The American Heart Association (AHA) has spent the last eight years revamping the 2017 Hypertension Guidelines, and it shows. There have been a notable number of new recommendations and improvements with an emphasis on prevention and lifestyle modifications. The AHA has also shifted to a more collaborative treatment approach, including nuanced guidance to navigate this multifaceted disease state that burdens nearly half of adult Americans.[1]
A New Method to Predicting the Probability of a Cardiovascular Event
Predicting risk of Cardiovascular (CVD) Events (PREVENT) replaces the Pooled Cohort Equations, a tool formerly used to calculate the 10-year risk of having a CVD event. PREVENT is the first of its kind that utilizes kidney, metabolic and socioeconomic factors to determine a more inclusive score. PREVENT predicts the 10- and 30-year risk for CVD events, including heart failure and Atherosclerotic CVD.[2] Studies have shown underestimation among certain demographics, which have led to missed opportunities to intervene and begin treatment. Although in need of more fine tuning, by shifting to a more inclusive approach, PREVENT can provide a more complete baseline and improve patient outcomes.
Categorization of Hypertension Stages
Historically, Prehypertension was defined as a systolic reading between 120-129 mm Hg and a diastolic reading of less than 80 mm Hg.[3] The new guidelines reclassified this simply as Hypertension or high blood pressure (BP), removing pre-hypertension all together, and prompting drug therapy initiation if the 10-year cardiovascular risk (defined by PREVENT score) is greater than, or equal to 7.5%. Hypertensive urgency is now a dated term, and is simply “hypertensive emergency”, a reading greater than180/120 mm Hg.
What About the Drug Therapy options?
Same drug classes—different execution. In 2025, the AHA shifted from race-based therapy recommendations to an individualized approach. Previously, for African Americans, initial treatment options were either thiazide diuretics, or calcium channel blockers not an angiotension Enzyme Inhibitors or angiotension Receptor Blockers. Comparatively, in other demographics, all four drug classes were considered. Despite the AHA’s previous recommendations, it did not yield favorable outcomes; for example, from 2017-2020, the control rate of high blood pressure in African Americans was 18% worse than their counterparts.[4] The riddance of race-based blood pressure recommendations will hopefully encourage practitioners to create more individualized treatment plans.
How Have the Therapy Recommendations Evolved?
The new guidelines have introduced initiating two drugs when the patient has systolic 2 consecutive systolic readings of 130mm Hg instead of 140mm Hg (per 2017 guidelines). Fifty-percent of patients are non-adherent to their blood pressure medications one year after therapy initiation, so introducing two drugs may exacerbate this problem. What’s more, from a provider perspective, it would be difficult to pinpoint which side effect profile corresponds to which medication, thus further complicating dosage titrations. A solution to reducing pill burden would be combination products, which the guidelines encourage. However, due to the ever-changing healthcare landscape of prior authorizations and insurance formulary changes, combination medications may not be accessible for many.
The Correlation Between High BP and Dementia: How in the World is Dementia Related to BP?
Midlife high blood pressure is the leading risk factor for white matter abnormalities in the brain, which are markers related to cognitive decline and dementia. In the previous 2017 guidelines, there were hypotheses that controlling systolic BP may reduce the occurrence of certain types of dementia. Since then, those theories have been confirmed with various studies, and current guidance is that reaching a target goal of 130mm Hg/80mm Hg can prevent cognitive impairment.
More Stringent Blood Pressure Goals in Pregnancy
Due to growing evidence that elevated BP can complicate pregnancy pre- and post-delivery, the new guidelines lowered the BP goal to 130mm Hg over 80mm Hg. The guidelines further recommend individuals that already have high blood pressure and are planning to become pregnant should be counseled on the use of aspirin to prevent preeclampsia.
[1] https://www.cdc.gov/high-blood-pressure/data-research/facts-stats/index.html
[2] https://professional.heart.org/en/guidelines-and-statements/prevent-calculator
[3] https://www.ahajournals.org/doi/10.1161/cir.0000000000000678
[4] https://minorityhealth.hhs.gov/heart-disease-and-blackafrican-americans
As Told By a Pharmacist 
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