Comparison of cardiovascular risk in individuals with normal vs isolated elevated diastolic blood pressure

BackgroundIn 2024, the European Society of Cardiology (ESC) hypertension guidelines introduced an "elevated blood pressure" category (120-139/70-89 mmHg), lowering the normal diastolic BP threshold from 85 to 70 mmHg. The implications of this change for risk stratification in primary prevention are uncertain. MethodsWe conducted a cross-sectional study of adults undergoing standardized preventive health assessments at a dedicated center in Paris, France. Office blood pressure was measured with a validated automated oscillometric device. Participants were classified using ESC/ESH{square}2018 and ESCL2024 definitions. We quantified shifts across BP categories and compared clinical, lifestyle, and biological profiles between individuals reclassified from ESCL2018 "Optimal" to ESCL2024 "Elevated" solely due to diastolic BP [&ge;]L70LmmHg with systolic BP<{square}120{square}mmHg. ResultsAmong 1,394 participants (mean age 49.9 {+/-} 12.1 years; 33.9% women), ESC 2024 classified 10.0% as non-elevated (<120/70 mmHg), 64.2% as elevated, and 25.8% as hypertensive ([&ge;]140/90 mmHg). Overall, 328 (23.5%) moved from ESC/ESH2018 "Optimal" (BP <120/80 mmHg) to ESC 2024 "Elevated" on the basis of diastolic pressure alone. Compared with individuals classified in the 2018 optimal and 2024 non-elevated subgroup (BP <120/70 mmHg), reclassified participants (systolic BP <120 and diastolic BP 70- 79 mmHg) were modestly older (45.5 vs 42.7 years; p = 0.007) but did not differ by sex, body-mass index, smoking exposure, alcohol consumption, self-rated health, cardiovascular history, or routine biomarkers. SCORE2 did not differ between these groups (p = 0.12), but increased progressively across successively higher ESC/ESH2018 categories. In line with this gradient, ESC/ESH2018 "Optimal" versus non-optimal groups differed significantly across multiple risk markers (all p < 0.05). ConclusionsIn this low-risk preventive cohort, lowering the diastolic threshold to 70 mmHg reclassified nearly one quarter of adults with previously optimal BP into the elevated BP category, without identifying a clinically distinct higher-risk phenotype. Prospective studies with adjudicated outcomes are needed to determine the utility of this threshold for primary prevention.