Europe vs. USA: One Blood Pressure, Two Diagnoses

Imagine checking your blood pressure and seeing 135/85 mmHg on the screen. In the United States, you'd be diagnosed with Stage 1 Hypertension. In Europe, however, you'd be told you have "High Normal" blood pressure and likely sent home without a prescription. The same numbers, the same body, but two completely different medical realities depending on which side of the Atlantic you're on.

This discrepancy isn't just a matter of terminology—it represents a fundamental divergence in medical philosophy between the American Heart Association (AHA)/American College of Cardiology (ACC) and the European Society of Cardiology (ESC)/European Society of Hypertension (ESH). Understanding these differences is crucial for anyone monitoring their heart health.

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The Core Conflict: 130/80 vs. 140/90

For decades, the global standard for high blood pressure was 140/90 mmHg. This changed dramatically in 2017 when US guidelines lowered the threshold, a stance reaffirmed and refined in the 2025 AHA/ACC Guidelines.

The American Approach: "Lower is Better"

The US guidelines define hypertension as any reading ≥130/80 mmHg. This aggressive stance is largely driven by the landmark SPRINT Trial, which showed that intensive blood pressure control (target <120 mmHg systolic) significantly reduced rates of heart attack, heart failure, and stroke compared to the standard target of <140 mmHg.

Key US Categories (2025 Guidelines):

• Normal: <120/80 mmHg
• Elevated: 120-129 / <80 mmHg
• Stage 1 Hypertension: 130-139 / 80-89 mmHg
• Stage 2 Hypertension: ≥140/90 mmHg

The American philosophy is proactive: label the condition early to encourage lifestyle changes and, if necessary, medication to prevent long-term damage.

The European Approach: "Treat the Risk, Not Just the Number"

Europe has maintained the traditional definition of hypertension as ≥140/90 mmHg. The 2024 ESC Guidelines introduced a new category called "Elevated Blood Pressure" for the 120-139/70-89 mmHg range, but they refrain from calling it a disease for everyone.

Key European Categories (2024 Guidelines):

• Non-Elevated: <120/70 mmHg
• Elevated: 120-139 / 70-89 mmHg
• Hypertension: ≥140/90 mmHg

European experts argue that labeling millions of lower-risk people as "hypertensive" causes unnecessary anxiety and over-medicalization. They prioritize treatment based on total cardiovascular risk rather than just blood pressure numbers alone.

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The "Grey Zone": 130-139 / 80-89 mmHg

The disagreement centers on this specific range. Here's how management differs:

• In the US: You have a chronic disease (Stage 1 Hypertension). Doctors will calculate your 10-year heart disease risk. If it's above 10%, you'll likely get medication. If lower, you'll be put on a strict lifestyle modification plan and reassessed in 3-6 months.
• In Europe: You have "Elevated Blood Pressure". Unless you have existing heart disease, kidney disease, or diabetes, you likely won't receive medication. The focus is almost exclusively on lifestyle changes.

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Why the Disagreement?

1. Interpretation of Evidence

US guidelines rely heavily on the SPRINT trial, which showed clear benefits to lower targets. European critics point out that SPRINT measured blood pressure in a very specific way (unattended, automated) that typically yields lower numbers than standard office measurements. They argue that applying SPRINT targets to real-world office readings could lead to dangerous overtreatment (hypotension, fainting, kidney injury), especially in the elderly.

2. Cultural Philosophies

• US Medicine: Tends to be interventionist. It values early detection and aggressive prevention, accepting the risk of over-treating some people to save more lives overall.
• European Medicine: Tends to be more conservative and pragmatic. It emphasizes avoiding harm from unnecessary medication and focuses resources on those with the highest proven risk.

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Converging Paths?

Despite the definitions, actual treatment goals are becoming more similar. The 2024 ESC Guidelines now recommend that for most patients taking medication, the target should be 120-129 mmHg systolic—remarkably close to the US target.

Both sides agree on the fundamentals:

1. Normal is <120/80 mmHg. Anything higher requires attention.
2. Lifestyle is the first line of defense. Salt reduction, exercise, weight loss, and alcohol moderation are universally recommended.
3. Home Monitoring is Essential. Both guidelines now strongly recommend home blood pressure monitoring to rule out "White Coat Hypertension" (high only at the doctor) and "Masked Hypertension" (high only at home).

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What This Means For You

If your blood pressure falls in the "grey zone" (130-139/80-89 mmHg), don't get hung up on the label. Whether it's called "Stage 1" or "Elevated", your body is telling you that your vascular system is under stress.

Actionable Steps:

• Don't Panic: You aren't in immediate danger, but you are in a warning zone.
• Validate the Numbers: Use a clinically validated home monitor (check validatebp.org). Measure twice in the morning and twice in the evening for a week to get your true average.
• Assess Your Risk: Talk to your doctor about your overall profile—cholesterol, blood sugar, family history. These factors matter just as much as the blood pressure number itself.
• Start Changes Today: You don't need a diagnosis to eat less salt or go for a daily walk. These habits are the most powerful medicine for the 130/80 range, regardless of which guidelines you follow.