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Introduction: A Clinical Practice Guideline (CPG) for pediatric hypertension was recently published, serving as an update to the previous guidelines (“4th Report”). The CPG includes changes to the cut-points defining pediatric hypertension, including the incorporation of absolute cut-points rather than percentiles for adolescents.Objective: To evaluate the impact of the new CPG (compared with the 4th Report) on the prevalence of hypertension and associations with cardiovascular risk factors (CVRFs) and target organ damage (TOD) in a population of high-risk youth.Methods: Subjects (N=364, 10-18 years) underwent fasting anthropometric, blood pressure (measured as per the Fourth Report), CVRF (lipid profile, insulin, glucose, HbA1C%), carotid artery intima-media thickness (cIMT), pulse wave velocity (PWV), and left ventricular mass and diastolic (via echocardiography) assessments. Blood pressure was categorized as normal, elevated, Stage 1, and Stage 2 hypertension, as defined by the 4th report and by the new CPG. The agreement between the prevalence of hypertension using the two guidelines and associations with other CVRFs and markers of TOD were evaluated using weighted Kappa statistics and tests of symmetry.Results: Of the 364 subjects (65% female, 15.1 +/- 2.1 years), 36 (10%) had Stage 1 and 11 (3%) had Stage 2 hypertension (as defined by CPG). Hypertension (Stage 1 & 2) was associated with the presence of other CVRFs and TOD (Table). With respect to hypertension prevalence distribution, the 4th Report and CPG produced only a moderate agreement (weighted kappa 0.82 (95% CI 0.78, 0.86)) with a significant departure from perfect agreement (test of symmetry p <0.001). Similar findings were noted for associations with other CVRFs and markers of TOD (Table).Conclusions: The 4th Report and CPG produced asymmetric blood pressure category distributions and associations with CVRFs and TOD. This finding should be considered when using the CPG in clinical and academic settings, and warrants further evaluation.