Impact of the new 2024 ESC blood pressure classification in a low-risk cohort: the 70 mmhg diastolic threshold may reduce risk discrimination in primary prevention.

Abstract

In 2024, the European Society of Cardiology (ESC) hypertension guidelines introduced an "elevated blood pressure" category (120-139 and/or 70-89 mmHg), lowering the diastolic threshold from 85 to 70 mmHg. Its relevance for cardiovascular risk stratification in low-risk primary prevention remains uncertain. We conducted a cross-sectional study of 1394 adults undergoing standardized preventive health assessment in France, with office blood pressure (BP) measured using a validated oscillometric device. Participants were classified by ESC/ESH 2018 and ESC 2024 definitions. We quantified category shifts and compared the clinical, lifestyle and biological profile of individuals reclassified from 2018 optimal to 2024 elevated on the basis of diastolic BP ≥70 mmHg (systolic BP < 120 mmHg) vs. those remaining nonelevated. SCORE2, available in 61% of participants, was used as a supporting risk estimate. ESC 2024 classified 10.0% as nonelevated, 64.2% as elevated and 25.8% as hypertensive; 70% of previously "optimal" individuals became "elevated." Compared with nonelevated peers, the diastolic-only reclassified group differed only in age (45.5 vs. 42.7 years; P = 0.007), with no difference in sex, body mass index, lifestyle, cardiovascular history or biomarkers. Their slightly higher SCORE2 was attributable to higher systolic BP and age, and was no longer significant after adjustment for systolic BP. By contrast, individuals reclassified from normal to elevated had a less favorable cardiometabolic profile. Lowering the diastolic threshold to 70 mmHg produced substantial reclassification but did not identify an independent higher-risk phenotype when systolic BP remained < 120 mmHg, questioning the relevance of such a low diastolic threshold for elevated BP in the new ESC 2024 classification. Prospective outcome studies are needed.