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Association of Blood Pressure Classification in Young Adults Using the 2017 American College of Cardiology/American Heart Association Blood Pressure Guideline With Cardiovascular Events Later in Life

Educational Objective
To understand that young adults with hypertension are at increased risk of cardiovascular disease (CVD) by middle age.
1 Credit CME
Key Points

Question  Do adults who develop hypertension, defined using the 2017 American College of Cardiology (ACC)/American Heart Association (AHA) blood pressure guideline, before age 40 years have a higher risk for cardiovascular disease events compared with those who maintain normal blood pressure?

Findings  In this prospective cohort study of 4851 young adults (aged 18-30 years), elevated blood pressure, stage 1 hypertension, and stage 2 hypertension occurring before age 40 years were each associated with a significantly higher risk for cardiovascular disease events compared with the reference group with normal blood pressure (hazard ratios: 1.67, 1.75, and 3.49, respectively).

Meaning  The blood pressure classification in the 2017 ACC/AHA blood pressure guideline may help identify young adults at higher risk for cardiovascular disease events.

Abstract

Importance  Little is known regarding the association between level of blood pressure (BP) in young adulthood and cardiovascular disease (CVD) events by middle age.

Objective  To assess whether young adults who developed hypertension, defined by the 2017 American College of Cardiology (ACC)/American Heart Association (AHA) BP guideline, before age 40 years have higher risk for CVD events compared with those who maintained normal BP.

Design, Setting, and Participants  Analyses were conducted in the prospective cohort Coronary Artery Risk Development in Young Adults (CARDIA) study, started in March 1985. CARDIA enrolled 5115 African American and white participants aged 18 to 30 years from 4 US field centers (Birmingham, Alabama; Chicago, Illinois; Minneapolis, Minnesota; and Oakland, California). Outcomes were available through August 2015.

Exposures  Using the highest BP measured from the first examination to the examination closest to, but not after, age 40 years, each participant was categorized as having normal BP (untreated systolic BP [SBP] <120 mm Hg and diastolic BP [DBP] <80 mm Hg; n = 2574); elevated BP (untreated SBP 120-129 mm Hg and DBP <80 mm Hg; n = 445); stage 1 hypertension (untreated SBP 130-139 mm Hg or DBP 80-89 mm Hg; n = 1194); or stage 2 hypertension (SBP ≥140 mm Hg, DBP ≥90 mm Hg, or taking antihypertensive medication; n = 638).

Main Outcomes and Measures  CVD events: fatal and nonfatal coronary heart disease (CHD), heart failure, stroke, transient ischemic attack, or intervention for peripheral artery disease (PAD).

Results  The final cohort included 4851 adults (mean age when follow-up for outcomes began, 35.7 years [SD, 3.6]; 2657 women [55%]; 2441 African American [50%]; 206 taking antihypertensive medication [4%]). Over a median follow-up of 18.8 years, 228 incident CVD events occurred (CHD, 109; stroke, 63; heart failure, 48; PAD, 8). CVD incidence rates for normal BP, elevated BP, stage 1 hypertension, and stage 2 hypertension were 1.37 (95% CI, 1.07-1.75), 2.74 (95% CI, 1.78-4.20), 3.15 (95% CI, 2.47-4.02), and 8.04 (95% CI, 6.45-10.03) per 1000 person-years, respectively. After multivariable adjustment, hazard ratios for CVD events for elevated BP, stage 1 hypertension, and stage 2 hypertension vs normal BP were 1.67 (95% CI, 1.01-2.77), 1.75 (95% CI, 1.22-2.53), and 3.49 (95% CI, 2.42-5.05), respectively.

Conclusions and Relevance  Among young adults, those with elevated blood pressure, stage 1 hypertension, and stage 2 hypertension before age 40 years, as defined by the blood pressure classification in the 2017 American College of Cardiology/American Heart Association (ACC/AHA) guidelines, had significantly higher risk for subsequent cardiovascular disease events compared with those with normal blood pressure before age 40 years. The ACC/AHA blood pressure classification system may help identify young adults at higher risk for cardiovascular disease events.

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Article Information

Accepted for Publication: August 21, 2018.

Corresponding Author: Yuichiro Yano, MD, PhD, Department of Community and Family Medicine, Duke University, 2200 W Main Street, Erwin Square Bldg, Suite 600, Durham, NC 27705 (yyano@jichi.jp or yuichiro.yano@duke.edu).

Author Contributions: Dr Yano had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Yano, Viera, Gidding, Muntner, Lloyd-Jones.

Acquisition, analysis, or interpretation of data: Yano, Reis, Colangelo, Shimbo, Allen, Gidding, Bress, Greenland, Muntner, Lloyd-Jones.

Drafting of the manuscript: Yano, Bress.

Critical revision of the manuscript for important intellectual content: Reis, Colangelo, Shimbo, Viera, Allen, Gidding, Bress, Greenland, Muntner, Lloyd-Jones.

Statistical analysis: Yano, Colangelo.

Obtained funding: Gidding, Lloyd-Jones.

Administrative, technical, or material support: Reis, Muntner.

Supervision: Reis, Gidding, Greenland, Lloyd-Jones.

Review and approval of the final manuscript: Bress.

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Ms Colangelo reported Northwestern University receiving grants from the National Heart, Lung, and Blood Institute (NHLBI) during the conduct of the study. Dr Gidding reported receiving grants from the National Institutes of Health (NIH) during the conduct of the study. Dr Bress reported receiving grants from Novartis and Amarain outside the submitted work. Dr Greenland reported receiving grants from NIH during the conduct of the study. Dr Muntner reported receiving grants from Amgen Inc outside the submitted work. No other disclosures were reported.

Funding/Support: The Coronary Artery Risk Development in Young Adults Study (CARDIA) was conducted and supported by grants HHSN268201300025C and HHSN268201300026C from NHLBI in collaboration with the University of Alabama at Birmingham, HHSN268201300027C from Northwestern University, HHSN268201300028C from the University of Minnesota, HHSN268201300029C from the Kaiser Foundation Research Institute, HHSN268200900041C from Johns Hopkins University School of Medicine, P20GM104357 from the National Institute of General Medical Sciences of the NIH (Dr Yano), 15SFRN2390002 from the American Heart Association (Dr Muntner), K24-HL125704 from NHLBI (Dr Shimbo), and by the Intramural Research Program of the National Institute on Aging (NIA) and an intra-agency agreement between NIA and NHLBI (AG0005).

Role of the Funder/Sponsor: The National Heart, Lung, and Blood Institute had input into design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: The views expressed in this manuscript are those of the authors and do not necessarily represent the views of the NHLBI, NIH, or the US Department of Health and Human Services. Dr Greenland, a JAMA senior editor, was not involved in the review of or decision to publish this article.

Additional Information: The article was reviewed by CARDIA for scientific content.

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