State of Hypertension as We Enter the 21st Century
A Societal Conundrum
As one considers the state of the field of hypertension today; and, as we reflect on its evolution over the past several decades, we can come to several important conclusions. First, our knowledge concerning the regulation of arterial pressure has dramatically expanded over the past 50 years. We are now aware of a myriad of physiological mechanisms that interrelate with one another into a highly sophisticated mosaic of mechanisms that account for the multifactorial causation of the number of hypertensive diseases. “Older” mechanisms have, in part, been subsumed by a plethora of candidate genes that, in turn, serve many of these homeostatic mechanisms.1 Each of these factors has provided the intellectual grist and “feedback” that continues to fuel and stimulate us to continue with our respective investigative activities related to the pathophysiology of the variety of clinical entities that we consider the hypertensive disease. This has truly been the excitement of the science of medical research that keeps us active and interested in this important field of study.
Superimposed on this active dimension of medical science is the satisfaction and success that we have also experienced clinically with the tremendous evolution and success in the care of patients with hypertensive diseases and their complications. At the time that I entered the hypertension scene over 40 years ago, these problems were at the root of a majority of hospitalizations in the 1950s and 1960s. At that time, the recent appearance of antibacterial agents was being appreciated by clinicians and, certainly, the public that we had been serving. But, at the time, there was the beginning of an increasing perception of the prevalence of ischemic heart disease, myocardial infarction, sudden death, and congestive heart failure. Our bastion of new and exciting epidemiological information in Framingham, Massachusetts, clearly demonstrated that hypertension was the major disease accounting for the most common cause of cardiac failure in both men and women; and the second most common cause was hypertension associated with ischemic heart disease.2 Even, in the lesser causes of cardiac failure, hypertension associated with rheumatic heart disease was a major cause. The Framingham Study had just identified systolic and diastolic hypertension as one of the three “factors of risk” for coronary heart disease.3 Associated with hypertension was the high prevalence of stroke in our society. Other frequent complications of hypertensive diseases at the time were malignant hypertension, hypertensive encephalopathy, dissecting aortic aneurysm, and other hypertensive emergencies. End-stage renal disease (ESRD) was on its ascendency, prompting long-term hemodialysis as a federally reimbursable treatment for all ages; and at present, ESRD, particularly in black patients and in diabetics with or without hypertension, is an increasingly common complication.4 Now, four decades later, deaths from stroke and coronary heart disease have diminished by over 70% and 40%, respectively. Malignant hypertension and hypertensive emergencies have been dramatically reduced and are present day rarities. We still face the very real public health challenges of congestive heart failure and ESRD; but these problems, hopefully, are on the cusp of clinical containment. What is all-the-more satisfying is to see the fruits of these achievements as special clinical hypertension services in most teaching hospitals have been discontinued. The outpatient care of the hypertensive patient has become the new paradigm for modern healthcare delivery.5
Throughout these years, our leaders in hypertension research have also generously stimulated new and important areas of academic pursuits. Consider, if you will, the conceptual development and many subsequent contributions of multicenter therapeutic trials to other areas of medicine, to stimulation of the new discipline of clinical pharmacology, to the transfer of new therapeutic concepts to other diseases, and to the many contributions by our of scientific leadership to volunteer health organizations and society, in general.
This, then, brings me to those remarkable leaders who championed new areas for governmental and other societal activities. As we have already cited in earlier issues of the journal, the work by: Irvine H. Page to stimulate the establishment of the Institute of Medicine; Theodore E. Cooper who conceived of the National High Blood Pressure Education Program, a model for professional and lay education not only in the United States but for the World Health Organization and other national programs; and the countless others who have served the American Heart Association, American Stroke Association, National Kidney Foundation, and other organizations as founders, presidents, and other roles for leadership.
This brings us to the current issue of our journal. We are privileged to benefit from the experiences and selfless contributions of still another leader of our worldwide hypertension community. Dr John Swales, already a successful clinical scientist in the field of hypertension, the first Editor-in-Chief of our “sister” journal the Journal of Hypertension, and Chairman of the Department of Medicine at the University of Leicester, in Great Britain, left his heady academic responsibilities to direct research and development for the National Health Service. I remember chatting with John soon after he came to London to assume that position and to share his talents and expertise. He commented on the challenge he was confronted with during his first weeks in office when he was obliged to deal with the issues associated with “mad cow disease.” Professor Swales has recently returned to Leicester where he remains as productive as ever in the Cardiovascular Research Institute (where he recently published a magnum opus multi-authored volume on hypertension).6 During my most recent visit with him, I asked him to share with us his thoughts on his recent experiences with the health care of his nation. In particular, I asked him to put into perspective his current thinking about hypertensive diseases as they pertain to his recent experiences in government. The journal was very pleased to have received his thoughts within a month of our discussion, and we are delighted to share his thinking and concerns with you this month.
McKee PA, Castelli WP, McNamara OM, Kannel WB. The natural history of congestive heart failure: the Framingham Heart Study. N Engl J Med. 1971;285:1441–1446.
Kannel WB, Dawber TR, Kagan A, Revorskie N, Sacks J. Factors of risk in the development of coronary heart disease: six year follow-up experience: the Framingham Study. Ann Intern Med. 1961;55:33–56.
Excerpts from United States Renal Data System. Annual Data Report II: incidence and prevalence of ESRD. Am J Kidney Dis. 1999; 34(suppl 1):S40–S50.
Perry HM, Freis ED, Frohlich ED. Department of Veterans Affairs Hypertension Meeting: a proposal for improved care. Hypertension. 2000;35:853–857.
Swales JD, ed. Textbook of Hypertension. Oxford, England: Blackwell Scientific Publications;1994:1328.