A shift from age-based treatment criteria to individualized cardiovascular risk assessment could reclassify about 240,000 US adults aged 65 to 79 years with stage 1 hypertension as no longer automatically eligible for antihypertensive pharmacotherapy, according to a cross-sectional analysis published in Annals of Internal Medicine.

Among untreated older patients with stage 1 hypertension, 11% would not meet criteria for immediate drug therapy initiation under the 2025 guideline from the American Heart Association and American College of Cardiology, the researchers reported.

Background and Guideline Change

The updated guideline retains traditional blood pressure staging but replaces an age-based trigger for pharmacologic treatment with individualized cardiovascular risk scoring.

Stage 1 hypertension remains defined as systolic blood pressure of 130 to 139 mmHg or diastolic blood pressure of 80 to89 mmHg.

Under the 2017 guideline, adults aged 65 years or older with stage 1 hypertension were eligible for pharmacotherapy even without additional risk factors.

The 2025 guideline instead recommends treatment based on either:

• a 10-year cardiovascular disease risk of 7.5% or higher using the Predicting Risk of Cardiovascular Disease Events (PREVENT) equations, or

• the presence of high-risk comorbidities such as diabetes, chronic kidney disease, or clinical cardiovascular disease.

Methods

Researchers analyzed data from the January 2013 through March 2020 cycles of the National Health and Nutrition Examination Survey, a nationally representative cross-sectional survey.

The study included adults aged 65 to 79 years.

Blood pressure was determined using the average of the last two measurements or a single available measurement.

Participants were categorized as having normal blood pressure, elevated blood pressure, or stage 1 hypertension according to guideline thresholds. Treatment status was determined from medication data.

High-risk comorbidities—including diabetes, chronic kidney disease, and clinical cardiovascular disease—were identified using questionnaire and laboratory data.

Ten-year cardiovascular risk scores were calculated using the base PREVENT equations, and survey weights were applied to produce nationally representative estimates.

Key Findings

Among 2,099 older adults in the sample, representing 23.8 million US adults, 169 patients (about 2.1 million nationally) had untreated stage 1 hypertension.

Under the 2017 guideline, all 169 patients would have qualified for antihypertensive pharmacotherapy based on age alone.

Under the 2025 guideline:

• 156 patients (89%) remained eligible for pharmacotherapy

• 13 patients (11%) were reclassified as not eligible for immediate drug therapy

This group corresponds to an estimated 240,000 US adults.

Patients reclassified as ineligible for pharmacotherapy had a consistent clinical profile.

All were female, nonsmokers, and aged 65 to 68 years. Their PREVENT risk scores ranged from about 5% to 7%, with an average risk of 7%, compared with 15% among patients who remained eligible.

None had high-risk comorbidities.

Additional characteristics included:

• systolic blood pressure of 114 to 136 mmHg

• body mass index of 20 to 36 kg/m²

• estimated glomerular filtration rate of 73 to 99 mL/min/1.73 m²

• total cholesterol of 155 to 262 mg/dL

• high-density lipoprotein cholesterol of 45 to 87 mg/dL

Among patients who remained eligible for pharmacotherapy under the 2025 guideline:

• 57% qualified because of high-risk comorbidities

• 43% qualified based on a PREVENT risk score of at least 7.5%

Already-Treated Population

Researchers also examined 883 older adults already receiving antihypertensive therapy, representing about 9.9 million US adults.

Because pretreatment blood pressure readings were unavailable, researchers could not determine whether these patients would have met the new guideline criteria before starting therapy.

However, 99% had either high-risk comorbidities or an elevated PREVENT risk score, suggesting most would likely meet eligibility criteria under the 2025 guideline.

Limitations

The cross-sectional design prevented researchers from determining pretreatment blood pressure values for patients already receiving antihypertensive therapy.

PREVENT risk scores for treated patients were calculated using models that account for antihypertensive use under previous guidelines, and the PREVENT equations do not currently have a defined role in guiding treatment decisions among patients already receiving therapy.

The researchers also noted that analyses accompanying the new hypertension guideline reported minimal changes in overall treatment eligibility across the broader population. The present study focused specifically on the age threshold of 65 years, where the 2017 and 2025 recommendations differ most.

“Our findings among older adults underscore the guideline shift toward personalized, risk-based care,” the researchers wrote.

Disclosures and Source

Disclosure forms are available with the article online.

Source: Annals of Internal Medicine