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Editorial Comment

Isolated systolic hypertension in young adults:

a heterogeneous finding
Michael Bursztyn

See original paper on page 1810

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ypertension in adults has been extensively studied, and more than a million in a Swedish study. They also have
with wide array of data about physiology, associ- disadvantages, being based on single-office BP measurement
ated pathophysiology, different phenotypes, treat- among other reasons. Such a single measurement may lend
ment, outcomes, and extensive sets of guidelines itself to effects such as white coat, or masked hypertension.
established in an attempt to facilitate practice [1,2]. Hyperten- This conscription setting may be more stressful than the
sion in children was also studied though not as extensively, doctor’s office for many. Significantly, knowledge of BP
and in the absence of solid clinical outcomes for these age elevation may in itself precipitate subsequently higher BP
groups, research mostly employed variety of surrogate out- [6]. This type of psychological influence culminates in higher
comes, such as left ventricular mass, intima/media thickness, stress response [6,7]. Such adrenergic response may elevate
and the like to help realize clinical meaning of hypertension in SBP by increasing cardiac output and reduce DBP by activa-
childhood, as summarized in recent American Heart Associa- tion of the vasodilatory b2-adrenergic receptors [8]. The
tion guidelines on hypertension in childhood [3]. Therefore, it combination of both effects is likely to cause increased
may appear that we have detailed sets of guidelines both for cardiac output and lower total peripheral resistance, which
children and for adults. Nevertheless, whereas childhood may culminate in SBP more than 140 mmHg and DBP less
hypertension lasts about a decade, that of adults spans several than 90 mmHg, that is, isolated systolic hypertension (ISH).
decades, resulting in quite a heterogeneity in age, and subse- Indeed the white-coat effect on pulse pressure (PP) was
quent characteristics and quite an age-dependent variability greater than that on SBP, indicating the reduction of DBP
in outcomes. Indeed, at least when it comes to outcomes in at that time [9]. If anything this type of white coat effect was
studies of hypertension, they appear to segregate among found to be associated with favorable cardiovascular out-
higher risk (older among other aspects) adults; thus, most come [10].
randomized outcome studies in latest years involved high-risk It was shown decades ago with invasive hemodynamics
individuals frequently older than 55 years. Thus we have that initially young hypertensive individuals have increased
guidelines based on randomized trials almost exclusively cardiac output and normal total peripheral resistance,
among older higher risk patients, whereas younger, standard, which gradually over 10 and 20 years, change progressively
or low risk young adults are not well represented in the to a lower cardiac output and higher total peripheral resis-
knowledge database we have about hypertension. tance [11].
Most if not all the information on hypertension in young Usually it is common to see elderly patients with ISH; it is
adults stems from observational studies. Of particular interest believed secondary to aortic stiffness that occurs over the
are studies on military conscripts who are examined ahead of years. Observational studies have documented progressive
recruitment, and yield if not population-based estimates as decrease of DBP after the 6th decade of life frequently
say in the case of Israel, with its mandatory recruitment laws accompanied by SBP rise as part of this process [12].
[4], to a sample of conscripts which produce an estimate and a However, ISH is not only a phenomenon of older age. As a
rare samples of blood pressure (BP) in young adults in matter of fact, there is a substantial minority of young
Sweden [5]. Such studies have the advantage of very large hypertensive patients with this condition [13,14]. This
numbers, more than 2 million adolescents in an Israeli study brought about a controversy; some investigators found that
it can be explained by brachial BP augmentation, especially,
in young fit individuals [15,16]. Others found that elevated
Journal of Hypertension 2018, 36:1791–1792 aortic stiffness expressed as increased pulse wave velocity
Hypertension Unit, Department of Medicine, Hadassah-Hebrew University Medical
Center, Jerusalem, Israel (PWV) could explain the phenomenon and regard it as a sign
Correspondence to Prof. Michael Bursztyn, Hypertension Unit, Department of Medi- that it not an innocent state, and may require treatment
cine, Hadassah-Hebrew University Medical Center, Mount-Scopus, PO Box 24035, [17,18]. I had the clinical (unfortunately undocumented)
Jerusalem 9124001, Israel. Tel: +972 2 5844706; fax: +972 2 5844705;
experience that teenagers with ISH discovered in the con-
J Hypertens 36:1791–1792 Copyright ß 2018 Wolters Kluwer Health, Inc. All rights
scription office, in whom secondary hypertension was ruled
reserved. out, when seen after discharge from the 3 years long military
DOI:10.1097/HJH.0000000000001763 service, with gained weight, or smoking habit, and less

Journal of Hypertension 1791

Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

devotion to physical activity, turned out to be normotensive! 2. Whelton PK, Carey RM, Aronow WS, Casey DE Jr, Collins KJ, Dennison
Himmelfarb C, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/
Such an observation if substantiated could support the theory ASH/ASPC/NMA/PCNA guideline for the prevention, detection, eval-
of brachial augmentation in lean athletic normotensive uation, and management of high blood pressure in adults: a report of
patients. the American College of Cardiology/American Heart Association Task
On this background, the new analysis of young partic- Force on Clinical Practice Guidelines. J Am Coll Cardiol 2017; [Epub
ipants of the Hypertension and Ambulatory Recording Ven- ahead of print].
3. Flynn JT, Kaelber DC, Baker-Smith CM, Blowey D, Carroll AE, Daniels
etia Study (HARVEST), published in the present issue of the SR, et al. Clinical practice guideline for screening and management of
Journal [14], is important. It examined 1206 never treated high blood pressure in children and adolescents. Pediatrics 2017; 140:;
with newly office-diagnosed individuals with essential pii: e20171904. doi: 10.1542/peds.2017-1904.
hypertension and subtyped them according to 24-h ambula- 4. Leiba A, Twig G, Levine H, Goldberger N, Afek A, Shamiss A, et al.
tory BP as ISH, diastolic, or combined hypertension, fol- Hypertension in late adolescence and cardiovascular mortality in
midlife: a cohort study of 2.3 million 16- to 19-year-old examinees.
lowed them up closely for at least 6 months and on the Pediatr Nephrol 2016; 31:485–492.
average 6.9 years. Of the 206 ISH, 48% had incident office 5. Sundström J, Neovius M, Tynelius P, Rasmussen F. Association of blood
hypertension by the end of follow-up, compared with 50% of pressure in late adolescence with subsequent mortality: cohort study of
normotensive patients (more correctly should have been Swedish male conscripts. BMJ 2011; 342:d643.
6. Rostrup M, Kjeldsen SE, Eide IK. Awareness of hypertension increases
labeled white coat hypertensive patients), 65% of those with blood pressure and sympathetic responses to cold pressor test. Am J
isolated diastolic hypertension, and 71% of those with com- Hypertens 1990; 3:912–917.
bined systolic and diastolic hypertension P less than 0.0001. 7. Rostrup M, Mundal HH, Westheim A, Eide I. Awareness of high blood
This finding somewhat confirms some of the previous studies pressure increases arterial plasma catecholamines, platelet noradrena-
[13,15,16]. However, the HARVEST investigators went one line and adrenergic responses to mental stress. J Hypertens 1991;
step further and found that those who had incident 8. Bruno R, Ghiadoni L, Seravalle G, Dell’Oro R, Taddei S, Grassi G.
office hypertension by the end of follow-up, were those Sympathetic regulation of vascular function in health and disease.
with the higher mean arterial pressure (MAP) than a thresh- Front Physiol 2012; 3:284.
old of 97 mmHg, which corresponds to the upper limit of 9. Ben-Dov IZ, Perk G, Ben-Arie L, Mekler J, Bursztyn M. Pulse pressure is
more susceptible to the white coat effect than is systolic blood pressure:
what is considered normal 24-h ambulatory BP [diastolic observations from real-life ambulatory blood pressure monitoring. Am
80 mmHg þ (systolic 130 mmHg  diastolic 80 mmHg)]. J Hypertens 2004; 17:535–539.
They found among those with ISH only those with higher 10. Saladini F, Fania C, Mos L, Mazzer A, Casiglia E, Palatini P. Office pulse
MAP, and likewise only those with diastolic hypertension pressure is a predictor of favorable outcome in young- to middle-aged
subjects with stage 1 hypertension. Hypertension 2017; doi: 0.1161/
and higher MAP were likely to develop office hypertension.
As MAP is affected more by diastolic than by SBP (see above), [Epub ahead of print].
this means in practice that in younger people future hyper- 11. Lund-Johansen P. Twenty-year follow-up of hemodynamics in essen-
tension is predicted better by DBP than by SBP even in ISH. tial hypertension during rest and exercise. Hypertension 1991; 18 (5
As PWV is influenced more by DBP [19], the young people Suppl):III54–III61.
12. Franklin SS, Gustin W, Wong ND, Larson MG, Weber MA, Kannel WB,
destined to hypertension later because of higher PWV [17], Levy D. Hemodynamic patterns of age-related changes in
and not necessarily higher PP (predictive of favorable out- blood pressure. The Framingham Heart Study. Circulation 1997;
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Bots M. Spurious systolic hypertension in young adults; prevalence of
Thus, this important analysis of the HARVEST demon- high brachial systolic blood pressure and low central pressure and its
strates some of the heterogeneity of ISH, which may explain determinants. J Hypertens 2006; 24:1033–1039.
in part the controversy about ISH in the young. Application 14. Palatini P, Saladini F, Mos L, Fania C, Mazzer A, Casiglia E. Clinical
of the threshold suggested by the American College of characteristics and risk of hypertension needing treatment in young
Cardiology/American Heart Association [2] may complicate patients with systolic hypertension identified with ambulatory moni-
toring. J Hypertens 2018; 36:1810–1815.
these finding further. 15. O’Rourke MF, Vlachopoulos C, Graham RM. Spurious systolic hyper-
tension in youth. Vasc Med 2000; 5:141–145.
16. Mahmud A, Feely J. Spurious systolic hypertension of youth:
ACKNOWLEDGEMENTS fit young men with elastic arteries. Am J Hypertens 2003; 16:
Conflicts of interest 17. McEniery CM, Yasmin. Wallace S, Maki-Petaja K, McDonnell B, Shar-
There are no conflicts of interest. man JE, et al., ENIGMA Study Investigators. Increased stroke volume
and aortic stiffness contribute to isolated systolic hypertension in
young adults. Hypertension 2005; 46:221–226.
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1792 Volume 36  Number 9  September 2018

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