CONQUERING THE QUIET KILLER

Fayore Curry, 47, a Chicago mental health worker whose unlined face and trim figure belie her age, knew from her first pregnancy at age 21 that she had high blood pressure. But it was not until two years ago that she realized what it meant. One day, a friend told her that she was slurring her words; her boyfriend noticed that she was limping; she herself found that she could not comb her hair. She then drove to a hospital, where she learned that she had suffered a stroke.

John Wilson, 57, a black construction worker from Katy, Tex., enjoyed vigorous good health until 1971, when he suddenly began complaining about feeling weak. A visit to his doctor quickly revealed why: his blood pressure was dangerously high, and unless it was brought down quickly, Wilson risked death from a stroke or heart attack.

Ann Naan, 60, a secretary for the American Heart Association in New York City, learned from her doctor during a postoperative checkup that her blood pressure was slightly elevated. About a year later she began to be short of breath, and a screening of A.H.A. staffers revealed that her blood pressure had risen dangerously.

Curry, Wilson and Naan are all victims of hypertension, a medical term that seems to suggest nervous disorder but really means high blood pressure. They are more fortunate than most of the 23 million people in the U.S. alone estimated by the A.H.A. to be suffering from the disease. They know about then” condition and are under treatment. Most hypertensives are not even aware that they are being stalked by a quiet killer that often produces no symptoms until it is too late. The A.H.A. believes that less than half of all hypertensives know that they have high blood pressure. Even worse, according to the A.H.A., only half the hypertensives who are aware of their illness are under treatment to control their blood pressure, and of these, only half are getting the proper therapy.

For the remainder, the consequences can be fatal. The damage produced by hypertension may well be the nation’s leading cause of death. Heart attacks and strokes kill more Americans than the other leading causes of death combined: cancer and accidents. High blood pressure alone is listed as the primary cause of only 60,000 deaths a year. But hypertension, which rarely appears on death certificates, is the underlying cause of hundreds of thousands of other deaths. Heart disease will claim an estimated 600,000 Americans in 1975, and hypertension is the major contributor to heart disease. Strokes will hit an estimated 2 million Americans and kill some 200,000 this year; hypertension is the leading cause of stroke. Kidney disease may account for as many as 60,000 deaths in 1975; hypertension is the major contributor to kidney disease. An untreated hypertensive is four times as likely to have a heart attack or a stroke as someone with normal blood pressure and twice as likely to develop kidney disease. Thousands of Americans will have their eyesight impaired, suffer from internal hemorrhages or miss work because of hypertension.

High blood pressure is no respecter of age or sex; men and women are almost equally susceptible to the disorder. It strikes the powerful as well as the poor. King Charles II of England and his mistress Nell Gwynn both died from the complications of severe hypertension; so did such modern-day statesmen as Woodrow Wilson, Franklin Roosevelt and Joseph Stalin. Hypertension hits the young as well as the middleaged; doctors have found a surprising number of cases of high blood pressure among teen-agers and “swinging singles” and have even detected the disease in young children.

It is no surprise that for the nation’s life insurance companies, measurement of blood pressure is the most important factor used in predicting life expectancy. Actuarial charts are based on figures that offer grim testimony to the effects of hypertension: at any given age, the higher the blood pressure, the shorter the life expectancy (see chart page 64).

The irony is that many of the deaths that can be traced to high blood pressure are, in fact, avoidable. Doctors may not be able to cure cancer or the common cold, but modern medicine can now treat virtually every case of hypertension, from the mildest to the most severe, effectively and relatively inexpensively.

Much of the credit for this successful treatment belongs to a perky professor of medicine named John Henry Laragh. Best known for untangling the hormonal relationships that control blood pressure, Laragh, 50, pioneered in the treatment of high blood pressure by founding the nation’s first hypertension center, at Manhattan’s Columbia Presbyterian Medical Center in 1971. Now he is expanding both his research and clinical interests into new fields. Last week he left Presbyterian Hospital, where he was vice chairman of the board of trustees for professional and scientific affairs, to assume an endowed professorship at The New York Hospital-Cornell Medical Center. There he will intensify his assault on hypertension and other circulatory disorders as director of a new cardiovascular center that has been organized to study and treat the entire circulatory system.

Laragh’s move comes at an appropriate time. Medicine is better equipped than it has ever been to handle hypertension. Yet the disease remains perhaps the most neglected of health problems. Many physicians, in fact, still believe that moderately elevated blood pressure need not be treated. Laragh is determined to change all that. “Hypertension does not have to be the single leading factor in disability and death in the U.S. today,” he insists. “We have the means to control it. What we have to do is use them. We’re ready for an all-out attack.”

That attack has been a long time coming, for high blood pressure has been an enemy of man throughout recorded history. A Chinese medical text dating back to 2600 B.C. noted that a diet high in salt (now known to affect blood pressure) could cause changes in pulse and complexion. The Bible contains several accounts of paralysis and apparent stroke that may well have been the resuits of hypertension. But it was not until the 17th century that the great English anatomist William Harvey provided the foundation for the understanding of blood pressure by mapping the human circulatory system. And not until the beginning of the 20th century did physicians develop a practical means of measuring the pressure that pushes blood through the body: the sphygmomanometer (see box page 62). The link between high blood pressure and fatal illness was not documented until 1929, when a Harvard physician, Dr. Samuel Albert Levine, noted that of 145 heart attack patients, 60% had been hypertensive.

Until Levine’s discovery, many doctors believed that elevated blood pressure was actually necessary to help force blood through aging arteries. Since then, they have become considerably more sophisticated about both blood pressure and its effects on the body.

The adult human body has some 60,000 miles of blood vessels. As the body’s blood (five quarts or more in the average adult) is driven through a network of arteries, capillaries and veins by the pumping action of the heart, it exerts force on the walls of these vessels. Without the pressure generated by the

heart, oxygen-carrying blood could not be forced up to the brain or out to the I muscles; the blood could not be returned to the lungs for reoxygenation or passed through the membranes of the kidneys for filtration and excretion of wastes.

To function properly, the body must carefully control blood pressure through a number of complex mechanisms. Baroreceptors—clusters of pressure-sensitive cells scattered throughout the arterial system—respond to changes in pressure and signal the nervous system to make the necessary adjustments. The nervous system in turn helps lower or raise pressure by 1) expanding or dilating arterioles, the smallest branches of arteries, or 2) retarding or speeding up the heart’s beat and changing its force of contraction.

When these systems function normally, the circulatory system has few problems. Blood pressure rises during exercise or excitement, falls during sleep or relaxation. Like pipes in a plumbing system, the arteries can tolerate high pressure for brief “surges.” But when the pressure persists, damage is likely.

One area where hypertension is particularly hazardous is the brain. High blood pressure can cause a rupture or blowout of an artery feeding the brain. When it does, part of the brain is deprived of its blood supply and thus its oxygen. The resulting damage is called a stroke. High blood pressure also forces the heart to work harder, for it must pump against increased resistance. The overworked organ may enlarge, demanding more oxygen than the system can provide; the chest pains of angina pectoris or even damage to irreplaceable heart muscle may soon follow. Or the enlarged heart may be unable to empty itself against the pressure of blood in the arteries, causing fluid to accumulate behind the heart, in the lungs and extremities. In either case, the result will be the same: a heart attack that can cripple or kill its victim. In a chicken-and-egg situation, high blood pressure can also trigger complex mechanisms that will reduce blood flow to the kidneys. That, in turn, reduces the capacity of the kidneys to help rid the body of its waste material, and the kidneys themselves may eventually fail.

For all their increasing ability to control high blood pressure, doctors are still not sure what causes it. Some cases of hypertension stem from kidney disease. Others can be traced to a condition called coarctation or pinching of the aorta, the main artery leading from the heart. A handful of cases have been attributed to pheochromocytomas and other tumors on the adrenal glands that cause overproduction of certain hormones involved in blood-pressure control. But all these conditions together probably do not account for more than 5% of hypertension victims. Most cases are described by doctors as “essential” —medical jargon meaning not that the condition is necessary or indispensable, only that its cause cannot be identified.

Nonetheless, researchers have discovered several factors that are almost surely involved in essential hypertension. Among them:

OBESITY. Excess weight, whether it is only a few extra pounds or many, may bring an increase in blood pressure. It takes a mile of capillaries to nourish each extra pound of fatty tissue. With each extra pound, there is a corresponding increase in blood volume. This means that the heart must work harder to pump more blood through a more extensive circulatory system.

HEREDITY. No researchers will go so far as to say that hypertension is inherited like, say, blue eyes or an aquiline nose. But most feel that heredity plays some role in high blood pressure. Those whose parents are hypertensive are far more likely to have high blood pressure than those whose parents have normal blood pressure.

DIET. Modern studies have strengthened the connection between salt intake and pulse changes. Tribesmen in Africa, who eat almost no salt, rarely if ever develop high blood pressure. But in northern Japan, where people eat around 50 grams of salt a day, half the population dies of strokes, a common complication of high blood pressure.

To Laragh, the explanation is obvious. “Salt is the hydraulic agent of life,” he explains. “It is salt that holds the water in humans, causes swelling and a high fluid volume. This means an increased blood pressure.” It does indeed. Doctors have known since 1900 that lowering salt intake drops a patient’s blood pressure, and most doctors agree that Americans eat too much salt. One of the first things a doctor tells, or should tell, a hypertensive patient is to throw away his salt shaker.

RACE. For reasons that remain to be fully determined, blacks are particularly prone to hypertension. According to the A.H.A., one out of every four adult black Americans has high blood pressure, compared with one out of seven adult whites. Some scientists theorize that blacks are genetically incapable of handling the large amounts of salt that are found in a diet rich in pork and highly seasoned soul food. Others suggest that the pressures of being black in America are enough to cause the disease. Indeed, a common joke among blacks is “If you’re black and you ain’t paranoid or suffering from hypertension, you don’t know what’s going on.”

STRESS. Though many of those with apparently complete control over their emotions have high blood pressure, researchers have found that there is a relationship between stress and hypertension. Blood pressure normally rises with excitement or alarm. In most people, the pressure drops when the excitement is over. But according to one theory, in many the level drops by smaller increments, eventually stabilizing at a higher level than before. Significant increases in blood pressure were recorded among Russians who survived the siege of Leningrad and Texans who survived the Galveston Harbor holocaust in 1970. Similar increases might well be found among people concerned by the current economic situation. A study has revealed that men facing the loss of their jobs experienced increases in blood pressure that lasted through the period of unemployment and did not drop until they found work again.

Until the end of World War II, doctors treated hypertensives, if they treated them at all, mainly by diet. Patients with high blood pressure were told to take off weight and lower their salt intakes. Some patients were put on an almost totally salt-free rice diet so unappealing that most of them abandoned it as soon as they left the hospital and medical supervision. A handful of doctors even tried surgery to depress blood pressure. The operation was called a sympathectomy; it cut certain nerves leading to the organs of the chest and abdomen on the theory that this would relax the arterioles. It did but only temporarily; the arterioles soon responded to hormonal signals to constrict.

Today doctors treating hypertension rarely resort to surgery; drugs are the therapy of choice. One of the first of the new drugs in the medical armory was discovered by Dr. Edward Freis, a researcher with the Veterans Administration. He had noted from test reports that large doses of an antimalarial drug called pentaquine dramatically lowered the blood pressures of normal men. Figuring that it might do the same for hypertensives, Freis administered it to a patient with severely elevated blood pressure. It worked, and although the patient eventually died of kidney failure (the organ had been badly damaged by his hypertension), his case demonstrated the practicality of drug treatment.

Since then, a host of other antihypertensive drugs have been introduced. Some, such as hexamethonium and chlorisondamine, are blocking agents. They work by interfering with the nerve signals and chemical reactions that cause blood vessels to constrict and raise blood pressure. Others, like hydralazine, are relaxers that seem to act directly on the muscle walls of the blood vessels, causing them to dilate and thus decrease pressure. Still others, such as guaneth-idine and reserpine—a drug extracted and purified from the Indian plant Rauwolfia serpentina—achieve the same effect by reducing the action of norepinephrine, the body chemical that causes blood vessels to constrict. Another class of drugs has proved equally useful. Diuretics decrease the kidneys’ retention of salt. This in turn decreases the amount of fluid retained by the body. The volume of blood is lowered and blood pressure drops.

Used singly or in various combinations, these drugs have enabled physicians to offer the hypertensive something better and more certain than diet or surgery to control his disease. But they do not solve all the difficulties of dealing with high blood pressure. Many of the antihypertensive drugs can, and frequently do, produce undesirable side effects, such as impotence, dizziness and drowsiness. Doctors have learned to lessen these reactions by adjusting dosages or switching from one drug to another. Another problem was less easy to solve. Doctors had known for years that there are many forms of hypertension that affect different patients in a vast variety of ways. Some respond to one kind of treatment, others to something completely different. It remained for Dr. Laragh to show how to predict an individual patient’s response to a particular drug.

In many ways, Laragh was an ideal man for the job. A native of Yonkers, N.Y. (his grandfather was mayor), Laragh had always admired his family physician and the seeming miracles he could perform. He soon found himself exposed even more closely to medicine; he and a younger sister were orphaned when they were in their teens and went to live with a physician uncle.

It seemed only natural for Laragh himself to go into medicine. After Cornell University and Cornell University Medical College, he moved to Presbyterian Hospital for his internship. There he came under the tutelage of Dr. Robert Loeb, a great physician who co-edited what has since become one of medicine’s standard texts: Cecil & Loeb’s Textbook of Medicine. The association was a fortunate one for Laragh. “Loeb was a despot, but a benevolent one,” Laragh recalls. “He was fair but demanding, and his standards were the highest.” Loeb was also a first-rate teacher who did not believe in spoiling his pupils by assigning laboratory technicians to help them. “I had to do every experiment myself,” says Laragh. “But it was worth it. I really learned about research.”

After his internship, Laragh combined research with clinical practice ” (“You learn more from patients than you do from samples in a laboratory”). As a cardiologist, he concentrated most of his efforts on the workings—and failings—of the heart. But he also looked elsewhere in the circulatory system, and in 1955 he made an important discovery: he learned that increases in the blood levels of potassium can stimulate the production of aldosterone, an adrenal hormone that raises blood pressure by causing the kidneys to retain salt.

In the years that followed, Laragh made even more spectacular findings, which like so many other achievements in science, were serendipitous. Doctors had been aware of the role of aldosterone for some time. But they had been puzzled by the part played by renin,* a kidney hormone produced in response to a drop in blood pressure. Laragh solved the puzzle. In 1958 he and his colleagues began treating a man with malignant hypertension, a rare form of the disease that is characterized by kidney damage and usually kills its victims within a year. Tests showed that the man was, to their surprise, producing far more than the normal amount of aldosterone. This finding led to another series of tests that proved even more revealing. They showed that high aldosterone was probably due to increased secretion of renin.

Usually renin production ceases when blood pressure reaches the proper level. In this case, the cutoff mechanism had failed. The man’s renin was triggering the production of excess aldosterone, which in turn was increasing the body’s tendency to retain salt. The process caused fatally high blood pressure.

Laragh’s discoveries, which won him a share in the $50,000 Stouffer Prize in 1969, explained the hormonal controls of blood pressure for the first time. They also permitted the development of a renin profile—a computer-aided analysis of the patient’s hormonal output. There are patients with low renin levels who nonetheless have high blood pressure; excess of fluid is probably at the root of their problem. Diuretics counteract this tendency to store salt and fluids, thus lowering the blood pressure. Those with high renin levels can be best helped with renin inhibitors that will slow or even shut off production of the hormone. “Until we figured out just what renin did,” says Laragh, “therapy was conducted on a hit-or-miss basis. You’d try a drug, see if it worked, and if it didn’t, switch to something else. Now you know in advance what to try.”

Laragh’s finding also cleared up another of the mysteries surrounding hypertension. Many hypertensives dismiss the seriousness of their conditions by citing the case of a relative who lived to be 80 despite a blood pressure that nearly popped the mercury out of the doctor’s sphygmomanometer. Laragh’s work indicates that these exceptions, which seemingly violate the rule that high blood pressure is dangerous, were probably low-renin hypertensives. Patients with this condition are less likely to suffer strokes and heart attacks than high-renin types. But they do not escape hypertension’s hazards; the damage merely takes longer.

Some physicians still challenge Laragh’s theories. But many doctors now do, or plan to do, renin profiling on all their hypertension patients. Most physicians already follow Laragh’s lead in another area. In 1967 Laragh discovered and reported a link between oral contraceptives and high blood pressure. Other researchers confirmed the connection, but it remained for Laragh to explain it: the Pill’s estrogen-like substances stimulate the renin system, which in turn causes increased aldosterone production. The result in about 25% of all women who use the Pill: high blood pressure. Laragh and his colleagues now routinely recommend that victims of Pill hypertension try another method of birth control.

A quiet, modest man, Laragh credits his accomplishments to an open mind (“You have to consider every possibility”) and painstaking research. “You learn more by studying a few patients in great depth than you do by studying thousands superficially,” he says. “If your methods are good and your experiments carefully conceived, it doesn’t matter whether you study a handful or a multitude; the results should be the same.”

Laragh, like his mentor, also believes in hard work. He gets to his office by 7 o’clock most mornings and shuttles between there, the Hypertension Center and his laboratory until hunger, exhaustion or Jean Sealey—a biochemist and his bride of four months—forces him to stop. “We haven’t even had a honeymoon yet,” complains Jean in a soft burr that attests to her origins in Glasgow, Scotland. “The day after we were married we went off to a hypertension meeting in Milan.” But Laragh, who has two sons by a previous marriage that ended in divorce, does find time to relax. His golf game is good enough (in the low 80s) to allow him to pair up occasionally with an acquaintance named Jack Nicklaus.

Many of Laragh’s colleagues and co-workers at Columbia Presbyterian plan to follow him in the 100-block move to The New York Hospital because they like what one calls “the atmosphere of scientific ferment” that surrounds their leader. One female lab technician has another reason for tagging along with Laragh. “It’s those Irish eyes,” she says. Laragh’s reason for taking his new post: “It’s a chance to do more.”

Whatever the reason, Laragh’s move should come as good news for most victims of hypertension. The new cardiovascular center will not only treat but study hypertensives and all the problems caused by their disease; it should help to focus more attention on a controllable illness that has suffered from professional neglect for too many years.

Elsewhere, doctors, health officials and concerned citizens are also making a concerted effort to identify and treat as many victims of high blood pressure as they can find. Stanford University has been working through its Heart Disease Prevention program to acquaint people in three northern California cities with the dangers of high blood pressure. Baylor College of Medicine in Houston has just begun a massive education effort. Hospitals in some 20 cities are participating in the federally funded “Mr. Fit” program designed to prevent heart attacks in a test group of men between 35 and 57. It aims at identifying probable heart attack victims and helping them to reduce their risks by giving up smoking, losing weight, reducing cholesterol and bringing their blood pressure under control. The Chicago board of health has a mobile blood-pressure unit cruising the streets of the city giving free hypertension tests to all. Local health organizations are setting up sphygmomanometers in supermarkets to test shoppers; in some states dentists and dental technicians are taking their patients’ pressures. The A.H.A. is urging both patients and their physicians to take blood pressure seriously. DO YOU HAVE HIGH BLOOD PRESSURE? asks an A.H.A. poster. ONLY YOUR DOCTOR CAN TELL.

For those who have high blood pressure, the outlook is bright. Exercise and diet groups to help hypertensives shape up are in operation in most major cities and many smaller communities. Researchers at Rockefeller University and other institutions are experimenting with biofeedback* to teach hypertensives to dilate their arteries and lower their blood pressures slightly. A Boston physician, Dr. Herbert Benson, has taught some of his patients to reduce their blood pressure by means of what he calls “relaxation response,” a sort of transcendental-meditation technique.

Drug treatments for hypertension continue to improve. Propranolol, a British-developed drug licensed in the U.S. for use in heart problems other than hypertension, is nonetheless widely and successfully used to control high blood pressure. Other potentially valuable drugs, though widely used in Britain, have not yet been approved by the Food and Drug Administration for use in this country. Reserpine remains an effective antihypertensive despite reports linking it with a slightly increased incidence of breast cancer in some women (TIME Oct. 7).

Despite these encouraging advances, many hypertensives still fail to get treatment. Either their condition is not diagnosed, or their doctors do not realize the importance of mildly elevated blood pressure. Others, bored by the drug regimen and lulled into a sense of false security by a lack of symptoms, drop out of treatment programs. Such lapses can be lethal. Dr. Freis once treated a young, dangerously hypertensive law student by putting him on diuretics but could not induce him to continue with the medication. The patient died of a stroke at 29. Other dropouts have been more fortunate. Helga Brown, 46, of San Francisco, followed her doctor’s orders carefully for a year after a faulting episode revealed that she had high blood pressure; then she dropped both the drugs and her diet. She suffered a recurrence of dizziness and was hospitalized. She recovered and now takes her medication faithfully.

Treatment for hypertension, whether by diet or drugs, cannot undo the damage that has already been done, but it can unquestionably prevent the disorder from getting worse. In a now classic study, Freis compared death rates from stroke, heart disease and other hypertension-related ailments among treated and untreated patients at 17 Veterans Administration hospitals. His findings showed that treatment can reduce the death rate from hypertension by half.

The lesson is one that should not be lost on anyone suffering from high blood pressure. Laragh and his colleagues have given medicine the weapons for conquering the quiet killer. All its potential victims must do is arm themselves.

*Not to be confused with rennin, an enzyme or chemical catalyst used, among other things, in the manufacture of cheese.

*A technique that employs electronic monitoring devices to help patients learn how to control autonomic nervous system functions such as heartbeat and blood circulation.