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Hypertension in young adults

Toni De Venecia, Marvin Lu & Vincent M Figueredo

To cite this article: Toni De Venecia, Marvin Lu & Vincent M Figueredo (2016) Hypertension in
young adults, Postgraduate Medicine, 128:2, 201-207, DOI: 10.1080/00325481.2016.1147927

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POSTGRADUATE MEDICINE, 2016
VOL. 128, NO. 2, 201–207
http://dx.doi.org/10.1080/00325481.2016.1147927

CLINICAL FOCUS: CARDIOVASCULAR DISEASE

REVIEW

Hypertension in young adults

Toni De Veneciaa, Marvin Lua and Vincent M Figueredob
a
Medicine, Einstein Medical Center Philadelphia, Philadelphia, PA, USA; bCardiology, Einstein Medical Center Philadelphia, Philadelphia, PA,
USA

ABSTRACT ARTICLE HISTORY

Hypertension remains a major societal problem affecting 76 million, or approximately one third, Received 4 November 2015
of US adults. While more prevalent in the older population, an increasing incidence in the Accepted 25 January 2016
younger population, including athletes, is being observed. Active individuals, like the young Published online
and athletes, are viewed as free of diseases such as hypertension. However, the increased 29 February 2016
prevalence of traditional risk factors in the young, including obesity, diabetes mellitus, and KEYWORDS
renal disease, increase the risk of developing hypertension in younger adults. Psychosocial factors Athletes; Obesity; African
may also be contributing factors to the increasing incidence of hypertension in the younger American; Hypertension;
population. Increased left ventricular wall thickness and mass are increasingly found in young young adults
adults on routine echocardiograms and predict future cardiovascular events. This increasing
incidence of hypertension in the young calls for early surveillance and prompt treatment to
prevent future cardiac events. In this review we present the current epidemiological data,
potential mechanisms, clinical implications, and treatment of hypertension in young patients
and athletes.

Introduction cohort investigation.[6] The CARDIA investigators are

Hypertension, being one of the most prevalent dis-
eases in the world,[1] has been increasing in inci-
dence among the young, especially in the United
States.[2] The prevalence of hypertension (age-
adjusted) among US adults ≥18 years of age is esti-
mated to be 28.6%, based on National Health and
Nutrition Examination Survey (NHANES) data.[3]
Traditionally observed to have a higher prevalence
in the elderly population, recent epidemiological stu-
dies have shown an increased incidence of hyperten-
sion among the younger adult population (Figure 1).
[3–5]
In this review, we present the current epidemiologi-
cal data, potential mechanisms, clinical implications,
and treatment of hypertension in young patients and
athletes.
Epidemiological studies of hypertension in the
young
An increasing hypertension incidence among the
younger adult population, aged 18–30, is the finding
of the ongoing Coronary Artery Risk Development in
Young Adults (CARDIA) study’s population-based
studying the development of clinical and subclinical
cardiovascular disease and related risk factors in the
young adult population. Initial findings from CARDIA
showed that increased levels of modifiable cardiovas-
cular risk factors in early adulthood (ages 18–30), such
as hypertension and diabetes, predicted plaque calcifi-
cation in the coronary arteries, suggesting increased
future cardiovascular event risk.[7] Hypertension preva-
lence was 20% in these younger adults.
The Framingham Offspring Study examined risk fac-
tors for developing hypertension in young adults, aged
20–49. In young men, increased adiposity, high uric acid
level, high resting heart rate, and hypertriglyceridemia
were independent predictors of hypertension.[8] In
young women, the same predictors as well as alcohol
consumption were present.[8] They found a hyperten-
sion prevalence of 14.2% among 20–49-year-old men
and 12.9% among women of the same age.[8] Another
study from Thadhani and colleagues also showed an
association between alcohol consumption and risk of
chronic hypertension in young women aged 25–45.
While light drinkers demonstrated a modest decrease
in hypertension risk, more regular heavy drinkers
demonstrated an increase in hypertension risk.[9]

CONTACT Vincent M Figueredo figueredov@einstein.edu

© 2016 Taylor & Francis
202 T. DE VENECIA ET AL.
Figure 1. Prevalence of high blood pressure in adults >20 years old of age and sex (National Health And Nutrition Examination
Survey:2007–2010). Reprinted with permission from reference [3].
Higher levels of fasting insulin have also been asso-
ciated with unfavorable cardiovascular risk factors,
including hypertension, in young adults with an age
range of 18–30 years.[10]
Young African Americans are more likely to have
high blood pressure compared to young white or
Hispanic Americans.[11,12] An observational study by
Geronimus and colleagues found that black men and
Figure 2. Predicted probability of being hypertensive in rela-
tion to race/ethnicity among young adults aged 20–40 years
old. Reprinted with permission from reference [13].
women have nearly twice the hypertension prevalence
rates as their white counterparts by the age of 25
(Figure 2.) [13] Gender also appears to have an impact
on hypertension, with black women aged 25–34 having
higher hypertension rates compared to black men in
the same age range.[14]
Worrisome are the recent findings that hypertension
is increasingly present at even earlier ages. According
to data from the 2011–2012 National Health and
Nutrition Examination Survey, the prevalence of high
or borderline hypertension in children and adolescents
aged 8–17 was 11% in 1665 nationally representative
subjects.[15] Either high or borderline hypertension was
higher in boys (15.4 %) versus girls (6.8 %), higher in
teens (15 %) versus children (6.5 %), higher in non-
Hispanic blacks (15.3 %) versus whites (9.4 %) or
Hispanics (11.5 %), and associated with obesity (18 %)
or overweight (12.8%) versus normal weight (8.4 %).
Population changes in factors associated with hyperten-
sion, such as diet, physical activity, and anthropometric
(e.g., obesity) factors, are thought to play a role. Chen
and Wang performed a meta-analysis of 50 cohort stu-
dies tracking blood pressure from childhood to adult-
hood, finding that hypertension in childhood confers a
high risk of hypertension in adulthood, supporting the
need for early identification of high-risk individuals.[16]
Hypertension risk factors in the young
Long-established risk factors for hypertension in the
general population, which are increasing in prevalence
in the younger population, such as physical inactivity,
 POSTGRADUATE MEDICINE 203

Figure 3. Incidence of Hypertension for all Young adult Men and Women ages 22–35 years old, adjusted for age, race and sex with
p values linear trend across 4 strata of psychosocial variables, namely TUI, time urgency/impatience; ASC, achievement striving/
competitiveness; Hostility, Depression, Anxiety. Reprinted with permission from reference [17].

diabetes, and obesity certainly, but not completely,
explain the increasing incidence of hypertension being
observed in young adults.[17] Among these traditional
risk factors, baseline blood pressure at childhood was
most predictive as supported by the Bogalusa Study. In
this study, the childhood characteristics of baseline
blood pressure level were most predictive of the ele-
vated blood pressure at follow-up level, followed by
change in body mass index.[18] However, different psy-
chological, social, and nutritional factors may also be
playing a role.
Data from the CARDIA study found that depressive
states were predictive of a higher incidence of hyper-
tension in young adults aged 22–35, particularly in
young black patients.[19] In another cohort study
examining psychosocial risk factors, higher time
urgency, impatience, and hostility were associated
with the risk of developing hypertension at 15 years
of follow-up for young adults aged 18–30 (Figure 3).[17]
Systolic blood pressure response to exercise has been
shown to predict development of hypertension in young
adults.[20] Young subjects aged 20–35 who had an
exaggerated response to exercise at baseline had higher
systolic and diastolic pressures after a 15-year follow-up,
and were more likely to develop chronic hypertension,
even after adjusting for age, sex, and other confounding
factors.[20] Lower socioeconomic status, assessed by
education level, has also been associated with a higher
incidence of hypertension in young adults aged 18–
30.[21]
Plant food intake (whole grains, refined grains, fruit,
vegetables, nuts, or legumes) was found to be inversely
associated with development of hypertension, while
red meat intake had a direct relationship with hyper-
tension in young adults aged 18–30.[22]
Serum markers of hypertension in the young
Two serum chemistry predictors of hypertension in
the young adult population have been identified.
Serum γ-glutamyltransferase (GGT), a marker for oxi-
dative stress, within a range regarded as physiologi-
cally normal, was associated with incident
hypertension in 18–30-year-old subjects.[23]
C-reactive protein, a marker of inflammation, was
associated with hypertension in young adults aged

Figure 4. Incident Hypertension by CRP category at year 15 based on CARDIA study. Reprinted with permission from reference [23].
204 T. DE VENECIA ET AL.
18–30 (Figure 4).[24] However, in contrast to the
finding in older populations, the association was no
longer present after adjusting for body mass index.
Clinical implications of hypertension in the
young
The Strong Heart Study examined cardiac and hemody-
namic consequences of hypertension in 14–39-year-old
subjects.[25] Hypertensive young adults had a higher
incidence of left ventricular wall thickness, left ventri-
cular mass, relative wall thickness, and left ventricular
hypertrophy than their normotensive counterparts.
Hypertension was associated with higher mean pulse
pressure, stroke volume index, and total peripheral
resistance index.[26] These findings have been asso-
ciated with developing adverse cardiovascular events
in the future. A study by Sarafidis and colleagues
showed that cumulative high blood pressure in the
younger years, more than a single elevated blood pres-
sure later as an adult, portends higher cardiovascular
events after a 25-year follow-up.[27] A Swedish nation-
wide cohort study of over 1.2 million military men,
mean age 18 years, found that higher blood pressure
(systolic or diastolic) was associated with increased car-
diovascular mortality over a 24-year follow-up. [28]
Hypertension in athletes
Lack of physical activity is a known risk factor for the
development of hypertension in young adults.[8] This
would suggest that athletes, having daily vigorous activ-
ity, are less susceptible to hypertension. However, in one
study, 12.2% of high school athletes who engaged in
heavy resistance weight training had significantly ele-
vated blood pressures.[27] Eighty percent demonstrated
significantly and persistently elevated blood pressures at
1-year of follow-up.[27] A recent study by Tucker and
colleagues found that National Football League players
had a 13.8% incidence of hypertension, compared with a
5.5% incidence among age-matched men from the gen-
eral US population.[29] A review by Leddy et al. observed
that athletes who have traditional risk factors, such as
obesity and black race, have a higher incidence of hyper-
tension than their counterparts.[30]
Hypertension diagnosis in the young
The diagnosis of hypertension in young adults is the
same as for the general population, as mandated by
current guidelines.[31] The Joint National Committee
(JNC) 7 and 8 guidelines recommend checking blood
pressure on two separate occasions, especially with the
high incidence of white coat hypertension among this
population.[31,32] Of note, out-of-office blood pressure
recordings (home blood pressure in the morning and
evening or 24-hour ambulatory blood pressure moni-
toring [ABPM]) should be obtained in any young person
or athlete with elevated office readings. Using data
from the CARDIA study, Muntner and colleagues
found that, on average, young African Americans have
higher ABPM measurements compared with whites
(average age 30 years).[33]
Once a diagnosis of hypertension is made, further
assessment of target organ damage should be consid-
ered. Work-up should include a basic metabolic serum
panel, urinalysis, and electrocardiogram, as recom-
mended in the general hypertensive population.[34] It
is reasonable to recommend that any athlete with sus-
tained hypertension, after ruling out white coat hyper-
tension, should have an echocardiogram performed,
mostly to rule out hypertrophic cardiomyopathy,
which is not uncommon in this population [34]
Secondary hypertension incidence in young adults
and athletes is roughly the same as that of the general
population.[34] Routine testing for such etiologies is
not recommended unless suspicion is high. When
entertaining secondary hypertension in a young patient
based on symptomatology and physical exam, fibro-
muscular dysplasia and thyroid dysfunction are the
two most common causes in this age group.[35]
Hypertension treatment in the young
A study by Johnson and colleagues found that young
adults with hypertension, aged 18–39, have the lowest
prevalence of controlled blood pressure when com-
pared to older adults (Figure 5.)[36] It is important to
note that uncontrolled hypertension, even among
young adults, increases future cardiovascular event
risk, as demonstrated by the CARDIA cohort study.[6]
The study by Johnson and colleagues further showed
that despite regular physician visits with documented
persistent elevated blood pressure, young adults had
slower rates of antihypertensive medication initiation
than middle-aged or older adults [36] This is supported
by the Heart Disease and Stroke Statistics from
American Heart Association, as shown in Figure 6.[3]
Young adults, aged 20–39, have the lowest rate of
awareness of having hypertension, reflecting lower
treatment initiation and control rates. Early recognition
and treatment initiation are key to decrease future
cardiovascular risks.
Treatment should include both lifestyle changes and
pharmacologic treatment, as recommended by current
guidelines.[31] Treatment should take into account
 POSTGRADUATE MEDICINE 205

Figure 5. Kaplan-Meier estimates: likelihood of antihypertensive medication initiation or hypertension control, *Achievement of
hypertension control per JNC 7 guidelines prior to medication initiation. Reprinted with permission from reference [34].

Figure 6. Extent of awareness, treatment, and control of high blood pressure by age National Health And Nutrition Examination
Survey:2007–2010) Reprinted with permission from reference [3].

race, age, and stage of hypertension, similar to the
general population. According to the Report from the
Eighth Joint National Committee (JNC 8), in non-black
patients, including those with diabetes mellitus, initial
antihypertensive treatment should start with thiazide-
type diuretics, calcium channel blockers, angiotensin-
converting enzyme (ACE) inhibitors, and/or angiotensin
receptor blockers (ARBs). In black patients, initial ther-
apy should be with thiazide-type diuretics or calcium
channel blockers. To improve renal outcomes in those
with evidence of concomitant renal disease, initial treat-
ment should include an ACE inhibitor or ARB.[31]
The most common and best tolerated medications
used for the treatment of hypertension in athletes are
vasodilators, especially ACE inhibitors and ARBs.[37] In
athletes, beta blockers and diuretics are not recom-
mended, as they can affect athletic performance. The
physiologic effects of beta blockers on cardiac output
and oxygen delivery can produce an earlier sensation of
fatigue and lower the threshold for lactate
206 T. DE VENECIA ET AL.
accumulation.[38] Possible side effects of thiazide diure-
tics include increased urinary loss of potassium and
magnesium, which can lead to muscle cramps and
cardiac arrhythmias, particularly in warm weather.[39]
Participation in strenuous activities needs to be
addressed for athletes diagnosed with sustained hyper-
tension. Asymptomatic individuals with controlled
hypertension and no cardiovascular disease or other
target organ damage may participate in exercise or
competitive athletics, but should be monitored clo-
sely.[40]
Conclusions
An increasing hypertension incidence has been
observed among young adults and athletes. Despite
this, diagnosis is still overlooked and time to treatment
is delayed in younger patients. Studies have shown
increased future cardiovascular risks and complica-
tions for uncontrolled hypertension in young adults.
This increasing incidence of hypertension in the young
calls for early surveillance and prompt treatment to
prevent future cardiac events.
Financial & competing interests disclosure
The authors have no relevant affiliations or financial involve-
ment with any organization or entity with a financial interest
in or financial conflict with the subject matter or materials
discussed in the manuscript. This includes employment, con-
sultancies, honoraria, stock ownership or options, expert tes-
timony, grants or patents received or pending, or royalties.
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