2025 Hypertension Criteria May Expand Treatment Eligibility

Key Takeaways

• Among U.S. adults with hypertension and no baseline CVD, 22.8 million adults, or 28% of the weighted sample, were estimated to be newly eligible for antihypertensive therapy under the 2025 criteria.
• Among adults who met those updated criteria, 43% were untreated.
• Antihypertensive therapy was associated with lower all-cause and cardiovascular mortality over time, including reported reductions of 23% and 50%, respectively.
• Modeling suggested that treating all eligible but untreated adults could prevent about 200,900 all-cause deaths and 162,600 cardiovascular deaths over 10 years, corresponding to roughly 21 and 17 lives saved per 10,000 person-years, respectively.

Risk-based treatment thresholds in hypertension care increasingly shift medication decisions beyond blood pressure alone for adults whose estimated cardiovascular risk or comorbid kidney and metabolic disease lowers the threshold for therapy. Under the 2025 American Heart Association/American College of Cardiology/Multisociety approach, adults with hypertension but no baseline cardiovascular disease form a large primary-prevention group in whom PREVENT-based risk assessment can change whether medication is considered. That clinical question underlies the hypertension treatment-eligibility analysis under the 2025 guideline in a nationally representative U.S. sample.

Investigators evaluated the potential long-term impact of the 2025 hypertension guideline on treatment eligibility, antihypertensive medication use, and mortality. They used 2009 to 2018 National Health and Nutrition Examination Survey (NHANES) data from a nationally representative weighted sample of more than 81 million U.S. adults with hypertension and no cardiovascular disease (CVD) at baseline. In the analysis, the newly eligible group included adults with blood pressure of at least 130/80 mm Hg plus a PREVENT-estimated 10-year CVD risk of at least 7.5%, diabetes, or chronic kidney disease; the guideline description also notes immediate medication initiation for blood pressure of at least 140/90 mm Hg and for blood pressure 130-139/80-89 mm Hg with comorbid conditions, whereas lower-risk patients in the 130-139/80-89 mm Hg range are advised lifestyle modification first.

Investigators estimated that 22.8 million U.S. adults would be newly eligible for pharmacologic therapy under the 2025 criteria; 13.1 million were already receiving antihypertensive medication and 9.7 million were not. Untreated eligible adults tended to be younger, more often women, and more likely to have diabetes or chronic kidney disease than treated eligible adults.

Over a mean follow-up of 115 months, the reported mortality associations with antihypertensive therapy showed an all-cause mortality hazard ratio of 0.77 (95% CI, 0.63-0.94; P=.009) and a cardiovascular mortality hazard ratio of 0.50 (95% CI, 0.36-0.68; P<.001).

In the same analysis, modeling suggested that treating all eligible but untreated adults could prevent approximately 200,900 all-cause deaths and 162,600 cardiovascular deaths over 10 years. The largest modeled mortality benefit was reported among people with diabetes.

These mortality findings remain observational associations, and the deaths-prevented totals are modeled estimates rather than directly observed event reductions. Interpretation is limited to adults with hypertension and no baseline CVD. Even with those limits, the results point to a sizable untreated primary-prevention gap under the updated risk-based criteria.

In this reported JAHA analysis, the 2025 risk-based hypertension criteria corresponded to a larger treatment-eligible primary-prevention population in the United States and to a substantial untreated gap. Treated eligible adults had lower mortality over time, and modeled expansion of treatment to all eligible untreated adults suggested large population benefits. The findings describe the scope of eligibility and undertreatment under the updated criteria rather than prescribe a specific management strategy.

Clinician Questions

Which adults with hypertension become newly eligible for medication under the 2025 risk-based criteria?

In this analysis, adults with hypertension became eligible for medication when blood pressure was at least 130/80 mm Hg and they also had a PREVENT-estimated 10-year CVD risk of at least 7.5%, diabetes, or chronic kidney disease.

What population does this hypertension eligibility analysis apply to?

The analysis used 2009 to 2018 NHANES data to represent a nationally weighted sample of more than 81 million U.S. adults with hypertension and no CVD at baseline, so the findings are bounded to a primary-prevention population rather than adults with established cardiovascular disease.

How were untreated eligible adults different from treated eligible adults in this analysis?

Untreated eligible adults in this hypertension analysis were described as younger, more often women, and more likely to have diabetes or chronic kidney disease than treated eligible adults.

Which subgroup had the largest modeled mortality benefit in the hypertension analysis?

The analysis reported the largest modeled mortality benefit among adults with diabetes.