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Introduction: In the SPRINT trial, intensive blood pressure (BP) treatment saved lives and was cost-effective in high-risk older adults. It is unclear if intensive BP treatment should be extended to high-risk adults aged 40-49 years.Objectives: We used individual patient computer simulation to assess the incremental value of extending intensive BP treatment to adults as young as age 40 with high cardiovascular disease (CVD) risk. We selected patients aged <60 years with high lifetime risk because few have high ten-year risk.Methods: Male and female cohorts of 100,000 individuals were assembled from NHANES surveys 1999-2010 using sampling weights. BP and other risk factor trajectories were projected for ages 40 to 69 years based on Framingham Offspring Cohort analyses. The “standard of care” treatment scenario simulated treating BP <140/90 mmHg in all patients ≥140/90 mmHg. Two alternative scenarios were simulated: add intensive treatment (goal <130/90 mmHg) from age 40-69 or from age 50-59 in patients with high lifetime risk. The lifetime risk thresholds (Table 1) were chosen in order to capture patients with forecasted ten-year CVD risk ≥ 10% at age 60. Costs included added treatment and side-effect costs and avoided CVD costs; indexed to 2016. Incremental cost-effectiveness ratios (ICERs) assessed changes in costs and quality-adjusted life years due to adding intensive BP goals.Results: Over a 30-year time horizon, adding intensive treatment in high lifetime risk patients at age 40 would prevent 2,880 additional CVD events in males and 2,958 in females compared to treating only BP <140/90 mmHg. Intensive treatment in high lifetime risk patients before age 60 appeared generally cost-effective except in females aged 40 years (ICER $59,000).Conclusion: Our results suggest that over the long term, intensive BP treatment may be cost-effective in high-risk men as young as 40 and high-risk women as young as 50. Lifetime cardiovascular disease risk might be used to select high risk middle-aged adults for intensive BP treatment.