Improving Blood Pressure Screening and Treatment Strategies in Young Adults

Project Summary
The overall reduction in the rate of cardiovascular disease (CVD) over the past decades in the US has not
extended to young adults aged 18-39 years. An increasing prevalence of CVD risk factors in young adults,
including high blood pressure (BP), likely contributed to the increase in CVD rates. About 20% of US young
adults have stage 1 or 2 hypertension (BP 130-139/80-89 mm Hg and ≥140/90 mm Hg, respectively). Despite
the high prevalence of hypertension in young adults and its association with CVD, there is little evidence to
guide BP screening and treatment recommendations in young adults. For BP screening, >25% of young adults
in the US with hypertension are unaware that they have it. Moreover, social determinants of health (SDOH), an
important influence on the health of young adults, is not considered in BP screening recommendations. For BP
management, the benefits of initiating antihypertensive medications during young adulthood are unknown and
are extrapolated from data among older adults. Due to the lack of evidence, most of the 13 million young adults
with stage 1 hypertension are currently not recommended to initiate antihypertensive medication, and 50% (2.5
million) of young adults with stage 2 hypertension are currently left untreated. Although randomized controlled
trials (RCTs) with hard CVD outcomes will provide definitive evidence, it may not be feasible to perform such a
trial in young adults due to high costs and long follow-up time needed to determine CVD risk reduction
benefits. In the absence of RCTs, high quality observational and simulation studies can provide clinically
relevant and actionable evidence for policy makers, patients, and clinicians in a cost-efficient manner. The
overall study objectives are to determine the optimal BP screening intervals for young adults and to identify
those with a high risk of premature and/or lifetime CVD who may benefit from antihypertensive medication
during young adulthood. The aims of this study are to (1) determine BP screening intervals by examining the
timing of transitioning from normal BP into stage 1 or 2 hypertension and long-term BP trajectories, (2) identify
characteristics of young adults with stage 1 or 2 hypertension who are at high risk for adverse CVD or renal
outcomes, (3) quantify the benefits and harms of antihypertensive medication among young adults with stage 1
or 2 hypertension by emulating a hypothetical RCT using a large observational database and state-of-the-art
statistical models to minimize confounding and selection bias, and (4) compare the short- and long-term health
and economic impact of BP screening and management strategies for US young adults identified in Aims 1 to
3 vs. current BP guidelines. To address these aims, we will study ~500,000 young adults aged 18-39 years
from both Kaiser Permanente Southern California and four epidemiologic cohorts. Findings from this study will
inform future BP guidelines, reduce health inequity by directing screening and treatment to high risk
subgroups, and improve cardiovascular health of US young adults.

Grant Number: 5R01HL158790-05
NIH Institute/Center: NIH
Principal Investigator: Jaejin An