Prehypertensive and Cardiovascular Risk
Prevalence of Prehypertension and Associated
Cardiovascular Risk Profiles Among Young Israeli Adults
Itamar Grotto, Ehud Grossman, Michael Huerta, Yehonatan Sharabi
Downloaded from http://hyper.ahajournals.org/ by guest on June 18, 2017
Abstract—Recently the Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood
Pressure introduced the term “prehypertension” for systolic blood pressure levels of 120 to 139 mm Hg and diastolic BP levels
of 80 to 89 mm Hg. Little is known about the prevalence of this entity and the cardiovascular risk factors associated with it.
We aimed to determine the prevalence of prehypertension and the cardiovascular risk factors associated with it in a large
population-based sample of young Israeli adults. We studied 36 424 Israel Defense Forces employees during the years 1991
to 1999. Subjects completed a detailed questionnaire and underwent physical examination, and blood samples were drawn
after a 14-hour fast. Prehypertension was defined as a systolic blood pressure of 120 to 139 mm Hg, and/or a diastolic blood
pressure of 80 to 89 mm Hg. We calculated the age- and sex-specific prevalence of prehypertension and other cardiovascular
risk factors associated with this condition. Prehypertension was observed among 50.6% of men and 35.9% of women. The
prehypertensive group had higher levels of blood glucose, total cholesterol, low-density lipoprotein cholesterol, and
triglycerides, higher body mass index, and lower levels of high-density lipoprotein cholesterol than did the normotensive
group. Multivariate logistic regression analysis showed that body mass index was the strongest predictor of prehypertension
among both males and females (odds ratio, 1.100; 95% CI, 1.078 to 1.122 and odds ratio, 1.152; 95% CI, 1.097 to 1.21,
respectively, for every 1 kg/m2 increase). Our findings support the recommendation of lifestyle modification for prehypertensive patients. Further prospective studies are required to determine the role of pharmacotherapy in prehypertension.
(Hypertension. 2006;48:254-259.)
Key Words: cardiovascular diseases 䡲 young adults 䡲 hypertension, borderline
H
Evidence supporting a prehypertensive state has been demonstrated in several studies,4 –11 chief among them the longitudinal Framingham Heart Study, which showed that BP in the
prehypertensive range preceded the diagnosis of hypertension in
90% of subjects aged ⱖ55 years.12 In another longitudinal study,
Winegarden11 showed that, relative to normotensive subjects,
the risk of hypertension was substantially higher among subjects
with “high normal” BP (130 to 139/85 to 89 mm Hg). However,
whereas several reports have documented an increased risk of
CVD among prehypertensive subjects,5,6,8,12,13 others suggest
that prehypertension increases the risk of CVD only modestly or
that this risk increases only when prehypertension is associated
with additional risk factors.4,7
Data on prehypertension in young adults are lacking,
and little is known on the risk factors for prehypertension
and their association with other CVD risk factors. It is
presently unclear whether the increased risk of CVD
among prehypertensive subjects is wholly related to increased BP or whether it can be attributed to a deleterious
CVD risk factor profile. The purpose of this study was to
determine the prevalence of prehypertension among the
young Israeli adult population and to characterize the CVD
ypertension is likely the most common disease on
Earth.1 It is associated with an increased risk of morbidity and mortality from cardiovascular disease (CVD) and
represents the single greatest preventable cause of death in
humans. The standard definition of hypertension as blood
pressure (BP) ⱖ140/90 mm Hg is based on the observation
that the risk of CVD increases sharply above this level.
However, recent data have shown that an increased risk of
CVD is present in persons with BP levels as low as 115/
70 mm Hg and that this risk increases steadily with rising
BP.2 The incremental association between BP and CVD risk
has been reflected recently in the Seventh Report of the Joint
National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC7).3 In its
report, the JNC7 introduced a new BP category, “prehypertension,” defined as a systolic BP (SBP) of 120 to
139 mm Hg and/or a diastolic BP (DBP) of 80 to 89 mm Hg.
Since the publication of the JNC7 report, several studies have
assessed the prevalence and significance of prehypertension.
Still, the importance of this entity in regard to global CVD
risk and the preferred approach to its treatment are still a
matter of debate, and the term prehypertension has yet to be
widely adopted.
Received February 12, 2006; first decision February 23, 2006; revision accepted May 8, 2006.
From the Department of Epidemiology (I.G.), Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel; Hypertension Unit,
C. Sheba Medical Center and Periodic Examination Center (E.G., Y.S.) and Army Health Branch (M.H.), IDF Medical Corps, Tel Hashomer, Israel
(affiliated with Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel).
Correspondence to Yehonaytan Sharabi, Hypertension Unit, C. Sheba Medical Center, Tel Hashomer, 52621, Israel. E-mail [email protected]
© 2006 American Heart Association, Inc.
Hypertension is available at http://www.hypertensionaha.org
DOI: 10.1161/01.HYP.0000227507.69230.fc
254
Grotto et al
risk profiles and CVD risk scores of prehypertensive
subjects within this population.
Methods
Study Population
Downloaded from http://hyper.ahajournals.org/ by guest on June 18, 2017
The Israel Defense Force (IDF) employs career service personnel in
a wide array of occupations, ranging from highly educated professionals and trained technicians to skilled and unskilled workers.
Personnel education levels vary widely, and occupational environments include white-collar office-based surroundings, blue-collar
factory-like conditions, and unskilled field-based laboring conditions. Most career personnel enter the IDF workforce at the age of 21
and end their service at the compulsory military retirement age of 50.
The workforce includes both combatants and noncombatants, but the
proportion of combatants is small. All career employees are required
to undergo periodic medical examination, which includes a thorough
medical history, physical examination, and laboratory tests. We
analyzed the periodic examination data of subjects aged 20 to 50.
This group represents the overall Israeli working population and
provides a basis for comparison with data collected previously in
Israel and elsewhere.
Data Collection
Between January 1991 and December 1999, 36 424 healthy subjects
(32 024 males and 4400 females) underwent periodic medical evaluation. Subjects were examined at 3- to 5-year intervals starting at the age
of 20 and were summoned automatically for examination by our
computerized queuing system. Compliance with examination was high,
and 93% of the summoned population presented at the testing center and
underwent testing. Subjects completed a detailed medical questionnaire,
which included items on smoking habits and physical activity. Questions regarding physical activity included the following: whether the
subject performed any physical activity on a regular basis, the type of
activity performed, and the weekly frequency of the activity. Physical
activity was defined in the questionnaire as an aerobic activity of ⬎30
minutes’ duration. The questionnaire listed examples (walking, cycling,
jogging, etc) for the purpose of clarity. Blood samples were drawn after
a 14-hour fast and were analyzed for levels of glucose, triglycerides,
total cholesterol, and, from 1996, high-density lipoprotein (HDL)
cholesterol and low-density lipoprotein (LDL) cholesterol. Total cholesterol was measured by means of oxidation and peroxidation reactions,
and LDL cholesterol was calculated using the Freidewald formula.
SBP and DBP were measured according to American Heart Association guidelines using a mercury column sphygmomanometer and a cuff
suitable to the subject’s arm circumference. BP was measured twice by
skilled, trained physicians after 5 minutes of rest in the sitting position,
and the average of the measurements was recorded. Physical examination included measurement of height (centimeters) and weight (kilograms), and a resting 12-lead ECG was recorded. Results were entered
into the computerized Young Adult Periodic Examinations in Israel
(YAPEIS) database.14 For subjects examined more than once, results of
the latest examination were used for analysis.
Data Analysis
We analyzed the physical, metabolic, and lifestyle parameters of our
subjects. Physical parameters included body mass index (BMI) and BP.
BMI was calculated by dividing weight (in kilograms) by the square of
the height (in meters). Subjects were defined as overweight and obese
when BMI was 25 to 29.99 and ⱖ30 kg/m2, respectively. Normotension
was defined as SBP ⬍120 mm Hg and DBP ⬍80 mm Hg. Prehypertension was defined as SBP 120 to 139 mm Hg and/or DBP 80 to
89 mm Hg. We further divided the prehypertension group into 2
categories15,16: “low prehypertension” (SBP, 120 to 129 mm Hg
and/or DBP, 80 to 84 mm Hg) and “high prehypertension” (SBP, 130
to 139 mm Hg and/or DBP, 85 to 89 mm Hg). Hypertension was
defined as SBP ⱖ140 mm Hg and/or DBP ⱖ90 mm Hg or by the use
of antihypertensive medications.
Metabolic parameters included fasting glucose, triglycerides, total
cholesterol, LDL cholesterol, and HDL cholesterol. Subjects were
Prevalence of Prehypertension in Young Adults
255
considered hyperglycemic if their fasting blood glucose level was
ⱖ126 mg/dL or if they used hypoglycemic medications. Subjects
were considered hypercholesterolemic if their total cholesterol was
ⱖ200 mg/dL or if they used lipid-lowering medication. A high LDL
cholesterol level was defined as a concentration ⬎129 mg/dL.
Lifestyle parameters included cigarette smoking and physical
activity habits. The reported number of cigarettes smoked per day
was recorded, and subjects were defined as smokers if they smoked
ⱖ1 cigarette per day. Sedentary lifestyle was defined by the routine
performance of ⬍1 physical activity per week.
Because we did not measure waist circumference, we modified the
National Cholesterol Education Programme (NCEP) criteria for the
definition of the metabolic syndrome and used BMI ⱖ25 kg/m2 as a
substitute criterion for waist circumference. Metabolic syndrome
was, therefore, defined by the presence of ⱖ3 of the following
criteria: fasting blood glucose level of 110 to 125 mg/dL; triglyceride
level ⱖ150 mg/dL; HDL cholesterol ⱕ40 mg/dL for men or ⱕ50
mg/dL for women; BMI ⱖ25 kg/m2; and SBP ⱖ130 mm Hg or DBP
ⱖ85 mm Hg.17 The Framingham–Anderson Heart Study Coronary
Heart Disease prediction model was used to define the probability of
developing coronary heart disease within the next 10 years.18 The
calculation, which was sex stratified, took into account the status of
7 risk factors: age, total cholesterol level, HDL cholesterol level,
SBP, smoking status, and the presence or absence of diabetes
mellitus and left ventricular hypertrophy. This calculation was completed only for data collected after 1996, because HDL cholesterol was
not routinely tested before this time.
We calculated the prevalence of normotension, prehypertension,
and hypertension among males and females in 3 age groups: 21 to 30
years, 31 to 40 years, and 41 to 50 years. Differences in the means
and prevalence of study variables between the prehypertensive group
and the 2 remaining BP groups, as well as between the low and high
prehypertension groups, were compared using Student t tests for
continuous variables and ␹2 tests for categorical variables. Comparisons between men and women in each BP group were carried out
using Student t test. For each BP group, we also calculated the
sex-specific prevalence of hyperglycemia, hypercholesterolemia,
high LDL cholesterol, overweight, obesity, metabolic syndrome,
smoking, and sedentary lifestyle and calculated the proportion of
subjects with a ⬎15% risk of developing coronary heart disease
within the following 10 years. Logistic regression analyses were
used to test significant determinants of prehypertension status, with
prehypertension serving as the dichotomous outcome variable (prehypertension versus normal hypertension) and age, sex, presence of
metabolic syndrome, lifestyle parameters, and BMI as the independent predictor variables. Backward selection was used as the method
for variable selection, and variables with P⬎0.05 were eliminated
from the model. Data were analyzed using SPSS software (version
12.0; SPSS Inc, Chicago, Ill).
Results
Prehypertension was observed in 48.9% (50.6% among men,
35.9% among women) of the subjects. The prevalence of
prehypertension remained constant across age groups among
men but increased with age among women (Figure; P for trend
in females ⬍0.001). The overall prevalence of hypertension was
19.1% (20.4% among men, 9.8% among women).
When compared with the normal BP group, the prehypertensive group was older; had higher levels of blood glucose, total
cholesterol, LDL cholesterol, triglycerides, and BMI; and had
lower levels of HDL cholesterol (Table 1). Prehypertensive
subjects were more likely than normotensive subjects to be
smokers but less likely to maintain a sedentary lifestyle. Similar
but more pronounced differences were apparent in the comparison between the hypertensive and normotensive groups, although fewer hypertensive subjects than normotensive subjects
reported smoking (Table 1).
256
Hypertension
August 2006
Prevalence of prehypertension, by sex
and age group, among YAPIES subjects,
1991 to 1999.
Downloaded from http://hyper.ahajournals.org/ by guest on June 18, 2017
sion among both men and women (OR, 1.100; 95% CI, 1.078
to 1.122; and OR, 1.152; 95% CI, 1.097 to 1.210, respectively; Table 4). The risk of prehypertension was lower
among smokers (Table 4). Within the prehypertension group
there was an increment in the risk profile (Table 5). Subjects
in the high range of prehypertension were older; had higher
levels of blood glucose, total cholesterol, LDL cholesterol,
triglycerides, and BMI; had lower levels of HDL; and were
more likely to be smokers, as compared with subjects in the
low range of prehypertension.
In all of the BP groups, men were younger than women and
had higher mean blood glucose, LDL cholesterol, and triglyceride levels and lower mean HDL cholesterol levels (Table
2). Normotensive and prehypertensive men had higher BMI
values than women.
The prevalence of cardiovascular risk factors was significantly higher in the prehypertension group than in the
normotensive group (Table 3). Fewer prehypertensive men
reported a sedentary lifestyle than did normotensive men. The
prevalence of CVD risk factors was highest among hypertensive subjects, but in this group the prevalence of smoking and
sedentary lifestyle was also the lowest. The risk of developing
CVD within 10 years, as predicted by the Framingham–
Anderson Heart Study Coronary Heart Disease model, was
⬎15% for 8.5%, 19.7%, and 43.1% of normotensive, prehypertensive, and hypertensive men and 0.4%, 3.2%, and 12.6%
of women, respectively (Table 3).
Multivariate logistic regression analysis showed that male
gender was the most powerful predictor of prehypertension,
with an odds ratio (OR) of 1.930 (95% CI, 1.614 to 2.308).
BMI was the strongest modifiable predictor of prehyperten-
Discussion
The significance of the prehypertension category in the JNC7
report is a matter of controversy. The term was established after
the results of longitudinal studies of subjects ⬎55 years of age,
which suggested that subjects with BP 120 to 139/80 to 89
mm Hg are at risk for developing hypertension. Moreover, some
reports indicated that these subjects are at a greater risk of CVD.
Our survey is the first that is based on a standardized and comprehensive medical evaluation of a large young population. We
observed Israeli adults between the ages 25 and 45, assessed the
TABLE 1. Demographic, Metabolic, and Behavioral Characteristics of Subjects by BP
Group (MeanⴞSD)
Variable
Normotensive
(n⫽11 742)
Prehypertensive
(n⫽17 804)
P*
Hypertensive
(n⫽6878)
P†
Age, y
33.9⫾7.1
35.9⫾7.5
⬍0.001
38.9⫾7.0
⬍0.001
Sex, males/females
9349/2393
16 227/1577
⬍0.001
6448/430
⬍0.001
Glucose, mg/dL
90.8⫾14.5
94.3⫾19.3
⬍0.001
99.0⫾25.1
⬍0.001
⬍0.001
210.8⫾41.0
⬍0.001
⬍0.001
Total cholesterol, mg/dL
190.6⫾47
198.9⫾40.2
LDL cholesterol, mg/dL
118.8⫾37.3
126.7⫾41.7
⬍0.001
135.1⫾43.3
HDL cholesterol, mg/dL
50.7⫾17.9
47.9⫾14.9
⬍0.001
46.1⫾15.5
⬍0.001
113.7⫾78.6
136.9⫾101.6
⬍0.001
171.1⫾177.2
⬍0.001
24.2⫾3.5
25.7⫾3.7
⬍0.001
27.9⫾4.3
⬍0.001
Current smokers, %
31.4
33.2
0.001
30.8
⬍0.001
Sedentary lifestyle, %
86.2
83.9
0.009
80.7
0.004
Triglycerides, mg/dL
BMI, kg/m2
*P for comparison between normotensive and prehypertensive subjects; †P for comparison between hypertensive
and prehypertensive subjects.
Grotto et al
TABLE 2.
Prevalence of Prehypertension in Young Adults
257
Mean Age, Metabolic Parameters, and BMI by BP Group and Sex
Normotension
Variable
Men
Women
Age, y
33.9⫾7.2
34.2⫾7.1
Prehypertension
P*
0.012
Hypertension
Men
Women
P*
Men
Women
P*
35.9⫾7.6
36.9⫾7.4
⬍0.001
39.1⫾7.1
40.1⫾6.1
⬍0.001
91.7⫾15.1
87.5⫾11.5
⬍0.001
94.7⫾20.0
90.7⫾12.3
⬍0.001
99.2⫾24.8
96.8⫾28.1
0.075
Cholesterol, mg/dL
190.3⫾49.5
192.0⫾35.2
0.050
198.9⫾40.5
201.2⫾36.8
0.020
211.0⫾41.1
209.0⫾38.0
0.370
LDL cholesterol, mg/dL
119.7⫾36.2
115.5⫾41.9
⬍0.001
127.3⫾42.3
123.0⫾34.0
⬍0.001
135.9⫾43.6
128.5⫾37.5
0.005
HDL cholesterol, mg/dL
48.2⫾17.6
61.4⫾14.9
⬍0.001
46.8⫾14.3
59.9⫾15.3
⬍0.001
45.3⫾14.2
58.1⫾25.7
⬍0.001
⬍0.001
Glucose, mg/dL
Triglycerides, mg/dL
BMI, kg/m2
119.0⫾83.3
94.0⫾55.2
⬍0.001
139.9⫾104.6
109.8⫾69.2
⬍0.001
173.8⫾180.0
136.3⫾109.7
24.5⫾3.4
23.0⫾3.5
⬍0.001
25.8⫾3.6
24.9⫾4.5
⬍0.001
27.9⫾4.1
28.1⫾6.0
0.327
*P s are for male–female comparisons.
Downloaded from http://hyper.ahajournals.org/ by guest on June 18, 2017
prevalence of prehypertension in this population, identified determinants of prehypertension, characterized the CVD risk factor
profile of prehypertensive subjects, and calculated the risk among
prehypertensive subjects for developing future CVD. Our results
show that prehypertension is very common among young adults,
that men are affected more often than women at this age, and that
the rate in women increases with age. We also found that obesity
had the strongest association with prehypertension. Furthermore, the
global CVD risk profile among prehypertensive subjects, as manifested by the Framingham risk score, shows that prehypertensive
subjects carry more than double the risk of a future CVD event than
do normotensive subjects. This is most likely because of the fact that
prehypertension is associated with a higher prevalence of the
additional CVD risk factors, which collectively result in a riskheavy profile. This finding probably explains the increased rate of
CVD events observed among prehypertensive subjects.5,6,13
TABLE 3.
The prevalence of prehypertension in our study was higher
than that found in National Health and Nutrition Examination
Survey (NHANES) data derived from 4805 adults studied
between 1999 and 2000.19 In that cross-sectional analysis,
prehypertension was found in 31% of the cohort. Similar to our
findings, men were affected more often than women (40%
versus 23%). A similar rate was found in a survey in Taiwan,
where 34% of the adult population was found to be prehypertensive.20 Our findings reinforce these smaller-scale studies. The
minor differences observed between studies might be attributable to variations in methodology and population characteristics,
because ethnic differences have been shown to play a role in the
in the prevalence of prehypertension.21 Our results show that
prehypertension is associated with an increased prevalence of
other CVD risk factors. Similarly, a further analysis of the
NHANES database on a small population sample supports our
Prevalence of Risk Factors (%) for CVD by BP Group and Sex
Men
Variable
Glucose ⬎126 mg/dL
Women
Normal
Pre-HTN
RR* (95% CI)
HTN
RR† (95% CI)
Normal
Pre-HTN
RR† (95% CI)
HTN
1.2
2.5
2.09
5.1
4.33
0.3
1.3
5.06
4.1
(1.69 to 2.58)
Total cholesterol ⬎200 mg/dL
37.5
46.9
1.25
(3.49 to 5.37)
59.9
(1.21 to 1.29)
LDL cholesterol ⬎129 mg/dL
36.2
44.9
1.24
40.2
55.1
1.37
55.2
6.3
12.3
1.96
74.4
9.5
21.3
2.24
27.5
32.4
33.5
1.04
54.1
87.0
83.9
0.96
31.0
8.5
19.7
2.32
(2.11 to 2.55)
HTN indicates hypertension; RR, risk ratio.
*Ratio of prehypertension group to normal blood pressure group.
†Ratio of hypertension group to normal blood pressure group.
1.85
4.39
5.67
0.96
80.9
0.93
22.5
41.0
5.08
(4.64 to 5.57)
1.31
1.82
4.4
12.7
2.86
47.2
9.1
3.48
64.4
30.2
1.10
32.6
83.7
1.02
41.8
3.2
9.03
(3.49 to 23.36)
15.91
(11.64 to 21.75)
27.2
0.99
(0.84 to 1.17)
74.6
(0.95 to 1.09)
0.4
7.35
(5.84 to 9.26)
(0.99 to 1.21)
82.2
2.87
(2.59 to 3.17)
(2.47 to 4.90)
27.5
1.58
(1.37 to 1.81)
(2.28 to 3.59)
2.6
1.49
(1.36 to 1.65)
(1.66 to 2.01)
(0.90 to 0.96)
43.1
57.3
(1.18 to 1.45)
(0.91 to 1.00)
(0.94 to 0.99)
Risk for coronary heart disease
⬎15% within 10 years
39.1
(5.26 to 6.12)
(1.00 to 1.07)
Sedentary lifestyle, %
29.9
(4.02 to 4.79)
(2.07 to 2.42)
Current smoking, %
1.53
1.29
15.82
(6.28 to 39.9)
(1.2 to 1.38)
(1.8 to 1.9)
(1.79 to 2.14)
Metabolic syndrome, %
49.4
(1.47 to 1.59)
(1.33 to 1.41)
BMI ⬎30 kg/m2
38.3
(1.54 to 1.65)
(1.19 to 1.29)
BMI ⬎25 kg/m2
1.6
(2.04 to 12.56)
RR* (95% CI)
0.91
(0.79 to 1.05)
12.6
35.88
(14.18 to 90.78)
258
Hypertension
TABLE 4.
August 2006
Determinants of Prehypertension vs Normal Hypertension From Multivariable Logistic Regression Model by Sex
All Population
Men
Variable
OR
95% CI
P
Male sex
1.930
1.614 to 2.308
⬍0.001
Women
OR
95% CI
P
⬍0.001
OR
95% CI
1.038
1.012 to 1.064
0.003
1.003 to 1.012
0.001
1.097 to 1.210
⬍0.001
Age*
1.022
1.014 to 1.03
⬍0.001
1.020
1.011 to 1.028
Blood glucose*
1.006
1.001 to 1.01
0.009
1.005
1.001 to 1.01
0.022
Total cholesterol*
1.002
1.001 to 1.004
0.004
1.002
1.000 to 1.004
0.022
1.008
Triglycerides*
1.002
1.001 to 1.003
0.002
1.002
1.001 to 1.003
0.003
Not included
Not included
BMI*
1.106
1.086 to 1.126
⬍0.001
1.100
1.078 to 1.122
0.000
1.152
Smoking
0.818
0.718 to 0.931
0.002
0.814
0.710 to 0.933
0.003
Not included
0.815
0.688 to 0.965
0.018
Not included
Sedentary lifestyle
Not included
P
*The OR for age, blood glucose, total cholesterol, triglycerides, and BMI was continuous and calculated for 1 unit.
Downloaded from http://hyper.ahajournals.org/ by guest on June 18, 2017
findings.5 Furthermore, a study of 506 Japanese subjects found
that the prevalence of the metabolic syndrome among prehypertensive subjects was higher than that among normotensive
subjects but lower than among hypertensive subjects.22 These
results are consistent with our findings.
Obesity was found to be a major determinant of prehypertension even after controlling for other risks, such as age and
sedentary lifestyle. Similar findings were found in the NHANES
report and in the Taiwanese survey.19 The association between BP and weight is strong and linear, even in the normal
range of BP and BMI.23 Therefore, it follows that weight
should be a major determinant of prehypertension.
The link among prehypertension, CVD risk factors, and
the increased risk of CVD morbidity and mortality may be
explained by the proinflammatory nature of prehypertension
and the association of this condition with increased C reactive
protein levels,24 tumor necrosis factor ␣, amyloid A, and
homocysteine.25 Moreover, endothelial dysfunction is known to
be prevalent at the high end of the normotension spectrum.26
Thus, endothelial dysfunction and a generalized inflammatory
state, coupled with a high prevalence of CVD risk factors,
together provide a likely explanation for the increased rate of
CVD events among prehypertensive subjects.
It is well established that hypertension should be controlled
and, when possible, prevented. Some question remains, however, as to the appropriate therapeutic approach to prehypertension. Over the last decade, attention has been drawn to the
diagnosis and treatment of disease during the preclinical stages,
before the progression to overt clinical manifestations. The true
question regarding prehypertension is not the mere method of its
progression to overt hypertension but rather the global CVD risk
associated with this condition and the potential risk reduction to
be gained by early initiation of treatment. A simulation model
has shown that elimination of prehypertension results in a
substantial public health benefit, thus providing the rationale for
an interventional approach to this condition.27 It is important to
note that prehypertension, per se, is not associated with an
increased risk of CVD, unless accompanied by additional risk
factors.7 However, ⬍10% of prehypertensive subjects have this
condition alone. Accordingly, subjects with prehypertension are
at risk for CVD events, and a global risk reduction is indicated.
Current guidelines recommend lifestyle modifications alone,
because no studies have evaluated the efficacy of pharmacological interventions on prehypertension. Ongoing studies of thioglitazone in prediabetic patients and statins in patients with LDL
⬍130 mg/dL might encourage similar trials in prehypertension.
TABLE 5. Demographic, Metabolic, and Behavioral Characteristics of Subjects
Within the Prehypertension Group (MeanⴞSD)
Variable
Age, y
Sex, males/females
Glucose, mg/dL
Low Prehypertension*
(n⫽13 590)
High Prehypertension†
(n⫽4214)
P
35.5⫾7.5
36.9⫾7.5
⬍0.001
12 276/1314
3951/263
⬍0.001
93.5⫾17.5
96.7⫾24.2
⬍0.001
Total cholesterol, mg/dL
197.5⫾40
203.5⫾40.4
⬍0.001
LDL cholesterol, mg/dL
125.5⫾42.6
131.0⫾38.5
⬍0.001
HDL cholesterol, mg/dL
48.4⫾15.3
46.2⫾13.2
⬍0.001
133.0⫾98.7
149.5⫾109.6
⬍0.001
25.4⫾3.6
26.6⫾3.9
⬍0.001
Triglycerides, mg/dL
BMI, kg/m2
Current smokers, %
32.4
35.8
⬍0.001
Sedentary lifestyle, %
84.1
83.1
0.466
*Low prehypertension: SBP⫽120 to 129 mm Hg and/or DBP ⬍85 mm Hg, or DBP to 80 –
84 mm Hg and SBP ⬍130 mm Hg.
†High prehypertension: SBP⫽130 to 139 mm Hg and DBP ⬍90 mm Hg, or DBP⫽85 to 89 mm Hg
and SBP ⬍140 mm Hg.
Grotto et al
Downloaded from http://hyper.ahajournals.org/ by guest on June 18, 2017
That said, we believe that the increased prevalence of obesity and
sedentary lifestyle observed today would make behavioral changes
the most logical and effective choice for modifying the natural
history of prehypertension and its progression to overt hypertension.
Our study has several limitations. First, we conducted a
cross-sectional study, and the prevalence of the various BP
categories is based on single BP measurement. Nevertheless,
other reports of the same nature, such as the NHANES, used
similar methodology, making it suitable for purposes of comparison. Second, we used BMI ⱖ25 kg/m2 as a marker of obesity
in place of waist circumference, as described previously.17
Finally, all of the subjects included in this study were IDF
employees, which may limit the external validity of the findings.
In conclusion, the association between BP and CVD risk is
notable even when BP levels are ⬍140/90 mm Hg. Prehypertension is a risk factor for overt hypertension, and several
small-scale studies have demonstrated its association with increased CVD morbidity. Our study shows that this condition is
very common among young adults and is associated with a poor
CVD risk factor profile. Collectively, prehypertension doubles
the risk for future CVD events. Currently there are no clinical
studies on specific interventions to regress prehypertension or
prevent its progression to hypertension. However, current JNC7
recommendations indicate lifestyle modification for prehypertensive patients. Our findings, mainly that obesity is a major
determinant of prehypertension and that a lack of physical activity
is common in these patients, indicate that such an approach
would probably be the most effective strategy. This recommendation, however, remains to be validated in a clinical study, as
does the need for antihypertensive therapy in high-risk prehypertensive patients.
Perspectives
Our study demonstrates that among a large group of young,
healthy, working adults, prehypertension is prevalent and is associated with multiple cardiovascular risk factors. These results
further underline the need for routine BP measurements in young
adults to identify subjects with prehypertension who should be the
target of lifestyle modification. Further studies should be designed
to assess the role of prehypertension as an independent cardiovascular risk factor and to assess the effect of lifestyle modification and therapeutic interventions on the progression to hypertension, as well as on cardiovascular morbidity and mortality.
Disclosures
None.
References
1. Kearney PM, Whelton M, Reynolds K, Muntner P, Whelton PK, He J.
Global burden of hypertension: analysis of worldwide data. Lancet. 2005;
365:217–223.
2. Lewington S, Clarke R, Qizilbash N, Peto R, Collins R. Age-specific
relevance of usual blood pressure to vascular mortality: a meta-analysis of
individual data for one million adults in 61 prospective studies. Lancet.
2002;360:1903–1913.
3. Lenfant C, Chobanian AV, Jones DW, Roccella EJ. Seventh report of the
Joint National Committee on the Prevention, Detection, Evaluation, and
Treatment of High Blood Pressure (JNC 7): resetting the hypertension
sails. Hypertension. 2003;41:1178 –1179.
4. Bowman TS, Sesso HD, Glynn RJ, Gaziano JM. JNC 7 category and risk
of cardiovascular death in men: are there differences by age? Am J
Geriatr Cardiol. 2005;14:126 –131.
Prevalence of Prehypertension in Young Adults
259
5. Greenlund KJ, Croft JB, Mensah GA. Prevalence of heart disease and
stroke risk factors in persons with prehypertension in the United States,
1999 –2000. Arch Intern Med. 2004;164:2113–2118.
6. Liszka HA, Mainous AG 3rd, King DE, Egan BM. Prehypertension and
cardiovascular morbidity. Ann Fam Med. 2005;3:294 –299.
7. Mainous AG 3rd, Everett CJ, Liszka H, King DE, Egan BM. Prehypertension and mortality in a nationally representative cohort. Am J Cardiol.
2004;94:1496 –1500.
8. Qureshi AI, Suri MF, Kirmani JF, Divani AA, Mohammad Y. Is prehypertension a risk factor for cardiovascular diseases? Stroke. 2005;36:1859–1863.
9. Vasan RS, Larson MG, Leip EP, Evans JC, O’Donnell CJ, Kannel WB,
Levy D. Impact of high-normal blood pressure on the risk of cardiovascular disease. N Engl J Med. 2001;345:1291–1297.
10. Vasan RS, Larson MG, Leip EP, Kannel WB, Levy D. Assessment of
frequency of progression to hypertension in non-hypertensive participants in
the Framingham Heart Study: a cohort study. Lancet. 2001;358:1682–1686.
11. Winegarden CR. From “prehypertension” to hypertension? additional
evidence. Ann Epidemiol. 2005;15:720 –725.
12. Vasan RS, Beiser A, Seshadri S, Larson MG, Kannel WB, D’Agostino RB,
Levy D. Residual lifetime risk for developing hypertension in middle-aged
women and men: The Framingham Heart Study. JAMA. 2002;287:
1003–1010.
13. Washio M, Tokunaga S, Yoshimasu K, Kodama H, Liu Y, Sasazuki S,
Tanaka K, Kono S, Mohri M, Takeshita A, Arakawa K, Ideishi M, Nii T,
Shirai K, Arai H, Doi Y, Kawano T, Nakagaki O, Takada K, Hiyamuta K,
Koyanagi S. Role of prehypertension in the development of coronary
atherosclerosis in Japan. J Epidemiol. 2004;14:57– 62.
14. Sharabi Y, Grotto I, Huerta M, Eldad A, Green MS. Risk factor profile for
atherosclerosis among young adults in Israel–results of a large-scale
survey from the young adult periodic examinations in Israel (YAPEIS)
database. Eur J Epidemiol. 2001;17:757–764.
15. 1999 World Health Organization-International Society of Hypertension
Guidelines for the Management of Hypertension. Guidelines Subcommittee. J Hypertens. 1999;17:151–183.
16. 2003 European Society of Hypertension-European Society of Cardiology.
Guidelines for the management of arterial hypertension. J Hypertens.
2003;21:1011–1053.
17. Executive Summary of the Third Report of the National Cholesterol
Education Program (NCEP) Expert Panel on Detection, Evaluation, and
Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel
III). JAMA. 2001;285:2486 –2497.
18. Anderson KM, Wilson PW, Odell PM, Kannel WB. An updated coronary
risk profile. A statement for health professionals. Circulation. 1991;83:
356 –362.
19. Wang Y, Wang QJ. The prevalence of prehypertension and hypertension
among US adults according to the new joint national committee guidelines:
new challenges of the old problem. Arch Intern Med. 2004;164:2126–2134.
20. Tsai PS, Ke TL, Huang CJ, Tsai JC, Chen PL, Wang SY, Shyu YK.
Prevalence and determinants of prehypertension status in the Taiwanese
general population. J Hypertens. 2005;23:1355–1360.
21. Okosun IS, Boltri JM, Anochie LK, Chandra KM. Racial/ethnic differences in prehypertension in Am adults: population and relative attributable risks of abdominal obesity. J Hum Hypertens. 2004;18:849 – 855.
22. Kanauchi M, Kanauchi K, Hashimoto T, Saito Y. Metabolic syndrome
and new category ‘pre-hypertension’ in a Japanese population. Curr Med
Res Opin. 2004;20:1365–1370.
23. Sharabi Y, Grotto I, Huerta M, Grossman E. Susceptibility of the
influence of weight on blood pressure in men versus women: lessons from
a large-scale study of young adults. Am J Hypertens. 2004;175:404 – 408.
24. King DE, Egan BM, Mainous AG 3rd, Geesey ME. Elevation of
C-reactive protein in people with prehypertension. J Clin Hypertens
(Greenwich). 2004;6:562–568.
25. Chrysohoou C, Pitsavos C, Panagiotakos DB, Skoumas J, Stefanadis C.
Association between prehypertension status and inflammatory markers
related to atherosclerotic disease: The ATTICA Study. Am J Hypertens.
2004;17:568 –573.
26. Cugini P, Baldoni F, De Rosa R, Pandolfi C, Colotto M, Buccarella PA,
Zamparelli C, Berti D, Passini B, Roncoroni V, Sabino D, Capria A.
Higher blood pressure load (baric impact) in normotensives with endothelial dysfunction: a paraphysiological status of “pre-hypertension.” Clin
Ter. 2002;153:309 –315.
27. Russell LB, Valiyeva E, Carson JL. Effects of prehypertension on admissions
and deaths: a simulation. Arch Intern Med. 2004;164:2119–2124.
Prevalence of Prehypertension and Associated Cardiovascular Risk Profiles Among Young
Israeli Adults
Itamar Grotto, Ehud Grossman, Michael Huerta and Yehonatan Sharabi
Downloaded from http://hyper.ahajournals.org/ by guest on June 18, 2017
Hypertension. 2006;48:254-259; originally published online June 5, 2006;
doi: 10.1161/01.HYP.0000227507.69230.fc
Hypertension is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231
Copyright © 2006 American Heart Association, Inc. All rights reserved.
Print ISSN: 0194-911X. Online ISSN: 1524-4563
The online version of this article, along with updated information and services, is located on the
World Wide Web at:
http://hyper.ahajournals.org/content/48/2/254
Permissions: Requests for permissions to reproduce figures, tables, or portions of articles originally published
in Hypertension can be obtained via RightsLink, a service of the Copyright Clearance Center, not the Editorial
Office. Once the online version of the published article for which permission is being requested is located,
click Request Permissions in the middle column of the Web page under Services. Further information about
this process is available in the Permissions and Rights Question and Answer document.
Reprints: Information about reprints can be found online at:
http://www.lww.com/reprints
Subscriptions: Information about subscribing to Hypertension is online at:
http://hyper.ahajournals.org//subscriptions/