Pathophysiology and Natural History Coronary Artery Disease

Analysis of the Framingham Heart Study experience between 1958 and 1970 showed a progressive increase in the rate of treatment and control of hypertension. With cross-sectional criteria to define diastolic hypertension, the treatment rate rose from 35% in 1958 through 1960 to 69% in 1968 through 1970 (p < .001), and the treatment rate for sustained hypertension rose from 55% in 1958 through 1960 to 85% in 1968 through 1970 (p < .001). Treated hypertensive subjects had higher pretreatment values of blood pressure but not of other cardiovascular risk factors than untreated hypertensive subjects. Treatment was more successful in controlling hypertension in later years (p < .001), but in all years treatment reduced systolic and diastolic blood pressure without causing significant changes in mean serum cholesterol or glucose levels. In treated hypertensive subjects, the 8 year predicted risk of coronary heart disease declined by 2.3 events per 100 people compared with that in untreated hypertensive subjects (p < .0001). The observed incidence of coronary heart disease was consistent with these predictions and suggested that treatment may be especially beneficial in subjects who have systolic blood pressures of 180 mm Hg or higher and who are treated for more than 2 successive years. Circulation 71, No. 1, 22-30, 1985. NATIONAL health statistics indicate that mortality from ischemic heart disease in the United States has declined since the mid 1960s.' While the causes remain controversial, one hypothesis is that reductions in risk factors, including cigarette smoking, cholesterol intake, and blood pressure, have played an important role." 2 Several investigations3-7 have demonstrated improvement in the detection and control of hypertension in the United States, but data on free-living subjects in a community are limited and have not commonly followed individual subjects over time.7 In this report we describe data from the Framingham From the Division of General Medicine, the Henry J. Kaiser Family Foundation Fellowship Program in General Internal Medicine, and the Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston; the Section of Preventive Medicine and Epidemiology, Department of Medicine, Boston University School of Medicine, Boston; and the Framingham Heart Study, Framingham, MA. Supported in part by a grant from the James Hilton Manning and Emma Austin Manning Foundation. Address for correspondence: Lee Goldman, M.D., M.P.H., Department of Medicine, Brigham and Women's Hospital, 75 Francis St., Boston, MA 02115. Received Nov. 25, 1983; revision accepted Sept. 27, 1984. This research was performed when Dr. Shea was a Henry J. Kaiser Family Foundation Fellow in General Internal Medicine. Dr. Goldman is a Henry J. Kaiser Family Foundation Faculty Scholar in General Internal Medicine. Heart Study during the period 1958 to 1970, immediately preceding the downturn in cardiovascular mortality. We describe secular trends in the rates of treatment and control of hypertension, factors that influence which subjects are treated, and the effects of treatment on other cardiovascular risk factors and on the overall risk of coronary heart disease.