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High blood pressure (HBP) in the range 90—104 DBP (»mild») has been shown to carry a sizeable excess risk of coronary death, at least in countries with atherogenic diets. Effective treatment to control HBP should result in lowering CHD risk. Early trials comparing drug treatment vs placebo in such hypertensives were generally too small or too limited to demonstrate this, although overall trends favored treatment. The U.S. Hypertension Detection and Follow-up Program (HDFP), a population based trial with 10,940 patients, did demonstrate large reductions in CHD mortality and in nonfatal CHD, as measured by a variety of indices. A subsequent large trial, the Multiple Risk Factor Trial (MRFIT), found benefit in reducing CHD deaths for most hypertensives, but for the subgroup with resting ECG abnormalities, CHD deaths were greater in the Special Intervention than in the Usual Care group. The overall findings of the several studies indicate benefit of effective antihypertensive treatment in reducing CHD mortality and morbidity for most hypertensives with DBP 90—104. However, need to highlight a number of other aspects of anti-hypertensive treatment is indicated: use of lowest drug level possible to achieve BP normalization; need to control all major CHD risk factors in hypertensives; need to utilize nutritional means to further both these aims; need to monitor and counteract unwanted metabolic effects of antihypertensive drug therapy.

Summary Background Studies of underlying differences in adult mortality between black and white individuals in the USA have been constrained by limitations of data or small study size. We investigated the extent to which differences in socioeconomic position between black and white men contribute to differences in all-cause and cause-specific mortality. Methods 361 662 men were screened for the Multiple Risk Factor Intervention Trial between 1973 and 1975, in 22 sites. Median family income of households by zipcode (postal) area of residence was available for 20 224 black and 300 685 white men as well as data on age, cigarette smoking, blood pressure, serum cholesterol, previous heart attack, and treatment for diabetes. We classified deaths during 16 years of follow-up into specific causes and compared differences in death rates between black men and white men, before and after adjustment for differences in income and other risk factors. Findings Age-adjusted relative risk of death (black vs white) was 1·47 (95% CI 1·42–1·53). Adjustment for diastolic blood pressure, serum cholesterol, cigarette smoking, medication for diabetes, and previous admission to hospital for heart attack decreased the relative risk to 1·40 (1·35–1·46). Adjustment for income but not the other risk factors decreased the risk to 1·19 (1·14–1·24) and adjustment for other risk factors did not alter this estimate. For cardiovascular death, relative risk on adjustment for income was decreased from 1·36 to 1·09; for cancer from 1·47 to 1·25; and for non-cardiovascular and non-cancer deaths from 1·71 to 1·26. For some specific causes of death, including prostate cancer, myeloma, and hypertensive heart disease, the higher death rates among black men did not seem to reflect differences in income. Rates of death for suicide and melanoma were lower among black than white men, as were those for coronary heart disease after adjustment for income. Interpretation Socioeconomic position is the major contributor to differences in death rates between black and white men. Differentials in mortality from some specific causes do not simply relect differences in income, however, and more detailed investigations are needed of how differences are influenced by environmental exposures, lifetime socioeconomic conditions, lifestyle, racism, and other sociocultural and biological factors.

Geoge Davey Smith and Andrew Phillips raise some issues concerning methods used in correcting for regression dilution in Intersalt but offer no judgment on the crucial issue of the strength and importance of the relation of dietary salt to blood pressure. To assess this matter properly, in the context of Intersalt findings, three judgments must be made: firstly, on the aetiological significance of the salt-blood pressure relation; secondly, on the probable underestimate of the size of this relation in Intersalt analyses of individuals; and thirdly, on the soundness of Intersalt's updated estimates “revisiting” the strength of this relation, both from its within population and its cross population analyses.1 Davey Smith and Phillips deal not at all with the first and second of these points, and only partially and inconsistently with the third. Much of their commentary deals with generalities, not with specifics of the salt-blood pressure relation and Intersalt results. As a consequence, their commentary neither sheds light on the substantive matter nor contributes positively to public policy. Davey Smith and Phillips state that corrections for regression dilution and other biases “could as well be applied to spurious associations as to causal ones…. Judgment has to be applied to decide if an association is causal.” They make no such judgment on the salt-blood pressure relation, the subject of their commentary. In fact, the totality of the evidence—the only sound basis for judgment on this matter—supports the conclusion that this association is causal. The significant independent findings on the sodium-blood pressure relation in Intersalt's within population and cross population analyses1 are components of that total evidence. Independent expert groups, national and international, have repeatedly concluded that the extensive, concordant, strong data from all disciplines—clinical investigation, randomised controlled trials, animal experimentation, epidemiological research …

Objectives: To assess further the relation in Intersalt of 24 hour urinary sodium to blood pressure of individuals and populations, and the difference in blood pressure from young adulthood into middle age. Design: Standardised cross sectional study within and across populations. Setting: 52 population samples in 32 countries. Subjects: 10 074 men and women aged 20-59. Main outcome measures: Association of sodium and blood pressure from within population and cross population multiple linear regression analyses with multivariate correction for regression dilution bias. Relation of sample median daily urinary sodium excretion to difference in blood pressure with age. Results: In within population analyses (n=10 074), individual 24 hour urinary sodium excretion higher by 100 mmol (for example, 170 v 70 mmol) was associated with systolic/diastolic blood pressure higher on average by 3/0 to 6/3 mm Hg (with and without body mass in analyses). Associations were larger at ages 40-59. In cross population analyses (n=52), sample median 24 hour sodium excretion higher by 100 mmol was associated with median systolic/diastolic pressure higher on average by 5-7/2-4 mm Hg, and estimated mean difference in systolic/diastolic pressure at age 55 compared with age 25 greater by 10-11/6 mm Hg. Conclusions: The strong, positive association of urinary sodium with systolic pressure of individuals concurs with Intersalt cross population findings and results of other studies. Higher urinary sodium is also associated with substantially greater differences in blood pressure in middle age compared with young adulthood. These results support recommendations for reduction of high salt intake in populations for prevention and control of adverse blood pressure levels. Key messages The within population findings were previously underestimated because of incomplete correction for the regression dilution problem Revised estimates of the within population association of sodium to blood pressure in Intersalt are concordant with the cross population findings for 52 samples Estimates of the effect of median sodium excretion higher by 100 mmol/day over a 30 year period (age 55 minus age 25) were a greater difference of 10-11 mm Hg in systolic blood pressure and 6 mm Hg in diastolic blood pressure These results lend further support to recommendations for mass reduction of high salt intake for the prevention and control of adverse blood pressure levels and high blood pressure in populations

OBJECTIVES: This study examined socioeconomic differentials in risk of death from a number of causes in a large cohort of Black men in the United States. METHODS: For 20 224 Black men screened for the Multiple Risk Factor Intervention Trial between 1973 and 1975, data were collected on median family income of Black households in zip code of residence, age, cigarette smoking, blood pressure, serum cholesterol, previous heart attack, and drug treatment for diabetes. The 2937 deaths that occurred over the 16-year follow-up period were grouped into specific causes and related to median Black family income. RESULTS: There was an inverse association between age-adjusted all-cause mortality and median family income. There was no attenuation of this association over the follow-up period, and the association was similar for the 22 clinical centers carrying out the screening. The gradient was seen for most of the specific causes of death, although the strength of the association varied. Median income was markedly lower for the Black men screened than for the White men, but the relationship between income and all-cause mortality was similar. CONCLUSIONS: Socioeconomic position is an important determinant of mortality risk for Black men. Even though Blacks lived in areas with substantially lower median family income than Whites, the association of income with mortality was similar for Blacks and Whites.

Background. High salt and nitrate intake are considered as risk factors for stomach cancer, but little is known about possible interactions. This ecological study examines the respective importance of both factors for stomach cancer mortality at the population level using data obtained under standardized conditions and with biochemical analyses performed in the same laboratories. Method. Randomly selected 24-hour urine samples from 39 populations, sampled from 24 countries (N = 5756 people for sodium, 3303 for nitrate) were obtained from the INTERSALT study. Median sodium and nitrate levels were age- and sex-standardized between ages 20-49 years and averaged per country. Ecological correlation-regression analyses were done in relation to national stomach cancer mortality rates. Results. The Pearson correlation of stomach cancer mortality with sodium for the 24 countries was : 0.70 in men and 0.74 in women (both P < 0.001), and with nitrate : 0.63 (P = 0.001) in men and 0.56 (P < 0.005) in women. In multiple regression of stomach cancer mortality, using sodium and nitrate as independent variables, the adjusted R 2 was 0.61 in men and 0.54 in women (both P < 0.001). Addition of the interaction term (sodium x nitrate) to the previous model increased the adjusted R 2 to 0.77 in men, and to 0.63 in women. The analysis of this model showed that the importance of nitrate as risk factor for stomach cancer mortality increased markedly with higher sodium levels. However, the relationship of stomach cancer mortality with sodium was always stronger than with nitrate. Conclusions. Salt intake, measured as 24-hour urine sodium excretion, is likely the rate-limiting factor of stomach cancer mortality at the population level.

Background. There is considerable interest in the possible role of nitrate in gastric carcinogenesis, but little information on nitrate intake around the world. This is the first study to give comprehensive standardized data on nitrate excretion as a marker of intake, using 48 worldwide population samples. Methods. Urinary nitrate excretion has been shown to be a valid measure of nitrate intake in people under 50. This report presents data on 24-hour urinary nitrate excretion from urine collections obtained in the INTERSALT study, based on random samples of men and women aged 20-49 from each of 48 population samples in 30 countries. Results. There was large variation in urinary nitrate excretion both within and between samples ; within-sample (individual) distributions tended to be skewed towards higher values. Median values of the samples ranged from 0.42 mmol/day (Labrador, Canada) to 3.52 (Beijing, People's Republic of China) in men and 0.44 mmol/day (Colombia) to 3.44 (Beijing) in women. Overall, median values were higher in men than women by 11% on average (higher in men in 37 of 48 population samples). Comparison by geographical region of median values for men and women combined showed relatively low values in the samples in North America and Northern Europe (range 0.46-0.88 mmollday), slightly higher values in Western Europe and Africa (0.68-1.11), and intermediate to high values in Southern Europe, Eastern and Central Europe and India (0.86-2.47). The highest median values were found in the Far Eastern samples (up to 3.48). Median values in the Central and South American samples ranged from 0.48 mmol/day (Colombia) to 1.37 (Xingu Indians of Brazil, and Argentina). Conclusions. For the first time, these data give standardized information on urinary nitrate excretion from different geographical regions of the world, and provide a basis for the further exploration of the role of nitrate in the aetiology of disease in human populations.

In the United States population, black men have higher prevalence rates of electrocardiographic (ECG) high QRS voltage, more ST-segment and T-wave abnormalities, and more ECG left ventricular hypertrophy (LVH) than do white men. Reasons for these differences have not been fully elucidated. The prevalence rate of ECG LVH and associated characteristics were compared in black and white men in the Chicago Heart Association Detection Project in Industry population study. Data were from 1,391 black men and 19,126 white men (age range 20 to 64 years) employed by 84 Chicago organizations. ECG LVH was defined by the presence of both high QRS (Minnesota code 3.3) and ST-T abnormality (code 4.1-4.3 or 5.1-5.3). Black men had a significantly higher prevalence rate of ECG LVH than did white men in each 15-year age group (15.9 vs 2.4, 14.6 vs 2.8, and 35.7 vs 12.5/1,000 in the 20- to 34-, 35- to 49-, and 50-to 64-year age groups, respectively; p < 0.01 for each comparison). Multiple logistic regression analyses indicated that systolic blood pressure and age were associated positively with ECG LVH (p < 0.01) in both black and white men. Men with history of hypertension and receiving drug treatment had a greater likelihood of having ECG LVH than did those with history of hypertension but not receiving drug treatment, possibly because those with more severe hypertension were more likely to have been prescribed medication. Serum cholesterol, cigarettes smoked/day, 1-hour post-load plasma glucose and education were not consistently related to ECG LVH.(ABSTRACT TRUNCATED AT 250 WORDS)

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.

Specific causes of death were analyzed for 10,908 participants in the Hypertension Detection and Follow-up Program, to explore possible explanations for the observed excess 8.3-year mortality from all causes in hypertensives with low body mass. Although the cardiovascular mortality rate among men in the lowest decile of body mass (body mass index 21.96 or less) was 50% higher than that of men in the median class (body mass index 26.4-28.8), death rate for noncardiovascular deaths was more than 2 1/2 times higher in men with lean versus median body mass. The pattern was similar among women. Among noncardiovascular causes, striking differences in mortality rates between lean hypertensives and those of average body mass were observed for cirrhotic death (relative risk of 12+ in men and 11+ in women), for nonmalignant respiratory disease in men (relative risk of 7+), for violent death (both sexes), and for malignant neoplasms in men. Prevalence of smoking was almost twice as high in the lowest compared with the median body mass group; among the lean, excess deaths, particularly noncardiovascular deaths, were concentrated among smokers. Thus, male smokers in the lowest decile of body mass constituted only 3% of the study population, but contributed 8% of all deaths, 11% of all noncardiovascular deaths, and 22% of all cirrhotic deaths. A larger proportion of deaths occurred early in follow-up in the lean versus other hypertensives, suggesting occult disease among the lean at baseline. There was no evidence that more severe or treatment-resistant hypertension was present in or could explain excess mortality among the hypertensives with low body mass. The inference from the findings is not that overweight is protective for hypertensives nor that excess risk is due to leanness per se. Rather, a reasonable hypothesis, particularly from findings on specific causes of death, is that excess mortality in lean hypertensives is due to deleterious lifestyles, particularly smoking and excess alcohol intake, contributing to both leanness and risk of death.

The association between hypertension and a number of cardiovascular disease risk factors was assessed in the large population sample of Gubbio, a town in central Italy that dates back to medieval times. The data confirm those of previous studies showing that hypertension is strongly associated with other metabolic abnormalities, such as markedly overweight subjects, hyperuricaemia, hyperglycaemia, hypercholesterolaemia, that may be related to the aetiopathogenesis of high blood pressure and, in addition, compound the risk of major clinical cardiovascular events in people with hypertension. The findings are therefore relevant for prevention strategies. In addition, the association between erythrocyte sodium-stimulated lithium countertransport and hypertension is being studied.

The Salt Institute continues to misrepresent the findings of Intersalt (and other studies) on salt and blood pressure, and the availability of Intersalt data. It not only incorrectly attempts to discredit the Intersalt finding that average population salt intake is positively related to slope of blood pressure with age1; it also ignores or misrepresents two other important results—the positive relations between sodium excretion of individuals and their blood pressure (found in over 10 000 adults), and the positive association of average population sodium intake with average blood pressure and prevalence of hypertension across the 52 populations in the Intersalt study. The institute's statement that “the primary Intersalt hypotheses were largely negative” is incorrect. The Salt Institute was clearly not happy with the implications of the original Intersalt findings on salt intake and blood pressure slope with age—an additional 9 mm Hg higher systolic blood pressure over 30 years (for example, from age 25 to 55) for an additional 100 mmol population sodium intake. It therefore requested that the Intersalt group perform several additional analyses on the slope of blood pressure with age, using statistical methods suggested by the institute. These were done, and all analyses again showed a significant relation of average population salt intake (as assessed by average 24 hour urinary sodium excretion) and population blood pressure slope with age.2 The analyses included those that had controlled for pressure in young adults (ages 20-29). Findings were similar to the original results: the higher the population salt intake, the greater the upward slope of blood pressure with age—for all 52 population samples and also when the four low sodium samples were excluded (fig 1). These findings were made …

High salt intake is believed to have adverse effects on blood pressure levels in humans. Now, for the first time, it has been shown to increase blood pressure in chimpanzees (pages 1009–1016).

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 (

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 Sodium-lithium countertransport (Na-Li CT) activity is high in persons with hypertension. This study investigated whether high Na-Li CT relates to development of hypertension. Methods and Results At the baseline visit of the Gubbio Population Study, 4210 people of the 5376 surveyed were 18 to 74 years old; of these, 1599 were hypertensive (systolic pressure ≥140 mm Hg, or diastolic pressure ≥90 mm Hg, or on antihypertensive drug therapy). Of the 2611 nonhypertensives, 302 did not have Na-Li CT measured and 580 did not participate in 6-year follow-up. This analysis, therefore, deals with data collected on 1729 men 18 to 74 years old and women 18 to 74 years old who at baseline were nonhypertensive and had Na-Li CT measurement. Compared with individuals who were nonhypertensive at baseline and follow-up, individuals with incident hypertension at follow-up (systolic pressure ≥140 mm Hg, or diastolic pressure ≥90 mm Hg, or on antihypertensive drug therapy) had higher baseline values of Na-Li CT, blood pressure, age, body mass index, plasma cholesterol, and alcohol intake ( P P −1 ·h −1 ). In univariate logistic regression, incidence of hypertension was related to baseline value of Na-Li CT, blood pressure, age, body mass index, plasma cholesterol, and alcohol intake ( P P Conclusions Na-Li CT is a predictor of hypertension risk in adults.

Abstract Sodium-lithium countertransport activity in red blood cells relates to blood pressure (BP) and the prevalence of hypertension. This study investigated in adults the relation of sodium-lithium (Na-Li) countertransport to BP change from baseline to 6-year follow-up. In the Gubbio Population Study, 4210 men and women were 18 to 74 years old at baseline (1983-1986), and 3766 had a valid baseline Na-Li countertransport measurement; of these, 2729 were reexamined at 6 years of follow-up (1989-1992) and made up the study cohort. At baseline, data collection included age, height, weight, BP, pulse rate, drug treatment, alcohol intake, ratio of sodium to potassium in spot urine, plasma cholesterol, and Na-Li countertransport in red blood cells. At 6-year follow-up, data for age, BP, and drug treatment were collected as at baseline. From baseline, average BP declined for people on antihypertensive medication at follow-up and for those with baseline BP greater than or equal to 140/90 mm Hg (systolic/diastolic) and did not change or increased for the remaining participants. In quartile and correlation analyses controlled for sex, baseline BP, and antihypertensive treatment, BP change related significantly and directly to baseline Na-Li countertransport. In multiple linear regression analyses done for the entire cohort with control for other confounders, the regression coefficient of baseline Na-Li countertransport to BP change over time was positive and borderline significant. The Na-Li countertransport coefficient was positive and significant when analyses were done with the use of a categorical value of baseline Na-Li countertransport (quartile 4 and quartiles 1 through 3 combined). In both models, the Na-Li countertransport coefficient was the strongest for people with baseline BP greater than or equal to 120/80 mm Hg or for people with baseline age of 45 years or older. In conclusion, Na-Li countertransport significantly relates to BP change over time in adults.

This report further examines the relation of body mass index (BMI) to associations of 24-hour urinary sodium, potassium, and sodium-potassium ratio with blood pressure in INTERSALT, a 52-center international study of electrolytes and blood pressure. Analyses without adjustment for BMI indicated average systolic pressure greater by 6.00 mm Hg per 100 mmol higher sodium and diastolic by 2.52 mm Hg. With adjustment for BMI, these values were reduced to 3.14 and 0.14 mm Hg, respectively. For the sodium-potassium ratio, blood pressure associations were stronger when not adjusted for BMI, and for potassium, adjustment generally had little effect. To explore possible interactions of these variables with BMI in relation to blood pressure, the 52 centers were divided into two groups of 26 based on whether the center median for BMI was less than or greater than or equal to 24.5 kg/m2, and individuals within each of the 52 centers were classified into lower- or higher-BMI groups based on individual BMI less than or greater than or equal to 24.1 kg/m2. Sodium and the sodium-potassium ratio were positively and significantly and potassium inversely and significantly related to systolic pressure in all four of these subgroups, and the sodium-potassium ratio and potassium were related to diastolic pressure in two and three subgroups, respectively. Electrolyte-blood pressure associations did not differ significantly between the two subgroups of centers or between the two subgroups based on individuals.(ABSTRACT TRUNCATED AT 250 WORDS)

The focus here is on relationships between major risk factors and long-term mortality from coronary heart disease (CHD) and all causes, and on longevity, in Chicago cohorts: 25-year follow-up for Peoples Gas (PG) men aged 25-39 (n = 1,119), 30-year follow-up for PG men aged 40-59 (n = 1,235), 24-year follow-up for Western Electric (WE) men aged 40-55 (n = 1,882); also 15-year follow-up for five cohorts of the Chicago Heart Association (CHA) Study: men aged 25-39 (n = 7,873), 40-59 (n = 8,515), 60-74 (n = 1,490), and women aged 40-59 (n = 7,082) and 60-74 (n = 1,243); also 12-year findings for very low risk men (n = 11,098) and other men (n = 350,564) screened for the Multiple Risk Factor Intervention Trial (MRFIT). With a high degree of consistency, multivariate analyses showed independent positive relationships of baseline serum cholesterol, blood pressure and cigarette use to risk of death from CHD and all causes. For the WE cohort, with baseline nutrient data, dietary cholesterol was also independently related to these mortality risks. Combined risk factor impact was strong for both men and women of all baseline ages. Thus, for WE men, favorable compared to observed levels of serum cholesterol, blood pressure, cigarette use and dietary cholesterol were estimated to result in 24-year risk of CHD death 69% lower, all-cause death 42% lower and longevity 9 years greater. For CHA middle-aged and older women, favorable baseline levels of serum cholesterol, blood pressure and cigarette use were estimated to yield 15-year-CHD risk lower by about 60% and longevity greater by about 5 years. For MRFIT, very low risk men (serum cholesterol182 mg/dl, systolic/diastolic blood pressure120/80), nonsmokers, nondiabetic, no previous heart attack), compared to all others, observed 12-year death rates were lower by 89% for CHD, 79% for stroke, 86% for all cardiovascular diseases, 30% for cancers, 21% for other causes, 53% for all causes, and longevity was estimated to be more than 9 years longer. These findings indicate great potentials for prevention of the CHD epidemic and for increased longevity with health for men and women, through improved life-styles and consequent lower risk factor levels.

Population based data on 24-h urinary excretion of calcium, oxalate, magnesium, phosphate, uric acid and creatinine were collected from 220 children (aged 3-16 years) living in Cimitile, Campania, southern Italy. Mean excretion rates for 7 days were correlated with age, body weight, body mass index and height. The prevalence of hypercalciuria (greater than 4 mg/kg body weight) and of hyperoxaluria (greater than 60 mg/day) were 9.1% and 1.8%, respectively. The same 20 children were also identified as hypercalciuric when a calcium/creatinine ratio of greater than 0.15 was considered. No significant differences between boys and girls were found in the urinary excretion of the five constituents implicated in urolithiasis. The study data provide additional childhood reference values for urinary excretion of compounds related to stone formation.

An inverse association between social class and disease has frequently been reported; education, an indicator of social class, was negatively related to blood pressure in several studies. Reasons are not clear. INTERSALT, an international study on electrolytes and blood pressure, obtained data on years of education for 10,079 adults in 52 centers in 32 countries. Data presented here are for 47 centers, omitting five where the population in the sample had no education or no differences in educational level. Regression coefficients were calculated for the education-blood pressure association in each center. An inverse association was found for men in 28 centers and for women in 38. Center coefficients were combined to give a studywide estimate of that association. When adjusted only for age, systolic pressure in men was 1.3 mm Hg higher for 10 fewer years of education (p less than 0.05) and for women 4.5 mm Hg higher (p less than 0.001). However, when adjusted also for five lifestyle factors (24-hour sodium and potassium excretion, body mass index, alcohol intake, and smoking), these estimates were reduced by about one half, and the inverse association was no longer significant for men. Similar findings were obtained for diastolic pressure. Those with less education had on average higher sodium excretion, lower potassium excretion, greater body mass, and higher alcohol intake, all factors tending to increase blood pressure. Improvement of these factors, which help explain the differences in blood pressure related to years of education, has the potential to reduce the blood pressure disadvantage associated with lower socioeconomic status.

In the 1950s, World Health Organization data indicated that for Italy and several other Mediterranean countries, death from coronary he art disease (CHD) was much less common than in Northern Europe or the U.S. What has happened to this “Mediterranean advantage” in the ensuing years? Death from CHD in the 1980s is still lower in Italy than in the U.S., but the gap has narrowed, e. g., for men age 45–64 the Italian rate was about one-third that of the U.S. rate in the early 1950s, but by the late 1970s the Italian CHD death rate was more than half that in the U.S. This narrowing reflected two trends—an important decrease in CHD death rate in U.S. men and rising CHD rates for middle-aged Italian men from the 1950s through the middle 1970s.

INTERSALT, an international cooperative study on electrolytes and other factors related to blood pressure, found, in within-population analyses involving 10,079 persons, a significant positive association between 24-hour urinary sodium excretion and systolic blood pressure and between the sodium/potassium ratio and systolic blood pressure. These significant findings were derived from analyses for individuals from all 52 centers and from the 48 centers remaining when persons from four low sodium centers were excluded. Potassium excretion of individuals was significantly and independently related inversely to their systolic blood pressure. For men and women, both separate and combined, the relation between sodium and systolic blood pressure was stronger for older than younger adults, perhaps reflecting the result of longer exposure with age or diminished capacity to handle a sodium load. Relations between electrolyte excretion and diastolic blood pressure in individuals were weaker than for systolic blood pressure. Body mass index and heavy alcohol consumption of individuals were strongly and independently related to blood pressure. In cross-population analyses with n = 52 or n = 48, sample median sodium excretion was significantly and independently related to the slope of systolic blood pressure and diastolic blood pressure with age. Other ecological analyses yielded inconsistent results. Four isolated populations showed low sodium excretion, low sodium/potassium excretion, low body mass index, and low alcohol consumption; sample median blood pressures were low, there was little or no upward slope of blood pressure with age, and high blood pressure was rare or nonexistent.

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.

Objectives: To compare blood pressures in northern (Beijing) and southern (Guangzhou) Chinese population samples aged 35-54 years, males and females, urban and rural, and to assess the role of blood pressure-related traits in explaining north-south differences. Design: Cross-sectional surveys were conducted in 1983-1984 of northern and southern populations employed in industry (urban) or farming (rural). Methods: In the north samples were selected from the Capital Iron and Steel Complex (urban) and Shijingshan district (rural); in the south samples from the Guangzhou Shipyard (urban) and Panyu County (rural) were used. Results: The number of subjects surveyed in north and south were 4706 and 4179, respectively: 1500 and 1052 urban males, and 717 and 914 rural males; and 1300 and 1061 urban females, and 1189 and 1152 rural females, respectively

Data from 10,559 men and women, age 30–64, participating in the morning and afternoon in a Chicago Health Department multiphasic screening project, were used to determine the effects of time of day and time since last meal on the values for plasma glucose one and two hours following oral challenge with 100 gm. of glucose. Mean plasma glucose values and rates of suspect glucose intolerance (based on several cutpoints) were sizeably higher in the afternoon than in the morning. In addition, plasma glucose values increased with time elapsed since the last meal, up to 10 hours postprandially. Thereafter, both one- and two-hour plasma glucose values tended to exhibit a decline. Analysis of covariance confirmed that fluctuations in glucose tolerance were related to time of day and time since last meal, but the effects of each parameter were exerted independently.

A four-year trial assessed whether less severe hypertensives could discontinue antihypertensive drug therapy, using nutritional means to control blood pressure. Randomization was to three groups: group 1—discontinue drug therapy and reduce overweight, excess salt, and alcohol; group 2—discontinue drug therapy, with no nutritional program; or group 3—continue drug therapy, with no nutritional program. In groups 1 and 2 patients resumed drug therapy if pressure rose to hypertensive levels. Loss of at least 4.5 kg (10+ lb) was maintained by 30% of group 1, with a group mean loss of 1.8 kg (4 lb); sodium intake fell 36% and modest alcohol intake reduction was reported. At four years, 39% in group 1 remained normotensive without drug therapy, compared with 5% in group 2. Study findings demonstrated that nutritional therapy may substitute for drugs in a sizable proportion of hypertensives or, if drugs are still needed, can lessen some unwanted biochemical effects of drug treatment. ( JAMA 1987;257:1484-1491)

Population studies that demonstrated risk from elevation of blood pressure were a necessary foundation for a sound clinical approach to hypertension. Clinical trials then demonstrated that lowering pressure with drug therapy dramatically reduced risk of cardiovascular catastrophes, including death. The U.S. Veterans Administration (VA) study proved the need to treat moderate and severe hypertension, but left unproven the benefit for so-called mild hypertension (diastolic blood pressure 90–104 mm Hg). The Hypertension Detection and Follow-up Program (HDFP) investigated applicability of VA findings to the “average” hypertensive, particularly to the majority in the range 90–104 mm Hg. Two randomly constituted groups, Stepped Care (SC) and Referred Care (RC), included 10,940 hypertensives, age 30–69, identified in population-based screening in 14 communities, and followed for 5 years. Almost 34 (71%) were so-called mild hypertensives. SC patients were treated vigorously in special clinical centers to lower pressure to a diastolic goal no higher than 80–90 mm Hg (depending on entry level), starting with low dose diuretics and adding medication stepwise as needed, until the goal was reached. RC patients were treated by usual sources of medical care. A larger proportion of SC than RC patients were on therapy and at the goal each year of the study. The fifth year diastolic average was 84 mm Hg in SC and 89 mm Hg in RC. The 5-year all causes mortality rate was 17% lower in SC than RC. In the mild hypertension stratum, this difference was 20%. Clinical implications from the HDFP trial include demonstration of: the validity of the VA findings on the benefit of treating moderate and severe hypertension; the benefit of treatment also for those with sustained average diastolic pressures 90–104 mm Hg; the utility of lowering pressure before target organ damage; the utility of stepwise drug treatment to a normotensive goal; the ability to achieve long-term patient adherence; the contribution of nonphysician personnel in helping achieve these aims. The possible role of non-pharmacologic measures was not tested in these trials and remains an important question in determining best methods for control of hypertension.

This report, the third in a series on pulse pressure and pure systolic hypertension, examines the associations between blood pressure and the cardiovascular diseases and coronary heart disease, both cross-sectionally and prospectively, utilizing data from four Chicago epidemiologic studies, in an effort to determine whether or not a widened pulse pressure, or pure systolic hypertension, is an independent risk factor. In these analyses, blood pressure is divided into two components, one related to level and the other to pulse pressure, with pulse pressure redefined so that the association between pulse pressure and the prevalence of ECG abnormalities or mortality, indicates whether the endpoint is more strongly related to systolic or diastolic blood pressure. In these studies, blood pressure level is significantly related to both ECG abnormalities and mortality. In the cross-sectional analyses, pulse pressure is generally positively related to the prevalence of ECG abnormalities, indicating a stronger association for systolic blood pressure, and thus a possible association with pure systolic hypertension. However, in the prospective analyses, pulse pressure is generally not related to mortality, indicating an equal association with mortality for systolic and diastolic blood pressure in these studies. Thus, although the cross-sectional analyses generally support the hypothesis that a widened pulse pressure, or pure systolic hypertension, is an independent risk factor for the cardiovascular diseases and coronary heart disease, the prospective analyses do not.

Data from 10,559 men and women, aged 30–64, participating in the morning and afternoon in a Chicago Health Department multiphasic screening project, were used to evaluate the relationship of time of day and time since last meal to group mean serum cholesterol, hematocrit, systolic and diastolic blood pressure, and heart rate. Serum cholesterol showed no definable differences with time of day and time since last meal. Hematocrit values tended to be slightly higher in the morning than in the afternoon and showed no consistent differences with time since last meal. Systolic blood pressure values, but not diastolic, were slightly higher in the afternoon than in the morning. Mean heart rates tended to be slightly higher in the afternoon and lower with time elapsed since last meal. All these differences were small and not of an order to present significant problems with regard to carrying out mass screening for these variables over the course of the day.

In several large Chicago companies and institutions, workplace screening of 7,151 persons yielded 833 suspect hypertensives. Of these, 91% attended a follow-up verification visit, where for 513 persons high diastolic pressure was confirmed. One-half of these persons were referred to their physicians for treatment and one-half were randomly assigned to be treated directly by HDFP, in a step-wise pharmacologic regimen to normalize diastolic pressure. Of the 257 persons assigned to program treatment, 94% accepted such treatment, and over 90% of these still living in the community were active participants at one year. Average diastolic pressure of these active participants was 83.1 mm Hg at one year, compared to 102.6 at first screen and 98.8 at the second confirmatory screening. A strenuous effort has been made to reduce or eliminate obstacles to treatment, including lack of understanding of the need for long-term therapy, cost barriers and barriers of inconvenience of treatment. The medical team conducting the program combined physicians with nonphysician therapist-health counselors, plus "outreach" staff, to maximize program adherence. Preliminary experiences in the Chicago Center of the Hypertension Detection and Follow-Up Program (HDFP) give encouraging evidence that the workplace is a useful base for successful hypertension control efforts.

SUMMARY The relationship of education to risk factors at baseline and to long-term mortality from coronary heart disease (CHD), cardiovascular diseases (CVD), and all causes was analyzed for three cohorts of middle-aged employed white men in Chicago: 8047 from the Chicago Heart Association Detection Project in Industry (CHA) (entry 1967-1973), 1250 from the Peoples Gas Company Study (PG) (entry 1958-1959) and 1730 from the Western Electric Study (WE) (entry 1957-1958). Each man was classified into one of four groups: not a high school graduate, high school graduate, some college but not a graduate, or college graduate. For all three cohorts, a graded, inverse association was observed at baseline between education and blood pressure, which was statistically significant for CHA and WE men and independent of age and relative weight. For all three cohorts, a significant, graded, inverse association was also recorded between education and cigarette use at entry. For serum cholesterol, no clear pattern was observed for the education groups in any of the three cohorts. CHA men showed a graded, inverse relationship between education and relative weight. This cohort was the only one of three showing a significant, graded inverse association between education and prevalence of ECG abnormalities at entry. For this CHA cohort, 5-year follow-up data showed a statistically significant, graded, inverse relationship between education and ageadjusted mortality rates from CHD, CVD and all causes. With adjustment for entry age, diastolic pressure, cigarettes, serum cholesterol, relative weight and ECG abnormalities, this inverse relationship remainedreduced in degree, but still statistically significant for CVD mortality. Similarly, for the pooled PG-WE cohort of 2980 with 20-21 years of follow-up, education and the three mortality end points were inversely related but not graded, with statistical significance for all three end points in the univariate analyses. The results of these studies indicate inverse relationships between education and lifestyle-related risk factors at baseline and between education and long-term risk of CHD, CVD and all-causes mortality. The inverse relationship between education and mortality is accounted for in part by the established major biomedical risk factors.

Two methodological problems in characterizing an individual's plasma glucose level are examined in this study. First, how large is the intra-individual variation of an individual's 1-hr post-load glucose level and for this estimated intra-individual variation what are the probabilities of misclassifying individuals based on a one-time measurement only of glucose level? Second, do different tests—i.e. fasting, 1-hr, 2-hr post-load, GTT—yield consistent ranking for the same individual? The first of these was explored with data on subsamples from the Chicago Peoples Gas Company (PG) study and the Chicago Heart Association Detection Project in Industry (CHA) study; the second, with data from the Chicago Coronary Prevention Evaluation Program (CPEP). For both the PG and CHA studies, the estimated ratios of the intra- to inter-individual variances were generally higher for post-load plasma glucose than blood pressure, heart rate, weight and serum uric acid. The conditional probabilities of misclassifying individuals into quintiles or deciles based on one measurement of 1-hr post-load glucose were also estimated from these data. These estimated probabilities indicate that the possible attenuation due to intraindividual variation cannot abolish a strong association; however, it may create some problem if the relationship is not very strong. Furthermore, both rank correlation and quintile classification analyses show that fasting, 1-hr and 2-hr plasma glucose level characterize individuals differently. Thus it is possible that the inconsistent results of previous studies, all using a one-time measure of plasma glucose, are partially due to the large intra-individual variation of this variable, and the use of methods that are not highly consistent in their classification of individuals.

Are overnight urine specimens adequate for characterizing the daily salt intake of individuals, i.e., can the overnight specimen replace the 24-hour specimen? Data from 142 male participants of an ongoing trial on the primary prevention of hypertension were used to examine this question with correlation analysis and quantile classification. Estimated correlation between the true mean 24-hour and the true mean overnight sodium excretion was 0.72. Furthermore, 67% of the individuals in the upper third of the distribution of true mean overnight urine sodium were also in the upper third of the distribution of true mean 24-hour sodium. Thus, these data are promising in regard to the use of overnight urine specimens for characterizing the salt intake of individuals. The number of overnight urine collections required to estimate accurately the correlation between an individual's true mean overnight urine sodium and a variable of interest (e.g., blood pressure) was calculated. Given the observed intra- and inter-individual variation, the data indicate that 14 measurements are needed to limit the diminution of the correlation coefficient to 10%.

This epidemiologic study explored the sex differential in risk of death from coronary heart disease in persons with or without clinically diagnosed diabetes or asymptomatic hyperglycemia. Use was made of 9-year follow-up data from the Chicago Heart Association Detection Project in Industry for 11,220 white men and 8,030 white women aged 35-64 years at entry to the Project (November 1967-January 1973). Both clinically diagnosed diabetes and asymptomatic hyperglycemia were associated with an increased risk of death from coronary heart disease. The extent of this association was greater in women than in men in regard to relative risk. However, absolute excess risk for both diabetics and those with asymptomatic hyperglycemia was larger for men than for women. Clinical diabetes appeared to be an independent risk factor for coronary heart disease in both men and women based on multivariate Cox regression analyses. On the other hand, for men, no significant independent effect of asymptomatic hyperglycemia was apparent. Women with asymptomatic hyperglycemia had significantly higher coronary heart disease death rates than normoglycemic women, with adjustment for major coronary heart disease risk factors; in multivariate analyses, the relationship of asymptomatic hyperglycemia to risk of coronary heart disease was of borderline significance (p = 0.054). This study indicates the independent associations of diabetes and possibly asymptomatic hyperglycemia with coronary heart disease mortality, with greater relative significance in women than in men.

We compared the effect on serum lipids of an alpha-blocker (prazosin) and a diuretic (hydrochlorothiazide) used as initial antihypertensive drug treatment for 102 men and women with less severe hypertension (average entry blood pressure, 148/97 mm Hg, with no major organ system damage). A two-center trial randomized patients to treatment with either prazosin or hydrochlorothiazide; the alternate drug was added if adequate blood pressure control was not achieved with the originally assigned drug, and patients were removed from any drug they were not able to tolerate. After an average of 40 weeks on the assigned drug regimen, a decline was observed in prazosin-treated patients in both serum total cholesterol (-9.3 mg/dl) and serum triglycerides (-33.9 mg/dl). In contrast, an increase in both these lipids was seen in hydrochlorothiazide-treated patients (+5.0 mg/dl for serum total cholesterol and +18.6 mg/dl for serum triglycerides). The net trial differences between the groups were 14.3 mg/dl for total cholesterol and 52.5 mg/dl for triglycerides, in favor of prazosin (p less than 0.001 for both comparisons). These differences in lipids between the two groups persisted into the second year of the trial (p less than 0.05). There were no significant differences between the drug groups in regard to the level of high density lipoprotein cholesterol or its subfractions or low density lipoprotein cholesterol. In patients who required a combination of the two drugs to achieve blood pressure control, the alpha-blocker diminished or eliminated the lipid-raising effects of the diuretic. Both drugs were similar in their ability to control the elevation of diastolic pressure.(ABSTRACT TRUNCATED AT 250 WORDS)

With advancing age from youth on, there is an increase in mean serum cholesterol level of populations in "western" industrialized countries. Since serum cholesterol is one of the established major risk factors for premature coronary heart disease, it is important to explore the degree to which this age trend is physiologic or due to modern life styles. This study used cross-sectional data for 19,730 white men and 13,872 white women from the Chicago Heart Association Detection Project in Industry to investigate one aspect of this question: does weight explain the association between age and serum cholesterol, in particular whether older age is associated with higher serum cholesterol in the absence of overweight. The relationships among age, relative weight, and serum cholesterol were examined through assessment of mean serum cholesterol levels in 25 subgroups stratified by age (18-24, 25-34, 35-44, 45-54, 55-64) and by relative weight (less than 100, 100-109, 110-119, 120-134, greater than or equal to 135). Age and serum cholesterol were positively associated with each other. In women, it was a simple, linear relationship. In men, the degree of this positive association was less in people over age 35-44 than people in younger ages. These age-cholesterol patterns were present in men and women at desirable weight. However, in men aged 18-54, the positive association between age and prevalence of marked hypercholesterolemia (serum cholesterol greater than or equal to 250) was lower in people at desirable relative weight in comparison to those at higher relative weight.(ABSTRACT TRUNCATED AT 250 WORDS)

The coronary heart disease mortality rate in Italy—lower than in many other industrialized countries—has changed little in the last 20 years, whereas in the United States, a major decline in deaths resulting from coronary heart disease has occurred. These differing trends have reduced considerably the gap between the two countries in coronary mortality rates. Several recent population studies in Italy have found a change in the previously more favorable risk factor profile. In the northern hill town of Gubbio, studied in 1983–1985, median serum cholesterol level of men ages 40–59 was 223 mg/dl, considerably higher than was found in the 1960 Italian population samples of the Seven Countries Study (197–206 mg/dl). In the earlier study, the cholesterol levels in the Italian men who were still mainly consuming the traditional Mediterranean diet were 30–40 mg/dl lower than in the U.S. sample. The 1980 Gubbio levels, however, were at least as high as those of their U.S. contemporaries. Cigarette smoking was much higher among the middle-aged men of Gubbio than among a similar U.S. population sample (56% vs 36%). Hypertension prevalence was high, and several risk factors for hypertension—obesity, high salt intake, and alcohol—were common in the Gubbio as well as in other recent Italian population studies. The changing coronary risk profile in Italy, which now includes higher population levels of serum cholesterol as well as the other major coronary heart disease risk factors of cigarette smoking and hypertension, threatens to reduce markedly the “Mediterranean advantage” enjoyed by Italy in the past.

Intervention to control hypertension and prevent coronary heart disease was initially undertaken in the United States in the late 1950s. It was conducted along three lines: randomized controlled trials, community demonstration projects, and broad public health and medical care efforts involving both the general population and its high-risk strata. This article reviews findings from the United States trials, particularly those on the primary prevention of coronary heart disease by unifactorial means (such as fat-modified diet, serum cholesterol-lowering drugs, antihypertensive drug treatment) and by multifactorial interventions. Results of unifactorial and multi-factorial trials are discussed with reference to the prevention of high blood pressure. Studies in the United States are compared with research abroad, and current research needs are reviewed together with the implications for medical practice and public health. The United States population as a whole has a large high-risk segment. Since the late 1950s, significant population-wide changes have occurred in life-styles (diet, smoking, exercise habits), and this is especially true of the more educated. The proportion of persons with detected, treated, and controlled high blood pressure has risen markedly in all population strata. Consequently, a favorable shift has occurred in the population distribution of the major established risk factors: "rich" diet, hypercholesterolemia, high blood pressure, and cigarette smoking. It can be reasonably inferred that the steady and marked declines in death rates in the United States from coronary heart disease, stroke, all cardiovascular diseases, and all causes since 1968 are related to reductions in these risk factors.

Because systolic blood pressure rises more sharply than diastolic blood pressure for those middle aged and beyond, leading to an increasing prevalence with advancing age of elevated systolic blood pressure without elevated diastolic pressure, i.e. so-called pure systolic hypertension, the question arises as to whether or not factors that have been shown to be related to blood pressure and hypertension are related to pure systolic hypertension or to 'classical' hypertension, i.e. hypertension defined solely by the level of the diastolic pressure. This question was examined in four Chicago epidemiologic studies by examining the associations between several variables and pulse pressure, with pulse pressure redefined so that the association between a variable and pulse pressure indicated whether the variable was more strongly related to systolic or diastolic blood pressure. In these four studies, glucose, heart rate and cigarette use tended to show a stronger association with systolic pressure, suggesting a possible association with pure systolic hypertension, while hematocrit, serum cholesterol, and uric acid tended to be more strongly associated with diastolic pressure, or equally associated with systolic and diastolic pressure, suggesting an association with 'classical' hypertension. Relative weight tended to be more strongly associated with systolic pressure under the age of 35 and more strongly associated with diastolic pressure after age 45.

In the Hypertension Detection and Follow-up Program, 7825 (71.5 per cent) of the 10,940 participants had diastolic blood pressures averaging between 90 and 104 mm Hg on entry into the study and were designated Stratum 1. Half were referred to their usual source of care in the community (the referred-care group), and half were treated intensively in special clinics (the stepped-care group). Five-year mortality in the Stratum 1 patients given stepped care was 20.3 per cent lower than in those given referred care (P less than 0.01). Particularly noteworthy was the beneficial effect of stepped-care treatment on persons with diastolic pressures of 90 to 104 mm Hg who had no evidence of end-organ damage and were not receiving antihypertensive medication when they entered the study. This subgroup had 28.6 per cent fewer deaths at five years among those treated with stepped care than among those treated with referred care (P less than 0.01). These findings support a recommendation that in patients with mild hypertension, treatment should be considered early, before damage to end organs occurs.