9.7 Million Americans Just Became Eligible for Blood Pressure Drugs. Most Have Not Been Told.

In 2023, the American Heart Association and the American College of Cardiology replaced the calculator doctors use to decide who needs blood pressure medication. The replacement, called PREVENT, weighs kidney and metabolic health alongside the usual cardiovascular risk factors. It redrew the line, and the clinic has not caught up.

A peer-reviewed modeling study published Tuesday in the Journal of the American Heart Association puts a number on the lag. Of the roughly 22 to 23 million U.S. adults who became newly eligible for blood pressure therapy under the updated criteria, about 9.7 million (43% of them) are on no treatment at all. The remaining 13 million were already on some medication and may now be candidates for tighter control.

The new threshold is not a single blood-pressure number. The 2025 guideline update adopts PREVENT, which stands for Predicting Risk of cardiovascular disease EVENTs, for adults aged 30 to 79 without known cardiovascular disease. PREVENT was designed to surface risk drivers that earlier tools underweighted, including kidney function and metabolic status, so a patient whose old score sat comfortably under the treatment line can now find themselves on the other side. (Healio)

The researchers, using nationally representative CDC survey data from NHANES (2009-2018), estimate that expanding treatment to the newly eligible could prevent up to 200,000 deaths over the next decade. That projection is a model, not a clinical-trial outcome, and it carries the usual caveats about how PREVENT is calibrated and how treatment effects are extrapolated to people who were not in the original efficacy studies. (News-Medical)

The gap between eligibility and treatment is not a willpower problem. It is a system problem. Clinicians who trained on the old calculator may not yet be using PREVENT in routine visits. Risk calculators are slow to roll out in primary care, and electronic health records do not always surface the new score at the point of care. Patients told a year ago that their numbers were fine may reasonably assume that has not changed. The 9.7 million are, in the main, people who have not been told the line moved.

Underneath the eligibility expansion sits a real under-treatment problem. About 81 million U.S. adults already carry a hypertension diagnosis, and many have blood pressure that is poorly controlled on their current regimen. The new eligibility wave adds to that load rather than replacing it. For a clinic with a 15-minute visit, the new conversation is one more thing to fit in.

What a reader can do is straightforward. At the next appointment, ask the clinician whether PREVENT changes the risk category, and whether medication is now on the table. Bring a recent home blood-pressure log if you have one; office readings can be misleadingly high or low. If the answer is that the score has shifted, ask what changed and what the options are, including non-pharmacologic steps such as sodium reduction, weight management, and structured physical activity, which the new guidelines still treat as first-line for borderline risk.

A constructive reading of the study is not a one-sided one. "Newly eligible" includes people who were previously considered borderline, and over-treatment is a legitimate concern. The authors are explicit that medication is one tool, not the only one, and that the projection depends on how the new threshold is applied. The 9.7 million figure is best read as a system lag, not a refusal rate: a clinical decision rule changed under these patients, and the machinery that turns rules into prescriptions is a step behind.

The PREVENT-based guideline is now the standard of care. How quickly primary care absorbs it is the part worth tracking.