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

Background In 2024, the European Society of Cardiology (ESC) hypertension guidelines introduced an elevated blood pressure category, lowering the normal diastolic BP threshold from 85 to 70 mmHg. The implications of this change for risk stratification in primary prevention are uncertain. Methods We 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 2018 and ESC 2024 definitions. We quantified shifts across BP categories and compared clinical, lifestyle, and biological profiles between individuals reclassified from ESC/ESH 2018 Optimal to ESC 2024 Elevated solely due to diastolic BP with systolic BP. Results Among 1,394 participants (mean age 49.9 years; 33.9% women), ESC 2024 classified 10.0% as non-elevated, 64.2% as elevated, and 25.8% as hypertensive. Overall, 328 (23.5%) moved from ESC/ESH2018 Optimal to ESC 2024 Elevated on the basis of diastolic pressure alone. Compared with individuals classified in the 2018 optimal and 2024 non elevated subgroup, reclassified participants 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). Conclusions In 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.