DALLAS – Nearly 23 million Americans with blood pressure of 130/80 mm Hg or higher may be eligible for blood-pressure-lowering medications under the 2025 American Heart Association/American College of Cardiology guideline, according to new independent research published in the Journal of the American Heart Association.

The study, one of the first detailed assessments of the 2025 guideline, found that among 81 million US adults with high blood pressure and no cardiovascular disease, 22.8 million people, or 28%, were eligible for therapy under the guideline. Of those eligible adults, 9.7 million, or 43%, were still untreated, indicating a substantial treatment gap in a condition that is common, often managed over time, and closely tied to long-term cardiovascular risk. The analysis estimated that providing medication to all untreated eligible adults could prevent about 200,000 all-cause deaths and 162,000 cardiovascular deaths over the next decade.

“What stood out most was the size of the treatment gap – more than 40% of people who were clearly eligible under the new guideline were not receiving treatment, as well as the scale of the potential benefit,” said lead author Mustafa Al-Jarshawi, M.B.Ch.B., M.Sc., MRCPUK, PgCert, an academic clinical fellow at Keele University in the United Kingdom.

The 2025 guideline recommends lifestyle changes, including a healthy diet, weight management, regular physical activity, and reducing salt and alcohol intake, as the foundation of treatment, with medication used when appropriate. It also advises healthcare professionals to use the American Heart Association’s PREVENT risk equations to calculate 10-year cardiovascular disease risk for adults ages 30 to 79 without known cardiovascular disease, adding a risk-based layer to treatment decisions rather than relying on blood pressure alone.

Researchers analyzed data from the National Health and Nutrition Examination Survey (NHANES) collected between 2009 and 2018 and linked blood pressure treatment status to mortality rates. Among eligible adults, those receiving blood-pressure-lowering medications had a 23% lower risk of death from any cause and a 50% lower risk of death from heart-related causes than untreated individuals. The people most likely to benefit were older adults, with an average age of 66, and they were more likely to have diabetes, chronic kidney disease, and other cardiovascular risk factors.

“Lifestyle modification remains the foundation of high blood pressure management,” said senior author Mamas A. Mamas, M.D., DPhil., professor at Keele University. “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.” He added that if a person’s 10-year risk is low, with a PREVENT score below 7.5%, maintaining a healthy lifestyle can help delay or avoid medication.

Daniel W. Jones, M.D., FAHA, chair of the 2025 guideline writing committee, stressed the need for individualized treatment. “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 to reduce the risk of serious complications from untreated high blood pressure,” he said.

The study had limitations. Blood pressure was measured during a single NHANES visit, while the current guideline recommends multiple readings across multiple visits. The researchers also did not randomly assign treatment, meaning other unmeasured factors may have influenced the results.

Even with those limitations, the findings point to the potential public health impact of the updated guideline and underscore the importance of identifying who meets treatment thresholds so the gap between eligibility and care can be narrowed.