New guidelines limit hypertension treatment in adults over 65

1. In this cross-sectional study, 11.4% of adults aged 65 years or older with untreated stage 1 hypertension, predominantly women with moderate cardiovascular risk, would no longer be eligible for pharmacotherapy under the new risk-based hypertension guidelines.

2. The majority of older adults already receiving antihypertensive therapy would remain eligible under the updated guidelines.

Evidence Rating Level: 3 (Average)

Study Rundown: The 2025 hypertension guidelines from the American Heart Association and the American College of Cardiology introduce a risk-based approach to stage 1 hypertension, using PREVENT (Predicting Risk of Cardiovascular Disease EVENTs) equations to guide treatment decisions. Under these guidelines, pharmacotherapy is recommended for individuals whose estimated 10-year cardiovascular risk exceeds 7.5%, representing a shift from traditional age-based treatment criteria. This study examined how applying risk-guided therapy would influence treatment recommendations for older adults, particularly those aged 65 years and older. Among participants in this age group, roughly one-eighth had untreated stage 1 hypertension. While all would have been eligible for pharmacotherapy under previous age-based guidelines, the new risk-based approach reclassified just over one-tenth as ineligible. These individuals were predominantly younger women with lower PREVENT risk scores and no major high-risk comorbidities. In contrast, most participants already receiving antihypertensive therapy remained eligible for treatment under the current guidelines, regardless of measured blood pressure. However, determining eligibility among treated individuals remains challenging in cross-sectional analyses. The study’s generalizability is limited by the inability to definitively determine treatment eligibility in already treated participants. Overall, these findings support a shift from age-based treatment decisions toward personalized, risk-based care, highlighting the potential for more targeted and individualized hypertension management.

Click to read this study in the Annals of Internal Medicine

Relevant Reading: Development and Validation of the American Heart Association’s PREVENT Equations

In-Depth [cross-sectional study]: This study examined how new risk-guided hypertension guidelines might affect pharmacotherapy recommendations in adults aged 65 years or older. Data were drawn from the January 2013 to March 2020 cycles of NHANES (National Health and Nutrition Examination Survey), including older adults aged 65 to 79 years, classified as having normal blood pressure, elevated blood pressure, or stage 1 hypertension according to guideline thresholds. Among 2,099 older adults (representing 23.8 [95% CI, 21.3–26.3] million), 169 (≈2.1 [CI, 1.6–2.6] million) had untreated stage 1 hypertension. Under prior age-based guidelines, all 169 would have been eligible for pharmacotherapy. Under the new risk-based guidelines, 156 of 169 (88.6%; ≈1.9 [CI, 1.4–2.3] million) remained eligible, while 11.4% were reclassified as ineligible. All newly ineligible individuals were women, non-smokers, aged 65–68 years, with total cholesterol 4.0–6.8 mmol/L (155–262 mg/dL), HDL cholesterol 1.2–2.3 mmol/L (45–87 mg/dL), body mass index 20–36 kg/m², estimated glomerular filtration rate 73–99 mL/min/1.73 m², systolic blood pressure 114–136 mm Hg, and PREVENT risk 4.8–7.4%. Among 883 participants (≈9.9 [CI, 8.8–11.0] million) on antihypertensive therapy, 874 (98.7% [CI, 96.6–99.5%]; ≈9.8 million) had either high-risk comorbidities (65.3%; ≈6.1 million) or elevated PREVENT risk (98.5%; ≈9.8 million), meeting criteria under the new guidelines. Overall, these findings suggest that risk-based guidelines would render 11.4% of older adults with untreated stage 1 hypertension ineligible for pharmacotherapy, supporting a shift toward more individualized treatment decisions.

Image: PD

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