Abstract
Purpose
This study examines national trends in mortality from cardiovascular disease (CVD) and select subtypes among U.S. young adults aged 18–34 years from 2000 to 2023.
Methods
National mortality data from the National Vital Statistics System were used to identify CVD, heart disease, stroke, and hypertension-related CVD deaths among U.S. residents aged 18–34 from 2000 to 2023. Crude and age-standardized death rates were calculated overall and by age group, sex, and race and ethnicity. Temporal trends were calculated as percent change using a log-linear model.
Results
From 2000 to 2023, age-standardized CVD and heart disease death rates among young adults did not statistically change (percent change: −2.2% [95% CI: −7.8, 3.7] and −2.4% [95% CI: −8.3%, 3.8%], respectively). Stroke death rates decreased (percent change: −15.7% [−21.0%, −10.0%])). However, hypertension-related CVD death rates increased by 78.5% [95% CI: 63.6%, 94.7%]). Patterns across demographic groups were broadly similar.
Conclusion
Despite stability or modest declines in CVD death rates among young adults, hypertension-related CVD death rates increased sharply during 2000–2023. These findings merit public health action and underscore the need for better identification and management of hypertension and other CVD risk factors among young adults.
INTRODUCTION
In the United States (US), declines in cardiovascular disease (CVD) death rates slowed from 2010 through 2019, signaling a plateauing of longstanding progress [1]. National death rates among adults aged 35 years and older then increased in 2020 amid the COVID-19 pandemic and have not yet recovered to pre-pandemic levels [2].
Trends in national death rates for adults, especially those aged 35 years and older, are well documented, with notable differences by sex and race and ethnicity [2–7]. However, monitoring CVD death rates among younger adults aged <35 years is challenging. Young adults are at lower risk of CVD than older adults, leading to smaller numbers of deaths that are obscured in overall national mortality estimates. Furthermore, identifying CVD deaths in young adults must account for congenital CVD [8]. These challenges have resulted in a lack of current public health surveillance data focused on CVD mortality among young adults, and none stratified by demographic characteristics.
Documenting national CVD death rates in early adulthood is essential to better understanding and responding to outcomes arising from poor cardiovascular health in childhood and adolescence [9]. Expanding efforts to analyze and report CVD mortality among young adults can provide evidence to help clinicians, public health professionals, and decision‐makers establish and tailor CVD prevention and control initiatives. Therefore, this study examines trends in death rates from CVD and its subtypes among young adults aged 18–34 years overall and by age group, sex, and race and ethnicity from 2000 through 2023.
METHODS
Data sources
Mortality data were sourced from the National Center for Health Statistics (NCHS) National Vital Statistics System (NVSS). These files contain individual-level data on deaths among residents of the 50 states and the District of Columbia, including the decedent’s age at death, sex, race and ethnicity, underlying cause of death, and up to 20 additional contributing causes of death. Race and Hispanic ethnicity on death certificates are reported by the surviving next of kin or other informants or are based on observation. We included deaths from 2000 to 2023 among U.S. residents aged 18–34 years at the time of death, representing adults often excluded from CVD mortality studies.
For 2000–2017, we use NCHS bridged-race, postcensal estimates population estimates [10]. These estimates account for state differences in reporting of race and ethnicity on death certificates over this time period. These differences were eliminated starting in 2018. Therefore, from 2018–2023, we used postcensal estimates from the U.S. Census Bureau [11].
Outcome definitions
Using International Classification of Diseases, 10th edition (ICD-10) codes, we identified deaths with any form of CVD (I00-I99) listed as the underlying cause of death. Among CVD deaths, we identified those with an underlying cause of death of heart disease (I00–09, I11, I13, I20-I51) or stroke (I60-I69). We defined hypertension-related CVD deaths as those with CVD (I00-I99) as the underlying cause of death and hypertension (I10-I15) included as any listed cause. Underlying cause alone does not adequately capture hypertension mortality because death certificate coding rules prioritize using other CVD codes as the underlying cause when mentioned with hypertension [12]. Consequently, hypertension-related deaths may overlap with those of other CVD categories. We excluded deaths listing congenital malformations of the circulatory system (ICD-10 codes Q20-Q28) as any listed cause of death.
Statistical analysis
We calculated crude death rates overall and by age group (18–24, 25–29, 30–34 years). These age groups approximate the five-year age groups used in national statistics while providing granularity for age standardization. Using the 2000 U.S. Standard Population, we also calculated age-standardized overall rates for adults aged 18–34 years [13]. Use of the 2000 standard U.S. population permits comparison with other federal statistics.
For adults aged 18–34 years, we also calculated age-standardized death rates by sex and by race and ethnicity using the following race and ethnicity groups: American Indian or Alaska Native (AIAN), Asian or Pacific Islander (API), Black, Hispanic, and White. Hispanic ethnicity includes all races; all races include only individuals of non-Hispanic ethnicity. These groups are constructed to harmonize state implementation of changing federal standards for classifying race during this time period. In 1997, standards for the classification of federal data on race and ethnicity were revised [14]. First, the “Asian or Pacific Islander” race category was separated into two categories: “Asian” and “Native Hawaiian or Pacific Islander”. We have combined these two groups starting in 2018. Additionally, the revised standard allows multiple race groups to be selected, creating a “More than one race” category and restricting other racial categories to individuals who mark a single race. In our analysis, individuals reporting more than one race during 2018–2023 are excluded from race-stratified analyses, but are included in all other analyses. These changes were fully implemented on death certificates in all states and the District of Columbia in 2018. Consequently, comparisons of race-specific values before and after 2018 must be made with caution.
For subgroup analyses, we suppressed all results for that group if the death rate for any year was unreliable (i.e. the death count was <20) [15].
To estimate temporal trends, we used log-linear regression on both crude and age-standardized rates from 2000 through 2023 for all demographic groups and outcomes. From these models, we calculated total percent change and 95% CI. Trends with a statistically significant percent change (i.e., those with a 95% CI excluding zero) were interpreted as either increasing or decreasing.
RESULTS
CVD Mortality among Young Adults
From 2000 to 2023, 130,116 U.S. adults aged 18–34 years died of CVD (Table 1). More than half of these deaths were in adults aged 30–34 years, with almost two-thirds of hypertension-related CVD deaths (65.3%) occurring in this group. Approximately two-thirds of CVD, heart disease, and hypertension-related CVD deaths were in males, and more than half of stroke deaths were in males (Table 2). By race and ethnicity, approximately half of CVD, heart disease, and stroke deaths occurred in White young adults. However, 41.4% of hypertension-related CVD deaths were in Black young adults, 40.3% in Hispanic young adults, and only 13.9% in White young adults.
Table 1.
Cardiovascular disease mortality by age group among adults aged 18–34 years, United States, 2000–2023
| Number of deaths, 2000–2023 (%) | Death rate (per 100,000) (95% CI), 2000 | Death rate (per 100,000) (95% CI), 2023 | Percent change (%) (95% CI), 2000–2023 | |
|---|---|---|---|---|
| CVD | ||||
| Overall | 130116 (100) | 7.4 (7.2, 7.6) | 7.1 (6.9, 7.3) | −0.5 (−6.7, 6.2) |
| Age group (years) | ||||
| 18–24 | 25391 (19.5) | 3.9 (3.6, 4.1) | 2.9 (2.8, 3.1) | −23.6 (−28.7, −18.1) |
| 25–29 | 36763 (28.3) | 6.9 (6.6, 7.3) | 6.8 (6.5, 7.2) | −2.4 (−8.2, 3.7) |
| 30–34 | 67962 (52.2) | 12.4 (12.0, 12.9) | 12.9 (12.4, 13.4) | 6.8 (0.0, 14.0) |
| Heart disease | ||||
| Overall | 100317 (100) | 5.6 (5.4, 5.8) | 5.4 (5.3, 5.6) | −0.7 (−6.9, 6.0) |
| Age group (years) | ||||
| 18–24 | 19495 (19.4) | 2.9 (2.7, 3.2) | 2.3 (2.1, 2.4) | −24.6 (−29.6, −19.3) |
| 25–29 | 28452 (28.4) | 5.2 (4.9, 5.5) | 5.2 (4.9, 5.5) | −2.3 (−9.0, 4.8) |
| 30–34 | 52370 (52.2) | 9.4 (9.0, 9.8) | 9.8 (9.4, 10.2) | 6.7 (−0.3, 14.1) |
| Stroke | ||||
| Overall | 16887 (100) | 1.1 (1.0, 1.2) | 0.9 (0.8, 1.0) | −14.3 (−20.8, −7.3) |
| Age group (years) | ||||
| 18–24 | 3442 (20.4) | 0.6 (0.5, 0.7) | 0.4 (0.3, 0.5) | −29.6 (−38.7, −19.2) |
| 25–29 | 4605 (27.3) | 1.1 (0.9, 1.2) | 0.8 (0.7, 0.9) | −18.7 (−25.9, −10.8) |
| 30–34 | 8840 (52.3) | 1.9 (1.7, 2.1) | 1.7 (1.5, 1.9) | −8.4 (−14.5, −2.0) |
| Hypertension-related CVD | ||||
| Overall | 26452 (100) | 0.9 (0.9, 1.0) | 1.9 (1.8, 2.0) | 82.7 (68.3, 98.3) |
| Age group (years) | ||||
| 18–24 | 2533 (9.6) | 0.3 (0.2, 0.3) | 0.3 (0.3, 0.4) | 24.1 (7.3, 43.4) |
| 25–29 | 6653 (25.2) | 0.8 (0.7, 0.9) | 1.5 (1.4, 1.7) | 56.9 (38.1, 78.3) |
| 30–34 | 17266 (65.3) | 2.0 (1.8, 2.1) | 4.3 (4.0, 4.5) | 96.6 (80.0, 114.7) |
CI: confidence interval. CVD: cardiovascular disease.
Note: All values exclude deaths with congenital malformations of the circulatory system (ICD-10 codes Q20-Q28) as any listed cause of death. CVD (I00-I99), heart disease (I00-09, I11, I13, I20-I51), and stroke (I60-I69) are included as the underlying cause of death. Hypertension-related CVD deaths are included if CVD (I00-I99) is the underlying cause of death and hypertension (I10-I15) is included as any listed cause. Deaths categorized as hypertension-related CVD may overlap with those of other CVD categories. Death rates are crude death rates.
Table 2.
Cardiovascular disease mortality by sex and race and ethnicity among adults aged 18–34 years, United States, 2000–2023
| Number of deaths, 2000–2023 (%) | Death rate (per 100,000) (95% CI), 2000 | Death rate (per 100,000) (95% CI), 2023 | Percent change (%) (95% CI), 2000–2023 | |
|---|---|---|---|---|
| CVD | ||||
| Overall | 130116 (100) | 7.4 (7.2, 7.6) | 7.1 (6.9, 7.3) | −2.2 (−7.8, 3.7) |
| Sex | ||||
| Female | 45943 (35.3) | 5.8 (5.5, 6.0) | 4.9 (4.7, 5.2) | −6.5 (−13.6, 1.3) |
| Male | 84173 (64.7) | 8.9 (8.6, 9.3) | 9.2 (8.9, 9.5) | 0.4 (−5.4, 6.5) |
| Race and ethnicity | ||||
| AIAN | 1682 (1.3) | 7.0 (5.0, 9.5) | 12.6 (10.0, 15.7) | 75.5 (43.6, 114.6) |
| API | 4067 (3.1) | 3.2 (2.7, 3.9) | 3.7 (3.2, 4.2) | −5.5 (−17.3, 8.0) |
| Black | 39676 (30.6) | 17.3 (16.5, 18.2) | 15.5 (14.8, 16.3) | −10.5 (−18.1, −2.2) |
| White | 17426 (13.4) | 5.1 (4.7, 5.5) | 5.2 (4.9, 5.6) | 6.5 (−4.4, 18.7) |
| Hispanic | 66719 (51.5) | 6.2 (6.0, 6.5) | 6.1 (5.8, 6.3) | 1.1 (−4.4, 7.0) |
| Heart disease | ||||
| Overall | 100317 (100) | 5.6 (5.4, 5.7) | 5.4 (5.2, 5.6) | −2.4 (−8.3, 3.8) |
| Sex | ||||
| Female | 33204 (33.1) | 4.0 (3.8, 4.2) | 3.6 (3.4, 3.8) | −2.9 (−10.7, 5.7) |
| Male | 67113 (66.9) | 7.1 (6.8, 7.4) | 7.2 (6.9, 7.4) | −2.1 (−8.2, 4.4) |
| Race and ethnicity | ||||
| AIAN | 1345 (1.3) | 5.5 (3.7, 7.7) | 9.6 (7.3, 12.3) | 58.8 (27.0, 98.4) |
| API | 2968 (3.0) | 2.4 (1.9, 2.9) | 2.6 (2.2, 3.1) | −8.5 (−20.4, 5.1) |
| Black | 30734 (30.8) | 13.4 (12.7, 14.2) | 12.1 (11.4, 12.7) | −10.7 (−18.1, −2.6) |
| White | 12340 (12.4) | 3.4 (3.0, 3.7) | 3.8 (3.5, 4.1) | 9.2 (−2.4, 22.3) |
| Hispanic | 52516 (52.6) | 4.8 (4.6, 5.0) | 4.7 (4.5, 4.9) | 1.8 (−4.7, 8.8) |
| Stroke1 | ||||
| Overall | 16887 (100) | 1.1 (1.0, 1.2) | 0.9 (0.8, 1.0) | −15.7 (−21.0, −10.0) |
| Sex | ||||
| Female | 7620 (45.1) | 1.1 (1.0, 1.2) | 0.8 (0.7, 0.9) | −25.5 (−31.3, −19.1) |
| Male | 9267 (54.9) | 1.1 (1.0, 1.3) | 1.0 (0.9, 1.1) | −6.6 (−13.9, 1.2) |
| Race and ethnicity | ||||
| AIAN | Suppressed | Suppressed | Suppressed | Suppressed |
| API | Suppressed | Suppressed | Suppressed | Suppressed |
| Black | 4474 (26.6) | 2.2 (1.9, 2.5) | 1.7 (1.5, 2.0) | −25.2 (−33.9, −15.4) |
| White | 3298 (19.6) | 1.2 (1.0, 1.5) | 0.9 (0.7, 1.0) | −13.8 (−23.9, −2.3) |
| Hispanic | 8116 (48.2) | 0.9 (0.8, 1.0) | 0.7 (0.6, 0.8) | −16.3 (−22.8, −9.2) |
| Hypertension-related CVD | ||||
| Overall | 26452 (100) | 0.9 (0.9, 1.0) | 1.9 (1.8, 2.0) | 78.5 (63.6, 94.7) |
| Sex | ||||
| Female | 7899 (29.9) | 0.7 (0.6, 0.8) | 1.0 (0.9, 1.1) | 46.7 (32.7, 62.1) |
| Male | 18553 (70.1) | 1.2 (1.1, 1.3) | 2.7 (2.5, 2.8) | 94.9 (76.9, 114.8) |
| Race and ethnicity | ||||
| AIAN | Suppressed | Suppressed | Suppressed | Suppressed |
| API | Suppressed | Suppressed | Suppressed | Suppressed |
| Black | 10892 (41.4) | 3.5 (3.1, 3.9) | 5.0 (4.6, 5.4) | 29.8 (16.2, 45.0) |
| White | 3652 (13.9) | 0.7 (0.5, 0.8) | 1.4 (1.2, 1.5) | 113.1 (83.7, 147.3) |
| Hispanic | 10598 (40.3) | 0.5 (0.5, 0.6) | 1.3 (1.2, 1.5) | 116.3 (90.8, 145.1) |
AIAN: American Indian or Alaska Native. API: Asian or Pacific Islander. CI: confidence interval. CVD: cardiovascular disease.
Note: All values exclude deaths with congenital malformations of the circulatory system (ICD-10 codes Q20-Q28) as any listed cause of death. CVD (I00-I99), heart disease (I00-09, I11, I13, I20-I51), and stroke (I60-I69) are included as the underlying cause of death. Hypertension-related CVD deaths are included if CVD (I00-I99) is the underlying cause of death and hypertension (I10-I15) is included as any listed cause. Deaths categorized as hypertension-related CVD may overlap with those of other CVD categories. Death rates are age-standardized to the 2000 US Standard Population.
The national age-standardized CVD death rate for this age group fluctuated but did not statistically change from 2000 (7.4 deaths per 100,000 [95% CI: 7.2, 7.6]) to 2023 (7.1 deaths per 100,000 [95% CI: 6.9, 7.3]; percent change: −2.2% [95% CI: −7.8%, 3.7%]) (Table 2, Figure 1, Figure 2). Similarly, heart disease death rates did not statistically change from 5.6 deaths per 100,000 (95% CI: 5.4, 5.7) in 2000 to 5.4 deaths per 100,000 (95% CI: 5.2, 5.6) in 2023 (percent change: −2.4% [95% CI: −8.3%, 3.8%]). Stroke death rates declined from 1.1 deaths per 100,000 (95% CI: 1.0, 1.2) in 2000 to 0.9 deaths per 100,000 (95% CI: 0.8, 1.0) in 2023 (percent change: −15.7%, 95% CI: −21.0%, −10.0%). In contrast, death rates for hypertension-related CVD increased from 0.9 deaths per 100,000 (95% CI: 0.9, 1.0) in 2000 to 1.9 deaths per 100,000 (95% CI: 1.8, 2.0) in 2023 (percent change: 78.5% [95% CI: 63.6%, 94.7%]).
Figure 1. Age-standardized cardiovascular disease (CVD) death rates overall and by sex, ages 18–34 years, United States, 2000–2023.
CVD: Cardiovascular disease.
Note: All values exclude deaths with congenital malformations of the circulatory system (ICD-10 codes Q20-Q28) as any listed cause of death. CVD (I00-I99), heart disease (I00–09, I11, I13, I20-I51), and stroke (I60-I69) are included as the underlying cause of death. Hypertension-related CVD deaths are included if CVD (I00-I99) is the underlying cause of death and hypertension (I10-I15) is included as any listed cause. Deaths categorized as hypertension-related CVD may overlap with those of other CVD categories. Rates are age-standardized to the 2000 US Standard Population.
Figure 2. Total percent change in cardiovascular disease death rates overall and by age group, sex, and race and ethnicity among adults aged 18–34 years, United States, 2000–2023.
AIAN: American Indian or Alaska Native. API: Asian or Pacific Islander. CVD: Cardiovascular disease.
Note: Stroke and hypertension-related CVD results for AIAN and API were suppressed. Percent change is the total percent change over the entire study period (2000–2023) as calculated with log-linear regression.
CVD Mortality among Young Adults by Age Group
We observed similar patterns in trends across age groups, with CVD, stroke, and heart disease death rates remaining statistically unchanged or decreasing and hypertension-related CVD death rates increasing (Table 1, Figure 2, Figure 3). Temporal changes in hypertension-related CVD death rates were larger for older age groups, with total percent change rising from 24.1% (95% CI: 7.3%, 43.4%) per year in adults aged 18–24 years to 96.6% (95% CI: 80.0%, 114.7%) per year in adults aged 30–34 years. Only stroke death rates declined across all age groups. For all age groups, death rates for all outcomes increased in the first years of the COVID-19 pandemic (2020–2021) relative to 2019 death rates (Figure 3).
Figure 3: Cardiovascular disease (CVD) death rates by race and ethnicity, ages 18–34 years, United States, 2000–2023.
1 All values exclude deaths with congenital malformations of the circulatory system (ICD-10 codes Q20-Q28) as any listed cause of death. CVD (I00-I99), heart disease (I00–09, I11, I13, I20-I51), and stroke (I60-I69) are included as the underlying cause of death. Hypertension-related CVD deaths are included if CVD (I00-I99) is the underlying cause of death and hypertension (I10-I15) is included as any listed cause. Deaths categorized as hypertension-related CVD may overlap with those of other CVD categories.
CVD Mortality among Young Adults by Sex
For all CVD subtypes except for stroke, death rates for young males were higher than those for young females across the study period. Patterns in CVD mortality trends by sex mirror those observed overall, with one exception (Table 2, Figure 1, Figure 2). For CVD and heart disease, trends in death rates during 2000–2023 did not statistically change. Stroke death rates fell for females (percent change: −25.5% [95% CI: −31.3%, −19.1%]), but did not statistically change for males (percent change: −6.6% [95% CI: −13.9%, 1.2%]). Hypertension-related CVD death rates increased sharply for both females and males. However, the magnitudes of these changes differed markedly, with the hypertension-related CVD death rate for males roughly doubling and that for females increasing by approximately 50% (percent change 94.9% [95% CI: 76.9%, 114.8%] and 46.7 [95% CI: 32.7, 62.1] for males and females, respectively).
CVD Mortality among Young Adults by Race and Ethnicity
Patterns in trends in CVD death rates among young adults by race and ethnicity were similar to those observed overall, with some exceptions (Table 2, Figure 2, Figure 4). For CVD, death rates decreased for Black young adults (percent change: −10.5% [95% CI: −18.1%, −2.2%]), increased sharply for AIAN young adults (percent change: 75.5% [95% CI: 43.6%, 114.6%]), and remained statistically unchanged for all other race and ethnicity groups. We observed the same pattern for heart disease death rates. Stroke death rates during 2000–2023 declined for all racial and ethnic groups. Hypertension-related CVD death rates increased sharply. The greatest increases were among Hispanic and White young adults (percent change: 116.3% [95% CI: 90.8%, 145.1%] and 113.1% [95% CI: 83.7%, 147.3%], respectively) and the smallest increases were among Black young adults (percent change: 29.8 [95% CI: 16.2, 45.0]).
Figure 4. Age-standardized cardiovascular disease (CVD) death rates by race and ethnicity, ages 18–34 years, United States, 2000–2023.
AIAN: American Indian or Alaska Native. API: Asian or Pacific Islander. CVD: Cardiovascular disease.
Note: Stroke and hypertension-related CVD results for AIAN and API were suppressed. All values exclude deaths with congenital malformations of the circulatory system (ICD-10 codes Q20-Q28) as any listed cause of death. CVD (I00-I99), heart disease (I00–09, I11, I13, I20-I51), and stroke (I60-I69) are included as the underlying cause of death. Hypertension-related CVD deaths are included if CVD (I00-I99) is the underlying cause of death and hypertension (I10-I15) is included as any listed cause. Deaths categorized as hypertension-related CVD may overlap with those of other CVD categories. Rates are age-standardized to the 2000 US Standard Population.
DISCUSSION
From 2000 to 2023, CVD death rates among young adults aged 18–34 years declined or remained relatively stable across most subtypes while hypertension-related CVD death rates increased sharply. These increases in hypertension-related CVD death rates over a 24-year period occurred across age groups, sex, and race and ethnicity, signaling a warning about the cardiovascular health of young adults and the nation’s health and economic prosperity.
Except for hypertension-related CVD deaths, trends among young adults differed from those previously documented in older adults. Since the early 2000s, adults aged 35 years or older experienced substantial declines in CVD mortality, followed by slower declines or stagnation starting in 2010 [1, 2, 16]. In contrast, in our study, young adults experienced minimal changes in CVD death rates over this period. These differences between younger and older adults may represent the higher prevalence of CVD risk factors, including obesity and diabetes, in more recent generations [17, 18]. Additionally, our report documents that previously observed increases in CVD death rates during the COVID-19 pandemic among adults aged 35 years or older extended to young adults aged 18–34 years [2].
Reinforcing previous findings in adults aged 35 years or older, we found increasing hypertension-related CVD mortality among young adults, [19]. These deaths from hypertension-related CVD mirror trends in hypertension epidemiology among young adults [20–22]. During 2013–2023, hypertension prevalence in young adults ages 18–44 years remained steady, awareness decreased, and control remained steady [21]. By 2023, approximately one in four (23.4%) US adults aged 18–39 had hypertension, but only 13.9% of those were treated and less than one-in-twenty (4.5%) had controlled hypertension [22].
The observed sex-related differences in hypertension-related CVD death rates and associated trends are especially notable. Although males had higher death rates than females for all examined outcomes, trends in these outcomes were similar except for hypertension-related CVD deaths. Prior studies found that, compared to their female peers, males aged 18–39 years have approximately twice the hypertension prevalence, lower awareness among those with hypertension, and lower prevalence of hypertension treatment and control [20, 22]. However, hypertension control in both sexes is very low (7.2% and 3.1% for females and males, respectively).
By race and ethnicity, the highest death rates across outcomes were among Black and AIAN young adults. Reflecting these differences, compared to young White adults, young Black adults have an earlier age of hypertension onset, higher hypertension prevalence, and lower prevalence of hypertension control [20, 23]. However, hypertension control remains remarkably low (approximately 5%) among adults aged 18–39 years for all racial and ethnic groups [20]. Notably, only AIAN young adults experienced increasing CVD and heart disease death rates. This trend differs from patterns in CVD death rates for AIAN adults aged ≥35 years, who experienced declining CVD death rates from 2010–2019 and lower CVD death rates than their White peers [2, 3].
Therefore, in the presence of these epidemiologic trends, our observed increases in hypertension-related CVD mortality, especially marked differences by sex, may represent the accumulated, long-term effects of poor hypertension awareness and control. Combined, these epidemiologic patterns reinforce the importance of both primary and secondary CVD prevention, with an emphasis on hypertension [24, 25].
Given young adults’ lower risk of developing CVD, primary prevention of CVD may focus on establishing healthy behaviors and assessing lifetime CVD risk [24]. These opportunities to improve cardiovascular health may occur in communities and in clinical settings, through smoking cessation, physical activity, healthy nutrition, and mental health support. Successful efforts may address underlying social, environmental, and behavioral factors [24]. Clinically, young adults should receive periodic assessment of CVD risk factors, including hypertension and hyperlipidemia, which are increasingly relevant given the rising prevalence of multiple chronic conditions in children and young adults [26, 27]. Estimating lifetime atherosclerotic cardiovascular disease risk, rather than the standard 10-year risk, may help communicate long-term health implications and motivate lifestyle changes and medication adherence [24].
Current guidelines outline hypertension and blood cholesterol management among young adults with existing CVD or with CVD risk factors [26, 28]. However, implementing these guidelines requires overcoming challenges in patient engagement and care continuity. For young adults, this includes facilitating the transition from pediatric to adult care, improving clinician awareness and engagement, and reaching people where they live, study, and work [24].
Limitations
Our study has limitations. Cause of death may be misclassified and such misclassification may vary over time. Notably, changes in reporting hypertension on death certificates could lead to the observed increases in death rates, but completeness and accuracy of hypertension coding on death certificates has not been published in the United States. However, recent trends in hypertension prevalence, awareness, and control and low hypertension control among young adults support the validity of observed increases in hypertension-related mortality [21]. Similar trends among older adults further suggest that misclassification and changes in reporting are unlikely to solely explain the magnitude of the observed increases [21, 27]. Additionally, using hypertension as a multiple, rather than underlying, cause of death helps reduce this bias [12]. Likewise, our definition of hypertension-related deaths requires CVD as the underlying cause of death, excluding other causes of death that may be related to hypertension (i.e., diabetes, substance abuse). Additionally, US federal standards for categorizing race changed over our study period [14]. We have defined race and ethnicity categories to promote consistency over the study period, but the shift from single race to multiple race categories may complicate interpretation of temporal trends by race and ethnicity post-2018, especially in younger adults [29]. These changes to standards occur within known misclassification of race on death certificates, especially among AIAN populations for whom approximately half have race misclassified on death certificates [30]. Finally, the American Heart Association/American College of Cardiology hypertension definition changed in 2017 [28]. This change’s effect on hypertension-related CVD death rates during 2017–2020 is unclear.
CONCLUSION
From 2000 to 2023, mortality from CVD, heart disease, and stroke among young adults declined or remained stable across age groups, sex, and most race and ethnicity groups. Hypertension-related CVD mortality increased sharply during this period across all demographic groups, with notable differences by sex, reinforcing the importance of primary and secondary prevention of CVD with specific attention to timely detection and treatment of hypertension.
Footnotes
Disclaimer: The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
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