Executive Perspective Executive Perspective is a regular column in Public Health Reports in which leaders of offices under the Assistant Secretary for Health and agencies of the U.S. Department of Health and Human Services (HHS) offer their views on public health topics of the day. For this issue’s column, I asked leaders from CDC’s Division for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion, to write about CDC’s latest thinking on reducing heart disease and stroke in the U.S. population through the prevention and control of hypertension. Frederic E. Shaw, MD, JD Editor in Chief, Public Health Reports
IMPROVING POPULATION BLOOD PRESSURE CONTROL FOR BRAIN AND HEART HEALTH Mary G. George, MD, MSPH Yuling Hong, MD, MSc, PhD Barbara A. Bowman, PhD
Heart disease is the leading cause of death and disability-adjusted life years (DALYs) in the United States and the world. Stroke is the fifth-leading cause of death in the United States, the second-leading cause of death globally,1 and the third-leading cause of DALYs.2,3 Both heart disease and stroke are largely preventable by controlling risk factors such as hypertension, hyperlipidemia, diabetes, obesity, excessive alcohol intake, and tobacco smoking. However, in the United States and worldwide, interventions to control these risk factors often are poorly or incompletely implemented. Many interventions fail because they require sustained adherence to treatment even in the absence of symptoms or long-term adherence to healthy lifestyle behaviors, which may be challenging amid a busy work and home life. Hypertension, the leading risk factor for heart disease and stroke, is known as the “silent killer” because it often doesn’t produce symptoms until a major event such as a heart attack or a stroke occurs. Nearly one in three (approximately 70 million) U.S. adults has hypertension.4 It is the leading chronic condition among Medicare patients (more than 55% of beneficiaries are diagnosed with it), and it is the leading comborbid factor among those with multiple chronic conditions.5,6 It is not just a disease of the elderly: one in three adults aged 40–59 years and more than 7% of adults aged 18–39 years have hypertension.7 Notably, of adults who have hypertension, only slightly more 302
than half have it controlled,8 and more than 14 million Americans with hypertension are not even aware they have it.4 Hypertension is the most important risk factor for stroke. Up to half of all strokes may be due to uncontrolled hypertension;9 as such, it is a natural target for improving cardiovascular health in the United States and worldwide. The continued decline in mortality from acute stroke in recent years is a remarkable achievement10 and is likely due in large part to improved hypertension control10 as the result of tremendous efforts in public health strategies and advances in clinical treatment. Yet, stroke persists as the second-leading cause of death worldwide,1 a fact that underscores the need for even better hypertension prevention, detection, and control globally. Efforts by the U.S. Centers for Disease Control and Prevention (CDC) to reduce heart disease and stroke are multifaceted and include strategies that are aimed toward (1) epidemiology and surveillance to provide states and communities with relevant data to guide local interventions; (2) environmental approaches that can address healthy behaviors in various worksite, local, and related settings; (3) health-care system interventions that improve the use and delivery of preventive clinical services; and (4 ) community and clinical program/service linkages that improve the management of chronic disease or those at risk of chronic cardiovascular disease.11 To support these goals, CDC helps state and local public health agencies and communities work with health-care systems to implement clinical quality improvement processes (e.g., the use of electronic health records to address hypertension management) and to promote the adoption of teambased care (e.g., by including pharmacists and community health workers) and patient self-management for hypertension control.12,13 Additionally, CDC promotes sodium reduction programs in communities in the United States14 and globally, such as the Shandong &
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Ministry of Health Action on Salt and Hypertension Project in China.15 The Million Hearts® Initiative, which is co-led by CDC and the Centers for Medicare & Medicaid Services, is charged with preventing one million heart attacks and strokes from 2012 through 2016.16 This audacious goal employs several strategies, including the ABCS of heart health (i.e., use of aspirin/antiplatelet agents where appropriate, blood pressure control, cholesterol management, and smoking cessation counseling), coupled with sodium and transfat consumption reduction efforts, and using health information technology to advance vascular health quality improvement strategies at both the population and the individual patient levels (Figure 1). Since 2012, the predominant strategy promoted in Million Hearts® at the physician/clinical level for hypertension management has been one of detect, connect, and control. Hypertension, like stroke, is preventable in many and detectable in all, and hypertension is controllable in the vast majority of adults.17,18 However, control is challenging and requires diligence on the part of both the clinical team and the patient, using hypertension treatment protocols to guide treatment decisions, requiring patients and clinical teams to work together to solve issues related to medication adherence, and providing support to maintain healthy lifestyle choices, including being physically active, maintaining a healthy weight, and choosing lower sodium foods. The role of hypertension in causing stroke is well known. Less well recognized, however, is its important role in cognitive impairment. Cognitive impairment, vascular cognitive impairment, dementia, cerebral amyloid angiopathy, and Alzheimer’s disease are terms and conditions describing the cognitive decline associated with aging. These forms of dementia can coexist, leading to some confusion and difficulty in making an accurate diagnosis. The association between hypertension and cognitive impairment becomes particularly salient because hypertension is one cause of cognitive decline that is preventable.19,20 The term “vascular cognitive impairment” (VCI) has been defined as representing a wide spectrum of severity, from mild impairment to dementia. The diagnosis typically is based on the presence of a cognitive disorder (detected by testing) plus a history of stroke or the presence of vascular disease on brain imaging.20,21 On magnetic resonance imaging or other types of advanced imaging techniques, VCI may be associated with cerebral micro-infarcts, cerebral micro-bleeds, white matter hyperintensities (i.e., small areas of the brain that light up on imaging), or other abnormalities (Figure 2). These pathologies are thought to be related to small vessel disease and also
likely are associated with hypertension. Risk factors for VCI and vascular dementia include hypertension, smoking, diabetes mellitus, and other cardiovascular and cerebrovascular disease.22–24 A growing number of cohort studies show an association between hypertension and decreased cognitive functioning.25–28 These studies have examined this association in a wide range of age groups including children, young adults, midlife adults, and older adults. For example, the Honolulu Asia Aging Study29,30 found an association between untreated hypertension in midlife and the development of dementia in later life. Other studies have shown associations between brain integrity and blood pressure in adults younger than 50 years of age.31 VCI can affect brain functioning, from simple memory loss to limitations in executive function, such as managing time and attention, planning and organizing tasks, the speed of carrying out skills, and processing speeds.32 The Atherosclerosis Risk in Communities study33 found that people with treated hypertension had less cognitive decline than those with untreated hypertension, and people with no hypertension had less cognitive decline than those with treated hypertension. The Coronary Artery Risk Development in Young Adults study,34 which followed healthy young adults 18–30 years of age for 25 years, found that greater variability in blood pressure over time beginning in young adulthood was associated with declines in memory and processing speed 25 years later. In another cohort study of 5,367 people, Rusanen and colleagues found that heavy smoking in midlife was associated with later development of VCI.35 In a literature review of 38 longitudinal studies, randomized controlled trials, and meta-analyses, Rouch et al. found significant associations and possible preventive effects between the use of antihypertensive medication and decreases in the risk of vascular dementia in most of the longitudinal studies and randomized controlled trials.36 This growing body of literature on the association between hypertension and cognitive impairment resulted in a 2011 declaration by the American Heart Association (AHA)/American Stroke Association that, “There is reasonable evidence that in the middle-aged and young-elderly, lowering blood pressure can be useful for the prevention of late-life dementia (Class IIa; Level of Evidence B, defined as a recommendation in favor of the treatment being useful and/or effective and beneficial, and supporting data [are] derived from a single randomized trial or from nonrandomized studies).”20Traditionally, controlling hypertension has been promoted as a way to prevent heart disease and stroke, but we are now able to appreciate more than
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Figure 1. Million Hearts® Initiative: working together to prevent one million heart attacks and strokes through targeted clinical care, use of health-care technology, and sodium consumption reduction
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Figure 2. Examplesa of white matter hyperintensities (shown with arrows) thought to be related to mild cognitive impairment that is likely related to hypertension
a Panel A shows a brain scan of a 45-year-old woman with white matter hyperintensities and Panel B shows a normal brain scan of a 47-year-old woman. Source: Kruit MC, Thijs RD, Ferrari MD, Launer LJ, van Buchem MA, van Dijk JG. Syncope and orthostatic intolerance increase risk of brain lesions in migraineurs and control. Neurology 2013;80:1958-65. Used with permission from Wolters Kluwer Health.
ever its role in promoting healthy brain aging along with the prevention and control of other cardiovascular risk factors. Just seven healthy habits, the AHA’s “Life’s Simple 7,”37,38 can go a long way toward being not just heart healthy, but also brain healthy: (1) managing blood pressure, (2) controlling cholesterol, (3) reducing and controlling blood sugar, (4) being physically active, (5) eating a healthy diet that is low in sodium with plenty of fruit and vegetables, (6) maintaining a healthy weight, and (7) stopping smoking or never starting smoking. For additional tips on healthy eating, visit the Million Hearts® Healthy Eating & Lifestyle Resource Center.39 With researchers learning more and more about the relationship between hypertension early in life and development of cognitive impairment or dementia in later life, there is even more reason to prevent and control hypertension at every stage of life.
The findings and conclusions in this article are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention (CDC). Mary G. George is Deputy Associate Director for Science and Senior Medical Officer, Yuling Hong is Associate Director for Science, and Barbara A. Bowman is Director, all with the Division for Heart Disease and Stroke Prevention at CDC. Address correspondence to: Mary G. George, MD, MSPH, Centers for Disease Control and Prevention, Division for Heart Disease and Stroke Prevention, 4770 Buford Hwy. NE, MS-F72, Atlanta, GA 30341; tel. 770-488-8092; e-mail .
REFERENCES 1. Kochanek KD, Murphy SL, Xu J, Arias E. Mortality in the United States, 2013. NCHS Data Brief, No. 178. Hyattsville (MD): National Center for Health Statistics (US); December 2014. 2. Murray CJL, Lopez AD. Measuring the global burden of disease. N Engl J Med 2013;369:448-57. 3. Feigin VL, Forouzanfar MH, Krishnamurthi R, Mensah GA, Connor M, Bennett DA, et al. Global and regional burden of stroke during 1990–2010: findings from the Global Burden of Disease Study 2010 [published erratum appears in Lancet 2014;383:218]. Lancet 2014;383:245-54.
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4. Wall HK, Hannan JA, Wright JS. Patients with undiagnosed hypertension: hiding in plain sight. JAMA 2014;312:1973-4. 5. Centers for Medicare & Medicaid Services (US). Medicare chronic condition warehouse condition period prevalence, 2012 [cited 2015 Mar 4]. Available from: URL: https://www.ccwdata.org/web /guest/medicare-charts/medicare-chronic-condition-charts/#b2 _prevalence_2012 6. Valderrama AL, Gillespie C, King SC, George MG, Hong Y, Gregg E. Vital signs: awareness and treatment of uncontrolled hypertension among adults—United States, 2003–2010. MMWR Morb Mortal Wkly Rep 2012;61(35):703-9. 7. Centers for Medicare & Medicaid Services (US). Chronic conditions among Medicare beneficiaries—chartbook: 2012 edition. Baltimore (MD): CMS; 2012. Also available from: URL: http://www.cms.gov /research-statistics-data-and-systems/statistics-trends-and-reports /chronic-conditions/2012chartbook.html [cited 2014 Mar 4]. 8. Nwankwo T, Yoon SS, Burt V, Gu Q. Hypertension among adults in the United States: National Health and Nutrition Examination Survey, 2011–2012. NCHS Data Brief, No. 133. Hyattsville (MD): National Center for Health Statistics (US); October 2013. 9. Li C, Engstrom G, Hedblad B, Berglund G, Janzon L. Blood pressure control and risk of stroke: a population-based prospective cohort study. Stroke 2005;36:725-30. 10. Lackland DT, Roccella EJ, Deutsch AF, Fornage M, George MG, Howard G, et al. Factors influencing the decline in stroke mortality: a statement from the American Heart Association/American Stroke Association. Stroke 2014;45:315-53. 11. Bauer UE, Briss PA, Goodman RA, Bowman BA. Prevention of chronic disease in the 21st century: elimination of the leading preventable causes of premature death and disability in the USA. Lancet 2014;384:45-52. 12. Centers for Disease Control and Prevention (US). State public health actions to prevent and control diabetes, heart disease, obesity and associated risk factors and promote school health [cited 2015 Mar 8]. Available from: URL: http://www.cdc.gov/chronicdisease /about/state-public-health-actions.htm 13. Guide to Community Preventive Services. Cardiovascular disease prevention and control: team-based care to improve blood pressure control [cited 2015 Mar 11]. Available from: URL: www.thecommunityguide.org/cvd/teambasedcare.html 14. Centers for Disease Control and Prevention (US). Sodium Reduction in Communities Program (SRCP) [cited 2014 Mar 8]. Available from: URL: http://www.cdc.gov/dhdsp /programs/sodium_reduction.htm 15. Bi Z, Liang X, Xu A, Wang L, Shi X, Zhao W, Ma J, et al. Hypertension prevalence, awareness, treatment, and control and sodium intake in Shandong Province, China: baseline results from Shandong–Ministry of Health Action on Salt Reduction and Hypertension (SMASH), 2011. Prev Chronic Dis 2014;11:E88. 16. Frieden TR, Berwick DM. The “Million Hearts” initiative—preventing heart attacks and strokes. N Engl J Med 2011;365:e27. 17. Whelton PK, He J, Appel LJ, Cutler JA, Havas S, Kotchen TA, et al. Primary prevention of hypertension: clinical and public health advisory from the National High Blood Pressure Education Program. JAMA 2002;288:1882-8. 18. Kearney PM, Whelton M, Reynolds K, Muntner P, Whilton PK, He J. Global burden of hypertension: analysis of worldwide data. Lancet 2005;365:217-23. 19. Gorelick PB. Blood pressure and the prevention of cognitive impairment. JAMA Neurol 2014;71:1211-3. 20. Gorelick PB, Scuteri A, Black SE, DeCarli C, Greenberg SM, Iadecola C, et al. Vascular contributions to cognitive impairment and dementia: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2011;42:2672-713. 21. Chertkow H, Feldman HH, Jacova C, Massoud F. Definitions of dementia and predementia states in Alzheimer’s disease and vascular cognitive impairment: consensus from the Canadian conference on diagnosis of dementia. Alzheimers Res Ther 2013;5(Suppl 1):S2.
22. Haring B, Leng X, Robinson J, Johnson KC, Jackson RD, Beyth R, et al. Cardiovascular disease and cognitive decline in postmenopausal women: results from the Women’s Health Initiative Memory Study. J Am Heart Assoc 2013;2:e000369. 23. Okusaga O, Stewart MC, Butcher I, Deary I, Fowkes FG, Price JF. Smoking, hypercholesterolaemia and hypertension as risk factors for cognitive impairment in older adults. Age Ageing 2013;42:306-11. 24. Arntzen KA, Schirmer H, Wilsgaard T, Mathiesen EB. Impact of cardiovascular risk factors on cognitive function: the Tromsø study. Eur J Neurol 2011;18:737-43. 25. Goldstein FC, Levey AI, Steenland NK. High blood pressure and cognitive decline in mild cognitive impairment. J Am Geriatr Soc 2013;61:67-73. 26. Köhler S, Baars MA, Spauwen P, Schlevink S, Verhey FR, van Boxtel MJ. Temporal evolution of cognitive changes in incident hypertension: prospective cohort study across the adult age span. Hypertension 2014;63:245-51. 27. Yaffe K, Vittinghoff E, Pletcher MJ, Hoang TD, Launer LJ, Whitmer R, et al. Early adult to midlife cardiovascular risk factors and cognitive function. Circulation 2014;129:1560-7. 28. Muller M, Sigurdsson S, Kjartansson O, Aspelund T, Lopez OL, Jonnson PV, et al. Joint effect of mid- and late-life blood pressure on the brain: the AGES-Reykjavik study. Neurology 2014;82:2187-95. 29. Launer LJ, Hughes T, Yu B, Masaki K, Petrovitch H, Ross GW, et al. Lowering midlife levels of systolic blood pressure as a public health strategy to reduce late-life dementia: perspective from the Honolulu Heart Program/Honolulu Asia Aging Study. Hypertension 2010;55:1352-9. 30. Stewart R, Xue QL, Masaki K, Petrovitch H, Ross GQ, White LR, et al. Change in blood pressure and incident dementia: a 32-year prospective study. Hypertension 2009;54:233-40. 31. Maillard P, Seshadri S, Beiser A, Himali JJ, Au R, Fletcher E, et al. Effects of systolic blood pressure on white-matter integrity in young adults in the Framingham Heart Study: a cross-sectional study. Lancet Neurol 2012;11:1039-47. 32. O’Brien JT, Erkinjuntti T, Reisberg B, Roman G, Sawada T, Pantoni L, et al. Vascular cognitive impairment. Lancet Neurol 2003;2:89-98. 33. Gottesman RF, Schneider AL, Albert M, Alonso A, BandeenRoche K, Coker L, et al. Midlife hypertension and 20-year cognitive change: the Atherosclerosis Risk in Communities neurocognitive study. AMA Neurol 2014;71:1218-27. 34. Yano Y, Ning H, Allen N, Reis JP, Launer LJ, Liu K, et al. Long-term blood pressure variability throughout young adulthood and cognitive function in midlife: the Coronary Artery Risk Development in Young Adults (CARDIA) Study. Hypertension 2014;64:983-8. 35. Rusanen M, Kivipelto M, Quesenberry CP Jr, Zhou J, Whitmer RA. Heavy smoking in midlife and long-term risk of Alzheimer disease and vascular dementia. Arch Intern Med 2011;171:333-9. 36. Rouch L, Cestac P, Hanon O, Cool C, Helmer C, Bouhanick B, et al. Antihypertensive drugs, prevention of cognitive decline and dementia: a systematic review of observational studies, randomized controlled trials and meta-analyses, with discussion of potential mechanisms. CNS Drugs 2015;29:113-30. 37. Lloyd-Jones DM, Hong Y, Labarthe D, Mozaffarian D, Appel LJ, Van Horn L, et al. American Heart Association Strategic Planning Task Force and Statistics Committee. Defining and setting national goals for cardiovascular health promotion and disease reduction: the American Heart Association’s strategic Impact Goal through 2020 and beyond. Circulation 2010;121:586-613. 37. American Heart Association. Life’s Simple 7 [cited 2015 Mar 25]. Available from: URL: http://www.heart.org/HEARTORG/conditions /my-life-check---lifes-simple-7_UCM_471453_article.jsp 38. Million Hearts®. Healthy Eating and Lifestyle Resource Center [cited 2015 Mar 18]. Available from: URL: http://recipes.millionhearts. hhs.gov
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IMPROVING POPULATION BLOOD PRESSURE CONTROL FOR BRAIN AND HEART HEALTH Mary G. George, MD, MSPH Yuling Hong, MD, MSc, PhD Barbara A. Bowman, PhD
Heart disease is the leading cause of death and disability-adjusted life years (DALYs) in the United States and the world. Stroke is the fifth-leading cause of death in the United States, the second-leading cause of death globally,1 and the third-leading cause of DALYs.2,3 Both heart disease and stroke are largely preventable by controlling risk factors such as hypertension, hyperlipidemia, diabetes, obesity, excessive alcohol intake, and tobacco smoking. However, in the United States and worldwide, interventions to control these risk factors often are poorly or incompletely implemented. Many interventions fail because they require sustained adherence to treatment even in the absence of symptoms or long-term adherence to healthy lifestyle behaviors, which may be challenging amid a busy work and home life. Hypertension, the leading risk factor for heart disease and stroke, is known as the “silent killer” because it often doesn’t produce symptoms until a major event such as a heart attack or a stroke occurs. Nearly one in three (approximately 70 million) U.S. adults has hypertension.4 It is the leading chronic condition among Medicare patients (more than 55% of beneficiaries are diagnosed with it), and it is the leading comborbid factor among those with multiple chronic conditions.5,6 It is not just a disease of the elderly: one in three adults aged 40–59 years and more than 7% of adults aged 18–39 years have hypertension.7 Notably, of adults who have hypertension, only slightly more 302
than half have it controlled,8 and more than 14 million Americans with hypertension are not even aware they have it.4 Hypertension is the most important risk factor for stroke. Up to half of all strokes may be due to uncontrolled hypertension;9 as such, it is a natural target for improving cardiovascular health in the United States and worldwide. The continued decline in mortality from acute stroke in recent years is a remarkable achievement10 and is likely due in large part to improved hypertension control10 as the result of tremendous efforts in public health strategies and advances in clinical treatment. Yet, stroke persists as the second-leading cause of death worldwide,1 a fact that underscores the need for even better hypertension prevention, detection, and control globally. Efforts by the U.S. Centers for Disease Control and Prevention (CDC) to reduce heart disease and stroke are multifaceted and include strategies that are aimed toward (1) epidemiology and surveillance to provide states and communities with relevant data to guide local interventions; (2) environmental approaches that can address healthy behaviors in various worksite, local, and related settings; (3) health-care system interventions that improve the use and delivery of preventive clinical services; and (4 ) community and clinical program/service linkages that improve the management of chronic disease or those at risk of chronic cardiovascular disease.11 To support these goals, CDC helps state and local public health agencies and communities work with health-care systems to implement clinical quality improvement processes (e.g., the use of electronic health records to address hypertension management) and to promote the adoption of teambased care (e.g., by including pharmacists and community health workers) and patient self-management for hypertension control.12,13 Additionally, CDC promotes sodium reduction programs in communities in the United States14 and globally, such as the Shandong &
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Ministry of Health Action on Salt and Hypertension Project in China.15 The Million Hearts® Initiative, which is co-led by CDC and the Centers for Medicare & Medicaid Services, is charged with preventing one million heart attacks and strokes from 2012 through 2016.16 This audacious goal employs several strategies, including the ABCS of heart health (i.e., use of aspirin/antiplatelet agents where appropriate, blood pressure control, cholesterol management, and smoking cessation counseling), coupled with sodium and transfat consumption reduction efforts, and using health information technology to advance vascular health quality improvement strategies at both the population and the individual patient levels (Figure 1). Since 2012, the predominant strategy promoted in Million Hearts® at the physician/clinical level for hypertension management has been one of detect, connect, and control. Hypertension, like stroke, is preventable in many and detectable in all, and hypertension is controllable in the vast majority of adults.17,18 However, control is challenging and requires diligence on the part of both the clinical team and the patient, using hypertension treatment protocols to guide treatment decisions, requiring patients and clinical teams to work together to solve issues related to medication adherence, and providing support to maintain healthy lifestyle choices, including being physically active, maintaining a healthy weight, and choosing lower sodium foods. The role of hypertension in causing stroke is well known. Less well recognized, however, is its important role in cognitive impairment. Cognitive impairment, vascular cognitive impairment, dementia, cerebral amyloid angiopathy, and Alzheimer’s disease are terms and conditions describing the cognitive decline associated with aging. These forms of dementia can coexist, leading to some confusion and difficulty in making an accurate diagnosis. The association between hypertension and cognitive impairment becomes particularly salient because hypertension is one cause of cognitive decline that is preventable.19,20 The term “vascular cognitive impairment” (VCI) has been defined as representing a wide spectrum of severity, from mild impairment to dementia. The diagnosis typically is based on the presence of a cognitive disorder (detected by testing) plus a history of stroke or the presence of vascular disease on brain imaging.20,21 On magnetic resonance imaging or other types of advanced imaging techniques, VCI may be associated with cerebral micro-infarcts, cerebral micro-bleeds, white matter hyperintensities (i.e., small areas of the brain that light up on imaging), or other abnormalities (Figure 2). These pathologies are thought to be related to small vessel disease and also
likely are associated with hypertension. Risk factors for VCI and vascular dementia include hypertension, smoking, diabetes mellitus, and other cardiovascular and cerebrovascular disease.22–24 A growing number of cohort studies show an association between hypertension and decreased cognitive functioning.25–28 These studies have examined this association in a wide range of age groups including children, young adults, midlife adults, and older adults. For example, the Honolulu Asia Aging Study29,30 found an association between untreated hypertension in midlife and the development of dementia in later life. Other studies have shown associations between brain integrity and blood pressure in adults younger than 50 years of age.31 VCI can affect brain functioning, from simple memory loss to limitations in executive function, such as managing time and attention, planning and organizing tasks, the speed of carrying out skills, and processing speeds.32 The Atherosclerosis Risk in Communities study33 found that people with treated hypertension had less cognitive decline than those with untreated hypertension, and people with no hypertension had less cognitive decline than those with treated hypertension. The Coronary Artery Risk Development in Young Adults study,34 which followed healthy young adults 18–30 years of age for 25 years, found that greater variability in blood pressure over time beginning in young adulthood was associated with declines in memory and processing speed 25 years later. In another cohort study of 5,367 people, Rusanen and colleagues found that heavy smoking in midlife was associated with later development of VCI.35 In a literature review of 38 longitudinal studies, randomized controlled trials, and meta-analyses, Rouch et al. found significant associations and possible preventive effects between the use of antihypertensive medication and decreases in the risk of vascular dementia in most of the longitudinal studies and randomized controlled trials.36 This growing body of literature on the association between hypertension and cognitive impairment resulted in a 2011 declaration by the American Heart Association (AHA)/American Stroke Association that, “There is reasonable evidence that in the middle-aged and young-elderly, lowering blood pressure can be useful for the prevention of late-life dementia (Class IIa; Level of Evidence B, defined as a recommendation in favor of the treatment being useful and/or effective and beneficial, and supporting data [are] derived from a single randomized trial or from nonrandomized studies).”20Traditionally, controlling hypertension has been promoted as a way to prevent heart disease and stroke, but we are now able to appreciate more than
Public Health Reports / July–August 2015 / Volume 130
304 Executive Perspective
Figure 1. Million Hearts® Initiative: working together to prevent one million heart attacks and strokes through targeted clinical care, use of health-care technology, and sodium consumption reduction
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Improving Population Blood Pressure Control 305
Figure 2. Examplesa of white matter hyperintensities (shown with arrows) thought to be related to mild cognitive impairment that is likely related to hypertension
a Panel A shows a brain scan of a 45-year-old woman with white matter hyperintensities and Panel B shows a normal brain scan of a 47-year-old woman. Source: Kruit MC, Thijs RD, Ferrari MD, Launer LJ, van Buchem MA, van Dijk JG. Syncope and orthostatic intolerance increase risk of brain lesions in migraineurs and control. Neurology 2013;80:1958-65. Used with permission from Wolters Kluwer Health.
ever its role in promoting healthy brain aging along with the prevention and control of other cardiovascular risk factors. Just seven healthy habits, the AHA’s “Life’s Simple 7,”37,38 can go a long way toward being not just heart healthy, but also brain healthy: (1) managing blood pressure, (2) controlling cholesterol, (3) reducing and controlling blood sugar, (4) being physically active, (5) eating a healthy diet that is low in sodium with plenty of fruit and vegetables, (6) maintaining a healthy weight, and (7) stopping smoking or never starting smoking. For additional tips on healthy eating, visit the Million Hearts® Healthy Eating & Lifestyle Resource Center.39 With researchers learning more and more about the relationship between hypertension early in life and development of cognitive impairment or dementia in later life, there is even more reason to prevent and control hypertension at every stage of life.
The findings and conclusions in this article are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention (CDC). Mary G. George is Deputy Associate Director for Science and Senior Medical Officer, Yuling Hong is Associate Director for Science, and Barbara A. Bowman is Director, all with the Division for Heart Disease and Stroke Prevention at CDC. Address correspondence to: Mary G. George, MD, MSPH, Centers for Disease Control and Prevention, Division for Heart Disease and Stroke Prevention, 4770 Buford Hwy. NE, MS-F72, Atlanta, GA 30341; tel. 770-488-8092; e-mail .
REFERENCES 1. Kochanek KD, Murphy SL, Xu J, Arias E. Mortality in the United States, 2013. NCHS Data Brief, No. 178. Hyattsville (MD): National Center for Health Statistics (US); December 2014. 2. Murray CJL, Lopez AD. Measuring the global burden of disease. N Engl J Med 2013;369:448-57. 3. Feigin VL, Forouzanfar MH, Krishnamurthi R, Mensah GA, Connor M, Bennett DA, et al. Global and regional burden of stroke during 1990–2010: findings from the Global Burden of Disease Study 2010 [published erratum appears in Lancet 2014;383:218]. Lancet 2014;383:245-54.
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