Combined Pre-Hypertension, Pre-Diabetes, and Pre-Hyperlipidemia and Long-Term Cardiovascular Risk in Young Adults: A Nationwide Cohort Study

Background and aims Young adults with pre-hypertension, pre-diabetes, and pre-hyperlipidemia are often classified as “low risk” by conventional 10-year cardiovascular prediction tools, resulting in limited preventive attention. This study evaluated the long-term cardiovascular consequences of concurrently having all three premorbid metabolic conditions in a nationwide cohort of young adults. Methods We analyzed 1,743,696 Korean adults aged 30–39 years who underwent national health screening in 2009. Individuals with established hypertension, diabetes, or dyslipidemia were excluded. Participants were categorized into those with combined pre-hypertension (systolic blood pressure 120–139 mmHg or diastolic blood pressure 80–89 mmHg), pre-diabetes (fasting plasma glucose 100–125 mg/dL), and borderline dyslipidemia (LDL-C 130–159 mg/dL) versus those with none of the three conditions. The primary outcome was a composite of myocardial infarction, stroke, and cardiovascular death during long-term follow-up. Risks were estimated using multivariable Cox proportional hazards models. Results Among 497,316 eligible participants, 44,553 (9.0%) had all three premorbid conditions. During a mean 14.2-year follow-up, the incidence of the composite outcome was nearly twofold higher in the combined pre-disease group. After full adjustment, the combined pre-disease group was significantly associated with higher composite risk (adjusted HR 1.23, 95% CI 1.11–1.36), driven primarily by increased risks of myocardial infarction (aHR 1.18) and stroke (aHR 1.35). No significant differences were observed for all-cause mortality. Subgroup findings were consistent across BMI, lifestyle behaviors, and lipid patterns. Conclusions The simultaneous presence of pre-hypertension, pre-diabetes, and pre-hyperlipidemia in young adults confers a measurable and clinically relevant elevation in long-term cardiovascular risk, despite the absence of overt cardiometabolic disease. These findings highlight a metabolic “gray zone” that is underestimated by current guidelines and underscore the need for earlier identification and preventive attention in young adults with clustered borderline abnormalities.