Harold on History | Historical Perspectives on Hypertension

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The unveiling of the new 2017 High Blood Pressure Guideline at the AHA Scientific Sessions in Anaheim (see cover story) prompts a look back at the history of hypertension. After all, Confucius said: “Study the past if you would define the future.”

Awareness of the clinical aspects of hypertension dates to antiquity. The Chinese Yellow Emperor’s Classic of Internal Medicine (2600 BCE) noted: “…If too much salt is used in blood, the pulse hardens.” Treatment of ‘hard pulse disease’ during ancient times included acupuncture, venesection and bleeding by leeches. The relationship between the palpated pulse and the development of heart and brain afflictions was described by ancient Egyptian physicians in the Ebers Papyrus (1550 BCE).

Post-BCE, William Harvey first described the circulation of the blood in his book Exercitatio Anatomica de Motu Cordis et Sanguinis in Animalibus (On the Motion of the Heart and Blood) in 1628. It was in 1733 that English clergyman Stephen Hales invented a manometer and made the first published measurements of arterial blood pressure in the horse.

The recognition of hypertension as a clinical entity came with the invention of the cuff-based mercury sphygmomanometer by Italian physician Scipione Riva-Rocci in 1896. He measured the peak systolic blood pressure by noting the cuff pressure at which the radial pulse was no longer palpable. In 1905, Russian physician Nikolai Korotkoff described the sounds that are heard when an artery is auscultated with a stethoscope while the sphygmomanometer cuff is deflated. These sounds, dubbed the Korotkoff sounds, helped to define systolic and diastolic blood pressure measurements and clinical recording of blood pressure.

The history of contemporary hypertension management is an exciting story of a major successful effort in preventive cardiology.

Between 1910 and 1914, physicians made headway in defining both essential hypertension (elevated blood pressure when no other cause could be determined) and malignant hypertension (a syndrome of severe hypertension associated with target organ damage and high mortality from strokes, heart failure or kidney failure). It wasn’t until President Franklin D. Roosevelt that the impacts of untreated hypertension gained public attention.

Cardiology Magazine ImagePresident Franklin D. Roosevelt
(Library of Congress)

Roosevelt was documented as having hypertension at age 54, but did not receive treatment for another four years when he was prescribed phenobarbital and massage therapy for a blood pressure of 188/105 in 1941. In February 1945, Roosevelt had recorded blood pressures up to 260/150 at the time of the Yalta Conference, where he was noted to be in failing health with evidence of heart failure, including shortness of breath, orthopnea, lethargy and drowsiness. On the morning of April 12, 1945, a blood pressure of 300/190 was recorded after Roosevelt reported a severe occipital headache while sitting for a portrait session. He subsequently lost consciousness and died.

Roosevelt’s death highlighted the fact that prior to World War II there were few effective antihypertensive drugs and available agents were poorly tolerated. Non-pharmacologic methods to treat hypertension included strict sodium restriction, while other treatments included injections of pyrogens such as typhoid bacilli and surgical methods such as sympathectomy and adrenalectomy. Sodium thiocyanate was the first chemical used for hypertension in the 1900s but toxicity and marginal effectiveness limited its use. Additionally, physicians did not uniformly recognize the need to aggressively treat this potentially lethal disease.

Despite actuarial data from insurance companies available from the 1930s demonstrating the relationship between hypertension and mortality from cardiovascular or renal disease, it was not until the 1950s that hypertension management became more widely practiced. Paul Dudley White noted in 1937 that: “Hypertension may be an important compensatory mechanism which should not be tampered with, even were it certain that we could control it…” Subsequent prospective longitudinal epidemiologic studies such as the Framingham Heart Study confirmed the risk of hypertension on cardiovascular morbidity and mortality and the need for therapeutic intervention.

On the drug front, hexamethonium, hydralazine and reserpine were used after World War II. A breakthrough occurred in the 1950s with the introduction of the diuretic chlorothiazide, which was well tolerated and clearly prolonged life in hypertensive patients. British physician James Black developed beta blockers in the early 1960s. Calcium blockers subsequently followed. The discovery of the renin-angiotensin system led to the development of angiotensin-converting enzyme inhibitors, which then led to angiotensin-receptor blockers and renin inhibitors. With modern pharmacotherapy, we now have a powerful therapeutic arsenal to treat all forms of hypertension.

Until now, hypertension treatment guidelines were developed by the Joint National Commission (JNC) under the auspices of the National Heart, Lung, and Blood Institute at the National Institutes of Health. The first JNC report was published in 1977 and focused on treating elevated diastolic blood pressures, with the last official JNC report issued in 2003 as the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7). The ACC and AHA have assumed development of these guidelines with this month’s release.

The history of contemporary hypertension management is an exciting story of a major successful effort in preventive cardiology. There is no doubt we will only continue to make progress, building on the research and efforts of those who have come before.

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Clinical Topics: Cardiovascular Care Team, Diabetes and Cardiometabolic Disease, Dyslipidemia, Heart Failure and Cardiomyopathies, Prevention, Vascular Medicine, Lipid Metabolism, Novel Agents, Statins, Acute Heart Failure, Hypertension, Sleep Apnea

Keywords: ACC Publications, Cardiology Magazine, Animals, Antihypertensive Agents, Blood Pressure, Angiotensin-Converting Enzyme Inhibitors, Reserpine, Sodium, Hexamethonium, Angiotensin Receptor Antagonists, Pyrogens, Calcium, Mercury, Renin, Chlorothiazide, Renin-Angiotensin System, Diuretics, Hypertension, Malignant, Phlebotomy, Consciousness, Stethoscopes, Massage, Leeches, World War II, Inventions, Adrenalectomy, Prospective Studies, Lethargy, Egypt, Typhoid Fever, Hypertension, Thiocyanates, Blood Pressure Determination, Sphygmomanometers, Hydralazine, Sympathectomy, Stroke, Heart Failure, Renal Insufficiency, Arteries, National Institutes of Health (U.S.), Brain, Sleep Stages, Headache, Dyspnea

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