Abstract
BACKGROUND: Hypertension affects nearly half of U.S. adults. The 2025 American College of Cardiology/American Heart Association guideline adopts the Predicting Risk of Cardiovascular Disease Events (PREVENT) risk equations and updates treatment recommendations for stage 1 hypertension, potentially altering eligibility for antihypertensive therapy. OBJECTIVES: The primary objective was to quantify changes in antihypertensive treatment eligibility under the 2025 vs 2017 guidelines. Secondary objectives were to characterize adults newly meeting treatment thresholds, assess concordance and discordance in eligibility, and evaluate robustness across PREVENT model variants. METHODS: We conducted a simulation-based analysis using nationally representative National Health and Nutrition Examination Survey data (2017-2020) among adults aged 30 to 79 years. Treatment eligibility was assigned using 2017 and 2025 guideline criteria. Survey-weighted estimates quantified population-level eligibility, newly eligible adults, and concordance patterns. Analyses were repeated using PREVENT Base, Full, hemoglobin A1c, and albumin-to-creatinine ratio variants, and multivariable models identified predictors of eligibility. RESULTS: Among 5,578 adults (weighted population 160 million), 36.4% were eligible for treatment under the 2017 guideline and 36.6% under the 2025 guideline, representing a minimal net increase of 0.7% (approximately 400,000 adults). Most adults were consistently ineligible (63.3%), whereas one-third were consistently eligible (36.3%). Newly eligible adults were predominantly older women with higher body mass index and borderline glycemic measures but without established cardiovascular disease. Eligibility patterns were stable across racial and ethnic groups. Analyses were repeated across all PREVENT risk equation variants, and multivariable models identified predictors of eligibility. CONCLUSIONS: Adoption of the 2025 American College of Cardiology/American Heart Association guideline results in a minimal expansion of antihypertensive treatment eligibility. Results were robust across PREVENT model variants, supporting risk-based guideline implementation.