DALLAS – Nearly 23 million Americans with blood pressure 130/80 mm Hg or higher may be eligible for blood-pressure-lowering medications based on the 2025 American Heart Association/American College of Cardiology guideline, according to new independent research published in the Journal of the American Heart Association.
The study, one of the first detailed assessments of the 2025 guideline, found that among 81 million US adults with high blood pressure and no cardiovascular disease, 22.8 million (28%) were guideline-eligible for therapy. Of these, 9.7 million (43%) remained untreated, representing a significant treatment gap. The analysis estimated that extending medication to all untreated eligible adults could prevent approximately 200,000 all-cause deaths and 162,000 cardiovascular deaths over the next decade.
“What stood out most was the size of the treatment gap – more than 40% of people who were clearly eligible under the new guideline were not receiving treatment, as well as the scale of the potential benefit,” said lead author Mustafa Al-Jarshawi, M.B.Ch.B., M.Sc., MRCPUK, PgCert, an academic clinical fellow at Keele University in the United Kingdom.
The 2025 guideline recommends lifestyle changes—such as a healthy diet, weight management, regular physical activity, and reducing salt and alcohol—as a foundation for treatment, with medication prescribed when appropriate. It also advises healthcare professionals to use the American Heart Association’s PREVENT risk equations to calculate 10-year cardiovascular disease risk for adults aged 30-79 without known cardiovascular disease.
Researchers analyzed data from the National Health and Nutrition Examination Survey (NHANES) collected between 2009 and 2018, linking blood pressure treatments to mortality rates. Among eligible adults, those receiving blood pressure-lowering medications had a 23% lower risk of dying from any cause and a 50% lower risk of dying from heart-related issues compared to untreated individuals. People most likely to benefit were older, with an average age of 66, and had more health conditions such as diabetes, chronic kidney disease, and other cardiovascular risk factors.
“Lifestyle modification remains the foundation of high blood pressure management,” said senior author Mamas A. Mamas, M.D., DPhil., professor at Keele University. “For many people, especially those with blood pressure under 140/90 mm Hg and no history of heart disease, stroke, chronic kidney disease or diabetes, lifestyle changes can be enough at first.” He noted that if a person’s 10-year risk is low, with a PREVENT score under 7.5%, maintaining a healthy lifestyle can help delay or avoid medication.
Daniel W. Jones, M.D., FAHA, chair of the 2025 guideline writing committee, emphasized the importance of a personalized approach. “Controlling blood pressure is crucial for long-term health. 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.”
The study had limitations, including that blood pressure was measured during a single NHANES visit, whereas the current guideline recommends multiple readings over multiple visits. Additionally, researchers did not randomly assign treatment, so other unmeasured factors may have influenced results. Despite these limitations, the findings underscore the potential impact of the updated guideline on public health, highlighting the need to address the treatment gap and reduce cardiovascular mortality.
