A historical look at hypertension: celebrating 100 years with the Southern Medical Association.

As the Southern Medical Association (SMA) celebrates its 100th year anniversary, it is appropriate to look back on how the Southern Medical Journal (SMJ) has influenced the diagnosis and treatment of hypertension over the past century.

Hypertension, as we currently know it, had its origins as early as 2600 B.C., when the ancient Chinese could only suspect hypertension by the quality of one's pulse. (1) At that time, a hard pulse that could not be compressed was often treated with bleeding and leeches. It was not until thousands of years later, in 1733, when the English Reverend Stephen Hales performed his backyard experiments in horses using an almost 10 foot measuring device for the first direct measurement of blood pressure (BP). (2) Fortunately for us, while many others were trying to develop a more practical method of measuring BP, Riva-Rocci developed a wraparound rubber cuff in 1896 that occluded the artery of the upper arm. This was the first portable monitoring device used in humans to measure systolic BP, detected as the first pulse palpated as the cuff was slowly deflated. (3) It was not until 1905, a century ago, that a landmark breakthrough occurred when Korotkoff described the systolic and diastolic sounds he heard with a stethoscope, just below the levels that Riva-Rocci palpated using his inflatable cuff. Korotkoff's findings led to the clinical recording of blood pressure throughout the world. (4)

Hypertension at that time was felt to be an essential natural adaptive reaction to pathology in either the kidneys (white hypertension) or blood vessels (red hypertension), which was necessary to provide perfusion to vital organs. In fact, experts suggested that lowering elevated BP might do more harm than good. It was not until 1913 that any attempt was made to lower blood pressure, when Janeway abandoned the clinical use of the term "essential hypertension" and called the disorder "hypertensive cardiovascular disease," which is still in use today. (5) Despite some of these early ideas, practitioners were still unconvinced. Only four years later in the SMJ, it was stated that "Hypertension is neither a cause of nephritis or arterio-sclerosis nor is it caused by them, but is associated with them and may be influenced to some extent by them." (6)

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Despite Janeway's beliefs, as evidenced by writings in our own Journal, hypertension remained an untreated disease over the initial part of the 20th century. The prominent cardiologist Paul Dudley White, responsible for the cardiovascular care of many of our presidents, stated in 1937 that "The treatment of hypertension itself is a difficult and almost hopeless task in the present state of knowledge, and in fact for aught we know ... the hypertension may be an important compensation mechanism which should not be tampered with, even were it certain that we could control it."

Throughout the middle part of the 20th century, the treatment of hypertension was often ineffective. Even President Roosevelt, who was noted to have hypertension to levels greater than 250/150 mm Hg, was only treated with phenobarbital, a low-sodium diet, and rest at the time of his signing the Yalta treaty. (7) Although sympathectomy and the rice diet were later advised for specific patients with the most severe hypertension, bed rest, emotional tranquility, weight reduction, and sedatives, including phenobarbital and chloral hydrate, as well as vasodilators such as nitroglycerin were often all that was available. (8) Despite the advances that occurred with the availability of reserpine, veratum derivatives, ganglionic blocking agents, hydralazine, thiocyanates, and monamine oxidase inhibitors in the 1950s, which were able to lower BP and reverse the changes of malignant hypertension, the adverse effects that were often seen, especially when these BP-lowering agents were used in combination, limited the effective control of hypertension. (9)

A major advance in the control of BP occurred with the availability of thiazide-type diuretics in 1957 and 1958. (10) A breakthrough study by the US Veterans Administration (VA) found that lowering BP in patients with hypertension (diastolic BP 90-114 mm Hg) using thiazide-type diuretics, reserpine, and hydralazine significantly reduced cardiovascular morbidity and mortality compared with placebo. (11) One of the pioneers of those early VA studies was Dr. Edward Freis. He presented an extensive review on the treatment of hypertension at the Fifty-First Annual Meeting of the Southern Medical Association held in Miami Beach in 1957 which was later published in the SMJ. (12) These publications on the early successes of treatment led to the establishment of the National High Blood Pressure Education Program (NHBPEP) by the Secretary of Health, Education, and Welfare, Elliott Richardson, in an effort to promote national awareness and update the treatment of hypertension. This led to the Joint National Committee on the Detection, Evaluation, and Treatment of High Blood Pressure (JNC), created by the NHBPEP to establish national clinical guidelines for hypertension management.

The first JNC report was issued in 1977 (13) with updates occurring every 4 to 5 years. The most recent JNC 7 report was published in 2003. (14) Over this quarter of a century, the number of safe and effective antihypertensive medications has increased considerably with the additional availability of beta blockers (BBs), calcium channel blockers (CCBs), alpha adrenergic blockers (AABs), angiotensin-converting enzyme (ACE) inhibitors, and angiotensin II receptor blockers. With over 125 antihypertensive medications currently available, these consensus guidelines have consistently advocated a stepped-care, or modified stepped-care approach to hypertension treatment to achieve BP control at the recommended level of < 140/90 mm Hg. In JNC 6, for example, it was recommended that either thiazide-type diuretics or beta blockers be utilized as an initial antihypertensive medication in those with uncomplicated hypertension, but they also introduced the Dietary Approaches to Stop Hypertension (DASH) study, a diet high in fruits, vegetables, and low-fat dairy products shown to reduce BP more effectively than a typical American diet. (15,16) Five years later, in 2003, the JNC 7 report modified the previous JNC 6 guideline and recommend a thiazide-type diuretic as the preferred choice for initial mono-therapy in most patients with hypertension, based heavily on the Antihypertensive and Lipid-Lowering treatment to prevent Heart Attack Trial (ALLHAT). (17) In addition, it expanded on the original four compelling indications for therapy first mentioned in JNC 6 to now include six compelling indications (heart failure, postmyocardial infarction, high coronary artery disease risk, diabetes mellitus, chronic renal disease, and recurrent stroke prevention) for which practitioners are compelled to include specific antihypertensive therapies in their cocktail of therapy to improve clinical outcome while also achieving recommended BP control. (14) Realizing that single-agent therapy would not be effective in controlling BP at a level of 160/100 mm Hg or greater, JNC 7 for the first time recommended combination therapy as initial therapy in those with this degree of BP elevation which was highlighted in the SMJ several years earlier. (18)

Hypertension affects 31% of adults, or about 65 million people in the United States. (19) Currently, 53% of those on antihypertensive therapy are controlled to the goal of < 140/90 mm Hg with lower rates of control in the South. (20) The SMA has been involved in the treatment of hypertension over the past 100 years, especially as it applies to our southern region. Please join us at our 11th Annual SMA-ASH Hypertension Conference, June 22 to 24, 2007 at the Crowne Plaza Hotel on Hilton Head Island, South Carolina, where hypertension issues will be addressed in a CME format. For further information, please contact the SMA web site at www.sma.org.

References

1. Nei Ching. Yellow Emperor's Classic of Internal Medicine. Books 2-9, published between 2698 and 2598 B.C.

2. Hales S. Statistical Essays: Containing Hemostatics. London, Innys and Manhy, 1933.

3. Riva-Rocci S. Gaza Med Torino 1896;47:981-1001.

4. Korotkoff NS. Izvestiya Imperatorskoi Voenno-Meditsinskoy Akadernii. Rep ImperMIL-med Acca St Peterburg. 1905;11:365-367.

5. Freis ED. Chapter 164. In: Laragh JH, Brenner BM (eds). Hypertension, Pathophysiology Diagnosis and Management, 2nd ed. New York, Raven Press, pp 2741-2751.

6. Strickler CW. Significance of Hypertension. South Med J 1917;10:191-194.

7. Bruenn HG. Clinical notes on the illness and death of President Franklin D. Roosevelt. Ann Intern Med 1970;72:579-591.

8. Roberts SR. Hypertension. J Med Assoc Georgia 1936;25:413-417.

9. Moser M. Evolution of the treatment of hypertension from the 1940s to JNV V. Am J Hypertens 1997;10:2S-10S.

10. Freis ED, Wanko A, Wilson IM, et al. Treatment of essential hypertension with chlorothiazide (diuril); its use alone and combined with other antihypertensive agents. J Am Med Assoc 1958;166:137-140.

11. Effects of treatment on morbidity in hypertension. II. Results in patients with diastolic blood pressure averaging 90 through 114 mm Hg. JAMA 1970;213:1143-1152.

12. Freis ED. Treatment of Hypertension. Southern Medical Journal 1958;58:1281-288.

13. Report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure. A cooperative study. JAMA 1977;237:255-261.

14. Chobanian A, Bakris G, Black H, et al. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA 2003;289:2560-2572.

15. The sixth report of the Joint National Committee on prevention, detection, evaluation, and treatment of high blood pressure. Arch Intern Med 1997;157:2413-2446.

16. Basile JN. Hypertension 2001: pearls for the clinician. South Med J 2001;94:1054-1057.

17. ALLHAT Officers and Coordinators for the ALLHAT Collaborative Research Group. The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial. Major outcomes in high-risk hypertensive patients randomized to angiotensin-converting enzyme inhibitor or calcium channel blocker vs diuretic: The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). JAMA 2002;2981-2997.

18. Weir MR. When antihypertensive monotherapy fails: fixed-dose combination therapy. South Med J 2000;93:548-556.

19. Fields L, Burt V, Cutler J, et al. The burden of adult hypertension in the United States 1999 to 2000: a rising tide. Hypertension 2004;44:398-404.

20. Hajjar I, Kotchen T. Trends in prevalence, awareness, treatment, and control of hypertension in the United States, 1988-2000. JAMA 2003;290:199-206.

Jan N. Basile, MD, and Hector Ventura, MD

From the Primary Care Service Line, Ralph H. Johnson VA Medical Center, and the Division of General Internal Medicine/Geriatrics, Medical University of South Carolina, Charleston, SC; and the Section of Cardiomyopathy and Heart Transplant Center, Ochsner Clinic Foundation, Tulane University Medical School, New Orleans, LA.

Reprint requests to Jan N. Basile, MD, Ralph H. Johnson VA Medical Center, 109 Bee Street, Charleston, SC 29401.