Salute to the Icons of Hypertension

Marvin Moser, MD


The current dissatisfaction with the percentage of hypertensive patients controlled at goal levels tends to obscure the remarkable advances that have been made during the past 50 years in the management of this disease. Through the efforts of the National High Blood Pressure Education Program, the American Heart Association, the Citizens for the Treatment of High Blood Pressure, plus many other organizations and the pharmaceutical industry, the number of patients aware of hypertension has increased dramatically. The number undergoing treatment has also increased, but controlled patients make up only about one third of the approximately 50 million hypertensive individuals in the United States. Recent studies have confirmed what previous studies reported: More than 60% of patients with hypertension can be controlled at a goal level of <140/90 mm Hg if specific guidelines and protocols are followed.

Sometimes forgotten in our criticisms of the management of hypertension are the people who were the prime movers in increasing our understanding of the mechanisms of the disease as well as putting the facts into practice with innovative ideas for treatment control. Many of these icons are deceased. Dr. Irvine Page of the Cleveland Clinic attempted to lower blood pressure in severe hypertensives by injecting them with typhoid bacteria. Blood pressures were indeed lowered when vasodilation occurred as the result of a high fever. Some of the manifestations of malignant hypertension were also reversed. This was a remarkable demonstration that lowering blood pressure was possible and that some of the pathophysiologic changes of vasoconstriction could be, at least temporarily, reduced. This took place at a time when many physicians still believed that elevated blood pressure was a compensatory mechanism and should be left alone. Drs. Reginald Smithwick and Max Minor Peet performed extensive surgery, removing dorsal and later thoraco-lumbar sympathetic ganglia. Blood pressures were lowered. Patients were in the hospital for as long as 4-6 weeks and suffered frequent and annoying symptoms, but the manifestations of malignant hypertension were often reversed, and patients lived longer. Dr. Walter Kempner treated hundreds of people at Duke University where he prescribed rigid, hard-tofollow, insipid diets that only the most zealous would adhere to, but patients with malignant hypertension on the Kempner Rice and Fruit Juice Diet had their blood pressures reduced and experienced reversal of funduscopic findings and heart failure.

More recent icons include Drs. Harriet Dustan of the Cleveland Clinic, Texas-based Walter Kirkendal, Mitchell Perry of Washington University in St. Louis, and Herbert Langford of the University of Mississippi, who all played significant roles in helping us understand the pathophysiology of hypertension and the mechanisms of action of antihypertensive drugs. Drs. Henry Schroeder and Perry described dramatic results with triple-drug therapy. All of these scientists are deceased.

Some of the pathfinders, discoverers, and heroes of the hypertension story are, however, still telling their stories. In this and subsequent issues of The Journal of Clinical Hypertension we will be interviewing icons to highlight their achievements and share their views on challenges for the future.

It is appropriate that the first icon in the series is Dr. Edward Freis of Washington, DC. I first became acquainted with Dr. Freis in 1952 when I was at the Walter Reed Army Medical Center evaluating adrenergic blocking agents, specifically phenoxybenazmine (dibenzyline), and studying vascular resistance and the effects of sympathetic nervous system blockade on elevated blood pressure. Dr. Fries, who already had extensive training in many aspects of hypertension, was doing research at Georgetown on hexamethonium, a ganglion-blocking agent. Dr. Fries went on to study almost all of the antihypertensive drugs, including the first orally effective diuretic, chlorothiazide, in 1957. He is remembered most, however, for his organization and guidance of the first well designed, placebo-controlled clinical trial on hypertension -- the first VA Cooperative Study.

Included are some of Dr. Fries' comments about his major contributions to hypertension treatment as well as some of his thoughts on compliance, which he believes is probably the most important challenge for the future.