10 million remain untreated under new BP guideline

Clinical takeaway: Patients with blood pressure at least 130/80 plus diabetes, CKD, or a 10-year PREVENT risk of 7.5% or higher now meet the threshold for medication under the 2025 guideline.

Nearly a year after the American Heart Association and American College of Cardiology lowered the risk-based threshold for blood pressure treatment, the first population-level look at the new guideline is in. Among 81 million US adults with hypertension and no cardiovascular disease, 28% now qualify for drug therapy. But over 40% of those who qualify still aren't getting it.

Under the new thresholds, medication is advised at 130/80 mm Hg for adults with diabetes, CKD, or a PREVENT-estimated 10-year risk of 7.5% or higher. Hypertension remains the most important modifiable driver of cardiovascular death, contributing to nearly 700,000 US deaths each year.

Among the 22.8 million adults who met the new treatment criteria, 9.7 million were untreated. Being on blood pressure medication was associated with a 23% lower risk of death from any cause and a 50% lower risk of cardiovascular death over roughly 10 years of follow-up. In absolute terms, that's a 10-year all-cause mortality of 7.5% for treated adults versus 9.6% untreated.

If every untreated but eligible adult started therapy, the modeling projects about 200,000 all-cause deaths and 163,000 cardiovascular deaths prevented over a decade. The benefit was largest in diabetes, where treatment was tied to a 41% lower risk of all-cause death and a 69% lower risk of cardiovascular death.

The researchers analyzed a nationally representative federal health survey from 2009 to 2018 linked to mortality records through 2019, covering a weighted sample of 81 million adults ages 30 to 79 with hypertension and no baseline cardiovascular disease.

The authors call the current eligibility framework promising but unvalidated. PREVENT, the American Heart Association's newer risk calculator, now gatekeeps treatment decisions, but no randomized trial has enrolled patients selected by its thresholds. The next step is trials that recruit on those criteria and test optimal BP targets, including whether pushing systolic below 120 mm Hg improves cause-specific outcomes.

They also call for embedding automated risk calculators into EHRs, tying performance metrics to hypertension control, and reaching the patients most likely to be untreated, who skewed toward lower income and education. Without those steps, risk-based treatment thresholds may not translate into real-world gains.

"While lifestyle changes are the foundation for better overall health, people with high blood pressure and higher risk for cardiovascular disease may also need medication to reduce the risk of serious complications from untreated high blood pressure," said Daniel Jones, MD, chair of the American Heart Association's 2025 guideline writing committee, who was not involved in the study. "Healthcare professionals should assess overall cardiovascular risk and work together with their patients to combine lifestyle strategies and medication for optimal blood pressure control."

Source: Al-Jarshawi M, et al. J Am Heart Assoc. 2026 Jul 29. Population-Level 10-Year Implications of the New 2025 American Heart Association/American College of Cardiology Hypertension Guideline Recommendations for Primary Prevention in the United States: A NHANES-Based Cohort Study (2009–2018)