BackgroundHypertension (HTN) is known to be the leading cause of cardiovascular disease (CVD) and mortality. We aimed to assess the impact of changes in 3 years in different blood pressure (BP) categories on incident CVD.MethodsIn this study, 3,685 Tehranians aged ≥30 years (42.2% men) free of prevalent CVD with BP level <140/90 mmHg and not on BP-lowering medications were enrolled. Participants were grouped according to baseline BP category using the 2017 ACC/AHA hypertension guideline definition: normal BP (<120/80 mmHg), elevated BP (120–129/<80), and stage 1 HTN (130–139 and/or 80–89). The hazard ratio of incident CVD by changes in the BP category was estimated after adjustment for traditional risk factors using Cox's proportional hazard model, with stable normotension as a reference.ResultsDuring a median follow-up of 11.7 years, 346 CVD events (men = 208) occurred. Compared to the reference group, among participants with normal BP at baseline, only those with BP rising to stage 1 HTN [1.47 (0.99–2.16)], and among those with stage 1 HTN at baseline, regression to elevated BP [1.80 (1.11–2.91)], remaining at stage 1 [1.80 (1.29–2.52)], and progression to stage 2 HTN [1.81 (1.25–2.61)] had a higher risk for CVD; however, regression to normal BP attenuated this risk [1.36 (0.88–2.12)]. Conversion from elevated BP to any other categories had no significant association with CVD risk.ConclusionsGenerally, prevalent stage 1 HTN (regardless of changing category) and incident stage 1 HTN were significantly associated with a higher risk of CVD; even regression to elevated BP did not attenuate the risk. Accordingly, these populations are potential candidates for antihypertensive management.