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From page 1... ... INTRODUCTICXJ The appropriate a p p l i c a t i o n of the t r a c e r concept i n the e v a l u a t i o n of h e a l t h s e r v i c e s r e q u i r e s t h a t the d i s t r i b u t i o n and determinants of the t r a c e r be understood. Thus, the epidemiology of each t r a c e r has been reviewed and i s presented i n the s i x chapters t h a t f o l l o w . Read the entire page →
From page 2... ... v a r i a t i o n i n c l i n i c a l presentations t h a t the p r a c t i c i n g p h y s i c i a n faces. Thus, the management c r i t e r i a were not designed, and should not be viewed, as r i g i d formulae a p p l i c a b l e t o an i n d i v i d u a l p a t i e n t , b ut r a t h e r as p a r t of an o v e r a l l plan f o r e v a l u a t i n g services t o populations of p a t i e n t s . Read the entire page →
From page 3... ... The conmonly accepted d e f i n i t i o n o f e s s e n t i a l hypertension can be summar i z e d as a sustained e l e v a t i o n o f both s y s t o l i c and d i a s t o l i c blood pressure without evident cause. Attempts t o d e f i n e o p e r a t i o n a l l y the key elements o f t h i s c o n d i t i o n - "sustained," "elevated," and "without evident cause" - have been i n c o n s i s t e n t and d i f f i c u l t t o implement. Read the entire page →
From page 4... ... r e p o r t exceptions t o t h i s t r e n d , w i t h mean blood pressures among Negro females c o n s i s t e n t l y higher than Negro males from e a r l y adulthood (see 18,19 "Race," p.275) Read the entire page →
From page 5... ... Figure 1 Percentage Increase i n mean blood pressure of four surveys, 6 by age, f o r en and women. From N a t i o n a l Center f o r Health S t a t i s t i c s . Read the entire page →
From page 6... ... crossover among t h e i r white sample, w h i l e among bl a c k s , females maint a i n e d higher pressures at most agna. i n c o n t r a s t , data from Alameda 23 County on a large b i r a c l a l sample documented no sex p a t t e r n among b l a c k s ; among whi t e s , mean d i a s t o l i c pressure of males, however, was c o n s i s t e n t l y higher than females over the e n t i r e age range s t u d i e d . Read the entire page →
From page 7... ... Figure 2 Mean d i a s t o l i c blood pressure of fo u r surveys, by race, 23 sex, and age. From Borhani and Borkman. Read the entire page →
From page 8... ... Figure 3 Percentage Increase i n mean blood pressure i n fo u r surveys, 6 by age, f o r men and women. From Na t i o n a l Center f o r Health S t a t i s t i c s . Read the entire page →
From page 9... ... have c o n s i s t e n t l y shown mean blood pressure t o be s i g n i f i c a n t l y r e l a t e d 22,26-30 t o age and/or age-squared. Simple c o r r e l a t i o n c o e f f i c i e n t s between age and e i t h e r s y s t o l i c or d i a s t o l i c pressures i n each race-sex group of a nationwide sample, were h i g h l y s i g n i f i c a n t ; c o e f f i c i e n t s tended t o 28 be higher f o r s y s t o l i c pressures and f o r females. Read the entire page →
From page 10... ... to 220 200 M A L E S FEMALES DIASTOLIC DIASTOLIC PULS^ PRESSURE PULSE PRESSURE t Figure 4 Medians and q u a r t i l e s o f blood pressure i n age groups, by sex, i n Bergen, 22 Norway. Read the entire page →
From page 11... ... S 110 100 90 80 70 60 50 40 301White Females percentile percentile percentile 24 (N-150) Read the entire page →
From page 12... ... those of men i n the upper age ranges might be due t o s e l e c t i v e m o r t a l i t y the tendency f o r women t o t o l e r a t e pressure e l e v a t i o n s b e t t e r than men. Nearly a l l l o n g i t u d i n a l studies have been conducted on selected populations (e.g., s e r v i c e , h o s p i t a l , i n s u r e d , w o r k i n g ) Read the entire page →
From page 13... ... age." 13 The Framingham data was analyzed subsequently i n an attempt t o 20 r e p l i c a t e the f i n d i n g s of M i a l l and L o v e l l . Contrary t o the f i n d i n g s 13 of M i a l l and L o v e l l , F e i n l e l b e t a l . Read the entire page →
From page 14... ... these f i v e s t u d i e s . Whereas i n each the mean s y s t o l i c and d i a s t o l i c pressures of white females cross those of males around middle age, two 18,19 Southern surveys f a i l e d t o doctament t h i s p a t t e r n ; black females showed higher mean s y s t o l i c and d i a s t o l i c pressures a t most ages. Read the entire page →
From page 15... ... Figure 6 S y s t o l i c blood pressure f o r selected age-race groups. 23 From Borhani and Borkman. Read the entire page →
From page 16... ... Figure 7 D i a s t o l i c blood pressure for selected age-race groups. 23 Frcnn Borhani and Borkman. Read the entire page →
From page 17... ... study (Table 3 ) Read the entire page →
From page 18... ... TABLE 1 Number and Percent Distribution of S y s t o l i c Blood Pressures for White and Negro Adults, by Sex i n the United States, 1960-1962 Pressure in mm Hg No. of Persons (i n thousands) Read the entire page →
From page 19... ... TABLE 2 Number and Percent Distribution of D i a s t o l i c Blood Pressures for White and Negro Adults, by Sex, i n the United States, 1960-1962 No, of Persons ( i n thousands) Percent Distribution Pressure i n mm Hg Men Wonen Men Women White Negro White Negro White Negro White Negro Under 50 490 43 314 25 1.1 0.8 0.6 0.4 50-54 367 42 552 93 0.8 0.8 1.1 1.5 55-59 846 108 1,573 74 1.8 2.1 3.1 1.2 60-64 2,362 167 3,619 279 5.1 3.2 7.1 4.5 65-69 5,094 461 6,698 714 10.9 8.9 13.1 11.5 70-74 6,689 686 8,636 680 14.4 13.2 16.9 10.9 75-79 9,807 722 9,364 976 21.1 13.9 18.3 15.7 80-84 7,191 686 7,923 891 15.4 13.2 15.5 14.3 85-89 5,936 598 4,999 706 12.7 11.5 9.8 11.4 90-94 3,520 507 3,250 441 7.6 9.8 6.3 7.1 95-99 2,023 638 1,819 457 4.3 12.3 3.6 7.4 100-104 990 182 1,132 243 2.1 3.5 2.2 3.9 105-109 663 108 616 221 1.4 2.1 1.2 3.6 110-114 243 132 191 99 0.5 2.5 0.4 1.6 115-119 162 55 234 145 0.3 1.1 0.5 2.3 120-124 80 27 109 52 0.2 0.5 0.2 0.8 125-129 - 25 64 83 - 0.5 0.1 1.3 130-134 49 - 18 14 0.1 - 0.0 0.2 135 + 48 9 72 24 0.1 0.2 0.1 0.4 Total 46,561 5,195 51,184 6,219 100.0 100.0 100.0 100.0 39 Source: National Center for Health S t a t i s t i c s . Read the entire page →
From page 20... ... TABLE 3 Number of Age-Sex Comparisons^ ( i n mm Hg) Difference between Negroes and Whites i n Four Surveys Difference i n U.S. Read the entire page →
From page 21... ... systematic v a r i a t i o n i n presstire observed between the two populations i n South Wales. Examination of the i n t r a r a c i a l differences displayed i n the f i v e U Read the entire page →
From page 22... ... difference might, in fact, be due primarily to environmental factors. Most investigators agree that r a c i a l variation i n blood pressure needs to be c a r e f u l l y considered not only with respect to age and sex, but also i n the context of the following relevant variables: socioeconomic, e.g., 18,23,37,43 25,29,33,37,42 occupation; sociocultural, e.g., s t r e s s ; d i e t , e.g., 7,18,35,45 18,33,42,45,46 s a l t intake; and biomedical, e.g., body build. Read the entire page →
From page 23... ... well-known study of the physical demands of occupation i n r e l a t i o n to blood pressure conducted on a large British-employed population produced the following observations: no s i g n i f i c a n t trend i n women; no s i g n i f i c a n t trend i n men under 40 years of age; s i g n i f i c a n t l y higher mean s y s t o l i c pressures i n men engaged i n more physi c a l l y strenuous occupations. 7 Using age-adjusted scores, Miall demonstrated that men 50 years or older, engaged i n heavy labor most of the i r l i v e s , had s i g n i f i c a n t l y lower blood pressures than other groups. Read the entire page →
From page 24... ... be explained i n terms of f a i l u r e to control for body build factors, length of employment, socioeconomic status, or s e l e c t i v e mortality. In general, 48 the findings support the conclusion of Henry that variations i n amount of habitual physical exercise are i n s u f f i c i e n t to explain v a r i a t i o n i n blood pressure observed i n most populations. Read the entire page →
From page 25... ... 43 National Health Survey i n r e l a t i o n to t h i s occupational s t r e s s factor are d i f f i c u l t to interpret due to the nature of the occupational c l a s s i f i c a t i o n employed. However, a si g n i f i c a n t finding was a lower than expected prevalence among professionals i n both races i n each sex. Read the entire page →
From page 26... ... TABLE 4 Actual and Expected Prevalence Rates (%) of Definite Hypertension i n Adults, by Race, Education, and Sex i n the Unites States, 19601962 Years of Men Women Education Actual Expected Difference Actual Expected Difference White < 5 26.9 19.6 7.3 36.5 28.2 8.3 5-8 16.1 16.9 -0.7 26.4 23.0 3.4 9-12 10.7 10.5 0.1 10.3 11.4 -1.1 fcl3 9.3 10.3 -0.9 9.5 12.7 -3.3 Negro <5 42.9 37.7 5.2 46.3 41.4 4.9 5-8 27.8 29.9 -2.1 33.3 34.3 -1.0 9-12 18.3 18.4 -0.1 17.1 17.1 0.0 s:i3 15.5 22.5 -7.0 14.9 20.2 -5.3 43 Source: National Center for Health S t a t i s t i c s . Read the entire page →
From page 27... ... 23 Findings from the Alameda b i r a c i a l sample r e l a t i n g mean blood pressure to education reveal a similar pattern. 47 Cross-sectional analysis of che Framlngham data did not reveal a si g n i f i c a n t effect of educational status on blood pressure d i s t r i b u t i o n s . Read the entire page →
From page 28... ... TABLE 5 Actual and Expected Prevalence Rates (%) of Definite Hypertension i n Adults, by Race, Family Income, and Sex i n the United States, 1960-1962 Family Men Women Income Actual Expected Difference Actual Expected Difference White < $2,000 16.7 18.3 -1.6 30.3 25.5 4.9 $2,0003,999 13.9 13.5 0.4 16.3 17.0 -0.7 $4,0006,999 12.2 11.2 1.0 10.3 11.5 -1.2 $7,0009,999 10.6 11.1 -0.5 11.5 12.1 -0.7 -- $10,000 11.6 13.2 -1.6 11.9 13.5 -1.6 Unknown 14.6 13.2 1.4 20.1 18.4 1.7 Negro ^ $2,000 37.1 29.8 7.3 34.8 30.5 4.3 $2,0003,999 21.6 26.9 -5.4 24.7 22.9 1.9 $4,0006,999 20.3 23.7 -3.4 19.1 25.0 -6.0 $7,0009,999 5.4 19.2 -13.8 22.1 22.5 -0.4 ^$10,000 26.6 20.0 6.5 - 5.6 -5.6 Unknown 35.3 28.3 7.0 16.6 28.0 -11.4 43 Source: National Center for Health S t a t i s t i c s . Read the entire page →
From page 29... ... TABLE 6 Race D i f f e r e n t i a l s i n Prevalence of Definite Hypertension (160 and/or 95+ mm Hg) among Persons with Family Incomes of Less Than $2,000, by Place of Residence Geographic Location Wlaite Negro Metropolitan areas Men 11.6 13.7 Women 8.3 21.8 Rural South Men 15.4 31.5 Women 19.5 36.7 43 Source: National Center for Health S t a t i s t i c s . Read the entire page →
From page 30... ... than $4,000) had higher mean s y s t o l i c blood pressure than middle- or highincome groups; males over 45 with high family income ($8,000 - 9,999) Read the entire page →
From page 31... ... greater u t i l i z a t i o n of medical care to be at l e a s t p a r t i a l l y r e f l e c t e d i n the generally documented trend for blood pressures to be inversely r e l a t e d to socioeconomic factors but conclusions on the relevance of t h i s variable remain tenuous. Body Build Many investigators have postulated that, i n addition to age, body build i s the other most i] Read the entire page →
From page 32... ... t h i s study can be sunnnarized as follows: For syst o l i c pressure, weight indices and blood pressure were s i g n i f i c a n t l y correlated i n white males and females 55 years of age or less, and i n Negro females 45 years or less; s i g n i f i c a n t d i a s t o l i c correlations were fotind for white males of a l l ages and white females 45 years or less. No s i g n i f i c a n t correlations were found i n either d i a s t o l i c or systolic pressure for Negroes 45 years of age or more. Read the entire page →
From page 33... ... of observation. When the prevalence of f i n a l d i a s t o l i c pressures 90 mm Hg or more and 95 mm Hg or more were analyzed by f i r s t r e l a t i v e weight ( f i r s t actual weight divided by desirable weight calculated from standard l i f e insurance tables for height) Read the entire page →
From page 34... ... Figure 8 TWenty-year follow-up data on 746 men, age 40-59: Young adult f i r s t weight, 20-ycar weight slope, and development of hypertensive disease i n middle age. Read the entire page →
From page 35... ... Many problems emerge i n the i n t e r p r e t a t i o n of data on body b u i l d . Several investigators question the r e l i a b i l i t y and s e n s i t i v i t y of such meas33,35,54,60 urements. Read the entire page →
From page 36... ... Sodium Sodium chloride was o r i g i n a l l y implicated as a factor associated with blood pressure v a r i a t i o n on the basis of therapeutic success of low sodium diets 64 65 66 i n reducing pressure i n hypertensives, Dahl and Meneely et a l . undertook extensive animal investigations of the relationship between sodium intake and hypertension. Read the entire page →
From page 37... ... when sa l t intake was estimated from dietary interview, 24-hour urine output, or sodium potassium-to-urlne r a t i o . 12,47 Despite these c o n f l i c t i n g reports, many Investigators believe that sodium intake i s a s i g n i f i c a n t environmental factor related to blood pressure v a r i a t i o n . Read the entire page →
From page 38... ... r i b o f l a v i n , and ascorbic acid. The authors hypothesized that high s a l t intake i n combination with low intake of some vitamins predisposes toward 47 elevated blood pressure. Read the entire page →
From page 39... ... correlations and multiple regression analyses were carried out. Blood glucose was found to be s i g n i f i c a n t l y correlated with both sy s t o l i c and dias t o l i c blood pressure after the effects of age, physique, and race are removed. Read the entire page →
From page 40... ... findings on f a m i l i a l aggregation of pressures suggest that genetic factors may play a rol e i n blood pressure v a r i a t i o n . The r e l a t i v e contribution of genetic and environmental factors i s always d i f f i c u l t to evaluate. Read the entire page →
From page 41... ... i n support of t h i s association i s fragmentary due, i n no small measure, to the inherent d i f f i c u l t i e s i n defining and measuring these variables. The focus of much early work on psychological factors was on the 10,79-81 d e f i n i t i o n of the "hypertensive personality." An apparent weakness of t h i s type of study i s the i n a b i l i t y to determine whether the persona l i t y syndrome gave r i s e to the elevated presstire or whether i t was an 41,79 82 outcome of the elevated pressure. Read the entire page →
From page 42... ... d i a s t o l i c (90+ mm Hg) and higher mean pressures among the newly urbanized group. Read the entire page →
From page 43... ... neighborhoods of the same race. These results could not be a t t r i b u t e d to age, sex, or weight differences. Read the entire page →
From page 44... ... 61 percent maintained the same blood pressure, 12 percent recorded an increase, and 27 percent a decrease. Although essential hypertension i s often associated with headaches, vertigo , dyspnea on exertion, nosebleeds, nervousness, and chest pain, the frequency of these symptoms and the relationship to hypertension has not been care f u l l y defined. Read the entire page →
From page 45... ... 95 f a i l u r e but does not a f f e c t the death rate from myocardial i n f a r c t i o n . Although there i s controversy over the impact of treatment of "benign" es s e n t i a l hypertension, most studies indicate that treatment does reduce 96 morbidity, as well as mortality. Read the entire page →
From page 46... ... 2. Family history of high blood pressure, coronary artery disease, or stroke 3. Read the entire page →
From page 47... ... 9. Do you always sleep on two or more pillows? Read the entire page →
From page 48... ... F. Disposition* Read the entire page →
From page 49... ... Further evaluation should Include: 1) Serum sodium and potassium 2) Read the entire page →
From page 50... ... BIBLIOGRAPHY Report of Inter-Soclety Conmlsslon for Heart Disease Resources: Primary Prevention of Hypertension. Hypertension Study Group Circulation 42:A39A41, 1970 Report of Inter-Soclety Commission for Heart Disease Resources: Resources for the Management of Emergencies I n Hypertension. Read the entire page →
From page 51... ... REFERENCES 1. Schweitzer MD, Gearing FR, Perara GA: The epidemiology of primary hypertension. Read the entire page →
From page 52... ... 10. McKegney FP, Williams RB Jr.: Psychological aspects of hypertension. Read the entire page →
From page 53... ... 18. McDonough JR, Garrison GE, James CG: Blood pressure and hypertensive disease among Negroes and whites i n Evans County, Georgia. Read the entire page →
From page 54... ... 27. M i a l l WE, Oldham PK: A study of a r t e r i a l pressure and i t s inheritance i n a sample of the general population. Read the entire page →
From page 55... ... 37. Lennard HL, Block CY: Studies i n hypertension: VI. Read the entire page →
From page 56... ... 45. Shaper AG: Blood pressure studies i n East A f r i c a . Read the entire page →
From page 57... ... 54. Kannel WB, Brand N, Skinner JJ, et a l : The r e l a t i o n of adiposity to blood pressure and development of hypertension: The Framingham Study. Read the entire page →
From page 58... ... 63. Kempner W: Treatment of kidney disease and hypertensive vascular disease with r i c e d i e t . Read the entire page →
From page 59... ... 73, Inheritance of hypertension. B r i t Med J 5608:775-776, 1968 74, Schweitzer MD, Gearing FR, Perera GA: Family studies of primary hypertension: Their contribution to the understanding of genetic factors. Read the entire page →
From page 60... ... 82. Wolf S, Cardon PV Jr., Shepard EM, et a l : L i f e stress and essential hypertension -- A Study of Cardiovascular Adjustment i n Man. Read the entire page →

From page 1...

... INTRODUCTICXJ The appropriate a p p l i c a t i o n of the t r a c e r concept i n the e v a l u a t i o n of h e a l t h s e r v i c e s r e q u i r e s t h a t the d i s t r i b u t i o n and determinants of the t r a c e r be understood. Thus, the epidemiology of each t r a c e r has been reviewed and i s presented i n the s i x chapters t h a t f o l l o w .