Challenges and Opportunities for the Prevention and Treatment of Cardiovascular Disease Among Young Adults: Report From a National Heart, Lung, and Blood Institute Working Group

Abstract

Improvements in cardiovascular disease (CVD) rates among young adults in the past 2 decades have been offset by increasing racial/ethnic and gender disparities, persistence of unhealthy lifestyle habits, overweight and obesity, and other CVD risk factors. To enhance the promotion of cardiovascular health among young adults 18 to 39 years old, the medical and broader public health community must understand the biological, interpersonal, and behavioral features of this life stage. Therefore, the National Heart, Lung, and Blood Institute, with support from the Office of Behavioral and Social Science Research, convened a 2-day workshop in Bethesda, Maryland, in September 2017 to identify research challenges and opportunities related to the cardiovascular health of young adults. The current generation of young adults live in an environment undergoing substantial economic, social, and technological transformations, differentiating them from prior research cohorts of young adults. Although the accumulation of clinical and behavioral risk factors for CVD begins early in life, and research suggests early risk is an important determinant of future events, few trials have studied prevention and treatment of CVD in participants <40 years old. Building an evidence base for CVD prevention in this population will require the engagement of young adults, who are often disconnected from the healthcare system and may not prioritize long-term health. These changes demand a repositioning of existing evidence-based treatments to accommodate new sociotechnical contexts. In this article, the authors review the recent literature and current research opportunities to advance the cardiovascular health of today's young adults.

Keywords: cardiovascular disease prevention; cardiovascular disease risk factors; primary prevention; young adults.

Figure 1. Multilevel influences on young adult cardiovascular health.

The multilevel factors influencing young adult cardiovascular health are depicted here as concentric circles including individual, interpersonal, and community factors situated within a contemporary context referred to as cohort effects. Similar to the socioecological model, ⁷ this framework supposes that outer rings influence the rings within them. Similar to the pathways linking SES and health model, ⁸ there are bidirectional relationships and interactions among many of the factors. SES indicates socioeconomic status.

Figure 2. Causes of variation in trajectories of cardiovascular health.

The 3 cases illustrated in the figure vary from having a low early vulnerability burden that allows CVH to develop maximally (green curve) to having a high vulnerability burden that constrains the development of CVH (red curve). The case illustrated by the green curve shows high resilience to the young adult period of risk (ie, maintaining the high starting level of CVH until late in life). Both the yellow and the red curves show loss of CVH during the young adult risk period, illustrating a lack of resilience to the challenges imposed by this life period. Both the green and the yellow curves illustrate a steep slope, where CVH is lost rapidly. The comparison of the green and yellow curves illustrates that the clinical impact of such a rapid loss of CVH varies depending upon its timing in the life course. These 3 simplified curves are shown for illustrative purposes; dynamic changes to CVH trajectories across the life course are likely caused by alterations in the enduring vulnerabilities and risk behaviors through changes in life circumstances, individual, or public health interventions. CAC indicates coronary artery calcium; CHF, congestive heart failure; CIMT, carotid intima media thickness; CVA, cerebral vascular accident; CVD, cardiovascular disease; CVH, cardiovascular health; HTN, hypertension; MI, myocardial infarction; PVD, peripheral vascular disease; and YA, young adulthood.

Figure 3. Prevalence of adolescents (ages 12–19 years), young adults (ages 20–39 years), and middle‐aged adults (ages 40–59 years) meeting ideal status for each of the 7 cardiovascular health metrics.

Prevalence (unadjusted) estimates of US adults across 3 age strata meeting ideal status for each of the 7 metrics of cardiovascular health as reported in “Heart Disease and Stroke Statistics—2020 Update” from the American Heart Association. ¹⁷ BMI indicates body mass index; and CVH, cardiovascular health. *Healthy diet score reflects 2013 to 2014 NHANES (National Health and Nutrition Examination Survey). Source: National Center for Health Statistics, NHANES, 2015 to 2016 (healthy diet score, 2013 to 2014).

Figure 4. Risk factor intervention.

Two main intervention approaches to preventing the development of (primordial prevention) or treating already developed cardiovascular risk factors (primary prevention). Either intervention approach can deploy behavioral‐socioenvironmental or pharmacologic treatment modalities. The intervention targets depicted (in hexagons) are the established cardiovascular risk factors included in the American Heart Association's Simple 7 metric, but might also include developing markers: insufficient sleep, stress/depression, or inflammation.