REVIEWS

Epidemiology of cardiovascular
disease in young individuals
Charlotte Andersson1,2 and Ramachandran S. Vasan1,3
Abstract | In the past 2 decades, a high prevalence of risk factors for cardiovascular disease, such as
obesity, physical inactivity, and poor diet, has been observed among young individuals living in
developed countries. The rate of substance abuse (opioids, cocaine, electronic cigarettes, and
anabolic steroids) is also increasing among young adults, whereas cigarette smoking might be
declining. Among younger individuals (aged 18–50 years), the incidence of cardiovascular diseases
over the same time period has either been steady or has increased, in contrast to the trend towards
a lower incidence of cardiovascular disease in adults aged >50 years. Current observations might,
therefore, be used to forecast a potential epidemic of cardiovascular disease in the near future as
the younger segment of the population ages. In this Review, we discuss the burden of risk factors
for ischaemic heart disease, heart failure, atrial fibrillation, and sudden cardiac death among
young adults aged 18–45 years. Furthermore, we discuss the prevalence, incidence, and temporal
trends of various cardiovascular diseases among this young segment of the population.

1
Framingham Heart Study,
73 Mount Wayte Avenue,
Framingham, Massachusetts
01702–5827, USA.
2
Department of Cardiology,
Herlev and Gentofte Hospital,
Niels Andersens Road 65,
2900 Hellerup, Denmark.
3
Boston University Schools
of Medicine and Public
Health, 800 Massachusetts
Avenue, Boston,
Massachusetts 02118, USA.
Correspondence to C.A.
ca@heart.dk
doi:10.1038/nrcardio.2017.154
Published online 12 Oct 2017
Cardiovascular diseases among young adults (defined
in general as individuals aged 18–45 years) comprise
a hetero­geneous group of disorders that can be either
congeni­tal or acquired. The incidence and prevalence
of both congenital and acquired cardiovascular diseases
seem to be increasing over the past few decades in the
Western world, secondary to changing risk factor profiles
among children and young adults. This Review discusses
the risk factors, incidence, prevalence, and temporal
trends of acquired cardiovascular diseases, including
ischaemic heart disease, heart failure, atrial fibrillation,
and sudden cardiac death, among young individuals.
Risk factor burden
The high prevalence of risk factors among individuals
living in the USA has led the AHA to identify seven
key health metrics (‘ideal health factors’) to reduce the
future burden of cardiovascular disease (TABLE 1). These
ideal health factors have been linked with lower levels of
several biomarkers of subclinical atherosclerosis (such
as carotid intima–media thickness)1,2 and are linearly
associated with the risk of developing cardiovascu­
lar disease and the risk of all-cause and cardio­vascular
mortal­ity 3–5. Ideal levels of key cardio­vascular health
factors are also important in reducing the risk of pre­
mature  cardiovascular-­r elated death (defined as
the onset of  cardio­v ascular disease in individuals
aged <60 years)3. FIGURE 1 presents the prevalence of
each cardiovascular health metric for younger (aged
20–49 years) versus the prevalence in older individuals
(aged ≥50 years) based on estimates from the NHANES
study 6. High blood pressure, BMI, and levels of blood
cholesterol and blood glucose were more common over­
all in older than in younger individuals because these
risk factors tend to accumulate and increase with age.
By contrast, both smoking and the consumption of
unhealthy foods were more common in younger than
in older individ­uals. Very few individuals in the USA,
including children, have an ideal health profile6.
Obesity. Over the past 40 years, the global age-adjusted
prevalence of obesity has risen by nearly threefold
from 3.2% to 10.8% in men and from 6.4% to 14.9% in
women7. Between 1980 and 2013, the prevalence of chil­
dren who are overweight or obese has increased from
16% to 23% in developed countries and from 8% to 10%
in developing countries8. However, in some developing
countries, particularly those in South Asia, the high
prevalence of children who are underweight remains
as much of a major health issue as obesity 7. Although
BMI increases with age, steeper increases in weight have
been observed for more recent birth cohorts (particu­
larly since the 1960s) in both developing and developed
countries8. However, analyses of more recent cohorts of
the NHANES study have suggested that the previous
sharp increases in obesity prevalence among individ­
uals in the USA are levelling off 9. A comprehensive
review from 2010 similarly concluded that whereas
obesity rates are stabilizing in many Western countries,
including the USA and Europe, obesity might still be on

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Key points Smoking. The prevalence of cigarette smoking declined

• Young adults (aged 18–45 years) have developed increasingly unhealthy risk factors
over the past 2 decades, including obesity, poor diet, and physical inactivity
• In contrast to older adults, growing evidence in young adults shows that trends
in incident cardiovascular disease (especially heart failure) have been increasing
or stagnating over the past few decades
• Current observations forecast a new epidemic of cardiovascular disease in this young
segment of the population as they age
• Data on incident cardiovascular disease in young adults are scarce, and estimates
are associated with wide confidence intervals owing to the low absolute number
of individuals in this population with cardiovascular disease
• More data are therefore needed (especially harmonized data between various
studies) to establish the epidemiology and trends in overt cardiovascular diseases
in young adults
the rise in developing countries such as India, Nepal,
and Bangladesh10. Obesity rates among children and
adolescents living in Europe, Australia, Japan, and the
USA might also be levelling off 10; however, a NHANES
analysis reported that the proportion of children (aged
12–19 years) with a healthy BMI has declined from
nearly 70% in 1999 to 65% in 2012 (REFS 6,11).
Physical inactivity. Physical inactivity is an important
contributor to cardiovascular risk across all continents
and age groups. Although physical activity levels gener­
ally decline with advancing age, 80% of all adolescents
(aged 10–19 years) do not meet international public
health guidelines for WHO-recommended levels of
physical activity, and >30% of individuals in the USA
aged 15–29 years are categorized as being physically
inactive12. A similarly high proportion of young adults
living in the Eastern Mediterranean region, the Western
Pacific region, and Europe are also considered physi­
cally inactive12. In Africa and South Asia, >20% and
>10%, respectively, of all individuals aged 15–29 years
are physically inactive12. In the USA, physical activity
levels seem to have declined in children and remained
unchanged or possibly declined in adults from 1999 to
2012 (REF. 6).
globally by ~25% between 1980 and 2012; importantly,
this decline has also been observed among young adults
aged 15–35 years13. Data from the NHANES study con­
firmed these declining trends between 1988 and 2008
among individuals in the USA11. However, the preva­
lence of cigarette smoking remains considerable among
both men (15–20%) and women (~10%) in the USA11.
Furthermore, the prevalence of cigarette smoking remains
high among men (33–50%) and women (15–20%) living
in Asia and in individuals living in Europe (10–30%)13.
In adolescents, smoking rates are comparatively
lower in the USA (5–10%) compared with rates in other
regions, including South America (20–25%) and Europe
(20–30%)14,15. Data published by the WHO have sug­
gested that tobacco use is increasing among adolescents
in Europe16, and more women are beginning to smoke in
Asia, Africa, and South America14. Electronic cigarettes
are also being increasingly used by young adults. A study
conducted in Europe reported that 12% of the population
had tried electronic cigarettes in 2014, with many of these
individuals being aged 18–24 years17. The long-term
cardio­vascular consequences of electronic cigarette use,
and whether the cardiovascular risks of electronic cigar­
ette use are possibly lower than the risks of ­conventional
­cigarette smoking, remain to be determined18.
Abuse of opioids and other drugs. Opioid abuse is
another adverse trend observed among young adults that
is likely to carry adverse risks of future cardiovascular
events19. Data reported by the Centers for Disease Control
and Prevention showed that heroin use and deaths from
overdoses have more than doubled in individ­uals aged
18–25 years in the past decade, particularly among those
from a low socioeconomic background20. Many of these
individuals also abuse other drugs, such as prescribed
opioids, cocaine, and anabolic steroids, which all carry
well-known cardiovascular risks21,22. A 2001 Swedish
study reported that ~3% of boys aged 16–17 years had
used anabolic steroids23. In the USA, the lifetime use
of anabolic steroids among male college students was
1.53% in 1993, 1.75% in 1997, 1.80% in 1999, and 1.99%
in 2001 (REF. 24).

Table 1 | AHA definitions of seven ideal health factors for CVD prevention High blood pressure. The prevalence of hypertension
Health factor Criteria rises with advancing age. Age-standardized blood-­
Physical activity At least 150 min of moderate activity or 75 min of vigorous pressure levels have declined in many high-income
physical activity per week countries but have increased over the past 40 years
in developing countries within sub-Saharan Africa,
BMI <25 kg/m2
Oceania, and East and Southeast Asia25. The prevalence
Diet Fulfil 4–5 components of AHA diet score: of prehypertension and hypertension among individuals
• ≥2 servings of fish per week
• ≥4.5 cups of fruits and/or vegetables per day aged 8–17 years living in the USA increased by 2.3% and
• ≥3 servings of whole grains per day 1.0%, respectively, between 1988 and 2002, in parallel
• ≤36 oz of sugar-sweetened beverages per week with the increase in the prevalence of obesity 26. However,
• ≤1.5 g of sodium per day a comprehensive review of studies from high-income
Serum cholesterol <200 mg/dl countries concluded that blood-pressure levels dropped
Blood pressure <120/<80 mmHg in individuals aged 5–34 years between 1948 and 1998,
possibly as a result of improvements in early-life diet 27.
Fasting plasma glucose <100 mg/dl
Similarly, a systematic review published in 2017 that ana­
Smoking Never or quit >12 months ago lysed 18 studies assessing secular trends in blood pres­
CVD, cardiovascular disease. sure among ­children and adolescents (n = 2,042,4701)

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a Young adults (aged 20–49 years) with a high rate of overt manifestations of vasculopa­
100 thy within 8 years after diagnosis34. Increased arterial
90 stiffness and hypertension were present, respectively, in
Cumulative percentage (%)

80 47% and 21% of those with type 2 diabetes (mean age

Ideal
70 22 years) and 12% and 10% of individuals with type 1
60 diabetes (mean age 18 years)34.
50
40
Intermediate Pregnancy-related hypertension. The occurrence of
gestational diabetes has increased dramatically over the
30
past 3 decades. In the USA, the prevalence of gesta­tional
20 Poor diabetes increased from 0.3% in 1979–1980 to 5.8% in
10
2008–2010, which was thought to be partly attribut­
0
Smoking BMI Physical Healthy Total Blood Diabetes able to an increasing number of pregnant women who
activity diet cholesterol pressure mellitus were overweight or obese35. Similar increases have
b Middle-aged and elderly individuals (≥50 years) been reported in South Korea36 and China37. However,
100 a study conducted in Nordic women showed no tem­
90
Ideal
poral increase in the prevalence of gestational diabetes in
Cumulative percentage (%)

80 the past 15 years; notably, an increase in the prevalence

70
60
Intermediate
50
40
30
20
Poor
10
0
Smoking BMI Physical Healthy Total Blood Diabetes
activity diet cholesterol pressure mellitus
Figure 1 | Levels of various risk factors stratified by age groups
Nature(20–49 years and
Reviews | Cardiology
≥50 years) in the NHANES6. a | Young individuals (aged 20–49 years). b | Middle-aged
and older individuals (aged ≥50 years). Red represents poor risk factor levels, blue
represents intermediate risk factor levels, and green represents ideal risk factor levels.
concluded that blood-pressure levels have not increased
in this age group in the past 4 decades, despite increas­
ing obesity rates28. Data on young adults specifically are
more sparse, but elevated blood pressure might con­
ceivably be a later manifestation of obesity. Indeed, high
blood pressure in young adults has a strong heritable
component, and young adults with a familial predisposi­
tion to hypertension have high ­arterial stiffness before
developing overt hypertension29,30.
Diabetes mellitus. In contrast to the prevalence of
hypertension, which might not have increased in parallel
with obesity rates among young adults, the prevalence of
diabetes (predominantly type 2 diabetes) has been rising
exponentially in children and young adults over the past
3 decades. Globally, the prevalence of diabetes increased
by nearly 100% between 1980 and 2014 (REF. 31). In the
USA, the prevalence of any type of diabetes increased
by 250% in individuals aged 0–44 years and by 220%
in individ­uals aged >44 years between 1980 and 2014
(REF. 15). The prevalence of type 1 diabetes is also increas­
ing worldwide32, and projections among individuals
aged <20 years in the USA suggest that the incidence
of both type 1 and type 2 diabetes might increase by an
additional threefold and fourfold, respectively, by 2050
(REF. 33).
The development of either type 1 or type 2 diabetes
during childhood and adolescence has been associated
of gestational diabetes was noted among immigrants,
­particularly those from South Asia38.
Paralleling the data for gestational diabetes, the rates
of severe pre-eclampsia have also increased. Compared
with pregnant women delivering in 1980, those deliver­
ing in 2003 were at a 6.7‑fold increased risk of severe
pre-eclampsia39. The changes in the prevalence of ­obesity
and smoking in the studied populations during this time
might have driven these trends. Similarly, in Canada,
rates of pre-eclampsia increased from 26 to 51 per 1,000
deliveries between 1989 and 2012 (REF. 40). The preva­
lence of pre-eclampsia is higher in black women than
in white women in the USA, and temporal increases in
gestational pre-eclampsia have been more pronounced
in black women than in white women41. Gestational
hypertension has increased from 10 per 1,000 deliveries
in 1987–1988 to >30 per 1,000 deliveries in 2003–2004 in
the USA42. By contrast, the prevalence of pregnancy-­
related hypertension and pre-eclampsia might be
decreasing in Europe and Australia, possibly owing to
more planned deliveries and fewer births at >40 weeks
of gestation43,44. Notably, pregnancy-related hypertension
and diabetes are major risk factors for the development
of hypertension and ­diabetes in the mother in the years
following childbirth45,46.
Lipid levels. High cholesterol and triglyceride ­levels
are also important risk factors for cardiovascular
disease. Globally, blood cholesterol levels remained
unchanged between 1980 and 2008 among individuals
aged >25 years47. However, during this period, circu­
lating cholesterol levels declined in individuals from
high-­income countries in Europe and North America,
but levels increased in individuals from developing
countries in South Asia and the Pacific region47. In the
Framingham Heart Study, HDL-cholesterol levels
increased and triglycerides levels decreased between
1991 and 2006, despite increases in BMI, whereas
serum total cholesterol levels remained unchanged48.
Similar trends were reported by the NHANES study for
HDL cholesterol and triglyceride levels, but in contrast
to the Framingham study, total cholesterol levels were
also observed to decline49. Interestingly, age-specific

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analyses showed a lesser degree of reduction in lipid
­levels (total cholesterol, LDL cholesterol, and triglycer­
ides) among younger individ­u als (aged <50 years)
versus older individ­u als, and subgroup analy­s es
in NHANES showed no s­ ignificant change among
­individuals aged <50 years49.
In young adults, high levels of circulating LDL choles­
terol are often attributable to familial hypercholesterol­
aemia, which might partially explain the lesser degree
of reduction in lipid levels in younger individuals over
the past 2 decades. By use of the modified Dutch Lipid
Clinic Network criteria, which are based on nongenetic
data, familial hypercholesterolaemia is predicted to
affect approximately 1 in 130–250 individuals world­
wide; however, this condition is thought to be severely
underdiagnosed in most countries50–52. Changes in diet
and other nonpharmacological management strategies
would have rather limited effects on blood cholesterol
levels in patients with familial hypercholesterolaemia,
although a diet low in saturated fat and cholesterol
might reduce LDL‑cholesterol levels by up to 10% and
5%, respectively 53.
Dietary intake. Between 1980 and 2012, a reduction
in the dietary intake of total-fats, trans-fats, and satur­
ated fats was observed among individuals living in the
USA20,54. This reduction might have contributed to a
decrease in circulating LDL-cholesterol levels among
children between 1988 and 2010 (REF. 55). However,
1 in 10 children still had elevated total cholesterol ­levels
throughout the observation period, indicating that
­further efforts are needed to reduce high cholesterol
levels in young individuals. Although an unhealthy diet
(defined according to the AHA diet score) was found
to be more common in younger individuals (aged
12–19 years) than in older individuals (aged >19 years),
NHANES documented a significant improvement
in diet across all age groups between 1999 and 2012
(REF. 55). However, no changes were observed in individ­
uals with a low socio­economic status or among African
Americans and Mexican Americans55. A 2017 analysis
of NHANES data concluded that a suboptimal diet was
associated with 64% of all cardiometabolic deaths in
individuals aged 25–34 years, which was almost double
the proportion of cardiometabolic deaths attributable
to diet in individuals aged ≥75 years56. Among young
adults, the excess intake of sugar-sweetened bever­
ages and processed meat was strongly a­ ssociated with
­cardiometabolic disease-related mortality 56,57.
Ischaemic heart disease
Risk profile. The presence of traditional cardio­vascular
risk factors in young adulthood (aged 18–30 years) is
closely related to the burden of subclinical athero­
sclerosis in early midlife (aged 40–55 years)58. In addition
to well-established risk scores like the Framingham risk
score and the AHA/ACC risk score59–61, other risk scores
(based on the same set of risk factors as the Framingham
risk score) have been developed specifically to predict
the risk of coronary artery disease in young adults (aged
18–34 years)62.
Case or case–control studies of young patients with
myocardial infarction have confirmed that vascular
risk in this cohort is largely attributable to traditional
cardio­vascular risk factors63. More than half of young
adults with coronary artery disease have a family his­
tory of the disease, and many are also smokers64. The
international, case–control INTERHEART study 65
reported that smoking, abdominal obesity, psycho­social
stressors, reduced consumption of fruit and vegetables,
hyper­tension, diabetes, elevated lipid ­levels, and phys­
ical inactiv­ity contributed to 94% of the population-­
attributable risk of myocardial infarction among young
individuals (defined as disease onset in individuals
aged ≤55 years in men and ≤65 years in women). The
population-­attributable risk estimate was higher in
younger (94%) than in older individuals (88%) for the
risk factors listed above65. Similarly, a Portuguese study
reported that 77% of the population-­attributable fraction
of nonfatal myo­cardial infarction among Portuguese
men aged <45 years was associated with adverse lifestyle
factors; the three most important risk factors were a high
waist:hip ratio, smoking, and a low level of education66.
Cocaine use67, a Southeast Asian ethnicity 68, connective
tissue disorders, vasculitides (including Kawasaki dis­
ease), autoimmune diseases69, hypertensive disorders of
pregnancy and gestational diabetes46, use of oral contra­
ceptives70, high levels of lipoprotein(a)71, familial72 and
genetic predisposi­tions73,74, and retroviral therapy for
HIV infection75 have also been linked to early-­onset
coronary disease76. In an Italian study of 121 consecu­
tive patients with myocardial infarction aged <45 years,
only 3% had no identifiable risk factors77. All patients
aged <40 years in a Japanese study who underwent
percutaneous coronary inter­vention (n = 69) had at
least one conventional risk factor for athero­sclerosis78.
Interestingly, the risk of coronary artery disease associ­
ated with a high genetic predisposition was shown to
be modifiable with positive changes in lifestyle, such
as increased engagement in physical activity, adoption
of a healthy diet, maintenance of a healthy weight, and
not smoking 79. This observation might explain in part
why genetic risk scores overall have only modest addi­
tive predictive ability for coronary artery disease in
­multivariable risk models80–82.
Table 2 | Myocardial infarction in young adults
Study population Age group Incidence (per
(years) 1,000 person-years)
Atherosclerosis 35–44 • Black men 2.4
Risk in • Black women 1
Communities • White men 0.8
study6 • White women 0.3
45–54 • Black men 3.8
• Black women 2.6
• White men 2.2
• White women 1.0
Worcester Heart <55 0.7
Attack study98
Danish nationwide 35–49 • Men ~1
cohort study101 • Women <0.5

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Table 3 | Ischaemic heart disease in young adults
Study population Age group Prevalence
(years) (%)
NHANES (2011–2014)6 20–39 0.5–0.6
Centers for Disease 18–44 1.2
Control and Prevention
(2006–2010) 45–64 7.1
Denmark registry 45–54 ~2
(2001–2009)159
UK (2005)*160 35–44 • Men 0.5
• Women 0.2
*Prevalence of myocardial infarction only.
Prospective cohort studies of risk factors for inci­
dent cardiovascular disease in young adults are sparse
because of the overall low incidence of overt cardio­
vascular disease in younger individuals. The CARDIA
study 83, initiated over a period from 1985 to 1986
through the enrolment of 5,115 black and white men
and women aged 18–30 years, was conducted speci­
fically to investi­gate cardiovascular risk factors in young
adults. The study confirmed that coronary calcium
­levels (a pre­cursor of clinical ischaemic heart disease
and myo­cardial infarction) correlated strongly with the
traditional Framingham Heart Study risk f­ actors (hyper­
tension, hypercholesterolaemia, male sex, advanced
age, and diabetes)84,85, low education levels86, obesity
(including greater subclinical disease burden with longer
­obesity duration)87, and low levels of cardiorespiratory
fitness88. Similar observations have been made in the
Cardiovascular Risk in Young Finns Study 89. National
administrative registries from numerous countries
have provided additional insights on the longitudinal
relation­ship of risk factors with overt atherosclerotic
disease. A Danish study reported that childbearing
women who were overweight or obese had an increased
risk of develop­ing myocardial infarction in the years
following childbirth90. Other risk factors for incident
coronary disease in this population included smoking,
diabetes, hyper­tension, and dyslipidaemia; the last three
risk factors could largely explain the association between
obesity and a greater risk of myocardial infarction91.
Similar trends of increasing risks in individuals who
were overweight or obese have been observed among
young Danish men evaluated for military recruitment 92.
However, increased physical fitness has been shown
partly to mitigate the adverse effects of obesity on the
risk of developing hypertension93, stroke94, and ­ischaemic
heart disease in Swedish nationwide registries95.
Incidence and prevalence. The prevalence of c­ oronary
artery disease among asymptomatic individuals is not
well understood. In a sample of 914 self-referred asymp­
to­­matic South Korean individuals aged <45 years who
underwent coronary CT angiography and coronary
artery scoring, subclinical coronary athero­sclerosis was
present in 9%96. In the 1998 Bogalusa Heart Study97,
subclinical coronary atherosclerosis, detected dur­
ing autopsy, was reported in approximately one-third
of individuals aged 15–20 years, increasing to 70% in
those aged 26–39 years. Likewise, both the incidence
and prevalence of clinical ischaemic heart disease and
myocardial infarction rose rapidly with increasing age
in the Atherosclerosis Risk in Communities Study 6
(TABLES 2,3), with some ethnicity-related variation. For
all ages (including young adults aged 35–44 years),
black men have the highest incidence rate of myo­cardial
infarction, followed by black women, white men, and
white women6.
Temporal trends. As mentioned previously, very few
reports have focused on the incidence, prevalence, and
trends in ischaemic heart disease burden in young adults.
In the Worcester area of Massachusetts in the USA,
the incidence of myocardial infarction among individ­
uals aged <55 years remained unchanged between the
mid‑1980s and 2005 (REF. 98). However, the Centers for
Disease Control and Prevention reported that coronary
artery disease prevalence declined between 2006 and
2010 (from 1.6% to 1.2%; P <0.01) for individuals aged
18–44 years in the USA99. Similarly, a study involving five
European countries (Estonia, Finland, France, Germany,
and Spain) documented a significant decline in overall
rates of acute myocardial infarction events (including
both first and recurrent myocardial infarctions) between
1985 and 2010 in individuals aged 35–64 years100.
In Denmark, an overall decline in the incidence
of first-time myocardial infarction was observed for
individ­uals of all ages between 1984 and 2008 (REF. 101).
However, the decline after 1995 was less pronounced
than the decline for the period between 1984 and 1995,
and the incidence rates of myocardial infarction for
individuals aged <59 years were stable or increased
slightly at the end of the 1990s101. Similar worrisome
trends were noted in Norway, where the incidence rates
of myocardial infarction declined by 12% for those
aged 45–64 years, by 30% for those aged 65–84 years,
and by 23% for those aged >84 years between 2001 and
2009, but remained unchanged for young adults aged
25–44 years102. A similar pattern of stable incidence
rates for myocardial infarction among individuals aged
<50 years was reported in Western Australia between
1993 and 2012 (REF. 103). In France, nationwide data
collected between 2004 and 2014 documented a 6%
increase in hospitalization rates for both ST‑segment
elevation and non‑ST-segment elevation myocardial
infarction for women aged <65 years104. For men aged
<65 years, the rates of hospitalization for myo­cardial
infarction remained unchanged during the same
period. By contrast, among people aged >65 years, hos­
pitalization rates declined by 17% in women and 14%
in men104. A Chinese study conducted in two hospitals in
Beijing also reported that the number of patients aged
<45 years with coronary artery disease increased sub­
stantially between 2010 and 2014 (REF. 105). Together,
these data point towards a stable or increasing trend in
the incidence of coronary artery disease over time
in individuals aged <50 years, in contrast to declining
rates among older individuals. Additional investigations
are warranted to elucidate the factors responsible for this
worrisome trend.

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Heart failure idiopathic dilated cardiomyopathy, which contributed to

Aetiology. The most common cause of heart failure in 19% of all cases of heart failure113. By contrast, only 7.7%
children and young adults is dilated cardiomyopathy, for of cases of heart failure were of ischaemic origin113.
which the underlying aetiology is most often unknown106. In young Swedish men aged <25 years who were
Myocarditis and neuromuscular diseases are among the evalu­ated at the time of entrance into military services,
most common known aetiologies of dilated cardiomyo­ both low cardiorespiratory fitness and low muscle
pathy in children107. These factors are also an important strength were identified as significant risk factors for
cause of heart failure in young adults, although ischae­ incident early-onset heart failure (diagnosed at a mean
mic heart disease is likely to contribute with increasing age of 50 years)114. Similarly, the CARDIA study reported
age106,107. In the MAGGIC consortium108, which com­ that poor physical fitness was associated with impaired
prised 31 observational studies and randomized clin­ical myocardial systolic contractility and higher diastolic fill­
trials, 63% of individuals aged <40 years were reported to ing pressure at 25 years of follow‑up115,116. Other causes
have presumed idiopathic dilated cardiomyopathy. Only of heart failure in young adults include substance abuse,
14% of all patients with heart failure aged <40 years had especially cocaine use (which can cause cardio­myopathy,
a prior myocardial infarction, 22% had hypertension, heart failure, arrhythmias, angina, and myocardial infarc­
and 9% had diabetes108. For patients with heart failure tion)117. Anabolic steroid use is also an important risk
aged 40–49 years and 50–59 years, 38% and 46% had factor among young men, given its association with
prior myocardial infarction, 37% and 41% had hyper­ increased atherosclerotic burden and impairments in
tension, and 18% and 24% had diabetes, respectively 108. both systolic and diastolic heart function118.
Similarly, in the CHARM programme109, which included
patients with NYHA class II–IV heart failure for at least
4 weeks, idiopathic dilated cardiomyopathy (reported as Table 4 | Heart failure rates in selected cohorts
the primary aetiology) was present in 62% of patients Study population Age Results
aged 20–39 years. A notably high prevalence (75%) of
Incidence (per 1,000 person-years)
individuals with heart failure aged <40 years were over­
weight or obese (BMI ≥25 kg/m2), with 23% of these Danish nationwide 18–34 0.05–0.07
patients being severely obese (BMI ≥35 kg/m2)109. Using cohort study
(1995–2012)111 35–44 0.1–0.3
Swedish nationwide administrative registries, Barasa and 45–54 0.5–0.8
colleagues reported that among patients with heart fail­
ure aged 18–34 years, approximately 10% had congenital Swedish 18–34 0.02–0.04
nationwide cohort
heart disease, 5% had valve disease, 16–18% had a cardio­ study110 35–44 0.1–0.2
myopathy, 16–18% had ischaemic heart disease, and the 45–54 0.5–0.6
rest had heart failure of unknown or other causes110. London, UK 161
18–34 0.05
A similar prevalence of underlying heart failure aetiology
was reported in Denmark for patients aged <50 years111. 35–44 0.2
Together, these data suggest an age-dependent increase 45–54 0.2
in the relative contribution of traditional risk factors to Georgia, USA162 18–54 1.00–1.13
the development of heart failure.
CARDIA 112
18–34 Cumulative incidence
Among patients enrolled in the CARDIA study 112 over 20 years of follow‑up
(mean age 25 years at baseline), incident heart failure was 0.9% in black men,
was reported to be more common than incident myocar­ 1.1% in black women,
dial infarction over a 20‑year follow‑up period. Notably, 0.00% in white men, and
0.08% in white women
all but one case of heart failure occurred in an individual
of African-American descent. Obesity (34%), hyperten­ Prevalence (%)
sion (19%), diabetes (12%), and left ventricular hyper­ Stockholm, 18–34 <0.1
trophy (26%) were also present in a substantial proportion Sweden
(2006–2010)163 35–44 0.1
of the patients with heart failure112. Furthermore, overt
45–54 0.2
systolic dysfunction was often already present at baseline
among those who developed heart failure112. As in the NHANES 20–39 • Women 0.3
CARDIA study, an over-representation of black individ­ (2011–2014) • Men 0.5
uals was also noted in the CHARM programme among 40–59 • Women 1.4
the patients in the youngest age group who were diag­ • Men 1.9
nosed with heart failure; 18% of patients aged <40 years Georgia, USA162 18–54 0.3–0.5
with heart failure were black109. Importantly, this propor­ Madrid, Spain <40 0.3
tion decreased to 2% among patients aged >70 years109. (2007)164
40–49 0.7
Hypertension has been recognized as a strong risk
factor for acute heart failure among black individ­uals. 50–59 2.9
Approximately 45% of all cases of heart failure in a sur­ The Netherlands 0–24 <0.1
vey of African patients (mean age of onset 52 years) (2001)165
25–44 0.2
were estimated to be attributable to hypertension113.
The second most common cause of heart failure was 45–54 1.3

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Postpartum causes of cardiomyopathy and heart failure
include gestational hypertensive disorders119, gestational
diabetes120, obesity 121, and multifetal births121. The risk of
postpartum heart failure is also higher in black women
and in women born in poor developing countries121,122.
Incidence and prevalence. The incidence and prevalence
of heart failure are low overall among young individ­
uals (TABLE 4). For those aged 18–34 years, reported inci­
dence rates range from 0.02 to as high as 1.0 per 1,000
person-­years, probably due to varying disease diagnoses,
ascertain­ment criteria, diverse data sources, and geo­
graphical variation. The incidence of peripartum cardio­
myopathy is not well known, but has been reported to
range from 1 per 300 births in Haiti to 1 per 4,000 births
in the USA, depending on the diagnostic criteria used123.
Studies of individuals systematically screened for heart
failure are rare, and future research using a systematic
strategy is warranted to estimate the true prevalence and
incidence of heart failure in young adults and to compare
estimates from all regions of the world.
Temporal trends. In the past 20 years, divergent trends
in the incidence of heart failure have been reported
for older versus younger individuals. A Danish study
reported a nearly 50% increase in the incidence of heart
failure between 1997 and 2012 among individuals aged
<50 years, in contrast to a nearly 50% reduction in the
incidence of heart failure observed in older individ­
uals during the same period, which resulted in a lower
mean age at onset of heart failure111. Similar trends have
been noted in Sweden110. The US Nationwide Inpatient
Sample reported that hospitalization rates for heart
failure declined for older (aged >55 years), but not for
younger adults (aged 18–55 years) between 2001 and
2009 (REF. 124). Such stagnation in the incidence of heart
failure over time among young adults has also been
noted in Australia and Slovenia125,126.
For more specific heart failure aetiologies, the inci­
dence of peripartum cardiomyopathy increased by
nearly 40% (from 8.5 to 11.8 cases per 10,000 live births)
between 2004 and 2011 in the USA127. The number of
hospital admissions associated with congenital heart dis­
ease in young adults is also increasing, partly attributable
to their overall better survival over time, coupled with
increases in the prevalence of acquired risk factors for
cardiovascular disease128. However, whether the increas­
ing trend in the development of heart failure among
young adults can be explained by an increased number
of adult patients with congenital heart disease is unclear.
In Sweden, the proportion of patients with heart fail­
ure and congenital heart disease remained unchanged
between 1987 and 2006 (~5% for those aged 18–44 years
and ~1% for those aged 45–54 years)110. By contrast,
in Denmark, 8% of patients with heart failure aged
≤50 years had a diagnosis of congenital heart disease in
2010–2012, compared with 3% in 1995–1997, but large
fluctuations in prevalence were evident throughout the
years129. Therefore, the aetiological causes underlying
the apparent increase in the rate of heart failure among
young adults remain unclear.
Atrial fibrillation
Risk profile. Risk factors for atrial fibrillation in young
adults include structural heart diseases (congenital heart
disease, valve disease, left ventricular hyper­trophy, and
heart failure)130,131, hypertension130, diabetes132, a pos­
itive familial history (including known genetic muta­
tions)133,134, alcohol intake135, and extreme levels of
physical activity and participation in endurance sports136.

Table 5 | Prevalence of presumed underlying causes of sudden cardiac deaths among individuals aged <35 years
Eckart et al. 2004 (REF. 166) Eckart et al. 2011 (REF. 146) Bagnall et al. 2016 (REF. 145)
Population Military recruits aged 18–35 years All uniformed personnel at the All cases of sudden cardiac deaths
US Department of Defense aged in New Zealand and Australia
<35 years among people aged 1–35 years
Study period 1977–2001 1998–2008 2010–2012
n 126 (sudden nontraumatic deaths) 902 (suspected sudden cardiac deaths) 490 (sudden cardiac deaths)
Age (years) Median 19 Mean 26 ± 5 Mean 24 ± 10
Proportion of men (%) 88 97 72
Identifiable cardiac pathology (%) 51 79 60
Unexplained death (%) 35 41 40
Atherosclerotic disease (%) 8 23 24
Anomalous coronary artery (%) 17 4 NA
Myocarditis (%) 10 6 7
Cardiomyopathy (%) 8 19 16
Hypertrophic cardiomyopathy (%) 6 13 3–4
Idiopathic dilated cardiomyopathy 1 5 8
(%)
Arrhythmogenic right ventricular 1 1 4–5
dysplasia (%)
All data based on autopsies. NA, not available.

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125 of atrial fibrillation in individuals aged 35–64 years were

Men 150 per 100,000 person-years and ~700 per 100,000
100 Women ­individuals, respectively 144.
ASCAD
75 Temporal trends. In the USA, hospitalization rates for
Incidence per 100,000 people

50 atrial fibrillation increased for individuals across all

ages between 2000 and 2012 (REF. 143). However, the
40 incidence of atrial fibrillation in Australia remained
unchanged between 1995 and 2010 for individuals aged
30 35–64 years, in contrast to the declining rates noted
among older individuals144. The same study reported an
20 increased preva­lence of atrial fibrillation over the same
observational period144.
10

Sudden cardiac death

0
<20 20–24 25–28 30–34 35–39 40–44 45–49 50+ Aetiology. Autopsy data from cases of sudden cardiac
Age group (years) death in young individuals have indicated that at least
Men 3.37 2.44 3.32 3.99 9.69 19.22 44.65 111.45 one cardiac abnormality is present in >50% of all cases.
Women 0.83 1.09 0.62 0.68 2.13 3.96 4.08 25.94 TABLE 5 presents the underlying aetiology of sudden car­
RR 3.72 1.96 4.53 5.90 4.30 4.80 10.18 6.11 diac death in selected series of patients aged <35 years.
95% CI 0.9–15.5 1.0–3.9 1.4–14.4 1.5–24.0 1.8–10.5 2.0–11.7 2.5–41.1 1.9–19.2 The most common known causes include cardio­
ASCAD 0.26 0.33 0.52 1.77 5.82 14.40 31.90 83.54 myopathies (up to 20%) and coronary artery disease
(up to 25%)145. However, up to 50% of cases of sudden
Figure 2 | Incidence of sudden cardiac death in young adults in the US Department cardiac death were unexplained, especially in younger
Nature Reviews | Cardiology
of Defense Cardiovascular Death Registry. ASCAD refers to the proportion of cardiac individuals and for deaths that occurred during night-
arrests due to coronary artery disease. RR, relative risk. Reproduced with permission from
time145. By contrast, coronary artery disease was the most
REF. 146, Elsevier.
prevalent attributable cause in patients aged ≥35 years,
with up to 75% being diagnosed with coronary artery dis­
Obesity has also been shown to be causally related to ease at autopsy 145–147. In a subsample of individuals dying
the development of atrial fibrillation137 and might be a from an unexplained cause, at least 27% had a plausible
particularly important risk factor for atrial fibrillation cardiac gene mutation when tested145. Moreover, during
in young adults, in whom the incidence rates of atrial follow‑up, 13% of individuals who died of sudden car­
fibrillation are at least twice as high in individuals who diac arrest had at least one family member diagnosed
are obese compared with the rates in individuals with a with an inherited cardiovascular disease145. A similar
normal weight 138,139. genetic diagnostic yield was reported in a smaller series
Longitudinal studies of risk factors for incident of 61 patients (aged <50 years), in which 34% had genetic
atrial fibrillation in young adults are lacking. In the variants possibly involved in the pathogenesis of cardiac
CARDIA study140, significant correlates of increasing arrest; 40% were located close to or within loci associated
left atrial diameter (a precursor of atrial fibrillation) with cardiomyopathies, and 60% were in close proximity
over a 5‑year period (mean age 30 years) included male to or within genes implicated in channelopathies148.
sex, active smoking, high levels of alcohol consumption, Whether physical activity increases the risk of sudden
high BMI, high heart rate and systolic blood pressure, cardiac death in young individuals has been extensively
antihypertensive treatment, high left ventricular mass, debated. However, many investigators have reported
and black ethnicity. Over a 25‑year follow‑up period, an association between intense physical activity and
all risk factors, with the exception of smoking and ­sudden cardiac death in young adults. An Italian study
­alcohol consumption, remained significantly associ­ of nearly 1.5 million adolescents and young adults
ated with longi­tudinal increases in left atrial diameter 140. aged 12–35 years (of whom >100,000 were competitive
Interestingly, when adjusted for multiple risk factors, ­athletes) concluded that sport-related activity might
white individuals enrolled in the CARDIA study had trigger arrhythmias and sudden cardiac death among
greater left atrial diameters than black individuals, individ­uals with arrhythmogenic right ventricular dys­
in agreement with previously reported observations that plasia (relative risk [RR] of sudden cardiac death associ­
white individ­uals have higher risks of atrial f­ ibrillation ated with competitive sport of 5.4), coronary artery
than black individuals141,142. disease (RR 2.6), congenital coronary artery abnormal­
ity (RR 79), mitral valve prolapse (RR 3.2), myocarditis
Incidence and prevalence. Data on the incidence and the (RR 1.5), and conduction system disorder (RR 1.5)149.
prevalence of atrial fibrillation in the younger segment However, Bagnall and colleagues observed that the
of the adult population are sparse. A 2016 study based majority of cardiac arrests that occurred in young
on the US Nationwide Inpatient Sample 2000–2012 adults in Australia and New Zealand did not occur
reported atrial fibrillation-associated hospital­ization during physical activity, and they questioned whether
rates of 510 per 1,000,000 among individuals aged limiting physical activity could contribute to preventing
<50 years143. In Australia, the incidence and prevalence sudden cardiac death145.

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Incidence. In Australia and New Zealand, the annual
incidence of sudden cardiac death among individuals
aged 1–35 years was reported to be 1.3 per 100,000 per­
sons145. Similar numbers have been reported in other
studies, with a steep rise with increasing age (FIG. 2).
Temporal trends. An Australian study published in the
past year suggested that the incidence of sudden cardiac
death declined among older (aged ≥50 years) but not
in younger (aged 35–54 years) adults between 1997 and
2010 (REF. 150). Similarly, an Irish report concluded that
the rates of sudden cardiac deaths did not fall in Belfast
between 1966 and 2003–2004 for all ages151.
Limitations
Some important limitations with the data presented
in this Review should be noted. The articles that have
been cited were selected based on a systematic search
of the literature; however, this report is not intended as
a systematic review. Rather, we included papers that we
found to be highly relevant. In this context, no formal
meta-analysis or pooled analyses of trends reported in
individual publications were performed. Furthermore,
the studies cited in this Review include data from
around the world; the prevalence estimates, risk factor
trends, and trends in incident diseases are likely to differ
between countries and regions. Finally, screening and
diagnostic tools and practices might have changed over
the past few decades for many cardiovascular disorders,
and caution is needed when interpreting the data.
Conclusions
A large body of data suggests that in contrast to the
general improvement in cardiovascular health among
middle-aged and elderly individuals worldwide over the
past 2 decades, younger adults have tended to develop
an increasingly unhealthy cardiovascular risk profile,
especially in terms of an increased prevalence of being
overweight or obese. In addition, the rate of diabe­
tes, substance abuse, and electronic cigarette use have
increased among this young segment of the population.
The reported trends for the incidence of cardio­vascular
disease in young adults in the past few decades have
mostly been steady or slightly increasing (particularly
for heart failure), in contrast to the generally decreas­
ing trends observed in older adults. These observations
suggest an increasing burden of cardiovascular diseases
in the future, as this younger segment of the population
ages, unless the adverse trends in the prevalence of these
risk factors can be reversed. Although not specifically
covered in this Review, the rates of ischaemic stroke
have also been noted to be increasing in young adults in
Denmark, France, Sweden, and the USA over the past
2 decades152–156.
In the USA, obesity has been identified as the main
factor underlying the observed trends for the declining
prevalence of healthy risk factor profiles in the 1990s and
2000s compared with previous favourable trends observed
in the 1970s and 1980s157. Likewise, obesity might directly
contribute to the increasing trends in overt cardio­vascular
disease among young individuals and has, therefore,
been identified as the major risk factor to address for
the success­ful prevention of cardiovascular disease and
associ­ated mortality 158. Whereas adverse dietary patterns
and increases in obesity rates might finally be levelling off,
further studies are warranted to improve our understand­
ing of the magnitude of the problem of cardiovascular dis­
ease in young adults and to elucidate treatable risk factors
that underlie the observed trends by using s­ tandardized
­diagnostic ­criteria and large population samples.

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Acknowledgements
This work was supported in part by the Evans Medical
Foundation and Jay and Louise Coffman Foundation at the
Boston University School of Medicine.
Author contributions
Both authors researched data for the article, discussed its
content, wrote the manuscript, and reviewed and edited it
before submission.
Competing interests statement
The authors declare no competing interests.
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional
claims in published maps and institutional affiliations.

240 | APRIL 2018 | VOLUME 15 www.nature.com/nrcardio

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