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Original Investigation
November 6, 2018

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

Author Affiliations
  • 1Department of Community and Family Medicine, Duke University, Durham, North Carolina
  • 2Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, Maryland
  • 3Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
  • 4Department of Medicine, Columbia University Medical Center, New York, New York
  • 5Department of Community and Family Medicine, Duke University, Durham, North Carolina
  • 6Nemours Cardiac Center, Alfred I. DuPont Hospital for Children, Wilmington, Delaware
  • 7Division of Health System Innovation and Research, Department of Population Health Sciences, University of Utah, Salt Lake City
  • 8Department of Epidemiology, University of Alabama at Birmingham, Birmingham
JAMA. 2018;320(17):1774-1782. doi:10.1001/jama.2018.13551
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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