For years, most adults over 65 with mildly elevated blood pressure were told they needed drug treatment. The 2025 American Heart Association and American College of Cardiology hypertension guideline changes that. Treatment decisions now hinge on a person's overall cardiovascular risk, not just the number on the cuff.
A cross-sectional analysis of national health data, published in Annals of Internal Medicine, estimated that 11.4 percent of older adults with untreated stage 1 hypertension would become ineligible for medication under the new criteria. The reclassified group consisted exclusively of women aged 65 to 68, non-smokers, with 10-year cardiovascular risk scores between 4.8 and 7.4 percent.
The guideline does not tell anyone to stop their medication on their own. It says the decision to start treatment should be individualized, especially for older adults, where the risk of falls, dizziness and drug interactions can rival the benefit.
The PREVENT model is central to the shift
The 2025 guideline tells clinicians to use the American Heart Association's PREVENT (Predicting Risk of CVD Events) equations to estimate 10-year cardiovascular risk in adults aged 30 to 79. The calculator replaces the older Pooled Cohort Equations and factors in kidney function, statin use and social determinants of health that earlier tools left out.
Also read: 9 warning signs of lupus, the autoimmune disease that mainly strikes women
Anyone with a PREVENT score of 7.5 percent or higher, or with prior heart disease, stroke, diabetes, chronic kidney disease or stage 2 hypertension (140/90 mm Hg or above), is still clearly recommended for medication when readings reach 130/80. For lower-risk people with readings in the 130-139/80-89 range, the guideline recommends trying lifestyle changes first for three to six months before adding drugs.
What the numbers actually mean
The threshold for a hypertension diagnosis remains 130/80 mm Hg, unchanged from the 2017 guideline. What has changed is when medication is added on top of lifestyle changes.
A separate analysis by American Heart Association researchers estimated that nearly one in three US adults with high blood pressure, about 23 million people, may be newly eligible for medication under the guideline, because the individualized risk assessment picks up people at genuine cardiovascular risk who were missed before.
"Lifestyle modification remains the foundation of high blood pressure management," said study senior author Mamas A. Mamas. "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."
Also read: How drinking more water can affect your blood pressure
Daniel W. Jones, chair of the 2025 guideline committee, emphasized that the risk-based approach cuts both ways. "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," he said.
What to bring up at the next check-up
Older adults on blood pressure medication should not change anything without talking to their doctor. Three questions are worth bringing to the next visit. What is my 10-year cardiovascular risk under the PREVENT model? Do I have conditions such as diabetes or kidney disease that make my target stricter? And if I am already on medication, does my current dose still fit my overall risk and my risk of falls?
Also read: A personalized mRNA shot cleared a phase 3 first against aggressive melanoma
This article is made and published by Jesper Bengtson, who may have used AI in the preparation.