Introduction
Arterial hypertension is unequivocally one of the primary causes of cardiovascular (CV) morbidity and mortality (1). However, establishing the diagnosis of hypertension in athletes poses a particular challenge, as otherwise healthy young individuals or adults rarely come into contact with healthcare professionals who would confront them with the potential disease and its associated risks. Nonetheless, hypertension does affect athletes as well, sometimes even at a young age (2). Elevated blood pressure (BP) is frequently detected during routine screening examinations in athletes (3). Long-standing hypertension leads to the development of subclinical pathological alterations, which substantially increase CV risk and thereby promote the development of overt CV disease later in life (4). In competitive athletes, the principal aim of the sports medicine examination is to detect subclinical abnormalities in asymptomatic individuals. In Hungary, compulsory medical screening is conducted once a year for competitive athletes between the ages of 16 and 65, while those under 16 or over 65 are examined every six months (5). However, brachial BP measured once during the examination is usually insufficient to establish the diagnosis of hypertension. It may raise clinical suspicion, which must be further investigated in additional steps. First and foremost, to determine resting BP, home or ambulatory 24-hour BP monitoring is required, as a single measurement during the sports medical examination may overestimate BP due to stress-induced elevation.
Definition and interpretation of blood pressure
Studies focusing on hypertension in athletes do not present a uniform picture, primarily due to the evolving definition of hypertension itself. Most investigations have been conducted in adults or adolescents, with elevated BP commonly defined as systolic >140 mmHg and diastolic >90 mmHg. In 2024, the European Society of Cardiology introduced a new guideline that, in addition to defining BP thresholds in adults, clearly outlines the correct procedure for BP measurement and the diagnostic steps for hypertension (6).
According to the new European guideline, normal (non-elevated) BP in adults at rest is defined as systolic <120 mmHg and diastolic <70 mmHg (6). Home-measured elevated BP is defined as systolic between 120–134 mmHg and diastolic between 70–84 mmHg, while hypertension is diagnosed when daytime home BP readings reach or exceed 135 mmHg systolic and 85 mmHg diastolic (6).
In assessing the long-term CV risk associated with a patient’s BP, in addition to accurate measurement, other risk factors play a decisive role—such as moderate-to-severe chronic kidney disease, confirmed vascular disease, heart failure, diabetes mellitus, and familial hypercholesterolemia (6). The long-term CV risk stratification is further supported by the SCORE2 and SCORE2-OP algorithms (7,8).
When evaluating elevated BP in athletes, it is essential that no caffeine be consumed and no physical activity performed for at least 30 minutes prior to measurement (6). In children and athletes under 18 years of age, BP must be assessed based on percentile tables adjusted for age, height, and sex. This is particularly important in this age group, as the majority of competitive sports licenses are issued within this demographic. In children, BP at or above the 95th percentile corresponding to age, sex, and height is considered hypertensive (9).
Among children and young adults (<35 years), secondary hypertension is relatively common (15–30% of hypertensive patients), and must therefore always be investigated (10). Abdominal ultrasound, particularly renal ultrasonography, evaluation for sleep apnea, thyroid function tests, and the exclusion of hyperaldosteronism may all be necessary in the diagnostic work-up (11).
In Hungary, sports medicine screening includes not only BP measurement but also a 12-lead ECG, chest auscultation, and in senior athletes (>35 years), supplementary laboratory tests indicating CV risk (e.g., lipid profile, blood glucose), all aimed at more accurate risk stratification (5). In hypertensive athletes, the most accessible imaging modality, transthoracic echocardiography, is also warranted (12).
Prevalence of hypertension in athletes
The prevalence of hypertension among athletes is primarily derived from the findings of screening examinations. Earlier studies have demonstrated that due to methodological differences across various investigations, the reported prevalence of hypertension in athletes varies widely—ranging from 0% to 83% (13). Nevertheless, it has generally been accepted that the prevalence of hypertension in athletes is lower than in the non-athlete population (3,13), although this may change with advancing age and the appearance of comorbidities.
However, an analysis of a large-scale athlete database conducted in 2019 (using a cutoff value of 140/90 mmHg) found that one-third of elite athletes were hypertensive (2), a rate clearly higher than that observed in the general population (14). This proportion would likely have been even greater if the study had also classified individuals within the newly defined European guideline range for high-normal BP (120–134/70–84 mmHg) as hypertensive (6).
Interpreting BP readings obtained during athletic examinations in light of these new guidelines is of particular importance, as elevated BP at a young age significantly increases the risk of developing severe CV disease and elevates all-cause mortality in later life (15,16).
Substances contributing to elevated blood pressure in athletes
In the development of hypertension in athletes, the risk factors well known in the general population also play a significant role. However, athletes often consume dietary supplements that are known to enhance performance. Occasionally, they use substances whose effects they have only heard about through advertising or informal sources. In such cases, primary considerations include avoiding preparations that may pose health risks and those that are potentially prohibited from an anti-doping perspective.
Classical CV risk factors are particularly relevant among athletes engaged in high-intensity anaerobic training, especially those requiring greater body mass for optimal performance—typically in isometric disciplines. In these athletes, weight loss is often not a viable option for managing hypertension. On the contrary, to maintain their body mass and ideal body composition, they intentionally consume high-calorie, low-fiber diets (17).
Among strength athletes—either competitive or recreational but highly committed—the use of performance-enhancing agents, including substances listed on anti-doping registers, must always be considered as a possible etiological factor in hypertension. Anabolic steroids increase BP and contribute to the development of atherosclerotic vascular disease and pathological left ventricular hypertrophy (18). While some may assume that the use of anabolic steroids is limited to a fringe group of “muscle enthusiasts,” studies indicate that their prevalence remains approximately 10–20% even among both recreational and elite athletes (19).
In endurance sports, high sodium intake is often employed with the intent of enhancing performance and preventing exercise-associated muscle cramps. However, this practice increases the risk of hypertension and, furthermore, the ergogenic benefit of sodium loading remains highly questionable (20) (Figure 1).
Stimulants, such as caffeine and energy drinks, are also frequently consumed, as they may transiently improve performance. However, regular and excessive use—particularly prior to training or competition—may contribute to the development of hypertension (21,22).
Due to frequent muscle and joint pain, athletes often use non-steroidal anti-inflammatory drugs (NSAIDs), most of which are available over-the-counter. Athletes, being highly aware of their pain thresholds during training and competition, often take NSAIDs prophylactically, which significantly increases overall consumption. Excessive NSAID use—especially in combat sports—is associated with an increased risk of hypertension (23).
Lifestyle factors beyond nutrition also influence the development of hypertension. Chronic psychological stress and sustained high-intensity physical training—especially among elite athletes—likewise contribute to the elevated prevalence of hypertension in this population (13).
Sport-specific considerations
The type of sport is an important determinant in the development of hypertension among athletes. In assessing the risk of elevated BP, the classification of the given sport plays a critical role (24), as strength-based disciplines characterized by predominantly isometric training are associated with a higher prevalence of hypertension compared to purely endurance-based sports (13). Among endurance athletes, not only systolic but also diastolic BP tends to be lower than in strength athletes (13), which is partly attributable to a higher body mass index (BMI) observed in the latter group (25).
Female athletes typically present with lower BP values compared to males; however, the differences observed between endurance and strength sports are also evident among women (26). It is also important to emphasize that the nature of training performed within a given sport—particularly under a specific coach or at a particular club—can significantly influence CV outcomes. For example, in youth football players, recent years have seen an increased emphasis on strength training aimed at improving postural stability, alongside traditional endurance and skill-based (ball) training (27).
The higher BMI observed in strength athletes is associated not only with elevated BP, but also with a greater incidence of metabolic syndrome and dyslipidemia (25).
Senior athletes
Elite athletes over the age of 35 are typically referred to as senior athletes. The extent to which older athletes can remain competitive largely depends on the type of sport. In elite-level football, for example, older athletes usually transition to senior leagues and are no longer part of top-division teams. In contrast, in disciplines such as marathon running, it is common to find older age groups actively competing and achieving success.
The prevalence of hypertension in senior athletes is lower than in non-athletic individuals of the same age group (28). This may be attributed to several factors, including lower BMI and a higher proportion of endurance training among older athletes. Former elite athletes who do not use antihypertensive medication tend to exhibit lower BP levels compared to individuals who did not engage in competitive sports, regardless of current physical activity levels (29). This difference was most pronounced in former endurance athletes, suggesting that intensive endurance training exerts long-term protective effects against the development of hypertension, even after cessation of regular training.
However, senior endurance athletes are not healthier than non-athletes in every respect. Coronary computed tomography (CT) studies have shown that asymptomatic middle-aged athletes exhibit a higher degree of coronary artery calcification compared to age-matched non-athletic controls (30). The precise role of this finding in the long-term CV risk profile of athletes remains uncertain. One hypothesis suggests that the increased calcification may represent more stable, and thus less dangerous, plaques compared to those in non-athletes. This notion is partially contradicted by findings from a study that combined native cardiac CT and contrast-enhanced cardiac magnetic resonance imaging (MRI) in senior marathon runners and a non-athletic control group. In that study, the greater extent of coronary calcification observed in athletes was associated with increased late gadolinium enhancement, indicative of myocardial damage (31).
Pharmacological Considerations in the Treatment of Hypertension in Athletes
Because sport is generally regarded as a health-promoting activity—by both athletes and the public—it is often difficult to convey the reality of a disease diagnosis to the athlete. Moreover, since the majority of competitive athletes are young, initiating pharmacological treatment may require not only the athlete’s consent, but also the involvement and reassurance of parents, when applicable.
In otherwise healthy young athletes, understanding the long-term risks and consequences of hypertension—and recognizing that elevated BP may impair current physical performance—can facilitate the acceptance of pharmacological therapy (32). The first step in managing hypertension in athletes involves lifestyle modification, including education and counseling aimed at addressing contributing behavioral factors. Only after this should pharmacologic treatment be considered (Figure 1).
Aerobic exercise generally exerts a beneficial effect on BP and, in most cases, can be continued. This should be particularly emphasized in athletes whose primary training is strength-based (13). In this group, weight reduction is a critical recommendation; however, it should be acknowledged that discontinuing high-calorie diets may lead to a decline in performance. Regardless, all hypertensive athletes should be advised to reduce sodium intake and increase dietary potassium consumption (33).
Although lifestyle changes are essential, they are often insufficient for achieving optimal BP control. In such cases, pharmacotherapy must be initiated. Two primary aspects should be taken into account: Rapid and aggressive BP lowering may lead to fatigue and diminished performance. Therefore, treatment should not begin with the maximum anticipated dose, as this may negatively impact treatment adherence. And in competitive athletes, anti-doping regulations must guide medication selection to avoid prohibited substances (34).
First-line antihypertensive medications for athletes include angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, and dihydropyridine-type calcium channel blockers, either as monotherapy or in combination (35,36). Among these, dihydropyridine calcium channel blockers are particularly preferred due to their efficacy and the lack of requirement for renal function monitoring.
Beta-blockers, while not universally banned, fall under the category of sport-specific prohibited substances, meaning they are only restricted in certain sports such as golf and shooting (34). Nevertheless, beta-blockers are generally suboptimal for treating hypertension in athletes. They tend to further reduce resting heart rate in endurance athletes—who are often bradycardic at baseline—and they lower the attainable maximum heart rate during exertion. Moreover, non-selective beta-blockers inhibit β2-receptors in the airways, impairing respiratory efficiency and thus athletic performance (37).
Diuretics are among the most widely prohibited classes of medications in competitive sport, including thiazides, loop diuretics, and mineralocorticoid receptor antagonists. This is primarily because they may be used to mask the presence of other performance-enhancing substances (34). In cases where diuretic use is medically justified, it may still be permitted—but only if a Therapeutic Use Exemption is formally requested and granted in advance (34).
Return to sport in athletes with hypertension
When hypertension is appropriately managed, participation in sports—including competitive sports—is generally permitted. However, during the initial phase of treatment or in cases where BP is not adequately controlled, particularly when systolic BP exceeds 160 mmHg, high-intensity training is not recommended until proper antihypertensive therapy has been established.
If hypertension is well controlled but the athlete has a high CV risk (SCORE >5%) or documented target organ damage, then high-intensity resistance training is not advised. In contrast, athletes with well-managed hypertension and no evidence of organ damage may participate in any type of sport without restriction.
For hypertensive adults engaging in preventive recreational sports, it is recommended to perform resistance training at least three times per week, in combination with moderate to high-intensity aerobic exercise (minimum 30 minutes per session, 5–7 days per week), as this helps reduce resting BP and overall CV risk (38).
Conclusion
Arterial hypertension is present not only among competitive athletes but also in individuals who engage in regular recreational physical activity. Sports medical screening examinations offer enhanced safety for competitive athletes by facilitating the early detection of hypertension and raising suspicion of subclinical CV abnormalities, thereby enabling timely diagnostic evaluation and, when necessary, the initiation of effective therapy.
In the management of hypertension in athletes, lifestyle modifications—including adjustments to training regimens and the discontinuation of dietary supplements or prohibited substances that may contribute to elevated BP —can be effective on their own. Pharmacological treatment largely follows the same principles as in the general population; however, therapeutic strategies may require adjustment due to anti-doping regulations and the potential for performance impairment associated with certain medications.