Cardiovascular risk across blood pressure categories defined by the 2024 ESC and 2023 ESH hypertension guidelines: insights from a Korean nationwide cohort study

BACKGROUND AND AIMS: The most recent guidelines from the European Society of Cardiology (ESC) categorize blood pressure (BP) into three groups: (1) non-elevated BP, (2) elevated BP and (3) hypertension. This study aimed to determine whether the 2024 guidelines from the ESC for elevated BP and hypertension accurately identify populations at increased risk of future cardiovascular diseases. METHODS: In a population-based cohort derived from the Korean National Health Insurance Service database, we included individuals aged ≥40 years who underwent national health examinations in 2009. Those with a history of stroke or myocardial infarction were excluded. Multivariable Cox proportional hazards models were used to assess the association between blood BP categories and the risk of the composite outcome (stroke, myocardial infarction, and all-cause mortality). Risk estimates based on the 2023 European Society of Hypertension (ESH) classification were also analyzed to illustrate differences in categorization. RESULTS: A total of 2,604,340 participants were included in the final analysis, with a mean follow-up duration of 11.66 ± 2.25 years. Compared to the non-elevated BP group, both the elevated BP and hypertension groups showed significantly higher risks for the composite outcome (adjusted hazard ratio [aHR] 1.072 (95% CI: 1.059-1.084) and 1.201 (95% CI: 1.186-1.217)). The risks of stroke, myocardial infarction, and all-cause mortality were likewise significantly elevated in both the elevated BP and hypertension groups, respectively. Applying both the ESC and ESH frameworks demonstrated how differing BP thresholds can result in variation in risk assessment across population subgroups. CONCLUSIONS: Elevated BP and hypertension, as defined by the 2024 ESC guidelines, were associated with increased risk of future cardiovascular events. While findings were directionally consistent with the 2023 ESH classification, the ESC framework identified a broader at-risk population. These results indicate that individuals with elevated BP, as defined by the 2024 ESC classification, have a modestly higher risk of cardiovascular events, particularly ischemic stroke, compared with those with non-elevated BP.