A new scientific statement from the American Heart Association (AHA) and American College of Cardiology (ACC) outlines the rationale behind the updated 2025 High Blood Pressure Guideline, which recommends a shift in cardiovascular risk assessment. The guideline now endorses the use of the Predicting Risk of Cardiovascular Disease Events (PREVENT) equations to guide the initiation of antihypertensive drug therapy in primary prevention.¹

The 2025 guideline moves away from the previously recommended Pooled Cohort Equations (PCEs) in favour of the more contemporary PREVENT equations. This change is based on several factors, including the development of PREVENT using a large, diverse, and modern US population sample, which provides superior discrimination and calibration.² Unlike the PCEs, which estimate the 10-year risk of atherosclerotic cardiovascular disease (ASCVD), the PREVENT equations calculate the 10-year risk of total cardiovascular disease (CVD), a composite of ASCVD and heart failure (HF). The new model also incorporates markers of cardiovascular-kidney-metabolic health and social determinants of health, and notably, does not use race as a predictor variable to avoid potential bias.

For adults with stage 2 hypertension (systolic BP ≥140 mmHg or diastolic BP ≥90 mmHg), the recommendation to initiate drug therapy alongside lifestyle modification remains unchanged. The primary update concerns patients with stage 1 hypertension (systolic BP 130–139 mmHg or diastolic BP 80–89 mmHg). For these individuals, the 2025 guideline recommends initiating antihypertensive drug therapy if they have one of the following:

• Prevalent CVD (for secondary prevention)
• Diabetes
• Chronic kidney disease (CKD)
• An estimated 10-year total CVD risk of ≥7.5% calculated using the PREVENT equations

This new ≥7.5% PREVENT risk threshold was determined to be approximately equivalent to the previous threshold of ≥10% ASCVD risk using the PCEs and the ≥15% Framingham Risk Score used in key clinical trials like SPRINT. Analysis showed that the number of US adults eligible for antihypertensive therapy under the new guideline is expected to remain similar to the 2017 recommendations.

The updated guideline encourages a more holistic and individualised approach to risk assessment in primary prevention. By using the PREVENT equations, clinicians can better identify patients with stage 1 hypertension who are most likely to benefit from antihypertensive medication. The integration of total CVD risk, including HF, provides a more comprehensive picture of a patient's prognosis. The removal of race from the calculation is a significant step towards more equitable care, as risk is instead informed by clinical factors and optional social determinants of health. For patients with stage 1 hypertension who do not meet the ≥7.5% risk threshold, a 3- to 6-month trial of lifestyle modification is recommended before considering drug therapy.

The statement highlights the need for innovative strategies to improve the implementation of these risk-based guidelines, including the automation of PREVENT risk assessment within electronic health records and the development of decision-support aids. Future research will focus on further refining risk prediction by potentially incorporating biomarkers and polygenic risk scores, as well as expanding the validation of the PREVENT equations in diverse and underrepresented populations.

References

1. Khan SS, Abdalla M, Bello NA, et al. Use of risk assessment to guide decision-making for blood pressure management in the primary prevention of cardiovascular disease: a scientific statement form the American Heart Association and American College of Cardiology. J Am Coll Cardiol. 2025;86(18):1539-1559. https://doi.org/10.1016/j.jacc.2025.08.001

2. Khan SS, Matsushita K, Sang Y, et al. Development and validation of the American Heart Association’s PREVENT equations. Circulation. 2024;149:430-449. https://doi.org/10.1161/CIRCULATIONAHA.123.067626

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