Clinical Context

Cardiovascular disease (CVD) is the leading cause of mortality in the United States, and it is helpful to acknowledge trends in the prevalence of CVD when considering population and even individual health. Tsao and colleagues provided such facts in a review published in the February 22, 2022 issue of Circulation.^[1]

In a study including more than 30,000 US adults, White male persons had the highest 35-year risk for CVD (65.5%), followed by White female persons (57.1%). The respective risks among Black male and female individuals were 48.4% and 51.9%.

There was also good news for the epidemiology of stroke. A major study in the Central United States found that the prevalence of stroke declined between 1993 to 1994 and 2015. A meta-analysis also found that strict control of systolic blood pressure (SBP) < 130 mm Hg was associated with a 42% reduction in the risk for stroke compared with SBP control of 130 to 139 mm Hg.

Meanwhile, there are important changes in the epidemiology of heart failure (HF), which remains very common among US adults. The lifetime risk for HF after age 45 years ranges between 20% and 45%. Although the rate of heart failure with preserved ejection fraction (HFpEF) is rising, the prevalence of heart failure with reduced ejection fraction (HFrEF) has declined. The risk for mortality is similar in both types of HF.

The majority of data on CVD focuses on middle-aged and older adults. The current study by Aggarwal and colleagues offers an assessment of cardiovascular (CV) risk factors among adults between the ages of 20 and 44 years.

Study Synopsis and Perspective

New data show a high and rising burden of most CV risk factors among young adults aged 20 to 44 years in the United States.

In this age group, over the past 10 years, there has been an increase in the prevalence of diabetes and obesity, no improvement in the prevalence of hypertension, and a decrease in the prevalence of hyperlipidemia.

Still, medical treatment rates for CV risk factors are "surprisingly" low among young adults, study investigator Rishi Wadhera, MD, with Beth Israel Deaconess Medical Center and Harvard Medical School in Boston, told theheart.org | Medscape Cardiology.

The findings are "extremely concerning. We're witnessing a smoldering public health crisis. The onset of these risk factors earlier in life is associated with a higher lifetime risk of heart disease and potentially life-threatening complications," Wadhera added.

The study was presented March 5 at the American College of Cardiology (ACC) Scientific Session/World Congress of Cardiology (WCC) 2023 and was simultaneously published in JAMA.^[2]

The burden of CV risk factors among young adults is "unacceptably high and increasing," wrote the co-authors of a JAMA editorial.^[3]

"The time is now for aggressive preventive measures in young adults. Without immediate action there will continue to be a rise in heart disease and the burden it places on patients, families, and communities," say Norrina Allen, PhD, and John Wilkins, MD, with the University of Chicago Feinberg School of Medicine.

The findings stem from a cross-sectional study of 12,294 US adults aged 20 to 44 years (median age, 32; 51% women) who participated in National Health and Nutrition Examination Survey (NHANES) cycles for 2009 to 2010 and 2017 to March 2020.

Overall, the prevalence of hypertension was 9.3% in 2009-2010 and increased to 11.5% in 2017-2020. The prevalence of diabetes rose from 3% to 4.1%, and the prevalence of obesity rose from 32.7% to 40.9%. The prevalence of hyperlipidemia decreased from 40.5% to 36.1%.

Black adults consistently had high rates of hypertension during the study period -- 16.2% in 2009 to 2010 and 20.1% in 2017 to 2020 -- and significant increases in hypertension occurred among Mexican American adults (from 6.5% to 9.5%) and other Hispanic adults (from 4.4% to 10.5%), whereas Mexican American adults had a significant uptick in diabetes (from 4.3% to 7.5%).

Equally concerning, said Wadhera, only about 55% of young adults with hypertension were receiving antihypertensive medication, and just 1 in 2 young adults with diabetes were receiving treatment.

"These low rates were driven, in part, by many young adults not being aware of their diagnosis," he noted.

The NHANES data also show that the percentage of young adults who were treated for hypertension and who achieved blood pressure (BP) control did not change significantly over the study period (65% in 2009-2010 and 74.8% in 2017-2020). Blood sugar control among young adults being treated for diabetes remained suboptimal throughout the study period (45.5% in 2009-2010 and 56.6% in 2017-2020).

"The fact that [BP] control and glycemic control are so poor is really worrisome," Jeffrey Berger, MD, director of the Center for the Prevention of Cardiovascular Disease at NYU Langone Heart, who was not involved in the study, told theheart.org | Medscape Cardiology.

"Even in the lipid control, while it did get a little bit better, it's still only around 30% to 40%. So, I think we have ways to go as a society," Berger noted.

Wadhera said, "We need to double down on efforts to screen for and treat [CV] risk factors like high [BP] and diabetes in young adults. We need to intensify clinical and public health interventions focused on primordial and primary prevention in young adults now so that we can avoid a tsunami of [CVD] in the long term.

"It's critically important that young adults speak with their healthcare provider about whether -- and when -- they should undergo screening for high [BP], diabetes, and high cholesterol," Wadhera added.

Berger said one problem is that younger people often have a "superman or superwoman" view and don't comprehend that they are at risk for some of these conditions. Studies such as this "reinforce the idea that it's never too young to be checked out."

As a cardiologist who specializes in CV prevention, Berger said he sometimes hears patients say things such as, "I don't ever want to need a cardiologist" or "I hope I never need a cardiologist."

"My response is, 'There are many different types of cardiologists,' and I think it would really be helpful for many people to see a prevention-focused cardiologist way before they have problems," he told theheart.org | Medscape Cardiology.

"As a system, medicine has become very good at treating patients with different diseases. I think we need to get better in terms of preventing some of these problems," Berger added.

In their editorial, Allen and Wilkins say the "foundation of [CV] health begins early in life. These worsening trends in risk factors highlight the importance of focusing on prevention in adolescence and young adulthood in order to promote [CV] health across the lifetime."

The study was funded by a grant from the National Heart, Lung, and Blood Institute. Wadhera has served as a consultant for Abbott and CVS Health. Wilkins has received personal fees from 3M. Berger has disclosed no relevant financial relationships.

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