Guideline Reclassifies 11% of Older Adults With Stage 1 Hypertension

Overview

The 2025 AHA/ACC hypertension guideline reclassifies approximately 11% of untreated US adults aged 65 to 79 with stage 1 hypertension as no longer immediately eligible for antihypertensive pharmacotherapy. This change reflects a shift from age-based treatment criteria to individualized cardiovascular risk assessment.

Background

Stage 1 hypertension is defined as systolic blood pressure of 130 to 139 mmHg or diastolic blood pressure of 80 to 89 mmHg. The 2017 guideline recommended pharmacologic treatment for adults aged 65 years or older with stage 1 hypertension regardless of other risk factors. The 2025 guideline replaces this age-based trigger with treatment eligibility based on a 10-year cardiovascular disease risk of 7.5% or higher using the PREVENT risk equations or the presence of high-risk comorbidities such as diabetes, chronic kidney disease, or clinical cardiovascular disease.

Data Highlights

Key Findings

• Among untreated older adults with stage 1 hypertension, 11% were reclassified as not immediately eligible for drug therapy under the 2025 guideline.
• All reclassified patients were female, nonsmokers, aged 65 to 68 years, with PREVENT risk scores between 5% and 7% and no high-risk comorbidities.
• Patients remaining eligible had an average PREVENT risk score of 15%, with 57% qualifying due to high-risk comorbidities and 43% due to elevated risk scores.
• Among treated older adults, 99% had either high-risk comorbidities or elevated PREVENT risk scores, suggesting most would meet 2025 guideline criteria.
• The shift to risk-based treatment eligibility emphasizes personalized care rather than age alone.

Clinical Implications

Clinicians should incorporate individualized cardiovascular risk assessment using tools like the PREVENT equations when deciding on antihypertensive pharmacotherapy for older adults with stage 1 hypertension. This approach may reduce overtreatment in low-risk patients, particularly females aged 65 to 68 without comorbidities. Continued evaluation of patient risk profiles is essential to optimize treatment decisions under the updated guideline.

Conclusion

The 2025 hypertension guideline's move to risk-based treatment eligibility reclassifies a subset of older adults previously eligible by age alone, highlighting the importance of personalized cardiovascular risk assessment in guiding antihypertensive therapy.

References

1. Annals of Internal Medicine 2024 -- Guideline Reclassifies 11% of Patients With Stage 1 Hypertension