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Hypertension A Companion To Braunwalds Heart Disease 3Rd Edition George L Bakris Full Chapter
Hypertension A Companion To Braunwalds Heart Disease 3Rd Edition George L Bakris Full Chapter
HYPERTENSION
A Companion to Braunwald’s Heart Disease
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instructions, or ideas contained in the material herein.
Names: Bakris, George L., 1952- editor. | Sorrentino, Matthew J., editor.
Title: Hypertension : a companion to Braunwald’s heart disease / [edited by]
George L. Bakris, Matthew J. Sorrentino.
Other titles: Hypertension (Black) | Complemented by (expression):
Braunwald’s heart disease. 10th edition.
Description: Third edition. | Philadelphia, PA : Elsevier, [2018] |
Complemented by: Braunwald’s heart disease / edited by Douglas L. Mann,
Douglas P. Zipes, Peter Libby, Robert O. Bonow, Eugene Braunwald. 10th
edition. 2015. | Includes bibliographical references and index.
Identifiers: LCCN 2016054229 | ISBN 9780323429733 (hardcover : alk. paper)
Subjects: | MESH: Hypertension
Classification: LCC RC681 | NLM WG 340 | DDC 616.1/2--dc23
LC record available at https://lccn.loc.gov/2016054229
Printed in China.
v
vi
William C. Cushman, MD Philip B. Gorelick, MD, MPH, FACP, FAAN, FANA,
Chief, Preventive Medicine, Medical Service, Veterans Affairs FAHA
Medical Center; Professor, Preventive Medicine, Medicine, Medical Director, Mercy Health Hauenstein Neurosciences;
Contributors
and Physiology, University of Tennessee Health Science Professor, Department Translational Science & Molecular
Center, Memphis, Tennessee, United States Medicine, Michigan State University College of Human
Medicine, Grand Rapids, Michigan, United States
Peter Wilhelmus De Leeuw, MD, PhD
Professor of Medicine, Department of Medicine, Maastricht Elvira O. Gosmanova, MD
University Medical Center, Maastricht, Netherlands; Nephrology Section Chief, Medical Service, Samuel S Stratton
Department of Medicine, Zuyderland Medical Center, VA Medical Center, Associate Professor of Medicine, Division
Geleen/Heerlen, The Netherlands of Nephrology, Department of Medicine, Albany Medical
College, Albany, New York, United States
Georg B. Ehret, MD
Médecin Adjoint Agrégé et Chargé de Cours, Cardiology, Carlene M. Grim, BSN, MSN, SpDN
Department of Specialities of Medicine, Geneva University Founder and President, Shared Care Research and Education
Hospitals, Geneva, Switzerland; Research Associate, Consulting, Inc., Stateline, Nevada, United States
McKusick-Nathans Institute of Genetic Medicine, Johns
Hopkins University School of Medicine, Baltimore, Maryland, Clarence E. Grim, MS, MD, FACP, FAHA, FASH
United States Owner, High Blood Pressure Consulting, Stateline, Nevada;
Senior Consult, Shared Care Research and Education
William J. Elliott, MD, PhD Consulting, Inc., Stateline, Nevada; Retired (Semi) Professor
Professor of Preventive Medicine, Internal Medicine and of Medicine, Medical College of Wisconsin, UCLA, and
Pharmacology, Pacific Northwest University of Health Indiana U.; Board Certified Internal Medicine, Geriatrics,
Sciences, Chair, Department of Biomedical Sciences; Chief, Hypertension Specialist, United States
Division of Pharmacology, Pacific Northwest University of
Health Sciences, Yakima, Washington, United States Rajeev Gupta, MD, PhD
Chairman, Preventive Cardiology & Internal Medicine, Eternal
Michael E. Ernst, PharmD, FCCP Heart Care Centre and Research Institute, Jaipur, India
Professor, Department of Pharmacy Practice and Science,
College of Pharmacy; Professor, Department of Family John E. Hall, PhD
Medicine, College of Medicine, University of Iowa, Iowa City, Arthur C. Guyton Professor and Chair, Department of
Iowa, United States Physiology and Biophysics; Director, Mississippi Center of
Obesity Research, University of Mississippi Medical Center,
Muhammad U. Farooq, MD, FACP, FAHA Jackson, Mississippi, United States
Division of Stroke and Vascular Neurology, Mercy Health
Hauenstein Neurosciences, Grand Rapids, Michigan, Michael E. Hall, MD, MS
United States Assistant Professor of Medicine, Division of Cardiology,
Department of Medicine, University of Mississippi Medical
Anne-Laure Faucon, MD Center, Jackson, Mississippi, United States
Hypertension Unit, Hôpital Européen Georges Pompidou,
Assistance Publique-Hôpitaux de Paris, Paris-Descartes Coral D. Hanevold, MD
University, Paris, France Clinical Professor of Pediatrics, University of Washington,
Seattle Children’s Hospital, Division of Nephrology, Seattle,
Lauren Fishbein, MD, PhD Washington, United States
Assistant Professor of Medicine, University of Colorado
School of Medicine, Department of Medicine, Division of David G. Harrison, MD
Endocrinology, Metabolism and Diabetes, Aurora, Colorado, Betty and Jack Bailey Professor of Medicine, Clinical
United States Pharmacology, Department of Medicine, Vanderbilt
University, Nashville, Tennessee, United States
Joseph T. Flynn, MD, MS
Chief, Division of Nephrology, Seattle Children’s Hospital; Qi-Fang Huang, MD, PhD
Professor, Department of Pediatrics, University of Research Associate, The Shanghai Institute of Hypertension,
Washington School of Medicine, Seattle, Washington, Shanghai, China
United States
Alun Hughes, BSc, MB, BS, PhD
Toshiro Fujita, MD, PhD Professor of Cardiovascular Physiology and Pharmacology,
Chief, Division of Clinical Epigenetics, Research Center for Institute of Cardiovascular Science, Faculty of Pop
Advanced Science and Technology, The University of Tokyo, Health Sciences, University College London, London,
Emeritus Professor, The University of Tokyo, Tokyo, Japan United Kingdom
Contributors
of Medicine, Tochigi, Japan Auxologico Italiano, Milan, Italy
Community Health & Family Medicine, Colleges of Pharmacy Director, The Shanghai Institute of Hypertension; Director,
and Medicine, University of Florida, Gainesville, Florida, Department of Hypertension; Professor, Ruijin Hospital;
United States Professor, Shanghai Jiaotong University School of Medicine,
Shanghai, China
Matthew J. Sorrentino, MD, FACC, FASH
Professor of Medicine, Section of Cardiology, University of Seamus P. Whelton, MD, MPH
Chicago Medicine, Chicago, Illinois, United States Pollin Cardiology Fellow in Preventive Cardiology, Johns
Hopkins University School of Medicine and Ciccarone Center
George S. Stergiou, MD, FRCP for the Prevention of Heart Disease, Baltimore, Maryland,
Professor of Medicine and Hypertension, Hypertension United States
Center STRIDE-7, National and Kapodistrian University of
Athens, Third Department of Medicine, Sotiria Hospital, William B. White, MD
Athens, Greece Professor of Medicine and Division Chief, Division of
Hypertension and Clinical Pharmacology, Calhoun Cardiology
Hillel Sternlicht, MD Center, University of Connecticut School of Medicine,
Fellow in Hypertension, ASH Comprehensive Hypertension Farmington, Connecticut, United States
Center, The University of Chicago Medicine and Biological
Sciences, Chicago, Illinois, United States Bryan Williams, MD
Department of Medicine, Institute of Cardiovascular Sciences,
Patrick J. Strollo, Jr., MD, FACP, FCCP, FAASM University College London, London, United Kingdom
Professor of Medicine and Clinical and Translational
Science; Chairman of Medicine VA Pittsburgh Health System; Talya Wolak, MD
Vice Chair of Medicine for Veterans Affairs, University of Head of Hypertension Services, Soroka University Medical
Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, Center, Faculty of Health Sciences, Ben-Gurion University of
United States the Negev, Beer Sheva, Israel
Akiko Tanaka, MD, PhD Clyde W. Yancy, MD, MSc, MACC, FAHA, MACP, FHFSA
Aortic Fellow, Department of Cardiothoracic and Vascular Vice Dean, Diversity & Inclusion, Magerstadt Professor
Surgery, The University of Texas, Austin, Texas, of Medicine, Professor of Medical Social Sciences;
United States Chief, Division of Cardiology, Northwestern University,
Feinberg School of Medicine; Associate Director, Bluhm
Stephen C. Textor, MD Cardiovascular Institute, Northwestern Memorial Hospital;
Professor of Medicine, Division of Nephrology and Deputy Editor, JAMA Cardiology, Chicago, Illinois,
Hypertension, Mayo Clinic, Rochester, Minnesota, United States
United States
William F. Young, Jr., MD, MSc
Raymond R. Townsend, MD Tyson Family Endocrinology Clinical Professor, Professor of
Professor of Medicine, Perelman School of Medicine, Medicine, Mayo Clinic College of Medicine, Division
University of Pennsylvania, Philadelphia, Pennsylvania, of Endocrinology, Diabetes, Metabolism, and Nutrition,
United States Mayo Clinic, Rochester, Minnesota, United States
Katherine R. Tuttle, MD, FASN, FACP Salim Yusuf, DPhil, FRCPC, FRSC, OC
Executive Director for Research, Providence Health Care, Professor of Medicine, McMaster University, Hamilton,
Regional Principal Investigator and Clinical Professor Ontario, Canada; Executive Director, Population Health
of Medicine, Institute of Translational Health Sciences, Research Institute, Hamilton Health Sciences & McMaster
University of Washington School of Medicine, Spokane, University, Hamilton, Ontario, Canada
Washington, United States
Foreword
Hypertension has been recognized as an important cardiovas- Drs. George Bakris and Matthew Sorrentino have accepted
cular disorder since the dawn of the 20th century, when Riva- the baton and have brilliantly edited the third edition. They
Rocci and then Korotkoff described the sphygmomanometric have selected internationally recognized authorities as
method of measuring arterial pressure. Despite intense study authors, who have summarized the important research car-
since then, hypertension currently presents an extraordinary ried out in the last 5 years. This edition also includes rigorous
opportunity and challenge for investigators, teachers, health comparisons among the classes of antihypertensive drugs.
officials, and clinicians in the field. Hypertension has spread The volume also presents revised practice guidelines that
to the developing world and is reaching pandemic propor- synthesize much useful information for clinical practice. This
tions. More inclusive definitions as well as more accurate and comprehensive book will be of great value and interest to cli-
detailed measurements of blood pressure indicate that the nicians, investigators, and trainees in this important subspe-
prevalence and health threat of hypertension worldwide are cialty of cardiology.
even greater than previously thought.
The Companions to Heart Disease: A Textbook of Eugene Braunwald
Cardiovascular Medicine aim to provide cardiologists and Douglas P. Zipes
trainees with important additional information in critically Peter Libby
important segments of cardiology that go beyond what is Robert O. Bonow
contained in the “mother book,” thereby creating an exten- Douglas L. Mann
sive cardiovascular information system. The first two editions Gordon F. Tomaselli
of Hypertension, edited by Drs. Henry R. Black and William J.
Elliott, clearly accomplished this goal.
ix
Preface
There have been many books published dealing with the topic quelling a silent killer, hypertension. There are chapters in
of hypertension across a spectrum of diseases. However, it is the book that address some of these issues, but the only real
rare to find one source that has an encyclopedic and timely solution is a multipronged approach involving governmental
spectrum of topics across the disease spectrum with a focus policy makers, the pharmaceutical industry, payers, and the
on hypertension. This third edition of Hypertension has medical professionals. We hope you will find the book a valu-
expanded the topic variety from previous editions and pres- able resource to address a spectrum of questions surrounding
ents novel topics of emerging areas of hypertension. Examples the disease of hypertension.
include a chapter dealing with hypertension as an immune The book is divided into multiple parts including epide-
disease with a pathophysiology based on immune changes miology, mechanisms of hypertension, pathophysiology of
relating to inflammation rather than hemodynamic changes. disease, pharmacology of antihypertensive drugs, clinical
There is also a focused chapter dealing with sleep disorders, outcome trials, and guideline discussions focusing on process
not just sleep apnea, as a major cause of hypertension. Lastly, rather than what was produced.
there is a novel chapter on environmental pollution and its
contribution to endothelial dysfunction. In addition to these ACKNOWLEDGMENTS
new chapters, all other chapters have been consolidated and
updated with the latest information sourced from basic sci- We would like to thank our families and our wives especially
ence to clinical trials and guidelines so that information is for being supportive through this editing and writing process.
applicable to the clinician. We are especially thankful to all the authors that contributed
Although there are now more than 125 different antihy- time and effort and produced excellent chapters for your
pertensive medications, blood pressure control rates around reading knowledge and pleasure.
the world vary from as low as 15% in some Southeast Asian
countries to over 50% in North America. Clearly, this does George L. Bakris, MD, FASN, FAHA, FASH
not relate to the price of medication but rather to individual Matthew J. Sorrentino, MD, FACC, FASH
patients, understanding, attitudes, and behaviors toward
xi
Braunwald’s Heart Disease Family of Books
xv
xvi
KORMOS AND MILLER MANN AND FELKER
Mechanical Circulatory Heart Failure
Support
Braunwald’s Heart Disease Family of Books
CREAGER, BECKMAN,
OTTO AND BONOW
AND LOSCALZO
Valvular Heart Disease
Vascular Medicine
xvii
KRAMER AND HUNDLEY BHATT
Atlas of Cardiovascular Cardiovascular Intervention
Magnetic Resonance
MORROW
Myocardial Infarction
Systemic arterial hypertension is the condition of persistent, that the prevalence of hypertension among adults 18 years
nonphysiologic elevation of systemic blood pressure (BP). It of age and older in the U.S. was 29%, or nearly one in three
is typically defined as a resting systolic BP (SBP) 140 mm Hg adults, with 30% of men and 28.1% of women affected.3
or higher, or diastolic BP (DBP) 90 mm Hg or higher, or receiv- In the context of the entire population, approximately 80
ing therapy for the indication of BP-lowering.1 Hypertension million U.S. adults are estimated to have hypertension.
afflicts a substantial proportion of the adult population world- Despite significant advances in our understanding of the
wide, and a growing number of children. Numerous genetic, risk factors, pathogenesis, and sequelae of hypertension,
environmental, and behavioral factors influence the develop- and multiple trials over the past 5 decades indicating the
ment of hypertension. In turn, hypertension has been identi- benefits of antihypertensive therapy, hypertension remains
fied as one of the major causal risk factors for cardiovascular a significant public health problem. Although there were
disease (CVD), including heart disease, peripheral vascular steady and significant reductions over the last 4 decades
disease and stroke, as well as renal disease. An understand- in population levels of BP and prevalence of hypertension
ing of the basic epidemiology of hypertension is essential for in the U.S., recent data indicate a plateau in these favor-
effective public health and clinical efforts to prevent, detect, able trends. Between the late 1970s and the mid-1990s, the
treat, and control this common condition. prevalence of hypertension in the U.S. declined from about
32% to 25%.4,5 However, more recent survey data indicate
EPIDEMIOLOGY AND RISK FACTORS that there was an increase in prevalence between 1988 to
1994 and 1999 to 2002. The prevalence appears to have
An epidemiologic association between a proposed risk factor been stable from 1999 to 2014, however, at approximately
and a disease is likely to be causal if it fulfills the following 29%.3,6 The current pandemic of obesity and aging of the
criteria: (1) exposure to the proposed risk factor precedes population are likely to increase rates of hypertension sub-
the onset of disease; (2) there is a strong association between stantially over the next decades.
exposure and incidence of disease; (3) the association is dose- Huffman et al examined trends in SBP levels in the U.S. from
dependent; (4) exposure is consistently predictive of disease 1991 to 2008.7 They observed that SBP levels declined in US
in a variety of populations; (5) the association is independent adults during this time period. However, there were significant
of other risk factors; and (6) the association is biologically and differences noted when stratified by age group in men and
pathogenetically plausible, and is supported by animal experi- women. In the overall population, SBP declined significantly
ments and clinical investigation.2 In addition, more definitive only in those older than 60 years of age, from an average of
support for a causal association between a proposed risk fac- 139 to 133 mm Hg, whereas in younger and middle-aged indi-
tor and disease may arise from clinical trials in which inter- viduals, SBP levels were essentially unchanged. Patterns were
vention to modify or abolish the risk factor (by behavioral or similar among untreated individuals, with untreated men over
therapeutic means) is associated with a decreased incidence age 60 years experiencing an 11 mm Hg decline and women a
of the disease. As discussed later, hypertension fulfills all of 6 mm Hg decline in mean SBP from 1991 to 2008, and stable
these criteria, and represents an important target for inter- mean SBP in younger individuals. Among treated individu-
vention in reducing the population and individual burden of als, mean SBP levels declined from 1991 to 2008 in men and
CVD and renal disease. women of all age groups.7
African Americans, and especially African-American
PREVALENCE AND SECULAR TRENDS women, have a prevalence of hypertension that is among the
highest in the world. Currently, it is estimated that 41.2% of
Data from recent United States National Health and Nutrition non-Hispanic African-American adults have hypertension
Examination Surveys (NHANES) from 2011 to 2014 indicated (including 40.8% of men and 41.5% of women), compared with
1
2
TABLE 1.1 Trends in Prevalence, Awareness, Treatment and Control of Hypertension in the United States, From the
I National Health and Nutrition Examination Surveys
Epidemiology
sion is highest in the southeastern U.S., but so are awareness, Data from Nwankwo T, Yoon SS, Burt V, Gu Q. Hypertension among adults in the
treatment and control of hypertension. Areas of the south- United States: National Health and Nutrition Examination Survey, 2011–2012. NCHS
data brief, no 133. Hyattsville, MD: National Center for Health Statistics;2013.
western U.S. in New Mexico, Colorado, and Texas have some
of the lowest rates of awareness, treatment and control.10
of diseases.11,12 Fig. 1.2 reveals the estimated proportion of
deaths attributable to high systolic blood pressure by country
Global Burden of Hypertension across the globe. There is substantial variation globally and
International data indicate that hypertension is even more regionally, with the lowest proportion of deaths attributable
prevalent in other countries, including developed countries. to high systolic blood pressure in Chad, at 3.8%, and the high-
Hypertension is also the leading single cause of global burden est in Georgia, at 40.4%.13
3
FIG. 1.2 Percentage of deaths attributable to high systolic blood pressure worldwide for both sexes and all ages. Global Burden of Diseases study 2013. (Data from Institute for
Health Metrics and Evaluation [IHME]. GBD Compare. Seattle, WA: IHME, University of Washington, 2015. Available from http://vizhub.healthdata.org/gbd-compare/. Accessed
April 20, 2016.)
Although data from low-income and middle-income coun- practice guidelines have typically recommended higher BP
tries around the world had been sparse, in recent years the thresholds before initiation of drug therapy, causing even
scope and trends in the global burden of hypertension have lower rates of treatment and control of BP.14,16 Of the European
become clearer. Danaei and colleagues14 described the cur- countries studied, Italy had the lowest prevalence (38%),
rent levels and trends in SBP for adults 25 years and older whereas Germany had the highest (55%).15 The increase in BP
in 199 countries using data from published and unpublished and in prevalence of hypertension with age has been steeper
health examination surveys and epidemiologic studies includ- in European countries compared with the U.S. and Canada.
ing 5.4 million participants. In 2008, age-standardized mean The correlation between hypertension prevalence and stroke
SBP worldwide was 128.1 mm Hg in men and 124.4 mm Hg mortality rates is very strong (r = 0.78), with a stroke mor-
in women. The investigators estimated that between 1980 tality rate of 27.6 per 100,000 in North America and 41.2 per
and 2008, global SBP decreased by 0.8 mm Hg per decade 100,000 in European countries.15 Furthermore, treatment
in men and 1.0 mm Hg per decade in women. There was sig- rates in Europe have been substantially lower, in association
nificant regional variation in SBP trends over time. Female with higher BP thresholds for treatment in clinical practice
SBP decreased by 3.5 mm Hg or more per decade in Western guidelines promulgated in Europe and Canada until recently.
Europe and Australasia. Male SBP fell most, by 2.8 mm Hg per Among 35- to 64-year-old hypertensives, over half (53%) were
decade in high-income North America. SBP rose in Oceania, treated in the U.S., compared with 36% in Canada and 25%
East Africa, and South and Southeast Asia for both sexes, and to 32% in European countries. The associated differences in
in West Africa for women. Female SBP was highest in some levels of BP control were dramatic, with 66% of U.S., 49% of
East and West African countries, with means of 135 mm Hg Canadian, and 23% to 38% of European hypertensives con-
or greater. Male SBP was highest in Baltic and East and West trolled to BP levels of less than 160/95 mm Hg, and 29%, 17%,
African countries, at 138 mm Hg or more. Men and women in and 10% or lower, respectively, controlled to levels of less
Western Europe had the highest SBP in high-income regions. than 140/90 mm Hg.16
SBP is currently highest in low-income and middle-income
countries overall, creating a substantial burden of disease in RISK FACTORS FOR HYPERTENSION
these countries.14
Surveys of the prevalence of hypertension indicate a grow- Hypertension is a complex phenotype with multiple genetic
ing global burden. Using data from the 1990s, the prevalence and environmental risk factors, as well as important
of hypertension in adults aged 35 to 74 years in Canada has gene-environment interactions. Age, with its concomitant
generally been similar to that of the U.S. (at approximately changes in the vasculature, and demographic and socio-
28%), and concurrent data from six European countries economic variables are among the strongest risk factors for
revealed an overall prevalence of 44%.15 In Europe, clinical hypertension.
4
Age hypertension among obese individuals, with a body mass
I The prevalence of hypertension increases sharply with index (BMI) 30 kg/m2 or higher, is 42.5%, compared with 27.8%
advancing age: although only 8.6% of men and 6.2% of women for overweight individuals (25 to 29.9 kg/m2), and 15.3% for
Epidemiology
ages 20 to 34 years are affected, 76.4% of men and 79.9% of individuals with BMI less than 25 kg/m2.23 Comparing NHANES
women aged 75 years and over have hypertension (Fig. 1.3).9 1988-1994 with NHANES 1999-2004, Cutler et al found an over-
Thus, in older patients, hypertension is by far the most preva- all increase in the prevalence of hypertension by 13% in men
lent risk factor for CVD. About 81% of hypertensive individu- and 24% in women. After adjustment for BMI, there was no
als in the U.S. are aged 45 years and older, although this group statistically significant change in hypertension in men, indi-
comprises only 46% of the U.S. population.17 With the aging of cating that the increase in BMI accounted for nearly all of the
the population, the overall prevalence of hypertension in the increase in hypertension in men. For women, after adjust-
population is sure to increase. ment for BMI, there continued to be large relative increases
Viewed from another perspective, hypertension already in the prevalence of hypertension, indicating that some of the
affects more individuals during their lifespan than any other trait increases in hypertension in women were attributable to fac-
or disease studied to date. The concept of the “lifetime risk” of a tors other than their increases in BMI in the recent NHANES
given disease provides a useful measure of the absolute burden period.
and public health impact of a disease, as well as providing an Data from Framingham also reveal marked increases in risk
average risk for an individual during his or her lifetime. Lifetime for development of hypertension with higher BMI. Compared
risk estimates account for the risk of developing disease dur- with normal weight adult men and women, the multivariable-
ing the remaining lifespan and the competing risk of death from adjusted relative risks for development of hypertension in
other causes before developing the disease of interest. Data from long-term follow up were 1.48 and 1.70 for overweight men
the Framingham Heart Study (FHS), a longstanding study of CVD and women, and 2.23 and 2.63 for obese men and women,
epidemiology, indicate that, for men and women free of hyper- respectively.24
tension at age 55, the remaining lifetime risks for development Numerous studies have also demonstrated the important
of hypertension through age 80 are 93% and 91%, respectively. role of weight gain in BP elevation and weight reduction in
In other words, more than 9 out of 10 older adults will develop BP lowering. As discussed above, SBP and DBP tend to rise
hypertension before they die. Even those who reach age 65 free with age beginning at around age 25 years in most adults.19,20
of hypertension still have a remaining lifetime risk of 90%.18 However, recent data indicate that these “age-related”
In Western societies, SBP tends to rise monotonically and increases in SBP and DBP may be avoided in young adults who
inexorably with advancing age. Conversely, DBP levels rise maintain stable BMI over long-term follow up. In the Coronary
until about age 50 to 55 years, after which there is a plateau Artery Risk Development In young Adults (CARDIA) study,
for several years and then a steady decline to the end of the those who maintained a stable BMI at all six examinations
usual lifespan.15,19,20 A variety of factors, particularly related over 15 years had no significant changes in either SBP or DBP,
to changes in arterial compliance and stiffness,21,22 contribute whereas those who had an increase in their BMI of 2 kg/m2 or
to the development of systolic hypertension and to decreas- more had substantial increases in BP.25
ing DBP with age. Both of these phenomena contribute to a The influence of weight gain on BP, and the benefits of
marked increase in pulse pressure (PP), defined as SBP minus maintaining stable weight or losing weight extend down even
DBP, after age 50 years. Thus, hypertension, and particularly to young children. One large birth cohort study of children
systolic hypertension, is a nearly universal condition of aging, examined BMI at ages 5 and 14 and the association with SBP
and few individuals escape its development. Only in societies and DBP at age 14. Children who were overweight at age 5 but
where salt intake is low, physical activity levels are very high, had normal BMI at age 14 had similar mean systolic and dia-
and obesity is rare, are age-related increases in SBP avoided. stolic BP to those who had a normal BMI at both time points.
Conversely, children who were overweight at both ages, or
who had a normal BMI at age 5 and were overweight at age
Weight 14, had higher systolic and diastolic BP at age 14 than those
Increasing weight is one of the major determinants of who had a normal BMI at both ages, even after adjustment for
increasing BP. In recent NHANES surveys, the prevalence of potential confounders.26
diet and in BMI between less educated and more educated CLASSIFICATION OF BLOOD PRESSURE
individuals.30 1
Among dietary influences on BP level, high dietary sodium Formal classification of BP stages by consensus panels
all participants, 96% were correctly classified by knowledge risks for all manifestations of CVD, but its relative impact is
I of their SBP alone, whereas only 68% were correctly classified greatest for stroke and HF (Fig. 1.5). Because CHD incidence
by knowledge of the DBP alone. Thus, SBP elevation out of is greater than incidence of stroke and HF, however, the abso-
Epidemiology
proportion to DBP is common in middle-aged and older per- lute impact of hypertension on CHD is greater than for other
sons, and SBP appears to play a greater role in the determina- manifestations of CVD, as demonstrated by the excess risks
tion of BP stage and eligibility for therapy.36 Among younger shown in Fig. 1.5.
individuals, upstaging because of DBP is somewhat more To illustrate the importance of hypertension as a risk
common. However, after the age of 50 years, which includes factor, let us consider the case of HF. Between 75% and 91%
the vast majority of hypertensives, upstaging because of SBP of individuals who develop HF have antecedent hyperten-
clearly occurs for an overwhelming proportion of the popula- sion.41,42 In a study from the FHS, hypertension conferred a
tion and determines hypertensive status and/or eligibility for hazard ratio for the development of HF of approximately 2 for
therapy.38 men and 3 for women over the ensuing 18 years.42 As shown
Isolated systolic hypertension in older people reflects in Fig. 1.6, the hazard ratios for HF associated with hyper-
progressive large artery stiffening seen with aging. In tension (2 to 3) were far lower than the hazard ratios for HF
younger hypertensive patients, isolated diastolic hyperten- associated with MI, which were greater than 6 for both men
sion (SBP <140 and DBP ≥90 mm Hg) and systolic-diastolic and women. However, the population prevalence of hyper-
hypertension (SBP ≥140 and DBP ≥90 mm Hg) tend to pre- tension was 60%, compared with approximately 6% for myo-
dominate, whereas beyond age 50, isolated systolic hyper- cardial infarction. Therefore, the population-attributable risk
tension (ISH, SBP ≥140 and DBP <90 mm Hg) predominates. (PAR) of HF, that is, the fraction of HF in this population that
ISH is the most common form of hypertension over age 60, was because of hypertension, was 59% in women and 39% in
being present in more than 80% of untreated hypertensive men. The PARs for MI were 13% and 34% for women and men,
men and women.38 respectively.42
These observations, coupled with data on risks of systolic Investigators from the comprehensive Olmsted County
hypertension and the benefits of treating systolic hyperten- cohort in Minnesota have also estimated PARs for various
sion, prompted the National High Blood Pressure Education HF risk factors. In that study, the relative risks for HF were
Program’s Advisory Panel to recommend a major paradigm again high for CHD and DM, with odds ratios of 3.05 and
shift in 2000 in urging that SBP become the major criterion for 2.65, respectively, whereas the odds ratio associated with
the diagnosis, staging, and therapeutic management of hyper- hypertension was 1.44. However, hypertension was preva-
tension, particularly in middle-aged and older Americans.22 lent in two-thirds of the cohort. The PAR was highest for
This recommendation was incorporated into the staging CHD and hypertension; each accounted for 20% of (HF)
system and treatment guidelines for JNC 7 and subsequent cases in the population overall, although CHD accounted
guidelines.1,35 for the greatest proportion of cases in men (PAR 23% for
CHD versus 13% for hypertension) and hypertension was of
SEQUELAE AND OUTCOMES WITH greatest importance in women (PAR 28% for hypertension
HYPERTENSION versus 6% for CHD).43
80 80
1
Optimal BP (<120/<80) Optimal BP (<120/<80)
60 High-normal BP (SBP 130–139 or DBP 85–89) 60 High-normal BP (SBP 130–139 or DBP 85–89)
Stage 1 HTN (SBP 140–159 or DBP 90–99) Stage 1 HTN (SBP 140–159 or DBP 90–99)
Stage ≥ 2 HTN (SBP ≥ 160 or DBP ≥ 100) Stage ≥ 2 HTN (SBP ≥ 160 or DBP ≥ 100)
40 40
20 20
0 0
Total Chol 200 240 240 240 240 240 Total Chol 200 240 240 240 240 240
HDL-Chol 45 45 35 35 35 35 HDL-Chol 45 45 35 35 35 35
Diabetes – – – + + + Diabetes – – – + + +
Smoker – – – – + + Smoker – – – – + +
Anti-HTN Rx – – – – – + Anti-HTN Rx – – – – – +
A 60-Year-Old White Man B 60-Year-Old Black Man
80 80
Optimal BP (<120/<80) Optimal BP (<120/<80)
Normal BP (SBP 120–129 or DBP 80–84) Normal BP (SBP 120–129 or DBP 80–84)
60 High-normal BP (SBP 130–139 or DBP 85–89) 60 High-normal BP (SBP 130–139 or DBP 85–89)
Stage 1 HTN (SBP 140–159 or DBP 90–99) Stage 1 HTN (SBP 140–159 or DBP 90–99)
Stage ≥ 2 HTN (SBP ≥ 160 or DBP ≥ 100) Stage ≥ 2 HTN (SBP ≥ 160 or DBP ≥ 100)
40 40
20 20
0 0
Total Chol 200 240 240 240 240 240 Total Chol 200 240 240 240 240 240
HDL-Chol 45 45 35 35 35 35 HDL-Chol 45 45 35 35 35 35
Diabetes – – – + + + Diabetes – – – + + +
Smoker – – – – + + Smoker – – – – + +
Anti-HTN Rx – – – – – + Anti-HTN Rx – – – – – +
C 60-Year-Old White Woman D 60-Year-Old Black Woman
FIG. 1.4 Predicted 10-year risk for atherosclerotic cardiovascular disease by increasing burden of risk factors and systolic blood pressure, in a 60-year-old white man
(Panel A), African-American man (Panel B), white woman (Panel C), and African-American woman (Panel D), based on the Pooled Cohort Equations.66 ASCVD, Athero-
sclerotic cardiovascular disease; BP, blood pressure; DBP, diastolic blood pressure; HDL-Chol, high-density lipoprotein cholesterol; HTN, hypertension; SBP, systolic blood
pressure.
DBP. For example, at an SBP of 150 mm Hg, the estimated haz- the PAR for CVD conferred by SBP vastly outweighs the PAR
ards ratio for CHD was 1.8 if the DBP was 70 mm Hg, but only for DBP. Finally, lack of control to goal BP in the community
approximately 1.3 if the DBP was 95 mm Hg. The higher the appears to be overwhelmingly because of lack of SBP control
SBP level, the steeper the decline in CHD risk with increas- to less than 140 mm Hg.38,49,50
ing DBP.48 These data provide some compelling evidence for In national samples, significant cross-sectional predictors
the importance of PP as a measure of risk, because PP repre- of lack of BP control among those who are aware of their
sents the difference between SBP and DBP, and higher risk was hypertension include age 65 years or older, male sex, and no
observed in this study when the PP widened.48 Pulse pressure visits to a physician in the preceding 12 months.50 Age and the
will be discussed in greater detail later. presence of LVH likely represent higher initial SBP before ini-
The increased risks associated with SBP are clear. When it tiation of therapy and longer duration of hypertension, both
is also appreciated that systolic hypertension out of propor- of which can contribute to greater difficulty in achieving lower
tion to diastolic elevation is by far the most common form BP levels. In addition, it appears likely that clinicians are reluc-
of hypertension, as discussed earlier, it becomes clear that tant to treat older hypertensive individuals to lower BP goals,
8
70
I
60
Expected rate
50
36
40
23
30
21
20
29 12
10 22
14 9 5 10
9 4 5 4
3 2 5 2 4 2
0
Men Women Men Women Men Women Men Women Men Women
All CVD CHD Stroke PAD HF
Age-adjusted relative risk associated with hypertension
Men 2.2 2.0 3.8 2.0 4.0
Women 2.5 2.2 2.6 3.7 3.0
FIG. 1.5 Age-adjusted biennial rates, relative risks and absolute excess risks associated with hypertension for different cardiovascular endpoints: Framingham Study, 36-Year
follow-up, persons aged 35-64 years. CVD, Cardiovascular disease; CHD, coronary heart disease; HF, heart failure; HTN, hypertension; PAD, peripheral arterial disease.
60
Men
Population attributable risk (%)
Women
40
20
10
0
HTN MI AP VHD LVH DM
Hazards ratio for CHF
Men 2.07 6.34 1.43 2.47 2.19 1.82
Women 3.35 6.01 1.68 2.13 2.85 3.73
TABLE 1.4 Risks for Cardiovascular Disease Associated With Different Components of Blood Pressure in the Cardiovascular
Health Study
1 STANDARD ADJUSTED HAZARDS RATIO (95% CI)
DEVIATION Myocardial Infarction Stroke
Systolic Blood Pressure 21.4 mm Hg 1.24 (1.15-1.35) 1.34 (1.21-1.47)
Diastolic Blood Pressure 11.2 mm Hg 1.13 (1.04-1.22) 1.29 (1.17-1.42)
Pulse Pressure 18.5 mm Hg 1.21 (1.12-1.31) 1.21 (1.10-1.34)
CI, Confidence interval.
Data from Psaty BM, Furberg CD, Kuller LH, et al. Association between blood pressure level and the risk of myocardial infarction, stroke, and total mortality. Arch Intern Med.
2001;161:1183-1192.
9
4.0
1
3.5 DBP
2.5 2.4
Relative risk
2.0 1.8
1.7
1.5
1.5 1.3
1.2 1.2
1 1
1.0
0.5
0.0
1 2 3 4 5
A Blood pressure quintile
4.0 3.82
DBP
3.5
SBP
2.9
3.0
2.71
2.5
Relative risk
2.31
1.99
2.0 1.75 1.78 1.81
3.0 1.62
1.5 1.31 1.39 1.4
1.24 1.31
1.19 1.18
1 1 1.03
1.0
0.5
0.0
1 2 3 4 5 6 7 8 9 10
B Blood pressure decile
FIG. 1.7 Relative risks for coronary heart disease mortality among men screened for the Multiple Risk Factor Intervention Trial, by quintiles (Panel A) or deciles (Panel B) of
systolic and diastolic blood pressure. DBP, Diastolic blood pressure; SBP, systolic blood pressure.
perhaps as a result of concerns over orthostasis and risk for of large epidemiologic cohorts, and including data on more
falls, polypharmacy, or the controversial observation that than 56,000 decedents, demonstrated that risks for CVD death
there may be an increase in CVD events and mortality among increase steadily beginning at least at levels as low as an SBP
the oldest hypertensives when DBP is lowered below 60 or 65 of 115 mm Hg and DBP of 75 mm Hg. When considered in isola-
mm Hg (the J-shaped curve phenomenon).51 tion, for each 20 mm Hg higher SBP and each 10 mm Hg higher
ISH has been clearly demonstrated as a risk factor for DBP, there is approximately a doubling of risk for stroke death
adverse CVD outcomes in older individuals, but there has and ischemic heart disease death for both men and women.39
been some debate as to its importance in younger adults, in Similarly, the large data set of more than 347,000 men aged
whom it was felt to represent measurement artifact or labile 35 to 57 years screened for the MRFIT provides a precise esti-
blood pressure without significant consequences. Yano et al52 mate of incremental CVD risk beginning at lower BPs. The data
recently examined 31-year follow up of 27,000 men and women from the MRFIT screenees, shown in Fig. 1.8A, confirm a con-
aged 18 to 49 years in the Chicago Heart Association Detection tinuous, graded influence of SBP on multivariable-adjusted rel-
Project in Industry. They observed that, compared with those ative risk for CHD mortality beginning at BP levels well below
who had normal BP levels, men with ISH had significant 23% 140 mm Hg.53 Men with SBP of 150 to 159 mm Hg have over
and 28% higher hazards for CVD and CHD mortality. In women three times the risk and men with SBP greater than 180 mm
with ISH, hazard ratios were 1.55 (95% confidence interval 1.18 Hg nearly six times the risk of men with SBP less than 100 mm
to 2.05) and 2.12 (1.49 to 3.01), respectively.52 These data may Hg. These data also make an important point about BP levels
cause guidelines to change their approach to ISH in the young. in the population at which the majority of CVD events occur.
In Fig. 1.8B, the numbers above each bar indicate the number
of men in that stratum of SBP at baseline. Taking into account
Risk Across the Spectrum of Blood Pressure and the number of men in each stratum and the expected rates
the Importance of Stage 1 Hypertension of CHD death, the CHD death rates observed in the MRFIT
As noted above, increasing BP is associated with increasing screenee cohort indicate excess CHD deaths occurring at
risks for CVD, beginning at levels well within the so-called the rates indicated by the line in Fig. 1.8C. The proportion of
“normal” range. The Prospective Studies Collaboration, a pool- excess CHD deaths by SBP stratum is indicated in Fig. 1.8D. As
ing study of around 1,000,000 men and women in a number shown, nearly two-thirds of excess CHD deaths occurred in
10
6 6 3,191
I
Epidemiology
5 5
4,013
4 4
Adjusted RR
Adjusted RR
9,308
21,477
3 3
44,388
2 2 79,308
98,834
66,080
21,379
1 1
0 0
<110 110– 120– 130– 140– 150– 160– 170– 180+ <110 110– 120– 130– 140– 150– 160– 170– 180+
119 129 139 149 159 169 179 119 129 139 149 159 169 179
A SBP (mm Hg) B SBP (mm Hg)
4 4
Adjusted RR
Adjusted RR
15 15
3 3
10 10
2 2
5 5
1 1
0 0 0 0
<110 110– 120– 130– 140– 150– 160– 170– 180+ <110 110– 120– 130– 140– 150– 160– 170– 180+
119 129 139 149 159 169 179 119 129 139 149 159 169 179
C SBP (mm Hg) D SBP (mm Hg)
FIG. 1.8 Relative risks for coronary heart disease (CHD) mortality among screenees for the Multiple Risk Factor Intervention Trial by level of systolic blood pressure (SBP; Panel
A), with: number of men in each stratum of SBP (Panel B); distribution of excess CHD deaths by SBP stratum (Panel C); and distribution of excess CHD deaths by Joint National
Committee stage (Panel D).
men with SBP between 130 and 159 mm Hg, relatively “mild” the DBP, the mean arterial pressure, and the SBP. As discussed
levels of elevated BP. These findings were recently replicated earlier, Franklin et al demonstrated that increasing PP was
in the more contemporary Framingham and Atherosclerosis associated with marked increases in hazard of CHD for subjects
Risk in Communities cohorts.54 with the same SBP.48 Chae et al also found that PP was an inde-
Data from the FHS also indicate that the risk associated pendent predictor of HF in an elderly cohort, even after adjust-
with BPs in the range of 130 to 139 mm Hg systolic or 85 to ment for mean arterial pressure, prevalent CHD, and other HF
89 mm Hg diastolic are substantial, despite the fact that these risk factors.57 In another study, Haider and colleagues observed
levels are not classified as “hypertension.” These levels of that SBP and PP conferred similar risk for HF.58 However, other
BP are associated with significantly elevated multivariable- studies have found that SBP confers greater risk than PP, when
adjusted relative risks for CVD of 2.5 in women and 1.6 in SBP and PP are considered separately or as covariates in the
men.55 Likewise, individuals with SBP between 120 and 139 same multivariable model.45 The aforementioned Prospective
mm Hg or DBP between 80 and 89 mm Hg have a high likeli- Studies Collaboration, which pooled data from 61 large epide-
hood of progressing to definite hypertension over the next 4 miologic studies and around 1,000,000 men and women, found
years, especially if they are age 65 or older.56 that the best measure of BP for prediction of CVD events was
the mean of SBP and DBP, which predicted better than SBP or
DBP alone, and much better than the PP.39 The recommenda-
Pulse Pressure and Risks for Cardiovascular tion of JNC 7 was that clinical focus should remain on the SBP in
Disease determining need for therapy and achieving goal BP.1
Pulse pressure is defined as the systolic minus the diastolic BP. Mosley and colleagues compared the predictive utility of
In recent years there has been intense interest in PP as a risk PP and other BP measures for diverse CVD outcomes (includ-
factor for CVD. However, various investigators have struggled ing hospitalizations and mortality from stroke, MI and HF) using
with how best to “anchor” the PP. For example, a patient with a long-term follow-up data from the Chicago Heart Association
BP of 120/60 has the same PP (60 mm Hg) as a patient with a BP Detection Project in Industry.59 Baseline BP measures were
of 150/90, although the latter patient is clearly at higher risk for assessed for predictive utility for fatal and nonfatal events over
adverse events. Different investigators have anchored the PP to 33 years. Among 36,314 participants, who were a mean age of 39
11
years, 43.4% were women. In univariate analyses, hazards ratios Risk Group A – No risk factors, clinical CVD or target organ damage
for stroke death per one standard deviation of PP, SBP, and DBP, Risk Group B – 1 or more risk factors 1
respectively, were 1.49, 1.75, and 1.71. Multiple metrics all indi- Risk Group C – Diabetes, clinical CVD, or target organ damage
been termed the “metabolic syndrome.” Visceral adiposity and antihypertensive therapy across strata of baseline absolute
I insulin resistance appear to play central roles in the develop- predicted 5-year CVD risk. In 51,917 participants from 11 trials
ment of MS and elevated BP is a key diagnostic feature.65 In 4167 (8%) had a cardiovascular event during a median of 4.0
Epidemiology
some ethnicities, such as African Americans, elevated BP is the years (interquartile range 3.4–4.4) of follow up. The mean esti-
most common criterion leading to diagnosis of the metabolic mated baseline levels of 5-year cardiovascular risk for each of
syndrome. Hypertension confers increased risk for CVD in the four increasing risk strata were 6.0%, 12.1%, 17.7%, and 26.8%.
absence of risk factors, but absolute risk increases dramatically In each consecutive higher risk group, blood pressure-lowering
when other risk factors are present, as shown in Fig. 1.4. treatment reduced the relative risk of cardiovascular events
by 18% (95% CI 7–27), 15% (4–25), 13% (2–22), and 15% (5–24),
GLOBAL RISK ASSESSMENT AS A STRATEGY respectively (p = 0.30 for trend). However, in terms of absolute
FOR HYPERTENSION TREATMENT risk reduction, treatment was more efficient for higher risk than
lower risk individuals. Treating 1000 patients in each group with
For many international and U.S. clinical practice guidelines, espe- blood pressure-lowering treatment for 5 years would prevent 14
cially in the area of cholesterol-lowering therapy to prevent inci- (95% CI 8–21), 20 (8–31), 24 (8–40), and 38 (16–61) cardiovascular
dent CVD, the paradigm for the past two decades has been that events, respectively (p = 0.04 for trend). Similarly, Eddy et al used
the intensity of preventive treatment should match the absolute simulation modeling to estimate that risk-based approaches to
risk of the patient for developing disease. In other words, patients treatment of hypertension would be far more efficient than cur-
at low absolute risk for having a CVD event in the near term should rent BP threshold-based decisions, treating fewer patients to pre-
pursue lifestyle modification as needed, but typically should not vent the same number of CVD events, or preventing more CVD
be treated with drug therapy, given the concomitant costs and events for the same cost as guideline-directed BP thresholds.68
potential side effects. Patients at high enough risk should pursue
both lifestyle modification and drug therapy when their risk is IMPORTANCE OF PREVENTING THE
above the threshold where net clinical benefit has been demon- DEVELOPMENT OF ELEVATED BLOOD PRESSURE
strated and could be expected to accrue to the patient. In this
paradigm, guidelines use multivariable equations to predict the As noted earlier, BP levels tend to rise from young adulthood
10-year risk for CVD to estimate the risk for a given patient and to the end of life. Once hypertension has been diagnosed,
aid in decision making. In the U.S., recent cholesterol guidelines many effective lifestyle interventions and drug therapies can
in 2002 and 2013 adopted multivariable risk scores as decision lower blood pressure, with dramatic reduction in CVD risk.
aids. The 2013 American College of Cardiology/American Heart However, it has been an open question as to whether treat-
Association prevention guidelines developed and promulgated ment to lower BP once hypertension is diagnosed could
the Pooled Cohort Equations, based on data from 25,000 white fully reduce risk for CVD events to the low levels observed
and African-American men and women aged 40 to 79 years, to pre- in individuals whose blood pressure always remained low.
dict 10-year risks for CHD death, nonfatal myocardial infarction, Liu et al69 recently used data from the Multi-Ethnic Study of
or fatal or nonfatal stroke.66 These equations form the basis of the Atherosclerosis (MESA) to examine this issue. Outcomes were
data presented in Fig. 1.4, in which it is clear that BP levels (and compared between participants without or with antihyperten-
the requirement for antihypertensive therapy) contribute signifi- sive treatment at three BP levels: less than 120/80 mm Hg, sys-
cantly to the prediction of CVD risk. Gaziano and colleagues67 tolic BP 120 mm Hg to 139 mm Hg or diastolic BP 80 mm Hg to
have also promulgated a risk score that does not require the use 89 mm Hg, and systolic BP 140 mm Hg or higher or diastolic BP
of laboratory-based data, such as total cholesterol levels, instead 90 mm Hg or higher (systolic BP ≥130 or diastolic BP ≥80 mm
using all clinic-based values to predict CVD risk. In those equa- Hg for participants with diabetes). Among MESA participants
tions, which have shown good predictive utility in a variety of aged 50 years or over at baseline, those with BP lower than
international settings, body mass index is substituted for choles- 120/80 mm Hg on treatment had higher left ventricular mass
terol with good maintenance of predictive utility. index, prevalence of estimated glomerular filtration rate less
BP guidelines have generally not adopted this approach, than 60 mL/min per 1.73 m2, prevalence of coronary calcium
instead continuing to use absolute BP levels, rather than abso- score greater than 100, and twice the incident cardiovascular
lute levels of CVD risk, as thresholds for initiation of drug disease rate over 9.5 years of follow up than those with BP
therapy. However, increasing data suggest that risk-based lower than 120/80 mm Hg without treatment. At higher levels
treatment approaches may have a role for BP management as of BP, those who were treated to a given BP level also tended
well. Sundstrom et al recently used data from the large Blood to be at greater risk for CVD compared with those whose
Pressure Lowering Treatment Trialists’ Collaboration to exam- BP was at the same level without treatment (Table 1.5).69
ine the relative and absolute risk reductions associated with The data suggest that, based on the current approach,
TABLE 1.5 Multivariable–Adjusted Hazard Ratios for all Cardiovascular Disease, Coronary Heart Disease, Heart Failure
and Stroke, Stratified by Baseline Blood Pressure and Antihypertensive Treatment Status in 5798 Multi-Ethnic Study of
Atherosclerosis Participants
MULTIVARIABLE-ADJUSTED HAZARD RATIO (95% CI)
BP <120/<80 MM HG SBP 120-139 OR DBP 80-89 MM HG SBP ≥140 OR DBP ≥90 MM HG
AT BASELINE AT BASELINE AT BASELINE
NO. OF Treated and Well Treated and Treated and
OUTCOME EVENTS Untreated Controlled Untreated Controlled Untreated Uncontrolled
CVD 603 1.0 (ref) 2.19 (1.56, 3.07) 1.42 (1.03, 1.95) 2.21 (1.60, 3.05) 2.76 (2.04, 3.72) 2.96 (2.20, 3.97)
CHD 423 1.0 (ref) 2.02 (1.37, 2.97) 1.29 (0.89, 1.86) 2.09 (1.45, 3.03) 2.28 (1.60, 3.25) 2.52 (1.79, 3.55)
HF 226 1.0 (ref) 1.70 (0.92, 3.12) 1.41 (0.80, 2.51) 2.42 (1.40, 4.19) 2.43 (1.42, 4.15) 3.04 (1.83, 5.04)
Stroke 171 1.0 (ref) 2.56 (1.25, 5.28) 1.76 (0.90, 3.45) 3.13 (1.62, 6.09) 4.20 (2.27, 7.76) 4.67 (2.55, 8.56)
BP, Blood pressure; CHD, coronary heart disease; CI, confidence interval; CVD, cardiovascular disease; DBP, diastolic blood pressure; HF, heart failure; SBP, systolic blood pressure.
Data from Liu K, Colangelo LA, Daviglus ML, et al. Can antihypertensive treatment restore the risk of cardiovascular disease to ideal levels? The Coronary Artery Risk
Development in Young Adults (CARDIA) Study and the Multi‐Ethnic Study of Atherosclerosis (MESA). J Am Heart Assoc. 2015;4: e002275.
13
antihypertensive treatment that is begun after significant BP 23. Wang Y, Wang QJ. The prevalence of prehypertension and hypertension among US
adults according to the new Joint National Committee guidelines. Arch Intern Med.
elevation (typically to 140 mm Hg systolic) does not restore 2004;164:2126-2134.
1
cardiovascular disease risk to ideal levels. Emphasis should 24. Wilson PWF, D’Agostino RB, Sullivan L, Parise H, Kannel WB. Overweight and obesity
61. Yano Y, Ning H, Allen N, et al. Long-term blood pressure variability throughout young 66. Goff DC, Lloyd-Jones DM, Bennett G, et al. 2013 ACC/AHA Guideline on the Assessment
adulthood and cognitive function in midlife: the Coronary Artery Risk Development in of Cardiovascular Risk: a Report of the American College of Cardiology/American Heart
I Young Adults (CARDIA) Study. Hypertension. 2014;64:983-988. Association Task Force on Practice Guidelines. Circulation. 2014;129(25 suppl 2):S49-S73.
62. Yano Y, Ning H, Muntner P, et al. Nocturnal blood pressure in young adults and cognitive 67. Gaziano TA, Young CR, Fitzmaurice G, Atwood S, Gaziano JM. Laboratory-based versus
Epidemiology
function in midlife: the Coronary Artery Risk Development in Young Adults (CARDIA) non-laboratory-based method for assessment of cardiovascular disease risk: the NHANES
Study. Am J Hypertens. 2015;28:1240-1247. I Follow-up Study cohort. Lancet. 2008;371:923–931.
63. Lloyd-Jones DM, Leip EP, Larson MG, Vasan RS, Levy D. Novel approach to examining first 68. Eddy DM, Adler J, Patterson B, Lucas D, Smith KA, Morris M. Individualized guidelines:
cardiovascular events after hypertension onset. Hypertension. 2005;45:39-45. the potential for increasing quality and reducing costs. Ann Int Med. 2011;154:627-634.
64. Lloyd-Jones DM, Evans JC, Larson MG, O’Donnell CJ, Wilson PW, Levy D. Cross- 69. Liu K, Colangelo LA, Daviglus ML, et al. Can antihypertensive treatment restore the risk of
classification of JNC VI blood pressure stages and risk groups in the Framingham Heart cardiovascular disease to ideal levels? The Coronary Artery Risk Development in Young
Study. Arch Intern Med. 1999;159:2206-2212. Adults (CARDIA) Study and the Multi-Ethnic Study of Atherosclerosis (MESA). J Am Heart
65. Third Report of the National Cholesterol Education Program (NCEP) Expert Panel Assoc. 2015:4: e002275.
on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult
Treatment Panel III) Final Report. Circulation. 2002;106:3143-3421.
2 Hypertension in Latin/Hispanic
Population
Luis Miguel Ruilope, José R. Banegas, and Gema Ruiz-Hurtado
CARDIOVASCULAR DISEASE IN LATIN/ ARTERIAL HYPERTENSION IN THE LATIN ACKNOWLEDGMENTS, 18
HISPANIC POPULATION, 15 AMERICAN AND CARIBBEAN REGION AND
THE UNITED STATES, 15 REFERENCES, 19
The term Hispanic or Latino refers to a person of Cuban, Honduras, Mexico, Nicaragua, Panama, Venezuela), Tropical
Mexican, Puerto Rican, South or Central American, or other Latin America (Brazil, Paraguay) and Southern Latin America
Spanish culture or origin regardless of race according to the (Argentina, Chile, Uruguay). As can be seen, increased levels
definition of the United States Census Bureau published in of blood pressure (BP), body mass index and fasting plasma
2010. The term includes a very relevant part of the popula- glucose, in agreement with global data, are the three most
tion of Latin American and Caribbean (LAC) region to which frequent risk factors for CVD in the Latin/Hispanic population
around 50 million (16%) of the U.S. population has to be both in the U.S. and LAC. Unlike in global data, the presence
added. Brazil, French Guyana, and a few Caribbean islands are of low glomerular filtration rate (GFR) appears as a risk fac-
also included in the term LAC region. tor in LAC and the U.S. occupying positions from the fifth to
The LAC region is extremely diverse but exists as a conti- the eighth in LAC region and the tenth in the U.S. It is well
nent with historic entity and cultural, linguistic, and religious known that arterial hypertension, obesity and diabetes facili-
liaisons among the different countries.1 The territory exceeds tate together with CVD the development of chronic kidney
21 million square miles and the population approaches 600 mil- disease (CKD).8
lion inhabitants. Marked health care disparities within coun- Global prevalence of death attributed to CVD is increasing
tries exist related to striking economic differences that lead as a consequence of population growth, the aging of popu-
to important changes in health risk coverage and outcomes lations, and epidemiologic changes in diseases.9 Table 2.2
between the different countries. In fact the demographic, eco- contains the six different patterns of demographic and epide-
nomic and social changes observed in LAC in recent years miologic changes in cardiovascular mortality. As can be seen
are the main contributors to explain the growing epidemic there are significant differences among the different areas in
of cardiovascular disease (CVD) in this region.2 At the same the LAC region and in the U.S. The worst prognosis for the
time, all these facts explain why the literature related to car- near future corresponds to the Caribbean with a continuous
diovascular (CV) risk and arterial hypertension in particular increase in the number of CVD deaths. Relative increases
in the LAC region is both sparse and confusing. In this chapter because of population growth and aging are expected in
we will review the most recent literature dealing with CV risk Central, Tropical, and Andean Latin America. Large declines
and arterial hypertension in Latin/Hispanic population both in CVD death rates led to a small decline in mortality.
in LAC region and in the U.S.
ARTERIAL HYPERTENSION IN THE LATIN
CARDIOVASCULAR DISEASE IN LATIN/HISPANIC AMERICAN AND CARIBBEAN REGION AND THE
POPULATION UNITED STATES
Cardiovascular diseases account for around 30% of deaths in Arterial hypertension is one of the main risk factors for isch-
LAC (1.6 million) and is the leading cause of death in all coun- emic heart disease and the leading determinant of cerebro-
tries including the lowest-income countries (Haiti, Bolivia, vascular disease, and it affects between 20% and 40% of adults
and Nicaragua)3 and around half a million deaths take place in in the LAC region.10-13 The increase in CVD mortality in most
people younger than 70 years. One-third of premature deaths LAC region countries is facilitated by the frequent and growing
arising from CVD occurs in the poorest quintile of the popula- presence of arterial hypertension; in fact, the rising incidence
tion whereas only 13% are in the richest one.4 The prevalence of high BP could contribute to explain why in LAC countries,
of CVD among Latin/Hispanic population living in the U.S. is where rates of CVD death have declined, the trend has been con-
alarming and also represents the most important cause of siderably lower than that seen in the U.S.14 However, recently
death in this population accounting for 31% of the total.5 This published data15 reflecting that globally high BP is number one
can be explained by a higher prevalence of obesity, diabetes cause of deaths and burden of disease, show that the partici-
mellitus, hypertension, and dyslipidemia in Latin/Hispanic pation of the LAC region in both parameters is smaller than
than in Caucasians.5 As previously commented LAC region is that observed in high-income regions, Central Asia and Eastern
characterized by an extreme diversity, but the great majority Europe, East and Southeast Asia and Oceania and South Asia,
of countries are in the group of low to middle income coun- being comparable to the contribution of Middle East and North
tries where the CVD risk is the highest.6 Africa and Sub-Saharan Africa (Fig. 2.1). This relatively smaller
Table 2.1 contains the ten “level 3” risks in terms of contribution could be related to the fact that total population
disability-adjusted life years (DALYs) for both sexes for the in LAC region represents only around 8% of the global.
following locations: global, U.S., and the LAC region.7 The In the U.S., recent surveys indicate that the prevalence of
last is divided into Andean Latin America (Bolivia, Ecuador, arterial hypertension that increased continuously until 2000
Peru), Caribbean (Antigua and Barbuda, Barbados, Belize, has remained unchanged afterwards.16-18 This is shown in
Cuba, Dominica, Dominican Republic, Grenada Guyana, Table 2.3 illustrating the evolution since the early 2000s for
Haiti, Jamaica, Saint Lucia, Saint Vincent and the Grenadines, optimal BP, prehypertension, stage 1 and stage 2 hypertension
Suriname, the Bahamas, Trinidad and Tobago), Central Latin in the U.S. for white non-Hispanic, black non-Hispanic, and
America (Colombia, Costa Rica, El Salvador, Guatemala, Mexican Americans, the latter group representing 66% of the
15
Epidemiology
16
TABLE 2.1 The Ten Leading Level 3 Risks in 2013 in Terms of Disability-Adjusted Life Years by Location for Both Sexes Combined in Latin American and Caribbean
Region and United States
RISK 1 2 3 4 5 6 7 8 9 10
Global Blood Pressure Smoking Body mass index Childhood Fasting plasma Alcohol use Household air Unsafe water Unsafe sex Fruit
undernutrition glucose pollution
United States Body mass Smoking Blood Pressure Fasting plasma Alcohol use Total cholesterol Physical activity Drug use Fruit Glomerular
index glucose filtration
South Latin Smoking Body mass index Blood Pressure Alcohol use Fasting plasma Glomerular Total cholesterol Fruit Vegetables Drug use
America glucose filtration
Latin America & Body mass Blood Pressure Fasting plasma Alcohol use Smoking Glomerular Total cholesterol Whole grains Physical activity Fruit
Caribbean index glucose filtration
Andean Latin Alcohol use Body mass index Blood Pressure Fasting plasma Glomerular Smoking Childhood Iron deficiency Total cholesterol Unsafe sex
American glucose filtration undernutrition
Caribbean Blood Pressure Body mass index Fasting plasma Smoking Unsafe sex Childhood Alcohol use Glomerular Physical activity Whole grains
glucose undernutrition filtration
Central Latin Body mass Fasting plasma Blood Pressure Alcohol use Glomerular Smoking Processed meat Total cholesterol Whole grains Sweetened
America index glucose filtration beverages
Tropical Latin Blood Pressure Body mass index Alcohol use Fasting plasma Smoking Total cholesterol Sodium Glomerular Fruit Whole grains
America glucose filtration
Modified from Forouzanfar MH, Alexander L, Anderson HR, et al. Global, regional, and national comparative risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks in 188 countries,
1990-2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet. 2015;386:2287-2323.
17
TABLE 2.2 Patterns of Demographic and Epidemiologic Change in Cardiovascular Mortality in Latin American and
Caribbean Region and United States 2
Latin/Hispanic population in the U.S.19 As can be seen, there [ACEi/ARB], calcium channel blocker [CCB] and diuretic)
is generally an increase after the year 2000 in the prevalence is totally adequate.22 Table 2.5 contains data of prevalence,
of optimal BP and prehypertension whereas in stage 1 and awareness, treatment and control in a series of countries from
stage 2 hypertension changes occurred in the opposite direc- Europe, Asia, Africa, as well as Australia and Canada, to com-
tion albeit were less clear. Importantly, the current prevalence pare with the situation in LAC and Latin Hispanic in the U.S. As
of prehypertension amounted to one-third of the Mexican can be seen, there is a big variation among countries and con-
American population, and the prevalence of hypertension tinents. The situation in Latin/Hispanic in the U.S. compares
affected over half of the population. with several European countries and is above Asia and Africa,
Table 2.4 contains the degree of awareness and control in but still far from Canada. Data from the LAC region show vari-
a series of urban settings in LAC regions. As can be seen a rel- able data with countries similar to the U.S. and other in lower
evant percentage of hypertensive patients remains unaware values of control but still above Asia and Africa. In any case,
of their high blood pressure (and the accompanying risk), and there is still a long way before attaining a global control of
an adequate control is attained at the most in only one third of arterial hypertension.
patients. A comparison of prevalence and control performed On the other hand, a significant deficit in treatment and
in Mexico and in immigrant Mexicans and U.S.-born Mexicans control of hypertension among Latin/Hispanic population in
showed that hypertension was more common in Mexico than the U.S. has also been described particularly in those with-
among Mexican immigrants in the U.S.20 The most widely used out health insurance.19,23 However, the recent situation of
drugs are diuretics, beta-blockers, angiotensin converting awareness (80.2%), treatment (71.5%) and control (45.3%)
enzyme inhibitors, angiotensin receptor blockers, and calcium in the U.S. for the Latin/Hispanic population is significantly
channel blockers alone or in combination,1 and the low per- better than in LAC regions, albeit adequate control of hyper-
centage of good BP control indicate, as in other regions in the tension is lower than in non-Hispanic whites and non-His-
world, the need for an earlier start of combination therapy.21 In panic blacks.24 The use of antihypertensive medication and
any case the response of Latin/Hispanic population to the most in particular of single pill and multiple pill combinations has
widely used combinations (components ×2 or ×3 angiotensin- increased significantly in the U.S. contributing importantly
converting-enzyme inhibitor/angiotensin-receptor blocker to the improvement in BP control, including Latinos.25
18
High-income
regions
Central Asia
and central and
Latin America
and Caribbean
Middle East and
North Africa
Finally, it is worth mentioning that some organization
I eastern Europe such as the Pan American Health Organization (PAHO) is pri-
oritizing the prevention and control of hypertension in LAC
Epidemiology
TABLE 2.3 Age-Adjusted Percentage of Hypertensives With Optimal Blood Pressure, Prehypertension, Stage 1
Hypertension and Stage 2 Hypertension Levels in White Non-Hispanic, Black Non-Hispanic and Mexican Americans
2003-2004, % (SE) 2005-2006, % (SE) 2007-2008, % (SE) 2009-2010, % (SE) 2011-2012, % (SE)
n = 1664 n = 1518 n = 2113 n = 2116 n = 1844
Optimal Blood Pressure
White non-Hispanic 13.4 (1.2) 15.3 (1.1) 18.4 (1.6) 22.8 (1.4) 20.3 (2.2)a
Black non-Hispanic 13.3 (1.9) 13.3 (1.1) 18.1 (1.5) 19.6 (1.7) 14.6 (1.9)
Mexican Americans 10.6 (1.6) 11.5 (4.1) 14.4 (1.6) 11.6 (1.1) 13.9 (2.2)
Prehypertensive Level
White non-Hispanic 27.3 (2.0) 29.1 (2.0) 32.5 (1.3) 33.3 (1.9) 33.6 (2.0)a
Black non-Hispanic 24.4 (2.6) 29.5 (1.7) 26.8 (1.5) 28.0 (2.1) 34.8 (1.6)a
Mexican Americans 23.7 (2.8) 27.3 (2.3) 26.8 (2.3) 24.1 (2.5) 31.4 (5.2)
Stage 1 Hypertension
White non-Hispanic 43.9 (2.7) 41.5 (1.7) 38.9 (1.8) 35.1 (2.3) 36.0 (3.1)a
Black non-Hispanic 37.1 (2.2) 39.9 (2.5) 36.9 (2.1) 38.4 (2.6) 33.3 (1.6)
Mexican Americans 40.6 (2.6) 42.9 (4.6) 41.0 (3.3) 46.2 (3.7) 39.7 (5.6)
Stage 2 Hypertension
White non-Hispanic 15.4 (1.2) 14.1 (1.2) 10.2 (1.0) 8.9 (0.9) 10.1 (1.9)a
Black non-Hispanic 25.2 (2.8) 17.2 (1.4) 18.2 (1.5) 14.0 (2.3) 17.4 (1.8)a
Mexican Americans 25.1 (2.6) 22.0 (2.7) 17.8 (2.3) 18.1 (2.8) 15.0 (6.8)b
aP-trend<0.05.
brelative
SE is >30%.
SE, Standard error.
Modified from Yoon SS, Gu Q, Nwankwo T, Wright JD, Hong Y, Burt V. Trends in blood pressure among adults with hypertension: United States, 2003 to 2012. Hypertension.
2015;65:54-61.
19
TABLE 2.4 Hypertension Awareness and Control Estimates of Diverse Urban Settings in Latin American and Caribbean
Regions (2001-2010) 2
TABLE 2.5 Awareness, Treatment and Control of Hypertension in a Series of Countries From Europe, Asia, Africa, as well as
Australia and Canada
COUNTRY/YEAR PREVALENCE (%) AWARENESS (%) TREATMENT (%) CONTROL (%) REFERENCE
Australia/2005-2010 25 60 35 51 32
Canada/2012-2013 23a 84 80 68 33
Spain/2008-2010 33 59 79 49 34
Portugal/2011-2012 42 77 75 43 35
Finland/1982-2007 40 65 55 40 36
Italy/2013-2014 55 67 35 58 37
Germany/2008-2011 32 82 72 51 38
England/2011 32 71 58 37 39
Japan/1986-2002 39 — 44 50 40
China/2003-2012 27 45 35 11 41
India/1950-2013 (urban 30 42 38 20 42
data) 30 25 25 11
India/1950-2013 (rural
data)
Egypt/1995 26 38 24 8 43
Guinea/2009 30 24 35 16 44
South Africa/2011 39 — 31 13 45
aRepresents the number of treated patients.
12. Rivera-Andrade A, Luna MA. Trends and heterogeneity of cardiovascular disease 30. Richardson SI, Freedman BI, Ellison DH, Rodriguez CJ. Salt sensitivity: a review with a
and risk factors across Latin American and Caribbean countries. Prog Cardiovasc Dis. focus on non-Hispanic blacks and Hispanics. J Am Soc Hypertens. 2013;7:170-179.
I 2014;57:276-285. 31. Heiss G, Snyder ML, Teng Y, Schneiderman N, Llabre MM, Cowie C, et al. Prevalence
13. Avezum Á, Costa-Filho FF, Pieri A, Martins SO, Marin-Neto JA. Stroke in Latin America: of metabolic syndrome among Hispanics/Latinos of diverse background: the Hispanic
Epidemiology
Burden of Disease and Opportunities for Prevention. Glob Heart. 2015;10:323-331. Community Health Study/Study of Latinos. Diabetes Care. 2014;37:2391-2399.
14. Rasolt D. Rising hypertension, cardiovascular disease, in Latin America (2014). 32. Carrington MJ, Jennings GL, Stewart S. Pressure points in primary care: blood pressure
Madeira Beach, FL: Defeat Diabetes Foundation. http://www.defeatdiabetes.org/ris and management of hypertension in 532 050 patients from 2005 to 2010. J Hypertens.
ing-hypertension-cardiovascular-disease-latin-america/#sthas.KyhrN4Qg.wPYHEO01. 2013;31:1265-1271.
dpuf. 33. Padwal RS, Bienek A, McAlister FA, Campbell NR. ORTF of the CHE program. Epidemiology
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N Engl J Med. 2013;369:954-964. 34. Banegas JR, Graciani A, de la Cruz-Troca JJ, León-Muñoz LM, Guallar-Castillón P, Coca A,
16. Egan BM, Zhao Y, Axon RN. US trends in prevalence, awareness, treatment, and control of et al. Achievement of cardiometabolic goals in aware hypertensive patients in Spain: a
hypertension, 1988-2008. JAMA. 2010;303:2043-2050. nationwide population-based study. Hypertension. 2012;60:898-905.
17. Yoon SS, Ostchega Y, Louis T. Recent trends in the prevalence of high blood pressure and 35. Polonia J, Martins L, Pinto F, Nazare J. Prevalence, awareness, treatment and control
its treatment and control, 1999-2008. NCHS Data Brief. 2010:1-8. of hypertension and salt intake in Portugal: changes over a decade. The PHYSA study.
18. Yoon SS, Burt V, Louis T, Carroll MD. Hypertension among adults in the United States, J Hypertens. 2014;32:1211-1221.
2009-2010. NCHS Data Brief. 2012:1-8. 36. Kastarinen M, Antikainen R, Peltonen M, Laatikainen T, Barengo NC, Jula A, et al.
19. Ventura H, Piña IL, Lavie CJ. Hypertension and antihypertensive therapy in Hispanics and Prevalence, awareness and treatment of hypertension in Finland during 1982-2007.
Mexican Americans living in the United States. Postgrad Med. 2011;123:46-57. J Hypertens. 2009;27:1552-1559.
20. Barquera S, Durazo-Arvizu RA, Luke A, Cao G, Cooper RS. Hypertension in Mexico 37. Tocci G, Muiesan ML, Parati G, Agabiti Rosei E, Ferri C, Virdis A, et al. Trends in
and among Mexican Americans: prevalence and treatment patterns. J Hum Hypertens. prevalence, awareness, treatment, and control of blood pressure recorded from
2008;22:617-626. 2004 to 2014 during World Hypertension Day in Italy. J Clin Hypertens (Greenwich).
21. Ruilope LM. Current challenges in the clinical management of hypertension. Nat Rev 2016;18:551-556.
Cardiol. 2012;9:267-275. 38. Neuhauser HK, Adler C, Rosario AS, Diederichs C, Ellert U. Hypertension prevalence,
22. Lewin AJ, Kereiakes DJ, Chrysant SG, Izzo JL, Oparil S, Lee J, et al. Triple-combination awareness, treatment and control in Germany 1998 and 2008-11. J Hum Hypertens.
treatment with olmesartan medoxomil/amlodipine/hydrochlorothiazide in Hispanic/ 2015;29:247-253.
Latino patients with hypertension: the TRINITY study. Ethn Dis. 2014;24:41-47. 39. Falaschetti E, Mindell J, Knott C, Poulter N. Hypertension management in England: a serial
23. Sorlie PD, Allison MA, Avilés-Santa ML, Cai J, Daviglus ML, Howard AG, et al. Prevalence cross-sectional study from 1994 to 2011. Lancet. 2014;383:1912-1919.
of hypertension, awareness, treatment, and control in the Hispanic Community Health 40. Ikeda N, Gakidou E, Hasegawa T, Murray CJ. Understanding the decline of mean systolic
Study/Study of Latinos. Am J Hypertens. 2014;27:793-800. blood pressure in Japan: an analysis of pooled data from the National Nutrition Survey,
24. Yoon SS, Gu Q, Nwankwo T, Wright JD, Hong Y, Burt V. Trends in blood pressure among 1986-2002. Bull World Health Organ. 2008;86:978-988.
adults with hypertension: United States, 2003 to 2012. Hypertension. 2015;65:54-61. 41. Li D, Lv J, Liu F, Liu P, Yang X, Feng Y, et al. Hypertension burden and control in mainland
25. Gu Q, Burt VL, Dillon CF, Yoon S. Trends in antihypertensive medication use and blood China: analysis of nationwide data 2003-2012. Int J Cardiol. 2015;184:637-644.
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Nutrition Examination Survey, 2001 to 2010. Circulation. 2012;126:2105-2114. in India: a systematic review and meta-analysis of prevalence, awareness, and control of
26. Campbell PT, Krim SR, Lavie CJ, Ventura HO. Clinical characteristics, treatment patterns hypertension. J Hypertens. 2014;32:1170-1177.
and outcomes of Hispanic hypertensive patients. Prog Cardiovasc Dis. 2014;57:244-252. 43. Ibrahim MM, Rizk H, Appel LJ, el Aroussy W, Helmy S, Sharaf Y, et al. Hypertension
27. Daviglus ML, Talavera GA, Avilés-Santa ML, Allison M, Cai J, Criqui MH, et al. Prevalence prevalence, awareness, treatment, and control in Egypt. Results from the Egyptian
of major cardiovascular risk factors and cardiovascular diseases among Hispanic/Latino National Hypertension Project (NHP). NHP Investigative Team. Hypertension. 1995;26(6 Pt
individuals of diverse backgrounds in the United States. JAMA. 2012;308:1775-1784. 1):886-890.
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Dyslipidemia patterns among Hispanics/Latinos of diverse background in the United low awareness, treatment and control rates of hypertension in Guinea: results from a
States. Am J Med. 2014;127:1186-1194.e1. population-based STEPS survey. J Hum Hypertens. 2016;30:237-244.
29. Perez A. Acculturation, health literacy, and illness perceptions of hypertension among 45. Seedat YK. Control of hypertension in South Africa: time for action. S Afr Med J.
Hispanic adults. J Transcult Nurs. 2015;26:386-394. 2012;102:25-26.
3 Hypertension in East Asians and Native
Hawaiians
Ji-Guang Wang and Qi-Fang Huang
EPIDEMIOLOGY OF HYPERTENSION IN EAST SUMMARY, 25 ACRONYMS OF TRIALS, 25
ASIANS AND NATIVE HAWAIIANS, 21
CONFLICTS OF INTEREST, 25 REFERENCES, 25
OUTCOME TRIALS IN HYPERTENSION IN
EAST ASIANS AND NATIVE HAWAIIANS, 21
With the changes in lifestyle and increasing longevity, the preva- approximately 40% in Mongolians7 and Native Hawaiians
lence of hypertension increases worldwide. However, several (Table 3.1).8,9 The overall prevalence of hypertension was not
classes of efficacious antihypertensive drugs are readily avail- reported in the most recent Japanese national blood pressure
able for the management of hypertension in most countries or survey in 2010. The age-specific data suggested that the preva-
regions. In the past several decades, several national or regional lence of hypertension in Japanese was high.10 The prevalence
epidemiologic studies on hypertension and outcome trials on of hypertension in persons aged 60 to 69 years was more than
the management of hypertension were conducted in East Asians 60% in both men and women,10 much higher than the 49.1% of
and native Hawaiians. In this chapter, we review the literature of prevalence in Chinese aged 60 years or older in 2002.4
epidemiology and outcome trials on hypertension in this region.
Awareness, Treatment, and Control of
EPIDEMIOLOGY OF HYPERTENSION IN EAST Hypertension
ASIANS AND NATIVE HAWAIIANS There is not much high quality data on the management of
hypertension except for the national blood pressure surveys
Prevalence of Hypertension in China4 and Korea.5 According to the currently available data,
After World War II, the prevalence of hypertension increased Koreans6 and Japanese10 seemed to have higher awareness,
substantially in most countries and regions in East Asia and treatment, and control rates of hypertension than other East
Hawaii. If the case of China would be taken as an example, Asian populations4,5,7 and native Hawaiians (Table 3.1).9 The
the prevalence of hypertension increased from less than 10% control rate of hypertension was about 35% in Koreans6 and
before 19801,2 to approximately 25% in the latest nationwide Japanese,7 24% in Mongolians,7 and less than 10% in Chinese.4
survey in 2012 (Fig. 3.1).3,4 This increase can to some extent
be attributable to the increased number of elderly people over
the years. However, the Westernized lifestyle characterized by OUTCOME TRIALS IN HYPERTENSION IN EAST
high salt, high fat, high sugar and high calorie diet and physi- ASIANS AND NATIVE HAWAIIANS
cal inactivity could be a major risk factor for the increasing
prevalence of hypertension in these populations. Placebo-Controlled Trials
When the most recent data from East Asians and native Since the late 1980s, several placebo-controlled outcome tri-
Hawaiians were compared across countries or regions, the als were conducted in China to investigate whether antihyper-
prevalence of hypertension ranged from about 25% in Chinese tensive therapy would prevent cardiovascular complications
living either in the mainland4 or in Taiwan5 and Koreans6 to in hypertensive patients (Table 3.2).11-14
The Systolic Hypertension in China (Syst-China) trial inves-
tigated whether active antihypertensive treatment would
30 prevent fatal and nonfatal stroke in 2394 elderly (≥60 years)
patients with isolated systolic hypertension (systolic blood
2012 pressure ≥160 mm Hg and diastolic blood pressure <95 mm
25 Hg). Active antihypertensive treatment was initiated by nitren-
dipine, with the possible addition of captopril and hydrochlo-
20
rothiazide, to achieve the goal systolic blood pressure of 150
2002
mm Hg or lower. At 2 years of follow up, active treatment (n
Prevalence (%)
22
TABLE 3.1 Characteristics of Epidemiologic Studies on Hypertension in East Asians and Native Hawaiians
COUNTRY OR
REGION AND AGE RANGE, NUMBER OF AWARE AND TREATED AND
YEAR YEARS SUBJECTS PREVALENCE, % AWARENESS, % TREATMENT, % TREATED, % CONTROL, % CONTROLLED, %
China
19913 ≥15 950,356 11.3 26.6 12.1 45.5 2.8 23.1
20024 ≥18 141,892 18.8 30.2 24.7 81.8 6.1 25.0
20024 ≥60 NR 49.1 37.6 36.2 96.3 7.6 24.1
Japan10
2010 30-39 NR Men 20; — — — — —
Women 5.6
2010 40-49 NR Men 29.9; — — — — —
Women 12.6
2010 50-59 NR Men 63.2; — Men 43.4; — Men 32.1; —
Women 38.4 Women 31.2 Women 44.1
2010 60-69 NR Men 65.6; — Men 50.6; — Men 29.9; —
Women 62.3 Women 68.8 Women 40.9
2010 70-79 NR Men 80.8; — Men 29.9; — Men 33.3; —
Women 71.2 Women 12.6 Women 40.5
Korea6
2008 ≥30 9146 24.9 60.6 52.2 86.2 36.7 70.3
Mongolia7
2009 15-64 4502 36.5 65.8 35.9 54.6% 24.1 67.1
Native Hawaiians9
1985 20-59 257 25 — — — — —
Taiwan5
1993-1996 ≥19 6,479 23.5 — — — — —
NR, Not reported.
TABLE 3.2 Characteristics of Trials
23
Hypertension in East Asians and Native Hawaiians
3
24
stroke by 58%. Nifedipine also significantly reduced the of 140/90 mm Hg or below, diuretics, α-blockers, β-blockers,
I incidence of all fatal and nonfatal cardiovascular events by and/or αβ-blockers could be added. During a mean follow
60%.12 up of 3.2 years, systolic/diastolic blood pressures were
Epidemiology
The Felodipine Event Reduction (FEVER) trial compared 1.7/0.6 lower in the amlodipine group than the candesar-
felodipine (5 mg daily) with placebo in 9800 patients (50 to tan group, despite the fact that more patients in the can-
79 years of age) with a systolic/diastolic blood pressure in desartan group required addition of other antihypertensive
the range of 140 to 180/90 to 100 mm Hg after six weeks drugs (54.5% versus 42.7%; p < 0.0001). The incidence rates
of treatment with hydrochlorothiazide (12.5 mg per day). of the primary (sudden death and cerebrovascular, car-
During a mean follow up of 3.3 years, felodipine, compared diac, renal, and vascular events) and secondary endpoints
with placebo, reduced systolic/diastolic blood pressure by were not statistically different between the two treatment
4.2/2.1 mm Hg, and the primary endpoint (fatal and nonfa- groups. The risk of stroke was slightly but not significantly
tal stroke) by 27%. Felodipine also significantly reduced all lower in the amlodipine group than the candesartan group
cardiovascular events, all cardiac events, all-cause mortal- (−23%; p = 0.28).17
ity, coronary events, heart failure, cardiovascular death, The Combination Therapy of Hypertension to Prevent
and cancer by 27%, 35%, 31%, 32%, 30%, 33%, and 36%, Cardiovascular Events (COPE) trial was designed to com-
respectively.13 pare three combinations of antihypertensive drugs in the
The Post-stroke Antihypertensive Treatment Study (PATS) prevention of cardiovascular events in 3501 patients 40
was a double-blind blood pressure lowering trial with inda- to 85 years old and with uncontrolled hypertension (sys-
pamide (2.5 mg daily) in hypertensive and nonhypertensive tolic/diastolic blood pressure ≥ 140/90 mm Hg) by calcium
patients with a history of stroke or transient ischemic attack. channel blocker benidipine 4 mg per day. Patients were
During a median follow up of 2 years, indapamide reduced sys- randomly assigned to receive angiotensin receptor blocker
tolic/diastolic blood pressure by 5/2 mm Hg, and the incidence (n = 1167), β-blocker (n = 1166), or thiazide diuretic (n =
of recurrent stroke by 29%. Indapamide also significantly 1168) in addition to benidipine. During a median follow
reduced the incidence of all fatal and nonfatal cardiovascular up of 3.61 years, blood pressure was reduced similarly in
endpoints by 23%.14 the three groups, with a control rate of 64.1%, 66.9%, and
66.0% at the end of treatment in the benidipine-angiotensin
receptor blocker, benidipine-β-blocker, and benidipine-thi-
Actively Controlled Trials azide groups, respectively. The cardiovascular composite
Since 1990 several actively controlled outcome trials were endpoint occurred in 41 (3.7%), 48 (4.4%), and 32 (2.9%)
conducted in Japan to compare various classes or combi- patients, respectively, with a hazard ratio of 1.26 (p = 0.35)
nations of antihypertensive drugs as initial therapy for the in the benidipine-angiotensin receptor blocker and 1.54 (p =
prevention of cardiovascular complications (Table 3.2).15-18 0.06) in the benidipine-β-blocker groups compared with the
All these trials had an open design, except for the double- benidipine-thiazide group.18
dummy National Intervention Cooperative Study in Elderly None of these trials had sufficient power to detect a mod-
Hypertensives (NICS-EH),15 and had a relatively small sam- est or moderate but clinically relevant difference between var-
ple size in the detection of a modest or moderate difference ious classes of antihypertensive drugs. However, if the results
between antihypertensive drug classes. of these trials would be pooled with that of studies in other
NICS-EH compared two outdated antihypertensive drugs populations, there could be significant difference between
(sustained-release nicardipine [n = 204] versus trichlorme- different drug classes. For instance, if the CASE-J trial17 was
thiazide [n = 210]) in 414 elderly (≥60 years) patients with combined with the Valsartan Antihypertensive Long-term Use
hypertension (systolic blood pressure 160 to 220 mm Hg Evaluation (VALUE)19 and Irbesartan Diabetic Nephropathy
and diastolic blood pressure <115 mm Hg). During 5 years of Trial (IDNT),20 trials that also compared amlodipine with an
follow up, nicardipine was slightly less efficacious than tri- angiotensin receptor blocker, amlodipine provided superior
chlormethiazide in lowering systolic/diastolic blood pressure protection against stroke and myocardial infarction by 16%
(−1/−1 mm Hg). During follow-up, a total of 39 events occurred and 17%, respectively.21
in the two groups combined, and no significant difference
was observed in any outcome between the two treatment
groups.15 Intensive Versus Less Intensive Blood Pressure
The Japan Multicenter Investigation for Cardiovascular Control
Diseases-B (JMIC-B) trial compared nifedipine retard with Two Japanese trials compared intensive with less intensive
angiotensin-converting enzyme inhibitors (enalapril 5 to 10 blood pressure control in elderly hypertensive patients.22,23
mg, imidapril 5 to 10 mg, or lisinopril 10 to 20 mg, once daily) in These two trials again had a relatively small sample size and
1650 patients with both hypertension and coronary heart dis- hence inadequate power in the detection of a modest or mod-
ease, diagnosed according to coronary angiography (stenosis erate difference between different levels of blood pressure
≥75%), a history of angina pectoris (>2 episodes per week), or control.
ST-segment depression of at least 1 mm during the treadmill The Japanese Trial to Assess Optimal Systolic Blood
exercise test. During a mean follow up of 36 months, blood Pressure in Elderly Hypertensive Patients (JATOS) compared
pressure reductions were greater in the nifedipine group than two-year effect of intensive (systolic blood pressure <140 mm
the angiotensin converting enzyme (ACE) inhibitors group Hg, n = 2212) versus less intensive treatment (systolic blood
(−4/−1 mm Hg). The incidence rate of the primary endpoint pressure 140 to 159 mm Hg, n = 2206) in 4418 elderly (65 to
(cardiac events: cardiac death or sudden death, myocardial 85 years) patients with essential hypertension (pretreatment
infarction, hospitalization for angina pectoris or heart failure, systolic blood pressure ≥160 mm Hg). The first line drug was
serious arrhythmia, and coronary interventions) was similar a long-acting calcium channel blocker, efonidipine. At the last
in the nifedipine (116 events, 14.0%) and angiotensin convert- clinic visit, systolic/diastolic blood pressures were signifi-
ing enzyme inhibitors (106 events, 12.9%) groups (+5%; p = cantly lower in the intensive than the less intensive-treatment
0.75).16 group (135.9/74.8 versus 145.6/78.1 mm Hg), with a between
The Candesartan Antihypertensive Survival Evaluation group difference of 9.7/3.3 mm Hg. However, no significant
in Japan (CASE-J) trial compared amlodipine- with cande- difference between the two treatment groups was observed
sartan-based antihypertensive regimens in 4728 high risk for the incidence of the primary endpoint (combination of
hypertensive patients. To achieve the goal blood pressure cardiovascular disease and renal failure, 86 patients in each
25
group; p = 0.99) and for total mortality (54 in the intensive- SUMMARY
treatment group versus 42 in the less intensive-treatment 3
group, p = 0.22). In a post-hoc analysis, however, there was There is some but insufficient epidemiologic and outcome trial
16. Yui Y, Sumiyoshi T, Kodama K, et al. Comparison of nifedipine retard with angiotensin 22. JATOS Study Group. Principal results of the Japanese trial to assess optimal sys-
converting enzyme inhibitors in Japanese hypertensive patients with coronary artery tolic blood pressure in elderly hypertensive patients (JATOS). Hypertens Res.
I disease: the Japan Multicenter Investigation for Cardiovascular Diseases-B (JMIC-B) ran- 2008;31:2115-2127.
domized trial. Hypertens Res. 2004;27:181-191. 23. Ogihara T, Saruta T, Rakugi H, et al. Target blood pressure for treatment of isolated
Epidemiology
17. Ogihara T, Nakao K, Fukui T, et al. Effects of candesartan compared with amlodipine systolic hypertension in the elderly: valsartan in elderly isolated systolic hypertension
in hypertensive patients with high cardiovascular risks: candesartan antihypertensive study. Hypertension. 2010;56:196-202.
survival evaluation in Japan trial. Hypertension. 2008;51:393-398. 24. PROGRESS Collaborative Group: Randomised trial of a perindopril-based blood pressure
18. Matsuzaki M, Ogihara T, Umemoto S, et al. Prevention of cardiovascular events with lowering regimen among 6105 individuals with prior stroke or transient ischaemic attack.
calcium channel blocker-based combination therapies in patients with hypertension: a Lancet. 2001;358:1033-1041.
randomized controlled trial. J Hypertens. 2011;29:1649-1659. 25. Arima H, Anderson C, Omae T, et al. Perindopril-based blood pressure lowering reduces
19. Julius S, Kjeldsen SE, Weber M, et al. Outcomes in hypertensive patients at high cardio- major vascular events in Asian and Western participants with cerebrovascular disease:
vascular risk treated with regimens based on valsartan or amlodipine: the VALUE ran- the PROGRESS trial. J Hypertens. 2010;28:395-400.
domised trial. Lancet. 2004;363:2022-2031. 26. Beckett NS, Peters R, Fletcher AE, et al. Treatment of hypertension in patients 80 years of
20. Lewis EJ, Hunsicker LG, Clarke WR, et al. Renoprotective effect of the angiotensin- age or older. N Engl J Med. 2008;358:1887-1898.
receptor antagonist irbesartan in patients with nephropathy due to type 2 diabetes. 27. Liu L, Wang JG, Ma SP, et al. Chinese subjects entered in the Hypertension in the Very
N Engl J Med. 2001;345:851-860. Elderly Trial (HYVET). Chin Med J. 2008;121:1509-1512.
21. Wang JG, Li Y, Franklin S, Safar M. Prevention of stroke and myocardial infarction by amlodip-
ine and angiotensin receptor blockers: a quantitative overview. Hypertension. 2007;50:181-188.
4 Hypertension in South Asians
Philip Joseph, Rajeev Gupta, and Salim Yusuf
PREVALENCE OF HYPERTENSION IN SOUTH MANAGEMENT OF HYPERTENSION REFERENCES, 31
ASIAN POPULATIONS, 27 IN SOUTH ASIANS, 29
RISK FACTORS FOR HYPERTENSION IN CONCLUSIONS, 31
SOUTH ASIAN POPULATIONS, 27
Elevated blood pressure (BP) is a growing health problem in years) from India, Pakistan, and Bangladesh, hypertension
South Asia, where it is the second largest risk factor for dis- was diagnosed in one-third of individuals, with the high-
ability-adjusted life years lost, predominantly because of its est prevalence in Bangladesh (39.3%), followed by Pakistan
strong relationship with cardiovascular disease (CVD) devel- (33.3%), and lowest in India (30.7%).6 Despite these observed
opment. Within India, it has been estimated that hypertension differences between studies, the prevalence of hypertension
accounts for 57% of all stroke related deaths and 24% of coro- has been consistently shown to be higher in men compared
nary artery disease related deaths. Thus, a significant propor- with women, and in urban compared with rural areas.5
tion of death and disability in the region can be reduced by In fact, transition from the rural to urban environment is a
improving BP control.1 key societal factor driving the increasing prevalence of hyper-
In South Asia, there has been a steady rise in both the age- tension. In India, the prevalence of hypertension has increased
and sex-adjusted mean population BP, and the prevalence of dramatically over the past several decades with a higher bur-
hypertension, over the past two decades.2 Significant gaps den reported in urban areas.1 In a systematic review of 142 stud-
in hypertension management are also present across South ies conducted in India, it was estimated that 29.8% of adults had
Asia, with less than half of individuals with high BP aware hypertension; and in urban areas, where extensive changes in
of it, and poor control in more than 80% with high BP. If left health-related behaviors have already occurred, the prevalence
unaddressed, these trends will substantially increase CVD of hypertension was higher (33.8%) compared with rural areas
morbidity and mortality related to elevated BP. This chapter (27.6%) (Fig. 4.1). Furthermore, the prevalence of hypertension
will focus on the epidemiology of hypertension and its man- varied substantially in rural areas (which was not observed in
agement in South Asian populations. First we will examine the urban areas) likely reflecting the different stages of economic
prevalence of hypertension, and its variation across South development, urbanization and transitions in health-related
Asia. Next, we will examine the major modifiable and genetic behaviors occurring across rural environments in India.7
risk factors associated with hypertension incidence in South
Asians, and finally, we will summarize current gaps in hyper-
tension management that need to be addressed in the region. Prevalence of Hypertension in South
Asians Who Have Migrated to North
America or Europe
PREVALENCE OF HYPERTENSION IN SOUTH Compared with other ethnic groups living in the same mac-
ASIAN POPULATIONS roenvironment, South Asians have a unique cardiovascular
risk profile, characterized by a higher risk of diabetes, higher
Definition of Hypertension in the South Asian percent body fat, and lower high density lipoprotein concen-
Population tration compared with other ethnic groups. Some studies sug-
It has been recommended that some CVD risk factors in South gest that the risk of hypertension is also modestly increased
Asians (e.g., obesity) warrant lower thresholds to define risk in South Asians compared with Caucasians living in the same
when compared with other ethnic groups. This is because country. In a systematic review of 13 hypertension prevalence
of evidence that CVD in South Asians occurs at lower age studies (n ≈ 650,000 individuals) in Canada, the risk of hyper-
and risk factor thresholds. Studies also suggest that certain tension was slightly higher in South Asians compared with
physiologic BP parameters (e.g., pulse pressure, postexercise Caucasians (odds ratio [OR] 1.11, 95% confidence interval [CI]
BP) differ, and that BP may have a stronger association with 1.02 to 1.22, p = 0.02).8 However, this association has not been
stroke risk in South Asians compared with white Europeans.3,4 consistently observed among South Asian populations resid-
However, there is no definitive evidence that, for a given BP, ing in Europe.9 Also, while the prevalence of some cardiovascu-
South Asian populations are at a higher CVD risk, and a sys- lar risk factors (e.g., obesity) appear to be steadily increasing
tolic blood pressure (SBP) greater than 140 mm Hg and/or dia- in these South Asian populations over time, whether such a
stolic blood pressure (DBP) greater than 90 mm Hg remains trend is also occurring with the prevalence of hypertension is
the currently accepted threshold to diagnose hypertension in not clearly established.10
South Asian populations.
No of Total no of
I Place studies participants Prevalence (95% CI)
Epidemiology
Rural
North India Rural 6 7448 16.72 (7.84, 25.60)
East India Rural 8 18724 33.17 (24.88, 41.46)
West India Rural 2 4832 18.22 (12.73, 23.71)
South India Rural 9 21964 28.27 (21.41, 35.13)
Subtotal (I-squared = 84.0%, p = 0.000) 27.61 (23.22, 32.00)
Urban
North India Urban 4 4415 33.50 (26.73, 40.27)
East India Urban 4 3199 33.28 (23.52, 43.03)
West India Urban 10 249226 34.89 (30.81, 38.96)
South India Urban 7 16836 33.12 (25.48, 40.76)
Subtotal (I-squared = 0.0%, p = 0.956) 33.81 (29.78, 37.84)
0 5 10 15 20 25 30 35 40 45
Prevalence of hypertension in percentage
FIG. 4.1 Variations in hypertension prevalence in India by urban-rural area and geographic locations. In this systematic review of epidemiologic studies of hypertension in India,
significant variation in the prevalence of hypertension was observed across different geographic region in rural areas, whereas urban areas had a similar hypertension prevalence.
Overall, hypertension prevalence was higher in urban areas compared with rural areas. wgt, Weight. (From Anchala R et al. Hypertension in India: A systematic review and meta-
analysis of prevalence, awareness, and control of hypertension. J Hypertens. 2014;32:1170-1177).
approximately one-fifth appear to be shared in South Asians. of obesity has increased across the region; and in India,
Metaanalysis of 28 GWAS studies in 69,395 participants of approximately 9% of men and 13% of women now meet clinical
European ancestry identified 28 independent loci signifi- criteria for obesity, with a higher prevalence in South India, in
cantly associated with either SBP or DBP of which six were urban areas and among women.13
also significantly associated with BP in 23,977 participants of Diabetes is associated with a three-fold to four-fold
South Asian ancestry.11 Also, a recent transethnic metaanaly- increase in the risk of hypertension in South Asian popula-
sis of 320,251 participants of European, South Asian, and East tions; and its prevalence in South Asia is now among the high-
Asian origins identified polymorphisms from 12 independent est in the world.7 In India, between 5% and 15% of individuals
loci associated with BP traits, with consistent effects across have diabetes depending on geographic location, with a simi-
all three ethnic groups.12 These studies suggest that South lar prevalence reported among men and women, and a higher
Asians share a similar genetic predisposition to hyperten- prevalence in urban areas.15-17
sion compared with other ethnic groups. However, GWAS Smoking and alcohol consumption are each associated
have thus far failed to identify polymorphisms unique to with a 1.5-fold to two-fold increase in hypertension risk in
South Asians that impact BP; although this may be because South Asian populations.7 Both are substantially more com-
of methodologic factors, such as the relatively small sample mon in men compared with women. National survey data
sizes (and limited power) of current GWAS performed in from India report that 29% of men currently smoke, as com-
South Asians, the limited power of GWAS to identify signifi- pared with only 2% of women.18 Similarly, regular alcohol use
cant effects associated with rare polymorphisms, and dif- has been reported in 8% of males compared with only 1% of
ferences in linkage disequilibrium between ethnic groups. females.19
Some genetic associations may be further impacted by The nutrition transition in India as a consequence of
gene-environment interactions, which could result in differ- urbanization and economic development has resulted in lower
ent genetic effects between ethnic groups when patterns of consumption of fruits, vegetables and fiber; higher consumption
health-related behaviors also differ. of saturated fats/meat products; and higher sodium consump-
tion.20 Although there is limited evidence examining how diet
impacts BP in South Asians, available data in this population
Modifiable Risk Factors for Hypertension suggest that low fruit and vegetable consumption, higher fat
Risk factors for hypertension development are examined in consumption, and higher discretionary sodium consumption
detail in Section III of this book. Of these, several are of partic- are associated with hypertension. Mean sodium consumption
ular importance in South Asian populations because of their in the South Asian population is currently estimated between
high prevalence or increasing burden within the region. 3.5 and 4 g/day, a range where there is no clear impact on CVD
Overweight and obese: It is estimated that the risk of risk.21 However, in individuals who consume higher amounts
hypertension increases by 20% for each 5% gain in weight, of sodium (e.g., >5 g/day), counselling on dietary sodium
and in South Asian populations obesity (commonly defined as reduction should occur.
body mass index ≥25 kg/m2 for this group) is a common risk In individuals without hypertension, regular physical
factor for both hypertension development, and poor hyper- activity modestly reduces BP.22 However, epidemiologic data
tension control.7,13,14 In the past two decades, the prevalence suggest that 54% of adults in India are physically inactive, with
29
MANAGEMENT OF HYPERTENSION
IN SOUTH ASIANS 40
Lifestyle and Behavioral Modification
Adopting healthy behaviors is an important component for 20
both preventing hypertension and reducing BP in patients No BP 1 BP 2 BP 3 BP Polycap Polycap
with established hypertension. Particular emphasis should agent agent agents agents (single) (double)
be placed on weight loss in overweight or obese individu- No. of 119 62 197 108 127 150
als, reducing sodium consumption in those with high sodium participants
intake (e.g., >5 g/day), increasing fruit and vegetable intake, and FIG. 4.2 Proportion of participants with baseline hypertension achieving adequate
reducing saturated fat intake. Smoking avoidance or cessation, blood pressure control (defined as a systolic blood pressure <140 mm Hg) in TIPS-1
and limiting alcohol consumption should be promoted in all and TIPS-2. BP, Blood pressure. (From Mente A, et al. The Role of the Polypill in Hyper-
individuals, with a particular focus on men, where the preva- tension. Special Issues in Hypertension, 2012, with permission of Springer.)
lence of both is substantially higher compared with women.
Increasing physical activity can reduce BP both directly and
indirectly through weight loss. In patients with hypertension, low cardiovascular risk, a BP of less than 140/90 mm Hg is
these lifestyle changes have each been shown to have small an acceptable target with pharmacologic therapy. In patients
to moderate effects on BP reduction (ranging between 2 and with diabetes, lower treatment targets (e.g., <130/80 mm Hg)
3 mm Hg for SBP), but the promotion of a healthy lifestyle also may be considered because of its potential benefit for reduc-
reduces CVD risk independent of BP lowering, and should be ing stroke risk; and in patients with established CVD or at high
encouraged in all individuals with and without hypertension.24 risk of CVD development, intensive BP treatment to an SBP
target of 120 mm Hg can be considered if the therapies are
well tolerated.
Initiation of Antihypertensive Therapy and
Treatment Targets
Most patients with hypertension will require both lifestyle Choice of Pharmacotherapy
modification and pharmacologic therapy to control BP. There In some ethnic groups it has been shown that certain antihy-
is no consistent evidence to suggest that BP targets should pertensive agents are less efficacious (e.g., angiotensin con-
differ in South Asian populations compared with other eth- verting enzyme inhibitors in Africans), however there are no
nic groups. Clinical outcome studies have consistently studies that report different pharmacologic effects in South
observed that in patients with stage 2 hypertension (defined Asians. Therefore, any first line antihypertensive drugs can
as SBP of 160 to 179 mm Hg or DBP >100 to 109 mm Hg by be considered for the treatment of hypertension. Greater BP
the International Society of Hypertension), pharmacologi- reduction is achievable using low doses of combinations of
cally lowering BP is associated with a reduction in adverse two or three antihypertensive agents compared with standard
cardiovascular events. Proportionally larger reductions in doses of a single agent, and should be the preferred approach
CVD adverse events also occur with greater reductions in BP, in most individuals when initiating pharmacologic therapy.29
with no clear overall differences in outcomes based on the Two studies in Indian participants have evaluated combi-
particular pharmacologic agent used.25 In the SPRINT trial, nation BP and cholesterol reduction using fixed dose com-
which enrolled older subjects with CVD or at high CVD risk bination therapy with a polypill (ie, Polycap) containing
and an SBP between 130 mm Hg and 180 mm Hg (with mean hydrochlorothiazide (12.5 mg), atenolol (25 mg), Ramipril (5
enrollment BP of approximately 140/78 mm Hg), intensive mg), simvastatin (20 mg) and aspirin (75 mg). In a 12-week,
BP treatment (to a target SBP <120 mm Hg) reduced cardio- multiple comparison, randomized control trial comparing
vascular events compared with standard BP treatment to an once-daily Polycap with its individual pharmacologic com-
SBP of less than 140 mm Hg. Mean SBP was 122 mm Hg in the ponents it was reported that Polycap reduced SBP by 7.4
intensive-treatment group compared with 134 mm Hg in the mm Hg and DBP by 5.6 mm Hg. This was significantly larger
standard-treatment group, and although intensive treatment than the effects of any one BP lowering drug, and similar to
was associated with better cardiovascular outcomes, this the effect of all three BP lowering drugs given separately. In
required an average of three different drugs in these individu- fact, in participants with baseline hypertension, the number
als, and there were more side effects (including acute kidney of antihypertensive pills taken was significantly associated
injury and syncope).26 The large benefits observed in SPRINT with the achievement of better BP control (Fig. 4.2). Side-
are somewhat tempered by results of other studies, such as effects and discontinuation rates were similar to groups that
the ACCORD study in diabetics, where similar reductions in received only one of the component drugs.30 A second clini-
BP with intensive treatment compared with standard manage- cal trial compared low dose with high-dose Polycap in 518
ment (119 mm Hg versus 134 mm Hg) resulted in a 41% reduc- South Asian participants, and found that the high dose regi-
tion in stroke risk, but not in overall adverse CV events.27 men further reduced BP by 25%, with similar discontinuation
Furthermore, the recent HOPE-3 study found that in interme- rates.31 The use of a polypill has several potential benefits for
diate CVD risk individuals, pharmacologic blood pressure low- hypertension management in low- and lower-middle-income
ering only reduced major CVD events in those with a baseline countries. Firstly, larger BP reductions are achievable using
systolic BP > 143 mm Hg, with no benefit in lower BP ranges.28 combination antihypertensive treatment, which will result in
Based on current data, antihypertensive therapy should a greater proportion of patients with hypertension achieving
be strongly recommended for those with stage 1 or 2 hyper- adequate BP control. Secondly, reductions in both BP and
tension (e.g., a BP > 140/90 mm Hg). In patients at otherwise serum cholesterol can be achieved with a single pill, allowing
30
Capability barriers
Knowledge
Skills
HT
Intention barriers
awareness Motivation
Memory and attention
Beliefs about
consequences
Breaking habit
Social Influence
Clinical HT treatment Priority setting
guideline Professional Identity Adequate BP
(lifestyle+
adherence Beliefs about capabilities control
medication)
Stress, anxiety, depression
Memory and attention
FIG. 4.3 The influence of patient and provider/health system barriers on hypertension control. BP, Blood pressure; HT, hypertension. (From Khatib R, Schwalm JD, Yusuf S
et al. Patient and healthcare provider barriers to hypertension awareness, treatment and follow up: A systematic review and meta-analysis of qualitative and quantitative studies.
PloS One. 2014;9:e84238)
for better optimization of vascular risk factors with a simpli- to patients; provide adequate knowledge of medication side
fied regimen that can be applied to a broad range of socio- effects so patients can recognize problems and seek neces-
economic settings. Finally, using inexpensive components, a sary changes to their antihypertensive regimen; and provide
polypill can be marketed at a very low cost, which is of par- simplified dosing regimens, such as with single-pill combina-
ticular benefit in countries (including those in South Asia) tion therapy.32
where affordability remains a significant barrier to medica- At the provider and health system levels, opportunis-
tion use. tic BP evaluations at each physician health encounter can
significantly increase hypertension detection, as can task
sharing of hypertension screening to include nonphysician
Overcoming the Barriers to Hypertension health workers (NPHWs) (e.g., pharmacists, nurses, and
Management in South Asia skilled community health workers). In rural India, com-
The PURE study has reported that hypertension manage- munity based screening using a NPHW has been shown to
ment is subpar across South Asia, with only 40% of individu- improve the detection of CVD. In the Rural Andhra Pradesh
als with hypertension aware of the diagnosis, 32% of those Cardiovascular Prevention Study (RAFCAPS), commu-
with hypertension treated, and 13% controlled.6 Consistent nity screening using NPHWs resulted in a 12% increase in
results were observed in a recent systematic review of 142 CVD detection compared with usual care.33 It is possible
observational studies within India, with even poorer hyper- that similar NPHW initiated community based programs
tension management in rural areas of India; where 42% of can improve hypertension detection, and such programs
patients with hypertension were aware of the diagnosis in are currently being evaluated. It has also been shown that
urban areas compared with only 25% in rural areas; 35% allowing pharmacists or nurses to treat BP can further
received treatment in urban areas compared with 20% in improve control, and consideration should be given to
rural areas; and 20% achieved BP control in urban areas com- restructuring health care systems in the region to allow for
pared with 11% in rural areas.7 a broader number of health personnel to prescribe simple
The factors resulting in poor hypertension treatment are to administer and well-tolerated antihypertensive medica-
complex, and include barriers to care at the patient level, tions (which currently occurs in several high- and middle-
in addition to “upstream” barriers at the health care pro- income countries).34
vider and health systems levels (Fig. 4.3).32 To overcome Both the affordability and availability of CVD medications
these barriers, innovative and multifaceted policies and significantly impact their use, and the affordability of basic
interventions are needed to address these care gaps. Key medications is low in middle- and low-income countries.35 In
public health policies should include reducing smoking and India, although most cardiovascular disease medications are
alcohol consumption, promoting physical activity, reducing available as generics they are not affordable.35 In this situa-
saturated and transunsaturated fat intake, and national guid- tion, greater use of low-cost fixed-dose therapies may be
ance on the appropriate levels of sodium consumption for particularly useful for improving hypertension control and
the population. optimizing overall vascular risk. In addition to medication
Greater promotion of hypertension education is needed at costs, systematic methods to reduce additional health care
the patient level. Many patients with hypertension are asymp- provider costs to patients (e.g., affordable health insurance)
tomatic, and may be reluctant to make lifestyle changes or also need to be addressed. Additional barriers that may need
start pharmacologic treatments if they are feeling well. It to be overcome include difficulty with transportation to
is necessary to increase awareness of hypertension and its health facilities, absent or inaccessible facilities, shortage of
consequences, promote available resources for hyperten- physicians, inability to easily obtain medication refills, and
sion screening and treatment, and provide counselling on the the time-consuming nature of clinic visits.32 A summary of key
importance of lifestyle changes that reduce BP. It is also nec- strategies to improve hypertension detection, treatment and
essary to emphasize the benefits of medication adherence control is provided in Table 4.1.36
31
5 Pathogenesis of Hypertension
Michael E. Hall and John E. Hall
CONTROL OF BLOOD PRESSURE, BLOOD SYMPATHETIC NERVOUS SYSTEM, 41 POSSIBLE ROLE OF GENE VARIANTS,
FLOW, AND CARDIAC OUTPUT, 33 GENE-ENVIRONMENT INTERACTIONS, AND
ENDOTHELIN, 42 EPIGENETICS IN PRIMARY HYPERTENSION, 43
LONG-TERM BLOOD PRESSURE CONTROL:
ROLE OF RENAL PRESSURE NATRIURESIS, 34 NITRIC OXIDE, 42 ROLE OF OVERWEIGHT AND OBESITY IN
OXIDATIVE STRESS, 43 PRIMARY HYPERTENSION, 44
SALT SENSITIVITY AND HYPERTENSION, 36
PRIMARY (ESSENTIAL) HYPERTENSION, 43 SUMMARY AND PERSPECTIVES, 48
RENIN-ANGIOTENSIN ALDOSTERONE
SYSTEM, 39 REFERENCES, 49
Primary (essential) hypertension accounts for the vast major- BP control. However, chronic BP regulation is more com-
ity (>90%) of human hypertension and involves complex plex and involves additional systems that regulate circula-
interactions of multiple organ systems and neurohormonal tory volume in relation to vascular capacitance (sometimes
controllers of blood pressure (BP) as well as local tissue con- called “effective blood volume”); these systems may adjust
trol systems. Although primary hypertension is a heteroge- BP to satisfy other critical homeostatic needs, such as the
neous disorder, overweight and obesity account for as much requirement to maintain balance between intake and output
as 65% to 75% of the risk for increased BP in these patients.1,2 of salt and water.
Genetics and other factors such as increased dietary sodium CO represents the total blood flow of the circulation
intake, sedentary lifestyle, and excess alcohol consumption and is often described as the product of stroke volume and
may also contribute to primary hypertension. Activation of heart rate. Stroke volume, in turn, is determined by cardiac
neurohormonal systems such as the sympathetic nervous sys- pumping ability and by peripheral circulatory factors that
tem (SNS) and renin-angiotensin-aldosterone system (RAAS) influence venous return to the heart. The heart normally
also play an important role in the pathogenesis of hyperten- pumps the amount of blood returned to it (ie, venous return)
sion. Many of these contributors to primary hypertension ulti- which is the sum of all blood flows returning from the tis-
mately cause kidney dysfunction which initiates or sustains sues. Venous return and CO are therefore equal, except for
increased BP.3 momentary differences, and are determined by multiple
In this chapter we discuss short-term and long-term BP factors that influence tissue blood flow, especially the meta-
control systems and how multiple organ systems interact to bolic demands of the tissues. For example, normal growth of
maintain tissue blood flow, salt and water balance, and overall the tissues is associated with increases in CO whereas loss
homeostasis. We also briefly review various factors that influ- of tissue mass (eg, loss of muscle mass that may occur with
ence activities of the SNS and RAAS, endothelial function, and aging or with amputation of a limb) leads to decreases in CO.
oxidative stress that ultimately influence BP through effects Even without changes in tissue mass, metabolic rate
on cardiac output (CO), vascular resistance, and renal salt and greatly influences tissue blood flow and therefore CO. When
water excretion. metabolic rate increases during exercise or hyperthyroidism,
for example, tissue blood flow and CO also increase to meet
CONTROL OF BLOOD PRESSURE, BLOOD FLOW, the higher metabolic needs of the tissues. In most cases,
AND CARDIAC OUTPUT average daily CO remains relatively constant unless tissue
mass or metabolism is altered. Even with conditions that
Effective circulatory regulation involves complex interac- cause marked sodium retention and increased blood volume,
tions of neurohormonal and local control systems that regu- such as primary aldosteronism and sodium loading in sub-
late BP and tissue blood flow. According to the well-known jects with impaired kidney function, CO remains relatively
formula, BP is the product of CO and total peripheral vas- constant after initial transient changes that generally last
cular resistance (TPR): mean arterial BP = CO × TPR. This only a few days.4 This is because most tissues autoregulate
equation directs attention to factors that affect cardiac and their blood flow over a wide range of BP according to their
vascular function and is adequate for describing short-term specific needs.5 Thus, although many patients with chronic
hypertension have increased TPR, blood flows in most tis-
Acknowledgments: The authors’ research was supported by grants from the sues are maintained at relatively normal levels as a result of
National Heart, Lung and Blood Institute (PO1 HL51971), National Institute of local autoregulatory mechanisms. For example, increased BP
General Medical Sciences (P20 GM104357), National Institute of Diabetes and
Digestive and Kidney Diseases (1K08DK099415-01A1), and the American Heart
and vascular stretch activates myogenic vasoconstriction, a
Association. We thank Stephanie Lucas for expert assistance in preparing this response that can be observed even in isolated blood ves-
chapter. sels.6 Also, when blood flow increases above that required to
33
34
meet metabolic requirements, local vasoconstrictor mecha- LONG-TERM BLOOD PRESSURE CONTROL: ROLE
II nisms are activated in most tissues. With chronic increases
OF RENAL PRESSURE NATRIURESIS
in BP, there are structural changes in the blood vessels, such
Pathophysiology
as thickening of vessel walls and decreased numbers of cap- In contrast to the mechanisms that rapidly adjust vascular
illaries (rarefaction), which ensure relatively normal tissue and cardiac function for moment-to-moment BP regulation,
blood flow despite increased perfusion pressure. Therefore, long-term regulation of average daily BP is closely linked
TPR often changes in parallel with BP, helping to maintain with salt and water homeostasis. Fig. 5.1 shows a conceptual
normal tissue blood flow and attenuating changes in vascu- framework for integrating chronic control of BP and body fluid
lar stretch. volumes. A key element of this feedback system is the effect
In some instances, increased TPR and elevated BP are asso- of increased BP to raise renal sodium/water excretion, often
ciated with high levels of vasoconstrictors, such as angioten- called renal-pressure natriuresis/diuresis. Even temporary
sin II (Ang II) or endothelin, although it has been challenging imbalances between intake and output will change extracel-
to identify abnormally elevated levels of specific vasoconstric- lular fluid volume (ECFV) and potentially BP if cardiac and
tors in most patients with primary hypertension. Even in cases vascular functions are adequate. In some cases, increased BP
where high levels of vasoconstrictors are found, tissue perfu- serves to maintain salt and water balance, via pressure natri-
sion is usually maintained at a level that is appropriate for uresis, in the face of abnormalities that tend to cause salt/
the metabolic requirements.7 However, blood flow “reserve” water retention. Although temporary imbalances between
and the ability to increase tissue blood flow in response to intake and output of salt and water occur routinely in daily life
increased metabolic requirements (eg, during exercise) may and excess sodium can be stored in tissues such as skin, inde-
be impaired in some hypertensive subjects. pendent of volume retention,8 balance between average intake
Although adequate BP is obviously required to maintain and output must eventually be achieved; otherwise, contin-
blood flow and nutrient supply to the tissues, blood flow and ued expansion or contraction of body fluids would occur and
CO can be regulated independently of perfusion pressure when ultimately lead to circulatory failure.
BP is elevated above normal. Moreover, BP is regulated by fac- The kidneys have powerful intrarenal and neurohormonal
tors that may not be directly related to blood flow to most systems that help maintain salt and water balance, often with
peripheral tissues, except for the kidneys which require a BP minimal changes in extracellular fluid volume or BP over a
that maintains urinary excretion of water and electrolytes at a wide range of salt and water intakes. For example, when salt
level equal to intake. As discussed later, chronic hypertension intake is increased in persons who have normal kidney and
may represent a “trade off” that permits the kidneys to excrete neurohormonal functions, minimal changes in BP occur and
normal amounts of salt and water, equal to intake, in the face these individuals are called “salt-resistant.” However, in “salt-
of disturbances that impair renal function.3 For example, con- sensitive” individuals with impaired kidney function, because
striction of the renal arteries or aortic coarctation above the of abnormal neurohormonal control or because of intrinsic
renal arteries initiates compensatory increases in systemic kidney abnormalities (eg, kidney injury), increased BP and
arterial pressure that eventually restore renal perfusion and subsequent pressure natriuresis/diuresis provide another
excretion of salt and water to normal levels. In contrast, means of maintaining salt/water balance.4,9 In some circum-
reducing perfusion pressure to nonrenal tissues such as skel- stances, renal-pressure natriuresis may play a critical role in
etal muscle (eg, by aortic coarctation below the renal arteries) maintaining balance between intake and output of salt and
does not lead to chronic hypertension. Although insufficient water and in preventing excessive fluid retention.4
blood flow to the brain may initiate emergency mechanisms Some investigators have argued that pressure natriuresis
(eg, sympathetic activation) that acutely raise BP, the impor- has minimal role in long-term BP regulation because the kid-
tance of cerebral perfusion in long-term BP regulation is still neys can adapt to elevated BP.10 However, considerable evi-
unclear. dence indicates that renal perfusion pressure has a sustained
• Genetic
(x normal)
• Diet
• Neural
Na • Hormonal
1 • Intrarenal
intake
Heart strength
FIG. 5.1 Basic renal-body fluid feedback mechanism for long-term blood pressure regulation. A key component of this feedback is the effect of arterial pressure and urine
sodium excretion, called renal-pressure natriuresis/diuresis. The dashed pressure natriuresis lines show impaired pressure natriuresis in salt-sensitive and salt-insensitive hyper-
tension. Increased arterial pressure may cause secondary increases in total peripheral resistance via pressure-dependent or flow-dependent “autoregulation” in various tissues.
Increased vascular capacity tends to reduce mean circulatory filling pressure.
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vous chez vous? Rien. Pire que rien. Croyez-nous, Madame, il est ici à sa
place. Et, si Dieu le permet, une fois accomplis les deux ans que nous vous
avons demandés, il vous reviendra transformé enfin, aussi bien par le temps
que par nos cordiaux efforts.»
Elle monta le perron, trébuchante, sentant que son cœur lui manquait,
son cœur qui n’en pouvait plus. De ce voyage si joyeusement accompli, ne
rapporter que la certitude d’être haïe par son enfant!
Sur le seuil, dans l’ombre, une voix moqueuse:
—Eh bien?... Tu le ramènes?...
—Oh! Jacques!...
Elle venait de s’abattre sur l’épaule de son frère stupéfait. Ce fut toute
secouée par son chagrin qu’il l’emmena doucement jusqu’au petit salon de
leurs veillées. Il avait fait faire un peu de feu dans la cheminée. La lampe
basse éclairait la petite table.
Tombée dans son fauteuil de tapisserie, Mᵐᵉ Carmin pleura longtemps, la
tête dans ses mains. L’oncle Jacques, debout, ne voyait que son chapeau,
qui remuait par petites saccades. Il ne savait que dire ni que faire, rien ne
l’ayant habitué jamais aux gestes de la tendresse. Simplement il hochait la
tête en répétant: «Voyons!... Voyons!...» Et sa rancune contre Laurent
grandissait encore, car il savait bien que tout cela venait, naturellement, de
cet enfant épouvantable.
Quand elle se fut un peu calmée, qu’elle eut retiré son chapeau tout en
approchant ses pieds de la flamme, elle commença de raconter son voyage.
Et, tout d’abord, la vanité maternelle la redressa, face au sourd ennemi de
son fils.
—Tu sais, il travaille très bien! Ces messieurs sont absolument édifiés.
Ils ne savent que faire pour le récompenser!
Devant ce triomphe inattendu, l’autre pinçait les lèvres.
—Mais, alors, tout va bien! Pourquoi pleures-tu?
—C’est que je croyais le ramener... dit-elle.
Là-dessus, son cœur gros, une fois de plus, creva.
—Mais, alors, qu’est-ce qu’il y a?... demanda Jacques de Bonnevie. Est-
ce qu’il est malade?...
—Non... Non... sanglota-t-elle, il va très bien.
Et, tout en détournant sa pauvre figure, déformée par la lippe du chagrin,
elle se mit à fouiller dans son grand sac de soie noire, maladroitement,
gênée par ses larmes.
—Tiens!... Tu vas voir sa photographie. Ils me l’ont donnée...
Comme elle sortait les objets du sac pour mieux chercher, les deux écrins
qui contenaient le chapelet de nacre et la montre d’or apparurent.
—Comment?... s’étonna Jacques, tu rapportes tes cadeaux?...
Elle ne put pas répondre et fit signe avec sa tête: «Oui.» Puis, dans un
spasme qui entrecoupait les mots:
—Il... il n’en a pas voulu!...
Le vieux garçon ouvrit d’abord la bouche, puis mordit lentement sa lèvre
inférieure. Peut-être commençait-il à comprendre.
Nerveusement, pressée de se changer les idées, elle tendit la
photographie enfin trouvée.
—Tiens!...
Elle s’était levée pour regarder avec son frère. Ayant baissé la
photographie sous la lampe, celui-ci chercha son lorgnon. Quand il l’eut
enfin ajusté:
—Oh! mon Dieu!... cria-t-il.
—Eh bien! qu’est-ce que tu as?... Il a engraissé, n’est-ce pas, et
grandi?... Et puis... et puis, il n’a plus ses boucles sur le front...
Mais Jacques la regardait avec un visage tel qu’elle crut qu’il devenait
fou.
—Mais enfin, qu’est-ce que tu as?... Vas-tu me le dire, à la fin?
—Ce que j’ai?... Alice, Alice!... Et dire que j’ai écrit à mon
collectionneur d’Italie une lettre pour lui dire qu’il n’était qu’un imbécile et
que la gravure qu’il m’avait envoyée... Alice! Alice... Mais c’est effrayant!
Mais c’est admirable!... Ah! ah!... Vous ne direz plus que je rêve!... Oh!...
c’est trop fort!... C’est trop fort! Et dire qu’on ne voit pas ça sur les êtres et
qu’on le voit sur leurs portraits! Tu vas juger toi-même, tiens! Je cours là-
haut chercher la gravure. Où est la bougie? Attends-moi un instant, et tu vas
voir!
Avant qu’elle fût revenue de sa surprise, il s’était précipité, sa bougie à
la main.
—Vieux fou!... pensa-t-elle.
Mais un trouble étrange montait en elle, qui lui faisait trembler les
jambes.
Il redescendit, souffla sa bougie avec violence, faillit casser le bougeoir
en le remettant sur la cheminée, et, sous la lampe, à côté de la photographie,
il posa précieusement une petite gravure jaune, faite d’après quelque
tableau de la Renaissance, figure d’homme méticuleusement dessinée, qui,
la barbe frisée, le cou nu dans des mailles, reproduisait avec une exactitude
presque parfaite le front si particulier de Laurent, tel que le révélait la
photographie, maintenant que les boucles n’y étaient plus pour cacher tout.
Elles étaient là sur les deux portraits, les petites cornes prêtes à naître
sous la racine des cheveux, faunesques, diaboliques, signe
incompréhensible, anomalie dans la famille. Et même, en examinant de plus
près, on reconnaissait une ressemblance entre les yeux de Laurent, larges et
rapprochés, et ceux de la gravure, tandis que ses mâchoires vigoureuses, sa
bouche impérieuse et royale n’étaient pas sans similitude avec les traits du
personnage ancien.
—Regarde!... Regarde!... murmurait Jacques de Bonnevie avec une sorte
de peur. Tu vois? Celui-là, mon correspondant me l’affirme, c’est Laurent
Buonavita. Reconnais-tu ton fils?
—Laurent Buonavita?... tressaillit-elle, pourquoi l’appelles-tu Laurent?
—Mais, répondit-il, parce que Laurent et Lorenzo c’est le même nom!
Elle lui jeta furtivement un regard étrange. Et, penchée sur les deux
portraits:
—C’est pourtant vrai! Voilà bien son front, son front auquel on ne
comprend rien!
Béants, ils se dévisagèrent parmi le vert clair-obscur que leur renvoyait
l’abat-jour trop bas.
Est-ce que, pendant quinze ans, Jacques de Bonnevie, sans même y
croire, poussé par on ne savait quel mystérieux génie, avait travaillé, moqué
de tous, à découvrir la vérité?
Le vieux garçon s’essuya le front. En cette minute suprême il croyait
déchiffrer toutes les énigmes: son acharnement, sa foi malgré son propre
doute, et aussi des petits et des grands signes auxquels il n’avait pas su
prêter attention. Il revit son neveu dans le parc, enfonçant la lame de son
canif dans les arbres; il le revit saccageant les papiers dans son cabinet; il le
revit à cheval, la figure ensanglantée et riant; il entendit les histoires de
rapines racontées par les galopins du village; il s’expliqua le casse-tête, le
petit Quesnot éborgné, tout ce qu’ensuite avait raconté la lettre des
Jésuites...
Il y eut de l’épouvante et du triomphe dans le grand cri qu’il poussa:
—C’est un condottiere!
Sa sœur fit un geste pour lui mettre la main sur la bouche:
—Tais-toi!
Et tous les deux, comme envoûtés, restèrent, la tête basse, engloutis dans
leurs réflexions.
Au bout d’un long moment, approchant les fauteuils, ils se courbèrent de
nouveau sur les deux images.
—Et dire que nous ne savions pas!... murmura-t-il, car enfin, moi, je ne
croyais pas absolument ce que j’affirmais, dire que nous ne comprenions
pas que Laurent, que j’avais appelé comme ça sans savoir, c’était vraiment
Lorenzo, la répétition de notre premier ancêtre!
Elle parla si bas qu’il l’entendit à peine.
—Moi je le savais...
—Qu’est-ce que tu dis?... cria-t-il.
Elle continua, décomposée, haletante:
—Je le savais depuis... depuis ta lecture d’un soir. Tu te souviens?... Je
t’ai fait répéter ce passage?... Car... tu ne sais pas encore tout. La blessure
de Clémentine ne vient pas d’une chute. C’est Laurent qui l’a frappée, en
lui jetant son verre à la tête, un jour qu’il était entré à cheval dans la cuisine,
pour lui demander à boire...
Il écarquillait ses yeux myopes, tout en l’écoutant.
—Rien ne m’étonne, souffla-t-il, maintenant!
Alors, une sorte de lyrisme l’anima.
—Des Italiens, nous!... Toi!... Moi!... Nos parents!... Nos grands-
parents!... Nous, ces braves Normands encroûtés!... Mais qu’est-ce qui
dormait donc derrière notre bourgeoisisme de hobereaux tranquilles?
Enfin!... Tu n’es pas passionnée, toi!... Tu n’as pas l’air!... Et moi!... Et tous
les nôtres!... Pourquoi faut-il que ce petit... Qui sait?... C’est peut-être ce
mariage entre cousins qui a refait tout d’un coup le sang oublié du grand
passé, qui a refait un héros!
—Un héros!... répéta-t-elle amèrement.
—Oui, un héros!... s’emporta-t-il. Cet enfant-là, mais à une autre époque
que la pauvre nôtre, il aurait été chef, un grand chef! Il avait tout: la
violence, la fierté, le courage, l’autorité, la volonté, l’orgueil. Il était beau,
sain, dominateur. Il était né pour la gloire! Et voilà: dévoyé dans un temps
qui n’est pas le sien, il finit ou plutôt commence dans une maison de
correction!... Pauvre petit!
Elle fit entendre un rire désespéré.
—Ah! tu le plains, maintenant!
—Oui, je le plains! Car ce n’est pas un vrai vivant. C’est un réapparu!
Ils s’étaient tournés tous deux du côté de la cheminée. Le feu qui baissait
faisait passer par instants des ombres et des lumières sur leurs deux faces
profondément altérées. Un silence, encore une fois, les laissa plongés dans
les rêves. Alors, lentement, Jacques de Bonnevie, penché vers sa sœur,
articula tout bas, avec une espèce de curiosité terrifiée:
—Alice... Alice, dis?... Qu’est-ce que c’est... qu’est-ce que c’est donc
que cet enfant que tu as fait là?...
XI
LE MAITRE
Elle avait prié son frère de ne pas montrer à l’abbé Lost la troublante
gravure, et, du reste, de ne plus jamais faire allusion à leur découverte.
Ainsi lui semblait-il jeter un voile de silence sur cette nouvelle angoisse.
«Coïncidence...» songea-t-elle au bout d’un mois.
Au bout de deux, elle était en plein doute.
Cependant, une fièvre agitait Jacques de Bonnevie.
Celui-ci venait de toucher du doigt les réalités. Il n’était plus dans le
songe. Il travaillait en pleine lumière. Que sa sœur ne voulût plus le suivre
ne le décourageait en rien.
Avec quelle impatience il attendait désormais ce neveu qu’il avait vu
partir avec tant de plaisir!
—Ote-le donc de cette sale boîte, qu’on le revoie, maintenant!
Une curiosité de savant devant sa découverte, curiosité palpitante,
implacable, presque monstrueuse, lui faisait souhaiter le retour rapide du
galopin qui l’avait tant exaspéré. Car il ne s’agissait plus du «sale gosse»
renverseur d’encriers et casseur de carreaux; il s’agissait d’une apparition
quasi surnaturelle.
Jacques de Bonnevie était fier de son petit condottiere comme s’il l’eût
forgé de ses propres mains, comme si, d’entre ses paperasses de vieux
maniaque, le deuxième Lorenzo Buonavita fût sorti tout vivant, comme si,
secouant ses livres, l’historien eût vu tomber d’entre les pages, en chair et
en os, son personnage, comme si, l’ayant pendant quinze ans appelé du fond
des Légendes, l’autre eût soudainement répondu: «Me voici!»
*
**
L’abbé Lost et son église furent le grand refuge de la mère douloureuse
pendant les longs mois qui vinrent, pleins de privation maternelle,
d’angoisse et d’anxiété.
Les lettres régulières de l’institution répétaient toutes la même chose.
Laurent ne modifiait en rien l’attitude qu’il avait prise. Son cœur continuait
à ne pas s’ouvrir. Mais il travaillait. Que pouvait-on demander de plus?
—Tant qu’il ne m’écrira pas lui-même, sanglotait Mᵐᵉ de Bonnevie, je
serai plus malheureuse que si je l’avais perdu!
—Suivez pieusement les chemins de votre calvaire... disait l’abbé.
Les neuvaines se succédaient, et aussi les dons pour les pauvres de la
paroisse. Ces sacrifices d’argent coûtaient tant à la regardante châtelaine qui
lui semblait devoir en être récompensée à la fin.
Son visage se transforma, vieillit. Son austérité devint presque ascétique.
—Depuis qu’ son gas est dans les collèges, disaient les gens du pays,
Mâme Carmin n’en gagne pas, marchez! On dirait bientôt d’un crucifix de
campagne!
*
**
Madame,
Voici donc accomplies les deux années exigées par nous pour améliorer
votre fils, et nous ne craignons pas de dire que nous l’avons, en effet,
amélioré, puisque, après les effroyables tempêtes du début, il est parvenu à
un tel point de domination sur lui-même que, jamais plus, nous n’avons eu
l’occasion de sévir contre lui, puisque, jamais plus, ne se sont renouvelés
ces châtiments extrêmement sévères, il faut l’avouer, sans lesquels notre
tâche d’éducateurs serait impossible près des sujets très spéciaux remis
entre nos mains.
Nous vous proposerions volontiers de garder votre enfant jusqu’à sa
majorité, mais plusieurs raisons nous conseillent de vous dissuader d’un tel
projet.
La première de ces raisons est que la santé du jeune garçon, malgré sa
constitution puissante, pourrait finir par s’altérer à force de réclusion, car
notre médecin dit qu’avec son tempérament et à l’âge où il arrive, le grand
air lui est désormais indispensable.
La seconde raison est qu’en poussant trop loin les choses, en
prolongeant outre mesure cet exil qu’on lui a toujours dit ne devoir durer
que deux ans, nous pourrions craindre, à la fin, quelque néfaste revirement
de ce caractère que seul un miracle de volonté maintient au calme; nous
redoutons, en tout cas, de voir s’accentuer et se durcir définitivement en lui
les sentiments d’inimitié, de rancune qu’il semble, dans son for intérieur,
nourrir contre les siens.
Enfin, la troisième raison est que, malgré la régularité de son travail,
nous avons tout lieu de croire que Laurent ne sera jamais apte à passer son
baccalauréat, vu le système adopté par lui. Travail passif ne mène pas bien
loin, et le pauvre enfant n’a jamais pu ou jamais voulu faire collaborer son
initiative personnelle au labeur tout mécanique qu’il fournit.
Nous pensons donc, Madame, qu’il vaut mieux, pour vous et pour votre
fils, ne pas persister davantage, et le reprendre près de vous tandis qu’il est
encore un enfant, tandis qu’il vient de mériter sa libération par deux ans
d’effort, tandis que la tendresse maternelle, enfin, peut avoir encore
quelque chance de reprendre ses droits sur cette jeune âme repliée.
Votre fils, Madame, va bientôt avoir quatorze ans. Il entre dans
l’adolescence. Il va retrouver près de vous sa liberté d’autrefois, et toutes
ces douceurs du foyer, qu’il saura mieux apprécier après son long séjour
ici. Peut-être, ayant pris parmi nous l’habitude, à défaut de l’amour du
travail, en découvrira-t-il les charmes une fois remis sous la coupe
bienveillante de ses maîtres précédents. Tout est possible avec une nature
comme la sienne. Quoi qu’il arrive, il a goûté le plaisir de la discipline
intérieure, et nous sommes presque sûrs que vous n’aurez plus à déplorer
ces éclats et ces scandales qui l’ont conduit jusqu’à nous.
Et si ses études scolaires doivent s’arrêter là, ne lui reste-t-il pas à
apprendre ce devoir, qui fut celui de ses pères, de gérer ses biens et de
veiller sur ses cultures?
LE SCANDALE