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Hypertensive vascular disease
Hypertensive
Vascular
Disease*
Duration of Life in a Selected Series DAVID W. BLOOD, M.D. and GEORGE A. PERERA, M.D. .New York, New
I
T is a well recognized hypertensive sequelae
statistical
vascular
dise.ase and
have a detrimental
life expectancy.
fact that
It is also generally
effect
York
or five years after appearance
of their first
its
symptom. 2Blackford
on
only those patients with arterial
accepted
175/100
and Wilkinson
grouped
pressures of
or over and found that the majority
that the disease varies greatly in its intensity
were dead within ten years.3 Even actuarial
and
statistics4
rate of progression, with gradations asymptomatic form to from a benign, patients with so-called malignant hyper-
whom hypertension
tension
women
with
a rapidly
spite of this knowledge
fatal
outcome.
In
there is a tendency
to overlook the fact that a considerable
fail to give a true
subjects
standing
than in
runs a more severe
to obtain
a real under-
of the true outlook in this disorder
ber of patients carry on far better than might be anticipated on the basis of initial
from the available
observations. Many attempts
radical
Because
have been made to record
since
male, in
is less common
and in general
course. It is difficult
num-
picture
studied are predominantly
data.
of increasing
medical
measures,
and
interest
surgical
it seems timely
in more
therapeutic
to re-emphasize
the course and prognosis of essential hypertension. Keith, Wagener and Barker, whose
the long duration of hypertensive vascular disease in many patients. This study is con-
observations
cerned with a selected group of hypertensive
compare
are often
used as criteria
to
the results of surgery with medical
management,
describe
patients
four types of hyper-
tensive vascular
disease based chiefly on the degree of retinitis. l That their data do not give a representative picture is suggested by
with The
with
only 9 per cent
the
natural
difficulties
anticipate
the fact that 66 per cent of their patients fall into the most serious and advanced group,
whose benign
with that pictured
illustrated
the
course is in contrast
in most studies dealing history
inherent course
of hypertension. in attempting
of the
disease
to are
by this report. CLINICAL MATERIAL
of the entire The
series alive five to nine years after diagnosis.
records
of fifty patients
were
ana-
Earlier studies of prognosis employed varying diagnostic criteria. Some reports in-
lyzed. All were closely patients in the Vanderbilt
cluded patients followed from the date of the
wards
first symptom
basis of selection included repeated initial blood pressures in excess of 140/90 and at
only, others whose course had
already become compl’cated. Thus Janeway, using a systolic blood pressure of 160 mm. of mercury as his index, declared that hypertensives lived only an average of four * From the Department
AMERICAN
JOURNAL
of the
Presbyterian
followed as outClinic and on the Hospital.
The
least ten years of subsequent observation. Only such patients were included who were without significant symptoms when first
of Medicine, College of Physicians and Surgeons, Columbia University and the Presbyterian Hospital, New York, N. Y. OF
MEDICINE
83
Hypertensive Vascular Disease-Blood,
84
TABLE
-
STATISTICAL
-
-
-
DATA
ON
-
I 7
Age
Name
le:
_
FIFTY
I
I PATIENTS
Latest B.P.
Cardisc z;-
FOLLOWED
-
/
fears
Whel n $_ Initial First ~erva_ B.P. s SeenI tion
-
HYPERTENSIVE
Cere Rena .l bra1 FailAcci, ure dent
Living
L D
10 10
230/140210/130 150/90 170/100
;
3.
H. N.
M
55
11
140/98
220/110
+
4. 5. 6. 7.
M. H M. K S. K. E. E.
F F F F
33 41 35 22
11 12 12 12
268/160 295/170 240/120 220/130 185/100260/140 160/120 160/132
.
F F F F F
36 45 34 38 49
13 13 13 13 13
170/110200/120 178/96 200/100 185/100260/140 170/100 170/90 200/95 270/120
+
D L L L D
+
D
:
D D L L
+
+
13.
I. M.
M
32
13
180/140230/120
+
L
14. 15. 16.
E. S. s. M. E. S.
M M M
53 33 53
14 14 14
185/115 240/130 185/105 185/120 185/115210/130
+ +
,D D D
17. 18. 19. 20. 21.
E. W. L. H. A. R. ,G. S. M. T.
F F F F F
55 49 48 33 50
14 14 14 14 15
280/125 278/140 200/120270/140 158196 215/105 155/100225/125 195/100 190/120
+
22.
4. R.
F
35
15
160/90
+
140/110
23. 24. 25.
1L. F. t5. R. 4. D.
F F F
38 37 47
15 16 16
200/120 165/100 230/130275/145 162/90 210/90
+ +
26. 27. 28.
1R. T. 4. w. ;R. S.
F F F
29 40 20
16 17 18
190/110260/130 170/90 180/110 144/100200/114
+
29. 30. 31. 32. 33. 34. 35. 36.
‘(V. A. IM. H. ; 1. B.
1\. T. I2. T. I7. M.
M F F F F F F F
30 32 39 50 45 47 45 50
18 18 18 19 19 19 19 20
170/100180/120 196/100190/105 180/100175/120 170/100 120/85 200/90 240/130 165/100 200/100 170,‘110160/84 150/98 190/110
37.
I1. c.
I:
40
20
160/105200/160
38.
J . R.
vi
57
20
165/100210/110
39.
(:.
vl
48
21
180/120 170/100
i
-
-
MORE
Final Comments
Dzd
38 49
M.
OR
--
F F
s. P.
YEARS
Now
W. F. E. s.
$. B.
TEN
-L
1. 2.
8. 9. 10. 11. 12.
Perera
-
+
D
+ .
L D L
.
+ + +
L L L L L
+
D L L L L L L D L L L L
:
+
+
.
L D
+
L
.
Living and well Cardiac insufficiency first evident 9 yr. before death Died following cerebral hemorrhage Died following cerebral accident Died following cerebral accident Recent cardiac insufficiency Living and well; 3 normal pregnancies after development of hypertension Died of cardiac insufficiency Moderate headaches Living and well Living and well :Died 11 yr. after first episode of cardiac insufficiency Mild cardiac insufficiency 4 yrs. ago; no symptoms thereafter Postoperative death :Died of myocardial infarction Unexplained death 3 yrs. after development cardiac insufficiency :Recent cerebral accident :Living and well :Headaches, no other symptoms :Living and well Hypertension known 13 yrs. before first visit; has never had hypertensive symptoms 1Died in failure 7 yrs. after first cardiac symptom tCardiac insufficiency for 12 yr. 1Death attributed to arteriosclerosis 1Living and well; never had significant symptoms 1Died following cerebral accident 1Living and well 1Rare headaches; no other symptoms 1Living and well 1Lecent ankle edema only ISxertional dyspnea for the past 4 yr. 1Living and well 1Liremia and cardiac insufficiency ILiving and well I
AMERICAN
JOURNAL
OF
MEDICINE
Hypertensive Vascular Disease--Blood, Perera -
TABLE
-
Age
Sex
-
Nher First
Years of Ob:ervation
Initial B.P.
I. -(Continued)
-
Cardisc Failure
Latest B.P.
-
-
Rena. I Failure
’Cerebral Accident
Now Living
Final Comments
D::d
-
40. 41.
A. C. A. A.
F F
26 43
21 21
150/110 140/95 L70/100 195/100
::
42.
M. S.
F
42
21
165/105 210/115
+
43.
A. P.
F
45
22
!OO/lOO 250/100
44.
L. H.
F
46
23
!OO/llO 210/120
45.
H. M.
F
38
23
165/115 160/95
46. 47.
V. R. A. K.
F F
28 39
23 23
165/110 170/90 155/95 160/80
48.
L. s.
F
30
23
180/120 200/110
49. 50.
B. 0. G. L.
F M
43 41
27 27
.85/120 190/100 !OO/llO 180/94
i: ) 41I
42
17
82/108 204/115
Total and Averages
-
seen
and
1
-
who
showed
no
cardiac, renal or cerebral few patients in the series shown
turbance
to have
a primary
renal
secondary
blood
elevation
were
excluded,
as
patients
initially
exhibiting
minimal,
transient
albuminuria. in the
group
of
dis-
pressure
ences in’their
average
(forty-four years) group still living. Sex and Race.
age when first seen
in comparison Forty-one
with
(82 per cent)
the of
the patients were female and 9 (18 per cent)
than
were
male.
The
racial
The degree
comparable
as a whole
population. Years of Observatios.
years of age and the oldest fifty-seven. The average age was only slightly higher for males (forty-four years) than for those in the MEDICINE
series as a whole. Those patients followed until their death showed no major differ-
those
was forty-two years, the youngin the series being twenty-two
OF
-
were
The results are summarized in Table I. Age. The average age at the time of first
JOURNAL
-
L 34 D 16
more
RESULTS
AMERICAN
7
2
22
suggests that the disease had been well established prior to the initial observation.
observation est patient
+ +
All who were
with
of hypertension
+ +
involvement. A had mild head-
aches as their only complaint. later
+
~
evidence
Living and well Occasional headaches and palpitations Mild cardiac insufficiency for past 3 yr. No symptoms; slight cardiac enlargement Well except for moderate ankle edema Intermittent headaches; no abnormal signs other than hypertension Rare headaches the only complaint Died after cerebral accident; previously asymptomatic Living and well 11 yr. after cerebral accident Living and well Sudden unexplained death after 27 yr. without symptoms
to that
distribution
of the
average
was clinic
The average length of observation was seventeen years, varying from ten years and three months to twentyseven years and one month. Thirteen of the fifty patients over twenty
were observed for a period of years and twe,nty-nine of the
patients were followed for more years. Sixteen (32 per cent) Deaths. patients died during the course tion, the majority as a result
than fifteen of the fifty of observaof cardiac
Hypertensive Vascular Disease-Blood,
86 complications
or following
a cerebral
lar accident. Blood Pressure.
A composite
the
diastolic
systolic
Cardiac Ins@ciency. fifty patients
and
trends is shown in Figure was
vascu-
considerable
picture
blood
pressure
1. Although
variation
in
of
there
individual
B. P
(mm. Hg.)
,0°-
Perera
festations
of
dyspnea,
Twenty-two
of the
at some time developed congestive
orthopnea,
failure
such
paroxysmal
dyspnea
and ankle edema.
patients
the insufficiency
manias
nocturnal
In most of these came
late in the
course of the disease. The average
length of
observation
onset
cardiac
following
insufficiency
the
first
was seven years,
of the
longest period being fifteen years and eleven
\
MAX
months. Eight (39 per cent) of this group with congestive failure died during the course
of observation,
the,average
survival from the first symptom and one-half
age of
being eight
years.
Cardiac Pain.
Nine (18 per cent) of the complained of pain of cardiac
patients
origin at some time. The average
c
__---_
I YEARS
0----\/-w
-cc--
-
I
I
I
I
I
I
I
I
2
4
6
8’
10
12
14
16
observation
MIN.
the general
tendency
tension was to increase
of the hyper-
very slowly through-
out the years of observation. initial
blood pressure
mercury time
while
when
Blood
pressure
tained
during
observed visits
mm. of
pressure was
determinations clinic
average
was 182/108
the average
last
The
at the
204/l 15. were
by
from the onset of pain was five
years, the longest being nine years and five
FIG. 1. Mean, maximum and n&imum systolic and diastolic blood pressures of fifty hypertensive patients. _
patients,
period of
ob-
different
observers and under varying conditions, hence evaluation of these readings should take into account personal variations in measurement. Symptoms ana’ Signs. These have been analyzed under the following headings with emphasis on their relationship to prognosis. Patient’s Complaints. A conspicuous number of patients during the course of their disease complained of fatigue, nervousness, dizziness, palpitation, insomnia and weakness in addition to specific symptoms to be further enumerated. There was no relation of these complaints to the subsequent course of the disease.
months.
Only one of this group is still living.
X-ray Euidence of Cardiac Enlargement. Thirty-three (66 per cent) of the patients in the series showed an increased by x-ray
during period,
area
the course of their disease.
Of these, ten (33 per*cent) observed
cardiac
died during
with an average
the
survival
of nine years. The average period of observation for the entire group from the first sign of enlargement was ten years, the longest being twenty years and three months. Electrocardiographic Changes. per cent) of the fifty patients
Eighteen (36 had electro-
cardiographic changes indicative of myocardial damage. Two of these changes occurred just prior to death. The average length
of observation
was six and one-half
years, the longest being seventeen years and four months. Eight (43 per cent) of the group’ were followed until death with an average survival period of seven years. Renal Changes. Only two patients showed evidence of nitrogen retention. One of these died from cardiac failure seven years later; the second patient died from uremia a few months after nitrogen retention was apparAMERICAN
JOURNAL
OF
MEDICINE
Hypertensive ent. Twenty-nine patients
Vascular
(58 per cent)
developed
persistent
of the fifty albuminuria
Disease-Blood, at some
Perera
time
during
87
the
during the course of their disease. The aver-
and even the more intense
age period of observation
not constant
albuminuria
was seven and one-half
the longest
being
one month. died
from the onset of
twenty-seven
years,
years
and
Eight (27 per cent) of the group
during
the average
the
period
period
of
observation,
of survival
being
eight
years.
and
Changes.
cent)
developed
dent
during
disease. ment
cases
a cerebral
the
(14
vascular
observed
in
death.
had a cerebral
The
accident
per acci-
course
In six of these the cerebral resulted
patient
Seven
of the involve-
remaining after twelve
hypertension and was years of known without signs or symptoms for eleven years and was well when last seen in the clinic. Retinal Changes.
Thirty-three
patients
(66
or previous
migraine,
onset of arteriovenous years
but
it was
compression
present
in one
from the iyas ten patient
headaches
were
disappeared
assumed
a typical
frequency the
history
complained
com-
height
migraine
which
pattern.
whatsoever
of the
with no
of idiopathic
of headaches
and intensity
There
between
the
of the headaches,
blood
pressure
or
the
course of the disorder. Final of the
twenty-four free
Sixteen
Observations. patients
in this
observation.
The
(32 per cent)
series
(48 per cent)
of significant
died,
while
were living
symptoms
at
remainder
and
the
had
severe complaints or exhibited symptoms of cardiac insufficiency.
last more
signs
or
COMhENTS
during the course of their disease. The averof years of observation
often
It was of interest that a few patients, familial
per cent) had retinal changes of some degree age number
of their
pletely after months or years of great severity.
was no correlation
Cerebral
course
disease. Most of these were of a minor degree
This
series
of fifty
asymptomatic pertensive
who
were
and had uncomplicated
hy-
vascular
patients
disease
when
twenty-three years and five months before the date of the last observation. Eight (24
served,
per cent) of the group died during observation with an average period of survival of
no consideration to hypertension in its more progressive forms or to patients who first
nine years. Only seventeen (51 per cent) of the thirty-three patients with retinal changes
consult
developed
present study gives no statistical
by
more severe damage
hemorrhage,
The
average
group patient
exudate
period
or papilledema.
of observation
was six and one-half survived
as indicated
twenty-one
in this
conspicuously
the
their
physician
as to its frequency,
AMERICAN JOURNAI.
OF
it does indicate,
how-
is not a rarity.
years
and six
lished hypertension at the time of initial observation and may have had an elevation of blood pressure for an indefinite period
regressed their
of the fifty pa-
MEDICINE
the
information
showed
course .of
tients (74 per cent) complained
of compli-
Although
ever, that long survival in this group
prior to observation. Except for the mild the patients
appear
to be comparable
of headaches
studied
ported series of patients It is significant the initial
of their
in this group with
other
re-
with respect to age,
and general that
The
well estab-
character
disease,
sex distribution Thirty-seven
because
signs and symptoms.
majority
disease. Headaches.
cating
a selected one. It gives
but one
whose retinitis
during
10 years, is obviously
for at least
years
months after extensive exudate had been seen. Nine (53 per cent) of this group died the average survival during observation, being seven years. There were several patients in the group showing retinal exudate and hemorrhages
and who were followed
first ob-
characteristics.
in the group
level of the arterial
studied
pressure
did
Hypertensive
88 not
seem
to
symptoms,
associated
development
complications.
that palpitation, of cardiac
enlargement
the subsequent A steadily
x-ray
but in individual
pressure
over
a
in-
short life expectancy,
patients
a long period
of
such complications. that
irrespective
of
minimal
there
is cardiac and
early
retinal change, a definite prognosis should not be made since such a patient may live for one, two or more decades before fatal complications observations years,
appear. over
Without
a period
one is not justified
benign
from
The indications
a more
of months
results of such procedures
height
such
as
in
years, the
twenty-seven
of blood
pressure,
headaches
and
the presence
minimal venous
of cardiac
albuminuria,
diographic
years. symppalpita-
enlargement,
minor
electrocar-
changes
and
retinal
compression
bore
no
arterio-
relationship
to prognosis. 4. Essential hypertension may be compatible with many years of survival and 5. The tients
favorable
with
outlook
hypertension
for some
should
the indications
the results of such therapeutic
be
pacon-
for and
procedures
as
sympathectomy. The authors are greatly indebted and
Mary
to carry
or the
a relatively
malignant
for and the evaluation
process. of the
as sympathectomy
must take into consideration
of observation
Lasker
Foundation
to the Albert
for the means
out this study.
repeated
in foretelling
future trend or in differentiating
length
group was seventeen
sidered in evaluating
electrocardiographic
albuminuria
fol-
well being.
and palpitation,
whether minor
toms
in hypertensive
nervousness
hypertensive
3. It was found in the group studied that
tion,
even in those who may complain
enlargement,
average
longest period exceeding
pain or insufficiency,
were, in general,
uncomplicated
lowed for at least ten years.
to
signs of myocardial renal damage, cerebral retinal hemorrhages,
it is evident
of headaches,
and
disease and were subsequently
the initial
blood
of a relatively
survival followed
tomatic
this selected
arterio-
Perera
vascular 2. The
evidence
and retinal
vascular accidents, exudate or papilledema
change,
cardio-
course. rising
electrocardiographic damage, progressive
patients,
of major
bore no correlation
period of time, cardiac
Thus,
with
or with the
It was also apparent
headaches,
venous compression
dicative
either
rate of progression
subsequent vascular
be
Vascular Disease-Blood,
the not infre-
quent long period of survival and comparative well being of many patients. CONCLUSIONS 1. An analysis was made of fifty patients who, when first observed, exhibited asymp-
REFERENCES N. M., WAGENER, H. P. and BARKER, N. W. Some different types of essential hypertension; their course and prognosis. Am. 3. M. SC., 197: 332-334, 1939. 2. JANEWAY, T. C. A clinical study of hypertensive cardiovascular disease. Arch. Znt. Med., 12: 755-798, 1913. 3. BLACKFORD,J. M. and WILKINSON,J. N. Hypertension: A study of two hundred two cases followed for an average of ten years-with remarks on causes and treatment. Ann. Znt. Med., 6: 54-5.9, 1932. 4. Blood Pressure Study, 1939. The Actuarial Society of America and the Association of Life Insurance Medical Directors. New York, September, 1940. 1.
KEITH,
AMERICAN
JOURNAL
OF
MEDICINE
Vascular
Disease*
Duration of Life in a Selected Series DAVID W. BLOOD, M.D. and GEORGE A. PERERA, M.D. .New York, New
I
T is a well recognized hypertensive sequelae
statistical
vascular
dise.ase and
have a detrimental
life expectancy.
fact that
It is also generally
effect
York
or five years after appearance
of their first
its
symptom. 2Blackford
on
only those patients with arterial
accepted
175/100
and Wilkinson
grouped
pressures of
or over and found that the majority
that the disease varies greatly in its intensity
were dead within ten years.3 Even actuarial
and
statistics4
rate of progression, with gradations asymptomatic form to from a benign, patients with so-called malignant hyper-
whom hypertension
tension
women
with
a rapidly
spite of this knowledge
fatal
outcome.
In
there is a tendency
to overlook the fact that a considerable
fail to give a true
subjects
standing
than in
runs a more severe
to obtain
a real under-
of the true outlook in this disorder
ber of patients carry on far better than might be anticipated on the basis of initial
from the available
observations. Many attempts
radical
Because
have been made to record
since
male, in
is less common
and in general
course. It is difficult
num-
picture
studied are predominantly
data.
of increasing
medical
measures,
and
interest
surgical
it seems timely
in more
therapeutic
to re-emphasize
the course and prognosis of essential hypertension. Keith, Wagener and Barker, whose
the long duration of hypertensive vascular disease in many patients. This study is con-
observations
cerned with a selected group of hypertensive
compare
are often
used as criteria
to
the results of surgery with medical
management,
describe
patients
four types of hyper-
tensive vascular
disease based chiefly on the degree of retinitis. l That their data do not give a representative picture is suggested by
with The
with
only 9 per cent
the
natural
difficulties
anticipate
the fact that 66 per cent of their patients fall into the most serious and advanced group,
whose benign
with that pictured
illustrated
the
course is in contrast
in most studies dealing history
inherent course
of hypertension. in attempting
of the
disease
to are
by this report. CLINICAL MATERIAL
of the entire The
series alive five to nine years after diagnosis.
records
of fifty patients
were
ana-
Earlier studies of prognosis employed varying diagnostic criteria. Some reports in-
lyzed. All were closely patients in the Vanderbilt
cluded patients followed from the date of the
wards
first symptom
basis of selection included repeated initial blood pressures in excess of 140/90 and at
only, others whose course had
already become compl’cated. Thus Janeway, using a systolic blood pressure of 160 mm. of mercury as his index, declared that hypertensives lived only an average of four * From the Department
AMERICAN
JOURNAL
of the
Presbyterian
followed as outClinic and on the Hospital.
The
least ten years of subsequent observation. Only such patients were included who were without significant symptoms when first
of Medicine, College of Physicians and Surgeons, Columbia University and the Presbyterian Hospital, New York, N. Y. OF
MEDICINE
83
Hypertensive Vascular Disease-Blood,
84
TABLE
-
STATISTICAL
-
-
-
DATA
ON
-
I 7
Age
Name
le:
_
FIFTY
I
I PATIENTS
Latest B.P.
Cardisc z;-
FOLLOWED
-
/
fears
Whel n $_ Initial First ~erva_ B.P. s SeenI tion
-
HYPERTENSIVE
Cere Rena .l bra1 FailAcci, ure dent
Living
L D
10 10
230/140210/130 150/90 170/100
;
3.
H. N.
M
55
11
140/98
220/110
+
4. 5. 6. 7.
M. H M. K S. K. E. E.
F F F F
33 41 35 22
11 12 12 12
268/160 295/170 240/120 220/130 185/100260/140 160/120 160/132
.
F F F F F
36 45 34 38 49
13 13 13 13 13
170/110200/120 178/96 200/100 185/100260/140 170/100 170/90 200/95 270/120
+
D L L L D
+
D
:
D D L L
+
+
13.
I. M.
M
32
13
180/140230/120
+
L
14. 15. 16.
E. S. s. M. E. S.
M M M
53 33 53
14 14 14
185/115 240/130 185/105 185/120 185/115210/130
+ +
,D D D
17. 18. 19. 20. 21.
E. W. L. H. A. R. ,G. S. M. T.
F F F F F
55 49 48 33 50
14 14 14 14 15
280/125 278/140 200/120270/140 158196 215/105 155/100225/125 195/100 190/120
+
22.
4. R.
F
35
15
160/90
+
140/110
23. 24. 25.
1L. F. t5. R. 4. D.
F F F
38 37 47
15 16 16
200/120 165/100 230/130275/145 162/90 210/90
+ +
26. 27. 28.
1R. T. 4. w. ;R. S.
F F F
29 40 20
16 17 18
190/110260/130 170/90 180/110 144/100200/114
+
29. 30. 31. 32. 33. 34. 35. 36.
‘(V. A. IM. H. ; 1. B.
1\. T. I2. T. I7. M.
M F F F F F F F
30 32 39 50 45 47 45 50
18 18 18 19 19 19 19 20
170/100180/120 196/100190/105 180/100175/120 170/100 120/85 200/90 240/130 165/100 200/100 170,‘110160/84 150/98 190/110
37.
I1. c.
I:
40
20
160/105200/160
38.
J . R.
vi
57
20
165/100210/110
39.
(:.
vl
48
21
180/120 170/100
i
-
-
MORE
Final Comments
Dzd
38 49
M.
OR
--
F F
s. P.
YEARS
Now
W. F. E. s.
$. B.
TEN
-L
1. 2.
8. 9. 10. 11. 12.
Perera
-
+
D
+ .
L D L
.
+ + +
L L L L L
+
D L L L L L L D L L L L
:
+
+
.
L D
+
L
.
Living and well Cardiac insufficiency first evident 9 yr. before death Died following cerebral hemorrhage Died following cerebral accident Died following cerebral accident Recent cardiac insufficiency Living and well; 3 normal pregnancies after development of hypertension Died of cardiac insufficiency Moderate headaches Living and well Living and well :Died 11 yr. after first episode of cardiac insufficiency Mild cardiac insufficiency 4 yrs. ago; no symptoms thereafter Postoperative death :Died of myocardial infarction Unexplained death 3 yrs. after development cardiac insufficiency :Recent cerebral accident :Living and well :Headaches, no other symptoms :Living and well Hypertension known 13 yrs. before first visit; has never had hypertensive symptoms 1Died in failure 7 yrs. after first cardiac symptom tCardiac insufficiency for 12 yr. 1Death attributed to arteriosclerosis 1Living and well; never had significant symptoms 1Died following cerebral accident 1Living and well 1Rare headaches; no other symptoms 1Living and well 1Lecent ankle edema only ISxertional dyspnea for the past 4 yr. 1Living and well 1Liremia and cardiac insufficiency ILiving and well I
AMERICAN
JOURNAL
OF
MEDICINE
Hypertensive Vascular Disease--Blood, Perera -
TABLE
-
Age
Sex
-
Nher First
Years of Ob:ervation
Initial B.P.
I. -(Continued)
-
Cardisc Failure
Latest B.P.
-
-
Rena. I Failure
’Cerebral Accident
Now Living
Final Comments
D::d
-
40. 41.
A. C. A. A.
F F
26 43
21 21
150/110 140/95 L70/100 195/100
::
42.
M. S.
F
42
21
165/105 210/115
+
43.
A. P.
F
45
22
!OO/lOO 250/100
44.
L. H.
F
46
23
!OO/llO 210/120
45.
H. M.
F
38
23
165/115 160/95
46. 47.
V. R. A. K.
F F
28 39
23 23
165/110 170/90 155/95 160/80
48.
L. s.
F
30
23
180/120 200/110
49. 50.
B. 0. G. L.
F M
43 41
27 27
.85/120 190/100 !OO/llO 180/94
i: ) 41I
42
17
82/108 204/115
Total and Averages
-
seen
and
1
-
who
showed
no
cardiac, renal or cerebral few patients in the series shown
turbance
to have
a primary
renal
secondary
blood
elevation
were
excluded,
as
patients
initially
exhibiting
minimal,
transient
albuminuria. in the
group
of
dis-
pressure
ences in’their
average
(forty-four years) group still living. Sex and Race.
age when first seen
in comparison Forty-one
with
(82 per cent)
the of
the patients were female and 9 (18 per cent)
than
were
male.
The
racial
The degree
comparable
as a whole
population. Years of Observatios.
years of age and the oldest fifty-seven. The average age was only slightly higher for males (forty-four years) than for those in the MEDICINE
series as a whole. Those patients followed until their death showed no major differ-
those
was forty-two years, the youngin the series being twenty-two
OF
-
were
The results are summarized in Table I. Age. The average age at the time of first
JOURNAL
-
L 34 D 16
more
RESULTS
AMERICAN
7
2
22
suggests that the disease had been well established prior to the initial observation.
observation est patient
+ +
All who were
with
of hypertension
+ +
involvement. A had mild head-
aches as their only complaint. later
+
~
evidence
Living and well Occasional headaches and palpitations Mild cardiac insufficiency for past 3 yr. No symptoms; slight cardiac enlargement Well except for moderate ankle edema Intermittent headaches; no abnormal signs other than hypertension Rare headaches the only complaint Died after cerebral accident; previously asymptomatic Living and well 11 yr. after cerebral accident Living and well Sudden unexplained death after 27 yr. without symptoms
to that
distribution
of the
average
was clinic
The average length of observation was seventeen years, varying from ten years and three months to twentyseven years and one month. Thirteen of the fifty patients over twenty
were observed for a period of years and twe,nty-nine of the
patients were followed for more years. Sixteen (32 per cent) Deaths. patients died during the course tion, the majority as a result
than fifteen of the fifty of observaof cardiac
Hypertensive Vascular Disease-Blood,
86 complications
or following
a cerebral
lar accident. Blood Pressure.
A composite
the
diastolic
systolic
Cardiac Ins@ciency. fifty patients
and
trends is shown in Figure was
vascu-
considerable
picture
blood
pressure
1. Although
variation
in
of
there
individual
B. P
(mm. Hg.)
,0°-
Perera
festations
of
dyspnea,
Twenty-two
of the
at some time developed congestive
orthopnea,
failure
such
paroxysmal
dyspnea
and ankle edema.
patients
the insufficiency
manias
nocturnal
In most of these came
late in the
course of the disease. The average
length of
observation
onset
cardiac
following
insufficiency
the
first
was seven years,
of the
longest period being fifteen years and eleven
\
MAX
months. Eight (39 per cent) of this group with congestive failure died during the course
of observation,
the,average
survival from the first symptom and one-half
age of
being eight
years.
Cardiac Pain.
Nine (18 per cent) of the complained of pain of cardiac
patients
origin at some time. The average
c
__---_
I YEARS
0----\/-w
-cc--
-
I
I
I
I
I
I
I
I
2
4
6
8’
10
12
14
16
observation
MIN.
the general
tendency
tension was to increase
of the hyper-
very slowly through-
out the years of observation. initial
blood pressure
mercury time
while
when
Blood
pressure
tained
during
observed visits
mm. of
pressure was
determinations clinic
average
was 182/108
the average
last
The
at the
204/l 15. were
by
from the onset of pain was five
years, the longest being nine years and five
FIG. 1. Mean, maximum and n&imum systolic and diastolic blood pressures of fifty hypertensive patients. _
patients,
period of
ob-
different
observers and under varying conditions, hence evaluation of these readings should take into account personal variations in measurement. Symptoms ana’ Signs. These have been analyzed under the following headings with emphasis on their relationship to prognosis. Patient’s Complaints. A conspicuous number of patients during the course of their disease complained of fatigue, nervousness, dizziness, palpitation, insomnia and weakness in addition to specific symptoms to be further enumerated. There was no relation of these complaints to the subsequent course of the disease.
months.
Only one of this group is still living.
X-ray Euidence of Cardiac Enlargement. Thirty-three (66 per cent) of the patients in the series showed an increased by x-ray
during period,
area
the course of their disease.
Of these, ten (33 per*cent) observed
cardiac
died during
with an average
the
survival
of nine years. The average period of observation for the entire group from the first sign of enlargement was ten years, the longest being twenty years and three months. Electrocardiographic Changes. per cent) of the fifty patients
Eighteen (36 had electro-
cardiographic changes indicative of myocardial damage. Two of these changes occurred just prior to death. The average length
of observation
was six and one-half
years, the longest being seventeen years and four months. Eight (43 per cent) of the group’ were followed until death with an average survival period of seven years. Renal Changes. Only two patients showed evidence of nitrogen retention. One of these died from cardiac failure seven years later; the second patient died from uremia a few months after nitrogen retention was apparAMERICAN
JOURNAL
OF
MEDICINE
Hypertensive ent. Twenty-nine patients
Vascular
(58 per cent)
developed
persistent
of the fifty albuminuria
Disease-Blood, at some
Perera
time
during
87
the
during the course of their disease. The aver-
and even the more intense
age period of observation
not constant
albuminuria
was seven and one-half
the longest
being
one month. died
from the onset of
twenty-seven
years,
years
and
Eight (27 per cent) of the group
during
the average
the
period
period
of
observation,
of survival
being
eight
years.
and
Changes.
cent)
developed
dent
during
disease. ment
cases
a cerebral
the
(14
vascular
observed
in
death.
had a cerebral
The
accident
per acci-
course
In six of these the cerebral resulted
patient
Seven
of the involve-
remaining after twelve
hypertension and was years of known without signs or symptoms for eleven years and was well when last seen in the clinic. Retinal Changes.
Thirty-three
patients
(66
or previous
migraine,
onset of arteriovenous years
but
it was
compression
present
in one
from the iyas ten patient
headaches
were
disappeared
assumed
a typical
frequency the
history
complained
com-
height
migraine
which
pattern.
whatsoever
of the
with no
of idiopathic
of headaches
and intensity
There
between
the
of the headaches,
blood
pressure
or
the
course of the disorder. Final of the
twenty-four free
Sixteen
Observations. patients
in this
observation.
The
(32 per cent)
series
(48 per cent)
of significant
died,
while
were living
symptoms
at
remainder
and
the
had
severe complaints or exhibited symptoms of cardiac insufficiency.
last more
signs
or
COMhENTS
during the course of their disease. The averof years of observation
often
It was of interest that a few patients, familial
per cent) had retinal changes of some degree age number
of their
pletely after months or years of great severity.
was no correlation
Cerebral
course
disease. Most of these were of a minor degree
This
series
of fifty
asymptomatic pertensive
who
were
and had uncomplicated
hy-
vascular
patients
disease
when
twenty-three years and five months before the date of the last observation. Eight (24
served,
per cent) of the group died during observation with an average period of survival of
no consideration to hypertension in its more progressive forms or to patients who first
nine years. Only seventeen (51 per cent) of the thirty-three patients with retinal changes
consult
developed
present study gives no statistical
by
more severe damage
hemorrhage,
The
average
group patient
exudate
period
or papilledema.
of observation
was six and one-half survived
as indicated
twenty-one
in this
conspicuously
the
their
physician
as to its frequency,
AMERICAN JOURNAI.
OF
it does indicate,
how-
is not a rarity.
years
and six
lished hypertension at the time of initial observation and may have had an elevation of blood pressure for an indefinite period
regressed their
of the fifty pa-
MEDICINE
the
information
showed
course .of
tients (74 per cent) complained
of compli-
Although
ever, that long survival in this group
prior to observation. Except for the mild the patients
appear
to be comparable
of headaches
studied
ported series of patients It is significant the initial
of their
in this group with
other
re-
with respect to age,
and general that
The
well estab-
character
disease,
sex distribution Thirty-seven
because
signs and symptoms.
majority
disease. Headaches.
cating
a selected one. It gives
but one
whose retinitis
during
10 years, is obviously
for at least
years
months after extensive exudate had been seen. Nine (53 per cent) of this group died the average survival during observation, being seven years. There were several patients in the group showing retinal exudate and hemorrhages
and who were followed
first ob-
characteristics.
in the group
level of the arterial
studied
pressure
did
Hypertensive
88 not
seem
to
symptoms,
associated
development
complications.
that palpitation, of cardiac
enlargement
the subsequent A steadily
x-ray
but in individual
pressure
over
a
in-
short life expectancy,
patients
a long period
of
such complications. that
irrespective
of
minimal
there
is cardiac and
early
retinal change, a definite prognosis should not be made since such a patient may live for one, two or more decades before fatal complications observations years,
appear. over
Without
a period
one is not justified
benign
from
The indications
a more
of months
results of such procedures
height
such
as
in
years, the
twenty-seven
of blood
pressure,
headaches
and
the presence
minimal venous
of cardiac
albuminuria,
diographic
years. symppalpita-
enlargement,
minor
electrocar-
changes
and
retinal
compression
bore
no
arterio-
relationship
to prognosis. 4. Essential hypertension may be compatible with many years of survival and 5. The tients
favorable
with
outlook
hypertension
for some
should
the indications
the results of such therapeutic
be
pacon-
for and
procedures
as
sympathectomy. The authors are greatly indebted and
Mary
to carry
or the
a relatively
malignant
for and the evaluation
process. of the
as sympathectomy
must take into consideration
of observation
Lasker
Foundation
to the Albert
for the means
out this study.
repeated
in foretelling
future trend or in differentiating
length
group was seventeen
sidered in evaluating
electrocardiographic
albuminuria
fol-
well being.
and palpitation,
whether minor
toms
in hypertensive
nervousness
hypertensive
3. It was found in the group studied that
tion,
even in those who may complain
enlargement,
average
longest period exceeding
pain or insufficiency,
were, in general,
uncomplicated
lowed for at least ten years.
to
signs of myocardial renal damage, cerebral retinal hemorrhages,
it is evident
of headaches,
and
disease and were subsequently
the initial
blood
of a relatively
survival followed
tomatic
this selected
arterio-
Perera
vascular 2. The
evidence
and retinal
vascular accidents, exudate or papilledema
change,
cardio-
course. rising
electrocardiographic damage, progressive
patients,
of major
bore no correlation
period of time, cardiac
Thus,
with
or with the
It was also apparent
headaches,
venous compression
dicative
either
rate of progression
subsequent vascular
be
Vascular Disease-Blood,
the not infre-
quent long period of survival and comparative well being of many patients. CONCLUSIONS 1. An analysis was made of fifty patients who, when first observed, exhibited asymp-
REFERENCES N. M., WAGENER, H. P. and BARKER, N. W. Some different types of essential hypertension; their course and prognosis. Am. 3. M. SC., 197: 332-334, 1939. 2. JANEWAY, T. C. A clinical study of hypertensive cardiovascular disease. Arch. Znt. Med., 12: 755-798, 1913. 3. BLACKFORD,J. M. and WILKINSON,J. N. Hypertension: A study of two hundred two cases followed for an average of ten years-with remarks on causes and treatment. Ann. Znt. Med., 6: 54-5.9, 1932. 4. Blood Pressure Study, 1939. The Actuarial Society of America and the Association of Life Insurance Medical Directors. New York, September, 1940. 1.
KEITH,
AMERICAN
JOURNAL
OF
MEDICINE