High Blood Pressure in Babies Linked to Adult Atherosclerosis

The link between childhood blood pressure (BP) and adult atherosclerosis appeared stable going all the way back to infancy, suggesting that efforts to prevent arterial thickening may be beneficial starting at the earliest life stage.

In the STRIP trial, there was a consistent contribution of hypertensive systolic BP across early life stages to carotid intima-media thickness (IMT) in young adulthood:

• Infancy (age 7-13 months): relative weight 25.3% (95% credible interval [CrI] 3.6-45.8)
• Preschool childhood (2-5 years): relative weight 27.0% (95% CrI 3.3-57.1)
• Childhood (6-12 years): relative weight 18.0% (95% CrI 0.5-40.0)
• Adolescence (13-17 years): relative weight 13.5% (95% CrI 0.4-37.1)
• Young adulthood (18-26 years): relative weight 16.2% (95% CrI 1.6-46.1)

“In the absence of life-term clinical trials, our observations emphasize that infancy, preschool childhood, childhood, adolescence, and young adulthood contribute equally to vascular thickening, highlighting the necessity for targeted prevention at all these life stages. This extended view informs our understanding of the developmental origins of cardiovascular health and emphasizes a consistent life-course approach to BP management starting from infancy,” wrote Costan Magnussen, PhD, of Baker Heart and Diabetes Institute in Melbourne, Australia, and colleagues in JAMA Pediatrics.

They reported that each standard deviation increase in systolic BP, or 10 mmHg, in any stage of life was associated with 0.02 mm higher carotid IMT in young adulthood.

Based on these findings on carotid IMT — a surrogate marker for atherosclerotic cardiovascular disease (CVD) risk in asymptomatic individuals — Magnussen and colleagues suggested potential benefits to routine BP screening before age 3 years.

Screening from age 3 is already controversial, however. On one side are the American Academy of Pediatrics (AAP), the European Society of Hypertension, and the American Heart Association supporting BP screening starting at age 3 years to prevent CVD, while the U.S. Preventive Services Task Force (USPSTF) maintains that there is insufficient evidence to weigh benefit and harms.

How to define hypertension in the pediatric setting has been debated as well.

For children under 13 years of age, the definition of hypertension is still ≥95th percentile for age, sex, and height on ≥3 occasions. However, for older adolescents, the threshold for hypertension was arguably lowered — to BP ≥130/80 regardless of age, sex, or height — by the AAP in 2017.

Under the current definition, the overall prevalence of hypertension in childhood is approximately 4%. Elevated BP in childhood is generally recognized as not benign, and having even an occasional reading in the 95th percentile was previously linked to hypertension in adulthood. Pediatric hypertension is also associated with left ventricular hypertrophy and vascular stiffening.

High BP is expected to be a large contributor to the coming tide of CVD in an aging population. Estimates say that by 2060, there will be 162.5 million Americans with hypertension and 28.7 million with ischemic heart disease.

National data suggest that favorable population-level pediatric BP trends from 2001 to 2016 have stalled or even reversed in recent years, much like the BP trends in adult counterparts.

“Altogether, our study emphasizes a life-course approach to BP management, advocating for early intervention and continued prevention throughout all life-stages,” Magnussen’s team wrote. “Lifestyle interventions in childhood have demonstrated potential to prevent or delay high BP.”

STRIP was a randomized trial that tested a dietary counseling and nonsmoking education intervention starting in infancy and found it to reduce serum cholesterol concentration and systolic BP.

The trial started in 1989 with an infant cohort recruited from well-infant clinics in Finland. Annual BP readings were performed once at each study visit from age 7 months to 20 years and ultrasonography was used to assess carotid IMT at ages 11, 13, 15, 17, 19, with a final follow-up at age 26.

Out of 1,116 infants enrolled, the present analysis included 534 participants who had BP measured in infancy, preschool childhood, childhood, adolescence, and young adulthood, and who had carotid IMT data at age 26.

“In the absence of sufficient cardiovascular events among our participants, we used IMT as an indicator of arterial injury and future risk of accelerated CVD,” the study authors acknowledged.

In clinical practice, use of this surrogate marker is debatable in adults. The Society for Vascular Surgery recommends carotid screening for higher-risk individuals, and the American Heart Association/American College of Cardiology say that screening is reasonable for asymptomatic patients with a carotid bruit.

In contrast, the USPSTF does not recommend routine carotid imaging in asymptomatic adults in the U.S., as false positives and other harms are thought to outweigh the benefits of finding a carotid stenosis.

Magnussen and colleagues also cautioned that after some loss to follow-up, there was a higher proportion of girls among the participants included in this study. However, the investigators argued that this cohort remained representative of the original STRIP sample.

Additionally, the preponderance of white European participants did possibly limit the generalizability of the results, they noted.

“Our study emphasizes the need for future research to explore the most effective strategies for BP prevention and management across different life stages, including those highlighted in this study,” Magnussen’s group concluded.

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