High Adolescent BP Tied to Subclinical Disease in Middle Age

High systolic blood pressure in adolescence is tied to a significantly higher risk of developing coronary atherosclerosis later in life, according to results from a new Swedish observational study looking exclusively at men.

The higher the BP in these young people, the greater the risk of future, particularly severe coronary atherosclerosis, disease, report Angel Herraiz-Adillo, PhD (Linköping University, Sweden), and colleagues this week in JAMA Cardiology.

“There has been a shift in both the American and European guidelines—the Swedish guidelines have not fully adapted—to classify hypertension at a lower blood pressure,” senior author Pontus Henriksson, PhD (Linköping University), told TCTMD. “Our paper corroborates many other studies showing that the negative effects of blood pressure on cardiovascular disease start at these lower levels and begin already in childhood.”

Both the 2025 American College of Cardiology (ACC)/American Heart Association (AHA) hypertension guidelines and the 2024 European Society of Cardiology guidelines consider systolic BP exceeding 120 mm Hg to be elevated. While prior studies have shown an association between higher BP early in life and subclinical atherosclerosis over time, the present study focused on the relationship between these lower thresholds defined in the new guidelines and subclinical disease specifically in middle age.

Baseline BP Affects Later Disease

The population-based cohort study included 10,222 men (mean age 18.3 years) enrolled in the Swedish Military Conscription Register with data linked to the Swedish Cardiopulmonary Bioimage Study (SCAPIS). At the time of conscription, the mean systolic and diastolic BPs were 127.6 and 68.3 mm Hg, respectively, with 16.9% of participants having stage 2 hypertension, which is defined as systolic BP ≥ 140 mm Hg or diastolic BP ≥ 90 mm Hg by the 2025 ACC/AHA hypertension guidelines. 

After nearly 40 years of follow-up, at which the median patient age was 57.8 years, the median systolic BP was 128 mm Hg and the mean diastolic BP was 78.7 mm Hg, with roughly 25% of participants diagnosed with hypertension. In all, 54.3% of participants had evidence of coronary stenosis on CT angiography, of whom the majority had a stenosis between 1% and 49%. Additionally, 52% had a coronary artery calcium score greater than zero and 60.6% had evidence of carotid plaque.

After adjustment, participants with stage 2 hypertension in adolescence were significantly more likely than those with normal blood pressure to have evidence of coronary stenosis in follow-up, particularly severe coronary stenosis (OR 1.84; 95% CI 1.40-2.42). The adjusted prevalence of severe stenosis (defined as ≥ 50%) was 10.1% in those with stage 2 hypertension in adolescence versus 6.9% in those with normal BP when they were younger. However, even for those with elevated BP at baseline, defined as systolic blood pressure of 120 to 129 mm Hg, there was a 31% increased risk of severe coronary stenosis in follow-up. 

Additionally, there was a relationship between baseline BP and coronary plaque type later in life, with stage 2 hypertension associated with a significantly higher risk of mixed and calcific plaque but not with noncalcific plaque.

Overall, there was a dose-response relationship between the four US guideline categories for systolic BP—normal, elevated, stage 1 hypertension, and stage 2 hypertension—and coronary stenosis on CT angiography. Adolescents with systolic BP ≥ 140 mm Hg had the highest risk of coronary stenosis in follow-up when compared with normotensive participants (OR 1.97; 95% CI 1.50-2.60). The association was also observed when investigators used the 2024 European guidelines to categorize systolic BP in adolescence.

Using diastolic BP to define hypertension, there was no significant association with severe coronary stenosis, even at values ≥ 90 mm Hg. In a spline model, there was a positive association between adolescent diastolic BP and coronary atherosclerosis, specifically severe stenosis, although the relationship was much weaker than with systolic BP, say investigators.

“The association [with coronary stenosis] was mainly driven by systolic blood pressure rather than diastolic blood pressure,” said Henriksson. “Previous studies in adults have shown, and I think it’s quite well accepted, that systolic blood pressure is the most important blood pressure, but in children there have been some conflicting results. Our study was quite clear that it was also systolic blood pressure driving the association.”

Check BP Early and Often

To TCTMD, Henriksson noted that the burden of childhood/adolescent hypertension is not a small problem. Just last week in the Lancet, a large systematic review found a prevalence of sustained hypertension in people aged 19 years and younger to be 6.7%. Between 2000 and 2020, the prevalence in boys increased from 3.4% to 6.53% and jumped from 3.0% to 5.82% in girls.  

“The main advice from [our] paper would be to measure blood pressure routinely,” said Henriksson. “If you don’t measure it, you don’t know. People can go with high blood pressure for 20, 30, or 40 years and not recognize it before they have an event. If you had found out [about hypertension] decades earlier, you could have done a lot.”

In an editorial, Sadiya Khan, MD, and Clyde Yancy, MD (both from Northwestern University Feinberg School of Medicine, Chicago, IL), say the findings highlight the importance of intervening when patients are young, well before the signs and symptoms of heart disease are present.

“Emerging data highlight that [blood pressure] assessment as early as age 7 years is associated with cardiovascular mortality and suggest, now more than ever, that prevention of cardiovascular disease must move upstream and begin in early life,” they write. Routinely checking blood pressure, cholesterol levels, and Hba1c should be paired with recommendations for a healthy lifestyle, with medications used as needed, to optimize cardiovascular health, say the editorialists.