Hypertension in late adolescence and cardiovascular mortality in midlife: a cohort study of 2.3 million 16- to 19-year-old examinees.
BACKGROUND
The effect of early hypertension on midlife cardiovascular (CV) mortality remains controversial. We assessed the association of established hypertension in late adolescence with subsequent CV mortality.


METHODS
Of 2,298,130 Israeli adolescents (60% males; age 17.4 ± 0.3 years) who underwent a compulsory medical examination prior to military service between 1967 and 2010, 8720 teenagers (0.4%) were formally diagnosed with persistent hypertension. Using Cox proportional hazards modeling, we compared the hypertensive group to the large normotensive group with regard to time to event analysis of midlife mortality due to cerebrovascular accidents (CVA), coronary heart disease (CHD), sudden death (SD) and their summation as cardiovascular disease (CVD).


RESULTS
During 45,729,521 person-years of follow-up, we identified 2918 CV deaths-2879 and 39 among the 2,289,410 normotensive and 8720 hypertensive adolescents, respectively. Hypertension at a young age was associated with a threefold elevation of stroke mortality compared to normotension when adjusted for sex, age at examination, birth year, country of origin, socioeconomic status, education, body mass index (BMI) and height [hazard ratio (HR) 3.12; 95% confidence interval (CI) 1.76-5.54; p < 0.001]. There was no significant association of hypertension with CHD mortality or SD. An increased risk for overall CVD mortality among hypertensive youngsters (HR 1.51; 95 % CI 1.10-2.07) was attenuated after adjusting for BMI and other covariates (HR 1.24; 95% CI 0.90-1.72).


CONCLUSIONS
Established hypertension at a young age was independently associated with elevated stroke mortality in midlife. This finding warrants confirmatory large-scale long-term follow-up studies to address the distant effects of adolescent hypertension.
Institute of Nephrology and Hypertension, Sheba Medical Center, Tel Aviv University, Ramat Gan, Israel. aleiba@mah.harvard.edu.|The Israel Defense Forces Medical Corps, Ramat Gan, Israel. aleiba@mah.harvard.edu.|Department of Internal Medicine, Mount Auburn Hospital, Harvard Medical School, Cambridge, MA, USA. aleiba@mah.harvard.edu.
Adi
A
Leiba
Institute of Nephrology and Hypertension, Sheba Medical Center, Tel Aviv University, Ramat Gan, Israel.|The Israel Defense Forces Medical Corps, Ramat Gan, Israel.|The Dr. Pinchas Bornstein Talpiot Medical Leadership Program and Department of Medicine B, Sheba Medical Center, Ramat Gan, Israel.
Gilad
G
Twig
Hebrew University-Hadassah School of Public Health and Community Medicine, Jerusalem, Israel.
Hagai
H
Levine
Israel Ministry of Health, Jerusalem, Israel.
Nehama
N
Goldberger
Institute of Nephrology and Hypertension, Sheba Medical Center, Tel Aviv University, Ramat Gan, Israel.|Israel Ministry of Health, Jerusalem, Israel.
Arnon
A
Afek
Institute of Nephrology and Hypertension, Sheba Medical Center, Tel Aviv University, Ramat Gan, Israel.
Ari
A
Shamiss
The Israel Defense Forces Medical Corps, Ramat Gan, Israel.
Estela
E
Derazne
The Israel Defense Forces Medical Corps, Ramat Gan, Israel.
Dorit
D
Tzur
Israel Ministry of Health, Jerusalem, Israel.
Ziona
Z
Haklai
Hebrew University-Hadassah School of Public Health and Community Medicine, Jerusalem, Israel.
Jeremy D
JD
Kark
D000293:Adolescent; D000328:Adult; D000367:Age Factors; D001794:Blood Pressure; D002423:Cause of Death; D003327:Coronary Disease / Q000175:diagnosis / Q000401:mortality* / Q000503:physiopathology; D016757:Death, Sudden, Cardiac / Q000453:epidemiology*; D005260:Female; D006801:Humans; D006973:Hypertension / Q000175:diagnosis / Q000401:mortality* / Q000503:physiopathology; D007557:Israel / Q000453:epidemiology; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D016016:Proportional Hazards Models; D018570:Risk Assessment; D012307:Risk Factors; D020521:Stroke / Q000175:diagnosis / Q000401:mortality* / Q000503:physiopathology; D013997:Time Factors; D055815:Young Adult
Adolescent; Cardiovascular disease; Hypertension; Mortality; Screening; Stroke