Top Things to Know: Use of Risk Assessment to Guide Decision-Making for Blood Pressure Management in the Primary Prevention of Cardiovascular Disease
Published: August 28, 2025
Prepared by Maggie Eaton, PhD, APRN, FNP
- Risk-based assessment plays a central role in hypertension management by aligning treatment decisions with overall cardiovascular disease (CVD) risk and blood pressure levels.
- The 2025 ACC/AHA/Multi-Society Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults recommends the American Heart Association Predicting Risk of Cardiovascular Disease Events (PREVENT™) equations to estimate 10-year risk of total CVD (PREVENT-CVD) and establishes the evidence-based treatment threshold of 10-year risk of total CVD of 7.5% or higher for initiation of drug therapy in adults with Stage 1 hypertension (130–139/80–89 mm Hg).
- This AHA/ACC scientific statement outlines the rationale for the guideline’s framework for risk-based assessment, including the adoption of the PREVENT-CVD equations and the 7.5% treatment threshold, and provides practical guidance to support clinical implementation and shared decision-making.
- The PREVENT equations include equations for each CVD outcome (PREVENT-CVD, PREVENT-ASCVD, and PREVENT-HF) and were developed using contemporary, nationally representative U.S. data from over 6 million adults and have been externally validated with strong performance across population subgroups, supporting their use to guide treatment decisions in primary CVD prevention.
- A 10-year CVD risk threshold of 7.5% using the PREVENT-CVD equations was selected based on alignment with trial inclusion criteria (e.g., SPRINT), equivalence to thresholds used in earlier models such as the Pooled Cohort Equations and Framingham Risk Score, and population-level evidence supporting net clinical benefit.
- Antihypertensive drug therapy, along with lifestyle changes, is recommended for all adults with Stage 2 hypertension (≥140/90 mm Hg), regardless of CVD status, based on strong evidence for reducing CVD events.
- Antihypertensive drug therapy, along with lifestyle changes, is recommended for adults with Stage 1 hypertension (130–139/80–89 mm Hg) who are at increased risk because they have CVD, diabetes, chronic kidney disease, or a 10-year total CVD risk of 7.5% or higher using the PREVENT-CVD equations.
- Risk assessment should integrate quantitative estimates with individual clinical factors, social drivers, and patient preferences to guide treatment decisions, especially near the 7.5% threshold; this holistic approach is particularly important for younger adults and those from high-risk populations.
- Effective implementation of risk-based antihypertensive therapy is hindered by challenges such as limited electronic health record integration, clinician training, and access to health care in under-resourced settings, highlighting the need for system-level strategies to improve adoption and accessibility.
- A comprehensive strategy to reduce hypertension-related risk should combine accurate risk prediction and targeted therapy with lifestyle interventions, public health policy, and ongoing research to refine tools like the PREVENT equations and expand their reach across broad populations and care settings.
Citation
Circulation: Use of risk assessment to guide decision-making for blood pressure management in the primary prevention of cardiovascular disease: a scientific statement from the American Heart Association and American College of Cardiology. Circulation. Published online August 28, 2025. doi: 10.1161/CIR.0000000000001355
Hypertension: Use of risk assessment to guide decision-making for blood pressure management in the primary prevention of cardiovascular disease: a scientific statement from the American Heart Association and American College of Cardiology. Hypertension. Published online August 28, 2025. doi: 10.1161/HYP.0000000000000248