In the study population, whose blood pressure before and during treatment was in a narrow range, and after other cardiovascular risk factors had been considered, the renin profile before treatment remained independently associated with the subsequent risk of myocardial infarction.

The prognostic value of pretreatment pulse pressure as a predictor of myocardial infarction and the relation of pulse pressure and in-treatment diastolic blood pressure reduction to myocardial infarction were investigated in a union-sponsored systematic hypertension control program. In a prospective study, 2207 hypertensive patients with a pretreat-ment systolic blood pressure greater than or equal to 160 mm Hg and/or diastolic pressure greater than or equal to 95 mm Hg grouped according to fertile of pulse pressure (PP1, £46; PP2, 47 to 62; PP3, ^63 mm Hg) were further stratified by the degree of diastolic fall: large (L), £18; moderate (M), 7 to 17; small (S), £6 mm Hg. During an average follow-up of 5 years, 132 cardiovascular events (50 myocardial infarctions, 23 strokes) were observed. Myocardial infarction rates per 1000 person-years were positively related to pulse pressure (PP1, 3.5; PP2, 2.9; PP3, 7.5; PP3 versus PP1, />=.02). Wide pulse pressure was identified as a predictor of myocardial infarction (PP3 versus [PP1+PP2]: relative risk [RR]=2.2, 95% confi-T herapeutic decision making and management in patients with mild to moderate hypertension are complicated by the wide variation in their clinical characteristics. 1 ' 2 Clinicians therefore have sought more precise means to describe the outlook for individual patients. One approach has been to use different measures of baseline blood pressure (BP), such as 24-hour recordings, response to stress, and variability of BP, to prognostically stratify patients. 34 As Sleight 5 and others 6 have suggested, a wide pulse pressure (PP) may reflect atherosclerotic disease and stiff arteries and identify individuals with an increased risk. We have assessed the value of PP as a means of identifying patients with preexisting cardiovascular disease (CVD) who are therefore at increased risk of myocardial infarction (MI). Moreover, because it has been previously demonstrated in this population that a curvilinear (J-shaped) relation exists between the extent of BP reduction (as achieved through hypotensive therapy) 7 and the occurrence of MI, we have further explored this relation after stratifying patients according to their pretreatment PP. dence interval [CI]=1.2-4.1), controlling for other known risk factors by Cox regression. A curvilinear relation (resembling a J shape) between diastolic fall and myocardial infarction was observed in patients with the widest pulse pressure, PP3 (L, 9.5; M, 3.9; S, 11.2; L versus M: RR-2.5, 95% CI=1.0-6.2; S versus M: RR=2.9, 95% CI=1.1-8.0). Even after adjusting for age, sex, race, and previous cardiovascular disease using the Mantel-Haenszel method, this relation persisted in PP3 (L versus M: RR=2.6, 95% CI=1.0-6.5; S versus M: RR=3.3, 95% CI=1.2-9.5). A wide pretreatment pulse pressure (^63 mm Hg) was associated with subsequent cardiovascular complications and identified that subgroup of hypertensive patients at greatest risk of myocardial infarction from either too large or too small a fall in diastolic blood pressure. (Hypert...

Abstract-To determine whether pretreatment and/or in-treatment serum uric acid (SUA) is independently and specifically associated with cardiovascular events in hypertensive patients, we examined the 20-year experience of 7978 mild-to-moderate hypertensive participants in a systematic worksite treatment program. Clinical evaluation and treatment were protocol-directed. SUA was measured at entry and annually thereafter. Subjects were stratified according to gender-specific quartile of baseline SUA. Blood pressures at entry and in-treatment were, respectively, 152.5/95.6 and 138.9/85.4 mm Hg. SUA was normally distributed with a mean of 0.399Ϯ0.0893 and 0.321Ϯ0.0833 mmol/L for men and women, respectively. Subjects with highest SUA were heavier, had greater evidence of cardiovascular disease (CVD), higher systolic blood pressure, higher creatinine, more frequent diuretic use, and lower prevalence of diabetes.During an average follow-up of 6.6 years (52 751 patient-years), 548 CVD events (183 mortal) and 116 non-CVD events occurred. In bivariate analysis, the association of SUA to CVD was more robust in nonwhites than whites and in patients at low versus high CVD risk. In multivariate analysis, CVD incidence was significantly associated with SUA with a hazard ratio of 1.22 (95% confidence interval 1.11 to 1.35), controlling for other known cardiovascular risk factors, including serum creatinine, body mass index, and diuretic use. Despite blood pressure control, SUA levels increased during treatment and were significantly and directly associated with CVD events, independently of diuretic use and other cardiovascular risk factors. (Hypertension. 1999;34:144-150.)Key Words: uric acid, serum Ⅲ blood pressure Ⅲ cardiovascular disease Ⅲ hypertension, essential T he association of elevated serum uric acid (SUA) with cardiovascular disease (CVD) has been recognized for more than a century. During the last 50 years, a substantial body of clinical and epidemiological research has convincingly defined a positive association of SUA with myocardial infarction, stroke, and all cardiovascular events in both the general population 1-7 and, more particularly, among hypertensive patients. 8,9 Despite long-standing awareness of this association, little attention has been paid to its potential significance. This is particularly true with regard to hypertensive patients, of whom Ϸ1 in 4 have elevated levels of uric acid. 10 The existence of a large, long-term, and systematically treated hypertensive cohort has made it possible to determine whether an independent relationship of SUA levels to stroke, heart attack, and total CVD events exists and whether this relationship persists after normalization of blood pressure (BP). Methods SubjectsStudy subjects were patients with mild-to-moderate hypertension identified through screening for high BP who entered a unionsponsored treatment program in New York City between 1973 and 1996. Entry criteria, evaluation, and treatment methods of this worksite-based prospective cohort study have been previo...