Distribution and determinants of cardiovascular events during 20 years of successful antihypertensive treatment

OBJECTIVE: To define the distribution and determinants of cardiovascular disease events among participants undergoing long-term antihypertensive therapy, and to stratify them into risk groups on the basis of pretreatment clinical profiles. DESIGN: A prospective cohort study of participants in a worksite-based antihypertensive treatment program in New York city (1973-1994). PATIENTS: We studied 8690 systematically treated patients who had at least 6 months of follow-up (average of 5.7 years) and, at entry, had had a systolic blood pressure of > or = 160 mmHg or a diastolic blood pressure of > or = 95 mmHg (after 1992 > or = 140/90 mmHg), or had been being administered antihypertensive medication. MAIN OUTCOME MEASURES: Blood pressure and incidence of morbid and mortal cardiovascular events. RESULTS: Blood pressure control (to 140 +/- 3/87 +/- 7 mmHg) was achieved by the first year and maintained through 18 years of therapy. In nearly 50,000 person-years of follow-up, there were 468 cardiovascular disease events myocardial infarction including revascularization (282), strokes (93), congestive heart failure (30) and other cardiovascular deaths (63). Deaths from cardiovascular disease events accounted for 68% of all deaths. Myocardial infarction was most common throughout, but congestive heart failure incidence surpassed stroke incidence after 10 years. A scheme for risk stratification was constructed after analysis of the independent association of baseline factors and incident cardiovascular events. Upon the basis of ease of ascertainment and their demonstrated associations with occurrence of cardiovascular disease during treatment, we selected five pretreatment factors (history of heart attack, stroke, diabetes, age > or = 55 years and pulse pressure > or = 60 mmHg) to stratify patients into four groups. Those with no risk factor had a low risk (n=2999), those with one had a moderate risk (3042), those with two had a high risk (2237), and those with three or more had a very high risk (412). Overall, the unadjusted rates of incidence of cardiovascular disease events per 1000 person-years for patients in very high and low risk groups differed by factors of six and 14 for men and women, respectively. CONCLUSION: These results demonstrate that long-term control of blood pressure can be achieved in a general population. Nevertheless, cardiovascular disease events still accounted for most morbidity and mortality among these 'recovered' hypertensive patients. At entry, on the basis of readily identifiable characteristics, it was possible to stratify patients according to likelihood of subsequent events occurring despite control of blood pressure. This scheme could provide the basis for targeting more aggressive therapy where the potential for further cardioprotection is greatest.