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Global burden of cardiovasc
Original Article
ular diseases attributable
to hypertension in young adults from1990 to 2019
Jing Liua,d, Xiang Bub, Linyan Weia,d, Xiqiang Wanga,d, Lulu Laic, Caijuan Donga,d, Aiqun Maa,d,
and Tingzhong Wanga,d
Journal of Hypertension 2021, 39:2488–2496
aDepartment of Cardiovascular Medicine, bDepartment of Respiratory and Critical
Care Medicine, the First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, Shaanxi,
China, cCenter for Cardiovascular Research, Washington University School of Medi-
cine in Saint Louis, Missouri, USA and dKey Laboratory of Molecular Cardiology,
Shaanxi Province, China
Correspondence to Aiqun Ma, Tingzhong Wang, Department of Cardiovascular
Medicine, the First Affiliated Hospital of Xi’an Jiaotong University, No. 277 Yanta
West Road, Xi’an, 710061, Shaanxi, P.R. China. E-mail: tingzhong.wang@xjtu.edu.cn,
aiqun.ma@xjtu.edu.cn
Received 20 April 2021 Revised 5 June 2021 Accepted 25 June 2021
J Hypertens 39:2488–2496 Copyright � 2021 The Author(s). Published by Wolters
Kluwer Health, Inc. This is an open access article distributed under the terms of the
Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-
NC-ND), where it is permissible to download and share the work provided it is properly
cited. The work cannot be changed in any way or used commercially without
Background: Hypertension grows into a serious public
health problem among young adults, linking to a set of
life-threatening cardiovascular diseases (CVDs). Young
adults are not well represented in current knowledge
about the CVDs burden attributable to hypertension.
Methods: In this analysis of data from the GBD (Global
Burden of Disease) study 2019, we focus on young adults
and provide the first comprehensive and comparative
assessment of the hypertension attributable CVDs burden,
in terms of its mortality and years of living with disability
(YLD) from 1990 to 2019, stratified by location, sex, and
development status.
Results: Globally in 2019, the death and YLD numbers
caused by hypertension-related CVDs were 640 239 and 2
717 474 in young adults, marking a 43.0 and 86.6%
increase from 1990, respectively. The corresponding
mortality rate dropped by 10.5%, whereas the YLD rate
increased by 16.8% during the same period. V-shaped
association between CVDs burden and social development
status was observed. The largest burden and the most
pronounced increase were borne by middle-income
countries, while high-income countries had the lowest
death/YLD rate with a quicker annual decline. Men largely
outpaced women in hypertension attributable CVDs
mortality. Ischemic heart disease and stroke were the
leading cause for death and YLD burden, correspondingly.
Conclusions: Hypertension attributable CVDs burden in
young adults has greatly increased from 1990 to 2019,
with considerably spatiotemporal and sexual heterogeneity.
The largest burden was borne by middle-income countries,
especially by men. Establishment of geographically and
sexually tailored strategies were needed to prevent
hypertension-related CVDs in young adults.
Keywords: cardiovascular diseases, global disease burden
2019, hypertension, young adults
Abbreviations: BP, blood pressure; BRIC, Brazil, Russia,
India, and China; CI, confidence interval; CVDs,
cardiovascular diseases; EAPC, estimated annual
percentage change; ESBP, elevated systolic blood pressure;
GBD, Global Burden of Diseases; HHD, hypertensive heart
disease; IHD, ischemic heart disease; IHME, Institute for
Health Metrics and Evaluation; SDI, social-demographic
index; YLD, years lived with disability
2488 www.jhypertension.com
INTRODUCTION
H
ypertension is a complex condition associated with
multiple cardiovascular diseases (CVDs), and it is
progressively advanced to a major risk factor for
young individuals [1]. In 2013–2014, unadjusted hyperten-
sion prevalence was nearly 20% in American adults aged
18–49 years [2]. Previous studies have shown that young
adult exposure to systolic blood pressure (SBP)
�130 mmHg had significantly higher risk for subsequent
cardiovascular events compared to those with normal BP
[3], and a graded increase in adverse cardiovascular out-
comes with BP severity was observed among 4.5 million
young adults [4]. Even adults with SBP of 120–129 mmHg
before age 40 years had adjusted risk ratio of 1.67 (95%
confidence interval [CI], 1.01–2.77) for CVDs in later life
compared to those with normal BP before age 40 years [5].
The CVDs burden and economy loss due to early onset and
uncontrolled status of hypertension in young adults is
worrisome. Nevertheless, most studies of hypertension
appear to segregate among higher-risk individuals (fre-
quently older than 50 years). CVDs burden attributable to
elevated SBP (ESBP) in young adulthood, a vulnerable
period and crucial window for adult health determination
[5], is not well represented in current knowledge [6]. This
study aimed to explore the current condition and temporal
trends of fatal and nonfatal burden of CVDs attributable to
ESBP in young adults, stratified by location, sex, and
development status.
permission from the journal.
DOI:10.1097/HJH.0000000000002958
Volume 39 � Number 12 � December 2021
mailto:tingzhong.wang@xjtu.edu.cn
mailto:aiqun.ma@xjtu.edu.cn
Hypertension burden in young adults
METHODS
Patient and public involvement
Our study was based on Global Burden of Diseases (GBD)
Study 2019 [7,8]. A waiver of informed consent is reviewed
and approved by the Institute for Health Metrics and
Evaluation (IHME) review board at the University of Wash-
ington. No individual subjects were involved in this study.
Study design and data source
All anonymized data were publicly accessible at the website
of Global Health Data Exchange (http://ghdx.healthda-
ta.org/gbd-results-tool). The general methods for the estab-
lishment of GBD 2019 and the methods for estimation of
ESBP-related CVDs burden have been detailed in previous
studies [9,10]. The social-demographic index (SDI) data by
locations were obtained from the IHME website (http://
ghdx.healthdata.org/) and were displayed in Tables S1 and
S2, Supplemental Digital Content, http://links.lww.com/
HJH/B725.
Framework and definition
According to the GBD 2015 comparative risk assessment
study [10], ESBP was defined as the SBP of at least 110–
115 mmHg, a level that is associated with an increased risk
of ischemic heart disease (IHD) and stroke [11]. ‘Young
adults’ was defined as people aged 25–49, who are gener-
ally in the peak period of physical performance and form
the main labor force of society. Two metrics, death and
years of living with disability (YLD), were used to assess the
fatal and nonfatal burden. Regions were arranged into three
nested hierarchical levels: 204 countries and territories, 21
FIGURE 1 The global ESBP-related CVDs burden in young adults in 2019, by 204 countr
(c and d) of death and YLD in 204 countries and territories. Countries with top ranking
elevated systolic blood pressure; YLD, years lived with disability.
Journal of Hypertension
GBD World Regions and SDI quintiles (high, high-middle,
middle, low-middle, and low-SDI).
Statistical analysis
We used the estimated annual percentage change (EAPC)
and its 95% CI to quantify the temporal trends. Smoothing
splines model was fitted to assess the association between
EAPCs and SDI [12,13]. EAPC is computed by a well estab-
lished formula [14], and an EAPC of 0, positive or negative
value indicates that rates are stable, in a downward or
upward trend over time, respectively, and the greater the
absolute value of EAPC, the faster the rate changes over
time. SDI, ranging from 0 (worst) to 1 (best), is a statistic
composite index of the total fertility rate of population
under 25 years of age, average education level for adults,
and lag-distributed income per capita indicator [15]. R
program (Version 3.6.3; R core team) was used to perform
statistics and map the figures. The PGlobal burden in 2019
Globally in 2019, a total number of 640 240 deaths and 2 717
475 YLDs were caused by ESBP-related CVDs in young
adults. The countries with the highest absolute burden were
India (death: 136 029, YLD: 363 631) and China (death: 107
420, YLD: 623 628). Pakistan, Russian Federation, Brazil,
and the United states were all on the list of the most
burdened countries (Fig. 1a and b). The corresponding
rates of death and YLD were 23.6 and 100.0 per 100 000
population, respectively. Countries with top ranking death
ies and territories. The absolute numbers (a and b) and rates (per 100 000 persons)
number and rate were annotated in the map. CVDs, cardiovascular diseases; ESBP,
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Liu et al.
rates were mainly in Eastern Europe, Central Asia, and
Southeast Asia (Fig. 1c), and the highest record of death
rate and YLDs rate were observed in Mongolia (69.8 per 100
000) and Indonesia (249.2 per 100 000), respectively
(Fig. 1d). Apparently, as a country with large population
base, Indonesia will suffer a heavy and surging absolute
burden in the near future. After zooming out to GBD region
level, Australia, Southern Latin America, and Andean Latin
America clearly outperformed on the control of ESBP-
related CVDs compared to other regions with similar devel-
opment status (Figure S1, Supplemental Digital Content,
http://links.lww.com/HJH/B725, Table S1, Supplemental
Digital Content, http://links.lww.com/HJH/B725).
Relative change over time
From 1990 to 2019, the change of CVDs death number in
young adults with ESBP was spatially heterogeneous.
Broadly, countries in Western and Central Europe had
the most significant decline, and South Korea, Finland,
and Hungary were the top three countries that had fallen
furthest. The largest increases (>200% rise) were observed
in countries including Philippines, Pakistan, Libya, Uzbek,
etc. (Figure S2A, Supplemental Digital Content, http://link-
s.lww.com/HJH/B725). During the same period, YLD num-
ber showed sharp growth larger than 50% across the whole
Asia, Africa, and Latin America, but slight decline in South
Korea, Japan, and countries in Western and Central Europe
(Figure S2B, Supplemental Digital Content, http://link-
s.lww.com/HJH/B725).
The mortality rates of ESBP-related CVDs in young adults
decreased across the world except for several Asia and
Africa countries, including Indonesia, Philippines, Pakistan,
Libya, etc. (Fig. 2a). High-income Asia Pacific countries had
the largest decrease with an EAPC of �3.50 (�3.77, �3.22;
Table 1). Conversely, the YLD rates increased globally and
the descending trend was exclusively observed in High-SDI
quintile (Fig. 2b and c), including High-income Asia Pacific,
Western Europe, Australasia, Tropical Latin America, etc.
(Table 1). And the largest decrease were observed in female
population living in high-income Asia Pacific (EAPC¼
�2.15 [–2.69, –1.62]) (Fig. 2c).
Disparities across social-demographic index
quintiles
Among SDI quintiles, the global ESBP-related CVDs burden
in young adults varied dramatically. In 2019, one third of the
death and YLD numbers were contributed by Middle-SDI
quintile (death: 218 595.4, YLDs: 971 832.6) (Fig. 3a). Also,
the leading death rate and YLDs rate were observed in Low-
middle (29.5 per 100 000) and Middle (108.5 per 100 000)
SDI quintiles (Fig. 3b). High-SDI quintile was the least
burdened and displayed a downward trend for both death
and YLD rates over the past decades.
Proportion and relative distribution by cause
Globally in 2019, ninety percentage of ESBP-related CVDs
deaths in young adults were due to ischemic heart disease
(IHD, 320 142.5), stroke (220 538.1) and hypertensive heart
disease (HHD, 49 327.1) (Table 2). High-income North
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America had a much larger proportion of HHD death
comparing other very developed regions (Figure S3A, Sup-
plemental Digital Content, http://links.lww.com/HJH/
B725). The annual mortality rates for IHD, stroke and
HHD declined globally. High-SDI quintile had the rapidest
reduction of IHD (EAPC: �2.11 [–2.28, –1.94]) and stroke
(EAPC: –2.38 [–2.55, –2.20]) but a sharp and exclusive
increase of HHD (EAPC: 1.81 [1.58, 2.04]). In the terms of
YLDs, stroke was the main contributor with 1 684 328.6
global number. The proportion of rheumatic heart disease
pumped out obviously in developing regions, as did the
proportion of atrial fibrillation and flutter in developed
regions. The YLDs rates of IHD, stroke and HHD increased
globally except that high-SDI quintile had obvious decrease
for YLD rate of IHD.
Sex heterogeneity
Typical sex difference existed in ESBP-related CVDs death
among young adults. Male had much higher death num-
bers and rates than female globally and regionally (Figs. 3
and Fig. 4a, Figure S4A and B, Supplemental Digital
Content, http://links.lww.com/HJH/B725), as well as in
different age stratifications (Fig. 4b). Also, the ratio of IHC-
specific to entire CVDs deaths is much higher in male
(54.20%) than that in female (40.48%) (Table 2). The most
significant sex difference occurred in Russian Federation,
where the death rate of men was almost five times that of
women (Figure S4A and B, Supplemental Digital Content,
http://links.lww.com/HJH/B725). Some other notable
patterns were observed in middle- and low-middle
regions SDI, including South Asia, East Asia and Southeast
Asia, where the mortality rate increased consistently on a
higher base for male while decreased further on a lower
base for female (Figs. 2c and Fig. 4a). In addition, female
experienced much quicker declines on the global death
rates caused by IHD, stroke and HHD than male (Figure
S5A, Supplemental Digital Content, http://links.lww.com/
HJH/B725). No obvious sex difference was observed for
YLDs numbers and rates, but the annual increases of YLDs
rates for male outnumbered that in female across
SDI quintiles.
The relationship between burden and social-
demographic index
Generally, death rates of ESBP-related CVDs in young
adults by 21 GBD World Regions decreased with increasing
SDI (Fig. 4c). Eastern Europe, Central Asia and Oceania had
much higher death rates than expected based on SDI for all
years, and the death rates showed a sharp increase followed
by a rapid decline during 1990–2019. Conversely, an
increase in YLD rate was observed in most GBD World
Regions despite gains in SDI over time, and the YLDs rate in
different regions varied much larger than the death rates
(Fig. 4d). Taken as a whole, an asymmetrically inverted V-
shaped correlation was detected between SDI and death/
YLD rates, and the fitting curves reached the peak as SDI
was near 0.7. Also, the EAPCs of death/YLD rates in 204
countries and territories showed similar associations with
SDI in 2019 (Figure S5C and D, Supplemental Digital
Content, http://links.lww.com/HJH/B725).
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FIGURE 2 The annual variation of ESBP-related CVDs burden in young adults from 1990 to 2019, by location. EAPCs of death/YLD rates (per 100 000 persons) in
204 countries/territories (a and b), and in SDI quintiles and 21 GBD World Regions, by sex (c). EAPC, estimated annual percentage changes; GBD, Global Burden of Disease;
SDI, social-demographic index; other abbreviations as in Fig. 1.
Hypertension burden in young adults
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TABLE 1. The temporal trend of ESBP-related CVDs burden
(deathand YLD) in young adults from 1990 to 2019,
by location and development status
GBD World Regions Death EAPCs YLD EAPCs
Global –0.44 (–0.57, –0.32) 0.59 (0.55, 0.63)
High SDI –1.76 (–1.90, –1.62) –0.11 (–0.27, 0.05)
High-middle SDI –1.41 (–1.82, –0.99) 0.46 (0.32, 0.60)
Middle SDI –0.06 (–0.18, 0.06) 0.88 (0.83, 0.92)
Low-middle SDI –0.07 (–0.17, 0.04) 0.62 (0.56, 0.67)
Low SDI –0.51 (–0.54, –0.47) 0.56 (0.48, 0.64)
High-income Asia Pacific –3.50 (–3.77, –3.22) –1.26 (–1.68, –0.84)
Central Asia –0.47 (–1.11, 0.17) 0.27 (0.16, 0.38)
East Asia –0.02 (–0.23, 0.18) 1.40 (1.30, 1.51)
South Asia –0.06 (–0.23, 0.10) 0.30 (0.24, 0.36)
Southeast Asia 0.53 (0.36, 0.71) 0.71 (0.65, 0.77)
Australasia –2.55 (–2.70, –2.40) –0.26 (–0.35, –0.17)
Caribbean 0.35 (0.10, 0.60) 0.87 (0.81, 0.94)
Central Europe –3.41 (–3.71, –3.10) –0.52 (–0.61, –0.42)
Eastern Europe –0.77 (–1.72, 0.18) 0.10 (–0.19, 0.40)
Western Europe –3.13 (–3.23, –3.02) –0.62 (–0.74, –0.51)
Andean Latin America –0.58 (–0.97, –0.18) 1.77 (1.37, 2.18)
Central Latin America –0.88 (–1.16, –0.60) 0.26 (0.09, 0.44)
Southern Latin America –1.86 (–1.99, –1.73) 1.17 (1.07, 1.27)
Tropical Latin America –2.37 (–2.43, –2.30) –0.33 (–0.39, –0.26)
High-income North America –0.69 (–0.90, –0.48) 0.67 (0.45, 0.89)
North Africa and Middle East –1.32 (–1.40, –1.23) 0.30 (0.26, 0.35)
Oceania 1.18 (0.93, 1.42) 1.45 (1.19, 1.71)
Central Sub-Saharan Africa –1.15 (–1.29, –1.00) –0.59 (–0.70, –0.49)
Eastern Sub-Saharan Africa –1.08 (–1.21, –0.94) 0.67 (0.58, 0.76)
Southern Sub-Saharan Africa –2.20 (–2.72, –1.68) –0.33 (–0.42, –0.23)
Western Sub-Saharan Africa 0.00 (–0.17, 0.16) 1.39 (1.25, 1.53)
CVDs, cardiovascular diseases; ESBP, elevated systolic blood pressure; SDI, social-
demographic index; YLD, years lived with disability.
Liu et al.
DISCUSSION
A globally increasing burden of ESBP-related CVDs, both
fatal and nonfatal, was borne by young adults over the
years. The global deaths and YLDs number in 2019 were
640 239.6 and 2 717 474.7, marking a 43.0 and 86.6%
increase from 1990, respectively. With the annual increase
in SDI, the global death rate gradually declined while the
YLDs rates showed a rapid increase during the same period.
Substantive discrepancies existed in the ESBP-related CVD
burden across SDI quintiles and between sex groups. The
largest absolute burden and most pronounced increases of
YLD rates were observed in middle-SDI quintile. High-SDI
quintile had the lowest burden and showed an exclusively
downward trend for death number and YLD rate compared
to other SDI quintiles. Young men had largely outpaced
women in absolute fatal burden, with a much higher global
mortality rate than that of their female counterpart in 2019.
Overall, these results demonstrated the importance of
increased investment in prevention and treatment of
ESBP-related CVD for young adults across the world, espe-
cially for men in middle-SDI countries.
Geographical transition
As is well known, ESBP-related CVDs were once recog-
nized as the diseases of affluence due to its high prevalence
and heavy burden in affluent societies. It was reported to be
the leading cause of death for both men and women,
leading to one in four premature deaths in United States
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in 2009 [16]. However, ESBP-related CVDs in young people
were currently global and were undergoing a geo-specific
transition to middle-income countries. Brazil, Russia, India,
and China (BRIC) are emerging economies making up
almost half the global population [17]. They reiterated
the commitment to control non–communicable diseases
including CVDs in 2014 and made some efforts on the
reduction in premature CVD mortality after that [18–20].
Whereas, our analysis showed a depressing picture about
the current situation of ESBP-related CVD burden among
young adults in BRIC. In 2013, the United Nations (UN)
adopted measures of lowering behavioral and biological
risk to achieve the 25% reduction in CVDs mortality by 2025
[21]. Obviously, the work priority should be given to the
BRIC, especially Russia Federation, due to their heavy
burden, as well as their increasing global significance both
as individual countries and as an economic grouping. In
addition, as one of the countries with the heaviest absolute
burden, Indonesia had a very high and annually increasing
death/YLD rate. The BP control and concomitant CVDs
treatment in young adults could be an important public
health challenge for Indonesian government and health
department. Considering the fact that Indonesia is one of
the developing countries which have been experiencing
population increase and infectious diseases [22–24], more
attention and support from UN should be helpful.
Change trends related to social-demographic
index
The asymmetrically inverted V-shaped correlation between
SDI and death/YLDs rates, as well as the EAPCs, indicated
that countries in the middle-SDI quintile were bearing the
heaviest and increasing burden, and this situation was the
past of high-SDI regions but the near future of low-SDI
regions. Interpretation of this correlation needed to con-
sider some change drivers as follows. Some metabolic and
behavioral risk factors, including diabetes, obesity, tobacco
use and sedentary lifestyle, tend to increase with develop-
ment [25–29]. More importantly, attention to dietary struc-
ture and physical health, well established medical systems,
and popularization of low-cost treatment show the same
trend. This explains the current low burden in low-SDI
regions and the greatly reduced burden in high-SDI
regions. Countries sitting in the middle stage of develop-
ment face an awkward situation, the epidemic risk factors,
weak disease awareness and limited health funds invest-
ment largely aggravate young adults’ vulnerability to ESBP-
related CVDs. Large-scale hypertension screening cam-
paigns in young adults are highly recommended for mid-
dle-income countries.
Sex preponderance
Sex preponderance existed undoubtedly in CVDs [30], and
our data re-established the notion that young women were
relatively protected from ESBP-related CVDs compared with
men. This result was consistent to a pooled study in 2015 that
analyzed data from 844 studies performed in 154 countries,
estimating a 5mmHg lower global mean age-standardized
systolic BP in women than in men (122.3mmHg vs.
127mmHg) [11]. In both high- and middle-income countries,
Volume 39 � Number 12 � December 2021
TABLE 2. Global numbers and proportion of ESBP-related CVDs burden (death and YLD) for 11 causes, by sex, in 2019
Both sexes Female Male
Cause Number Percentage Number Percentage Number Percentage
Death
Ischemic heart disease 320142.5 50.00% 79212.0 40.48% 240930.5 54.20%
Stroke 220538.1 34.45% 76981.4 39.34% 143556.7 32.29%
Hypertensive heart disease 49327.1 7.70% 21338.7 10.90% 27988.5 6.30%
Rheumatic heart disease 15618.1 2.44% 7591.0 3.88% 8027.1 1.81%
Cardiomyopathy and myocarditis 12027.4 1.88% 2991.0 1.53% 9036.4 2.03%
Endocarditis 4054.9 0.63% 1215.5 0.62% 2839.4 0.64%
Aortic aneurysm 4045.8 0.63% 869.3 0.44% 3176.5 0.71%
Nonrheumatic valvar heart disease 1647.2 a0.26% 419.9 0.21% 1227.3 0.28%
Atrial fibrillation and flutter 878.8 0.14% 372.2 0.19% 506.6 0.11%
Peripheral arterial disease 139.4 0.02% 36.2 0.02% 103.2 0.02%
Other CVDs 11820.2 1.85% 4669.8 2.39% 7150.5 1.61%
YLD
Stroke 1684328.6 61.98% 877748.3 64.40% 806580.3 59.55%
Rheumatic heart disease 287450.4 10.58% 139598.1 10.24% 147852.2 10.92%
Ischemic heart disease 274661.5 10.11% 99515.5 7.30% 175145.9 12.93%
Hypertensive heart disease 97891.1 3.60% 42160.5 3.09% 55730.6 4.11%
Atrial fibrillation and flutter 81576.5 3.00% 29068.7 2.13% 52507.8 3.88%
Cardiomyopathy and myocarditis 10368.7 0.38% 3111.8 0.23% 7256.9 0.54%
Endocarditis 894.1 0.03% 354.6 0.03% 539.5 0.04%
Nonrheumatic valvar heart disease 580.4 0.02% 130.0 0.01% 450.5 0.03%
Peripheral arterial disease 54.6 0.00% 34.3 0.00% 20.3 0.00%
Other CVDs 279668.8 10.29% 171330.9 12.57% 108337.9 8.00%
CVDs,cardiovascular diseases; ESBP, elevated systolic blood pressure; YLD, years lived with disability.
FIGURE 3 The changing trends of ESBP-related CVDs in young adults during 1990–2019, by sex and SDI quintiles. The changing trend of death/YLD numbers (a) and rates
(b) in SDI quintiles, by sex. Abbreviations as in Figs. 1 and 2.
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FIGURE 4 The sexual and socioeconomic disparities of ESBP-related CVDs burden in young adults. (a) Death/YLD rates in 21 GBD world regions, by sex, in 1990 and 2019.
(b) Global numbers and rates of death/YLD in different age stratifications, by sex, in 2019. (c and d) Trends in death/YLD rates across 21 GBD world regions by SDI, 1990–
2019. Each colored point line represents the rates for each year from 1990 to 2019 in a specified region. The blue line shows estimate across the spectrum of the SDI.
Abbreviations as in Figs. 1 and 2.
Liu et al.
women have higher proportions of hypertension awareness,
treatment and control than men [31]. Also, men have a more
unfavorable CVDs risk factor profile [32], and the disparities
in behavioral and metabolic risk factors largely drive the sex
difference in hypertension and CVDs [33]. The huge sex
difference in mortality we observed in Russia Federation,
a country with severe alcoholic problem in men [34], illus-
trated the point well. Also, men’s higher ratio of IHC-specific
to entire CVDs deaths in our study was consistent with the
report that women have less prior myocardial infarction and
less extensive epicardial coronary artery disease compared
with men [35]. This clinically meaningful sex difference
requires increased awareness to adopt sex-specific BP con-
trol, and to improve the prevention and treatment of hyper-
tension and its concomitant CVDs in young men. In addition,
inherent sex heterogeneity, for example, the estrogen, could
contribute to this sex difference in young adults [36], a more
detailed understanding of its underlying mechanism in
CVDs might shed light into the design of new drugs targeting
sex-specific cardiovascular mechanisms and affecting
phenotypes.
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Public health implications
HSBP-attributable CVDs are highly preventable, and timely
intervention significantly improves outcomes. From a pub-
lic health perspective, shifting the distribution curve of
hypertension to the right by a small amount on the entire
population age axis can have a considerable effect on
disease burden, the overall benefit from emphasizing the
primary prevention of hypertension in young adults is likely
to exceed that from treating patients with hypertension-
related CVDs [37]. Our study improved the understanding
about levels and trends of the CVDs burden among young
adults, helped to appropriately guide efforts of improving
cardiovascular health in early stage at macro geographical
scale.
Highlights of this study
Comparing to old-age population, the full story of ESBP-
related CVDs in young adults is more nuanced and hetero-
geneous, indicating a notably broader range of character-
istics. In our study, the comprehensive and comparable
Volume 39 � Number 12 � December 2021
Hypertension burden in young adults
assessment focusing on young adults made a good effort to
quantify levels and trends of the fatal and nonfatal burden,
and offered insights into past policy successes and
highlighted the current priorities for the control of hyper-
tension and concomitant CVDs.
Study limitations
There were some inherent limitations in this study. Firstly,
the quality of our analysis largely depended on the quality
of initial GBD studies providing hypertension data, the
sparse data in low-SDI quintile could lead to inaccuracies
in summary analysis. Secondly, due to the limitation of GBD
data, effects from factors related to ESBP (e.g. high low-
density lipoprotein cholesterol), whether directly or indi-
rectly, was incorporated when aggregating the CVDs bur-
den attributable to ESBP. Thirdly, data on the prevalence,
awareness, treatment, and control of hypertension were not
collected in GBD database.
In conclusion, the hypertension-related CVDs burden
was increasing largely among young adults, with a consid-
erable spatiotemporal and sexual heterogeneity. The total
burden was undergoing a geo-specific transition from high-
SDI regions to middle-SDI regions. Male had largely out-
paced female in terms of fatal burden. The deteriorating
balance in CVDs burden demonstrated the importance of
increasing investment in cardiovascular health of young
adults, especially the male population in middle income
countries.
ACKNOWLEDGEMENTS
Ethics approval and consent to participate: Not applicable.
Consent for publication: Not applicable.
Availability of data and materials: The datasets generated
and/or analyzed during the current study are available
in the GBD database, (http://ghdx.healthdata.org/gbd-
results-tool).
Funding: No funding was received to assist with the
preparation of this manuscript.
Authors’ contributions: J.L. performed the data curation
and wrote the manuscript. X.B. and X.Q.W. was responsible
for software and data visualization. C.J.D. completed the
tables. L.Y.W. and L.L.L. was in charge of literatures retrieval
and arrangement. A.Q.M. planned the study. T.Z.W. guided
and revised this paper.
Conflicts of interest
There are no conflicts of interest.
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