Atherosclerotic Cardiovascular Disease Outcomes Research Articles

Blood Pressure as a Cardiovascular Risk Factor

Objective. —To examine the prevalence, incidence, predisposing factors for hypertension, its hazards as an ingredient of the cardiovascular risk profile, and the implications of this information for prevention and treatment. Methods. —Prospective longitudinal analysis of 36-year follow-up data from the Framingham Study of the relation of antecedent blood pressure to occurrence of subsequent cardiovascular morbidity and mortality depending on the metabolically linked burden of associated risk factors. Results. —Hypertension is one of the most prevalent and powerful contributors to cardiovascular diseases, the leading cause of death in the United States. There is, on average, a 20 mm Hg systolic and 10 mm Hg diastolic increment increase in blood pressure from age 30 to 65 years. Isolated systolic hypertension is the dominant variety. There is no evidence of a decline in the prevalence of hypertension over 4 decades despite improvements in its detection and treatment. Hypertension contributes to all of the major atherosclerotic cardiovascular disease outcomes increasing risk, on average, 2- to 3-fold. Coronary disease, the most lethal and common sequela, deserves highest priority. Hypertension clusters with dyslipidemia, insulin resistance, glucose intolerance, and obesity, occurring in isolation in less than 20%. The hazard depends on the number of these associated metabolically linked risk factors present. Coexistent overt cardiovascular disease also influences the hazard and choice of therapy. Conclusion. —The absence of a decline in the prevalence of hypertension indicates an urgent need for primary prevention by weight control, exercise, and reduced salt and alcohol intake. The urgency and choice of therapy of existing hypertension should be based on the multivariate cardiovascular risk profile that more appropriately targets hypertensive persons for treatment and prevention of cardiovascular sequelae. ( JAMA . 1996;275:1571-1576)

Blood Pressure as a Cardiovascular Risk Factor

- To examine the prevalence, incidence, predisposing factors for hypertension, its hazards as an ingredient of the cardiovascular risk profile, and the implications of this information for prevention and treatment. - Prospective longitudinal analysis of 36-year follow-up data from the Framingham Study of the relation of antecedent blood pressure to occurrence of subsequent cardiovascular morbidity and mortality depending on the metabolically linked burden of associated risk factors. - Hypertension is one of the most prevalent and powerful contributors to cardiovascular diseases, the leading cause of death in the United States. There is, on average, a 20 mm Hg systolic and 10 mm Hg diastolic increment increase in blood pressure from age 30 to 65 years. Isolated systolic hypertension is the dominant variety. There is no evidence of a decline in the prevalence of hypertension over 4 decades despite improvements in its detection and treatment. Hypertension contributes to all of the major atherosclerotic cardiovascular disease outcomes increasing risk, on average, 2- to 3-fold. Coronary disease, the most lethal and common sequela, deserves highest priority. Hypertension clusters with dyslipidemia, insulin resistance, glucose intolerance, and obesity, occurring in isolation in less than 20%. The hazard depends on the number of these associated metabolically linked risk factors present. Coexistent overt cardiovascular disease also influences the hazard and choice of therapy. - The absence of a decline in the prevalence of hypertension indicates an urgent need for primary prevention by weight control, exercise, and reduced salt and alcohol intake. The urgency and choice of therapy of existing hypertension should be based on the multivariate cardiovascular risk profile that more appropriately targets hypertensive persons for treatment and prevention of cardiovascular sequelae.

Cardioprotection and antihypertensive therapy: The key importance of addressing the associated coronary risk factors (the Framingham experience)

Hypertension directly predisposes to all of the major atherosclerotic cardiovascular disease outcomes, including coronary artery disease, stroke, cardiac failure, and peripheral artery disease. Coronary artery disease deserves a high priority in treatment of hypertension because it is the most common and lethal sequela. However, reduction of blood pressure as the sole therapeutic goal of antihypertensive therapy is no longer appropriate. Hypertension tends to cluster with other atherogenic risk factors, including dyslipidemia, glucose intolerance, insulin resistance, obesity, and elevated uric acid. Hypertension is only one of the many risk factors for atherosclerotic cardiovascular disease and is variably hazardous, depending on the number and severity of these coexistent metabolically linked risk factors. The presence of coexistent, already overt cardiovascular disease and left ventricular hypertrophy also greatly influence the hazard and choice of therapy. The urgency for, and choice of, therapy should be based on the multivariate cardiovascular risk profile rather than relying solely on the character and severity of the blood pressure elevation. In this way at-risk hypertensive persons can be more appropriately targeted for treatment designed to improve their muitivariate risk profile and to provide maximum benefit and cost effectiveness.

Risk Factors for Atherosclerotic Cardiovascular Outcomes in Different Arterial Territories

The major cardiovascular risk factors adversely affect all vascular territories, increasing the vulnerability to multiple clinical manifestations of atherosclerosis. The population at risk was the Farmingham cohort of 5209 men and women assessed bienially for the development of overt events of coronary heart disease (CHD), congestive heart failure, intermittent claudication, and atheroembolic brain infarction. In persons younger than 65 years, all the major risk factors were found to impact significantly on the incidence of coronary heart disease and intermittent claudication. For stroke and cardiac failure, all but the serum cholesterol level were important. In those older than 65 years, serum total cholesterol levels and smoking no longer influenced the incidence of coronary heart disease. The ratio of total- to high-density-lipoprotein-cholesterol levels, however, was related to all cardiovascular outcomes except stroke at all ages. The impact of cigarette smoking on stroke and intermittent claudication persisted in advanced age. Modification of risk factors for the purpose of preventing a particular cardiovascular event should also prevent other outcomes. The impact of any particular risk factor on any atherosclerotic cardiovascular disease outcome is profoundly influenced by the frequent coexistence of other risk factors. A correct appraisal of the hazard and urgency for treatment is best obtained from a cardiovascular risk profile estimating the conditional probability of an event given the existing constellation of factors.

An epidemiological perspective in hypertension problem solving.

Hypertension predisposes to all the major atherosclerotic cardiovascular disease outcomes, with coronary heart disease (CHD) the most common and lethal sequela. Hypertension is only one of many risk factors for CHD and is variably hazardous, depending on the number and severity of co-existent, metabolically linked risk factors. Importantly, about half the CHD events occur in hypertensive patients in the upper quartile of multivariate risk. An epidemiologist can recognize differences in hypertensive candidates for cardiovascular disease based on their cardiovascular risk profile rather than relying solely on the character of the blood pressure elevation. Once a composite risk profile for hypertensive patients has been established, at-risk individuals can be more readily identified, allowing treatment to be more appropriately targeted to improve the multivariate cardiovascular risk profile whilst reducing the blood pressure. Such an approach provides maximum benefit and cost effectiveness.