Nearly 23 million Americans with blood pressure of 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 today in the Journal of the American Heart Association.
The study, one of the first detailed assessments of the 2025 guideline, analyzed data from 81 million U.S. adults with high blood pressure and no cardiovascular disease. It found that 22.8 million (28%) were guideline-eligible for therapy, yet 9.7 million (43%) of those eligible were not receiving treatment. This treatment gap could have serious implications, as the analysis estimates 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.
The 2025 guideline emphasizes a personalized approach, using the American Heart Association’s PREVENTTM risk equations to calculate 10-year cardiovascular disease risk for adults aged 30-79 without known cardiovascular disease. This helps healthcare professionals identify who may benefit from medication in addition to lifestyle changes.
“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 study lead author Mustafa Al-Jarshawi, M.B.Ch.B., M.Sc., MRCPUK, PgCert, an academic clinical fellow in cardiology at Keele University in the United Kingdom.
The study found that among eligible adults, receiving blood pressure-lowering medications was associated with a 23% lower risk of dying from any cause and a 50% lower risk of dying from heart-related issues, compared to those who did not receive treatment. Those who would benefit most were older (average age 66) and had more health conditions, including diabetes, chronic kidney disease, and other cardiovascular risk factors.
Lifestyle modification remains the foundation of high blood pressure management. “Maintaining a healthy weight, consuming a heart-healthy diet, reducing sodium intake, increasing physical activity, getting enough sleep, managing stress and limiting alcohol can meaningfully lower blood pressure and overall cardiovascular risk,” said study senior author Mamas A. Mamas, M.D, DPhil., Professor of Cardiology 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. If 10-year risk is low (PREVENT score under 7.5%), maintaining a healthy lifestyle can help delay or avoid needing medication. However, for those with higher risk, medication may be necessary.
“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,” said Daniel W. Jones, M.D., FAHA, chair of the American Heart Association’s 2025 guideline writing committee, who was not involved in the study.
The study had limitations, including that blood pressure was measured during a single office visit, whereas the current guideline recommends multiple readings over multiple visits. Researchers also examined treatment at only one point in time, so the study could not capture changes in medication use over time. Despite these limitations, the findings underscore the importance of implementing the 2025 guideline to close the treatment gap and reduce cardiovascular mortality.
