Global Divergence in Hypertension Standards: Cardiovascular Outcomes Under U.S. (≥130/80) Versus European/Chinese (≥140/90) Diagnostic Thresholds in HRS, CHARLS, and ELSA.

INTRODUCTION

The optimal diagnostic threshold for hypertension remains debated globally, with American guidelines (American College of Cardiology/American Heart Association) recommending a lower threshold (≥130/80 mmHg) than European and Chinese guidelines (≥140/90 mmHg). This study systematically compared the predictive performance of these 2 standards in multiethnic cohorts.

METHODS

This prospective multicohort study analyzed harmonized data from 10,120 participants aged ≥45 years without prior cardiovascular disease or antihypertensive medication use from 3 nationally representative cohorts: the China Health and Retirement Longitudinal Study, the U.S. Health and Retirement Study, and the English Longitudinal Study of Ageing. Data were collected from 2010 to 2018 and analyzed in 2025. Multivariable Cox proportional hazards models assessed associations between hypertension definitions and incident cardiovascular disease. Predictive performance was evaluated using time-dependent area under the curve, net reclassification improvement, integrated discrimination improvement, and decision curve analysis.

RESULTS

The American College of Cardiology/American Heart Association criteria classified more individuals as hypertensive than the European/Chinese standard (47.1% vs 24.5%). Although the lower threshold showed a marginally stronger statistical association with incident cardiovascular disease, this did not translate into improved predictive utility. No significant differences were found in discrimination (6-year area under the curve=0.657 vs 0.656), risk reclassification (p>0.05), or net clinical benefit. Findings were consistent across all 3 cohorts.

CONCLUSIONS

The lower American hypertension threshold identifies more at-risk individuals but fails to demonstrate superior predictive value or net clinical benefit. Clinical focus should shift toward integrating blood pressure as a continuous variable within personalized cardiovascular risk assessments.