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Global Divergence in Hypertension Standards: Cardiovascular Outcomes Under U.S. (≥130/80) Versus European/Chinese

Yilin Pan1, Jingru Bi2, Lili Sun1

  • 1Department of Critical Care Medicine, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.

American Journal of Preventive Medicine
|May 28, 2026
PubMed

Insights

The American hypertension guideline (ACC/AHA) identifies more people with high blood pressure but does not better predict cardiovascular disease risk compared to European/Chinese guidelines. Focus should be on continuous blood pressure monitoring for personalized risk assessment.

Area of Science:

  • Cardiology
  • Public Health
  • Epidemiology

Background:

  • Global debate exists on optimal hypertension diagnostic thresholds, with differing guidelines (ACC/AHA vs. European/Chinese).
  • Comparative predictive utility of these hypertension criteria in diverse populations is not well understood.
  • This study addresses the need for evidence-based hypertension diagnosis in multi-ethnic cohorts.

Purpose of the Study:

  • To systematically compare the performance of American (ACC/AHA) and European/Chinese hypertension diagnostic criteria.
  • To evaluate the predictive utility of different hypertension thresholds for incident cardiovascular disease (CVD).
  • To assess clinical decision-making utility across diverse, real-world populations.

Main Methods:

  • Prospective analysis of 10,120 participants (≥45 years) from CHARLS, HRS, and ELSA cohorts (2010-2018).
  • Exclusion of individuals with prior CVD or antihypertensive medication use.
  • Assessment of hypertension definitions using multivariable Cox models, time-dependent AUC, NRI, IDI, and Decision Curve Analysis.

Main Results:

  • ACC/AHA criteria identified a larger hypertensive population (47.1%) versus European/Chinese (24.5%).
  • Lower ACC/AHA threshold showed marginal statistical association with CVD but no superior clinical predictive utility.
  • No significant differences in discrimination, risk reclassification, or net clinical benefit between the two guideline models were observed across cohorts.

Conclusions:

  • The lower American hypertension threshold identifies more at-risk individuals but lacks superior predictive value for CVD.
  • Findings challenge universal adoption of the lower threshold, suggesting limitations in current diagnostic cutoffs.
  • Clinical focus should shift towards continuous blood pressure variables and personalized absolute cardiovascular risk assessment.
Abstract

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