In August, the American College of Cardiology (ACC) and the American Heart Association (AHA) released a joint statement, Use of Risk Assessment to Guide Decision-Making for Blood Pressure Management in the Primary Prevention of Cardiovascular Disease. This statement follows the replacement of the Pooled Cohort Equations (PCE) recommended in 2017 with the Predicting Risk of Cardiovascular Disease Events (PREVENT) equations in 2025, which estimate the 10-year risk of total cardiovascular disease (CVD), as opposed to just atherosclerotic cardiovascular disease as with the 2017 PCE. The PREVENT equations represent a key advancement in accurate and precise CVD risk prediction, thereby improving the identification of individuals for risk-based hypertension management.

This statement summarizes the rationale and population-level implications of recommending the PREVENT equations and offers practical advice for implementing risk assessment as the first step in hypertension management. The statement features seven main sections, which are outlined below. The full-text version of the statement is also available online.

Key Elements of the 2025 ACC/AHA Statement

Initiation of Antihypertensive Drug Therapy for Stage 2 Hypertension

  • For adults with and without CVD, the initiation of drug therapy coupled with lifestyle modification is recommended for adults with an average systolic blood pressure ≥140 mm Hg or diastolic blood pressure ≥90 mm Hg to reduce blood pressure and their risk of CVD. This recommendation did not change from the 2017 guideline. 

Risk-Based Initiation of Antihypertensive Drug Therapy for Stage 1 Hypertension

  • The 2025 guideline recommends antihypertensive treatment for patients with stage 1 hypertension who are at increased risk of CVD and for whom treatment would confer clinically meaningful absolute risk reduction. Patient groups that may benefit the most were identified to include patients with prevalent CVD, diabetes, chronic kidney disease, and an estimated 10-year risk for total CVD ≥7.5% by the PREVENT equations for the primary prevention of CVD.
  • The PREVENT equations are the preferred way to calculate CVD risk and to guide initiation of antihypertensive therapy due to the large sample size of PREVENT, better discrimination and calibration compared to PCE, and the expansion of the predicted outcome to a more relevant outcome of total CVD.

Rationale for PREVENT-Based 10-Year CVD Risk Threshold ≥7.5% for Initiation of Antihypertensive Drug Therapy in Stage 1 Hypertension

  • The decision to opt for a new risk model in the 2025 guideline update came with the need to determine the appropriate equivalent predicted risk thresholds for PREVENT. The new thresholds were determined based on randomized controlled trials data that included distribution of predicted risk, subgroup analyses by predicted risk, and mean event rates; population-level predicted risk distributions to support equivalent risk thresholds across risk prediction models; and population-level implications of the 2025 guideline-selected risk threshold. 

Race in CVD Risk and Risk-Based Initiation of Antihypertensive Drug Therapy

  • Unlike the PCEs, PREVENT does not include race as a predictor for several reasons. The statement outlines those reasons to include the fact that race is not a biological trait, aligning with the larger consensus of removing race from care algorithms to prioritize race-conscious perspectives in clinical decision-making. 
  • Additionally, the statement notes that race does not contribute to predictive utility among a larger, diverse sample, and the discrimination and calibration metrics of PREVENT were tested in each racial and ethnic group as part of external validation and demonstrated better performance relative to the race-specific PCEs. The statement emphasizes the fact that the removal of race and ethnicity as a predictor in the PREVENT equations does not imply that racial disparities in CVD or racism do not exist, nor does it minimize the urgent need to address these health disparities.

Holistic Risk Assessment Beyond Quantitative Risk Estimation

  • Since PREVENT is intended for adults between the ages of 30 and 79 years old, risk estimates cannot be calculated for adults younger than 30 and adults 80 and older. However, the statement points out that it is a reasonable expectation that most adults 80 and older are at increased CVD risk, and that most adults younger than 30 are at a lower CVD risk, on the basis of age alone.
  • The 2025 guidelines recommend that antihypertensive drug therapy be initiated for younger adults with stage 1 hypertension for whom risk cannot be calculated if initial lifestyle interventions are not successful after a three- to six-month trial. This recommendation is particularly notable for minority populations who are more likely to develop hypertension at a young age.
  • Potential limitations are recognized in the PREVENT equations in populations who may have been underrepresented in the development or those at heightened CVD risk due to risk-enhancing factors. Thus, not all patients with a 10-year predicted total CVD risk of ≥7.5% are guaranteed to experience a CVD event over the next decade, and adults with a predicted risk of  <7.5% will experience a CVD event.

Addressing Implementation Gaps in Risk-Based Initiation of Antihypertensive Drug Therapy

  • Several identifiable barriers may hinder the integration of risk assessment tools into routine clinical practice. Limited access within workflows or inconsistent integration hinders their usability. Limited awareness or acceptability can hinder adoption. Time constraints can limit the ability to conduct comprehensive risk assessments during a routine visit. 
  • To overcome such barriers, the statement suggests integrating automated risk assessment prompts directly into EHR systems, which can improve documentation of risk factors and guideline-based management. Telehealth services can facilitate remote CVD risk assessment. 
  • Additionally, financial incentives can help reduce disparities in the implementation of risk assessment tools. 

Comprehensive Strategies to Reduce Hypertension-Related Risk

  • Modifiable lifestyle factors related to hypertension should be addressed to improve cardiovascular health and reduce blood pressure-related risk. 
  • Interventions that target stress reduction, physical activity, reduced alcohol intake, use of salt substitutes, reduced intake of sodium, heart-healthy dietary eating patterns, and weight loss are beneficial in treating and preventing hypertension.

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