Key result
The US ACC/AHA hypertension threshold (≥130/80 mmHg) classified more individuals as hypertensive (47.1% vs 24.5%) but did not improve 6-year AUC for incident CVD (0.657 vs 0.656).
Why the study?
The comparative predictive utility of US (≥130/80 mmHg) versus European and Chinese (≥140/90 mmHg) hypertension diagnostic thresholds in diverse, real-world populations remained unclear.
Does the US ACC/AHA hypertension diagnostic threshold (≥130/80 mmHg) improve the prediction of incident cardiovascular disease compared to the European/Chinese threshold (≥140/90 mmHg) in adults aged ≥45 years without prior CVD?
Cohort (n=10,120)
Yes
Does the US ACC/AHA hypertension diagnostic threshold (≥130/80 mmHg) improve the prediction of incident cardiovascular disease compared to the European/Chinese threshold (≥140/90 mmHg) in adults aged ≥45 years without prior CVD?
Answers are grounded in this paper and cite their sources.
The lower US hypertension threshold (≥130/80 mmHg) classifies nearly twice as many people as hypertensive but does not improve clinical prediction of incident CVD compared to the ≥140/90 mmHg threshold.
BACKGROUND: The optimal diagnostic threshold for hypertension is a subject of major global debate, with American guidelines (ACC/AHA) recommending a lower threshold (≥130/80 mmHg) than European and Chinese guidelines (≥140/90 mmHg). The comparative predictive utility of these criteria in diverse, real-world populations remains unclear. This study aimed to systematically compare the performance of these two diagnostic standards in multi-ethnic cohorts. METHODS: This prospective multi-cohort study analyzed harmonized data from 10,120 participants aged ≥45 years without prior cardiovascular disease (CVD) or antihypertensive medication use from three nationally representative cohorts: the China Health and Retirement Longitudinal Study (CHARLS), the US Health and Retirement Study (HRS), and the English Longitudinal Study of Ageing (ELSA). Data were collected from 2010 to 2018 and analyzed in 2025.Multivariable Cox proportional hazards models were used to assess the association between hypertension definitions and incident CVD. Predictive performance was evaluated using time-dependent Area Under the Curve (AUC), Net Reclassification Improvement (NRI), Integrated Discrimination Improvement (IDI), and Decision Curve Analysis. RESULTS: The ACC/AHA criteria classified a substantially larger proportion of individuals as hypertensive compared to the European/Chinese standard (47.1% vs. 24.5%). While the lower ACC/AHA threshold showed a marginally stronger statistical association with incident CVD in fully adjusted models, this superiority did not translate into improved clinical predictive utility. There were no significant differences between the two guideline models in discrimination (6-year AUC: 0.657 vs. 0.656), risk reclassification (NRI and IDI were negligible, P > 0.05), or net clinical benefit across a range of risk thresholds. These findings were robust and consistent across all three national cohorts. CONCLUSIONS: In this large, multi-ethnic analysis, the lower American hypertension threshold identifies a larger at-risk population but fails to demonstrate superior predictive value or net clinical benefit in multivariable models. These results challenge the utility of universally adopting the lower threshold and suggest that clinical focus should shift from a single diagnostic cutoff towards integrating blood pressure as a continuous variable within personalized, absolute cardiovascular risk assessments.
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Pan et al. (2026) conducted a cohort in Hypertension (n=10,120). US ACC/AHA hypertension threshold (≥130/80 mmHg) vs. European/Chinese hypertension threshold (≥140/90 mmHg) was evaluated on Incident CVD discrimination (6-year AUC) (p=>0.05). The US ACC/AHA hypertension threshold (≥130/80 mmHg) classified more individuals as hypertensive (47.1% vs 24.5%) but did not improve 6-year AUC for incident CVD (0.657 vs 0.656).
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