Association of blood pressure in late adolescence with subsequent mortality: cohort study of Swedish male conscripts

Modulation of the orthostatic blood pressure response by acute nitrate consumption is dependent upon ethnic origin

Orthostatic stress triggers a response to maintain cerebral perfusion and prevent syncope. Given the hypotensive effects of inorganic nitrate this response to orthostasis may be altered by acute supplementation with inorganic nitrate and modified by ethnic origin. Caucasian and SE Asian (n = 30 for both), were recruited and subjected to an 'active stand test' and brachial artery blood pressure (BP), digit blood flow and ECG were recorded. Following inorganic nitrate supplementation, (10 mg/kg body mass) the tests were repeated. For both Caucasian and SE Asians transition to standing increased diastolic pressure (DP) and heart rate (HR) (P < 0.001 for both) and by calculation increased rate-pressure product (P < 0.001) and decreased pulse pressure (P < 0.01 for both) indicative of decreased ventricular filling. Nitrate supplementation decreased both DP (P < 0.001) and HR (P < 0.001). Assessment of HR variability suggested sympathetic nerve activity, was higher throughout in Caucasians (P < 0.05) coupled with higher parasympathetic tone (P < 0.01). Nitrate had no effect on cardiac autonomic nerve activity, as estimated using HR variability, for supine or standing subjects. The tachycardia and hypertension associated with orthostatic stress were preserved in both Caucasian and SE Asian subjects, however, we highlight possible differences in autonomic nervous system activity between Caucasians and SE Asians. SE Asians are resistant to the hypotensive effects of inorganic nitrate supplementation suggesting the absence of a crucial mechanism for activation of the nitrate-nitrite-nitric oxide system.

Pharmacological Treatment of Arterial Hypertension in Children and Adolescents: A Network Meta-Analysis

Pharmacological treatment is indicated in children and adolescents with hypertension unresponsive to lifestyle modifications, but there is not enough evidence to recommend 1 class of antihypertensive drugs over others. We performed a network meta-analysis to compare the results of available randomized clinical trials on pharmacological treatment of pediatric hypertension. From a total of 554 potentially relevant studies, 13 randomized placebo-controlled clinical trials enrolling ≥50 patients and a follow-up ≥4 weeks were included. The reduction of systolic blood pressure (SBP) and diastolic BP (DBP) after treatment were the coprimary end points. A total of 2378 pediatric patients, with a median age of 12 years, were included in the analysis. After a median follow-up of 35 days, lisinopril and enalapril were found to be superior to placebo in reducing SBP and DBP, whereas only for DBP, losartan was found to be superior to placebo and lisinopril and enalapril were found to be superior to eplerenone. Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers were associated with a greater SBP and DBP reduction compared with placebo, likewise the mineralocorticoid receptor antagonist was inferior to angiotensin-converting enzyme inhibitors in DBP reduction. The analysis was adjusted for study-level mean age, percentage of women, mean baseline blood pressure, and mean weight, only the latter significantly affected DBP reduction. According to the present analysis, angiotensin-converting enzyme inhibitors and angiotensin receptor blockers could represent the best choice as antihypertensive treatment for pediatric hypertension. However, because of the paucity of available data for the other classes of antihypertensive drugs, definitive conclusions are not allowed and further randomized controlled trials are warranted.

The Joint Association of Small for Gestational Age and Nighttime Sleep with Blood Pressure in Childhood

Children born small for gestational age (SGA) are more likely to develop high blood pressure. In prior studies, longer sleep duration is associated with lower BP, and SGA is associated with shorter sleep duration in childhood. We investigated whether sleep duration in early childhood modifies the association between SGA and higher childhood SBP in 1178 children recruited at birth and followed up to age 9 years. We ascertained birthweight and gestational age from medical records. We derived child sleep duration from maternal questionnaire interview. We calculated child SBP percentile according to U.S. reference data. We defined elevated SBP as SBP ≥75^th percentile. In this sample, 154 (13.1%) children were born SGA. Children born SGA had higher SBP percentiles and higher risk of elevated SBP. Among children born SGA, those in the highest compared to the lowest tertile for sleep had a 12.28 lower (−22.00, −2.57) SBP percentile and 0.44 (0.25 to 0.79) times lower risk of developing elevated SBP. Our data are consistent with an interaction between SGA and sleep duration on childhood elevated SBP (P_interaction = 0.0056). In conclusion, in this prospective birth cohort, longer sleep duration in early childhood may mitigate the blood pressure-raising effect of being born small.

Relationships among cardiorespiratory fitness, muscular fitness, and cardiometabolic risk factors in Japanese adolescents: Niigata screening for and preventing the development of non-communicable disease study-Agano (NICE EVIDENCE Study-Agano) 2

OBJECTIVE

To examine the independent and combined associations of cardiorespiratory fitness (CRF) and muscular fitness (MF) with cardiometabolic risk factors in Japanese adolescents.

METHODS

A cross-sectional study including 993 Japanese adolescents (aged 13-14 years) was undertaken. Height, body mass, blood pressure, lipid profile (non-fasting), and HbA1c were measured. The physical fitness (PF) test included measurements of CRF (20 m multistage shuttle run test), upper limb strength (hand grip strength), lower limb strength (standing long jump), and muscular endurance (sit-ups). The clustered cardiometabolic risk (CCMR) was estimated by summing standardized Z-scores of body mass index (BMI), mean arterial pressure (MAP), non-high-density lipoprotein cholesterol (non-HDL-C), and HbA1c.

RESULTS

Linear regression analysis showed that all PF factors except for muscular endurance were inversely correlated with CCMR (P < .001). Among metabolic risk components, HbA1c was unrelated to PF, while non-HDL-C was inversely associated with CRF (B = -2.40; P < .001), upper limb strength (B = -1.77; P < .05), and lower limb strength (B = -1.53; P < .05) after adjustment for lifestyle factors. Logistic regression showed that the probability of having high CCMR (≥1SD) was synergistically higher in those with the lowest tertiles of both CRF and upper limb strength (P for interaction = .001); however, a substantially lower likelihood of having high CCMR was observed among individuals with the lowest tertile of upper limb strength but moderate CRF.

CONCLUSIONS

Lower CRF and MF were significantly and synergistically associated with an unhealthier metabolic risk profile.

Isolated Systolic Hypertension in Young and Middle-Aged Adults

Young and middle-aged adults (ages ≤50 years) are increasingly prone to stroke, kidney disease, and worsening cardiovascular disease (CVD) mortality. An alarming increase in the prevalence of high blood pressure (BP) may underlie the adverse trend. However, there is often uncertainty in BP management for young and middle-aged adults. Isolated systolic hypertension (ISH) is one such example. Whether ISH in young and middle-aged adults represents "pseudo" or "spurious" hypertension is still being debated. ISH in young and middle-aged adults is a heterogeneous entity; some individuals appear to have increased stroke volume, whereas others have stiffened aortae, or both. One size does not seem to fit all in the clinical management of ISH in young and middle-aged adults. Rather than treating ISH as a monolithic condition, detailed phenotyping of ISH based on (patho)physiology and in the context of individual global cardiovascular risks would seem to be most useful to assess an individual expected net benefit from therapy. This review provides an overview of the current understanding of ISH in young and middle-aged adults, including the prevalence, pathophysiology, and treatment.

Thiobarbituric acid-reactive substances relate to arterial stiffness and blood pressure in 6 to 8-year-old boys stratified by maternal risk

Early cardiovascular disease (CVD) onset can be inflicted by familial cardiovascular and lifestyle risk factors. We aimed to compare phenotypic characteristics and explore associations between oxidative stress and vascular function in boys stratified by maternal cardiovascular and lifestyle risk. We included 40 Black and 41 White boys (ages 6-8 years), along with the biological mother of each child. The study population was divided into two groups (nonmaternal risk vs. maternal risk) according to maternal risk predetermined by their selfreported cardiovascular and lifestyle risk factors. Pulse wave velocity (PWV) was measured at various sites and blood pressures were recorded. Urine samples were collected for analyses of thiobarbituric acid-reactive substances (TBARS), 8-hydroxy-2-deoxy guanosine (8-OHdG), albumin, and creatinine. Higher levels of urinary albumin to creatinine ratio (uACR) were found in the maternal risk group compared to the nonmaternal risk group (p = .038). Multiple regression analysis in the maternal risk group revealed diastolic blood pressure (R² = 0.159; β = 0.293; p = .050), carotid femoral PWV (R² = 0.158; β = 0.297; p = .038) and carotid dorsalis pedis PWV (adj R² = 0.322; β = 0.505; p < .001) to be positively associated with TBARS, while an inverse association of uACR (R² = 0.161; β = -0.261; p = .046) with TBARS was observed. Also, in the maternal risk group, independent associations of DBP (R² = 0.273; β = 0.289; p = .040) and uACR (R² = 0.283; β = 0.268; p = .027) with 8-OHdG were indicated. In boys, as young as 6 years of age, oxidative stress related to arterial stiffness and diastolic blood pressure was observed. This association was only evident in boys with linked maternal lifestyle and cardiovascular risk factors, suggesting potential family-related early onset of cardiovascular risk.

Cardiorespiratory Fitness and Blood Pressure: A Longitudinal Analysis

OBJECTIVES

To examine the association between cardiorespiratory fitness and cardiovascular indices 2 years later, and to determine whether changes in cardiorespiratory fitness are associated with cardiovascular indices at a 2-year follow-up in adolescents.

STUDY DESIGN

The sample comprised 734 adolescents (349 girls) aged 12-18 years followed for 3 years from the LabMed Physical Activity Study. Cardiorespiratory fitness was assessed by the 20-meter shuttle run test. Height, weight, waist circumference, and resting blood pressure (BP) were measured according to standard procedures.

RESULTS

Regression analyses showed a significant inverse association between cardiorespiratory fitness at baseline and systolic BP (B = -0.126; P = .047) and rate pressure product (B = -29.94; P = .016), at follow-up after adjustments for age, sex, height, pubertal stage, socioeconomic status, and waist circumference. Significant differences were found between cardiorespiratory fitness groups (fit vs unfit) at baseline and systolic BP and rate pressure product at follow-up (P < .05 for all). Analysis of covariance showed a significant association between cardiorespiratory fitness changes and systolic BP (P = .024) and rate pressure product (P = .014), after adjustment for age, sex, height, pubertal status, socioeconomic status, and waist circumference.

CONCLUSIONS

Changes in cardiorespiratory fitness during adolescence were associated with cardiovascular indices over a 2-year period. Adolescents with persistently low levels of cardiorespiratory fitness exhibited the highest levels of systolic BP and rate pressure product.

Prehypertension among 2.19 million adolescents and future risk for end-stage renal disease

OBJECTIVE

Persistent hypertension in adulthood is a leading cause of end-stage renal disease (ESRD). Whether lower blood pressure (BP) values, in the range of prehypertension, are also associated with future occurrence of ESRD is unclear. Even less clear is the potential risk of early prehypertension appearing in adolescence. To address this question, we examined whether BP measurements in the prehypertensive range at age 16-19 years predict adult ESRD.

METHODS

Medical data on 2194 635 16-19-year-old adolescents examined for medical fitness prior to military service from 1977 to 2013 were linked to the Israeli ESRD registry in this nationwide population-based cohort study. Incident cases of ESRD were recorded. Survival models were applied.

RESULTS

During 35 007 506 person-years of follow-up (median follow-up 16.8 years), there were 690 ESRD cases, with an overall incidence rate of 1.97 cases per 100 000 person-years. Examinees with elevated BP readings in the prehypertensive range (BP between the 90th and 95th percentiles or between 120 and 139/80-89 mmHg) had increased incidence of ESRD with a hazard ratio of 1.32 (95% confidence interval, 1.11-1.58) adjusted for year of birth, age at examination, sex, BMI, education, socioeconomic status, and country of origin. Hypertension (BP above the 95th percentile or above 140/90 mmHg) was associated with a hazard ratio of 1.44 (95% confidence interval, 1.17-1.79). A spline model demonstrated a nadir of risk at SBP values as low as 94 mmHg.

CONCLUSION

Asymptomatic, healthy adolescents with prehypertension have a 32% increased risk for subsequent ESRD, compared with adolescents with optimal BP.

Fatness and Fitness With Cardiometabolic Risk Factors in Adolescents

CONTEXT

The relative importance of fitness and fatness with cardiometabolic risk factors is uncertain during the crucial developmental stage of late adolescence.

OBJECTIVE

We aimed to compare the concurrent influences of cardiorespiratory fitness and fatness in relationship to cardiometabolic risk factors in adolescents from the Western Australian Pregnancy Cohort Study.

DESIGN, SETTING, AND PARTICIPANTS

Cross-sectional analysis was performed on 1128 participants with complete blood pressure (BP) data and 963 participants with complete blood biochemistry at 17 years of age. Fatness (waist circumference) and cardiorespiratory fitness (physical work capacity 170) were assessed as continuous measures to avoid the use of arbitrary cut points. Analyses used linear regression models adjusted for sex and potential lifestyle confounders.

MAIN OUTCOME MEASURE

Cardiometabolic risk factors.

RESULTS

Fatness was positively associated with systolic BP (coefficient, 0.19; P < 0.001; β coefficient, 0.20), triglycerides (log coefficient, 0.009; P < 0.001; β coefficient, 0.24), low-density lipoprotein cholesterol (coefficient, 0.005; P = 0.007; β coefficient, 0.10), and high-sensitivity C-reactive protein (log coefficient, 0.05; P < 0.001; β coefficient, 0.35). There were no significant effects of fitness on any of these measures. A positive association between homeostasis model of assessment for insulin resistance and fatness (log coefficient, 0.02; P < 0.001; β coefficient, 0.33) was attenuated by fitness (log coefficient, -0.0.18; P < 0.001; β coefficient, -0.18). Fatness was inversely associated with high-density lipoprotein cholesterol (HDL-C) in both sexes (coefficient, -0.006; P < 0.001; β coefficient, -0.23), whereas fitness was positively associated with HDL-C only in females (coefficient, 0.08; P = 0.03; β coefficient, 0.15).

CONCLUSIONS

The adverse effects of central adiposity seen across a broad range of cardiometabolic risk factors were only partially ameliorated by fitness in this adolescent population.

National Blood Pressure Reference for Chinese Han Children and Adolescents Aged 7 to 17 Years

We sought to develop and validate a national blood pressure (BP) reference based on age, sex, and height for Chinese children. Data were obtained on 197 430 children aged 7 to 17 who participated in the Chinese National Survey on Students' Constitution and Health in 2010. BP percentiles were estimated and fitted using the lambda, mu, and sigma method and then compared with a US reference and China existing reference. In an external independent validation sample of 59 653 children aged 7 to 18 from 7 Chinese provinces in 2013, the prevalence of elevated BP was compared applying the 3 references. BP values were similar for boys and girls at the younger ages (7-13 years) and lower height percentiles, whereas higher at the older ages (14-17 years) for boys than girls. At medial height in boys and girls aged 7 to 13, the 50th, 90th, 95th, and 99th percentiles of BP for the new national reference were consistent with US reference and lower than current Chinese reference. In the independent sample, elevated BP prevalence, based on the new national reference, ranged from 7.8% to 18.5% among children aged 7 to 17, which was higher than the US reference values (4.3%-14.5%) and lower than the current Chinese reference (12.9%-25.5%) in each age group. The new national BP reference for Chinese children based on age, sex, and height from large-scale and nationally representative data seems to improve the ability for identifying Chinese hypertensive children and for stratifying them with regard to cardiovascular risk.

Joint effect of maternal plasma homocysteine and prepregnancy obesity on child blood pressure: a prospective birth cohort study

BACKGROUND/OBJECTIVES

Elevated homocysteine (Hcy) is a known cardiovascular risk factor. However, its role in intergenerational cardiometabolic risk is unknown. We hypothesized that maternal elevated Hcy can act alone or in combination with maternal prepregnancy obesity to increase child systolic blood pressure (SBP).

METHODS

This study included 1279 mother-child pairs who were enrolled at birth and followed prospectively up to age 9 years from 2003 to 2014 at the Boston Medical Center. Child SBP percentile was calculated according to US reference data and elevated SBP was defined as SBP⩾75th percentile.

RESULTS

A U-shaped relationship between maternal Hcy and her child SBP was observed. The risk for child elevated SBP was higher among those in the lowest quartile (Q1, odds ratio (OR): 1.27; 95% confidence interval (CI): 0.94-1.72), and highest quartile (Q4, OR: 1.34; 95% CI: 1.00-1.81) as compared with those in quartiles 2 and 3. The highest risk of child elevated SBP was found among children born to obese mothers with Hcy in Q4 (OR: 2.22; 95%CI: 1.35-3.64), compared with children of non-obese mothers with Hcy in Q2-Q3. This association was independent from maternal folate and vitamin B12 status, and was not mediated by gestational age or size at birth.

CONCLUSIONS

In this prospective birth cohort, we observed a U-shaped association between maternal Hcy levels and child elevated SBP. Maternal high Hcy (Q4) and prepregnancy obesity jointly increased the risk of child elevated SBP by more than two-fold.

Suicide and all-cause mortality in Swedish deployed military veterans: a population-based matched cohort study

OBJECTIVE

To investigate suicide and mortality risk in deployed military veterans versus non-deployed comparators who had gone through military conscription testing.

DESIGN

Population-based matched cohort study.

SETTING

Sweden.

PARTICIPANTS

Participants were identified from the Military Service Conscription Register and deployment status from the Swedish Military Information Personnel Register. Of 1.9 million conscripts, 21 721 had deployed at some time between 1990 and 2013 (deployed military veterans). Non-deployed comparators were matched to deployed military veterans in two ways: (1) by cognitive ability, psychological assessment, mental health, body mass index, sex, birth-year and conscription-year (carefully matched), with further adjustment for exercise capacity and suicide attempt history; and (2) by sex, birth-year and conscription-year (age- and sex-matched).

MAIN OUTCOME

Suicide retrieved from the Swedish National Patient and Causes of Death Register until 31 December 2013.

RESULTS

During a median follow-up of 12 years, 39 and 211 deaths by suicide occurred in deployed military veterans (n=21 627) and carefully matched non-deployed comparators (n=107 284), respectively (15 vs 16/100 000 person-years; adjusted HR (aHR) 1.07; 95% CI 0.75 to 1.52; p=0.72) and 329 in age- and sex-matched non-deployed comparators (n=108 140; 25/100 000 person-years; aHR 0.59; 95% CI 0.42 to 0.82; p=0.002). There were 284 and 1444 deaths by suicide or attempted suicides in deployed military veterans and carefully matched non-deployed comparators, respectively (109 vs 112; aHR 0.99; 95% CI 0.88 to 1.13; p=0.93) and 2061 in age- and sex-matched non-deployed comparators (158; aHR 0.69; 95% CI 0.61 to 0.79; p<0.001). The corresponding figures for all-cause mortality for carefully matched non-deployed comparators were 159 and 820 (61 vs 63/100 000 person-years; aHR 0.97; 95% CI 0.82 to 1.15; p=0.71) and 1289 for age- and sex-matched non-deployed comparators (98/100 000 person-years; aHR 0.62; 95% CI 0.52 to 0.73; p<0.001).

CONCLUSION

Deployed military veterans had similar suicide and mortality risk as non-deployed comparators after accounting for psychological, psychiatric and physical factors. Studies of mental health in deployed veterans need to adjust for more factors than age and sex for comparisons to be meaningful.

Stress resilience and cancer risk: a nationwide cohort study

Background

Stress resilience is recognised as a determinant of both psychiatric and somatic health, but the potential link between stress resilience and cancer development has not been explored.

Methods

In this nationwide cohort study, we examined the association between stress resilience in adolescence and subsequent cancer risk. We identified a cohort of 284 257 Swedish men, born 1952–1956, who underwent compulsory military enlistment examinations including measures of psychological stress resilience (median age 18 years). The resulting score was categorised as low, moderate and high stress resilience. Individuals diagnosed with cancer during the follow-up time were identified through data linkage to the Swedish Cancer Register.

Results

Lowest stress resilience, compared with the highest, was associated with increased risks of liver (HR: 4.73, 95% CI 2.73 to 8.19) and lung (HR: 2.75, 95% CI 2.02 to 3.74) cancer after adjusting for markers of socioeconomic circumstances in childhood (p for trend <0.001 for both cancer types). Further adjustment for cognitive and physical fitness at conscription assessment had a marginal influence. In contrast, men with low stress resilience had a decreased risk of being diagnosed with prostate cancer (HR: 0.65, 95% CI 0.56 to 0.76) and malignant melanoma (HR: 0.65, 95% CI 0.55 to 0.76).

Conclusion

We conclude that adolescent stress resilience, plausibly by influencing behavioural choices and social patterns, constitutes an important determinant of adult cancer occurrence. Increased awareness of long-term consequences in susceptible individuals may help direct future efforts to reduce cancer burden in adults.

Effects of pentoxifylline on hemodynamic, hemorheological, and microcirculatory parameters in young SHRs during arterial hypertension development

The most common form of hypertension in young adults is isolated diastolic hypertension. Diastolic arterial pressure is determined by the total peripheral resistance and depends on both vascular hindrance and blood viscosity. The aim of our work was to study the efficiency of pentoxifylline (PTX) in young spontaneously hypertensive rats (SHRs) during the development of arterial hypertension. The effects of a treatment course with PTX (100 mg/kg/day p.o. for 6 weeks, from 5 to 11 weeks old) on the mean, systolic, and diastolic blood pressure (BP); stroke volume; cardiac output; total peripheral resistance (TPR); whole blood viscosity (BV); plasma viscosity; hematocrit; RBC aggregation and deformability; local cerebral blood flow (lCBF); and microvascularization of the visual cortex were studied in SHRs in comparison with control SHRs and Wistar Kyoto rats. PTX-treated SHRs had significantly lower systolic, diastolic, and mean BP (by 24%, 26%, and 15%, respectively) and BV (by 5-9%) and a higher erythrocyte deformability index (by 1.5-2%), lCBF (by 42%), average diameter of capillaries (by 11%), density of the capillary network (by 23%), and percentage of capillaries with a diameter of 3-7 µm in comparison with control SHRs. In conclusion, PTX exerted positive effects on the hemodynamic, hemorheological, and microcirculatory parameters in SHRs during the development of arterial hypertension.

Influence of Child and Adult Elevated Blood Pressure on Adult Arterial Stiffness: The Cardiovascular Risk in Young Finns Study

Elevated blood pressure (BP) in childhood has been associated with increased adult arterial stiffness, the independent predictor of cardiovascular and all-cause mortality. The favorable BP change from childhood to adulthood and the risk of high adult arterial stiffness has not been reported. We examined the effect of child and adult BP on pulse wave velocity (PWV) assessed in adulthood among 1540 white adults followed-up for 27 years since baseline (1980, aged 6-18 years). Childhood elevated BP was defined according to the tables from the National High Blood Pressure Education Program. In adulthood, BP was classified as elevated if systolic BP ≥120 mm Hg, diastolic BP ≥80 mm Hg, or self-reported use of antihypertensive medications. PWV was measured in 2007 by whole-body impedance cardiography, and high PWV was defined as values at or above the age-, sex-, and heart rate-specific 80th percentile. Individuals with persistently elevated BP and individuals with normal child but elevated adult BP had increased risk of high adult PWV (relative risk [95% confidence interval], 3.18 [2.22-4.55] and 2.64 [1.79-3.88], respectively) in comparison with individuals with normal (both child and adult) BP. In contrast, individuals with elevated BP in childhood but not in adulthood did not have significantly increased risk of high PWV (relative risk [95% confidence interval], 1.26[0.80-1.99]). The results were consistent when different definitions for child and adult elevated BP were applied. These findings highlight the importance of BP control in the primary prevention of cardiovascular diseases.

The effect of an electronic health record-based tool on abnormal pediatric blood pressure recognition

BACKGROUND

Recognition of high blood pressure (BP) in children is poor, partly due to the need to compute age-sex-height referenced percentiles. This study examined the change in abnormal BP recognition before versus after the introduction of an electronic health record (EHR) app designed to calculate BP percentiles with a training lecture.

METHODS AND RESULTS

Clinical data were extracted on all ambulatory, non-urgent encounters for children 3-18 years old seen in primary care, endocrinology, cardiology, or nephrology clinics at an urban, academic hospital in the year before and the year after app introduction. Outpatients with at least 1 BP above the age-gender-height referenced 90th percentile were included. Abnormal BP recognition was defined as a BP related ICD-9 code, referral to nephrology or cardiology, an echocardiogram or renal ultrasound to evaluate BP concern, or a follow-up primary care visit for BP monitoring. Multivariable adjusted logistic regression compared odds of recognition before and after app introduction. Of 78 768 clinical encounters, 3521 had abnormal BP in the pre- and 3358 in the post-app period. App use occurred in 13% of elevated BP visits. Overall, abnormal BP was recognized in 4.9% pre-app period visits and 7.1% of visits post-app (P < .0001). Recognition was significantly higher when the app was actually used (adjusted OR 3.17 95% CI 2.29-4.41, P < .001). Without app use recognition was not different.

CONCLUSIONS

BP app advent modestly increased abnormal BP recognition in the entire cohort, but actual app use was associated with significantly higher recognition. Predictors of abnormal BP recognition deserve further scrutiny.

Association of Maternal Plasma Folate and Cardiometabolic Risk Factors in Pregnancy with Elevated Blood Pressure of Offspring in Childhood

BACKGROUND

The prevalence of childhood elevated blood pressure (BP) has increased in the United States, particularly among African Americans. The influence of maternal plasma folate levels, alone or in combination with maternal cardiometabolic risk factors (hypertensive disorders, diabetes, and prepregnancy obesity), on child systolic BP (SBP) has not been examined in a prospective birth cohort. We hypothesize that adequate maternal folate levels can reduce the risk of elevated SBP in children born to mothers with cardiometabolic risk factors.

METHODS

This study included 1,290 mother-child dyads (875 African Americans (67.8%)) recruited at birth and followed prospectively up to age 9 years from 2003 to 2014 at the Boston Medical Center. Child SBP percentile was calculated according to US reference data and elevated SBP was defined as SBP ≥75th percentile.

RESULTS

Maternal folate levels, overall, were not associated with child SBP. However, we found a significant multiplicative interaction between maternal cardiometabolic risk factors and maternal folate levels (Pinteraction = 0.015) on childhood elevated SBP. Among children born to mothers with any cardiometabolic risk factors, those whose mothers had folate levels above (vs. below) the median had 40% lower odds of elevated childhood SBP (odds ratio = 0.60, 95% confidence interval: 0.40-0.90). The associations did not differ appreciably in analyses restricted to African Americans, and they were not explained by gestational age, size at birth, prenatal folate intake, or breastfeeding.

CONCLUSIONS

Findings from our urban minority birth cohort suggest that higher levels of maternal folate may help counteract the adverse associations of maternal cardiometabolic risk factors on child SBP.

Isolated Systolic Hypertension in Young Individuals: Pathophysiological Mechanisms, Prognostic Significance, and Clinical Implications

Isolated systolic hypertension (ISH) is the most common form of hypertension in older persons and its predictive value for adverse outcome is well known. However, ISH can be frequently found also in young individuals, especially among males, but its prognostic significance in this setting is still controversial. Increased large artery stiffness is the main determinant of ISH in elderly patients whereas the mechanisms that lead to ISH in the young are still debated. According to some authors ISH in youth is a totally benign condition that can be called "spurious hypertension" a phenomenon due to enhanced pulse pressure amplification of the pulse wave from central to peripheral sites. According to others the main determinant of ISH in young individuals is increased sympathetic activity and the consequent hyperkinetic state characterized by elevated heart rate and stroke volume. This phenomenon is often amplified by a powerful alarm reaction to the medical visit. However, recent research has shown that ISH in the young is a heterogeneous condition and that in some individuals also increased arterial stiffness can play a role. Although ISH seems to be a benign condition chiefly in young men, only few longitudinal data assessing the association with adverse outcomes are available. Future studies with long term follow-up are needed to better understand the clinical significance of this condition.

Muscle strength is associated with lower diastolic blood pressure in schoolchildren

Cardiorespiratory fitness (CRF) provides protection against the elevated blood pressure in overweight youth. Less is known regarding any similar protective effect of muscular fitness. We investigated how handgrip strength, an easy to implement measure of muscular strength, interacted with CRF and BMI to determine blood pressure in youth. We measured systolic (SBP) and diastolic (DBP) blood pressure, handgrip strength (HG), CRF and body mass index (BMI) in n=7329 10-16year-olds (47% girls). We defined elevated blood pressure as >91st percentile and Good HG as >33rd percentile. Participants were classified as Fit or Unfit and as Normal or Overweight/Obese based on international standards. The prevalence of elevated SBP was 23%, and 44% of participants had elevated DBP. In unfit participants Good HG was associated with lower SBP (z=0.41 (95%CI: 0.20-0.61) and DBP (z=0.29 (95%CI: 0.12-0.47). In Overweight/Obese participants, DBP was z=0.24 (95%CI: 0.14-0.34) lower in the Good (versus Low) HG group. Overweight/Obese participants with Good HG also had a 32% lower risk of elevated DBP (OR: 0.68, 95%CI: 0.57-0.82). This association was attenuated but remained important after adjusting for BMI (20% risk reduction, OR: 0.80, 95%CI: 0.63-1.01). Muscular fitness appears to play some protective role against the risk of elevated blood pressure; particularly for the more prevalent measure: elevated DBP (44%). Effects may be restricted to Overweight / Obese or unfit youth, who have an increased risk of elevated BP and also may be less likely to engage in traditional cardiorespiratory fitness training. Research to determine the effects of muscular fitness training on blood pressure is warranted in these subgroups.

Vascular Disease in Young Indians (20-40 years): Role of Hypertension

Hypertension (HTN) being one of the important risk factors for cardiovascular disease (CVD) is a significant health concern, especially in India. With age, prevalence of HTN, especially systolic HTN increases. Special attention needs to be directed to HTN in young ages (20-40 years) due to lower awareness, need for early treatment and better control of HTN. HTN in the age group of 20-40 years needs critical reappraisal. Given the high prevalence of HTN in the general population in India, in this review we attempt to provide current evidence and expert opinion on epidemiology, aetiopathogenesis and treatment of HTN in young (20-40 years) Indians.

Performance of Eleven Simplified Methods for the Identification of Elevated Blood Pressure in Children and Adolescents

The identification of elevated blood pressure (BP) in children and adolescents relies on complex percentile tables. The present study compares the performance of 11 simplified methods for assessing elevated or high BP in children and adolescents using individual-level data from 7 countries. Data on BP were available for a total of 58 899 children and adolescents aged 6 to 17 years from 7 national surveys in China, India, Iran, Korea, Poland, Tunisia, and the United States. Performance of the simplified methods for screening elevated or high BP was assessed with receiver operating characteristic curve (area under the curve), sensitivity, specificity, positive predictive value, and negative predictive value. When pooling individual data from the 7 countries, all 11 simplified methods performed well in screening high BP, with high area under the curve values (0.84-0.98), high sensitivity (0.69-1.00), high specificity (0.87-1.00), and high negative predictive values (≥0.98). However, positive predictive value was low for most simplified methods, but reached ≈0.90 for each of the 3 methods, including sex- and age-specific BP references (at the 95th percentile of height), the formula for BP references (at the 95th percentile of height), and the simplified method relying on a child's absolute height. These findings were found independently of sex, age, and geographical location. Similar results were found for simplified methods for screening elevated BP. In conclusion, all 11 simplified methods performed well for identifying high or elevated BP in children and adolescents, but 3 methods performed best and may be most useful for screening purposes.

Will Exercise Advice Be Sufficient for Treatment of Young Adults With Prehypertension and Hypertension? A Systematic Review and Meta-Analysis

Previous studies report benefits of exercise for blood pressure control in middle age and older adults, but longer-term effectiveness in younger adults is not well established. We performed a systematic review and meta-analysis of published randomized control trials with meta-regression of potential effect modifiers. An information specialist completed a comprehensive search of available data sources, including studies published up to June 2015. Authors applied strict inclusion and exclusion criteria to screen 9524 titles. Eligible studies recruited younger adults with a cardiovascular risk factor (with at least 25% of cohort aged 18-40 years); the intervention had a defined physical activity strategy and reported blood pressure as primary or secondary outcome. Meta-analysis included 14 studies randomizing 3614 participants, mean age 42.2±6.3 (SD) years. At 3 to 6 months, exercise was associated with a reduction in systolic blood pressure of -4.40 mm Hg (95% confidence interval, -5.78 to -3.01) and in diastolic blood pressure of -4.17 mm Hg (95% confidence interval, -5.42 to -2.93). Intervention effect was not significantly influenced by baseline blood pressure, body weight, or subsequent weight loss. Observed intervention effect was lost after 12 months of follow-up with no reported benefit over control, mean difference in systolic blood pressure -1.02 mm Hg (95% confidence interval, -2.34 to 0.29), and in diastolic blood pressure -0.91 mm Hg (95% confidence interval, -1.85 to 0.02). Current exercise guidance provided to reduce blood pressure in younger adults is unlikely to benefit long-term cardiovascular risk. There is need for continued research to improve age-specific strategies and recommendations for hypertension prevention and management in young adults.

In-Clinic Blood Pressure Prediction of Normal Ambulatory Blood Pressure Monitoring in Pediatric Hypertension Referrals

OBJECTIVE

Since younger patients have low pretest probability of hypertension and are susceptible to reactive and masked hypertension, ambulatory blood pressure monitoring (ABPM) can be useful. To better target use in referred patients, we sought to define in-clinic systolic blood pressure (SBP) measures that predicted normal ABPM and target end organ damage.

DESIGN, SETTING, PATIENTS, OUTCOME MEASURES

Data were collected on consecutive patients referred for high BP undergoing an ambulatory BP monitor from 2010 to 2013 (n = 248, 33.9% female, mean age 15.5 ± 3.6 years). Candidate in-clinic predictors were systolic maximum, minimum, or average BPs obtained by auscultative, oscillometric, or both. Multivariable logistic regression models were used to determine the prediction of normal ABPM by in-clinic BP predictors. Separate models considered predicting left ventricular hypertrophy (LVH) by in-clinic SBP vs. ABPM-defined hypertension. Identified predictor utility was tested with receiver operator characteristic curves.

RESULTS

Maximum (OR 0.97 [95% CI 0.94-0.99]; P = .047), minimum (0.96 [0.94-0.99]; P = .002), and average (0.97 [0.95-1.00]; P = .04) in-clinic auscultative SBP predicted normal ABPM. Each had a c-statistic of 0.58. LVH was associated with in-clinic auscultative minimum SBP treated continuously (1.05, [1.01-1.10], P = .01) or dichotomized at the 90th percentile (8.23, [1.48-45.80], P = .02), as well as ABPM-defined hypertension (3.31, [1.23-8.91], P = .02). Both predictors had poor sensitivity and specificity.

CONCLUSION

In youth, normal auscultative in-clinic systolic blood pressure indices weakly predicted normal ambulatory blood pressure and target end organ damage.

Performance of blood pressure-to-height ratio as a screening tool for elevated blood pressure in pediatric population: a systematic meta-analysis

The aim of this study was to assess the performance of the blood pressure-to-height ratio (BPHR) for screening elevated blood pressure (BP) in children and adolescents using a meta-analysis of eligible published studies. We retrieved studies that investigated the performance of the BPHR for identifying elevated BP from Pubmed and other databases. We performed meta-analyses by subgroups of sex, age and ethnicity using a fixed or random effect model based on whether there was between-study heterogeneity. A total of 13 publications including 262 830 children and adolescents aged 6-18 years on BPHR and a total of three publications including 95 343 children on the modified BPHR were included in this meta-analysis. The summary results suggested that BPHR performed well to identify pre-high BP and high BP for children aged 6-11 years and adolescents aged 12-18 years. The performance of BPHR was perfect for identifying severe high BP in adolescents aged 12-18 years. However, the modified BPHR did not improve accuracy for screening high BP in children aged 6-12 years. In summary, BPHR performed well for identifying elevated BP in children and adolescents, independently of sex, age and ethnicity group. In addition, the modified BPHR performed similarly with BPHR for screening high BP in childhood.

Hypertension in late adolescence and cardiovascular mortality in midlife: a cohort study of 2.3 million 16- to 19-year-old examinees

BACKGROUND

The effect of early hypertension on midlife cardiovascular (CV) mortality remains controversial. We assessed the association of established hypertension in late adolescence with subsequent CV mortality.

METHODS

Of 2,298,130 Israeli adolescents (60% males; age 17.4 ± 0.3 years) who underwent a compulsory medical examination prior to military service between 1967 and 2010, 8720 teenagers (0.4%) were formally diagnosed with persistent hypertension. Using Cox proportional hazards modeling, we compared the hypertensive group to the large normotensive group with regard to time to event analysis of midlife mortality due to cerebrovascular accidents (CVA), coronary heart disease (CHD), sudden death (SD) and their summation as cardiovascular disease (CVD).

RESULTS

During 45,729,521 person-years of follow-up, we identified 2918 CV deaths-2879 and 39 among the 2,289,410 normotensive and 8720 hypertensive adolescents, respectively. Hypertension at a young age was associated with a threefold elevation of stroke mortality compared to normotension when adjusted for sex, age at examination, birth year, country of origin, socioeconomic status, education, body mass index (BMI) and height [hazard ratio (HR) 3.12; 95% confidence interval (CI) 1.76-5.54; p < 0.001]. There was no significant association of hypertension with CHD mortality or SD. An increased risk for overall CVD mortality among hypertensive youngsters (HR 1.51; 95 % CI 1.10-2.07) was attenuated after adjusting for BMI and other covariates (HR 1.24; 95% CI 0.90-1.72).

CONCLUSIONS

Established hypertension at a young age was independently associated with elevated stroke mortality in midlife. This finding warrants confirmatory large-scale long-term follow-up studies to address the distant effects of adolescent hypertension.

Potential Misclassification of Blood Pressure Status in Children and Adolescents With Short or Tall Stature

Blood pressure (BP) is measured in percentiles that are adjusted for sex, age, and height percentile in children and adolescents. Standard tables for the conversion of BP percentiles do not present exact BP percentile cutoffs for extremes in stature, either short (<5th percentile) or tall (>95th percentile). An algorithm can be used to calculate exact BP percentiles across a range of height z scores. We compared values from standard BP tables with exact calculations of BP percentiles to see which were better at identifying hypertension in more than 5,000 children with either short or tall stature. Study subjects were 3-17-year-old patients within HealthPartners Medical Group, an integrated health care delivery system in Minnesota, at any time between 2007 and 2012. Approximately half of the subjects who met the criteria for hypertension using exact calculation would be misclassified as normal using available thresholds in the published BP tables instead of the recommended algorithm, which was not included in the tables.

Establishing International Blood Pressure References Among Nonoverweight Children and Adolescents Aged 6 to 17 Years

BACKGROUND

Several distributions of country-specific blood pressure (BP) percentiles by sex, age, and height for children and adolescents have been established worldwide. However, there are no globally unified BP references for defining elevated BP in children and adolescents, which limits international comparisons of the prevalence of pediatric elevated BP. We aimed to establish international BP references for children and adolescents by using 7 nationally representative data sets (China, India, Iran, Korea, Poland, Tunisia, and the United States).

METHODS AND RESULTS

Data on BP for 52 636 nonoverweight children and adolescents aged 6 to 19 years were obtained from 7 large nationally representative cross-sectional surveys in China, India, Iran, Korea, Poland, Tunisia, and the United States. BP values were obtained with certified mercury sphygmomanometers in all 7 countries by using standard procedures for BP measurement. Smoothed BP percentiles (50th, 90th, 95th, and 99th) by age and height were estimated by using the Generalized Additive Model for Location Scale and Shape model. BP values were similar between males and females until the age of 13 years and were higher in males than females thereafter. In comparison with the BP levels of the 90th and 95th percentiles of the US Fourth Report at median height, systolic BP of the corresponding percentiles of these international references was lower, whereas diastolic BP was similar.

CONCLUSIONS

These international BP references will be a useful tool for international comparison of the prevalence of elevated BP in children and adolescents and may help to identify hypertensive youths in diverse populations.

Rapid increases in infant adiposity and overweight/obesity in childhood are associated with higher central and brachial blood pressure in early adulthood

Background:

Small size at birth and greater BMI in childhood are associated with greater brachial blood pressure (BP) in later life. Aortic (central) BP differs from brachial BP and is more predictive of organ damage and cardiovascular events; the relationship between BMI in childhood and central BP is not known.

Methods:

Using data from 3154 people from the Avon Longitudinal Study of Parents and Children, we assessed associations between repeated measures of BMI from birth to age 10 with central and brachial BP at age 17.

Results:

Lower BMI at birth (thinness) was associated with greater central and brachial BP. No associations were seen between BMI in early childhood (<7 years) and later BP, but greater BMI from 7 to 10 years was associated with higher BP. Associations were similar for central and brachial SBP and for DBP, and were stronger in males compared with females. The highest BP was seen in participants who were low-birth-weight and overweight or obese at both the end of infancy (age 2) and at the time of BP assessment (age 17); mean central SBP was 104.2 mmHg (SD = 11.0) compared with 100.7 (SD = 10.5) in participants who were normal-birth-weight and overweight or obese at 2 and 17 years.

Conclusion:

Small size at birth followed by rapid adiposity gain in infancy and continued overweight/obesity are associated with greater BP in young adulthood. These findings emphasize the importance of maintenance of normal weight in childhood for the prevention of high BP.

Development of hypertension in overweight adolescents: a review

The upward trend in adolescent hypertension is widely attributed to the adolescent obesity epidemic. Secular trends in adolescent prehypertension and hypertension have risen in congruence with increasing trends in the prevalence of overweight and obesity. The correlation between body mass index and blood pressure in adolescence is moderate to strong in most studies and strongest in those classified as overweight or obese. The mechanisms relating to the development of hypertension in overweight adolescents are unclear; however, a number of nonmodifiable and modifiable factors have been implicated. Importantly, certain clinical and biochemical markers in overweight adolescents are indicative of high risk for hypertension, including family history of hypertension and hyperinsulinemia. These characteristics may prove useful in stratifying overweight adolescents as high or low risk of comorbid hypertension. The treatment of overweight and obesity related hypertension in this population focuses on two key modalities: lifestyle change and pharmacotherapy. These approaches focus almost exclusively on weight reduction; however, a number of emerging strategies target hypertension more specifically. Among adolescents with overt hypertension there are also several factors that indicate higher risk of concurrent subclinical disease, persistent adult hypertension, and adult cardiovascular disease. This group may benefit substantially from more aggressive pharmacological treatments. Limitations in the literature relate to the paucity of studies reporting specific effects for the adolescent age group of overweight and obese individuals. Nonetheless, intervention for adiposity-related hypertension in adolescence may partially mitigate some of the cardiovascular risk in adulthood.

A life course approach to cardiovascular aging

A life course approach in epidemiology investigates the biological, behavioral and social pathways that link physical and social exposures and experiences during gestation, childhood, adolescence and adult life, and across generations, to later-life health and disease risk. We illustrate how a life course approach has been applied to cardiovascular disease, highlighting the evidence in support of the early origins of disease risk. We summarize how trajectories of cardiometabolic risk factors change over the life course and suggest that understanding underlying 'normal' or 'healthy' trajectories and the characteristics that drive deviations from such trajectories offer the potential for early prevention and for identifying means of preventing future disease.

Understanding trends in blood pressure and their associations with body mass index in Chinese children, from 1985 to 2010: a cross-sectional observational study

OBJECTIVE

Understanding trends in blood pressure (BP) in childhood is crucial to addressing and reducing the burden of adulthood hypertension and associated mortality in the future. In view of growing obesity in Chinese children, we sought to investigate the trends in BP and the influence of body mass index (BMI) on them.

DESIGN, SETTING AND PARTICIPANTS

We included 1,010,153 children aged 8-17 years, with completed records from a large national successive cross-sectional survey, the Chinese National Survey on Students' Constitution and Health, between 1985 and 2010.

MAIN OUTCOME MEASUREMENTS

BP was measured according to the recommendation of the National High Blood Pressure Education Program Working Group, and the elevated BP was based on sex-, age- and height-specific 95th centile of the recommendation.

RESULTS

The adjusted mean systolic BP in boys and girls decreased by 3.9 and 5.6 mm Hg between 1985 and 2005, and increased by 1.3 and 1.0 mm Hg between 2005 and 2010, respectively. Corresponding adjusted prevalence of elevated systolic BP in boys and girls declined from 5.1% and 5.5% to 3.5% and 2.5% between 1985 and 2005, and increased to 4.9% and 3.5% in 2010, respectively. Adjusted mean BMI of boys and girls in 2010 was 2.0 and 1.2 kg/m(2) higher than those in 1985, respectively. The prevalence of obesity rose from 0% to 3.4% in boys and 0.9% in girls. Further adjusting for BMI did not change these trends in systolic BP. A similar pattern was also observed in diastolic BP.

CONCLUSIONS

After declining for 20 years, BP levels in Chinese children started to climb upwards. These trends in BP cannot be fully explained by BMI. The investigation of other determinants of BP may provide additional opportunity to curb the current upward BP trend in Chinese children.

Household income and adolescent blood pressure in a Chinese birth cohort: "Children of 1997"

The inconsistent relation of national income with population blood pressure raises questions as to whether social comparisons of relative income at individual or neighbourhood level may be more relevant than absolute income. We examined the associations of absolute household income (income per se), absolute neighbourhood median income (average income among geographically-proximate households), relative household income [deprivation using Yitzhaki index, or rank by position] (differences in income or rank compared with others) and relative neighbourhood income inequality [Gini coefficient] (income gap within a neighbourhood) with blood pressure z-score, prehypertension or hypertension at ∼13 years using a fixed effects multilevel linear or logistic model in a Chinese birth cohort (n = 5063, 61% of follow-up). Absolute household or neighbourhood income was not associated with adolescent blood pressure. Greater relative household income deprivation was associated with higher diastolic blood pressure (0.01 z-score per USD 128 difference in Yitzhaki index, 95% confidence interval (CI) 0.005 to 0.02), so was lower relative household income rank (-0.10, 95% CI -0.15 to -0.04), but relative neighbourhood income inequality was not, when considering each income measure separately. Such associations remained when considering all income measures together. Income measures were not associated with prehypertension or hypertension. Relative household income (greater deprivation or lower rank) were positively associated with adolescent blood pressure independent of absolute household income while absolute or relative neighbourhood income had little contribution, suggesting social comparisons at a key developmental stage could be relevant. Clarifying specific effects of socioeconomic position across the life-course could inform interventions.

Hypertension in Young People: Epidemiology, Diagnostic Assessment and Therapeutic Approach

High blood pressure (BP) still remains one of the most relevant cardiovascular risk factors, also due to its persistently high prevalence and growing incidence in the general adult and elderly population. Since almost all hypertension-related cardiovascular complications, mostly including coronary artery disease, myocardial infarction, ischemic stroke, and congestive heart failure, occurred in adult and elderly individuals, evidence on both prevalence and clinical management of hypertension in young individuals are lacking. Therefore, the clinical impact of high BP levels in young populations remains to be explored. In the recent years, the attitude of the scientific community has changed and more attention was devoted to young individuals with hypertension, also in view of the fact that early identification of these subjects may prevent developing of established hypertension in adulthood. In addition, unhealthy lifestyle habits have progressively involved children and adolescents worldwide, thus contributing to further increase the risk of developing hypertension in young individuals. On the basis of these considerations, the present review is aimed at providing a brief reappraisal of the major aspects of hypertension in the young age, as well as at promoting interest and discussion on this important issue.

Isolated systolic hypertension in young and middle-aged adults and 31-year risk for cardiovascular mortality: the Chicago Heart Association Detection Project in Industry study

BACKGROUND

Isolated systolic hypertension (ISH), defined as systolic blood pressure (SBP) ≥140 mm Hg and diastolic blood pressure (DBP) <90 mm Hg, in younger and middle-aged adults is increasing in prevalence.

OBJECTIVE

The aim of this study was to assess the risk for cardiovascular disease (CVD) with ISH in younger and middle-aged adults.

METHODS

CVD risks were explored in 15,868 men and 11,213 women 18 to 49 years of age (mean age 34 years) at baseline, 85% non-Hispanic white, free of coronary heart disease (CHD) and antihypertensive therapy, from the Chicago Heart Association Detection Project in Industry study. Participant classifications were as follows: 1) optimal-normal blood pressure (BP) (SBP <130 mm Hg and DBP <85 mm Hg); 2) high-normal BP (130 to 139/85 to 89 mm Hg); 3) ISH; 4) isolated diastolic hypertension (SBP <140 mm Hg and DBP ≥90 mm Hg); and 5) systolic diastolic hypertension (SBP ≥140 mm Hg and DBP ≥90 mm Hg).

RESULTS

During a 31-year average follow-up period (842,600 person-years), there were 1,728 deaths from CVD, 1,168 from CHD, and 223 from stroke. Cox proportional hazards models were adjusted for age, race, education, body mass index, current smoking, total cholesterol, and diabetes. In men, with optimal-normal BP as the reference stratum, hazard ratios for CVD and CHD mortality risk for those with ISH were 1.23 (95% confidence interval [CI]: 1.03 to 1.46) and 1.28 (95% CI: 1.04 to 1.58), respectively. ISH risks were similar to those with high-normal BP and less than those associated with isolated diastolic hypertension and systolic diastolic hypertension. In women with ISH, hazard ratios for CVD and CHD mortality risk were 1.55 (95% CI: 1.18 to 2.05) and 2.12 (95% CI: 1.49 to 3.01), respectively. ISH risks were higher than in those with high-normal BP or isolated diastolic hypertension and less than those associated with systolic diastolic hypertension.

CONCLUSIONS

Over long-term follow-up, younger and middle-aged adults with ISH had higher relative risk for CVD and CHD mortality than those with optimal-normal BP.

Pathological periodontal pockets are associated with raised diastolic blood pressure in obese adolescents

BACKGROUND

Obesity, a well-known risk factor for developing cardiovascular disease (CVD), is associated with chronic periodontitis in adults. This cross-sectional pilot study on obese adolescents was designed to investigate whether periodontal disease in terms of pathological periodontal pockets is associated with raised blood pressure and other risk markers for CVD.

METHODS

The study included 75 obese subjects between 12 to 18 years of age, mean 14.5. Subjects answered a questionnaire regarding health, oral hygiene habits and sociodemographic factors. A clinical examination included Visible Plaque Index (VPI %), Gingival inflammation (BOP %) and the occurrence of pathological pockets exceeding 4 mm (PD ≥ 4 mm). Blood serum were collected and analyzed. The systolic and diastolic blood pressures were registered.

RESULTS

Adolescents with pathological periodontal pockets (PD ≥ 4 mm; n = 14) had significantly higher BOP >25% (P = 0.002), higher diastolic blood pressure (P = 0.008), higher levels of Interleukin (IL)-6 (P < 0.001), Leptin (P = 0.018), Macrophage Chemoattractant Protein-1 (MCP-1) (P = 0.049) and thyroid stimulating hormone (TSH) (P = 0.004) in blood serum compared with subjects without pathological periodontal pockets (PD ≥ 4 mm; n = 61). The bivariate linear regression analysis demonstrated that PD ≥ 4 mm (P = 0.008) and systolic blood pressure (P < 0.001) were significantly associated with the dependent variable "diastolic blood pressure". The association between PD ≥ 4 mm and diastolic blood pressure remained significant (P = 0.006) even after adjusting for potential confounders BMI-sds, age, gender, mother's country of birth, BOP >25%, IL-6, IL-8, Leptin, MCP-1, TSH and total cholesterol in the multiple regression analysis.

CONCLUSION

In conclusion, this study indicates an association between pathological periodontal pockets and diastolic blood pressure in obese adolescents. The association was unaffected by other risk markers for cardiovascular events or periodontal disease. The results call for collaboration between pediatric dentists and medical physicians in preventing obesity development and its associated disorders.

Stress resilience in male adolescents and subsequent stroke risk: cohort study

OBJECTIVE

Exposure to psychosocial stress has been identified as a possible stroke risk, but the role of stress resilience which may be relevant to chronic exposure is uncertain. We investigated the association of stress resilience in adolescence with subsequent stroke risk.

METHODS

Register-based cohort study. Some 237 879 males born between 1952 and 1956 were followed from 1987 to 2010 using information from Swedish registers. Cox regression estimated the association of stress resilience with stroke, after adjustment for established stroke risk factors.

RESULTS

Some 3411 diagnoses of first stroke were identified. Lowest stress resilience (21.8%) compared with the highest (23.7%) was associated with increased stroke risk, producing unadjusted HR (with 95% CIs) of 1.54 (1.40 to 1.70). The association attenuated slightly to 1.48 (1.34 to 1.63) after adjustment for markers of socioeconomic circumstances in childhood; and after further adjustment for markers of development and disease in adolescence (blood pressure, cognitive function and pre-existing cardiovascular disease) to 1.30 (1.18 to 1.45). The greatest reduction followed further adjustment for markers of physical fitness (BMI and physical working capacity) in adolescence to 1.16 (1.04 to 1.29). The results were consistent when stroke was subdivided into fatal, ischaemic and haemorrhagic, with higher magnitude associations for fatal rather than non-fatal, and for haemorrhagic rather than ischaemic stroke.

CONCLUSIONS

Stress susceptibility and, therefore, psychosocial stress may be implicated in the aetiology of stroke. This association may be explained, in part, by poorer physical fitness. Effective prevention might focus on behaviour/lifestyle and psychosocial stress.

Time Spent on the Internet and Adolescent Blood Pressure

Internet use is nearly ubiquitous among adolescents. Growing evidence suggests heavy Internet use negatively impacts health, yet the relationship between time spent on the Internet and adolescent blood pressure (BP) is unknown. We examined the association between Internet use and elevated BP in a racially diverse cross-sectional sample of 331 healthy adolescents (ages 14–17 years). Heavy Internet use was defined as ≥2 hr/day, moderate use as <2 hr/day and ≥5 days/week, and light use as <2 hr/day and ≤4 days/week. Elevated BP was defined as systolic or diastolic BP ≥90th percentile. Heavy Internet users had statistically significantly higher odds of elevated BP compared to light Internet users. School nurses can play an important role in preventing high BP through assessment of BP and other health behaviors including Internet use, and health teaching to individuals, student groups, faculty, and parents to increase awareness of the relationship between Internet use and health.