Cosmos Study

2025 Hypertension Guideline Update Expands Stage 1 Treatment Eligibility from 57% to 73%

March 10, 2026

Team A:Kersten Bartelt, RNSam Sahakian

Team B:Louis Kazaglis, MDGrant Keane

Key Findings

After hypertension treatment guidelines changed in 2025, the share of patients with stage 1 hypertension who are eligible for treatment increased from 57% under the 2017 guideline to 73% under the new guideline.
51% of patients qualified for treatment under both the 2017 and 2025 guidelines, 22% became eligible under the 2025 guideline, and 6% became ineligible under the 2025 guideline.
Newly ineligible patients under the 2025 guideline were disproportionately female (75%) and aged 70 or older (64%).

The 2017 American Heart Association (AHA) guideline recommended antihypertensive medication for adults with stage 1 hypertension (130–139/80–89 mm Hg). The recommendation applies to patients who have established cardiovascular disease (CVD) or 10-year CVD risk greater than 10%, as estimated by the pooled cohort equations.¹ In August 2025, AHA released updated high blood pressure guidance that incorporates the AHA’s PREVENT risk equations and recommends a lower 10-year total CVD risk threshold of 7.5% for medication initiation in stage 1 hypertension.² Prior work comparing PREVENT with pooled cohort equations has found that PREVENT can generate different risk estimates across demographic groups,³ which raises practical questions about who gains eligibility, who loses eligibility, and whether these shifts could widen or narrow inequities in hypertension treatment.

We studied more than 1 million U.S. adults who had visits between August 1, 2024, and July 31, 2025, who had confirmed stage 1 hypertension based on two outpatient blood pressure readings in the stage 1 range (130–139 systolic or 80–89 diastolic). Patients were excluded if they had evidence of stage 1 or stage 2 hypertension prior to the first qualifying blood pressure reading, were prescribed antihypertensives prior to the study period, or had evidence of pregnancy between the two qualifying readings. We classified treatment eligibility at the index date under the 2017 guideline criteria (CVD, diabetes, CKD, or pooled cohort 10-year risk ≥10% documented in the record) versus 2025 criteria (CVD, diabetes, CKD, or PREVENT 10-year risk ≥7.5% calculated from available clinical data), which required all patients to have a score under both guidelines.

Across all included patients, 73% met the 2025 treatment-eligibility criteria compared with 57% under the 2017 criteria, as seen in Figure 1. This means clinicians could see a substantial expansion in treatment-eligible stage 1 patients. Of all patients, 51% were eligible under both guidelines, 22% were newly eligible under 2025 criteria (eligible under 2025 but not 2017), and 6% were no longer eligible under 2025 criteria (eligible under 2017 but not 2025); the remaining 21% were not eligible under either framework.

The increase in eligibility was not evenly distributed; most newly ineligible patients were women (75% of newly ineligible patients), and there was a high concentration of newly ineligible patients among those aged 70–79 (64%). By race and ethnicity, differences in newly ineligible patients were smaller than by sex or age but still present. These patterns are directionally consistent with published findings that PREVENT can yield lower predicted risk than pooled cohort equations in some subgroups.³

Figure 1

Stage 1 Hypertension Treatment Eligibility by Guideline

Figure 1. The distribution of patients with stage 1 hypertension who qualify for treatment based on the 2017 hypertension guidelines, the 2025 hypertension guidelines, both, or neither.

These data come from Cosmos, a dataset created in collaboration with a community of Epic health systems representing more than 300 million patient records from 1,900 hospitals and more than 44,000 clinics from all 50 U.S. states, Canada, Lebanon, and Saudi Arabia. This study was completed by two teams that worked independently, each composed of a clinician and research scientists. The two teams came to similar conclusions. Graphics by Brian Olson.

References

Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults. Hypertension. 2018;71(6). doi:10.1161/HYP.0000000000000065
Jones DW, Ferdinand KC, Taler SJ, et al. 2025 Guideline for the prevention, detection, evaluation and management of high blood pressure in adults. Circulation. Published online August 14, 2025. doi:10.1161/CIR.0000000000001356
Anderson TS, Wilson LM, Sussman JB. Atherosclerotic cardiovascular disease risk estimates using the Predicting Risk of Cardiovascular Disease Events equations. JAMA Intern Med. 2024;184(8):963-970. doi:10.1001/jamainternmed.2024.1302

Data Definitions

Study period: 8/1/2024 to 7/31/2025

Study population: inclusion

Patients who:

Have a residence in the U.S.
Were at least 30 years of age on the index date
Have an evaluated sex of female or male
Have a BP result that qualifies as stage 1 hypertension during the study period (considered the index event)
- BP measured in an outpatient face-to-face visit
- Last BP result from the visit taken
Have a second BP result that qualifies as stage 1 hypertension in the 1 week prior to 18 months prior to the index date
- BP measured in an outpatient face-to-face visit
- Last BP result from the visit taken

Study population: exclusion

Patients who:

Are prescribed an antihypertensive prior to study period
Qualify for stage 1 hypertension before the index date
Qualify for stage 2 hypertension before the index date
Have evidence of a pregnancy between the two qualifying BP readings

Index date: Date of the qualifying BP result during the study period

Exposures: 2017 treatment guidelines versus 2025 treatment guidelines

Stage 1 hypertension: A blood pressure result with a systolic that is 130–139 systolic or diastolic that is 80–89

Stage 2 hypertension: A blood pressure result that is greater than or equal to 140 systolic or 90 diastolic

Antihypertensives: A medication with an order type of “prescription” or “historical” and ATC code C08*, C07*, C09*, C03* or C02*

Pregnancy: A pregnancy episode or a billing or encounter diagnosis with ICD-10-CM code O* in the nine months preceding the first qualifying BP through the index date

2017 treatment guidelines

Any of the following (as of index date):

ACC/AHA CVD
Diabetes
CKD
Pooled cohort 10-year score >= 10% from within 18 months prior to the index date

Pooled cohort 10-year score: ASCVD 10-Year Risk Score result from patient’s record

2025 treatment guidelines

Any of the following (as of index date):

ACC/AHA CVD
Diabetes
CKD
PREVENT 10-year score >= 7.5%

ACC/AHA CVD: A billing, encounter, or problem list diagnosis with ICM-10-CM code I20*-I25*, I50*, I61*-I69* Z86.73, or G45*

Diabetes: A billing, encounter, or problem list diagnosis with ICD-10-CM code E08*-E13*

CKD: A billing, encounter, or problem list diagnosis with ICD-10-CM code N18*

PREVENT 10-year score: Values used in score were from index date or prior. If any were missing, the score was not calculated, and the patient did not qualify based on score but could qualify based on the other factors.
Scores were calculated based on the 10-year PREVENT equations defined here: Development and Validation of the American Heart Association’s PREVENT Equations | Circulation

Statin: A medication with an order type of “prescribed” or “historical” and a pharmaceutical subclass or “Antihyperlipidemic – HMG CoA Reductase Inhibitors (statins)”; “Antihyperlipidemic HMG CoA Reduct Inhib and Calcium Channel Blocker”; “Antihyperlipidemic-HMG CoA Reductase Inhibitor-Aspirin,Buffered Comb.”; or “Antihyperlipidemic-HMG CoA Reduct Inhib and Cholesterol Absorp Inhibit”

eGFR: Calculated from the creatinine lab value using the equation defined here: https://www.kidney.org/content/ckd-epi-creatinine-equation-2021

Creatinine: A lab result with LOINC code 38483-4 or 2160-0 from within 18 months prior to the index date that does not overlap with an admission

HDL: A lab result with LOINC code 2085-9 or 18263-4 from within 18 months prior to the index date

TC: A lab result with LOINC code 2093-3 from within 18 months prior to the index date

Current smoker: Most recent smoking status documented that is “Light Smoker”; “Heavy Smoker”; “Every Day”; “Current Every Day Smoker”; “Heavy Smoker”; “Light Tobacco Smoker”; “Current Some Day Smoker”; “Smoker, Current”; or “Some Days”

Outcomes: How many patients from the 2017 guidelines who were qualified or unqualified moved to the 2025 guidelines as qualified or unqualified

Model specifications: Descriptive statistics

Limitations: People may be more likely to get specific lab results done due to the new guidelines.
2017 score was what was known at the organization but 2025 score is calculated using all known data on the patient in Cosmos.