Comparison of the 2024 ESC and 2025 AHA/ACC classifications of elevated blood pressure with regards to prevalence and blood-pressure associated cardiac remodelling in the general population

Background/Introduction The 2024 ESC and 2025 AHA/ACC guidelines on elevated blood pressure and hypertension offer different classification systems. There is limited evidence directly comparing the association of these classifications with echocardiographic changes in the general population. Purpose We aimed to understand the differences in prevalence and re-classification between these two guidelines in the general population and the strength of their association with echocardiographic changes to evaluate their clinical meaningfulness. Methods Middle-aged adults from a population-based cohort study in Germany underwent standardized blood pressure measurements and in-depth transthoracic echocardiography. Elevated blood pressure and hypertension were categorized according to the 2024 ESC guidelines and 2025 AHA/ACC guidelines. Results We included 9,589 participants with complete blood pressure data (median age 63 years, 51% female). According to the ESC classification, 538 participants (5.6%) had normal blood pressure, 4,541 (47.4%) had elevated blood pressure and 4,510 (47.0%) had hypertension (Figure 1). According to the 2025 AHA/ACC classification, 1,342 participants (14.0%) had normal blood pressure, 1,072 (11.2%) had elevated blood pressure, 2,665 (27.8%) had stage 1 hypertension and 4,510 (47.0%) had stage 2 hypertension. ANOVA showed a stronger association of the ESC classification than AHA/ACC classification for left ventricular (LV) posterior wall diameter (F-value 142.50 for ESC vs. 120.88 for AHA/ACC, p<0.001 for both), mitral valve (MV) A-wave velocity (F-value 65.91 vs. 59.00, p<0.001 for both) and MV E/A (F-value 169.88 vs. 132.59, p<0.001 for both), whereas the AHA/ACC classification had stronger associations than the ESC classification with biplane LV cardiac index (F-value 6.80, p=0.001 for ESC vs. 9.61, p<0.001 for AHA/ACC) and biplane left atrial systolic volume (F-value 34.29 vs. 36.33, p<0.001 for both) (Figure 2). Effect size comparison showed negligible to small effect sizes (η²) for these five parameters for both classifications (η² between 0.002 and 0.052), slightly favouring the AHA/ACC guidelines for all parameters. In multivariate ANOVA the Pillai’s Trace was 0.095 for the ESC guideline, and 0.120 for the AHA/ACC guideline, translating into a 26.3% larger proportion of variance explained by the AHA/ACC classification compared to the ESC classification. Conclusions In our cohort, few participants had normal blood pressure, in particular according to the 2024 ESC classification. The 2025 AHA/ACC classification re-classifies individuals with elevated blood pressure according to the ESC guidelines both “up” and “down”. Both classifications are associated with structural remodelling, systolic and diastolic function, though the 2025 AHA/ACC classification explains a larger proportion of variance. These findings extend the evidence on the differential clinical impact of those classifications.