Implementing the 2025 American Heart Association and American College of Cardiology's hypertension guideline recommendations may expand eligibility for antihypertensive therapy and prevent mortality over the next decade among US adults with hypertension.
In a retrospective cohort study using 2009 to 2018 National Health and Nutrition Examination Survey data and linked mortality records through 2019, investigators examined outcomes among about 81 million US adults aged 30 to 79 years who had hypertension without established cardiovascular disease. Under the 2025 guideline, patients with blood pressure of at least 130/80 mmHg and either diabetes, chronic kidney disease, or an estimated 10-year cardiovascular disease risk of at least 7.5% using the Predicting Risk of Cardiovascular Disease Events (PREVENT) equations were considered eligible for antihypertensive therapy.
The primary outcome was all-cause mortality, and the secondary outcome was cardiovascular mortality. The investigators used adjusted survival models and performed simulation analyses to estimate the population-level effects of full and partial implementation of the guideline recommendations over 1, 5, and 10 years.
Among nearly 23 million US adults who met the new treatment criteria, about 57% (n = 13.1 million) were already receiving antihypertensive therapy and 43% (n = 9.7 million) remained untreated, representing a substantial treatment gap.
Among eligible patients, antihypertensive therapy was associated with a 23% lower likelihood of all-cause mortality and a 50% lower likelihood of cardiovascular mortality compared with no treatment following adjustment for baseline cardiovascular risk. At 10 years, treatment was associated with an absolute reduction of 2.1% in all-cause mortality and 1.7% in cardiovascular mortality. Simulation modeling projected that treating all eligible but untreated patients could prevent all-cause and cardiovascular mortality in nearly 201,000 and 163,000 individuals, respectively, during the next decade.
The greatest projected benefit was observed among patients with diabetes, for whom antihypertensive therapy was associated with a 41% lower likelihood of all-cause mortality and a 69% lower likelihood of cardiovascular mortality over 10 years. By contrast, patients with chronic kidney disease experienced lower cardiovascular mortality but not a statistically significant reduction in all-cause mortality. Patients meeting the PREVENT risk threshold had similar outcomes compared with those in the overall eligible population.
The investigators reported that projected benefits increased as treatment uptake improved, suggesting that even partial implementation of the guideline recommendations could translate to meaningful reductions in mortality. They noted that most eligible patients qualified because of elevated PREVENT-estimated cardiovascular risk and that untreated eligible patients were more likely to have lower income and educational attainment, underscoring persistent disparities in hypertension management.
The study had several limitations. Because treatment was not randomly assigned, residual confounding could not be excluded. Because projected mortality reductions were derived from observational data and simulation models, they should not be interpreted as causal. Blood pressure and drug use were assessed at baseline, and the findings may not be generalizable to all patient populations.
The hypertension guideline recommendations may improve long-term outcomes among US adults newly eligible for antihypertensive therapy, although prospective studies are needed to confirm the projected population-level benefits.
“Extending treatment to all eligible adults could prevent [more than] 200,000 all-cause and 160,000 cardiovascular deaths over the next decade,” wrote lead study author Mustafa Al-jarshawi, MBChB, MSc, MRCP, of the Centre for Health Informatics in the Division of Informatics, Imaging and Data Science in the Faculty of Biology, Medicine and Health at the University of Manchester, and colleagues.
The study authors reported no conflicts of interest.
