Study Underscores the Importance of Blood Pressure Monitoring and Intervention in Adolescence

The SHIP AHOY study shows that even modest elevations in blood pressure may affect cardiovascular health earlier than clinicians previously recognized. Because these changes are subclinical, providers may miss opportunities to identify and address them early.

A Clear Relationship Between Higher Blood Pressure and Target Injury Markers

The multisite study included 244 generally healthy adolescents. Investigators examined how blood pressure relates to early signs of organ injury, focusing on both individual markers and the accumulation of multiple abnormalities. These markers—left ventricular hypertrophy, diastolic dysfunction, impaired strain and increased arterial stiffness—reflect early changes in the heart and blood vessels that precede clinical disease.

“Previous research looked at just one abnormality at a time, not the combination,” said pediatric nephrologist Mark Mitsnefes, MD, MS, a co-investigator and the study’s senior author. “We wanted to see at what level of blood pressure this combination starts to develop.”

The results showed a clear pattern of increasing risk. Participants were divided based on systolic clinic and systolic awake ambulatory blood pressure into low-, mid- and high-risk groups. As systolic blood pressure increased, the number of target organ injury markers rose accordingly. This pattern suggests that youth may be at increasing risk for cardiovascular disease, even before they are diagnosed with hypertension.

Importantly, the association did not start at elevated blood pressure levels. Adolescents with “high-normal” blood pressure—below current diagnostic thresholds below the 90th percentile —also demonstrated increased evidence of organ injury, adds Mitsnefes, interim director of the Division of Nephrology and Hypertension and director of the institution’s Clinical and Translational Research Center.

Read the study of High Blood Pressure in Pediatrics: Adult Hypertension Onset in Youth (SHIP AHOY), which was published in Hypertension in May 2025.

SHIP AHOY was funded by the American Heart Association and led by Principal Investigator Elaine Urbina, MD, MS, a cardiologist and professor emerita at Cincinnati Children’s, with Mitsnefes serving as training director. The current analysis builds on earlier SHIP AHOY work that has helped translate research findings into clinical practice, including contributing to updates in ambulatory blood pressure monitoring classification in pediatric patients in 2022.

Hypertension is on the rise among children and adolescents globally. A recent study in the Journal of the American Medical Association found the incidence doubled between 2000 and 2020, from about 3% to 6%.

A Case for Early Monitoring and Intervention

The study also found that higher body mass index correlated with more abnormalities. This reinforces the link between hypertension, obesity and early cardiovascular risk.

Taken together, the findings suggest that clinicians may need to act earlier than current guidelines suggest. “Physicians need to pay attention to high-normal blood pressure, not just elevated blood pressure,” Mitsnefes explained. “It may not be time for medication. But we need to do more than check blood pressure once a year in these adolescents. Closer follow-up and lifestyle changes, such as diet and exercise, may help address risk earlier.”

The Importance of Accurate Blood Pressure Assessment

Both masked hypertension and white-coat hypertension were linked to more injury markers than in adolescents with normal blood pressure.

“I was surprised that white-coat hypertension was so associated with this,” Mitsnefes said. “It tells us that white-coat hypertension is not a completely benign condition, and providers need to monitor it carefully.”

These findings suggest that patterns often viewed as lower risk may still carry clinical significance. Ambulatory blood pressure monitoring remains essential for detecting white coat and masked hypertension and identifying findings that routine clinic readings may miss. The study also found that carefully measured clinic blood pressure correlated with organ injury, indicating it remains a valuable tool for assessing cardiovascular risk.

Mitsnefes notes that key questions remain. Researchers still need to define the blood pressure levels at which injury begins. They also need to determine whether early intervention can reverse these changes. Long-term studies may clarify whether these early markers predict future cardiovascular disease.

An Invitation to Collaborate

For patients with persistent elevated or borderline readings, unusual blood pressure patterns or multiple cardiovascular risk factors, more comprehensive evaluation may help clarify risk and guide next steps. This can include ambulatory blood pressure monitoring and assessment of early organ effects, particularly when findings or thresholds are unclear.

Cincinnati Children’s Hypertension Clinic brings together pediatric nephrology and cardiology specialists to provide comprehensive evaluation and management. The team offers ambulatory blood pressure monitoring, assessment of metabolic and cardiovascular risk factors, and coordinated multidisciplinary care. Their participation in SHIP AHOY is one example of how a multidisciplinary team of nephologists and cardiologists can advance clinical research and translate findings into care pathways.

For more information or to consult on a case, contact mark.mitsnefes@cchmc.org.

(Published April 2026)

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