OBJECTIVE: Psychological factors have been suspected of contributing to the development of cardiovascular disease. This study examined the relationship between a self-reported history of treatment for depression and subsequent myocardial infarction among treated hypertensive patients. METHODS: Participants (5564) in a union-sponsored, hypertension control program in New York City, who entered the program during 1981-1994 without a history of cardiovascular disease and who were asked whether they had been treated for depression, were followed in a prospective cohort study. The primary outcome of interest was hospitalization or death due to myocardial infarction. RESULTS: At entry, 3.5% of men and 6.4% of women reported a history of treatment for depression. During 4.9 years (average) of follow-up, 112 fatal and nonfatal myocardial infarctions were recorded. The sex-adjusted relative risk of myocardial infarction was 2.24 (confidence interval = 1.13-4.45). Controlling for known cardiovascular risk factors with multivariate proportional hazards models, history of treatment for depression was significantly associated with subsequent myocardial infarction (hazard ratio = 2.10, confidence interval = 1.04-4.23). CONCLUSIONS: A self-reported history of treatment for depression is independently associated with subsequent myocardial infarction in treated hypertensive patients without prior cardiovascular disease. Whether additional or different treatment for depression will be cardioprotective is unknown and merits further study.

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Management of the hypertensive patient: a continuing dilemma.

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

Adult↗

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

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

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Reduction of cardiovascular disease events by worksite hypertension treatment.

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

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Waist-to-hip ratio as an index of risk for hyperglycemia among hypertensive patients.

Participants in a systematic antihypertensive care program were examined to determine whether the site of fat predominance--measured by the waist-to-hip ratio--is related to hyperglycemia in patients taking diuretics. Among 1,044 hypertensive patients meeting a set of selection criteria, 22 men who developed hyperglycemia during a mean treatment period of 25.6 months were identified and individually matched for age, race, body mass index, and duration of diuretic treatment to a comparable group of hypertensive patients who remained normoglycemic. The mean waist-to-hip ratio was higher among the hyperglycemic men, although this difference did not reach conventional levels of statistical significance. However, a significantly greater proportion of the hyperglycemic men than those who were normoglycemic fell into a higher ratio category when waist-to-hip ratios were classified according to whether they were less than or greater than or equal to 0.90. When the ratios were examined in relation to body mass index, the greatest difference between the two groups was observed in the leanest group. This study suggests that the waist-to-hip ratio, in conjunction with total body fatness, may be an important tool for distinguishing persons with hypertension who may develop hyperglycemia when treated with diuretics.

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