HeartMEMO

Summer 1998

NATIONAL INSTITUTES OF HEALTH

NATIONAL HEART, LUNG, AND BLOOD INSTITUTE

Featured Articles 1 NATIONAL CONFERENCE 

ON CARDIOVASCULAR 

HEALTH

3 CONFERENCE 

HIGHLIGHTS 

12 HEART DISEASE RESEARCH

IN WOMEN

From the National Conference: 

The Changing Face of

Cardiovascular Health

(continued on page 13)

Change was the theme of the first National

Conference on Cardiovascular Health—

changes in the health care system, in cardiovascular disease (CVD) trends, and in the

practice of cardiovascular medicine as we

head into the next century.

The landmark meeting, subtitled “Coming Together for the 21st Century,” took

place February 19-21, 1998, in San Francisco, CA. Nearly 1,200 researchers and health

care professionals gathered to hear about the

latest developments in prevention and treatment of CVD and to brainstorm with their

colleagues. 

Many more participated without leaving

home. Some 2,000 viewers saw the major

sessions broadcast live via satellite at 165

local videoconferences. Still others, participating in a “net conference,” got transcripts

of major sessions and discussed the issues by

electronic mail.

Three years in the making, the conference

capped much hard work by its four sponsors:

the National Heart, Lung, and Blood Institute (NHLBI); the University of California,

San Francisco; the Cardiovascular Disease

Outreach, Resources, and Epidemiology

(CORE) Program; and the California Cardiovascular Disease Prevention Coalition. Dr.

Stephen Fortmann of the Stanford Center for

Research in Disease Prevention in California

was program chair; cochairing the conference were NHLBI Director Dr. Claude

Lenfant and Dr. Wes Alles, head of the California Cardiovascular Disease Prevention

Coalition.

Noting that the NHLBI celebrates its

50th birthday this year, Dr. Lenfant told the

opening plenary audience, “The past 50

years have seen tremendous advances in cardiovascular care—and our medical research

will undoubtedly continue to pay handsome

dividends in the future. We can only imagine what breakthroughs lie ahead.”

Reflecting the change theme, opening

session speakers addressed the “Past, Present,

and Future—Changing Paradigms in Cardiovascular Health.” Here are highlights

from that session:

Dr. Robert Brook tackled one of the

hardest questions: how to maintain quality

care for CVD patients in a cost-conscious

21st century. He is professor of medicine at

the University of California, Los Angeles and

director of the RAND Corporation Health

Sciences Program.

Dr. Brook framed the problem:

although “there has been exponential growth in science, the use of

science in practice is at best too

slow. At worst, we have a

chaotic health care system

that does not deliver the
HEARTMEMO

SUMMER 1998

2Letter From The Director

Contents

1 FROM THE NATIONAL 

CONFERENCE: THE CHANGING

FACE OF CARDIOVASCULAR

HEALTH

2 LETTER FROM THE DIRECTOR

3 HEARTFILE: NHLBI EDUCATION

PROGRAM UPDATES

17 MARK YOUR CALENDAR

18 HEARTFACTS: HEART DATA

19 HEARTNET: INTERNET SOURCES

20 HEARTFUNDS

20 NEW AT THE NHLBI INFORMATION CENTER

21 ORDER FORM

22 HEARTSOURCES: BEYOND THE

NHLBI

23 DITTO: REPRODUCIBLES

DEAR HEARTMEMO

READERS:

I am pleased and proud to report that

the National Conference on Cardiovascular Health, held February 19-21

in San Francisco, was a great success.

This historic gathering brought

together researchers, public health

experts, practitioners, and other

health care professionals from across

the Nation and around the world.

On the agenda were sessions examining virtually every aspect of cardiovascular health and disease—

including the latest research findings,

new clinical management approaches,

creative prevention strategies, health

care delivery trends, and cuttingedge communication techniques.

This issue of HeartMemo brings

you highlights from the conference.

For example, in HeartFile you will

find roundups of the major sessions

on high blood pressure control and

high blood cholesterol. Our cover

story recaps the opening plenary session, “Past, Present, and Future—

Changing Paradigms in Cardiovascular Health.” These speakers

took on difficult but critical issues:

what the trend toward 

managed care will mean for 

cardiovascular health—what lies

ahead in cardiovascular medicine—

and much more. 

As you can imagine, putting on

this conference was a great deal of

work. For their tireless efforts we

must thank our cosponsors: the University of California, San Francisco;

the Cardiovascular Disease Outreach,

Resources, and Epidemiology (CORE)

Program, a joint effort of the California Department of Health Services

and the University of California, San

Francisco’s Institute for Health and

Aging; and the California Cardiovascular Disease Prevention Coalition, a

partnership of 30 statewide organizations.

When we planned the conference,

one of our goals was to bring new

momentum to the fight against heart

disease. That fight is by no means

over. Despite great strides made over

the past 50 years in reducing the burden of cardiovascular illness, more

people still die from heart disease and

stroke than from any other single

cause. Moreover, recent data show a

slight rise in the death rate for stroke;

a slowing in the decline of the death

rate for coronary heart disease; and an

alarming jump in the prevalence of

heart failure among older Americans. 

Letter From The Director

But heart health is more than the

absence of disease, and that brings

me to the conference’s second goal:

to promote cardiovascular health by

addressing lifestyle and quality-of-life

issues. Since its beginnings 50 years

ago, the NHLBI has pioneered innovative ways to promote cardiovascular health—and will continue to do

so into the 21st century. Our work is

cut out for us. Today some 58 million

Americans still have some form of

cardiovascular disease. And more

Americans are overweight and less

physically active than ever before—

two key risk factors for heart disease.

I urge HeartMemo readers to 

renew and strengthen your efforts in

the war against cardiovascular illness.

The statistics tell us that we’ve come

a long way but we have a long way to

go. I see the national conference as a

milestone for the dramatic advances

we will see on every front of cardiovascular medicine in the next 

century. 

Claude Lenfant, M.D.

Director, NHLBI
there is concern that awareness,

treatment, and control rates are leveling off or perhaps even falling.

“Hypertension is still very prevalent

in the United States, and it is higher

among African Americans and older

Americans,” he noted. National data

show that only about two out of

three people with high blood pressure

(140/90 mm Hg or greater) are

aware that they have it; only one out

of two people with high blood pressure is being treated; and one out of

four people with high blood pressure

is controlling his or her blood pressure to below 140/90 mm Hg. To

achieve better treatment and

control, he said, efforts must

focus on specific populations that provide the

biggest challenges, such

as African Americans,

people with diabetes, 

and older Americans.

Dr. Elijah Saunders

presented data showing

that African Americans continue

to have the highest hypertension

rates in the Nation. While 24

percent of the total U.S. adult

population has high blood

The National High Blood

Pressure Education Program 3HEARTMEMO SUMMER 1998 HeartFile: NHBPEP—National Conference Session Highlights

NATIONAL CONFERENCE

SESSION HIGHLIGHTS

BLOOD PRESSURE

CONTROL

High blood pressure control was the

focus of a major session at the

National Conference on Cardiovascular Health. Called “High Blood Pressure Control at the Millennium,” the

panel discussion brought together a

nationally recognized group of

experts in preventive medicine to

review the progress and future of

high blood pressure control.

Moderator Dr. Jerome D. Cohen

began with a brief overview of the

history of our understanding of blood

pressure. As early as 1915, he said,

we knew that blood pressure played

an important role in health, and by

the 1930s, the earliest drugs to treat

high blood pressure had been introduced. However, it was not until the

late 1960s that research provided evidence that treating high blood pressure reduced mortality. 

In 1972, the National High Blood

Pressure Education Program

(NHBPEP) was formed to raise

awareness, treatment, and control of

high blood pressure in the Nation.

“The importance of the NHBPEP is

shown in the steady decrease in morbidity and mortality rates from stroke

and heart attack,” said Dr. Cohen.

“However, since 1990 awareness has

decreased, treatment has been stagnant, and control has declined. We

cannot be complacent. Despite the

progress made in informing the public of the dangers of uncontrolled

high blood pressure, there is still

room for improvement.”

Dr. Paul Whelton reported that

pressure, among African Americans

the rate is almost 29 percent. African

Americans also have an earlier onset

of high blood pressure as well as more

adverse consequences. African Americans have between 3 and 6 times

more strokes, 1.5 times greater incidence of heart disease, and 5 times

more end-stage renal disease than

other ethnic groups. 

Challenging the health care system

to respond, Dr. Saunders said, “We

know the problems and now we need

to formulate some goals of treatment.

For example, lifestyle changes, especially reduced sodium intake and

weight loss, can go a long way to help

control high blood pressure in many

African Americans.” Personal and

environmental stress also contributes

significantly to high blood pressure in

many African Americans, he said.

African Americans respond differently

to antihypertensive drugs than other

populations do; in general, better

responses have been shown to diuretics and worse responses to beta-blockers and angiotensin-converting

enzyme (ACE) inhibitors. Combination therapy

has been

shown to be a

successful

strategy,

yet few

physicians

consider

this when

prescribing drugs.

Dr. James

Sowers described

an increase in the

prevalence of

“Our changing health care 

system also puts limitations on

both physicians and patients

that can affect follow-up visits,

the types of drugs prescribed,

or the availability of other

resources to treat or prevent

high blood pressure.”

(continued on page 4)
National Conference Session Highlights HEARTMEMO SUMMER 1998

4

hypertension and diabetes as the population ages. Among some demographic groups, such as African

Americans, the effect is more pronounced. Research on hypertension

in people with diabetes is limited, and

much of it is based on renal outcomes, not cardiovascular outcomes. 

Dr. Sowers said that lifestyle

changes, such as reducing caloric

intake, should be an important

adjunct for people with diabetes and

hypertension. Research shows that

ACE inhibitors have been shown to

be an effective drug therapy in this

population because they control

blood pressure while providing renal

protection. His summary: “It’s clear

that the problem of taking care of the

patient with hypertension and diabetes is a challenge. Hopefully we

will know more from the results of

the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart

Attack Trial (ALLHAT) about the

effectiveness of lowering blood pressure to avoid cardiovascular events in

their hypertension,” Dr. Hill said. 

The challenges to care, she said,

include patient-related factors, health

care professional factors, health care

system factors, organizational factors,

and the increasing complexity of managed care and health insurance policies. The current lack of systems

approaches can create solutions to

some issues that create problems in

other areas. For example, pharmacies

provide child-proof cap bottles that

many older Americans have difficulty

opening. Patients do not fully comprehend the benefits of treatment and

so compliance decreases. Physicians

do not necessarily believe that treatment to below 140/90 mm Hg is warranted or beneficial. 

Dr. Hill summarized the challenges: “Our changing health care

system puts limitations on both physicians and patients that can affect follow-up visits, the types of drugs

prescribed, and the availability of

other resources to treat or prevent

high blood pressure. All of these

issues must be considered when developing effective treatment plans.”

people with these conditions.”

Dr. Henry Black reported that

“cardiovascular disease in the elderly

is a major cause of death, and better

control of hypertension could have a

significant positive effect on this population.” The elderly population

spends about 40 percent of the U.S.

health care dollar, so there is an economic incentive to reduce premature

mortality and morbidity. This incentive also holds for younger individuals. Although treatment in young

people seems expensive, it is more

cost-effective to treat high blood

pressure than to spend money on the

consequences, such as stroke. 

Dr. Martha Hill outlined the challenges in treating high blood pressure

and the need to develop strategies for

improving adherence to therapy.

Among factors to consider are special

populations that need attention,

approaches to improved awareness

and treatment, and coordinating systems to focus on control. “We have

to consider issues of where people live

and the environment in which

patients need to be taking care of

H IGH B LOOD P RESSURE C ONTROL

AT THE M ILLENNIUM — P ANEL M EMBERS

Jerome D. Cohen, M.D., Moderator

Director of Preventive Cardiology

St. Louis University Medical

Center

Henry R. Black, M.D.

Chairman, Department of

Preventive Medicine

Rush-Presbyterian-St. Luke’s

Medical Center

Martha Hill, Ph.D., R.N.

President, American Heart

Association

Associate Professor

Johns Hopkins University

(see related story on page 6)

Elijah Saunders, M.D.

Head, Division of Hypertension

University of Maryland School of

Medicine

James R. Sowers, M.D.

Director, Division of Endocrinology,

Metabolism, and Hypertension

Wayne State University School of

Medicine

Paul K. Whelton, M.D., M.Sc.

Dean, Tulane University School of 

Public Health

(continued from page 3)
HeartFile: NCEP—National Conference Session Highlights

5HEARTMEMO SUMMER 1998

HIGH BLOOD

CHOLESTEROL: WHAT’S

KNOWN, WHAT’S NEW,

WHAT’S AHEAD

Cholesterol as a cardiovascular risk

factor was a central theme at the

National Conference on Cardiovascular Health. In fact, no fewer than

eight sessions were devoted to the

topic. Space does not allow us to fill

you in on all of them—so

here are highlights from the

main Grand Ballroom session,

“Cholesterol Control: A Key

To Preventing and Treating

Atherosclerosis”:

Dr. Luther T. Clark opened

the crowded agenda with a look

at trends in cholesterol awareness,

levels, detection, treatment, and

control. Dr. Clark is chief of the

Division of Cardiovascular Medicine

and professor of medicine at the

State University of New York Health

Science Center, Brooklyn, NY.

“Public awareness of cholesterol is

high,” he summarized. “Attitudes,

awareness, and knowledge of cholesterol have increased. And National

Cholesterol Education Program

(NCEP) guidelines for cholesterol

management have become established

practice.”

Average cholesterol levels have

declined from 220 mg/dL in 1961-62

to 203 mg/dL or lower in the most

recent data from the third National

Health and Nutrition Examination

Survey (NHANES III). Age-adjusted

coronary heart disease mortality rates

also have dropped. Still, projected figures for cardiovascular disease beyond

the year 2000 suggest that these rates

of decline may be “flattening out.

Obviously, there is still a need for continued efforts,” Dr. Clark concluded.

Dr. Linda Van Horn, professor of

preventive medicine at Northwestern

University School of Medicine in

Evanston, IL, focused on trends in diet

and food consumption. Her assessment: there has been substantial

improvement, but there is room for a

lot more. This was clear from an

analysis of food trends in a U.S.

Department of

Agriculture 

nationally representative

survey of food consumption patterns

among ages 19 to 50, from 1965 to

1995. The good news: “when we

look at the percentage of total fat

intake over the past 30 years, there

has been a steady decline overall in

both men and women.” But “around

two-thirds of Americans still eat more

than 30 percent of their calories as fat,

and calorie intake has remained fairly

stable over the past 30 years,” she

said. Similarly, in the NHLBI’s Coronary Artery Risk Development in

Young Adults (CARDIA) study of

5,115 men and women ages 18 to 30,

“the vast majority continued to consume a high-fat diet” at the end of the

7-year intervention.

The National Cholesterol 

Education Program

Where do Americans get their fat

and calories? Research shows that

low-fat eaters consume more rice,

pasta, and bread, and children in the

low-fat eater category tend to consume more milk and fruit. 

For high-fat eaters, desserts, hamburgers, and, above all, french fries are

the main sources of dietary fat. Children in this group eat more meat, as

one would expect, and less milk or

fruit, Dr. Van Horn noted.

In closing, she said, “the vast

majority of the population

still eats more than 30

percent of their calories as

fat. Efforts to reinforce this

message, to encourage label

reading and widespread

awareness of the dietary prevention of cardiovascular disease, are needed to meet the

goals we have set.”

Dr. John C. LaRosa, chancellor of Tulane University Medical

School in New Orleans, LA,

reviewed the scientific basis for

nutritional interventions to lower

cholesterol. His first slide got everyone’s attention: a photo of a bear next

to an example of Homo sapiens.

“These are two mammals,” Dr.

LaRosa said. “Both eat diets high in

fatty meat. However, there are important differences. The bear has sharp,

tearing teeth, short intestines, a cholesterol level of 500 to 600 mg/dL, and

no atherosclerosis. Humans, on the

other hand, have flat, grinding teeth,

long intestines, cholesterol levels

between 150 and 300 mg/dL—all

more typical of herbivores—and atherosclerosis.”

His point: “We are natural herbivores and simply do not have the

(continued on page 16)
HEARTMEMO

SUMMER 1998

6HeartFile: NHAAP

ALLIANCE FOR HEALTH:

NEW CLINICAL GUIDE

TELLS HOW TO

CONTROL HIGH BLOOD

PRESSURE IN OLDER

WOMEN

“You have what it takes to control

high blood pressure” is the message of

a new clinical guide for health care

professionals on controlling high

blood pressure in older women.

The NHLBI teamed up with the

Alliance for Aging Research, an independent nonprofit health research

advocacy group, to produce this tool

for health care professionals. Supported by an unrestricted educational

grant from Hoechst Marion Roussel,

Inc., the guide is part of a joint

national campaign to improve hypertension prevention and control in

older women and reduce the incidence

of heart failure. 

Fewer than one in four women age

60 and older is controlling her blood

pressure sufficiently. Rates of heart

failure are increasing dramatically,

especially among older Americans.

The health care costs of heart failure

are about $12 billion each year—one

of the largest components of the

Medicare budget.

“Hypertension is a widespread,

deadly, yet readily treatable condition

among older people in this country,”

said NHLBI Director Dr. Claude

Lenfant. “Women make up a disproportionate share of the older population, have poor hypertension control

rates, and carry a greater risk of developing and dying from heart failure.”

The guide includes:

• a clinical reference manual on

treating and controlling hypertension in older women;

• a quick reference card that summarizes diagnostic techniques, treatment strategies, and follow-up

protocols;

• an educational brochure for women

who have high blood pressure;

• a form to order more copies of the

patient brochure and clinical guide;

and

• profiles of the program sponsors.

The guide emphasizes that controlling high blood pressure is a joint

effort between the patient and the

health care provider. The consumer

brochure explains in detail how

patients can adopt lifestyle modifications that have been shown to reduce

blood pressure. The reference manual

provides tips to health care professionals on improving adherence to

lifestyle modifications and pharmacologic therapy.

In November 1997, the guide was

mailed to 245,000 health care

providers across the Nation. To order a

free copy, call the NHLBI Information

Center at 301-251-1222 and ask for

publication #55-851. Many other

consumer publications on controlling

high blood pressure are also available

from the Information Center. 

The National Heart Attack 

Alert Program

NEW REPORT TARGETS

COMMUNITY AS THE

“ULTIMATE CORONARY

CARE UNIT” “Since 60 to 70 percent of sudden

deaths by cardiac arrest occur before

hospitalization, it is clear that the

community deserves to be the ultimate coronary care unit,” the American Heart Association has said.

The National Heart Attack Alert

Program (NHAAP) supports that

view—and to help communities plan

access to timely care for heart attack victims, NHAAP has just issued a new

report. Its title: Access to Timely and Optimal Care of Patients With Acute Coronary

Syndromes—Community Planning Considerations.

“We hope it will serve as a blueprint

and a resource for planning emergency

cardiac care at the local level,” said

NHAAP Executive Committee Chairman Dr. James M. Atkins, medical director, Emergency Medicine Education,

“Women make up a disproportionate share of the older 

population, have poor hypertension control rates, and carry

a greater risk of developing and

dying from heart failure.”
HEARTMEMO

SUMMER 1998

7HeartFile: OEI

University of Texas Southwestern Medical Center, Dallas, TX.

Like trauma victims, heart attack

patients have a much better chance of

survival when treated promptly—

ideally within 1 hour, sometimes called

the “golden hour.” Advanced technology and early intervention can save

many lives, research has documented.

Even so, the statistics are still alarming.

In 1994, 1.25 million Americans had a

heart attack, and nearly 500,000 died.

More than half of those deaths happened suddenly and outside a hospital

and might well have been prevented

with rapid detection and treatment.

The NHAAP report details the

essential elements of a community

plan for emergency cardiac care and

gives examples of model plans. It

recommends strategies for planning

for cardiac emergencies based on the

essential elements of a community

plan. The goal of a community plan,

it says, is to provide an optimal

“chain of survival” (see box at right)

by minimizing or eliminating factors

that delay or restrict emergency

treatment. 

The report will be mailed to every

State health department in the 

United States and will appear in a

special supplement to the Journal of

Thrombosis and Thrombolysis in summer 1998. It also will be posted

after publication on the NHAAP

page of NHLBI’s Web site at

http://www.nhlbi.nih.gov/nhlbi/

cardio/heart/prof/hattkhc.htm.

“We hope it will serve as a

blueprint and a resource for

planning emergency cardiac

care at the local level.”

STEPS TO

SURVIVAL

The American Heart Association has proposed the concept

of a “chain of survival” for heart

attack victims. The chain has

four parts:

• Early access to the emergency medical services 

system

• Early cardiopulmonary

resuscitation by bystanders

or first responders

• Early defibrillation by first

responders, emergency 

medical technicians, or 

paramedics

• Early advanced cardiac life

support: defibrillation, intubation, drug therapy.

Each link in the chain must

be strong to ensure maximum

survival rates for people who

have a heart attack outside a

hospital. The NHAAP’s new

report shows how communities

can work to strengthen each

part of the survival chain.

New Information Technology for a New Century

“New Information Technology and the National Heart Attack Alert Program: Setting a 5-Year Agenda” was held April 14-15 at the National Institutes of Health

(NIH) in Bethesda, MD. Participants explored how new tools coming from information technology can aid rapid diagnosis and treatment of heart attacks. 

The discussions by health care professionals and information technology experts

were lively and informative. Watch for details in the next HeartMemo.

The NHLBI Obesity 

Education Initiative

WHAT ARE EVIDENCEBASED GUIDELINES?

In 1995, the NHLBI’s Obesity Education Initiative (OEI) appointed an

expert panel to develop guidelines on

identifying, evaluating, and treating

obesity in adults. It was the first

panel convened under a new NHLBI

directive that such groups use an evidence-based approach to develop

clinical guidelines.

In 1998, as the panel gets ready to

release 3 years of work synthesizing

the science of obesity diagnosis and

treatment, health care professionals

can see and judge the results for

themselves. Why do it this way?

How is the evidence-based process

different from, and better than,

methods used before? 

Panel chair Dr. F. Xavier 

Pi-Sunyer explains: “The definition

of practice guidelines given by the

Institute of Medicine is that they are

systematically developed statements

to assist practitioner and patient

decisions about appropriate health

care for specific clinical circumstances. To meet this goal, it is

important to look at the literature

and make conclusions only on evidence-based information.

“This has been an exciting new

venture for us,” adds Dr. Pi-Sunyer,

(continued on page 8)
HEARTMEMO

SUMMER 1998

8HeartFile: OEI

who is director of the Obesity

Research Center at St. Luke’s/Roosevelt Hospital Center and professor

of medicine at Columbia University

in New York City. “We were asked

to develop the NHLBI’s first clinical

guidelines for treating obesity and to

pioneer an evidence-based model for

future guidelines.”

Although the evidence-based

process is complex, its basic structure is as follows:

• Develop an evidence model that

illustrates a list of key clinical

questions about obesity that

should be answered by the evidence—for example, “What is

the evidence that relates weight

to cardiovascular disease? What

is the evidence that weight loss

directly affects high blood 

pressure?”

• Conduct extensive searches

through the scientific literature,

using MEDLINE and other biomedical databases, to track down

all relevant research articles.

• Screen these citations, cull out

the most significant research

reports, abstract the data into

evidence tables for panel members to evaluate, and develop criteria to judge the evidence.

• Develop treatment recommendations based on this evidence. 

Starting with a MEDLINE search

that turned up more than 44,000

citations, the panel went through

several screenings that narrowed the

list down to about 25,000 records.

After further rounds of screening, the

panel identified 2,440 abstracts as

possibly important enough to retrieve

the full articles. In the end, 394 articles—all reporting results from randomized clinical trials—were selected

for review and analysis.

To date, the panel has identified

and considered evidence for 33 key

questions about the relationship

between weight and other factors.

An example: what is the evidence

that dietary interventions effect a

change in weight loss? “We found 86

randomized trials that evaluated the

effectiveness of diets on weight loss,”

said Dr. Pi-Sunyer. “Some of these

were low calorie, very low calorie,

reduced fat, and vegetarian.

“We then framed questions

regarding interventions that the primary care physician might want to

use and looked at the evidence as to

whether these interventions were successful or not,” he explained.

A critical step was to rate the

strength of the evidence for each recommendation in the guidelines. The

panel devised these rankings: 

• “A” denotes strong evidence from

well-designed, randomized, controlled clinical trials.

• “B” means suggestive evidence,

from the same kind of randomized

controlled trials, but a smaller

number of studies or a less consistent pattern of findings.

• “C” is suggestive evidence from

nonrandomized studies—for

example, observational studies or

uncontrolled trials.

• “D” denotes expert judgment—

evidence from clinical experience

or experimental research.

Assisting this massive effort is an

international group called the

Cochrane Collaboration. The

Cochrane group prepares, maintains,

and disseminates systematic reviews

and meta-analyses of health care

interventions. Cochrane’s San Antonio Center in Texas has been helping

the panel by abstracting scientific

literature, critiquing it methodologically, and organizing data into tables

that summarize the evidence.

What emerges will be a set of

treatment guidelines based on a careful and comprehensive review of the

most relevant scientific literature.

The guidelines promise to provide a

priceless tool for physicians, dietitians, nurses, exercise specialists, and

other health professionals who work

with overweight patients. An accompanying compendium of the most

relevant research on obesity will be

an important resource for researchers. 

“The guidelines document how

different strategies, such as diet and

physical activity, affect weight loss

and how weight control affects the

major risk factors for heart disease

and stroke,” said NHLBI OEI Coordinator Karen A. Donato.

The Expert Panel on the Identification, Evaluation, and Treatment of

Overweight and Obesity in Adults

comprises 23 experts in different

fields of obesity treatment as well as a

methodologist consultant. Their

report is expected to be released in

summer 1998 and will be featured in

a future issue of HeartMemo. 

“This has been an exciting

new venture for us. We were

asked to develop the NHLBI’s

first clinical guidelines for

treating obesity and to pioneer an evidence-based

model for future guidelines.”

“The guidelines document

how different strategies, such

as diet and physical activity,

affect weight loss and how

weight control affects the

major risk factors for heart

disease and stroke.” 

(continued from page 7)
demonstrations of CATCH to local

school representatives. “We gave our

public health partners copies of the

CATCH materials. They are contacting the schools and doing onsite

demonstrations, with great success,”

Mr. Hoffman related. “When school

representatives see the entire

CATCH curriculum, they cannot

believe the quality of the materials.”

The city of El Paso has become a

model for CATCH projects in Texas.

There, the Paso Del Norte Foundation took the lead in developing a

regional coalition to promote better

nutrition and physical fitness for all

El Paso residents. They called their

project Border Lean, after the nationwide Project Lean initiative to get

people to eat less fat. Coalition

members recommended that

a school-based initiative be

the foundation for the initiative—and after a

lengthy review of available programs, chose

CATCH for the

school component.

The Foundation

is donating $3,500

to each participating school to buy

physical education

equipment, and the

Texas Department

of Health provides CATCH

materials and

training for the

HEARTMEMOSUMMER 1998

9HeartFile: CHPP

The Cardiovascular Health

Promotion Project

CATCH CATCHES

ON IN TEXAS

NHLBI’s school-based heart health

education program, the Child and

Adolescent Trial for Cardiovascular

Health, or CATCH, has caught on in

Texas in a big way.

The State has bought 400 sets of

the CATCH curriculum for local

schools and is teaming up with State

and local school, health, and nutrition agencies to use CATCH to promote cardiovascular health among

Texas schoolchildren.

“We know that good nutrition

and physical activity improve health

status, cognitive skills, and behavior.

It is a win-win for both public health

and schools,” said Peter Hoffman,

program specialist with the Texas

Department of Health.

CATCH’s field-tested materials

include:

• A physical education curriculum

with lesson plans; a set of more

than 350, 5” x 8” cards showing

fun, easy-to-teach activities; and

three videotapes that show kids

and instructors in action.

• Heart-healthy classroom curricula,

with family components, for

grades 3, 4, and 5.

• An “eat smart” school cafeteria

program guide.

Initially the State tried to interest

schools in CATCH by mailing a

description of the program to all

schools statewide. The response was

poor. “We learned that written

descriptions do not adequately project the quality of the CATCH materials,” Mr. Hoffman said. “Seeing is

believing.”

That lesson was brought home

when the State arranged for onsite

family component. Twenty-two

schools are participating in school

year 1997-98, with another 25 projected for 1998-99.

Essential to the project were partnerships at both the State and local

levels. Within State government,

collaborations were developed among

the Texas Education Agency’s Child

Nutrition Program and Health and

Physical Education Program; the

Texas Department of Human Services’ Nutrition Education and 

Training Office; and the Texas

Department of Health’s Bureau of

Nutrition Services, Office of Tobacco

Control and Prevention, and Texas

Comprehensive School Health Network. In addition, the Texas Diabetes Council is underwriting many

costs of the project. Also key to the

project was the University of Texas,

which made many personal contacts

to promote the program and provided training to local school systems.

“Each of these agencies assumed

ownership of CATCH in Texas and

helped develop implementation strategies,” Mr. Hoffman said. 

At the local

level, partners

include individuals and organizations that support

the project’s goals. For

example, in El Paso

these included the local

health department, the

local school system,

community health

centers, and local

chapters of 

voluntary

health groups

“CATCH is a win-win for

both public health and for

schools.”

(continued on page 10)
HEARTMEMO

SUMMER 1998

10HeartFile: Minority Populations

Minority Populations

UNIVISION AND NHLBI

JOIN FORCES TO

PROMOTE HEART

HEALTH AMONG

LATINOS

The NHLBI has forged a powerful

new partnership with the nationwide

Latino television network Univision to

fight cardiovascular disease among

Latinos.

Over the next 6 months, Univision

will air a series of mini-telenovelas in

prime time on television stations that

it owns and operates in major Hispanic markets throughout the United

States. The telenovelas also will run

on Galavision, Univision’s Spanish

language cable network. Telenovelas

are short, humorous “slices of life”

that feature the Ramírez family’s

efforts to change their lifestyle to prevent cardiovascular disease. The

telenovelas are part of the NHLBI’s

comprehensive Latino outreach program Salud para su Corazón.

Said NHLBI Director Dr. Claude

Lenfant: “Cardiovascular disease is

the leading cause of death for Latinos,

the fastest-growing segment of the

American population. It’s time to

take bold action in this area of public

health.”

At a press conference February 18,

1998, in Los Angeles, the Institute

and Univision encouraged Latino community leaders to initiate and support

educational efforts to reduce cardiovascular disease in the Latino community. With one out of four Latino

deaths attributable to heart disease,

the partners urged Latino health professionals, community leaders, and the

media to join forces to bring public

health messages to Latinos.

“Many Latinos are cut off from

public health messages because they

don’t speak English,” noted Matilde

Alvarado, NHLBI minority outreach

coordinator. To bridge that gap, the

NHLBI developed Salud para su

Corazón. This program uses Latino

traditions to offer science-based 

heart health messages, bilingual 

educational materials, and strategies

for implementing the program in

communities.

To help Univision viewers get more

information, the NHLBI and the

Department of Health and Human

Services Office on Minority Health are

sponsoring a toll-free number that

will be shown at the end of the telenovelas. Callers reach a Spanishspeaking operator who can refer them

to products and resources in Spanish,

including the wealth of bilingual

materials from Salud para su Corazón.

These include eight easy-to-read

booklets in Spanish and English; a

bilingual cookbook; radio and television programs on keeping the heart

healthy; and a bilingual guide for

organizing charlas, which are group

discussions on cardiovascular health at

local community sites. 

Meanwhile, aiding the effort, the

National Council of La Raza—the

such as the American Heart Association. 

What was learned in Texas that

can be applied elsewhere? A surprising tip from the Texas experience

is that it’s better to charge schools a

minimal cost rather than donate the

materials outright. Mr. Hoffman

explains: “Schools need to have

some ownership of the materials,

even if it is minimal. And we have

not had one school report that price

was a barrier.” 

Finally, partnerships at both the

State and local levels are essential to

the success of the program. “Using

our existing public health infrastructure has proved to be very effective in

diffusing the CATCH materials,” said

Mr. Hoffman. Partners also can help

with training school staff, a critical

component of a successful program.

“We encourage other States and

organizations to create similar collaborative projects to implement

CATCH in their communities,” says

Karen A. Donato, coordinator of the

NHLBI’s Cardiovascular Health Promotion Project. For prices and ordering information, contact the NHLBI

Information Center at 

301-251-1222. 

“When school representatives

see the CATCH curriculum,

they cannot believe the quality of the materials.”

“Cardiovascular disease is

the leading cause of death for

Latinos, the fastest-growing

segment of the American population. It’s time to take

bold action in this area of

public health.”

(continued from page 9)
HEARTMEMO

SUMMER 1998

11HeartFile: Minority Populations

Nation’s largest network of Hispanic

organizations, with strong roots in

Hispanic communities—is conducting a survey of 600 of its affiliates

and network members to identify

needs and opportunities for promoting heart health in sites around the

country. 

“Given the continuing escalation

of cardiovascular disease in the 

United States, each and every Latino

must get involved,” said Dr. Henry

Pacheco, director of health 

promotion for the National Council

of La Raza.

“NEWS INSERT” HITS

THE STANDS

In another collaboration, the National Institutes of Health and several of

its institutes, including the NHLBI,

are contributing to, and will be featured in, a Spanish-language newspaper insert called Pro Salud.

Somewhat like Parade magazine,

the news insert will appear bimonthly in Spanish-language newspapers in

eight major Hispanic markets around

the Nation: New York City, Miami,

Los Angeles, San Francisco, Chicago,

Houston, San Antonio, and Puerto

Rico. For example, it will be carried

by El Diario/La Prensa (New York

City), the oldest Spanishlanguage daily in the United States,

and by El Nuevo Día, Puerto Rico’s

largest daily paper, which reaches

some 150,000 readers. The total

potential readership for Pro Salud is

estimated at 3.5 million. 

Inside, readers will find articles in

Spanish on health issues of interest to

Latino communities. NHLBI’s page

in the first issue includes lively pieces

on reducing risk factors for heart 

disease, heart-healthy eating, and

Spanish-language heart health publications available from the NHLBI.

There’s also a toll-free phone number

that readers can use to reach a Spanish-speaking operator and get more

information. 

F AMILY PICNIC

ART HERE

SEE “ BE HEART SMART ”

BOOKLET COVER

F O R A FRICAN A MERICANS : S EVEN

B OOKLETS AND A C OOKBOOK

Following up on the success of its eight easy-to-read heart

health booklets for Latinos, the NHLBI has produced a similar

series aimed at African American audiences.

With catchy titles and eye-catching graphics, each of the

eight-page booklets covers a major risk factor for

cardiovascular disease and what can be done to prevent it.

On the back cover is a checklist or log where readers can

record lifestyle changes related to that topic—for example, a

calendar for physical activity and a checklist of ways to lose

weight. The cookbook features low-fat, low-sodium versions

of popular African American foods such as homestyle biscuits,

candied yams, and barbecued and fried chicken.

To order the seven-booklet package (#55-832, $3) and

the cookbook (#3792, $2.50), call the NHLBI Information

Center at 301-251-1222. 
HEARTMEMO

SUMMER 1998

12HeartFile: Women

Women

HEART DISEASE

RESEARCH IN WOMEN:

A LOOK BACK AND A

VIEW TO THE FUTURE

“For nearly a century, heart disease

has been the leading cause of death in

American women,” NHLBI Director

Dr. Claude Lenfant told several hundred researchers and health care professionals gathered in Bethesda, MD,

last November. “And as things stand

now, nearly one-third of the women

in this room are likely to die of it.”

Dr. Lenfant was a keynote speaker

at “Beyond Hunt Valley,” a 3-day 

followup to the original 1991 Hunt

Valley, MD, conference on women’s

health research. Conferees came

from around the country to hear science updates and plan a women’s

health research agenda for the next

century. 

In his address Dr. Lenfant posed

the two big questions that have been

raised about heart disease research in

women:

• Has research on heart disease

neglected women?

• Has research on heart disease benefited women?

The answer to the first question,

he said, is generally “no.” Of the

NHLBI’s 59 major (at least 400 participants) clinical trials of cardiovascular disease in adults, 41 included

men and women, 14 included only

women, and only 4 covered just men.

In these four, men were selected as

the study population for two reasons:

overriding public health considerations and pragmatic considerations,

Dr. Lenfant said. For example, at the

time two of these studies were begun,

the heart disease epidemic was at its

peak—and men were the population

segment most affected. Similarly,

certain recent and current studies

include only women for similar public health and pragmatic rationales.

An example is the massive Women’s

Health Initiative, begun in 1991 and

recently placed under NHLBI’s management (see below). Its goal is to

determine whether hormone replacement therapy does in fact prevent

heart disease in women—a major

question for current clinical practice.

Dr. Lenfant’s answer to the second

question was “a big yes and a cautionary no.

“In support of the yes, let me

point out that the declines we’ve witnessed in overall death rates from

heart disease have been spectacular

both in men and in women,” he

THE WOMEN ’ S HEALTH INITIATIVE

One of the toughest questions facing postmenopausal women is whether to

use hormone replacement therapy (HRT). This treatment has been found

to improve some heart disease risk factors but may pose other dangers,

including a greater chance of breast cancer. 

The answer will come from the Women’s Health Initiative (WHI), a

large-scale, long-term clinical trial that will determine whether HRT really

prevents coronary heart disease and osteoporosis (bone thinning) in older

women and whether it raises the risk of breast and colon cancer.

Begun in 1991 and recently transferred to the NHLBI, WHI is one of

the largest studies of its kind ever done in the United States. More than

167,000 women ages 50 to 79 will be studied over 15 years. Of those,

67,000 will participate in the clinical trial and 100,000 in a strictly observational study to look for predictors and biological markers of disease.

In the clinical trial, women can enroll in one, two, or all three components: HRT use, a diet low in fat and high in fiber, and calcium and vitamin D supplementation. Women who enroll in the HRT part will take

hormone pills or a placebo. Researchers can then study HRT’s long-term

effect on coronary heart disease, bone thinning, and breast cancer. 

In the diet change study, women will follow their usual eating pattern or

a diet low in fat and high in fruit, vegetables, and grains. The goal is to see

if this diet reduces breast and colorectal cancer as well as heart disease. In

the third part of the trial, researchers will determine if calcium and vitamin

D supplements prevent bone fractures from osteoporosis.

Finally, a community prevention study will test ways to get women to

adopt healthy behaviors. This study will try to develop model programs

that can be implemented nationwide.

“In 1990, there were 37.5 million adult women over age 50 in the 

United States,” said Dr. Suzanne S. Hurd, director of the NHLBI’s Division

of Lung Diseases and acting director of the WHI. “For them, this study

promises not only a new century in women’s health but a new era as well.” 

For information and updates on WHI, call the NHLBI Information

Center at 301-251-1222 or check the WHI web site:

http://www.nhlbi.nih.gov/nhlbi/whi1/
HEARTMEMO

SUMMER 1998

13Cardiovascular Health Conference

caused the difference?

“Doctors’ knowledge

and action, nurses’

knowledge and

action, diagnostic

methods, and using

intensive care units.

“These differences

represent a 40 percent difference in

death rate,” Dr. Brook cautioned.

“It’s safe to say that this variation

may represent 50,000 to 100,000

excess deaths a year.

“That’s the message,” he said.

“We are clinically practicing in a

chaotic environment where some are

getting treatment they don’t need

and others aren’t getting the treatment they do need.”

What is the solution? Dr. Brook

outlined three goals for cardiovascular health care in the 21st century:

• Provide necessary care for everyone.

• Eliminate waste and provide what

is necessary more efficiently.

science to people and

does not exploit the

value of the science.

There’s an enormous

amount of preventable

morbidity and mortality.”

An example: “We [the

RAND Corporation] looked at

five California hospitals and found

that 25 percent of people who needed a cardiac revascularization procedure were not offered it. At the

same time, those hospitals were performing procedures on people who

did not need them.” 

And an example from another

RAND study: “We took 400 randomly selected hospitals across the

U.S. and grouped them according to

which had the best quality of care”

for inpatients with heart disease.

The alarming result, said Dr. Brook,

was that “there is at least a 6 percent

difference in outcome based on the

quality of care between the best hospitals and worst hospitals.” What

• Improve the mean level of quality

and decrease its variation as a

function of which physician or

hospital one sees.

Dr. Brook imagined an interesting

clinical dilemma for the future if

these goals are not met. “Imagine a

50-year-old with chest pain. There’s

a call to 911 and an ambulance

arrives. Imagine that there’s a computer in the ambulance—one the

patients can reach—listing the quality and efficacy of the nearby hospitals. What if they were able to reach

up and see that within a 7-minute

radius, they could choose between

hospitals A, B, C, and D? What if

this computer told them, ‘If you

choose the coronary care unit in hospital A, your death rate will be 20

percent. If you choose B, your death

rate will be 10 percent.’

“That’s competition. We need a

system where hospitals all have the

same quality of care,” he urged.

“We need to develop in the next

(continued from page 1)

noted. “The rate in women is actually

37 percent lower than it was at the

turn of the century in 1900.” 

Why, then, the qualified “no”?

“Women are not taking full advantage

of the heart-saving information that we

already possess,” Dr. Lenfant said. “Risk

factors for heart disease in women have

been known for years, and we have made

intensive efforts to educate the public

about them. But their current prevalence is disturbingly high—higher, in

some cases, than in men.”

For example, he observed, the

NHLBI’s popular Healthy Heart Handbook for Women has appeared in three

different versions over the past 10

years with its central message that

“heart disease is every woman’s concern.” Yet a recent survey of women

published in USA Today revealed that

women’s perception of heart disease as

a health risk vastly underestimates its

true risk, Dr. Lenfant said.

“In the area of hypertension,” he

continued, “our record of including

women in clinical trials has been

impeccable, and we continue to generate new evidence of the benefits of

hypertension control, even in the

elderly. Yet recent data show dismal

blood pressure control rates for hypertensive women over the age of 70.

“My point is that we can pour millions of dollars into research, but the

yield will be low if women and their

physicians fail to use this knowledge to

improve women’s health.”

Dr. Lenfant closed by reemphasizing the NHLBI’s strong commitment

to addressing new opportunities to

improve women’s heart health through

science and public health education.

And he urged conference participants

to help the Institute set a research

agenda for the 21st century to advance

women’s heart health. 

“In 1990, there were 37.5 million adult women over age 50

in the United States. For

them, this study promises not

only a new century in women’s

health but a new era as well.” “We can pour millions of dollars

into research, but the yield will

be low if women and their

physicians fail to use this

knowledge to improve women’s

health.” 

(continued on page 14)
HEARTMEMO

SUMMER 1998

14Cardiovascular Health Conference

few years a better

knowledge about the 

proportion of science 

that is implemented. We need to 

have real-time, useful data about quality so that we can practice better medicine and guarantee to all Americans

that they get necessary, high-quality

care when they need it. And we need

financial incentives to increase the likelihood and rapidity with which all this

happens.”

Next at the podium was Dr. Eugene

Braunwald, professor of medicine at

Harvard Medical School in Boston,

MA. He reviewed developments in

cardiovascular medicine in this century

and gazed into a medical crystal ball to

see what may lie ahead.

Despite overwhelming progress, he

said, there is much evidence that “the

cardiovascular war has not yet been

won.” For example, deaths from heart

diseases have risen steadily from 1900

through 1994. Why? “The reasons

are largely demographic,” Dr. Braunwald noted. “The population has

increased in number and is more pre

dominantly aging—and the baby 

boom generation is reaching the age 

for development of coronary heart 

disease.”

Taking the global view, he 

noted that world deaths due to

CVD equaled 29 percent of all deaths

in 1990. That number is projected to

increase to 36 percent by the year

2020, according to the World Health

Organization.

What obstacles remain in the fight

to eradicate CVD? “There are large

gaps of knowledge among the public

as well as among professionals,” Dr.

Braunwald said. “Also, available therapies are not applied broadly, and the

available therapies are inadequate.

And re-emergence of coronary risk factors, especially in teenagers, is of concern.” Moreover, he pointed out,

one-half of patients with coronary

heart disease have none of the established risk factors—so other, still

unidentified factors must be at work.

What might they be? Estrogen

deficiency, homocysteine, and plasma

fibrinogen are some that have emerged

from research (see box on page 15).

And “in the newly emergent field of

population genetics, I think there are

some very important answers,” said Dr.

Braunwald. Already, familial high

blood cholesterol and several other cardiovascular disorders have been linked

to abnormalities in single genes.

“We have the knowledge to prevent

cardiovascular disease,” Dr. Braunwald

summed up. “Genetic predisposition,

coronary risk factors, hypertension,

high cholesterol, coronary disease

events—all these need aggressive

treatment” as well as continued, concentrated research, he urged.

Continuing in the same vein, Dr.

Henry Blackburn celebrated the

advances of the past 50 years and laid

out the challenges ahead. Dr. Blackburn, who is Mayo professor emeritus

of public health at the University of

Minnesota in Minneapolis, focused on

epidemiologic trends and projections. 

“Those of us in the field of CVD

have participated with the National

Heart, Lung, and Blood Institute in a

remarkable health revolution that has

turned back the 20th century epidemic

of CVD,” he remarked. 

“In three decades, death rates have

fallen by more than half for heart

attack and by two-thirds for stroke.

Death rates both in and out of the hospital have plummeted, and survival

has improved. Population levels of the

major CVD risk factors—cigarette

smoking, blood pressure, and blood

cholesterol—have decreased steadily.

“Those of us in the field of

CVD have participated with

the NHLBI in a remarkable

health revolution that has

turned back the 20th century

epidemic of CVD.”

IF YOU MISSED IT

You didn’t know about the conference? You couldn’t get to San Francisco? Here

are three postconference options you may want to consider:

• Buy audiocassette tapes of the sessions you wanted to hear. They’re $10

each plus $2 shipping charge for the first tape and $1 for each additional

tape. For a catalog and order form, contact The Hour Recording 

Company, P.O. Box 1299, St. Petersburg, FL 33731, 813-323-1851; 

e-mail: HourRecord@juno.com.

• Order a videotape of the opening sessions (#55-857, $15) from the

NHLBI Information Center, 301-251-1222.

• Exchange ideas and information with conference participants by subscribing to the postconference ListServ, a free e-mail network. Here’s how: 

• Address an e-mail message to LISTSERV@LIST.NIH.GOV.

• Type anything in the subject field or leave it blank.

• Type the command SUBSCRIBE HEART-HEALTH in the body of 

the message and send the message.

• The LISTSERV will send you a confirmation. Hit the reply button, 

type OK in the body of the reply, and send the message back to

LISTSERV.

(continued from page 13)
HEARTMEMO

SUMMER 1998

15Cardiovascular Health Conference

E MERGING R ISK F ACTORS – S CIENCE ’ S

A GENDA FOR THE N EXT C ENTURY

And society’s mores have changed

favorably regarding smoking, eating,

and physical activity.”

But, said Dr. Blackburn, “We

should nevertheless be warned by current developments that threaten this

revolution.”

For example, he said, “epidemiologic observations indicate that we have

plateaued in certain death rates and in

some risk factor levels, while other

CVD rates, after a period of decline,

are on the rise again.” For example, he

said, hypertension control efforts are

losing ground, and “many Americans

appear to be backsliding regarding

healthy lifestyles. Inactivity is a major

factor in the rise in weight, particularly among youth.” 

What are the reasons? Dr. Blackburn thinks that “shifts in national

research priorities may threaten the

enterprise and the infrastructure of

cardiovascular prevention, so effectively built in pioneer efforts by the

NHLBI.” He also sees signs of a backlash against health promotion: “Junk

science is a term now being used to

derogate legitimate study results as

well as frivolous research claims.” 

Of equal concern, said Dr. Blackburn, is a public “that doesn’t understand, hears something different every

year,” and is unclear about what to

do—forgetting what good science has

shown. “I am reminded,” he said, “of

the admonition of one of my medical

One of the most remarkable health advances of the past 50 years has been a

better understanding of how blood pressure, cholesterol, and other factors

increase a person’s risk of heart disease. Yet some puzzles remain. For example,

why do most heart attacks happen in patients with moderately high, but still

average, blood cholesterol? What still unidentified factors might work with

known risk factors to trigger heart disease?

More than 300 possible new risk factors have been proposed; of those, nine

are “now entering prime time,” said Dr. Jeffrey M. Hoeg, chief, Section on Cell

Biology, Molecular Disease Branch, NHLBI, at a national conference press

briefing. That is, they are close to or are now being studied in clinical trials in

humans. Here’s the latest on the three most likely: 

Homocysteine: Findings from the NHLBI’s Framingham Heart Study and

elsewhere show that high levels of this amino acid may contribute to heart disease, stroke, and a reduced blood flow to the hands and feet. Researchers

believe that homocysteine may work in one or all of these ways: be involved

with atherosclerosis; make blood more likely to clot; and make blood vessels

less flexible and less able to widen to allow increased blood flow.

Homocysteine levels are determined partly by genetics but also by the consumption of vitamins, especially folic acid, B6, and B12. Those vitamins help

process homocysteine and in theory could be used to control abnormally high

homocysteine levels. However, people who follow a well-balanced diet should

get plenty of these vitamins; recommended daily values are 400 micrograms for

folic acid, 2 milligrams for B6, and 6 micrograms for B12.

Lp(a): This is a type of low density lipoprotein, often called the “bad cholesterol” because it carries most of the cholesterol in the blood. Lp(a) is now

thought to be a risk factor for early onset of heart disease. Apparently the Lp(a)

molecule has an extra protein particle attached; the particle resembles the protein involved in blood clotting. Lp(a) does its damage by preventing the

breakup of clots. 

Infectious agents: Viruses and bacteria may harm blood vessel walls, starting the atherosclerotic process. For example, researchers have found a kind of

herpes virus, cytomegalovirus (CMV), in lesions from diseased coronary arteries.

NHLBI researchers found that patients with antibodies for CMV have a high

rate of artery reclosure after the artery is cleared out with an atherectomy.

Chlamydia pneumoniae, an airborne bacterium that causes respiratory infections, may be another culprit. In small pilot studies, chlamydia-infected

patients who had had a heart attack were treated with antibiotics and had a

reduced risk of a second heart attack. 

How might these infectious agents work? Microbes invading the vessel

wall could trigger an immune response so that the tissue tries to heal itself,

forming a type of scar tissue that can narrow the vessel. Or the blood vessel

also can narrow as it tries to “remodel” itself; the vessel constricts, producing a

smaller opening. 

“We now realize that atherosclerosis is more than just an accumulation of

sludge and rusty pipes—the blood vessel is actually a living structure,” said Dr.

Peter Libby, director, Vascular Medicine and Atherosclerosis Unit, Brigham and

Women’s Hospital, Boston, explaining the connection between infection,

inflammation, and atherosclerosis. Like any other tissue, this living structure

can react to invading microbes, triggering an inflammatory response that

changes the vessel’s shape and character.

“The past 50 years have seen

tremendous advances in cardiovascular care, and our medical research will undoubtedly

continue to pay handsome 

dividends in the future. We

can only imagine what breakthroughs lie ahead.”

(continued on page 16)
HEARTMEMO

SUMMER 1998

16Cardiovascular Health Conference

anatomical equipment needed to 

properly process animal fat.” This

point was made graphically in a startling closeup of brachial arteries

immediately after high-fat meals.

“The results are dramatic,” said Dr.

LaRosa. “Just minutes after eating, a

high-fat meal can substantially

restrict the arterial passages.” 

Compelling evidence also comes

from Japan, he noted. “Dietary

changes in Japan began after the loss

of the war. Being poor after the war,

and basically vegetarian to begin

(continued from page 5)

with, the Japanese didn’t change their

basic diet until after the 1950s. Then,

they started selling us TVs, VCRs, and

all those other cool electronics. We

got even with them by selling them

hamburgers.

“Recent trends in Japan are the

opposite of those in the United

States,” he said. “Animal fat intake

has risen and so has the rate of coronary disease.” Moreover, studies of

Japanese people who emigrate to the

United States demonstrate a linear

increase in saturated fat intake, blood

cholesterol levels, and coronary risk.

“I am extremely confident,” he concluded, “that diet is by far the most

important factor in coronary heart disease. Metabolic studies reproduced in

clinical trials show that we are achieving success over and over again. Diets

do work, even if the patients don’t

always follow them!” 

Even if we were not natural herbivores, he added, we would still need to

watch our fat intake. Dr. LaRosa illustrated with a case study: his cat,

Thelonious. 

“Thelonious has lived a very carefree life, no doubt assuming that as a

natural carnivore he could eat whatever he wanted. So I showed him this

slide. As you can see, in this study,

cats who ate a high-fat diet raised their

total cholesterol substantially and also

increased the mean intimal thickness

of the artery wall.

“So even carnivores,” he noted,

“given enough animal fat and sedentary living – and I guarantee you that

no one is more sedentary than Thelonious – can develop atherosclerosis.”

Dr. Scott M. Grundy considered

the implications of recent clinical trials, focusing on questions that have

been answered and problems that have

yet to be resolved. He is director of

the Center for Human Nutrition, University of Texas Southwestern Medical

Center in Dallas. 

“Perhaps the most pressing 

question,” he said, “is whether lowering cholesterol really reduces the risk

of heart disease at all.” Although the

early trials were ambiguous, this

cause-effect relationship has now

been documented beyond any doubt,

he said. For example, following a

meta-analysis by Dr. David Gordon

of NHLBI’s Division of Heart and

Vascular Diseases, Dr. Grundy said,

“the combined results point to an

overall positive effect of lowering 

cholesterol: a reduction of coronary

heart disease of 15 to 45 percent.”

A related question is whether lowering cholesterol reduces recurring

coronary events for patients who

already have coronary heart disease.

Again, results from a meta-analysis of

secondary prevention trials “point to

a highly significant reduction of

about 25 percent.”

“A later study from the statin trials

confirms these findings,” he noted.

“These drugs produced a 34 percent

reduction in total coronary events.”

Moreover, the statin trials “demonstrated conclusively that cholesterol

lowering is not clinically dangerous.”

The next question asked was

whether lowering cholesterol works

in special populations such as smokers and people with diabetes. “Once

again, experimental trials—this time

the Scandinavian 4S study—proved

that the answer was yes,” said Dr.

Grundy. Does it also hold for

women? The 4S study again said yes.

And the elderly? Again the 4S trial

showed marked improvement in the

treatment group older than age 60,

school mentors: ‘Keep an

open mind

but not so

open that

your brains

fall out.’

“Where do

we go from

here?” he

asked. “There

is a clear challenge ahead of us internationally. Enough is known about

the effects of CVD—solutions should

be pursued. Those of us working in

prevention know the answers: promotion of heart-healthy strategies,

school-based education, and regional

efforts need to be carried out, especially legislative efforts.”

Also, “a healthy stand must be

maintained against the health backlash. And current evidence points to

an urgent need for new research.

“In closing,” Dr. Blackburn said, “I

emphasize at this 50th celebration of

our partnership with the NHLBI that

a population strategy, wedded to a

modern medical strategy, is the more

effective and efficient approach to prevention. In this effort, the medical

community, the NHLBI, voluntary

and government health agencies, and

the people all have a role.” 

“We’re seeing the enthusiasm

for aggressive drug treatment

diminishing the stress on

dietary treatment. We have 

to ask ourselves if this is 

altogether a good thing.”

(continued from page 15)
HEARTMEMO

SUMMER 1998

17Mark Your Calendar

as did another study of the effects of

statin drugs on people in that age

group. So we can say, yes, lowering

cholesterol is effective across the

board.

“Importantly, the 4S study also

showed a reduction in strokes,” he

added, “an outcome that we do not

clearly understand and that warrants

further research.

“The biggest remaining question

is the cost-effectiveness of lowering

cholesterol,” Dr. Grundy said. For

secondary prevention, the trials have

convincingly demonstrated that lowering cholesterol is cost-effective. For

primary prevention in low-risk individuals, this is still an open question.

Other issues that remain:

• In secondary prevention, “we have

to figure out exactly how low we

should drive the cholesterol level,

and whether or not we should

treat patients who have low 

cholesterol already.”

• In primary prevention, “who

should receive aggressive cholesterol-lowering therapy? Just the

estimated 12 million people across

the country who are seen as high

risk, or also the estimated 40 

million classified as having moderate risk?

• “How do we connect this kind of

aggressive therapy to a lifetime

prevention or public health

approach? We’re seeing the

enthusiasm for aggressive drug

treatment diminishing the stress

on dietary treatment. We have to

ask ourselves if this is altogether a

good thing.”

Finally, Dr. Antonio M. Gotto

looked at research frontiers that point

the way to cholesterol science in the

21st century. Dr. Gotto is Stephen

and Suzanne Weiss Dean at Cornell

University Medical College, New

York, NY.

“I judge that the top [cholesterol]

research advances of the past 10 years

Mark Your

Calendar

•July 12-15, 1998:

13th International Interdisciplinary Conference on Hypertension in Blacks, sponsored by the

International Society on Hypertension in Blacks. Theme: “Metabolic

Risk Factors and Hypertensive Cardiovascular Disease.” Charleston

Place Hotel, Charleston, SC. Call

404-875-6263.

• August 30-September 2, 1998:

“Third International Heart Health

Conference: Heart Health Into the

Next Millenium.” The 50th

anniversary symposium will cover

the Framingham Heart Study,

NHLBI clinical trials, the National

High Blood Pressure Education Program, and NHLBI national guidelines for clinical practice. Raffles

City Convention Centre, Singapore.

Call 65-336-3875 or e-mail

wxpsin@singnet.com.sg.

• September 14, 1998: “Oxidative

Stress and Disease,” NHLBI 50th

anniversary symposium. Theme:

how oxidative stress leads to damage of biological macromolecules

and how this free-radical-induced

damage is involved in the causes or

progression of various diseases.

Lister Hill Auditorium, National

Institutes of Health, Bethesda,

MD. Call 301-496-4910. 

• September 30-October 2, 1998.

5th National Scientific Session of

the Consortium for Southeastern

Hypertension Control (COSEHC).

Grand Hyatt Atlanta, Buckhead,

Atlanta, GA. Call 800-267-3421.

• November 8-11, 1998: American

Heart Association, 71st Annual

Scientific Sessions, Dallas Convention Center, Dallas, TX. Call 214-

706-1543 or check this Web site:

www.amhrt.org/Scientific/confer/

sessions/sessions.html. 

A B IRTHDAY F O R F RAMINGHAM

Fifty years have passed since researchers began tracking the course of

cardiovascular disease in a small New England town. This September, the

now-famous Framingham Heart Study in Massachusetts will celebrate its

50th birthday with 2 days of special events. Tentative plans for the first day

include a tribute to the entire town and the 6,000 people who have participated in the NHLBI-sponsored study; television’s prime time physician, Dr.

Tim Johnson, will moderate. That night there will be a banquet to honor

the scores of researchers who have conducted the study. Day two features a

scientific symposium at which researchers will present the latest findings

from Framingham data. National media coverage is expected, and you can

read all about it in a future HeartMemo.

(continued on page 18)
HEARTMEMO

SUMMER 1998

18Cardiovascular Health Conference

have been statin drugs, gene therapy,

and inflammatory responses.” Starting from these, he said, “we can anticipate the primary concerns of

tomorrow.”

One of them will be to determine

exactly how lipid-lowering drugs exert

their anti-atherosclerotic effects in the

arteries, he said. This basic research

“Calorie intake has remained

fairly stable over the past 30

years, and around two-thirds

of Americans still eat more

than 30 percent of their 

calories as fat.” 

on mechanisms may lead to new ways

of attacking the atherosclerotic

process. Statin drugs for stroke prevention are an important new direction, Dr. Gotto said. And researchers

need to determine and compare the

clinical benefits of statins versus other

cholesterol-lowering drugs. 

An extremely promising lead

comes from research on gene therapy

to reverse atherosclerosis. “In an

experiment that I am working on

now, we wanted to see if we could

take coronary arteries that were totally clogged and unblock the vessels

with gene therapy,” he related. “Initially we worked with pigs. We

observed a completely blocked artery

for 3 weeks and then added the 

therapeutic gene.

“We waited another 4 weeks and

then observed the artery,” he said.

“We found that blood flow had been

completely restored. We took these

data to the FDA and have obtained

approval to test this gene therapy on

15 human patients.” 

Finally, he said, the role of inflammation in atherosclerosis will be a

research focus in the next century.

Reducing this inflammatory

response—for example, with medication—is an important line of inquiry.

“In conclusion,” Dr. Gotto

observed, “I want to reaffirm that the

relation between cholesterol modification and reduction in coronary

heart disease is well accepted. Substantial strides have been made in

refining our understanding of lipidbased risk, but clearly much work

remains to be done.” 

HeartFacts: Heart Data

REPORT CARD: THE HEART OF AMERICA’S CHILDREN

 Heart disease begins early in life. How are America’s children doing? Here’s an update:

 ̋ About 1 percent of U.S. children and adolescents have high blood pressure.

 ̋ Average blood pressures tend to rise with age—slowly before adolescence and faster after puberty.

 ̋ Children’s high blood pressure tends to persist into adulthood, even for children with high-normal

pressure.

 ̋ Average blood cholesterol levels in American children and adolescents are too high.

 ̋ Children and adolescents with elevated blood cholesterol levels are more likely to have elevated levels 

as adults.

 ̋ Children typically start smoking cigarettes in grades 5 and 6.

 ̋ Eleven percent (or 4.7 million) of those ages 6 to 17 are overweight—more than double the percentage

of a decade ago.

 ̋ Up to 20 percent of overweight children remain so throughout life.

 ̋ Most children accumulate at least 1 hour of physical activity daily, but a sizable percentage do not get

frequent, vigorous, continuous activity.

 ̋ Of high school students, only about half of boys and a quarter of girls do vigorous physical activity

three or more times a week.

 ̋ Activity levels of girls are below those of boys and tend to decline with age.

(continued from page 17)
HEARTMEMO

SUMMER 1998

19HeartNet

HeartNet

Here are some Web sites that offer useful information on special populations:

National Women’s Health Information Center

http://www.4woman.org

This site provides answers to many frequently asked questions about

women’s health as well as news releases, links to Federal government and other

sites that deal with women’s health, and access to several online medical

resources including MEDLINE and online medical dictionaries. The database,

which you can search by topic, will point you to publications of interest and link

you to their download site if available.

Administration on Aging

http://www.aoa.dhhs.gov

For information on resources such as Eldercare, legal resources, or links to

Web sites of interest to older Americans, go to this Web site. An office of the

Department of Health and Human Services, the Administration on Aging,

offers a multitude of resources including directories of nursing homes, State

agencies, and other Web sites. A variety of fact sheets and publications

produced by the Administration on Aging also are available.

The National Rural Health Association

http://www.nrharural.org

The National Rural Health Association provides resources and support to

health care professionals who work in rural areas. Among the items of interest

on its Web site are a bulletin board for members to exchange ideas, information

on advocacy for rural health issues, upcoming rural health meetings, and links

to others sites that provide related resources.

The Disability Resource

http://www.disabilityresource.com

The Disability Resource provides information and resources for people with

all types of disabilities. Its Web site hosts chat rooms, lists upcoming events,

sells publications of interest, and allows you to search for other resources using a

variety of Internet search engines. Members can schedule chats on specific

topics and design their own Web page.

National Health Information Center

http://nhic-nt.health.org

Finally, if you work with another special population and do not know where

to look for information, there’s the National Health Information Center. This

site provides a searchable database of Federal government and private

clearinghouses—so you can find all those toll-free numbers and Web sites in one

place. It also lists national health observances such as National High Blood

Pressure Education Month and National Cholesterol Education Month. 

Get in Shape 

on the Web

Remember Dr. C. Everett Koop,

former surgeon general and

health conscience of America?

He’s founded a lively Web site

called Shape Up America! Its

goal is to offer “the latest

information on safe weight

management and physical

fitness.” It does this with some

nifty interactive “rooms.” For

example, click on the

“cyberkitchen,” give it some vital

statistics about your height,

weight, etc., and get the total

daily calories you need to

maintain or lose weight, with

customized meal plans to help

you do this. Click on the BMI

room, enter some vitals, and

you’ll learn your body mass index,

plus what it means in terms of

fitness and overweight. The

health and fitness room overflows

with interesting exercises,

including some you probably

never heard of. For instance, to

make walking more interesting,

Shape Up America suggests a

“total walking plan” that includes

animal walks (walk like a bear, a

giraffe, etc.), walking backward,

and other unusual variations.

There’s also a professional center, a

media center, and a library. The

address is http://www.shapeup.org.
HEARTMEMO

SUMMER 1998

20HeartFunds

HeartFunds

GETTING A GRANT FROM

THE GOVERNMENT

Tracking down sources of money for

cardiovascular health research and

education can be frustrating and timeconsuming. Here is some basic

information on two sources you might

consider: the National Institutes of

Health (NIH) and the Centers for

Disease Control and Prevention (CDC)

in Atlanta, GA. 

The NIH, NHLBI’s parent agency,

funds biomedical research that aids in

the detection, diagnosis, and

treatment of disease and disability.

NIH-funded grants in cardiovascular

disease range from basic research on

atherosclerosis to innovative

cardiovascular health education

programs in schools and communities.

Proposals must have a research or

evaluation component to compete for

NIH funding.

To find NIH-sponsored funding

opportunities that might fit your

project, the key source is the NIH

Guide for Grants and Contracts, a

periodical that lists current requests for

grant and contract proposals. It’s

accessible through the Internet at

www.nih.gov/grants/oer.htm. The site

allows you to search current and back

issues of the Guide for announcements

related to your interests. You can

receive weekly e-mail updates by

registering for the LISTSERV option. 

You can also call ASKNIH at 301-

435-0714 or e-mail questions to

asknih@od.nih.gov. Grant application

forms and instructions are available

from either the Guide Web page or the

ASKNIH phone number.

The CDC funds research and

programs that promote health and

quality of life by preventing and

controlling disease, injury, and

disability. Areas of interest include

public health concerns such as chronic

disease prevention, health promotion,

nutrition, and diabetes control. 

CDC grant announcements are

published in the Federal Register, 

which you can find at local libraries.

CDC funding opportunities and

application forms are available online

at http://www.cdc.gov/funding.htm.

Questions can be e-mailed to

netinfo@cdc.gov. Application

packets can be ordered by telephone,

404-332-4561.

GRANTSNET HELPS

SCIENTISTS, STUDENTS

FIND RESEARCH FUNDS

A new Web site helps biomedical

scientists, students, and faculty find

funding sources. GrantsNet was

developed by the Howard Hughes

Medical Institute and the American

Association for the Advancement of

Science. According to its founders,

the site “provides one-stop shopping

for grants, fellowships, and other

sources of support.” You can use it

for free, although you are asked to

register. Automatic e-mail

notification of updates is offered as an

option. Here’s the address:

grantsnet@aaas.org. 

New at the NHLBI 

Information Center

Problem Sleepiness in Your

Patient (#4073, $2.50 each).

Getting sleepy at the wrong time can

cause many problems ranging from

poor functioning at home, work, and

school to life-threatening auto and

industrial accidents. Primary care

physicians are in an ideal position to

identify the problem and start treatment. This physicians’ guide covers

the causes, consequences, identification, and management of problem

sleepiness. It includes sample 

questions for assessing patients, a comprehensive reference list, and sources

for more information.

Facts About Problem Sleepiness

(#4071, single copy free). 

The companion piece for patients, this

lay-language fact sheet explains what is

known about the causes, diagnosis, and

treatment of different sleep disorders.

Special sections cover shift workers,

adolescents, and medical conditions

and drugs that can disrupt sleep. The

fact sheet emphasizes tips for

avoiding problem sleepiness and its

consequences.

Educational Strategies To

Prevent Prehospital Delay 

in Patients at High Risk for

Acute Myocardial Infarction

(#3787, $3 each). For the estimated

13 million Americans with

cardiovascular disease, the risk of

heart attack and death is five to seven

times higher than for the general
HEARTMEMO

SUMMER 1998

21New at the NHLBI Information Center

population. This report, from a

working group of the National Heart

Attack Alert Program, advises

physicians and other health care

providers on how to reduce treatment

delays for their high-risk patients.

Included are educational strategies, a

sample patient advice sheet, and

instructions for setting up an office

telephone triage system to minimize

time to treatment. 

The Sixth Report of the Joint

National Committee on

Prevention, Detection,

Evaluation, and Treatment of

High Blood Pressure (#4080,

free). The definitive clinical guide on

the subject, this publication has

everything the health care professional needs to know about high

blood pressure. Sections are included

on blood pressure measurement and

clinical evaluation, prevention,

treatment, and managing high blood

pressure in special populations.

Based on an exhaustive review of the

latest science by more than 100

experts, it comes from the National

High Blood Pressure Education

Program and updates a 1991 clinical

guide. (For highlights, see

HeartMemo Fall 1997.) 

Charge my VISA account: Charge my MasterCard account:

Check enclosed made payable to NHLBI Information Center

Indicate your method of payment.

Your satisfaction is important to us.

If you have any problems with your order,

call the Information Center:

301-251-1222.

Exp. Date

Signature

National Heart, Lung, and Blood Institute

Order Form

Order # Title of Item Total Price

Price per

Unit Discount

To order materials, please complete the order form. 

All orders must be prepaid. 

Fax or phone your charge card order. 

Fax number: 301-251-1223

Telephone number: 301-251-1222

15% on orders of 25 or more copies 

of a single item.

20% on orders of 100 or more copies 

of a single item.

No discounts on Package Prices.

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+ Shipping and Handling

(from box at left)

TOTAL DUE

SHIPPING & HANDLING

All orders sent by First Class Mail

Name (please print)

Value of Order S/H Charge*

$.50—$6.00 or up to 5 free items No Charge

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$25.01—$50.00 $6.00

$50.01—$100.00 $8.00

$100.01—$200.00 $12.00

$200.01—$300.00 $25.00

$300.01+ Call the Information Center

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*Add $2.00 for orders to Canada and Mexico.

Add $5.00 for orders to all other countries outside the United States.

Make checks payable to 

NHLBI Information Center and send to:

NHLBI Information Center

P.O. Box 30105

Bethesda, MD 20824-0105
HEARTMEMO

SUMMER 1998

22HeartSources

HeartSources

PUTTING THE RIGHT

SPIN ON NUTRITION

If you work with elementaryschoolers, you may want to check out

the Special Program in Nutrition

(SPIN).

New from the Gladstone Institute

of Cardiovascular Disease in San

Francisco, CA, SPIN is a lively and

entertaining nutrition education

program for third- and fourth-grade

students. It was pilot-tested and

evaluated in the Millbrae, CA,

elementary school district for 2 years

and proved so popular that the

Institute is making it available

nationwide.

The two-volume program includes:

• 27 lessons for third-graders and 7

lessons for fourth-graders. The

lessons include objectives for

students, a lesson plan, background

on the topic for teachers, worksheets, activities, homework

assignments, extra materials such

as flash cards and posters, and an

evaluation form for the teacher.

• A parents’ program with plans for

10 meetings. Each plan contains

objectives, background information, an agenda, procedures,

handouts, and other supplements.

• An in-service training section for

teachers.

SPIN is a flexible program that can

be integrated into an established

health curriculum. It can be used

with or without the in-service

teacher training, the parental

component, or the classroom

tastings. The curriculum costs

$30, a companion cookbook $10,

and a curriculum/cookbook set

$35; prices include shipping.

To find out more or to order

materials, contact the Gladstone

Institute of Cardiovascular Disease,

P.O. Box 419100, San Francisco, CA

94141, 415-826-7500.

SEND YOUR EMPLOYEES

ON A HEALTH TRIP

The Wellness Councils of America

(WELCOA) has launched HealthTrip,

a worksite program to promote

physical activity.

Developed under a grant from the

Centers for Disease Control and

Prevention, HealthTrip contains 13

modules on diverse health issues such

as physical activity, high blood

pressure, heart health, cholesterol

awareness, low-fat eating and

shopping, and weight control. 

Employees who participate in

HealthTrip embark on a fictitious

journey across the country to 13

familiar-sounding cities, where they

learn how to make changes to improve

their health. At each stop, travelers

receive handouts and a personal

passport log to record mileage earned

through physical activity. Along the

way, they practice healthy lifestyle

choices, log

their

activity

points,

and get

recognition and rewards.

Here is the HealthTrip itinerary,

with areas of interest:

Aerobiquerque (exercise, fitness

basics, proper shoes), Cholesterol

Springs (low-fat cooking, food

labels), The Great Smokey

Mountains (quitting smoking,

secondhand smoke), Heartford

(heart-smart eating, lifestyle tips),

Las Veggies (salad bar savvy, eating

more fruits and vegetables),

Minnepeopleis (prenatal care, family

activities), Newbalancewick (stress

management), OnTheRocks Island

(alcohol use and abuse), Pressureburg

(blood pressure control, salt

substitutes), Weightville (diets and

food cues), Wella Wella (self-care,

immunizations, and checkups), and

YoSafety National Park (safety belts,

bike and sun safety).

The HealthTrip “suitcase” also

contains an 80-page tour director’s

planning guide with low-cost

motivational ideas to get people on

board, 58 camera-ready handouts, a

poster to promote the program, and

a customized passport cover.

For more information or to order

HealthTrip, contact the Wellness

Councils of America, 7101 Newport

Avenue, Suite 311, Omaha, NE

68152, 402-572-3590. Each

suitcase costs $89 plus 8 percent

shipping and

handling;

discounts are

available for

bulk quantities.
HEARTMEMO

SUMMER 1998

23Ditto: Reproducibles

D O Y O U K NOW Y OUR N UMBERS ?

Here are the levels for healthy adults for blood cholesterol and blood pressure:

BLOOD CHOLESTEROL LEVELS

Desirable Borderline-High High

Total Cholesterol < 200 mg/dL 200-239 mg/dL ≥ 240 mg/dL

LDL Cholesterol < 130 mg/dL 130-159 mg/dL ≥ 160 mg/dL

HDL Cholesterol a low HDL cholesterol is < 35 mg/dL

BLOOD PRESSURE LEVELS

Systolic Diastolic

Optimal <120 mm Hg and <80 mm Hg

Normal <130 mm Hg and <85 mm Hg

High-Normal 130-139 mm Hg or 85-89 mm Hg

Hypertension

Stage 1 140-159 mm Hg or 90-99 mm Hg

Stage 2 160-179 mm Hg or 100-109 mm Hg

Stage 3 > 180 mm Hg or >110 mm Hg
HeartMemo is a National Heart, Lung, and

Blood Institute (NHLBI) publication for health

professionals working in disciplines and settings related to cardiovascular health. HeartMemo reports on the activities of the NHLBI’s

national education programs, projects, initiatives, and research advances and on other news

of interest to the field. Readers are urged to

submit information on current treatment and

prevention activities as well as research findings

and activities.

HeartMemo is a publication of the U.S. Government published by the Office of Prevention,

Education, and Control of the NHLBI. Unless

otherwise specified, all materials appearing in

HeartMemo are in the public domain and may

be reproduced without permission from the

NHLBI or the authors. Citation of the source

is appreciated.

To subscribe to HeartMemo (at no charge), order

extra copies, or submit an address change, contact the NHLBI Information Center, P.O. Box

30105, Bethesda, MD 20824-0105; phone

301-251-1222; fax 301-251-1223.

MANAGING EDITOR:

June R. Wyman

R.O.W. Sciences, Inc.

PRODUCTION EDITOR:

Laina Pack

Office of Prevention, Education, and 

Control, NHLBI

COPY EDITORS:

Daria T. Donaldson

Meredith H. Pond

R.O.W. Sciences, Inc.

ART DIRECTOR:

Douglas R. Bishop

R.O.W. Sciences, Inc.

EDITORIAL BOARD:

National Heart, Lung, and Blood

Institute

Keith Hewitt

Coordinator, NHLBI Information Center,

Office of Prevention, Education, and 

Control

Terry Long

Senior Manager, Health Communications

and Information Science, Office of 

Prevention, Education, and Control

Laina Pack

Writer/Editor, Office of Prevention, 

Education, and Control

Edward J. Roccella

Coordinator, National High Blood 

Pressure Education Program

Louise Williams

Senior Science Writer, Office of Prevention,

Education, and Control

R.O.W. Sciences, Inc.

Maureen Harris

Manager, Support for NHLBI Obesity

Education Initiative

Marian Kratage

Marketing Manager, NHLBI Support

Contract

Margot Raphael

Manager, NHLBI Information Center

CONTRIBUTING WRITERS:

Darrell E. Anderson, Claudia

Flatau, Louise Williams

This publication is produced by 

R.O.W. Sciences, Inc., Rockville, MD,

under Contract No. NO1-HO-39208

from the National Heart, Lung, and

Blood Institute.

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