What is young hypertension?

What is Young Hypertension?

Young hypertension refers to persistently elevated blood pressure occurring in adolescents (ages 13-17 years) and young adults (typically ages 18-40 years), defined by the same thresholds used in adults: ≥130/80 mm Hg for stage 1 hypertension and ≥140/90 mm Hg for stage 2 hypertension. 1

Definition and Diagnostic Thresholds

For adolescents ≥13 years and young adults, the blood pressure categories are:

• Normal BP: <120/80 mm Hg 2, 3
• Elevated BP: 120-129/<80 mm Hg 1, 2
• Stage 1 Hypertension: 130-139/80-89 mm Hg 1, 2
• Stage 2 Hypertension: ≥140/90 mm Hg 1, 2

The 2017 American Academy of Pediatrics guidelines aligned adolescent blood pressure thresholds with the ACC/AHA adult guidelines to simplify detection and management, eliminating the previous percentile-based approach for this age group. 1, 3

Epidemiology and Prevalence

Young hypertension affects approximately 1 in 8 adults aged 20-40 years, with the global prevalence in children and adolescents at approximately 3.5%. 2, 4

• High BP (elevated, stage 1, or stage 2) affects 15-19% of boys and 7-12% of girls in screening settings 2
• Among youth with overweight and obesity, hypertension prevalence ranges from 3.8% to 24.8% 2
• The prevalence is increasing due to rising rates of obesity and unhealthy lifestyle behaviors 1, 5

Clinical Significance and Long-Term Risk

Young hypertension is no longer considered benign—it carries substantial lifetime cardiovascular risk and promotes target organ damage even by midlife. 1

Cardiovascular Event Risk

In the landmark CARDIA study of young adults followed over 18.8 years, the adjusted hazard ratios for cardiovascular events compared to normal BP were:

• Elevated BP: 1.67 (95% CI, 1.01-2.77) 1, 2
• Stage 1 Hypertension: 1.75 (95% CI, 1.22-2.53) 1, 2
• Stage 2 Hypertension: 3.49 (95% CI, 2.42-5.05) 1, 2

These events included coronary heart disease, heart failure, stroke, transient ischemic attacks, and peripheral arterial disease requiring intervention. 1

Target Organ Damage

Hypertension onset before age 35 years is associated with significantly increased odds of target organ damage by midlife:

• Left ventricular hypertrophy: OR 2.29 (95% CI, 1.36-3.86) 6
• Coronary calcification: OR 2.94 (95% CI, 1.57-5.49) 6
• Diastolic dysfunction: OR 2.06 (95% CI, 1.04-4.05) 6

Additional evidence demonstrates brain volume changes and white matter abnormalities in young people with elevated BP. 1

Distinct Phenotype of Young Hypertension

Younger patients with hypertension have a markedly different risk profile compared to elderly hypertensive patients:

• Earlier onset of hypertension: Mean age 24.7±7.4 years in those ≤40 years versus 55.0±14.1 years in those ≥71 years 7
• Higher rates of obesity: 53.4% versus 26.9% in elderly 7
• Higher plasma aldosterone levels: 11.3±9.8 versus 8.9±7.4 ng/dL 7
• Higher dietary sodium intake: 195.9±92.0 versus 146.8±67.1 mEq/24h 7
• Both systolic and diastolic BP are important predictors of cardiovascular risk in this age group 1

Key Risk Factors

The primary modifiable risk factors for young hypertension are:

• Obesity and overweight status (the single most important modifiable factor) 2
• Excessive sodium consumption (only ~15% of youth aged 12-19 consume <1500 mg/day) 2
• Poor diet quality (>80% of youth 12-19 years have poor overall diet quality) 2
• Physical inactivity 2
• Insulin resistance and metabolic syndrome 1

Clinical Challenges

Young patients with hypertension face unique barriers to diagnosis and treatment:

• Lower awareness and slower time to diagnosis compared to older patients 1
• Poorer BP control rates (only 4% were taking medication in the CARDIA study) 1
• Provider concerns about labeling young adults with illness, medication safety (especially in women of childbearing age), potential misdiagnosis, and impact on life insurance rates 1
• Lack of event-based randomized controlled trial evidence specifically in young populations 1

Screening Recommendations

All children ≥3 years should have BP measured at routine healthcare visits, and children with obesity should have BP monitored at every clinical encounter. 2

Diagnosis requires confirmation:

• BP measurements on at least 3 separate occasions to exclude white-coat hypertension 3
• Ambulatory blood pressure monitoring (ABPM) is the gold standard for confirmation 8, 3

Treatment Approach

The evidence supports treatment of young hypertension using lifestyle modification with the addition of BP-lowering medications when lifestyle interventions are inadequate. 1

• Allowing 6-12 months for lifestyle modification is reasonable but only in the absence of target organ damage 1
• Do not delay pharmacologic treatment when target organ damage is present 1
• First-line medications include thiazide/thiazide-like diuretics, ACE inhibitors/ARBs, and calcium channel blockers 9