Four hundred thirty-nine consecutive patients (143 men and 296 women) with essential hypertension were followed on conservative therapy for a minimum of 5 years or until death. The initial blood pressure taken by a standard method and the presence and degree of vascular involvement at the time of registration were recorded on all patients. On the basis of these observations, each patient was classified in one of four classes of over-all hypertensive severity. At the end of the 5-year follow-up period, 161 patients were dead, 78 men and 83 women. The higher mortality among men was significant and was apparent after the first year of follow-up. A progressive rise in 5-year mortality was observed with increasing degrees of initial blood pressure elevation, fundal involvement, cardiac size by radiogram, and electrocardiographic evidence of left ventricular hypertrophy, as well as with progressively higher classification of over-all hypertensive severity. Patients with mild hypertension and minimal cardiovascular impairment (class I) had an 11 per cent 5-year mortality, while patients with malignant hypertension, renal failure, or congestive heart failure (class IV) had an 84 per cent 5-year mortality. Early deaths in patients with mild hypertension were found to be largely due to atherosclerotic complications or noncardiovascular causes. Possible explanations for long survivals in patients with advanced vascular involvement on initial examination are discussed. The increased mortality of men over women was attributed in part to greater severity of disease on initial registration and in part to a higher incidence of coronary atherosclerosis. The mortality in patients with headache, dizziness, and nervous tension was found to be a factor of the associated vascular complication rather than of the symptoms alone. Patients with clinical obesity were found to have a lower over-all mortality than patients who were not obese. The prognostic value of a standardized initial blood pressure measurement is stressed and is discussed in the light of previous work by Perera, Smirk, and Gilchrist. The prognostic data were presented as a framework against which the long-term treatment of mild and moderate hypertension can be tested.

Although it is clear that antihypertensive treatment is beneficial in reducing stroke morbidity and mortality, the results of the major outcome studies show less impact on coronary heart disease. Studies utilizing 24-h blood pressure (BP) monitoring show a positive association between target organ damage and the level of 24-h BP, and with variability in BP, which is an independent determinant of target organ damage. Current understanding of the pathogenesis and pathophysiology of coronary heart disease suggests that optimal antihypertensive treatment should ensure the following: effective 24-h BP control, smooth antihypertensive effect with reduced variability; attenuation of the early morning surge in BP; maintenance of the normal circadian pattern of BP; effective therapeutic coverage in the face of suboptimal compliance; and lack of reflex activation of the sympathetic nervous system. On the basis of our current understanding, this optimum is most likely to be achieved by the use of antihypertensive agents with a long duration of action.

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Two patients with hypermineralocorticoidism due to deoxycorticosterone (DOC) excess are described. The plasma 17-deoxysteroids of the zona fasciculata (ZF), namely DOC, corticosterone, 18-hydroxydeoxycorticosterone, and 18-hydroxycorticosterone, were elevated. Plasma androgen concentrations were normal, and plasma aldosterone and renin levels were low. One patient, who had benign adrenocortical adenoma, had normal plasma cortisol levels. The other patient, who had metastatic adrenocortical carcinoma, had low plasma cortisol, presumably due to elevated plasma corticosterone levels. While tumors producing only 17-deoxysteroids are rare, they have provided new insights into the regulation of 17-deoxysteroid secretion by the ZF. Presumptive suppression of a non-ACTH factor by adenoma-produced DOC transiently impaired the early postoperative responses to ACTH of the ZF 17-deoxysteroids of the contralateral adrenal. The dissociation of 17-deoxysteroids from cortisol in normal subjects given either dexamethasone or DOC acetate provides additional evidence for such a factor.