ORIGINAL INVESTIGATION

Relationship of Blood Pressure to 25-Year Mortality

Due to Coronary Heart Disease, Cardiovascular
Diseases, and All Causes in Young Adult Men
The Chicago Heart Association Detection Project in Industry
Katsuyuki Miura, MD, PhD; Martha L. Daviglus, MD, PhD; Alan R. Dyer, PhD; Kiang Liu, PhD;
Daniel B. Garside, MA; Jeremiah Stamler, MD; Philip Greenland, MD

Background: Data are limited on blood pressure (BP)
in young adults and long-term mortality. Moreover,
screening and hypertension treatment guidelines have
been based mainly on findings for middle-aged and older
populations. This study assesses relationships of BP mea-
sured in young adult men to long-term mortality due to
coronary heart disease (CHD), cardiovascular diseases
(CVD), and all causes.
Methods: This cohort from the Chicago Heart Associa-
tion Detection Project in Industry included 10 874 men
aged 18 to 39 years at baseline (1967-1973), not receiv-
ing antihypertensive drugs, and without CHD or diabe-
tes. Relationship of baseline BP to 25-year CHD, CVD,
and all-cause mortality was assessed.
Results: Age-adjusted association of systolic BP to CHD
mortality was continuous and graded. Multivariate-
adjusted CHD hazard ratios (HRs) for 1 SD higher sys-
tolic BP (15 mm Hg) and diastolic BP (10 mm Hg) were
1.26 (95% confidence interval [CI], 1.11-1.44) and 1.17
(95% CI, 1.01-1.35), respectively. Compared with the
Sixth Report of the Joint National Committee on Pre-
vention, Detection, Evaluation, and Treatment of High
Blood Pressure stratum with normal BP (and lowest mor-
tality rates), the large strata with high-normal BP and stage
1 hypertension had 25-year absolute risks for death of
63 and 72 per 1000, respectively, and absolute excess risks
of 10 and 20 per 1000, respectively; accounted for 59.8%
of all excess CHD, CVD, and all-cause mortality; and were
estimated to have life expectancy shortened by 2.2 and
4.1 years, respectively.
Conclusions: In young adult men, BP above normal was
significantly related to increased long-term mortality due
to CHD, CVD, and all causes. Population-wide primary
prevention, early detection, and control of higher BP are
indicated from young adulthood on.
Arch Intern Med. 2001;161:1501-1508

From the Department
of Preventive Medicine,
Northwestern University
Medical School, Chicago, Ill
(Drs Miura, Daviglus, Dyer,
Liu, Stamler, and Greenland
and Mr Garside), and the
Department of Public Health,
Kanazawa Medical University,
Ishikawa, Japan (Dr Miura).
F
OR MIDDLE-AGED and older
populations worldwide,
blood pressure (BP) has re-
peatedly been shown to be a
significant risk factor for the
major cardiovascular diseases (CVD), in-
cluding coronary heart disease (CHD) and
stroke.1-6 For systolic (SBP) and diastolic
BP (DBP), these relationships are continu-
ous, graded, independent of other risk fac-
tors, consistent, predictive, and generally
assessed as etiologically significant. Data
indicate that SBP is a stronger predictor
than DBP at these ages.7-10
In contrast, long-term observations of
BP and mortality due to CHD and CVD in
young adults are limited. Because major
CVD events are rare before 50 years of age
in men and 60 years of age in women, stud-
ies on risk factors measured at an average
age of about 30 years require long-term fol-
low-up or large sample sizes to accrue ad-
equate numbers of events. The few reports
of prospective population-based studies are
from nested case-control investigations in
former college students11-13 and analyses of
life insurance actuarial data.14-16 Other evi-
dence comes from autopsy studies show-
ing that coronary risk factors relate to early
atherosclerotic lesions in young adults.17-19
Although hypertension treatment guide-
lines are usually considered applicable for
persons aged 18 years and older,20,21 there
is limited documentation supporting screen-
ing and treatment of young adults.
This report adds information on this
matter. The Chicago Heart Association De-
tection Project in Industry (CHA) Study is
one of the largest and longest prospective
studies providing CVD mortality data.
Approximately 11000 men aged 18 to 39
years at baseline were followed up for an
average of 25 years. The goals of this re-
search were to determine (1) whether SBP,
DBP, and SBP/DBP categories of the Sixth
Report of the Joint National Committee on
Prevention,Detection,Evaluation,andTreat-
ment of High Blood Pressure (JNC-VI)20

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 MATERIALS AND METHODS
POPULATION
Methods of the CHA study have been described.22,23 Briefly,
39 573 men and women aged 18 years and older under-
went screening from November 1967 through January 1973.
All employees at 84 cooperating Chicago-area companies
and organizations, with a labor force of approximately 75000
people, were invited to participate; volunteer rate was 53%.
SURVEY METHODS
Screening was performed by 2 trained and standardized
4-person field teams. Data collected at baseline included
age, sex, ethnicity, education, BP, serum total cholesterol
level, smoking status, height and weight, resting electro-
cardiographic (ECG) findings, medical history, and cur-
rent treatment for chronic diseases, including hyperten-
sion and diabetes. A single casual supine BP measurement
was obtained by trained staff using a standard mercury
sphygmomanometer. Standardized high-quality methods
were used for determination of total serum cholesterol lev-
els.24 Criteria of the National Cooperative Pooling Project
and the Hypertension Detection and Follow-up Program
were used to code ECG abnormalities.25
MORTALITY END POINTS
Vital status was ascertained through 1995, with average fol-
low-up of 25 years. Deaths were determined before and in-
cluding 1979 by means of direct mail, telephone, contact with
employer, and matching of cohort records with Social Secu-
rity Administration files, and after 1979 by means of match-
ing of study records with National Death Index records. Mul-
tiple causes of death from death certificates were coded by
trained research staff according to the International Classifi-
cation of Diseases, Eighth Revision (ICD-8).26 Coding deci-
sions were cross-checked by study team members. All cod-
ers were blinded to baseline data. For this report, underlying
cause of death was used. Mortality due to CHD was defined
as ICD-8 codes 410.0 to 414.9; that due to CVD, ICD-8 codes
400.0 to 445.9.
EXCLUSIONS
Men aged 18 to 39 years at baseline numbered 11 248. Of
these, 374 were excluded for the following reasons: data
predict long-term mortality due to CHD, CVD, and all
causes for young men; (2) whether SBP is a better predic-
tor than DBP in young men; and (3) long-term absolute
risks, absolute excess risks, and impairment of life expec-
tancy in young men with higher BP, with comparison of
risks in young and middle-aged men.
RESULTS
BASELINE FINDINGS
Table 1 presents data on baseline variables. At base-
line, 8.6% of the cohort had optimal BP (JNC-VI crite-
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missing at baseline or on follow-up (n=114); baseline ECG
evidence of myocardial infarction (n = 5); history of myo-
cardial infarction or other CHD (n = 12); antihypertensive
drug treatment at baseline (n = 125); or previously diag-
nosed diabetes mellitus (n=118). Thus, this report is based
on 10 874 men.
STATISTICAL ANALYSES
Age-adjusted mortality rates per 10000 person-years of fol-
low-up and per 1000 men were computed for CHD, CVD,
and all-cause mortality. Mortality rates were calculated by
categories of SBP or DBP and by the following classifica-
tion according to the JNC-VI20: optimal (SBP of ,120 mm
Hg and DBP of ,80 mm Hg); normal not optimal (SBP of
120-129 mm Hg and DBP of ,85 mm Hg, or SBP of ,130
mm Hg and DBP of 80-84 mm Hg); high normal (SBP of
130-139 mm Hg and DBP of ,90 mm Hg, or SBP of ,140
mm Hg and DBP of 85-89 mm Hg); stage 1 hypertension
(SBP of 140-159 mm Hg and DBP of ,100 mm Hg, or SBP
of ,160 mm Hg and DBP of 90-99 mm Hg); stage 2 hy-
pertension (SBP of 160-179 mm Hg and DBP of ,110 mm
Hg, or SBP of ,180 mm Hg and DBP of 100-109 mm Hg);
and stage 3 hypertension (SBP of $180 mm Hg or DBP of
$110 mm Hg). Rates were age adjusted by the direct method
to the overall cohort age distribution.
Cox proportional hazards regression was used to cal-
culate multivariate-adjusted hazard ratios (HRs) of death and
their 95% confidence intervals (CIs) for baseline BP catego-
ries, and to obtain multivariate-adjusted coefficients for the
relation of BP to mortality. The HRs were adjusted for age
(years), race (African American or not), education (years),
serum total cholesterol level (millimoles per liter [milli-
grams per deciliter]), cigarette smoking (cigarettes/day), body
mass index (BMI) (weight in kilograms divided by square of
height in meters), BMI2, and any ECG abnormality (no or yes).
Absolute excess death rates per 1000 in 25 years by
JNC-VI stratum were calculated from age-adjusted mortal-
ity rates per 1000 in 25 years. The reference group was the stra-
tum with normal (not optimal) BP. Numbers of excess deaths
for other JNC-VI strata were calculated from these absolute
excess rates and numbers of men in these strata. Percentage
of all excess deaths in each stratum was also calculated.
Cox multivariate proportional hazards regression co-
efficients for the relation of JNC-VI strata to all-cause mor-
tality were used to estimate years of shorter life expec-
tancy for men with higher baseline BP levels compared with
men with normal BP. Detailed methods for these calcula-
tions have been described elsewhere.23,27
ria); 20.2%, normal (not optimal) BP; 25.5%, high-
normal BP; and 36.4%, stage 1 hypertension.
BASELINE SBP AND DBP AND MORTALITY
During follow-up, 197 men died of CHD; 257 of CVD;
and 759 of all causes.
Age-Adjusted Mortality Rates
With higher SBP, age-adjusted mortality due to CHD and
CVD increased continuously and markedly (Table 2).
For DBP, mortality due to CHD and CVD was lower for
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 men with DBP of 70 to 79 mm Hg than for those with
DBP of less than 70 mm Hg. For strata with DBP of greater Table 1. Baseline Characteristics of Men Aged 18-39 Years*
than 70 to 79 mm Hg, mortality rates were progres-
sively and markedly higher. Variable
For all-cause mortality, rates were lowest in men with No. of men 10 874
SBP of 120 to 129 mm Hg and with DBP of 70 to 79 mm Age, y 29.7 (5.5)
African American, % 8.1
Hg; for strata with higher levels, rates were generally pro-
Education, y 13.8 (2.6)
gressively higher. Systolic blood pressure, mm Hg 134.4 (15.2)
Diastolic blood pressure, mm Hg 78.0 (10.4)
Multivariate-Adjusted HRs Blood pressure classification by JNC-VI criteria, %
Optimal 8.6
With SBP of 120 to 129 mm Hg and DBP of 70 to 79 mm Normal (not optimal) 20.2
High-normal 25.5
Hg as the references, HRs for CHD, CVD, and all-cause
Hypertension, stage 1 36.4
mortality generally increased with higher SBP and DBP Hypertension, stage 2 7.8
level (Table 2). Hypertension, stage 3 1.5
For men with DBP of less than 70 mm Hg, HRs Serum cholesterol level
were nonsignificantly higher for all 3 end points (1.63, mmol/L 4.91 (0.94)
1.32, and 1.22 for CHD, CVD, and all-cause mortality, mg/dL 189.7 (36.1)
respectively) compared with men with DBP of 70 to BMI, kg/m2 26.0 (3.6)
Current cigarette smokers, % 47.4
79 mm Hg. No. cigarettes per day, smokers 21.2 (10.5)
No. cigarettes per day, all 10.0 (12.8)
Cox Multivariate-Adjusted Coefficients Electrocardiographic abnormality, % 6.6

For SBP and DBP, Cox coefficients were statistically sig-
nificant for all 3 mortality end points (Table 2). For CHD
deaths, these coefficients yielded HRs—for 1-SD higher
SBP (15.2 mm Hg) and DBP (10.4 mm Hg)—of 1.26 (95%
CI, 1.11-1.44) for SBP and 1.17 (95% CI, 1.01-1.35) for
DBP. For comparison, these estimates for the CHA co-
hort of middle-aged men (aged 40-59 years) were 1.23
(95% CI, 1.15-1.32) for SBP and 1.29 (95% CI, 1.21-
1.38) for DBP (coefficients 0.0108 and 0.0223; 1 SD, 19.3
mm Hg and 11.5 mm Hg).
BASELINE SBP/DBP ( JNC-VI CRITERIA)
AND LONG-TERM MORTALITY
Overall Findings
Age-adjusted death rates and multivariate-adjusted HRs
were lowest for the normal (but not optimal) stratum
(Table 3). Adjusted rates and HRs increased progres-
sively for strata above normal BP, eg, CHD HRs of 1.37
for the high-normal stratum and of 1.62, 2.51, and 3.60
for hypertension stages 1, 2, and 3 strata, respectively,
compared with the normal stratum.
HRs in Men With Optimal BP
For men with optimal BP, risks were relatively (nonsig-
nificantly) higher for CHD, CVD, and all causes than for
those with normal BP (Table 3). As mentioned in JNC-V
and JNC-VI guidelines on optimal BP, unusually low BP
readings need clinical evaluation.20,28 For men with op-
timal BP in this cohort, 45 deaths (of 59 due to all causes)
were attributed to noncardiovascular causes, and about
half of these deaths were due to neoplasms (Table 4).
In a further analysis, age-adjusted rates for CHD and CVD
for men with optimal BP were equal to or lower than those
for men with normal BP ( Table 5 ). Multivariate-
adjusted HRs, particularly for CHD and CVD, were lower
than those in Table 3, ie, 1.08 (CHD), 1.06 (CVD), and
*Men were participants in the Chicago Heart Association Detection Project
in Industry (1967-1973). Values are given as mean (SD) unless otherwise
indicated. JNC-VI indicates the Sixth Report of the Joint National Committee
on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure;
BMI, body mass index.
1.24 (all causes). With exclusion also of men with DBP
of 60 to 64 mm Hg, HR for all causes was reduced to 1.15
(95% CI, 0.79-1.68) (detailed data not shown).
ABSOLUTE EXCESS RISKS AND EXCESS DEATHS
BY JNC-VI BP CLASSIFICATION
Absolute excess risks for CVD death were 6.3, 10.8, 33.1,
and 74.1 per 1000 in 25 years for men with high-normal
BP and stages 1, 2, and 3 hypertension, respectively
(Table 6). For all-cause death, absolute excess risks
ranged from 10.1 to 107.6 per 1000 in 25 years. For men
with higher BP levels, ie, high-normal BP and stages 1,
2, and 3 hypertension, estimated life expectancy was
shorter by 2.2, 4.1, 8.4, and 12.2 years, respectively, com-
pared with men with normal BP.23,27
For each mortality end point, the highest propor-
tion of all excess deaths—41.6% to 45.6%—was in the
large stratum (3963 of the 10874 men) with stage 1 hy-
pertension (Table 6). Of all excess deaths, 15.6% to 16.9%
were in the sizable high-normal stratum (2773 men), more
than in the small stratum (161 men) with stage 3 hyper-
tension. Together, the high-normal and stage 1 hyper-
tensive strata accounted for 58.5% of excess CVD deaths
and 59.4% of excess deaths due to all causes.
COMMENT
The main findings on this cohort of young adult em-
ployed men are as follows. (1) Even at their age (aver-
age, 30 years), SBP/DBP at optimal or normal levels pre-
vailed in only 28.8% (8.6%+20.2%), whereas (2) SBP/
DBP was high-normal or stage 1 hypertension in 61.9%
(25.5%+36.4%). These findings almost certainly reflect

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 Table 2. Relationship of Baseline Blood Pressure (BP) to 25-Year Mortality
From Coronary Heart Disease, Cardiovascular Diseases, and All Causes

Coronary Heart Disease* Cardiovascular Diseases†

Multivariate Multivariate
Adjusted Adjusted
Age-Adjusted Relative Risk§ Age-Adjusted Relative Risk§
No. of Person-years No. of Rate per 10 000 (95% Confidence No. of Rate per 10 000 (95% Confidence
BP Level Men of Follow-up Deaths Person-years Interval) Deaths Person-years Interval)
Systolic BP, mm Hg
,120 1070 25 698 11 4.4 1.04 (0.51-2.12) 15 6.1 1.06 (0.58-1.96)
120-129 2237 54 022 25 4.6 1.00 33 6.1 1.00
130-139 2910 70 283 47 6.7 1.34\ (0.83-2.18) 61 8.7 1.33\ (0.87-2.03)
140-149 2612 62 495 51 8.3 1.50\ (0.93-2.43) 65 10.5 1.46\ (0.96-2.24)
150-159 1178 28 092 24 8.4 1.30 (0.74-2.30) 33 11.7 1.41 (0.86-2.30)
160-169 568 13 457 21 14.6 2.07¶ (1.13-3.77) 25 17.4 1.87¶ (1.09-3.20)
170-179 174 4035 8 18.6 2.60¶ (1.16-5.84) 10 22.1 2.41¶ (1.17-4.95)
$180 125 2804 10 31.0 4.25# (1.96-9.22) 15 46.8 4.36# (2.27-8.41)
Diastolic BP, mm Hg
,70 1218 28 570 16 7.8 1.63 (0.90-2.96) 19 9.1 1.32 (0.76-2.24)
70-79 3442 83 197 34 4.2 1.00 50 6.3 1.00
80-89 4169 100 554 80 7.7 1.58¶ (1.05-2.37) 99 9.6 1.34\ (0.95-1.88)
90-99 1638 39 159 44 10.4 1.80¶ (1.14-2.85) 53 12.4 1.47\ (0.99-2.19)
100-109 325 7609 15 14.2 2.23¶ (1.18-4.19) 24 23.0 2.46# (1.48-4.11)
$110 82 1797 8 28.6 3.11** (1.31-7.36) 12 38.0 3.03** (1.50-6.14)
Total 10 874 260 886 197 ... ... 257 ... ...

*Cox multiple coefficient for systolic BP, 0.0154 (SE, 0.0070) ( P,.001); for diastolic BP, 0.0148 (SE, 0.0070) ( P,.05) (also in analyses: age, serum cholesterol
level, cigarettes per day, body mass index (BMI), BMI 2, electrocardiographic abnormality, race, and education).
†Cox multiple coefficient for systolic BP, 0.0151 (SE, 0.0038) ( P,.001); for diastolic BP, 0.0169 (SE, 0.0060) ( P,.01) (also in analyses: age, serum cholesterol
level, cigarettes per day, BMI, BMI 2, electrocardiographic abnormality, race, and education).
‡Cox multiple coefficient for systolic BP, 0.0098 (SE, 0.0023) ( P,.001); diastolic BP, 0.0148 (SE, 0.0036) ( P,.001) (also in analyses: age, serum cholesterol
level, cigarettes per day, BMI, BMI 2, electrocardiographic abnormality, race, and education).
§Adjusted for age, serum cholesterol level, cigarettes per day, BMI, BMI 2, electrocardiographic abnormality, race, and education.
\P,.10.
¶P,.05.
#P,001.
**P,.01.

Table 3. Relationship of Baseline JNC-VI Classification to 25-Year Mortality

Due to Coronary Heart Disease, Cardiovascular Diseases, and All Causes*

Coronary Heart Disease Cardiovascular Diseases All Causes

Age-Adjusted Adjusted Age-Adjusted Adjusted Age-Adjusted Adjusted

Person- Rate per Relative Risk† Rate per Relative Risk† Rate per Relative Risk†
JNC-VI No. of years of No. of 10 000 (95% Confidence No. of 10 000 (95% Confidence No. of 10 000 (95% Confidence
Classification Men Follow-up Deaths Person-years Interval) Deaths Person-years Interval) Deaths Person-years Interval)
Optimal 930 22 290 11 5.3 1.39 (0.67-2.86) 14 6.7 1.28 (0.68-2.41) 59 26.9 1.29 (0.94-1.77)
Normal 2194 53 037 22 4.2 1.00 30 5.7 1.00 115 21.8 1.00
High-normal 2773 66 928 40 6.1 1.37 (0.81-2.30) 54 8.3 1.36¶ (0.87-2.13) 171 26.0 1.15 (0.91-1.46)
Hypertension 3963 94 885 78 8.2 1.62‡ (1.00-2.61) 97 10.2 1.50¶ (0.99-2.27) 287 30.2 1.31‡ (1.05-1.63)
stage 1
Hypertension 853 20 080 33 15.0 2.51§ (1.44-4.37) 44 19.9 2.45\ (1.52-3.97) 96 44.2 1.76\ (1.33-2.33)
stage 2
Hypertension 161 3666 13 28.0 3.60\ (1.71-7.59) 18 39.0 3.46\ (1.83-6.54) 31 71.1 2.29\ (1.50-3.50)
stage 3
Total 10 874 260 886 197 257 759

*See the footnote to Table 1 for an explanation of the abbreviations.

†Relative risks are adjusted for age, serum cholesterol level, cigarettes per day, BMI, BMI 2, electrocardiographic abnormality, race, and education.
‡P,.05.
§P,.01.
\P,.001.
¶P,.10.

the adverse impact of dietary and other lifestyle traits lead- pressure measured in young adulthood predicted long-
ing to BP rise from youth onward in most people (eg, on term risks for CHD, CVD, and all-cause mortality. As in
average the cohort was overweight [BMI, 26.0]). (3) Blood middle-aged and older persons,1-6 relationships of SBP,

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 tension, 25-year absolute risks and absolute excess risks
for mortality—for the years from average ages of 30 to
55 years—were substantial, eg, all-cause mortality rates
of 63 and 72 per 1000 and absolute excess rates of 10
All Causes‡
and 20 per 1000, translating into estimated shorter life
Multivariate expectancy of 2.2 and 4.1 years. These 2 strata ac-
Adjusted counted for 59.4% of all excess deaths attributable to
Age-Adjusted Relative Risk§ above-normal SBP/DBP.
No. of Rate per 10 000 (95% Confidence
Deaths Person-years Interval) Observations on BP and CHD or total CVD mortal-
ity in young adults are limited, mainly because elucida-
68 26.7 1.20 (0.90-1.62) tion of this matter requires large sample sizes and long-
122 22.7 1.00 term follow-up to accrue sufficient events for statistical
181 25.8 1.10\ (0.87-1.38) analysis. In the 1960s, Paffenbarger et al11-13 reported
184 29.8 1.25\ (0.99-1.57) nested case-control investigations of 45000 college en-
100 35.3 1.40¶ (1.07-1.83) trants (average age, 19 years) from the University of Penn-
50 35.0 1.30 (0.93-1.83)
sylvania and Harvard University examined from 1921
28 66.1 2.31# (1.52-3.51)
26 82.6 2.64# (1.68-4.13)
through 1950. They demonstrated that higher percent-
ages of those who died of CHD and stroke had higher
70 26.7 1.22 (0.93-1.61) SBP ($130 mm Hg) at entry examination. However,
182 22.8 1.00 analyses of BP and mortality were not multivariate ad-
286 28.0 1.17 (0.97-1.41) justed, and detailed relations by BP strata were not in-
149 35.2 1.39** (1.11-1.73) vestigated. Other long-term cohort studies have inves-
52 56.0 209# (1.52-2.89)
20 74.5 2.38# (1.45-3.90)
tigated cardiovascular risk factors in young adults on a
759 ... ... smaller scale. Thirty-year follow-up data on Framing-
ham Study participants aged 31 to 39 years at baseline
did not provide results on blood pressure29; 14- and 18-
year follow-up reports on Framingham young adults com-
bined participants aged 30 to 49 years.7,30 The Johns Hop-
kins Precursors Study on almost 1000 young male medical
students (mean age, 22 years) reported 30-year CVD mor-
tality in relation to serum cholesterol levels31 and vas-
cular reactivity,32 but these reports gave no data on blood
pressure and subsequent CVD events. Investigations by
the Society of Actuaries yielded detailed findings on BP
levels at entry and all-cause mortality among approxi-
Table 4. Underlying Cause for 45 Noncardiovascular Deaths
mately 4 million entrants aged 15 to 69 years.14-16 These
With Optimal Blood Pressure at Baseline large-scale data showed continuous and graded relation-
ships of SBP/DBP to mortality in entrants aged 20 to 29
Cause of Death No. (%) and 30 to 39 years, but the data were not multivariate
adjusted and may have limitations related to accuracy of
Infectious diseases* 5 (11.1)
Acquired immunodeficiency syndrome 5 (11.1) BP measurement in insurance examinations. Recently,
Neoplasms† 23 (51.1) a study from Glasgow, Scotland, briefly reported a sig-
Esophageal cancer 1 (2.2) nificant relationship between SBP in university students
Colon cancer 3 (6.7) and subsequent CVD mortality, but detailed relations by
Liver cancer 1 (2.2) BP strata were not given.33 Thus, our data go beyond the
Pancreatic cancer 2 (4.4)
few previous findings and constitute, to our knowledge,
Lung cancer 8 (17.8)
Lymphoma and leukemia 4 (8.9)
the first detailed report from a large, long-term study of
Other neoplasms 4 (8.9) young adults from the general population showing a sig-
Liver cirrhosis 1 (2.2) nificant independent association of BP level and CHD or
Accidents, poisonings, and violence‡ 12 (26.7) CVD mortality.
Other causes 4 (8.9) Advanced coronary atherosclerosis was seen in most
Total 45 (100.0) young American men undergoing autopsy during the Ko-
rean and Vietnam wars.34,35 Other studies of the natural
*International Classification of Diseases, Eighth Revision (ICD-8), codes
000-136. history of atherosclerosis indicate that in populations with
†ICD-8 codes 140-239. high rates of premature coronary artery disease, ad-
‡ICD-8 codes 800-900. vanced lesions appear with increasing frequency during
the years of childhood and young adulthood.36 In au-
DBP, and SBP/DBP (JNC-VI strata) to mortality were gen- topsy studies from the Bogalusa Heart Study, among chil-
erally graded, strong, and independent. (4) Multivariate- dren and young adults who died prematurely of noncar-
adjusted HRs tended to be greater for SBP than DBP, and diac causes, the extent of involvement of aortic and
similar in size to those for middle-aged men. (5) For the coronary artery wall with fatty streaks and fibrous plaques
2 large strata with high-normal BP and stage 1 hyper- was associated with major coronary risk factors, includ-

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 ing BP.17,18 Another autopsy study of youth showed a re-
lation of coronary atherosclerosis to an index of mean
arterial pressure based on findings in small renal arter-
ies.19 Correspondingly, a recent report on electron-
beam computed tomography showed that, in young
adults, BP related to presence of coronary artery calcifi-
cation.37 It is reasonable to interpret our data as concor-
dant, ie, indicating that such BP-related early atheroscle-
rotic lesions lead to greater risk for fatal CVD during the
decades from young adulthood through middle age.
Our data indicate that SBP may be more useful in pre-
dicting future CHD and CVD deaths than DBP. Risk gen-
erally increased throughout the range of SBP from 120 to
180 mm Hg and above. This finding for young adults lends
support to recent assessments, based on data for older adults,
that SBP might be more important than DBP and that both
(SBP/DBP) merit consideration in assessment of CVD risk.7-10
Although not statistically significant, our data on low
DBP (,70 mm Hg) suggest it may be related to increased
long-term CHD, CVD, and all-cause mortality and that low
SBP (,120 mm Hg) may be related to increased all-cause
mortality. These results should be interpreted with cau-
tion for several reasons. First, HRs were not significant and
95% CIs were wide, given small numbers of CHD and CVD
deaths in these categories. Second, as footnoted in the BP
classification of JNC-V and JNC-VI,20,28 people with very
low BP, especially very low DBP, may have medical abnor-
malities, eg, aortic insufficiency or preclinical neoplastic
disease, hence needing medical evaluation. We could not
completely exclude men with medical conditions. After
exclusion of those with low DBP (,60 mm Hg, also ,65
mm Hg), risks for CHD and CVD mortality in the optimal
and normal BP strata were almost identical. Therefore, it
is reasonable to infer that these data do not critically bring
into question the conclusion that the relationship be-
tween SBP/DBP and CVD risks is generally continuous
(monotonic), and that for healthy adults, including young
as well as older adults, SBP/DBP of less than 120/80
mm Hg (,120/,80 mm Hg) or of less than or equal to
120/80 mm Hg (#120/#80 mm Hg) is optimal.
A limitation of the present study is that results were
based on a single measurement of blood pressure, hence,

Table 5. Relationship of Baseline JNC-VI Classification to 25-Year Mortality

From Coronary Heart Disease, Cardiovascular Diseases, and All Causes*

Coronary Heart Disease Cardiovascular Diseases All Causes

Age-Adjusted Adjusted Age-Adjusted Adjusted Age-Adjusted Adjusted

Person- Rate per Relative Risk† Rate per Relative Risk† Rate per Relative Risk†
JNC-VI No. of years of No. of 10 000 (95% Confidence No. of 10 000 (95% Confidence No. of 10 000 (95% Confidence
Classification Men Follow-up Deaths Person-years Interval) Deaths Person-years Interval) Deaths Person-years Interval)
Optimal 892 21 436 8 4.0 1.08 (0.48-2.45) 11 5.5 1.06 (0.53-2.13) 54 25.6 1.24 (0.90-1.72)
Normal 2164 52 338 21 4.0 1.00 29 5.6 1.00 112 21.5 1.00
High-normal 2746 66 313 40 6.2 1.43 (0.84-2.42) 54 8.4 1.40 (0.89-2.20) 171 26.2 1.18 (0.93-1.50)
Hypertension 3932 94 189 78 8.3 1.69‡ (1.04-2.74) 96 10.2 1.52\ (1.00-2.31) 284 30.1 1.32† (1.05-1.64)
stage 1
Hypertension 851 20 032 33 15.1 2.60§ (1.48-4.57) 44 20.0 2.51§ (1.55-4.07) 96 44.4 1.78§ (1.35-2.37)
stage 2
Hypertension 160 3640 13 28.4 3.78§ (1.78-8.01) 18 39.6 3.54§ (1.86-6.73) 31 72.0 2.33§ (1.53-3.56)
stage 3
Total 10 745 257 948 193 252 748

*Excludes men with very low diastolic blood pressure (,60 mm Hg). See the footnote to Table 1 for an explanation of the abbreviations.
†Relative risks are adjusted for age, serum cholesterol level, cigarettes per day, BMI, BMI 2, electrocardiographic abnormality, race, and education.
‡P,.05.
§P,.001.
\P,.10.

Table 6. Absolute Excess Risk per 1000 in 25 Years and Percentage of All Excess Deaths in Strata of JNC-VI Classification*

Coronary Heart Disease Cardiovascular Diseases

Age-Adjusted Excess Rate No. of % of All Age-Adjusted Excess Rate No. of % of All
JNC-VI No. of No. of Rate per 1000 per 1000 Excess Excess No. of Rate per 1000 per 1000 Excess Excess
Classification Men Deaths in 25 Years in 25 Years Deaths† Deaths Deaths in 25 Years in 25 Years Deaths† Deaths
Optimal 930 11 12.7 2.7 3 3.0 14 16.2 2.5 2 2.2
Normal 2194 22 10.0 0.0 0 0.0 30 13.7 0.0 0 0.0
High-normal 2773 40 14.8 4.8 13 15.8 54 20.0 6.3 17 16.9
Hypertension 3963 78 19.7 9.7 38 45.6 97 24.5 10.8 43 41.6
stage 1
Hypertension 853 33 35.3 25.2 22 25.6 44 46.8 33.1 28 27.5
stage 2
Hypertension 161 13 62.4 52.3 8 10.0 18 87.8 74.1 12 11.6
stage 3

*JNC-VI is described in the footnote to Table 1.

‡Estimated number of excess deaths compared with the normal blood pressure stratum by JNC-VI criteria during 25 years of follow-up.

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 they probably underestimate true associations because
of regression dilution bias.1 Nonetheless, as shown here
and in many other prospective population studies, a single
BP reading is strongly predictive of future CVD events.
Since this cohort was identified at employment sites, the
role of the “healthy worker effect” should be consid-
ered, ie, because working populations tend to be healthier
than general populations, the mortality rate of the CHA
cohort was about 30% lower than that expected for a
similar sample of the general population. However, this
phenomenon has little or no bearing qualitatively on the
relation of baseline risk factors (including BP) to long-
term mortality, as shown by many prospective studies
with similar qualitative results on this matter for work-
place-based and community-based populations samples.1,2
It is possible that because of this phenomenon, our study
quantitatively underestimates absolute risk and abso-
lute excess risks of adverse blood pressure levels for young
adult men. Thus, it is a reasonable inference, supported
by the limited data available from other studies of young
adults, that these findings are generalizable.
Our results indicate that levels of blood pressure above
normal in young adults is a large unsolved problem for
medical care and public health. Long-term absolute risks
and absolute excess risks, ie, from average age of 30 years
at baseline to 55 years, were substantial for these young
adult men, making up 61.9% of this cohort, with 59.4% of
all excess deaths in men with high-normal BP and stage 1
hypertension.
These data lend strong support to 2 strategic con-
cepts. First population-wide primary prevention by safe
nutritional-hygienic means of adverse BP levels, highly
prevalent at present in middle-aged and older people, is im-
portant. With such primary prevention, a substantial in-
crease can be achieved in the proportion of people in the
population who throughout life have favorable levels of BP
(and other risk factors). Second, population-wide efforts
should be made for early detection of children, teenagers,
young adults, and others with unfavorable BP levels, so that
therapeutic efforts can be instituted early, first and fore-
most to improve lifestyles. Initial lifestyle recommenda-
tions to prevent and treat high BP involved avoidance of
high levels of salt intake, inadequate potassium intake, ex-
cess alcohol use, overweight, and sedentary habit.38-40 Based
All Causes
Age-Adjusted Excess Rate No. of % of All
No. of Rate per 1000 per 1000 Excess Excess
Deaths in 25 Years in 25 Years Deaths† Deaths
59 64.6 11.9 11 6.2
115 52.7 0.0 0 0.0
171 62.8 10.1 28 15.6
287 72.4 19.7 78 43.8
96 104.1 51.4 44 24.6
on recent research advances, these recommendations have
been expanded to include high intake of fruits, veg-
etables, whole grains, and legumes; fat-free and low-fat pro-
tein sources; and low intake of lipid-rich foods (ie, re-
duced dietary total fat, saturated fat, and cholesterol) and
sweets.20,41-43
Our results also support recommendations by JNC-VI
on dealing with risks for persons aged 18 years and older
with high BP. Because our study was observational, not
interventional, it yielded no direct data related to treat-
ment of high BP in young adults by lifestyle and (as indi-
cated) pharmacological means. For hypertensive men of
this age, there are no clinical trial data, no trials on-going,
and to the best of our knowledge none planned, because
sample size and duration are forbidding. Therefore, use
of drugs for this age group must rely on judgment con-
cerning the likely mix of benefit and risk with decades-
long treatment. Our data are important evidence on risks;
they reinforce JNC-VI recommendations to base drug
(along with lifestyle) treatment on BP levels, findings for
other risk factors and for target organ damage, and re-
sponse to initial lifestyle intervention, and not on age.
In conclusion, the data of this study on young adult
men underscore the soundness of recommendations for
population-wide lifestyle modifications to prevent ad-
verse BP levels, population-wide efforts for early detec-
tion and lifestyle counseling for those who already have
unfavorable BP levels, and, for those with frank high BP
at any adult age, implementation of JNC-VI guidelines
for treatment.
Accepted for publication November 7, 2000.
The Chicago Heart Association Detection Project in
Industry has been supported by the American Heart Asso-
ciation and its Chicago and Illinois affiliates, Chicago, Ill;
the Illinois Regional Medical Program, Chicago; grant
HL21010 from the National Heart, Lung, and Blood Insti-
tute, Bethesda, Md; the Chicago Health Research Founda-
tion, Chicago; and private donors.
Presented at the 18th Scientific Meeting of the Inter-
national Society of Hypertension, Chicago, Ill, August 23,
2000.
The work of the Chicago Heart Association Detection
Project in Industry Study was accomplished thanks to the in-
valuable cooperation of 84 Chicago companies and organi-
zations and their officers, staff, and employees, whose volun-
teer efforts made the project possible. Acknowledgment is also
gratefully extended to all those in the Chicago Heart Associa-
tion—staff and volunteers—serving the project. Many of these
individuals are cited by name in Stamler et al.22,23
Corresponding author and reprints: Martha L. Davig-
lus, MD, PhD, Northwestern University Medical School, De-
partment of Preventive Medicine, 680 N Lake Shore Dr, Suite
1102, Chicago, IL 60611-4402 (e-mail: daviglus@nwu.edu).
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