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Original Investigation
April 2017

Racial Differences in Associations of Blood Pressure Components in Young Adulthood With Incident Cardiovascular Disease by Middle AgeCoronary Artery Risk Development in Young Adults (CARDIA) Study

Author Affiliations
  • 1Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
  • 2Department of Preventive Medicine, The University of Mississippi Medical Center, Jackson
  • 3Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, Maryland
  • 4Department of Epidemiology, Colorado School of Public Health, Aurora
  • 5Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis
  • 6Division of Research, Kaiser Permanente of Northern California, Oakland
JAMA Cardiol. 2017;2(4):381-389. doi:10.1001/jamacardio.2016.5678
Key Points

Question  Which blood pressure components best determine incident premature cardiovascular events in young adults and does the association vary by race and age at blood pressure measurement?

Findings  This community-based cohort of 4880 young adults at baseline followed up for up to 28 years observed that in young adults (mean age, 25 years) systolic blood pressure is the most robust indicator of premature cardiovascular disease risk in black individuals, whereas diastolic blood pressure performed better than systolic blood pressure in determining premature cardiovascular disease in white individuals. In middle-aged adults (mean age, 40 years), systolic blood pressure instead of diastolic blood pressure better determined incident cardiovascular disease in both races.

Meaning  Our data question the classic view that diastolic blood pressure more often identifies cardiovascular disease events than systolic blood pressure in all individuals younger than 50 years.


Importance  Data are sparse regarding which blood pressure (BP) components in young adulthood optimally determine cardiovascular disease (CVD) by middle age.

Objectives  To assess which BP components best determine incident CVD events in young adults and determine whether these associations vary by race and age at BP measurement.

Design, Setting, and Participants  Using data from the Coronary Artery Risk Development in Young Adults (CARDIA) study, this study assessed the longitudinal race-stratified associations between BP and cardiovascular outcomes. CARDIA is a community-based cohort that recruited black and white individuals (age range, 18-30 years) from March 26, 1985, through June 7, 1986. CARDIA followed up participants for up to 28 years, and 94% of the surviving cohort completed at least 1 telephone interview or examination from August 2009 through August 2014.

Exposures  Blood pressures measubred at baseline (Y0) and 15 years later (Y15).

Main Outcomes and Measures  Composite CVD events, including coronary heart disease, stroke, heart failure, and other vascular diseases.

Results  A total of 4880 participants participated in the study (mean [SD] age, 24.9 [3.6] years at Y0 and 25.0 [3.6] years at Y15; 2223 male [45.6%] at Y0 and 1800 [44.2%] at Y15; 2657 female [54.4%] at Y0 and 2277 [55.8%] at Y0; 2473 black individuals [50.7%] at Y0 and 1994 [48.9%] at Y15; and 2407 white individuals [49.3%] at Y0 and 2083 [51.1%] at Y15). The mean SBP/DBP was 112/69 mm Hg in blacks and 109/68 mm Hg in whites at Y0 and 117/77 mm Hg in blacks and 110/72 mm Hg in whites at Y15. During a 25-year follow-up from Y0, 210 CVD events occurred (twice as many events in blacks [n = 140] compared with whites), of which 131 (87 in blacks) occurred after Y15. With adjustments for covariates, results from Cox proportional hazards models, including SBP and DBP, jointly suggested that, at Y0, SBP (hazard ratio [HR] per 1-SD increase, 1.32; 95% CI, 1.09-1.61) but not DBP (HR, 1.05; 95% CI, 0.88-1.26) was associated with CVD risk in blacks, whereas DBP (HR, 1.74; 95% CI, 1.21-2.50) but not SBP (HR, 0.82; 95% CI, 0.57-1.18) was associated with CVD risk in whites. At Y15, SBP was the strongest indicator of CVD in blacks (HR, 1.64; 95% CI, 1.25-2.16) and whites (HR, 1.67; 95% CI, 1.02-2.69).

Conclusions and Relevance  This study questions the classic view that DBP is more able to identify future CVD events than SBP in all individuals younger than 50 years. In young adulthood, SBP in black individuals and DBP in white individuals were the most robust indicators of future CVD. In middle-age, SBP in both races identified risk of incident CVD.