Population-Level 10-Year Implications of the New 2025 American Heart Association/American College of Cardiology Hypertension Guideline Recommendations for Primary Prevention in the United States: A NHANES-Based Cohort Study (2009–2018)

BACKGROUND: In August 2025, the American Heart Association and American College of Cardiology released updated hypertension guidelines. Under the new guidelines, therapy is advised at blood pressure ≥130/80mmHg in adults with diabetes, chronic kidney disease, or a Predicting Risk of Cardiovascular Disease Events-estimated 10-year cardiovascular disease risk ≥7.5%. The long-term population-level changes following these guidelines remains uncertain. METHODS: We analyzed NHANES (National Health and Nutrition Examination Survey) 2009 to 2018 data linked to mortality through 2019. Hypertensive adults without baseline cardiovascular disease were included. Treatment eligibility was defined using guideline criteria. Cox models estimated associations between antihypertensive therapy and all-cause and cardiovascular mortality. Simulation analyses projected lives saved under full and partial treatment uptake. RESULTS: The weighted cohort represented 81.0 million US adults with hypertension. Of these, 22.8 million (28%) were guideline eligible for therapy; 13.1 million (57%) were treated, and 9.7 million (43%) remained untreated. Antihypertensive therapy was associated with a 23% reduction in all-cause mortality (hazard ratio [HR], 0.77 [95% CI, 0.63–0.94]) and 50% reduction in cardiovascular mortality (HR, 0.50 [95% CI, 0.36–0.68]). At 10years, universal treatment of eligible but untreated adults was projected to prevent ~200900 all-cause and~162600 cardiovascular deaths. Benefits were greatest in adults with diabetes. CONCLUSIONS: In this nationally representative cohort, nearly 1 in 3 US adults with hypertension were newly eligible for therapy under the guideline, yet >2 in 5 remained untreated. Extending treatment to all eligible adults could prevent >200000 all-cause and 160000 cardiovascular deaths over the next decade.