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2001 Relationship of Blood Pressure To 25-Year Mortality Due To Coronary Heart Disease, Cardiovascular Diseases, and All Causes in Young Adult Men
2001 Relationship of Blood Pressure To 25-Year Mortality Due To Coronary Heart Disease, Cardiovascular Diseases, and All Causes in Young Adult Men
Background: Data are limited on blood pressure (BP) 1.26 (95% confidence interval [CI], 1.11-1.44) and 1.17
in young adults and long-term mortality. Moreover, (95% CI, 1.01-1.35), respectively. Compared with the
screening and hypertension treatment guidelines have Sixth Report of the Joint National Committee on Pre-
been based mainly on findings for middle-aged and older vention, Detection, Evaluation, and Treatment of High
populations. This study assesses relationships of BP mea- Blood Pressure stratum with normal BP (and lowest mor-
sured in young adult men to long-term mortality due to tality rates), the large strata with high-normal BP and stage
coronary heart disease (CHD), cardiovascular diseases 1 hypertension had 25-year absolute risks for death of
(CVD), and all causes. 63 and 72 per 1000, respectively, and absolute excess risks
of 10 and 20 per 1000, respectively; accounted for 59.8%
Methods: This cohort from the Chicago Heart Associa- of all excess CHD, CVD, and all-cause mortality; and were
tion Detection Project in Industry included 10 874 men estimated to have life expectancy shortened by 2.2 and
aged 18 to 39 years at baseline (1967-1973), not receiv- 4.1 years, respectively.
ing antihypertensive drugs, and without CHD or diabe-
tes. Relationship of baseline BP to 25-year CHD, CVD, Conclusions: In young adult men, BP above normal was
and all-cause mortality was assessed. significantly related to increased long-term mortality due
to CHD, CVD, and all causes. Population-wide primary
Results: Age-adjusted association of systolic BP to CHD prevention, early detection, and control of higher BP are
mortality was continuous and graded. Multivariate- indicated from young adulthood on.
adjusted CHD hazard ratios (HRs) for 1 SD higher sys-
tolic BP (15 mm Hg) and diastolic BP (10 mm Hg) were Arch Intern Med. 2001;161:1501-1508
F
OR MIDDLE-AGED and older from nested case-control investigations in
populations worldwide, former college students11-13 and analyses of
blood pressure (BP) has re- life insurance actuarial data.14-16 Other evi-
peatedly been shown to be a dence comes from autopsy studies show-
significant risk factor for the ing that coronary risk factors relate to early
major cardiovascular diseases (CVD), in- atherosclerotic lesions in young adults.17-19
cluding coronary heart disease (CHD) and Although hypertension treatment guide-
stroke.1-6 For systolic (SBP) and diastolic lines are usually considered applicable for
BP (DBP), these relationships are continu- persons aged 18 years and older,20,21 there
ous, graded, independent of other risk fac- is limited documentation supporting screen-
tors, consistent, predictive, and generally ing and treatment of young adults.
assessed as etiologically significant. Data This report adds information on this
indicate that SBP is a stronger predictor matter. The Chicago Heart Association De-
than DBP at these ages.7-10 tection Project in Industry (CHA) Study is
In contrast, long-term observations of one of the largest and longest prospective
From the Department BP and mortality due to CHD and CVD in studies providing CVD mortality data.
of Preventive Medicine, young adults are limited. Because major Approximately 11000 men aged 18 to 39
Northwestern University CVD events are rare before 50 years of age years at baseline were followed up for an
Medical School, Chicago, Ill
in men and 60 years of age in women, stud- average of 25 years. The goals of this re-
(Drs Miura, Daviglus, Dyer,
Liu, Stamler, and Greenland ies on risk factors measured at an average search were to determine (1) whether SBP,
and Mr Garside), and the age of about 30 years require long-term fol- DBP, and SBP/DBP categories of the Sixth
Department of Public Health, low-up or large sample sizes to accrue ad- Report of the Joint National Committee on
Kanazawa Medical University, equate numbers of events. The few reports Prevention,Detection,Evaluation,andTreat-
Ishikawa, Japan (Dr Miura). of prospective population-based studies are ment of High Blood Pressure (JNC-VI)20
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predict long-term mortality due to CHD, CVD, and all ria); 20.2%, normal (not optimal) BP; 25.5%, high-
causes for young men; (2) whether SBP is a better predic- normal BP; and 36.4%, stage 1 hypertension.
tor than DBP in young men; and (3) long-term absolute
risks, absolute excess risks, and impairment of life expec- BASELINE SBP AND DBP AND MORTALITY
tancy in young men with higher BP, with comparison of
risks in young and middle-aged men. During follow-up, 197 men died of CHD; 257 of CVD;
and 759 of all causes.
RESULTS
Age-Adjusted Mortality Rates
BASELINE FINDINGS
With higher SBP, age-adjusted mortality due to CHD and
Table 1 presents data on baseline variables. At base- CVD increased continuously and markedly (Table 2).
line, 8.6% of the cohort had optimal BP (JNC-VI crite- For DBP, mortality due to CHD and CVD was lower for
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For SBP and DBP, Cox coefficients were statistically sig- *Men were participants in the Chicago Heart Association Detection Project
nificant for all 3 mortality end points (Table 2). For CHD in Industry (1967-1973). Values are given as mean (SD) unless otherwise
indicated. JNC-VI indicates the Sixth Report of the Joint National Committee
deaths, these coefficients yielded HRs—for 1-SD higher on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure;
SBP (15.2 mm Hg) and DBP (10.4 mm Hg)—of 1.26 (95% BMI, body mass index.
CI, 1.11-1.44) for SBP and 1.17 (95% CI, 1.01-1.35) for
DBP. For comparison, these estimates for the CHA co- 1.24 (all causes). With exclusion also of men with DBP
hort of middle-aged men (aged 40-59 years) were 1.23 of 60 to 64 mm Hg, HR for all causes was reduced to 1.15
(95% CI, 1.15-1.32) for SBP and 1.29 (95% CI, 1.21- (95% CI, 0.79-1.68) (detailed data not shown).
1.38) for DBP (coefficients 0.0108 and 0.0223; 1 SD, 19.3
mm Hg and 11.5 mm Hg). ABSOLUTE EXCESS RISKS AND EXCESS DEATHS
BY JNC-VI BP CLASSIFICATION
BASELINE SBP/DBP ( JNC-VI CRITERIA)
AND LONG-TERM MORTALITY Absolute excess risks for CVD death were 6.3, 10.8, 33.1,
and 74.1 per 1000 in 25 years for men with high-normal
Overall Findings BP and stages 1, 2, and 3 hypertension, respectively
(Table 6). For all-cause death, absolute excess risks
Age-adjusted death rates and multivariate-adjusted HRs ranged from 10.1 to 107.6 per 1000 in 25 years. For men
were lowest for the normal (but not optimal) stratum with higher BP levels, ie, high-normal BP and stages 1,
(Table 3). Adjusted rates and HRs increased progres- 2, and 3 hypertension, estimated life expectancy was
sively for strata above normal BP, eg, CHD HRs of 1.37 shorter by 2.2, 4.1, 8.4, and 12.2 years, respectively, com-
for the high-normal stratum and of 1.62, 2.51, and 3.60 pared with men with normal BP.23,27
for hypertension stages 1, 2, and 3 strata, respectively, For each mortality end point, the highest propor-
compared with the normal stratum. tion of all excess deaths—41.6% to 45.6%—was in the
large stratum (3963 of the 10874 men) with stage 1 hy-
HRs in Men With Optimal BP pertension (Table 6). Of all excess deaths, 15.6% to 16.9%
were in the sizable high-normal stratum (2773 men), more
For men with optimal BP, risks were relatively (nonsig- than in the small stratum (161 men) with stage 3 hyper-
nificantly) higher for CHD, CVD, and all causes than for tension. Together, the high-normal and stage 1 hyper-
those with normal BP (Table 3). As mentioned in JNC-V tensive strata accounted for 58.5% of excess CVD deaths
and JNC-VI guidelines on optimal BP, unusually low BP and 59.4% of excess deaths due to all causes.
readings need clinical evaluation.20,28 For men with op-
timal BP in this cohort, 45 deaths (of 59 due to all causes) COMMENT
were attributed to noncardiovascular causes, and about
half of these deaths were due to neoplasms (Table 4). The main findings on this cohort of young adult em-
In a further analysis, age-adjusted rates for CHD and CVD ployed men are as follows. (1) Even at their age (aver-
for men with optimal BP were equal to or lower than those age, 30 years), SBP/DBP at optimal or normal levels pre-
for men with normal BP ( Table 5 ). Multivariate- vailed in only 28.8% (8.6%+20.2%), whereas (2) SBP/
adjusted HRs, particularly for CHD and CVD, were lower DBP was high-normal or stage 1 hypertension in 61.9%
than those in Table 3, ie, 1.08 (CHD), 1.06 (CVD), and (25.5%+36.4%). These findings almost certainly reflect
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Multivariate Multivariate
Adjusted Adjusted
Age-Adjusted Relative Risk§ Age-Adjusted Relative Risk§
No. of Person-years No. of Rate per 10 000 (95% Confidence No. of Rate per 10 000 (95% Confidence
BP Level Men of Follow-up Deaths Person-years Interval) Deaths Person-years Interval)
Systolic BP, mm Hg
,120 1070 25 698 11 4.4 1.04 (0.51-2.12) 15 6.1 1.06 (0.58-1.96)
120-129 2237 54 022 25 4.6 1.00 33 6.1 1.00
130-139 2910 70 283 47 6.7 1.34\ (0.83-2.18) 61 8.7 1.33\ (0.87-2.03)
140-149 2612 62 495 51 8.3 1.50\ (0.93-2.43) 65 10.5 1.46\ (0.96-2.24)
150-159 1178 28 092 24 8.4 1.30 (0.74-2.30) 33 11.7 1.41 (0.86-2.30)
160-169 568 13 457 21 14.6 2.07¶ (1.13-3.77) 25 17.4 1.87¶ (1.09-3.20)
170-179 174 4035 8 18.6 2.60¶ (1.16-5.84) 10 22.1 2.41¶ (1.17-4.95)
$180 125 2804 10 31.0 4.25# (1.96-9.22) 15 46.8 4.36# (2.27-8.41)
Diastolic BP, mm Hg
,70 1218 28 570 16 7.8 1.63 (0.90-2.96) 19 9.1 1.32 (0.76-2.24)
70-79 3442 83 197 34 4.2 1.00 50 6.3 1.00
80-89 4169 100 554 80 7.7 1.58¶ (1.05-2.37) 99 9.6 1.34\ (0.95-1.88)
90-99 1638 39 159 44 10.4 1.80¶ (1.14-2.85) 53 12.4 1.47\ (0.99-2.19)
100-109 325 7609 15 14.2 2.23¶ (1.18-4.19) 24 23.0 2.46# (1.48-4.11)
$110 82 1797 8 28.6 3.11** (1.31-7.36) 12 38.0 3.03** (1.50-6.14)
Total 10 874 260 886 197 ... ... 257 ... ...
*Cox multiple coefficient for systolic BP, 0.0154 (SE, 0.0070) ( P,.001); for diastolic BP, 0.0148 (SE, 0.0070) ( P,.05) (also in analyses: age, serum cholesterol
level, cigarettes per day, body mass index (BMI), BMI 2, electrocardiographic abnormality, race, and education).
†Cox multiple coefficient for systolic BP, 0.0151 (SE, 0.0038) ( P,.001); for diastolic BP, 0.0169 (SE, 0.0060) ( P,.01) (also in analyses: age, serum cholesterol
level, cigarettes per day, BMI, BMI 2, electrocardiographic abnormality, race, and education).
‡Cox multiple coefficient for systolic BP, 0.0098 (SE, 0.0023) ( P,.001); diastolic BP, 0.0148 (SE, 0.0036) ( P,.001) (also in analyses: age, serum cholesterol
level, cigarettes per day, BMI, BMI 2, electrocardiographic abnormality, race, and education).
§Adjusted for age, serum cholesterol level, cigarettes per day, BMI, BMI 2, electrocardiographic abnormality, race, and education.
\P,.10.
¶P,.05.
#P,001.
**P,.01.
the adverse impact of dietary and other lifestyle traits lead- pressure measured in young adulthood predicted long-
ing to BP rise from youth onward in most people (eg, on term risks for CHD, CVD, and all-cause mortality. As in
average the cohort was overweight [BMI, 26.0]). (3) Blood middle-aged and older persons,1-6 relationships of SBP,
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*Excludes men with very low diastolic blood pressure (,60 mm Hg). See the footnote to Table 1 for an explanation of the abbreviations.
†Relative risks are adjusted for age, serum cholesterol level, cigarettes per day, BMI, BMI 2, electrocardiographic abnormality, race, and education.
‡P,.05.
§P,.001.
\P,.10.
Table 6. Absolute Excess Risk per 1000 in 25 Years and Percentage of All Excess Deaths in Strata of JNC-VI Classification*
Age-Adjusted Excess Rate No. of % of All Age-Adjusted Excess Rate No. of % of All
JNC-VI No. of No. of Rate per 1000 per 1000 Excess Excess No. of Rate per 1000 per 1000 Excess Excess
Classification Men Deaths in 25 Years in 25 Years Deaths† Deaths Deaths in 25 Years in 25 Years Deaths† Deaths
Optimal 930 11 12.7 2.7 3 3.0 14 16.2 2.5 2 2.2
Normal 2194 22 10.0 0.0 0 0.0 30 13.7 0.0 0 0.0
High-normal 2773 40 14.8 4.8 13 15.8 54 20.0 6.3 17 16.9
Hypertension 3963 78 19.7 9.7 38 45.6 97 24.5 10.8 43 41.6
stage 1
Hypertension 853 33 35.3 25.2 22 25.6 44 46.8 33.1 28 27.5
stage 2
Hypertension 161 13 62.4 52.3 8 10.0 18 87.8 74.1 12 11.6
stage 3
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31 160.3 107.6 17 9.7 1. MacMahon S, Peto R, Cutler J, et al. Blood pressure, stroke, and coronary heart
disease, I: prolonged differences in blood pressure: prospective observational
studies corrected for the regression dilution bias. Lancet. 1990;335:765-774.
2. Stamler J, Stamler R, Neaton D. Blood pressure, systolic and diastolic, and car-
diovascular risks: US population data. Arch Intern Med. 1993;153:598-615.
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