A new analysis found that updated hypertension guidance modestly reduces the number of older adults recommended for immediate drug therapy.

The cross-sectional analysis, published in the Annals of Internal Medicine, examined National Health and Nutrition Examination Survey data from 3000 adults aged 65-79 years. Of those with untreated stage I hypertension, 11.4% would no longer meet criteria for immediate treatment under the updated 2025 guideline from the American Heart Association and the American College of Cardiology. Data were drawn between 2013 and 2020.

Among those already receiving antihypertensive medications, the vast majority would still qualify for treatment under the 2025 framework, either because of high-risk comorbidities or elevated PREVENT scores.

PREVENT captures a person’s 10-year risk of developing major cardiovascular disease (CVD) by combining their age, sex, blood pressure, cholesterol levels, kidney function, diabetes status, smoking status, and medication use into a single absolute risk estimate.

Patients reclassified as ineligible were female aged 65-68 years, nonsmokers, and those with cholesterol levels of 4.0-6.8 mmol/L, high-density lipoprotein cholesterol levels of 1.2-2.3 mmol/L, BMI scores of 20-36, estimated glomerular filtration rates of 73-99 mL/min/1.73 m², and systolic blood pressure scores of 114-136 mm Hg. Their PREVENT scores were between 4.8% and 7.4%.

Under the prior age-based framework, these patients may have moved more quickly toward pharmacotherapy.

“In the past, many adults age 65 and older with stage I hypertension would often have been considered candidates for medication based mainly on age,” said Sridhar Mangalesh, MD, resident physician at Jacobi Medical Center in Bronx, New York, and a first author of the study. “We wanted to understand what this important conceptual change looks like in the real world: which older adults remain eligible for immediate therapy, which may no longer need immediate medication, and what those patients tend to look like.”

“The 2025 guideline places strong emphasis on lifestyle changes across a wide range of patients, and in lower-risk people with stage I hypertension, it explicitly supports a 3- to 6-month trial of lifestyle intervention before medication,” said Michael Nanna, MD, assistant professor of internal medicine at Yale School of Medicine in New Haven, Connecticut, and an author of the study.

Under the 2017 guideline, adults with stage I hypertension were recommended for pharmacotherapy if they had a 10-year atherosclerotic (ASCVD) risk ≥ 10%, diabetes, chronic kidney disease, established CVD, or were aged 65 years or older.

Unlike ASCVD, PREVENT explicitly integrates kidney and metabolic function into risk prediction, said Laura Mayeda, MD, MPH, clinical assistant professor in the Department of Medicine at the University of Washington School of Medicine in Seattle.

The new guidelines aren’t likely to upend clinical practice because most people were found to remain eligible for medication in the analysis, Nanna said.

But calculating risk using PREVENT becomes most relevant where eligibility is otherwise uncertain, said Mangalesh. “Our study adds practical value by showing that this is not a futile exercise, as risk will not simply come out high for everyone in this age range.”

The new guidelines “could stave off medications for a couple of years in individuals who are very successful in lifestyle intervention,” Mayeda said. Lifestyle interventions include a low-salt or Dietary Approaches to Stop Hypertension diet and three to five 30-minute sessions of exercise per week.

The sources cited in this article reported no relevant financial disclosures. No funding was reported.

Brittany Vargas is a journalist covering medicine, mental health, and wellness.