hypertension and hipertensive heart disease in adult

7/28/2019 Hypertension and Hipertensive Heart Disease in Adult

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NATIONAL CENTER Series 11For HEALTH STATISTICS I Number 13

VITALandHEALTW.STATISTICSDATA FROM THE NATIONAL HEALTH SURVEY

Hypertension andHypertensive Heart Diseasein AdultsUnited States =1960- 1962A discussion of the criteria used for the diagnosis of hypertensionand hypertensive heart disease, with data on the prevalence ofhypertension and hypertensiveand an analysis of differentialsmarital status, usual activity,,

Washington, D.C.

U.S. DEPARTMENT OFHEALTH, EDUCATION, AND WELFARE

John W. GardnerSecretary

heart disease by age, sex, and race,by place, family income, education,

occupation, and industry.

May 1966

Public Health ServiceWil liam H. Stewart

Surgeon General


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Public Healt h Service Publication No. 1000~Series ll-No. 13

For sale by the Superintendent of Documents, U.S. Government Printing OfficeWashington, D.C., 20402 - Price 45 cents


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NATIONAL CENTER FOR HEALTH STATISTICSFORREST E. LINDER, PH. D., Director

THEODORE D. WOOLSEY, Deputy Director.., . OSWALD K. SAGEN, PH. D., ./hsirlant Director/.,. : j / .,4 WALT R. SIMMONS, M.A., Statistical Advisor, , .;;., ,3ALICE M. WATERHOUSE, M.D., Medical Advisor

JAMES E. KELLY, D.D.S., Dental AdvkorLOUIS R. STOLCIS, M.A., Executive Ojicer

DIVISION OF HEALTH EXAMINATION STATISTICSARTHUR J. MCDOWELL, Chief

IAVIA GORDON, Assistant Chief

COOPERATION OF THE BUREAU OF THE CENSUSIn accordance with specifications established by the National Health Survey, the Bureau of the Census, under a contractual agreement, participated in the design and selection ofthe sample, and carried out the first stage of the field interviewing and certain parts of the statistical processing.

Public Health Service Publication No. 1000~Series 11-No. 13Library of Congress Catalog Card Number 66-60034


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CONTENTSPage

Introduction ________________________________________------------------The Medical History -_----------------------------------------------Blood pressure Measurement------------------------------- ---------X-ray and Electrocardiogram----------------------------------------

Hypertension and HHD Diagnosis ____-__ _______ - _________________________Averaging Blood Pressures------------------------------------------Interpretation of the X-ray and Electrocardiogram---------------------Classification and Criteria -__ __ ___ ____ -___-___- _____ ____ _-____ ____-_Hypertension-------------------------------------------------------Hypertensive HeartDisease------------------------------------------Diagnosis----------------------------------------------------------Comparision With Clinical Examination-------------------------------

Hypertension ________________-_______________________-----------------Age and Sex--------------------------------------------------------Race--------------------------------------------------------------

Hypertensive Heart Disease--------------------------------------------Age---------------------------------------------------------------Sex -_--___-_-__-___________________________-----------------------Race--------------------------------------------------------------

Other DemographicVariables-------------------------------------------Residence _____________-__________________________-----------------Income and Education-----------------------------------------------Marital Status-- ----_-----------------------------------------------Usual Activity Status __c_____________________________________--------Occupation and Industry---------------------------------------------

Discussion ________________________________________-------------------Summary-------------------------------------------------------------References-----------------------------------------------------------Detailed Tables-------------------------------------------------------

7889999

101112


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CONTENTS-Con.

Appendix I. Medical History Questions Related to Cardiovascular Disease----Appendix II. ElectrocardiographicReadings------------------------------

Criteria and Classification -_______-__________ ________________________

Page313535Appendix III. Interpretation of Chest X-ray------------------------------- 37Form USed in pulmonary Reading ____________________________________ 37Form USed in Cardiovascular Reading ________________________________ 38pulmonary Readers------------------------------------------------- 39Cardiovascular Readers--------------------------------------------- 39Final Evaluation---------------------------------------------------- 40

Appendix IV. magnostic Review-----------------------------------------Appendix V. Evidence of Hypertension and Hypertensive Heart Disease-----

43Hypertension-------------------------------------------------------Hypertensive HeartDisease------------------------------------------Stroke and UrineAlbumin------------------ ---------------- ----------Urine Albumin-----------------------------------------------------

4444444545

Appendix VI. Demographic Terms--------------------------------------- 54Appen dix VII . Statis tical Notes------------------------------------------

The Survey Design--------------------------------------------------Reliability in probability Surveys ___-___ _ ___ ___ ___ _____-__-_-__- -_----Sampling and Measurement Error------------------------------------Expected Values----------------------------------------------------Small Numbers -----_-------_-_-------------------------------------Tests of Significance------------------------------------------------

58585858626262


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IN THIS REPORT findings are presented on the prevalence of hyper-tension and hypertensive heart disease (HHD) obtained from Cycle I ofthe Health .Examination Survey (HES) . Cycle I consisted of examinationsof a nationwide probability sample of persons 18-79 years of age select-ed from the U.S. civilian, noninstitutional population.This report describes the steps taken in diagnosing hypertension andHHD, presents the data collected, andcompare+ the information obtainedin this Survey with that obtained in other surveys. The relationship ofthe prevalence of hypertensionand HHD to the demographic variables ofage, race, sex, family income, education, residence, marital status,usual activity status, occupation, and industry aye examined.Definite hypertension and definite HHD weye moye prevalent in men thanin women. The rates for the Negro population weye substantially greaterthan those for the white population in bothsexes and in every agegroup.The prevalence of hypertension and HHD also varied by residence andoccupation. There was no strong pattern of prevalence associated withincome OY education, but there was an apparent trend toward a lowerprevalence with greater education, particularly for white women.

SYMBOLSData not available _______________________ _--Category notapplicable------------------ . . .Quantity zero-------------------------- _Quantity more than 0 but less than0.05---- 0.0Figure does not meet standards of

reliability or precision------------ ----- *


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HYPERTENSION ANDHYPERTENSIVEHEART DISEASE IN ADULTS

Tavia Gordon and Brian II&vine, Division of Health Examination StatisticsINTRODUCTION

The Health Examination Survey (HES) foundestimated 17.0 million adults in the United

have definite hypertension and 10.5adults to have definite hypertensive heart(HHD), in addition to those persons withor suspect forms of these diseases.

15.3 percent of U.S. adults had definiteand 9.5 percent had definite hyper-

The high prevalence of these diseases lendse importance to any evidence of varia-prevalence. This report discusses the

e of hypertension and hypertensive heartby age, race, sex, and certain otherfactors. It alsocompares the findings

this Survey with that of other surveys.This is one of a series of reports describingevaluating the plan, conduct, and findings offirst cycle of the Health Examination Survey.

in order to obtain healthon the population of the United States

use of direct examination. Between Octoberand December 1962 a series of examinationsconducted by the Survey using a probability

noninstitutionalized U.S. adults agedThe purpose of this cycle of thewas to obtain information on the

of cardiovascular diseases and certaindiseases, dental health, and the

of a number of anthropometric andAltogether, 6,672 of a

of 7,710 persons were examined. Thesepersons were given a standard examina-

tion, which lasted about 2 hours, by medical andother staff members of the Survey in speciallydesigned mobile clinics.

The descriptions of the general plan and ofthe sample population and response have beenpublished. These provide the general back-ground for all the reports of findings. Two reportson blood pressure findings have been published.3 4In these, the technique and context for bloodpressure measurement are described and someinformation on the reliability of the blood pressuremeasurement is provided. In addition, an intro-ductory report on heart disease f indings has beenpublished,5 which includes detailed information onthe cardiovascular examination and an extendedaccount of the method of evaluating the findingsrelated to heart disease and of the proceduresused in arriving at heart disease diagnoses. Inthis report, a briefer account is given of thoseparts of the examination specifically directed to-ward the diagnosis of hypertension and hyperten-sive heart disease.The Medical History

The cardiovascular examination began with aself-administered medical history which theexaminee was asked to complete. The receptionistwas available to provide the examinee with anynecessary assistance. Questions regarding car-diovascular symptoms and disease were includedand are shown in Appendix I. After the self-administered history had been completed, thereceptionist asked several additional questionsconcerning physical handicaps, major healthprob-

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lems, and operations. These questions weredesigned to elicit relevant medical informationwhich had not appeared in response to the morespecific questions on the history. The reception-ist, at the same time, reviewed the history bothfor completeness and for consistency and queriedthe examinee further where any deficiencies wereevident.The examining physician reviewed the medi-cal history before beginning the physical examina-tion. He attempted to correct any incompletenessor inconsistency remaining in the record and toarrive at a definite yes or no answer, byfurther questioning when the examinee had beenuncertain in his answer. In some cases this wasnot possible. For most of the cardiovascularquestions the physician was instructed to ask aseries of standard probe questions to obtainmore information if an answer of yes or 7

had been checked or if the examinee indicatedthat he did not know the answer. When theseprobes were completed, the physician was freeto question the examinee further until he wassatisfied that he had all the relevant informationthat could be obtained in a single session. Amongthe cardiovascular questions, one was of especialimportance for the diagnosis of hypertensive heartdisease--question 66 (Append ix I). This dealt withhigh blood pressure.Blood Pressure Measurement

Three blood pressure measurements weremade: the first just after the physician met theexaminee; the second midway in the examination,after completing the auscultation of the heart inthe sitting position; and the third at the end ofthe examination. Blood pressures were takenwhile the examinee was sitting on the examiningtable. The nurse placed the middle of the cuffover the bulge in the upper left arm. The cuffwas left on the arm between the first and secondmeasurements, removed after the second, andreturned for the third. The physician held the armat the level of the atrium, with the nurse holdingthe Baumanometer a t the physicians eye level.Using the bell of his stethoscope, the physiciannoted the pressure when *the sound was firstheard, when it first became muffled, and whenit disappeared. All three measurements were

recorded. The point at which Korotkoffs sounddisappeared was taken as the diastolic pressureIf the sounds did not disappear, the point muffling, if distinctly heard, was used. Since thBaumanometer is scaled in intervals of 2 mmmeasurements were so recorded. Some resultfrom this examination have already been reported. 3 4X-ray and Electrolcardiogram

The chest X-ray was a posterior-anteriorview taken at a distance of 6 feet and recordeon a 14 by 17 inch film. The exposure was takein inspiration but was not timed for a fixephase of the heart cycle. The electrocardiogram(ECG) was obtained by a Twin Viso machin(model 60-1300). Twelve leads were recordedI, II, III, AVR, AVL, AVF, Vl -V6HYPERTENSION AND HHD

DIAGNOSISThe progression from the blood pressurefindings of the examination to a diagnosis concerning hypertension involved an averaging of ththree blood pressures and a fixing of criteriato be used for classification of these averagpressures as regards hypertension. Severaadditional steps were involved in progressing from

examination findings to a hypertensive heardisease diagnosis. The first step was interpretingthe chest X-ray film and he electrocardiographictracing. The second was constructing a set odiagnostic criteria. The third was developing procedure for translating the findings from thexamination and the interpretation of the X-rayand electrocardiogram into specific diagnosesHow these steps were taken for the HealtExamination Survey is discussed in the followingsections.Averaging Blood Pressures

Blood pressure may vary considerably over short period of time, even under relatively standard conditions. Because of this fluctuation, iseemed reasonable to average the three bloopressure measurements obtained for each individ-ual and to use this average as the best measure

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his blood pressure. This procedure also tendedreduce the effect of reading preference for

end digits in measurements, discussed inprevious report.

of the X-ray and

Both the electrocardiogram and the chestwere interpreted independently by severalThese interpreta.tions were madeany other information about the examinee.

The electrocardiogram was read independ-by three cardiologists according to criteria

in advance. These criteria are spec-in Appendix II, which also contains a repro-

of the preceded form on which the findingsentered. For all major findings, it was

to designate an electrocardiographicoutside criteria if the reader

an abnormality which the criterianot adequately describ,e. After the forms werethe three independent determinations

Where they all agreed, the unani-was used for subsequent diagnosis.

there was any disagreement, the threemet with Dr. Michael A. Corrado, George-

Scho~~l of Medicine, who servedcoordinator for this work, and together they

a final decision. This final decision was

The evaluation of the chest X-ray was a some-more complicated undertaking. Initially,were made to have the X-rayfilms

by radiologists specializing in pulmo-disease. In addition to noting evidence of

disease, the pulmonary readers wereto record evidence of distinct cardio-

abnormality. ks had been anticipated,led to an estimate of the prevalence of

abnormalities which was muchthan is ordinarily found in cardiovascular

Another group of radiologists was there-to reexamine the films for evidencecardiovascular abnormality. These cardio-

were chosen on the basis ofset by Dr. Lloyd E. Hawes, radiologistthe Framingham Heart Study. A set of films

he Health Examination Survey were firstby Dr. Hawes and then by a number of

radiologists. Three were found to employ

about the same standards as Dr. Hawes and werechosen to read the Health Examination Surveyfilms for cardiovascular abnormalities. Eachwas given a random third of the films to read.The forms used in recording the radiologicalfindings both for the pulmonary readers and thecardiovascular readers are reproduced in Appen-dix III.

The reading procedure was designed as fol-lows. A finding of general cardiac enlargement orleft ventricular hypertrophy (LVH), definite orpossible, was considered positive. All filmswere read by two pulmonary readers and onecardiovascular reader. The determination of thetwo pulmonary readers provided a preliminaryevaluation and if both considered the film positivea decision of enlargement was made whatever thefindings of the cardiovascular reader. If theydisagreed and the cardiovascular reader con-sidered the film positive, the decision was thatenlargement was present; otherwise, a secondcardiovascular reader interpreted the film andhis decision was binding. If the two pulmonaryreaders considered the film negative, and thecardiovascular reader agreed with them, thedecision was that no enlargement was present;otherwise, a second cardiovascular reader ex-amined the film and his decision was binding.All decisions were made independently of eachother and no reconciliation of differences wasundertaken.The rationale for this procedure is too com-plicated to be discussed at this point. It is partlyexplained in Appendix III. The effect was to pro-duce reading results which conformed well, bothin the level of abnormalities found and in attribu-tions to specific individuals, with the standards ofthe Framingham Heart Study.Classification and Criteria

After extensive consultation, the Health Ex-amination Survey arrived at the following diagnos-tic categories and criteria for hypertension andhypertensive heart disease. Ultimately, thesecategories and criteria were derived from defini-tions of the New York Heart Association6 but weremodified to fit the circumstances of populationsurveys in genera17- and of the Health Exam-ination Survey in particular.

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HypertensionHypevtension.460 mm. Hg. or over systolic,

or 9.5 mm. Hg. or over diastolicBorderline hypertension.-Below 160 mm.

Hg. systolic and below 9G mm. Hg. diastolic, butnot simultaneously below both 140 and 90 mm. Hg.

Normotension .-Below both 140 mm. Hg.systolic and 90 mm. Hg. diastolic.(When aortic insufficiency was present or the heartrate was under 60, hypertension or borderline hy-pertension was defined by the diastolic pressure.)Hypertensive Heart DiseaseDefinite .- One of the following:

1. Hypertension plus left bundle branch blockor left ventricular hypertrophy by ECG.(By voltage criteria when 35 years of ageor over. If under 35 yearsleftventricularor subendocardial ischemia must be pres-ent in addition to LVH by voltage criteria.No person under 35 had hypertension orborderline hypertension with this com-bination of ECG findings.)

2. Hypertension plus LVH or general cardiacenlargement (GCE) by X-ray.

3. A history of hypertension, currently onmedication for hypertension, and LVH orGCE by X-ray and/or LVH by ECG.

Suspect.-One of the following:1. Borderline hypertension plus LVH by ECG.2. Borderline hypertension plus LVH or

GCE by X-ray.It will be noted that no allowance for treat-

ment was made in the diagnosis of hypertension,but the criteria for HHD did admit cases withoutcurrently hypertensive blood pressures providedthat they gave a history of hypertension undertreatment. The criteria were invariant for age,race, and sex except for LVH by ECG.Diagnosis

After all the findings were available, thefinal step was to arrive at a diagnosis. Even

under favorable circumstances this is a difficulprocess to standardize. In the Health ExaminationSurvey, it was more difficult than usual. Therwere 62 different physicians and to rely on theiconsistent use of the same diagnostic standardand criteria was impossible. Moreover, they dnot have the specialists judgments on the electro-cardiographic tracing or the chest X-ray. Thualthough the examining physician was requesteto enter his diagnostic impressions, these werused only as indicators; the final diagnosiwas made by the permanent staff of the Surveywith consultant help in difficult cases.The first step in this procedure was tosuppla set of rules suitable for diagnosis bycomputer,which would convert the coded information fromthe medical record and from the interpretation the X-ray film and the electrocardiogram intodiagnostic decision. An example of the computeoutput is given in Appendix IV. Some of thedecisions were then subject to review. Includein this review were:

1. Cases where the diagnosis depended on history of hypertension.

2. Cases where a significant murmur wanoted.3. Cases diagnosed as having heart disease

by the examining physician but not by thcomputer.

This omitted from review those cases withclear and definite diagnosis of heart disease on tavailable evidence and those cases where thewas no possibility of diagnosing heart diseasfrom the available evidence.

In most cases where the computer diagnosiwas reviewed, the diagnostic decision made by tcomputer was unaltered. In a few instanceshowever, there was a diagnostic change on tbasis of review. Where a review decision seemeto require a specialists judgment the case wreferred to Dr. Abraham Kagan of the FraminghamHeart Program for a final decision.Comparison With Clinical Examination

There is a distinct difference between tpurpose of the standardized single-visit examination used by the Health Examination Surve

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a clinical examination, and this leads toin diagnostic findings. A study by

Jeremiah StamlerlO found that for hypertensivedisease the two main causes of diagnostic

between a standardizedexaminationa clinical examination lay in the differences

blood pressure found at separate examinationsthe reading and interpretation of the elec-

. Interpretation of the X-ray wasas a minor factor in accounting for observedon HHD. He did find, however, that

overall results on hypertension diagnosesabout the same for both types of examinations

that somewhat fewer HHD diagnoses wereby the standardized examination.

The Health Examination Survey, however,somewhat different and less conservative

than those used in this methodologicalAvailable evidence for a sample of exam-

indicates that their personal physician wouldless likely to make a finding of hyper-than would the HES. The chief differencein the category of borderline hypertension;was used less frequently by the

physician than by the HES. Since theblood pressure reported by the personal

is similar to that found by the HES, thedifference must arise from differences

definition. It could arise, for example, if thephysician required a persistent elevation

blood pressure, perhaps sustained on repeatedto declare hypertension to beWith HHD, differences between the HES and

personal physician may well be due in part todifference in the examination (since a chest

and ECG are not a routine part of medicalthey were standard for the HES). In

case, the personal physician used the categorysuspect HHD as commonly as the HES but used

category of definite HHD substantially less

HYPERTENSIONHypertension was the most commonly encoun-

specific form of chronic disease found by themillion (a rate of 15.3 per 100

aged 18-79 years) were estimated to havehypertension, another 16.2 million (a rate

of 14.6 per 100 persons aged 18-79 years) ,wereestimated to have borderline hypertension (table1).

In the following sections the findings fordefinite hypertension are presented by age, race,and sex. The discussions on prevalence by otherdemographic variables will also be limited todefinite hypertension only.Age and Sex

With increasing age the prevalence of definitehypertension rises (table 1, fig. 1). At 18-24 years,less than 2 percent of all persons had definitehypertension while nearly 40 percent of all personsaged 75-79 years had this disease. Men aremorelikely to have definite hypertension than are womenin age groups under 50 years, whereas at olderages the relationship is reversed. This corre-sponds to the crossover point in mean bloodpressures. (Appendix V, Table II)Race

The preponderance of hypertension in theNegro population of the United States is welldocumented. At every age covered by the HES,the prevalence of definite hypertension was rough-ly twice as great for the Negro population as forthe white (table 2, fig. 1). Were the prevalence ofhypertension as high in the population as a whole asamong Negroes, 29 million American.adults wouldhave definite hypertension. The prevalence ofdefinite and borderline hypertension in the whiteand Negro populations was as follows:

White NegroNumber in thousands

Definite-----------Borderline---------

Definite----------- 14.1 26.7Borderline--------- 14.9 12.9

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0.8 1 7 I I I I I I20 30 40 50 60 70 8CAGE IN YEARS

Figure I. Percent of adults with definite hyper-tension, by age, race, and sex.

This racial difference in the prevalence ofhypertension is associated with a difference inmean blood pressures but is larger than would besuggested on the basis of mean differences alone.In other words, not only are blood pressuredistributions for Negroes displaced to the rightrelative to distributions for white persons, butthey exhibit greater skewing to the right, towardhigher values.

HYPERTENSIVE HEART DISEASEHypertensive heart disease was the most

commonly encountered specifi c form of heartdisease in American adults. Some 10.5 million(a rate of 9.5 per 100 persons aged 18-79 years)had definite HHD. Another 4.8 million (or 4.3per 100) were estimated to have suspect HHD(table 3). In the remaining discussion attentionis restricted to definite diagnoses of HHD.

Nearly 9 out of 10 adults diagnosed as havingdefinite HHD had definitely hypertensive blood

pressures on examination; the remaining casesdid not, but they did give a history of hypertensionand were under medication for it.

The more frequently encountered evidenceof heart disease was a finding of enlargement oX-ray: 86 cases in a hundred of definite HHD wereso characterized. Nearly 36 cases had ECGfindings of LVH. Thus, about one case out of fourwith X-ray evidence also had ECG evidence whilenearly two cases out of three with ECG evidencehad concurrent X-ray evidence. This subject istreated more extensively in Appendix V.Age

As with hypertension, the prevalence of HHDrose sharply with age (table 3, fig. 2).At ages18-24 years 0.3 per lOOpersons haddefinite HHD.Atages 75-79 years the rate was 31.8 per 100

The rate of increase with age was steeper.for definite HHD than for definite hypertension,indicating that the likelihood that a person withhypertension would also have heart disease in-creased with age. Restricting attention to thosepersons who had definitely hypertensive bloodpressures on examination, about 2 out of 10 hadHI-ID at ages 18-24 years, 4 out of 10 had HHD aages 45-54 years, while 7 out of 10 had HI-ID aages 75-79 years. The likelihood that the evidenceof heart disease would include an ECG finding oLVH also rose with age, as did the likelihood thatin any given case of HHD both X-ray and electro-cardiographic evidence of disease would be found.

SexWomen had a higher prevalence of definite

HHD than did men at ages over 55 years. Atyounger ages, however, the prevalence was higherfor men (table 3). The likelihood that persons witha definitely hypertensive blood pressure on exam-ination would also have HI-ID was about the same inboth sexes under age 55 but was greater for womenthan men over age 55. Men, however, were morelikely than women to have an ECG finding of LVHassociated with the diagnosis. The likelihood thata case would manifest both X-ray and ECGevidence of HHD was about the same for bothsexes.


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100.0 I I I I I I80.0 -

-, Men60.0 - mllll. Women

40.0 -

10.0 -8.0 -

?:

6.0 -: 4.0 -;

1.0 -0.8 -06 -

0.4 -

0.1 1 I I I I I20 30 40 50 60 70 81

AGE IN YEARS

Figure 2. Percent of adults with hypertensiveheart disease, by age, race, and sex.

RaceIn every age group of either sex the prevalence

of definite HHD was greater for Negroadults thanwhite (table 4, fig. 2). The rate was about threetimes as great for Negro men as white men andmore than twice as great for Negro womenas forwhite women.

These race differentials were greater thanthose for definite hypertension. As this implies,the likelihood of finding HI-ID associated withdefinite hypertension was greater in Negro than inwhite persons. What is more, the likelihood in

these cases that ECG findings of LVH would beencountered was substantially greater for Negromen than white men and greater for Negro womenthan white women. There was also a greaterlikelihood in the Negro population that a diagnosisof HHD would be supported by concurrent ECG andX-ray findings. The prevalence of HHD in the whiteand Negro populati ons was as follows:



White I NegroNumber in thousands

8,0574,019 I 2,372689Percent?I 20.86.0

OTHER DEMOGRAPHIC VARIABLESIn the discussions that follow, the population is

classified in a variety of ways; by family income,education, etc.; and the prevalence of definitehypertension or definite HI-ID in different groupsis compared. If the population is classified byin-come, for example, the prevalence of definitehypertension in different income groups is exam-ined to determine whether prevalence varies fromone group to another. These data are summarizedin tables 5-8.

In evaluating these findings allowance must bemade for the fact that there are differences fromone group to another in the distribution of peopleby age, race, and sex, and that the prevalence ofdefinite hypertension or definite HI-ID varies byage, race, and sex. Because t he sampli ng varia-bility of age-race-sex-specifi c values for eachgroup is usually very large, a summary compari-son was thought preferable to the presentation ofprevalence rates specific by age. For this reason,the actual prevalence rate for each race-sexgroup is compared with an expected rate. Theexpected value is obtained by weighting age-specific rates for t he total United States by theage distribution for the race-sex group. Theobvious meaning can be attached to differences

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between actual and expected rates, with theunderstanding that differences may arise bychance. A positive difference, for example, indi-cates that the prevalence rate for the group ishigher than expected, In general, where there is nostatistically significant difference between theactual and expected values for a group, differencesfor individual age-race-sex groups exhibit onlyrandom fluctuations.Definite hypertension is considered in thispart of the discussion but the observationsgenerally carry over to definite hypertensiveheart disease. Disagreements between differen-tials for these two disease categories are suffi-ciently uncommon to be attributable to randomvariation, although, of course, this may notalways be true. In general, differentials areweaker for definite HHD than for definite hyper-tension.Residence

Regional differences in hypertension rates(table 9) are both large and consistent for thewhite population. For all age groups the rates forwhite men and white women are higher thanexpected in the Northeast and lower than expectedin the West. The Negro population, however,presents a different picture, as the rates for

the Northeast. This is the only significant regionapattern in the Negro rates. The effect is a greatlynarrowed gap between white and Negro prevalencein the Northeast.In terms o f residence classifications, on thebasis of population density (tables lo-12), thereare only small differentials evident for the whitepopulation. These seem generally to be indis-tinguishable from random variation. Howeverfor white men but not for women there is asuggestive variation by population-size group,rates apparently increasing with population size.There are a number of residence differentialsevident for Negro men. In rural areas they havehigher than expected rates. This is more markedin rural-nonfarm areas than farm areas but isevident in both. In urban areas and especiallyin standard metropolitan statistical areas, on theother hand, the rates for Negro men are lowerthan expected (fig. 3).Income and Education

In the white population there is no clearpattern of prevalence associated with familyincome (table 13). There does appear to be a trendtoward a lower prevalence of hypertension withgreater education, however, which is especiallyNegro adults are apparently lower than expected in evident for white women (table 14).

EXCESS RATES PER 100 ADULTSPupulotion-size ,I roup 8.0 6.0 4.0 2.0 -o.o+ 2. 0 4.0 6.0 8.0 IO.0 12.0 14.0 16.0

Giant metropolitan areas . . .

Other very largemetropolitan areas . . . . . . . . . . . . . . . .

Other standard metropolitanstatistical areas . . . . . . . . .

Other urbcn areas . . . . . . . . . . . . . . . . . . . . . * . . . . .

I,,Rural areas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .t

14.1

Figure 3. Excess of actual over expected prevalence of definite hypertension in Negro men, by popula-tion-size group.8


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In the! Negro population family incomes aboveand educational attainment beyond highare relatively uncommon. Below thesethere appear to be clear differentials,higher than expected prevalences both for menwomen with family incomes of less thanor with less than 5 years of schooling. Tothese findings must be related to thedifferentials noted for Negroes, but thesample size is really too small to disentanglevarious factors.

arital StatusIn the white population, divorced men andwomen have apparently lower than

rates of hypertension. Otherwise therates by marital status arethe same as the expected rates (table5). It cannot be said that no other maritalexist, but those that do existsmall or occur in those categoriesexhibit too great a variance for the differ-to be deemed statistically significant.

Activity StatusThe actual prevalence rates by usual activityare essentially the same as the expected(table 16). Only for working Negro males is

apparent difference between the actualexpected rate, the actual rate being less thanWhatever other usual activity differ-are either small or occur in categoriestoo great a variance to be deemed

and IndustryWhite farmers and farm managers, or, inof industry, white men employed in agri-have a lower than expected prevalencehypertension, while white laborers have a higherprevalence (tables 17 and 18).and sales workers have a lower

than expected, though this is statisti-significant only for Negro women, and Negroand farm managers also have lower thanprevalence rates. Paradoxically, Negroin agricultural industries, as a whole, have a

higher than expected prevalence. Professionalpersons generally have a lower than expectedprevalence regardless of race or sex.There are a number of other differentialssuggested by the data but they are of less relia-bility.

DISCUSSIONDespite the large number of published studies

on hypertension, usable data on demographicvariables other than age, race, and sex aresurprisingly sparse. There is considerable infor-mation from mortality statistics, but it would behazardous to compare HES findings (which referlargely to mild manifestations of hypertension andhypertensive heart disease) with mortality data.Age, race, and sex differentials in blood pressurehave been discussed in previous reports. 4Two studies are of special interest because ofthe evidence they give that blood pressures inNegroes have been modified by changes in milieu.A. G. Shaper has reported that Samburu warriorsserving in the army in Kenya had higher bloodpressures than their tribal counterparts and thatthis elevation increased with length of service>lHe attributes the change in blood pressure to achange in diet. In a study by Miall et al., urbanJamaicans were found to have lower blood pres-sures than rural Jamaicans. l2 These indications

are in accord with the HES findings that the prev-alence of hypertension among U.S. Negroesvaries from one group to another.In the Framingham Study, T. R. Dawber andhis associates have noted that in the age groupSO-59 years blood pressures were lower forper-sons with more education than in the remainder ofthis age group. I1 This is in accord with the HESfindings. In a study of men 40-59 years employedby a Chicago Utility Company, J. Stamler foundthat the prevalence of hypertensioq varied withoccupation, with the highest prevalence in semi-skilled, unskilled, and service workers, and thelowest in professionals, executives, managers,and supervisors.ll HES data are not inconsistentwith these two findings. A study made of menworking for the General Electric Company inBirmingham, England, found lower blood pres-sures among men engaged in sedentary work thanin moderate to heavy work-l3 This was also noted

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in the Chicago study. On the other hand, theFramingham Study found no relationship betweenthe level of physical activity and blood pressureleveLrl The HES findings in that respect are am-bivalent: white farmers had a lower than expectedhypertension prevalence (while the prevalence forwhite laborers was higher than expected.In the reports of the blood pressure findingsof the HES, data were presented which indicatedthat the blood pressures for the American popu-lation were comparable with those reported for avariety of other populations. This was true notonly of the general level of prevalence but alsofor age and sex differentials. It was also notedthat other studies have found Negroes to havehigher blood pressures than white persons, andthat the HES findings indicate that the racialdifferential in the prevalence of high bloodpressures is greater than would be expected fromracial differences in mean blood pressures.The present report adds the information thatNegro-white differentials appeared to vary indifferent milieus. For example, the prevalence ofdefinite hypertension in the two races was muchcloser in the Northeast than in the Southor West.It was closer in giant metropolitan areas thanrural areas, and closer at incomes over $2,000than at incomes less than $2,000. These are not,of course, entirely independent variables and thesample-size of the HES is too small to separatethem statistically, but there are clear indicatorsin the data that hypertension in Negroes (andespecially for Negro men) is related to environ-ment.Among persons living in giant metropolitanareas with family incomes of $2,000 or more. thefollowing race differentials are evident in theprevalence of definite hypertension:

White NegroMen-------------------- 11.6 13.7Women _________________ 8.3 21.8

(These rates for white persons are adjusted to theage distribution of the parallel Negro group.) Inthis population there is only a trivial differencein the prevalence of definite hypertension forwhite and Negro men but the race differential for

women is, if anything, greater than that found the population as a whole. In a contrasting population group, composed of the rural Southerpopulation with incomes less than $2,000, comparable figures are:White Negro

Men-------------------- 15.4 31.5Women _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 19.5 36.7The nature of this relationship is anothequestion, however. The Northeast and the bicities, for example, have been the terminals heavy migration from rural areas and from thSouth. Are persons with hypertension less likelyto migrate than persons without hypertension?If so, would the selective factor be weaker fowhite persons than for Negroes? A similar question might be asked with respect to occupationor industry groups: what are the selective factorsinvolved and how do they differ by race? Becausof the relatively benign character of hypertensionfound ,in a general population it might be assumedthat selection would play a relatively minor rolebut this is not known at present.Similar considerations apply to the othe

demographic differentials noted. At this pointhese must be treated as indicative, bothas to thfacts and their interpretation.SUMMARY

Hypertension was the most commonly encoun-tered specific form of chronic disease found by thHES. Some 17.0 million persons were estimatedto have definite hypertension.Men were more likely to have definite hyper-tension than women in age groups under 50 years,whereas at older ages the relationship wareversed (table 19). This corresponds to thcrossover point in mean blood pressures.At every age covered by the HES the prev-alence of definite hypertension was roughlytwice as great in the Negro population as thwhite. This racial difference in the prevalence ohypertension was associated with a difference imean blood pressures but was larger than wouldbe suggested on the basis of mean differencesalone.

10


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Hypertensive heart disease was the mostencountered specific form of heartin American adults. Some 10.5 millionhad definite HHD.As with hypertension the prevalence of HHD

with age. The rate of rise withwas steeper for definite HHD than for definitethus indicating that as age in-the likelihood that a person with hyper-would have heart disease also increased.

The sex crossover point was slightly higher(table 20) and the race differentialsfor definite HHD than for definite hyper-The likelihood of finding HHD associateddefinite hypertension was greater for womenmen and for Negro than for white persons.Various other demographic variations weregeneral, these differentials were similarsomewhat weaker for definite HHD than for

Rates for hypertension and HHD were higherin the Northeast and lower thanin the West for white adults. For Negrothey were lower than expected in the North-Residential differentials were especially

evident for Negro men. In rural areas they hadhigher than expected rates, and in urban areas,especially in standard metropolitan statisticalareas, the rates for Negro men were lower thanexpected.There was no clear pattern of prevalenceassociated with family income, but there was anapparent trend to a lower prevalence with greatereducation, particularly for white women. AlsoNegro men and women with family incomes ofless than $2,000 or with less than 5 years ofschooling exhibited higher than expected prev-alence .Divorced white men and women had apparentlylower than expected prevalence.Negro males who were working also hadapparently lower than expected rates.White farmers and farm managers hadlowerthan expected prevalence, while white laborers hadhigher than expected prevalence. Negro clericaland sales workers and farmers and farm managershad lower than expected prevalence. Professionalpersons generally had a lower than expectedprevalence regardless of race or sex.

REFERENCESINational Center for Health Statistics: Plan and initial

of the Health Examination Survey. Vital and Health. PHSPub. 1000-Series l-No. 4. Public Health Serv-U.S. Government Printing Office, July 1965.2National Center for Health Statistics: Cycle I of theExamination Survey, sample and response. Vita7 andStatistics. PHS Pub. No. 1000Series ll-No. 1. Pub-Washington. U.S. Government Printing3National Center for Health Statistics: Blood pressure of

sex. Vital and Health Statistics. PHS Pub.1000Series 11-No. 4. Public Health Service. Washing-U.S. Government Printing Office, June 1964.4National Center for Health Statistics: Blood pressure of

by race and area. Vital and HeuIth Statistics. PHSNo. 1000Series ll-No. 5. Public Health Service. Wash-U.S. Government Printing Office, July 1964.5National Center for Health Statistics: Heart disease in

Vital and Health Statistics. PHS Pub. No. lOOO-Series6. Public Health Service. Washington. U.S. Govem-Printing Office, Sept. 1964.6New York Heart Association: Nomenclature and Critetiu

Diagnosis of Diseases of the Heart and Blood Vessels.York Heart Association, 1955.

National Heart Institute: Report of the Conference OF.Longitudinal Cardiovascular Studies. National Institutes ofHealth. Bethesda, Md., 1957.

8Pollack, H., and Kreuger, D. E., eds.: Epidemiology ofcardiovascular diseases-hypertension and arteriosclerosis.Supplement ta Bm. J. Pub. Health, Vol. 50, No. 10, 1960.World Health Organization: Arterial hypertension andischemic heart disease-preventive aspects. w.H.0. Tech.

Rept. Ser., 231, 1962.%.s. NationalHealthSurvey: Evaluationof a single-visitcardiovascular examination. Health Statistics. PHS Pub. NO.584-D7. Public Health Service. Washington. U.S. GovernmentPrinting Office, Dec. 1961.l%tamler, J., Stamler, R., and Pullman, T. N., eds., Epi-demiology of Hypertensive Disease-proceedings of an inter-national working conference. (To be published.)12Miall, W. E., Kass, E. H., Ling, J., and Stuart, K. L.:Factors influencing arterial pressure in the general populationin Jamaica. Brit. M. J. London. 11:497-506, Aug. 1962.13Lowe, C. R.: Arterial pressure, physique, and occupa-tion. B&t. J. Prev. G Social Med. l&115-124, 1964.14Hilbish, T. I?., and Morgan, R. H.: Cardiac mensurationby roentgenologic methods. Am. J. M. SC. 224(5):586-596, NOV.

1952.000

11


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DETAILED TABLESTable 1.

2.3.4.5.6.7.8.

9.

10.

11.

12.

13.

14.

15.

16.

17.

18.

19.20.

Prevalence of definite and borderline hypertension in men and women, by age:United States, 1960-62------------------------------------- -------------------- -Prevalence rates of definite and borderline hypertension for white and Negroadults, by age and sex: United States, 1960-62------------------------------ ----Prevalence of definite and suspect hypertensive heart disease in men and women,by age: Unit-d States, 1960-62----------------- ------------------- --------------Prevalence rates of definite and suspect hypertensive heart disease for whiteand Negro adults, by age and sex: United States, 1960-62---------------------i--Prevalence rates of definite hypertension and definite hypertensive heart dis-ease in adults,by specified residence categories and sex: United States,1960-62-Prevalence rates of definite hypertension and definite hypertensive heart dis-ease in adults, by family income, education, and sex: United States, 1960-62----Prevalence rates of definite hypertension and definite hypertensive heart dis-ease in adults, by marital status and sex: United States, 1960-62---------------Prevalence rates of definite hypertension and definite hypertensive heart dis-ease in adults, by usual activity status, occupation, industry, and sex: UnitedStat-s, 1960-62-----------------------------------------------------------------Actual and expected prevalence rates of definite hypertension and definite hy-pertensive heart disease in adults, by race, geographic region, and sex: UnitedStates, 1960-62-----------------------------------------------------------------Actual and expected prevalence rates of definite hypertension and definite hy-pertensive heart disease in adults, by race, population-size group, and sex:United States, 1960-62-------------------- -------------------- ------------------Actual and expected prevalence rates of definite hypertension and definite hy-pertensive heart disease in adults, by race, place description, and sex: UnitedStates, 1960-62-----------------------------------------------------------------Actual and expected preval'ence rates of definite hypertension and definite hy-pertensive heart disease in adults, by race, residence, and sex: United States,1960-62-------------------------------------------------------------------------Actual and expected prevalence rates of definite hypertension and definite hy-pertensive heart disease in adults, by race, family income, and sex: UnitedStates, 1960-62-----------------------------------------------------------------Actual and expected prevalence rates of definite hypertension and definite hy-pertensive heart disease in adults, by race, education, and sex: United States,1960-62-------------------------------------------------------------------------Actual and expected prevalence rates of definite hypertension and definite hy-pertensive heart disease in adults, by race, marital status, and sex: UnitedStates, 1960-62-----------------------------------------------------------------Actual and expected prevalence rates of definite hypertension and definite hy-pertensive heart disease in adults, by race, usual activity status, and sex:United States, 1960-62------------------------------------- ---------------------Actual and expected prevalence rates of definite hypertension and definite hy-pertensive heart disease in adults, by race, occupation, and sex: United States,1960-62-------------------------------------------------------------------------Actual and expected prevalence rates of definite hypertension and definite hy-pertensive heart disease in adults, by race, industry, and sex: United States,1960-62-------------------------------------------------------------------------Definite hypertension in adults, by sex and 5-year age groups: United States,1960-62-------------------------------------------------------------------------Definite hypertensive heart disease in adults, by sex and 5-year age groups:United Stat-s, 1960-62------------------------------------- ---------------------

Pag

2

2

2

2

2

2

2

2

233

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Prevalence of definite and borderline hypertension in men and women,United States, 1960-62 by age:

Age

Total, 18-79 years----------- 17.008 7,462 9,547 16,182 9.076 7,106years------------------------ 219 121 98 894 779 116years------------------------ 840 489 352 1,592 1,228 364years------------------------ 2,578 1,535 1,044 2,720 1,615 1,106years------------------------ 3,754 1,833 1,921 3,393 1,777 1,616years------------------------ 4,207 1,674 2,532 4,054 2,064 1,990years------------------------ 4,297 1,347 2,949 2,739 1,233 1,507

75-79 years------------------------ 1,114 463 651 789 381 408

Total, 18-79 years----------- 15.318-24 years------------------------ 1.4

years------------------------ 3.9years------------------------ 10.9years------------------------ 18.2years------------------------ 26.9years------------------------ 38.5

38.8

HypertensionDefinite Borderline

Bothsexes Men Women Bothsexes Men Women

Number of adults in specified group in thousands

Percent of specified group14.11 16.4

1.23.18.5

18.231.247.645.1

14.6 17.25.7 10.97.4 11.9

11.5 14.216.5 17.725.9 27.524.5 24.827.5 26.7

12.21.43.29.0

15.324.524.328.3

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Table 2. Prevalence rates of definite and borderline hypertension for white and Negro adults, byage and sex: United States, 1960-62

Hypertension and age

DefiniteTotal, 18-79 years------------ ----------- -

18-24 years-------------------------------------25-34 years-------------------------------------35-44 years-------------------------------------45-54 years-------------------------------------55-64 years-------------------------------------65-74 years-------------------------------------75-79 years-------------------------------------

BorderlineTotal, 18-79 years------------ ---------- --


-

i

Men WomenWhite Negro White Negro

12.8 26.7 15.2 26.61.7 1.9 0.4 3.43.6 12.5 2.3 8.6

11.8 26.5 6.2 25.716.5 30.9 15.5 41.320.2 44.6 3006 37.925.0 52.7 46.6 64.130.3 59.8 44.1 69.5

17.7 14.9 12.3 11.211.6 7.3 1.611.7 15.4 3.414.9 10.4 8.317.3 23.1 15.428.4 21.7 24.426.6 2.6 24.827.1 21.4 27.3

Percent of specified group

1.612.314.627.120.830.5


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Prevalence of definite and suspect hypertensive heart disease in men and women, by age:United States, 1960-62

Age

Total, 18-79 years-----------

years------------------------years------------------------years------------------------years------------------------years------------------------

Total, 18-79 years-----------years------------------------years------------------------years------------------------

years------------------------years------------------------years------------------------

Hypertensive heart diseaseDefinite Suspect

Number of adults in specified group in thousands10,499

44280

1,1031,9692,8053,384

913

0.31.34.79.6

17.930.331.8

1,025941351

6,44915

134516998

1,7802,443

562

106247617906

1,3191,160

405Percent of specified group

2,716106175481502589635230

7.77 .41.45.29.7

13.618.924.6

11.10.21.24.29.5

21.939.539.0

0.71.12.64.48.4

10.414.l

5.11.51.74.25.07.8

12.816.1

2,043

72136405730525175

3.5

0.61.13.89.08.5

12.1

15


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Table 4. Prevalence rates of definite and suspect hypertensive heart disease for white and Negroadults, by age and sex: United States, 1960-62

Hypertensive heart disease and age

Definite

IIMen Women

White Negro White Negro

Percent of specified groupTotal, la-79 years-------------------- ---- 6;5


Suspect

0.21.14.07.7

11.716.324.0

19.1lt.95.2

15.224.433.150.232.3

9.8 22.2

0.72.76.8

19.537.537.1

1.64.7

14.031.546.466.469.5

Total, la-79 years-------------------- ---- 5.0 7.6 3.3 4.718-24 years-------------------------------------25-34 years-------------------------------------35-44 years-------------------------------------45-54 years-------------------------------------55-64 years-------------------------------------65-74 years-------------------------------------75-79 years-.------------------------------------

1.51.24.04.37.3

13.815.7

1.57.36.2

10.513.8

-

21.4

0.70.83.4a.58.4

10.7

3.65.9

15.010.314.2


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Prevalence rates of definite hypertension and definite hypertensive heart disease inadults, by specified residence categories and sex: United States, 1960-62

Residence categories

Region Percent of specified group17.1 15.8 18.2 10.0 8.0 11.816.0 15.7 16.3 10.8 8.7 12.512.9 11.4 14.4 7.8 6.7 9.0

Population-size groupmetropolitan areas-----------

metropolitan areas----------------standard metropolitanstatistical areas-----------------

15.8 14.4 17.1 9.6 6.9 i2.015.5 13.9 16.8 8.7 6.8 10.214.1 12.4 15.6 8.8 6.5 10.913.4 13.3 13.5 8.4 7.6 9.217.7 16.8 18.6 l.1.6 10.7 12.5

Place descriptionMSA-in central city--------------MSA-outside central city---------

15.6 14.0 16.9 10.415.0 13.2 16.6 8.013.4 14.0 12.9 8.216.7 15.5 18.3 12.116.9 16.0 17.5 10.6

7.95.97.9

11.99.0*

12.410.1

8.412.412.2

Place15.4 14.315.2 13.9

J-

16.316.5

9.5 7.8 11.09.3 7.5 11.2

Definite hypertension Definite hypertensiveheart diseaseBothsexes Men Women Bothsexes Men Women

NOTE: See tables 9-12 for effect of age and racial differences among these various groups.

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Table 6. Prevalence rates of definite hypertensionadults, and definite hypertensive heart disease inby family income, education, and sex: United States, 1960-62

Income and education

Income Percent of specified groupUnder $2,000----------------------- 26.2 20.5 30.4 19.7 14.5 23.5$2,000-$3,ggg---------------------- 16.4 15.4 17.3 9.8 7.5 11.4$4,000-$6,999---------------------- 11.8 12.8 10.7 6.7 6.6 6.8$7,ooo-$g,ggg---------------------- 11.2 10.4 12.0 4.3 3.2 5.4$lO,OO~--------------------------- 11.8 11.8 11.8 7.9 7.9 8.0Unknown---------------------------- 18.7 17.9 19.4 11.9 9.4 13.8

EducationUnder 5 years---------------------- 32.7 29.6 35.7 25.3 20.7 29.65-8 years-------------------------- 22.5 17.8 27.1 14.5 10.2 18.8g-12 years------------------------- 11.1 11.3 10.9 6.0 5.3 6.513+ years-------------------------- 9.6 9.5 9.6 5.4 4.7 6.1

-I

efinite hypertension IDefinite hypertensiveheart disease

Bothsexes Men Women Bothsexes Men Women

NOTE: See tables 13 and 14 for effectof age and racial differences among these various groups.

Table 7. Prevalence rates of definite hypertension and definite hypertensive heart disease inadults, by marital status and sex: United States, 1960-62I II Definite hypertension I Definite hypertensiveheart diseaseMarital status

Bothsexes Men Women Bothsexes MfnPercent of specified group

Married---------------------------- 14.2 14.2 14.130.7 36.716.3 13.527.5 18.4

8.6 8.9

8.2 7.519.713.2

7.75.4

8.9Widowed---------------------------- 35.7Divorced--------------------------- 14.6Separated-------------------------- 22.4Never married---------------------- 8.7

29.49.1

14.34.8

NOTE: See table 15 for effect of age and racial differences among these various groups.

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Prevalence rates of definite hypertension and definite hypertensive heart disease inadults, by usual activity status, occupation, industry, and sex: United States, 1960-62

Usual activity status, occupation, and industryBothsexes Men Both'Omen sexes Men Women

Usual activity status Percent of specified group12.5 13.0 12.8 6.7 6.Z 7.118.1 * 18.4 13.3 9 13.227.: 25.8 * 18.5 17.1 *

or unknown------------- -------------- --------- 10-t 12.3 8.2 6.2 7.1 4.5Occupation

technical, and managerial------------ - 9.E 10.1 9.3 5.5 6.C 4.3and farm managers--------------------------- 12.: 12.8 * 7.9 8.1 *

and sales workers----------------- --------- Il.6 14.7 9.6 4.3 4.4 4.2and kindred workers------------- 10.i 10.5 * 4.8 5.c *

and kindred workers-------------- --------- 12.4 12.6 11.9 5.5 5.8 5.0household and service workers----------- ---- 18.6 19.2 18.3 13.9 13.8 13.9

and other laborers (except mine)----------- ---- 19.4 19.9 * 11.2 11.c *Industry

forestry, and fisheries----------------and construction-----------------------------

communication, and other publicand retail trade--------------------------

and real estate---------------- -and miscellaneous------------- ------------ --

15.716.811.111.412.614.012.9

9.8

15.017.011.2

11.313.111.913.710.9

19.2*

10.9*

12.016.812.4

*

11.0 10.0 15.98.9 9.3 *5.1 5.7 3.45.1 5.6 *5.9 5.8 6.05.1 2.9 7.98.4 7.8 8.85.0 4.9 *

L

Definitehypertension Definite hyperten-sive heart disease

NOTE: See tab&s 16-18 for effect of age and racial differences among the various groups.

19


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Table 9. Actual and expected prevalence rates of definite hypertension and definite hypertensiveheart disease in adults, by race, geographic region, and sex: United States, 1960-62

Race and region

DEFINITE HYPERTENSIONWhite

Northeast---------------South-------------------West--------------------

NegroNortheast- _---- - ----- ---South-------------------West--------------------

DEFINITE HYPERTENSIVEHEART DISEASEWhite

Northeast---------------South-------------------west--------------------

NegroNortheast---------------South-------------------west--------------------

-I

Men WomenActual Expected Difference Actual Expected Difference

15.5 12.7 2.8 18.0 15.6 2.12.7 12.2 0.5 12.9 14.1 -1.310.1 13.2 -3.1 14.3 16.0 -1.7

21.1 26.0 -4.9 21.6 25.3 -3.727.4 27.2 0.2 30.3 28.1 2.30.8 26.4 4.5 22.5 23.8 -1.3

7.7 6.4 1.3 11.6 10.2 1.5.5 6.0 -0.5 9.1 8.8 0.5.9 6.9 -1.0 8.5 10.2 -1.7

13.8 18.4 -4.6 14.8 20.1 -5.321.1 19.6 1.5 26.6 24.0 2.19.6 18.6 1.0 19.2 19.6 -0.4


20


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10. Actual and expected prevalence rates of definite hypertension and definite hyperten-sive heart disease in adults, by race, population-size group, and sex: United States, 1960-62

Race and population-size group

DEFINITE HYPERTENSIONWhyh Percent of specified group

metropolitan areas-------------very large metropolitan areas--standard metropolitan statis-tical areas-------------------------

Negrometropolitan areas-------------very large metropolitan areas--standard metropolitan statis-tical areas-------------------------

DEFINITE 'HYPERTENSIVE HEART DISEASEWhite

metropolitan areas-------------very large metropolitan areas--standard metropolitan statis-tical areas-------------------------urban areas--------------------

Negrometropolitan areas-------------very large metropolitan areas--standard metropolitan statis-tical areas-------------------------urban areas-------- ------__-_ --

l


14.1 13.3 1.1 16.t 16.2 0.413.1 12.7 0.8 16.: 15.0 1.211.; 12.1 -0.4 14.: 14.7 -0.31l.f 12.2 -0.8 12.c 13.9 -1.912.E 13.5 -0.7 17.: 16.8 0.7

15.i 23.7 -8.0 23.C 23.9 -0.918.b 23.7 -5.2 23.1 26.7 -3.721.: 29.1 -7.6 32.5 28.8 4.126.i 28.4 -1.7 24.C 26.2 -2.241.6 27.5 14.1 30.5 28.4 2.5

7.0 6.9 0.1 11.4 10.5 0.95.9 6.4 -0.5 9.4 9.4 0.0

5.9 6.0 -0.1 9.4 9.3 0.15.4 6.1 -0.7 7.1 8.7 -1.68.2 7.1 1.1 11.2 11.0 0.2

7.3 16.1 -8.8 17.4 18.0 -0.615.9 17.0 -1.1 17.4 22.1 -4.716.6 20.4 -3.8 31.2 25.5 5.722.5 20.6 1.9 23.2 22.0 1.228.1 20.1 8.0 23.3 24.6 -1.3

21


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Table 11. Actual and expected prevalence rates of definite hypertension and definite hypertensiveheart disease in adults, by race, place description, and sex: United States, 1960-62

Race and place descriptionMen Women

Actual Expected Difference Actual Expected Difference

DEFINITE HYPERTENSIONWhite Percent of specified group

SMSA-in central city--------------- 13.2 13.3 -0.2 15.5 16.5 -1.0SMSA-outside central city----------- 13.2 12.2 1.0 16.2 14.3 1.9Urban, not SMSA---------------- ----mm 12.0 11.8 0.2 11.8 14.3 -2.5Rural, farm-------------------------- 13.4 15.4 -2.0 18.8 16.6 2.2Rural, nonfarm----------------------- 11.6 13.1 -1.5 15.7 15.9 -0.2

SMSA-in central city----------------

SMSA-outside central city-----------Urban, not SMSA----------------------Ru,--1, farm--------------------------Rural, nonfarm-----------------------

DEFINITEHYPERTENSIVE-lEART DISSASE

WhiteSMSA-in central city---------------- 7.1 7.1 0.0 10.9 10.8 0.1SMSA-outside central city----------- 5.7 5.9 -0.2 9.5 9.0 0.5Urban, not SMSA---------------------- 6.3 5.7 0.6 6.7 8.9 -2.2Rural, farm-------------------------- 10.6 8.3 2.3 13.3 10.4 2.9Rural, nonfarm----------------------- 5.8 6.9 -1.; 10.4 10.5 -0.1

NegroSMSA-in central city-------- --------SMSA-outside central city-----------Urban, not SMSA----------------------Rural, farm--------------------------Ru,-al, nonfarm-----------------------

18.9 26.1 -7.3 24.7 26.1 -1.413.6 22.2 -8.6 32.6 25.8 6.734.6 30.1 4.6 23.0 25.6 -2.731.4 25.2 6.2 22.7 23.8 -1.141.3 28.5 12.7 34.9 31.1 3.8

13.0 18.4 -5.4 21.2 21.5 -0.310.7 14.4 -3.7 27.2 18.7 8.525.2 22.2 3.0 22.6 22.5 0.124.5 17.5 7.0 13.5 19.7 -6.228.8 21.4 7.4 27.0 27.2 -0.2

22


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12. Actual and expecisd prevalence rates of definite hypertension and definite hypertensiveheart disease in adults, by race, residence, and sex: United States, 1960-62

Race and residence

DEFINITE HYPERTENSIONm Percent of specified group

Negro

DEFINITEHYPERTENSIVE HEART DISEASEWhite

Negro


13.5 12.8 0.7 15.3 15.7 -0.411.4 12.8 -1.4 15.3 14.5 0.8

21.1 26.4 -5.3 24.8 26.1 -1.237.4 27.2 10.2 31.1 28.0 3.1

7.0 6.5 0.5 9.7 10.1 -0.45.6 6.5 -0.9 10.1 9.1 1.0

15.3 18.6 -3.3 22.1 21.5 0.626.3 19.9 6.4 22.5 23.9 -1.4

23


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Table 13. Actual and expected prevalence rates of definite hypertension and definite hypertensiveheart disease in adults, by race, family income, and sex: United States, 1960-62

Race and family income


Under $z,OOO-------------------------$2,000-$3,ggg --_---------------------$4,oOO-$6,999------------------------$7,000-$9,999------------------------$.10,000+ ---_-_--_--------------------Unknown------------------------------

NegroUnder $z,OOO------------------------- 37.1 29.8 7.3$2,000-$3,999------------------------ 21.6 26.9 -5.4$4,000-$6,999------------------------ 20.3 23.7 -3.4$7,000-$9,999------------------------ 5.4 19.2 -13.8$10,000+ ----------------------------- 26.6 20.0 6.5Unknown --_---_--------_-------------- 35.3 28.3 7.0

DEFINITEHYPERTENSIVE HEART DISEASE

Under $2,000------------------------- 10.9 11.4 -0.5 22.5 18.7 3.8$2,OOOi$3,999 ---_--------_-_-_------- 6.7 7.5 -0.8 10.7 11.0 -0.3$4,000-$6,999------------------------ 6.0 5.3 0.7 6~0 6.7 -0.7$7,000-$9,999------------------------ 3.2 5.0 -1.8 5.1 7.2 -2.1$1O,Ol)o+ ---------------_------------- 7.7 6.3 1.4 8.1 8.0 0.1Unknown -_-_------_------------------- 7.4 6.9 0.5 13.0 12.0 1.0

NegroUnder $2,000------------------------. 30.1 21.9 8.2$2,000-$3,999-----------------------. 12.4 19.0 -6.6$4;000-$6,999------------------------ 13,8 16.0 -2.2$7,000-$9,999----~------------------. 5.4 12.3 -6.9$10,000+ ----------------------------- 26.6 14.7 11.9Unknown------------------------------ 22.5 21.6 0.9

Men WomenRctual Expected Difference Actual Expected Difference

Percent of specified group16.7 18.3 -1.6 30.3 25.5 4.913.9 13.5 0.4 16.3 17.0 -0.712.2 11.2 1.0 10.3 11.5 -1.210.6 11.1 -0.5 11.5 12.1 -0,711.6 13.2 -1.6 11.9 13.5 -1.614.6 13.2 1.4 20.1 18.4 1.7

34.824.719.122.116.6

30.5 4.322.9 1.925.0 -6.022.5 -0.4

5.6 -5.628.0 -11.4

29.715.620.510.820.5

27.0 2.716.8 -1.219.7 0.817.2 -6.4

2.9 -2.924.8 -4.3

24


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Table 14. Actual and expected prevalence rates of definite hypertension and definite hypertensiveheart disease in adults, by race, education, and sex: United States, 1960-62

Race*and education


Under 5 years------------------------ 26.9 19.6 7.3 36.5 28.2 8.35-8 years---------------------------- 16.1 16.9 -0.7 26.4 23.0 3.49-12 years--------------------------- 10.7 10.5 0.1 10.3 11.4 -1.113+ years---------------------------- 9.3 10.3 -0.9 9.5 12.7 -3.3

Under 5 years------------------------ 42.9 37.7 5.2 46.3 41.45-8 years---------------------------- 27.8 29.9 -2.1 33.3 34.39-12 years--------------------------- 18.3 18.4 -0.1 17.1 17.113+ years---------------------------- 15.5 22.5 -7.0 14.9 20.2


Under 5 years------------------------ 16.3 11.9 4.4 25.7 20.75-8 years---------------------------- 8.7 9.5 -0.8 17.5 15.89-12 years--------------------------- 4.9 4.8 0.1 6.1 6.813+ years---------------------------- 4.7 4.8 -0.1 6.4 7.7

NegroUnder 5 years-----------------------5-8 years---------------------------9-12 years--------------------------13+ years---------------------------

,, L

Men WomenActual1 Expected1 Difference1 Actual1 Expected Difference

36.2 29.0 7.2 49.8 38.720.3 21;5 -1.2 26.8 29.110.2 12.1 -1.9 11.5 11.5

8.7 15.9 -7.2 3.2 14.3

4.9-1.0

0.0-5.3

5.01.7

-0.7-1.3

11.1-2.3

0.0-11.1

25


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Table 15. Actual and expected prevalence rates of definite hypertension and definite hypertensiveheart disease in adults, by race, marital status, and sex: United States, 1960-62

Race and marital status


Married------------------------------ 13.0 13.4 -0.4 13.0 13.1 -0.1Widowed------------------------------ 25.4 24.2 1.2 35.8 35.9 -0.1Divorced----------------------------- 10.6 15.0 -4.3 12.1 17.2 -5.1Separated---------------------------- 22.6 13.1 9.5 19.0 12.4 6.Never married------------------------ 9.1 6.9 2.2 8.9 7.5 1.4

NegroMarried------------------------------ 28.1 29.2 -1.2 27.5 25.5 2.Widowed------------------------------ 63.6 44.5 19.2 46.4 47.5 -1.2Divorced---------------------------- 40.2 31.2 9.0 18.3 27.5 -9.2Separated---------------------------- 31.7 30.6 1.1 17.3 19.5 -2.3Never married------------------------ 7.1 10.5 -3.3 10.7 12.5 -1.7


WhiteMarried------------------------------Widowed------------------------------Divorced-----------------------------

Separated ----------_------_-_--------Never married------------------------

NegroMarried------------------------------ 20.6 21.0 -0.4 21.4 20.4Widowed------------------------------ 63.6 31.2 32.4 50.1 47.1Divorced----------------------------- 4002 22.3 17.9 8.9 19.2Separated---------------------------- 9.6 22.1 -12.5 17.1 13.8Never married------------------------ 3.1 7.0 -309 5.6 9.5

MenActual Expected Difference

604 6.7 -0.3 7.7 7.812.6 16.1 -3.5 26.9 2609

6.6 8.2 -1.6 9.5 10.56.1 6.7 -0.6 12.6 6.85.9 3.1 2.8 4.8 4.4

WozenActual Expected Difference

-0.10.

-1.05.0.

1.3.

-10.33.

-3.9

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Table 16. Actual and expected prevalence rates of definite hypertension and definite hypertensiveheart disease in adults, by race, usual activity status, and sex: United States, 1960-62

Race and usual activity status


Usually working---------------------- 12.0 11.7 0.4 11.4 13.1 -1.8Keeping house------------------------ * * * 17.4 16.6 0.7Retired------------------------------ 23.2 25.4 -2.2 * * *Other or unknown----------------- ---- 7.2 8.2 -1.0 8.3 6.7 1.6

NegroUsually working---------------------- 21.6 25.4 -3.8 22.5Keeping house------------------------ * * * 30.2Retired------------------------------ 59.8 51.9 7.9 *Other or unknown----------------- ---- 37.7 22.2 15.5 11.6

24.328.7

*12.6

-1.91.6

*-1.0


Usually working---------------------- 5.8 5.4Keeping house------------------------ * *Retired------------------------------ 14.7 17.4Other or unknown----------------- ---- 3.5 4.2

7.41 1.0

*

4

0.4 5.9* 11.8

-2.7 *-0.7 4.7 4.3

-1.50.8

*0.4

NegroUsually working---------------------- 14.9 17.4 -2.5 14.5 18.3 -3.8Keeping house------------------------ * * * 28.0 25.2 2.8Retired------------------------------ 49.2 42.6 6.6 * * *Other or unknown----------------- ---- 26.7 17.0 9.7 4.4 10.5 -6.1

Men I WomenActual Expected Difference Actual Expected Difference

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Table 17. Actual and expected prevalence rates of definite hypertension and definite hypertensiveheart disease in adults, by race, occupation, and sex: United States, 1960-62Men I WomenRace and occupation


Professional, technical, andmanagerial--------------------------Farmers and farm managers----------- -Clerical and sales workers-----------Craftsmen, foremen, and kindredworkers-----------------------------Operatives and kindred workers-------Private household and serviceworkers-----------------------------Farm and other laborers(except mine)-----------------------Negro

Professional, technical, andmanagerial---------:----------------Farmers and farm managers----------- -Clerical and sales workers-----------Craftsmen, 'foremen, and kindredworkers-----------------------------Operatives and.kindred workers-------Private household and serviceworkers-----------------------------Farm and other laborers(except mine)-----------------------DEFINITEHYPERTENSIVE HEART DISEASE

Professional, technical, andmanagerial--------------------------Farmers and farm managers----------- -Clerical and sales workers-----------Craftsmen, foremen, and kindredworkers-----------------------------Operatives and kindred workers-------Private household and serviceworkers-----------------------------Farm and other laborers(except mine)---2-------------------Negro

Professional, technical, andmanagerial--------------------------Farmers and farm managers----------- -Clerical and sales workers-----------Craftsmen, foremen, and kindredworkers-----------------------------Operatives and kindred workers-------Private household and serviceworkers-----------------------------Farm and other laborers(except mine)-----------------------

Actual Expected Difference Actual Expected Difference

10.1 12.110.9 16.814.8 11.410.0 11.710.3 9.417.6 12.314.4 10.0

14.2 30.127.0 31.24.4 10.716.4 24.027.1 23.727.4 25.730.1 27.2

2::4.44.83.7

11.16.9

2:513$26.35.0

19.:4.42::;27.418.7

20.8 -20.824.2 -4.75.9 -1.515.6 -6.915.7 5.119.2 8.219.7 -1.0


-2.0-5.93.5-1.70.9

5.34.4

-15.9-4.2-6.3-7.73.4

1.72.9

-;*;-0:9-0.9-0.44.81.9

8.6 11.3 -2.79.; 8.: 1.:

11.; 11.;: 0.;16.1 14.8 1.2

* *

17.8 19.2 -1.45.: 17.1: -11.;

15.; 18.: -2.;23.9 22.5 1.4

* *

4.4 5.64.; 4.;4.; 5.::

11.0 7.8* >k

-1.2

-1.:3.2

3.1*

10,:20.5

*

10.3 -7.210.; -10.;

8.; 1.:18.1 2.4

*

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Table 18. Actual and expected prevalence rates of definite hypertension and definite hypertensiveheart disease in adults, by race, industry, and sex: United States, 1960-62

Race and industryWomen

Expected Difference


Agriculture, forestry, and fisheries-Mining and construction--------------Manufacturing------------------------Transportation, communication, andother public utilities--------------Wholesale and retail trade-----------Finance, insurance, and real estate--Service and miscellanecus---------- --Government---------------------------

Negro .Agriculture, forestry, and fisheries-Mining and construction--------------Manufacturing------------------------Transportation, communication, andother public utilities--------------Wholesale and retail trade-----------Finance, insurance, and real estate--Service and miscellaneous------------Government---------------------------


Agriculture, forestry, and fisheries-Mining and construction--------------Manufacturing------------------------Transportation, communication, andotner public utilities--------------Wholesale and retail trade-----------Finance, insurance, and real estate--Service and miscellaneous------------Government--------------------------.Negro

Agriculture, forestry, and fisheries.Mining and construction--------------Manufacturing-----------------------.Transportation, communication, andother public utilities-------------.Wholesale and retail trade-----------Finance, insurance, and real estate--Service and miscellaneous--------- --~Government--------------------------.

1:-z91710.613.412.311.912.0

14.511.710.911.011.412.011.910.8

35.931.626.819.88.131.;

26.528.625.425.120.59.325.824.2

2:4:25.95.72:514

go;5:1

27.6 19.814.4 20.122.6 17.27::

25.i18.513.51i.i15:s

-4.6-::z

3.;1:4-5.3-12.4-9.3

-2221

-1.6-2;

0.7-go;0:10.6

-;*;514-15.2-5.4-4.1-1k8'

15.711.:10.;15.810.5*

10.89.:

10.;1;:: *

4.81.;-0.:6.0-2.1*

23.3 20.311.; 20.:32.: 19.:100.0 33.119.8 21.7* *

3.1-9.:

*12.566.9-1.9*

13.43.:4.;6.77.2*

5.64.;

*Ei6:4*

7.8-1.:-0.:

ii:"s*

18.9 17.3 1.64.: 10.; -5.;

23.:: 13.;100.0 27.715.1 16.6* *

*7X-1:s *

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Table 19. Definite hypertension in adults, by sex and 5-year age groups: United States, 1960-62Age

18-24 years -_------------_-------------------------------------------------- 1.7 1.225-29 years --------------_-_----------------------------------------- ---m-m- 1.9 1.730-34.years --------------__-_---------------------------------------- ---e--m 7.0 4.635-39 years ,,,,,,,,,,,,,,,,,,,,,---------,L,,------------------------- 14.2 6.740-44 years----------------------------------------------------------------- 12.8 10.545 -49 years -------------_--------------------------------------------------- 18.4 16.650-54 years ----------------------------------------------------------------- 18.1 20.255-59 years----------------------------------------------------------------- 19.0 27.460-64 years -_------------_------------------------------------------- ------s 25.9 35.965-69 years --_--_------_-_----_-----------"--------------------------------- 21.6 42.470-74 years -----_----------------------------------------------------------- 34.4 54.775-79 years --_--_---------_------------------------------------------------- 32.4 45.1

Table 20. Definite hypertensive heart disease in adults, by sex and 5-yearStates, 1960-62 age groups: United

Age 1 Womenen

18-24 years-----------------------------------------------------------------25-29 years --------------_--_______________________-------------------------30-34 years -------------_____--____________________-------------------------35-39 years _--_--------------______________________-------------------------40-44 years ---_----_-___--_---_---------------------------------------------45-49 years---------------------------------------'--------------------------50-54 years-----------------------------------------------------------------55-59 years ---------------__-__---------------------------------------------60-64 years-------------------------------------------------~---------------65-69 years-----------------------------------------------------------------70-74 years --_--------_----_--_---------------------------------------------75-79 years ---_-----_---_-----_---------------------------------------------

( Women,

Percent ofspecified group

Percent ofspecified group0.4

2.54.65.78.1

11.5a.7

19.216.622.124.6

0.20.51.92.56.18.9

10.216.528.636.743.239.0

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APPENDIX IMEDICAL HISTORY QUESTIONS RELATED TO CARDIOVASCULAR DISEASE

(Excerpts From HES-204, Medical History-Self Adminisiered)

1. a. In the past few years have you had any headaches?If YES b. How often?

c. Do they bother you

2. a. In the past few years have you had any nosebleeds? pq pq j?JIf YES b. How often? Every few days IjTiGEq

c. Do they bother you 'm, just a little

3. a. At any time over the past few years, have you ever noticed rinqinoin your ears or have you been bothered by other funny noisesIn your ears? ]yEs pitq p1

If YES b. How often? 1 Every few days [C. Do they bother you v]

4. a. Have you ever had spells of dizziness? F'rES pi-q 171If YES b. How often? ]pTGiJ

c. Do they bother you just a little

5. Have you ever fainted or blacked out?

6. a. Have you ever had a stroke?If YES b. Have you had a stroke in the past 12 months?

c. Have you ever seen a doctor about it?

7. Has any part of your body ever been

9. Has there anytime in your life whenthroats?

paralyzed?you had a .lot of bad sore

16. a. Have you ever been bothered by shortness of breath when climbingstairs? lVEsl j7Yq pJIf YES b. How often? Almost everytime 1-1

C. Does it bother you 1-1 pLzT-mx]

Probes A,B

Probe A

Probes A.E

Probe A

Probes A.D

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Probe A

Probe A

Probes A,B

17. a.

18. a.

19. a.

20. a.

21. a.

Have you ever been bothered by shortness of breath when doingphysical work or exercising? pqpiq?-]If YES b. How often? Almost everytime 1 piE7q

c. Does it bother you quite a bit 1 /just a little 1

Have you ever been bothered bydoing physical work or exercisIf YES b. How often?

c. Does it bother you

Have you ever been bothered by shortness of breath when you areexcited or upset about something? pq pz-p--1

Almost everytime ]p-ziqf YES b. How often?c. Does it bother

Have you ever waked up atbreath?

you lquitel just a little 1

night because you were short of

If YES b. How often?c. Does it bother

Every few nights 1you lquitel

~piq-q~[Ijust a little 1

shortness of breath when you were noting? El

In the past few years, have you ever had any pain,or tightness in your chest?

discomfort,(YESI(NOI/?J

IF YES. please answer questions b through j below.b. How often?c. Does it bother youd. Where does it bother you? (Check every place it bothers you.]I Front pzq pzJzT%q fiiiaiq l--EXGJ

Somewhere else 1 State wheree. Does it usually stay in one place 1 ITaroundf. Hoti long does the pain usually last?

Just a few minutes

q. Does it usually come When you take a lot of exercise orwhen you are quiet oris there, no difference

h. Does it usually come when you are upset ordoesn't this make any difference I

j. Do you take any pills or medicine for it? (j-iq~]

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22. a. In the past few years, have you ever had any pain, discomfort,or trouble in or around your heart? pqpii7jp-j

b. How often? Every feN days 1 ]-oftenc. Does it bother you h, just a little Id. Where does it bother you? (Ch ec every place it bothers you.)m l-G-1 IRight -1 j.Txzq

Somewhere else State where Ie. Does it usually 1 stay in one place 1 piiGzqaround'f. How long does the pain usually last?

Just a few minutes 1 1 Few minutes to an hour 1 I More than an hourp. Does it usually come When you take a lot of exercise or

Probes A.B

when you are quiet oris there no difference

h. Does it usually come when you are upset ordoesn't this make any difference I,

j. Do you take any pills or medicine for it? pEsJ

23. a.

24. a.

25. a.

26. a.

62. a.

Sometimes, our heartsor beating real fast,noticed your heart doIf YES b. How often?

"act funny" (odd) like missi ng a beat,or seem to turn over. Have you everanything like that? pJ

Every few days [ rGFxqC. Does it bother you -1 just a little

Have you ever been bothered by your heart beating hard? /=Tgicq~IIf YES b. How often?

c. Does this bother you -1

Are your ankles ever swollen at bedtime? f-?iq piiq 171If YES b. Is the swelling gone by morning? pi5-l IlFl

When you walk, do you have pains or cramps in your legs? pEJ pC!JT-1If YES b. How often? Every few days (1

c. Does it bother you 1-1 just a littleHas a doctor ever said you Clad rheumatic fever (inflammatoryrheumatism) pE-pqIf YES b. Have you had it in the past 12 months? piq-q)I?l

c. Are you taking any pills or medicine for it? pTq pi6-1

Probes A,B

Probes A,B

Probe A

Probe A

If YES d. What is it?

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63. Has a doctor ever said you had chorea or St. Vitus' Dance? jT5-l~

Probe C

Probe C

Probe C

65.. a. Has a doctor ever told you that you have hardening of thearteries? p-/YES]If YES b. Have you had this condition in the past 12 months? [wmIp[

66. a. Have you ever had any reason tcthink you may have high bloodpressure? piq piq E]If YES or '7 b. Did a doctor tell you it was high blood

pressure? pi?qTqc. How long ago did you first start having it?

Ilyear jTG&q (over1d. Have you had it in the past 12 months? IYES]JNOI]?]e. Do you take any pills or medicine for it? p-pq~

If YES f. Give name of the medicine

67.a. Have you ever had any reason to think you may have hearttrouble? fTE--pJ(N61(?)If YES or ? b. Did a doctor tell you that you had heart

trouble? pE-pqIf YES, what did he call it?

c. How long ago did you first start having it?~~yeard. Have you had it in the past 12 months? j-TE-pql?je. Do you take any pills or medicine for it? piqJJNb]pJ

If YES f. Give name of the medici ne

Probes: A. Do you have any idea what causes your ?6. Tell me how it feels.C. In what way does it bother or affect you?D. How many flights?

These questions were used, where indicated, if the examineeanswered either "yes" or 'I?"

000

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APPENDIX IIELECTROCARDIOGRAPHIC READINGS

Criteria and ClassificationThe following are the criteria and classifications

used in electrocardiographic (ECG) reading by theHealth Examination Survey relevant to the diagnosisof hypertensive heart disease. They were developedby the cardiologists who read the ECGs. The draftversion of these criteria was submitted to cardiologistsexperienced in reading electrocardiograms for surveypurposes, and their criticisms and suggestions weretaken into account in this working version. A completelisting of all ECG criteria was included in the intro-ductory report on heart disease.The general ECG reading procedure is describedin the main body of this report.

Two exceptions to this procedure were accepted.(1) When a case was reviewed the full documentationwas c