JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY
VOL. 65, NO. 4, 2015
ª 2015 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION
ISSN 0735-1097/$36.00
PUBLISHED BY ELSEVIER INC.
http://dx.doi.org/10.1016/j.jacc.2014.11.016
EDITORIAL COMMENT
Interpreting Blood Pressure in Young Adults* Michael A. Weber, MD
E
pidemiologic studies show a strong relationship
between
establish a relationship between baseline BP and
pressure
(BP)
mea-
long-term cardiovascular outcomes, specifically car-
incidence
of
major
diovascular death and coronary heart disease (CHD)
cardiovascular events (1). The primary basis for the
death, in subgroups of individuals with normal BP
treatment of hypertension has been the belief that
and with hypertension.
surements
and
blood the
reducing BP provides cardiovascular protection. This
SEE PAGE 327
is supported by evidence from pivotal clinical trials (2–7), conducted mostly in older patients at high car-
This work focused on isolated systolic hyperten-
diovascular risk, because they experience sufficient
sion (ISH), defined as systolic BP $140 mm Hg and
events to power the analysis of outcomes. An unfor-
diastolic BP <90 mm Hg. Using a reference patient
tunate consequence is the scarcity of data for
group with optimal-normal BP (<130/85 mm Hg), the
younger, less complex patients.
investigators calculated hazard ratios for major events
Even so, published guidelines on the management
in patients defined as high-normal (130 to 139/85 to
of hypertension have tended to treat all adults ($18
89 mm Hg), ISH (defined previously), isolated dia-
years of age) alike, despite the probability of age-
stolic hypertension (<140/$90 mm Hg), and systolic
dependent differences in outcomes. But 1 group of
diastolic hypertension ($140/90 mm Hg). In both
U.S. experts recently recommended a higher BP
sexes, the risks for death from cardiovascular disease
threshold for diagnosis and treatment of hyperten-
and CHD in the high-normal and the ISH groups were
sion in adults $60 years of age than in younger adults
significantly higher. Men, but not women, with iso-
(8), and an expert opinion in another guideline rec-
lated diastolic hypertension also had a greater risk,
ommended treating young adults to a lower BP than
although relatively few patients had this condition.
recommended for middle-aged and older adults (9).
Patients with combined systolic and diastolic hyper-
IMPORTANT NEW OBSERVATIONS IN YOUNG ADULTS In this issue of the Journal, Yano et al. (10) report a study in which they used the database of the Chicago Heart Association Detection Project in Industry, a 31-year longitudinal observation of cardiovascular outcomes in young to middle-aged adults (11), to
tension had the greatest incidence of events. Whether these elevated BP category definitions provide insights beyond simply establishing higher than normal BP as a cardiovascular risk is uncertain. For instance, systolic and diastolic BPs were both clearly higher in patients with ISH compared with the normal reference group. Furthermore, those with systolic and diastolic hypertension had both higher systolic and diastolic BPs than those with ISH. Thus, it is difficult to ascertain whether diastolic and systolic BPs are independent major determinants of outcomes
*Editorials published in the Journal of the American College of Cardiology
and whether these various BP categories—on the basis
reflect the views of the authors and do not necessarily represent the
of the traditional 140/90 mm Hg threshold—provide
views of JACC or the American College of Cardiology. From the Division of Cardiovascular Medicine, State University of New York, Downstate College of Medicine, Brooklyn, New York. Dr. Weber has
practical assistance. Still, ISH in younger people has largely been un-
reported that he has no relationships relevant to the contents of this
recognized, so this report resolves an important un-
paper to disclose.
certainty (10). Consistent with recommendations