Guideline‐Directed Treatment Eligibility and Burden of Untreated Stage‐1 Hypertension Under the 2025 American College of Cardiology/American Heart Association Hypertension Guideline: Insights From NHANES 2015 to 2020

Background Hypertension is a major risk factor for cardiovascular disease. Adoption of the Predicting Risk of Cardiovascular Disease Events risk model in the 2025 American College of Cardiology/American Heart Association guideline may substantially alter the number and characteristics of adults with untreated stage 1 hypertension who are recommended for treatment. We aimed to quantify treatment‐recommendation reclassification among adults with untreated stage 1 hypertension under the 2025 Predicting Risk of Cardiovascular Disease Events–based guideline compared with the 2017 pooled cohort equations–based guideline. Methods This cross‐sectional, nationally representative study used data from NHANES (National Health and Nutrition Examination Survey) 2015 to March 2020. The study population included adults aged 30 to 79 years with stage 1 hypertension, focusing on untreated participants. The exposure was the guideline‐endorse cardiovascular risk assessment framework, pooled cohort equations, and Predicting Risk of Cardiovascular Disease Events, respectively. The primary outcome was recommendation for antihypertensive pharmacotherapy. Results Among 1926 adults with stage 1 hypertension (weighted 32.57 million), 59.59% (19.41 million) were untreated. Under the 2025 guideline, 13.84% (95% CI, 7.06%–20.63%) of untreated adults eligible under the Predicting Risk of Cardiovascular Disease Events threshold (0.42 million) became newly eligible for pharmacotherapy compared with the 2017 guideline. Newly eligible adults were older (mean±SE, 60.48 [0.77] years) and had higher diabetes prevalence (37.74% [95% CI, 15.45%–60.04%]) than those below the treatment threshold. Conclusions The 2025 American College of Cardiology/American Heart Association hypertension guideline recommendations were largely concordant with the prior guideline among adults with untreated stage 1 hypertension, while still newly identifying a subset of individuals with elevated cardiometabolic risk who may benefit from earlier intervention.