blood lipid levels and analysis of other serum components, echocardiographic and electrocardiographic changes, and incidence of cardiovascular events over an average of 4.4 years of follow-up. Results. —Blood pressure reductions were sizable in all six groups, and were significantly greater for participants assigned to drug treatment than placebo ( — 15.9 vs — 9.1 mm Hg for systolic blood pressure and — 12.3 vs —8.6 mm Hg for diastolic blood pressure;p Conclusions. —As an initial regimen, drug treatment in combination with nutritional-hygienic intervention was more effective in preventing cardiovascular and other clinical events than was nutritional-hygienic treatment alone. Drug-treatment group differences were minimal. Pending results from large-scale clinical trials to evaluate drug treatments for their effect on cardiovascular clinical events, these findings support the recommendations of the new fifth Joint National Committee report regarding treatment choices for people with stage 1 ("mild") hypertension. (JAMA. 1993;270:713-724)

A 5-year trial involving 201 men and women with high-normal blood pressure at baseline demonstrated the ability to reduce the incidence of hypertension in participants randomized to nutritional-hygienic intervention compared with a control group. The incidence of hypertension was 8.8% among 102 intervention group participants vs 19.2% among 99 control group members. The odds ratio for the incidence of hypertension in the control group was 2.4. Mean trial blood pressure also was lower in the intervention compared with the control group ( -1.2 and -1.9 mm Hg, respectively, for diastolic blood pressure at work-site and office visits and -1.3 and - 2.0 mm Hg, respectively, for systolic blood pressure at the two sites). Net weight loss in the intervention group averaged 2.7 kg during the trial; sodium intake was reduced by 25% and reported alcohol intake decreased by 30%. The majority of intervention participants also reported an increase in physical activity. Effect on blood pressure was related particularly to degree of weight loss. Results indicate that even a moderate reduction in risk factors for hypertension among hypertension-prone individuals contributes to the primary prevention of the disease. ( JAMA . 1989;262:1801-1807)

In the nationwide Community Hypertension Evaluation Clinic screening of more than 1 million people, the group classifying itself as overweight had prevalence rates of hypertension 50% to 300% higher than other screenees. Frequency of hypertension in overweight persons aged 20 to 39 years was double that of normal weight and triple that of underweight persons. Among those aged 40 to 64 years, the overweight group had a 50% higher hypertension prevalence rate than the normal-weight group and 100% higher than the underweight group. With each higher degree of blood pressure elevation, relative frequency of hypertension with overweight was larger. Thus this study confirms, in the largest group surveyed to date, similar findings in previous cross-sectional surveys. It is also consistent with data from longitudinal and intervention studies on the importance of overweight in relation to hypertension. ( JAMA 240:1607-1610, 1978)

The authors studied 110 consecutive cases of children hospitalized for a first attack of rheumatic fever. In each case a judgment was made as to the adequacy of the preceding treatment in the light of recommendations made by the American Heart Association. In 94 of the 110 cases there had been an infection within 5 weeks before the onset of rheumatic fever. The patient had been seen by a physician in 62 cases, throat cultures had been made in 17, and antibiotics had been given in 50. In only 10 patients was the preceding therapy deemed adequate. Residual cardiac involvement was noted in 54 of the 110 at the time of discharge from the hospital. It was estimated that about 84% of these cases of rheumatic fever had been preventable.

IT IS GENERALLY RECOGNIZED that atherosclerosis is a complex disease of the arteries and that a number of factors influence its development. In particular, coronary atherosclerosis and the resultant heart disease have been the subject of many studies because of the high morbidity and mortality rates and because of the limitations of present-day therapy. Much evidence implicates diet as one of the key etiological factors. Within the last 10 years several investigators have undertaken studies to examine the influence of dietary modification on the occurrence of clinical coronary heart disease. By 1959 it was apparent that large-scale field trials might be feasible and that a national cooperative effort might be the appropriate means to accomplish this difficult research mission. In 1960, with the support of the National Heart Institute of the US Public Health Service, an Executive Committee on Diet and Heart Disease was established under the chairmanship of Dr.

This study, begun in 1952, assessed long-term estrogen therapy in middle-aged men surviving acute myocardial infarction. By double-blind stratified randomization, 275 such men under age 50 were assigned either to a placebo-treated or to an estrogen-treated group. In the estrogen-treated group, significantly prolonged survival and decreased mortality were found in both good-risk patients and poor-risk patients. Five-year mortality rates were reduced about 50% or more by hormone treatment. However, an unexpected number of deaths occurred in the first two months of study among those men started on 10.0 mg estrogens within three months of their most recent infarction. Mixed conjugated equine estrogens seemed to be effective in the long term therapy of myocardial infarction when high initial dosage was avoided, particularly in the months immediately after infarction.

During 1973 through 1975, more than 1 million persons were screened in the nationwide Community Hypertension Evaluation Clinic (CHEC) program at 1,171 sites. While those screened were not from defined populations, findings paralleled those of recent surveys of US population samples. First, CHEC confirmed the scope of the problem of elevated blood pressure in the United States. Of those screened, 247 of 1,000 had a diastolic reading of 90 mm Hg or higher; 116 of 1,000 had a reading of 95 mm Hg or greater. Prevalence of elevated blood pressure rose with age up to age 50 years, was higher in blacks than in whites, and was higher in men than in women. Second, CHEC data confirmed the challenge of undetected, untreated, and uncontrolled hypertension. Previously undetected hypertension was present in 27.7% of hypertensive people, detected but untreated in 10.7%, and treated but uncontrolled in 16.7%—totaling 55.1%. (JAMA235:2299-2306, 1976)

In the Chicago Coronary Prevention Evaluation Program (CPEP), 115 men had definite mild hypertension at entry; another 101 men had high-normal diastolic blood pressure (BP). The nutritional-hygienic nonpharmacologic CPEP regimen achieved years-long moderate weight loss, slowing of pulse rate, and reduction in serum cholesterol levels. Sustained falls in BP were recorded—about 10/13 mm Hg for hypertensive men, resulting in long-term normalization of BP, and about 7/4 mm Hg for men with high-normal BP at entry. Change in weight and change in BP were significantly correlated. Long-term improvements in eating and exercise habits yielding moderate sustained weight loss are apparently useful in preventing high BP in hypertension-prone persons and in controlling established "mild" hypertension. (JAMA243:1819-1823, 1980)

The 356 222 men aged 35 to 57 years, who were free of a history of hospitalization for myocardial infarction, screened by the Multiple Risk Factor Intervention Trial (MRFIT) in its recruitment effort, constitute the largest cohort with standardized serum cholesterol measurements and long-term mortality follow-up. For each five-year age group, the relationship between serum cholesterol and coronary heart disease (CHD) death rate was continuous, gradecf, and strong. For the entire group aged 35 to 57 years at entry, the age-adjusted risks of CHD death in cholesterol quintiles 2 through 5 (182 to 202, 203 to 220, 221 to 244, and ≥245 mg/dL [4.71 to 5.22, 5.25 to 5.69, 5.72 to 6.31, and ≥6.34 mmol/L]) relative to the lowest quintile were 1.29, 1.73, 2.21, and 3.42. Of all CHD deaths, 46% were estimated to be excess deaths attributable to serum cholesterol levels 180 mg/dL or greater (≥4.65 mmol/L), with almost half the excess deaths in serum cholesterol quintiles 2 through 4. The pattern of a continuous, graded, strong relationship between serum cholesterol and six-year age-adjusted CHD death rate prevailed for nonhypertensive nonsmokers, nonhypertensive smokers, hypertensive nonsmokers, and hypertensive smokers. These data of high precision show that the relationship between serum cholesterol and CHD is not a threshold one, with increased risk confined to the two highest quintiles, but rather is a continuously graded one that powerfully affects risk for the great majority of middle-aged American men. (JAMA1986;256:2823-2828)

In a nationwide screening program, blood pressure measurements, family (parental) histories of hypertension, and self-evaluations of weight class were obtained for more than a half million people. Positive family history was associated with hypertension prevalence double that found in persons with negative history and was independent of weight. When overweight was also present, however, hypertension prevalence was three to four times as high. Hypertension was more likely to have been previously diagnosed in screenees if family history was positive. However, such screenees did not have a higher proportion receiving effective treatment than those with negative family history. When an index case of hypertension is found, other family members should be examined. For persons with positive family history, nutritional-hygienic recommendations to avoid overweight may be important in reducing the risk of becoming hypertensive. ( JAMA 241:43-46, 1979)