Intended for healthcare professionals

Letters High blood pressure in young people

Blood pressure targets for young adults: are we being too stringent?

BMJ 2020; 371 doi: (Published 09 October 2020) Cite this as: BMJ 2020;371:m3910
  1. Divyani Garg, assistant professor1,
  2. Ayush Agarwal, assistant professor2
  1. 1Department of Neurology, Lady Hardinge Medical College, New Delhi 110001, India
  2. 2Department of Neurology, All India Institute of Medical Sciences, New Delhi 110029, India
  1. divyanig{at}

Hypertension is a harbinger of a huge cardiovascular disease burden globally, with an estimated one in three adults in low and middle income countries having hypertension, previously defined as blood pressure ≥140/90 mm Hg.1 The burden is probably greater, given the current definition of ≥130/80 mm Hg.2

Luo and colleagues pooled data from 17 observational studies of more than 4.5 million young adults (18-45 years), with an average follow-up of 14.7 years.3 They found a graded increase in adverse cardiovascular outcomes with blood pressure severity. So far, reports on cardiovascular outcomes in hypertensive adults have largely focused on middle aged or older adults. Hypertension in younger adults is steadily rising, but robust data on long term cardiovascular effects are lacking.45

Interestingly, the authors reported that even individuals with “normal” blood pressure (120-129/80-84 mm Hg) had a higher stroke risk compared with those with optimal blood pressure (<120/80 mm Hg). Relative risk in the normal category (1.14; 95% confidence interval 1.03 to 1.27) alone was not associated with significant heterogeneity for stroke, with number needed to treat being a substantial 7599 for stroke and 2672 for cardiovascular outcomes. This indicates highly stringent blood pressure targets for young adults at the expense of large numbers needed to treat.

The authors also noted a graded influence of isolated systolic and diastolic blood pressure on cardiovascular outcomes. In another cohort of over six million young adults with a mean follow-up of 13.2 years, adjusted hazard ratios for new cardiovascular events were 1.32 (95% CI 1.28 to 1.36) for stage 1 isolated diastolic hypertension (diastolic 80-89 mm Hg; systolic <130 mm Hg) and 1.36 (1.29 to 1.43) for stage 1 isolated systolic hypertension (systolic 130-139 mm Hg; diastolic <80 mm Hg). Both were lower than that for combined systolic and diastolic hypertension.6 This might further enable risk stratification towards optimum blood pressure targets among young adults. Overall, the study raises important concerns regarding thresholds for treatment of hypertension in young adults.



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