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CLINICAL STATEMENTS AND GUIDELINES

September 16, 2025 Circulation. 2025;152:e114–e218. DOI: 10.1161/CIR.0000000000001356 e146

1 A 5 In adults with hypertension without clinical CVD but

with diabetes or CKD or at increased short-term CVD risk (ie, estimated 10-year CVD risk ≥7.5% based on PREVENT*), initiation of medications to lower BP is recommended when average SBP is ≥130 mm Hg to reduce the risk of CVD events and total mortality.5–10

1 C-LD 6 In adults with hypertension without clinical CVD but

with diabetes or CKD or at increased 10-year CVD risk (ie, ≥7.5% based on PREVENT*), initiation of medications to lower BP is recommended when average DBP is ≥80 mm Hg to reduce the risk of CVD events and total mortality.5–10

1 B-R 7 In adults with hypertension without clinical CVD

and with estimated 10-year CVD risk <7.5% based on PREVENT,* initiation of medications to lower BP is recommended if average SBP remains ≥130 mm Hg after a 3- to 6-month trial of lifestyle intervention to prevent target organ damage and mitigate further rise in BP.7,9,10

1 B-R 8 In adults with hypertension without clinical CVD

and with estimated 10-year CVD risk <7.5% based on PREVENT,* initiation of medications to lower BP is recommended if average DBP ≥80 mm Hg after a 3- to 6-month trial of lifestyle intervention to prevent target organ damage and mitigate further rise in BP.7,9,10

*Increased short-term or 10-year risk is defined as a 10-year predicted risk for CVD events of ≥7.5% based on PREVENT (Predicting Risk of cardiovascular disease EVENTs).

Synopsis

For a given BP level, absolute risk for CVD varies accord­ ing to age, sex, and presence of CVD or CVD risk fac­ tors (Figures 1 and 2). Therefore, the decision to initiate antihypertensive treatment should be based on BP level and risk (Section 5.2.1, “Initiation of Pharmacological BP Treatment in the Context of Overall CVD Risk”). Based on BP level alone, all adults with hypertension benefit from antihypertensive therapy at a threshold of ≥140/90 mm Hg.3,10,11 Adults with hypertension and clinical CVD (coro­ nary heart disease, stroke, or HF) are at increased risk for CVD events and benefit from antihypertensive therapy at a lower BP threshold of ≥130/80 mm Hg to prevent recurrent events.3,7,8,10 Among adults without clinical CVD, identification of patients at increased risk for CVD selects those who derive greatest benefit from antihypertensive therapy at a threshold of ≥130/80 mm Hg.7,8,12 Adults with hypertension are defined at increased risk if they have diabetes, CKD, or an estimated 10-year CVD risk of ≥7.5%, according to PREVENT. As described in Sec­ tion 1.4 (“Scope of the Guideline”), the PREVENT equa­ tions are validated for US adults aged 30 to 79 years and represent the most accurate, contemporary, and gener­ alizable risk prediction tool available, including data from 5 207 517 White adults, 605 036 Black adults, 318 141 Hispanic adults, and 163 741 Asian adults.13,14 To date, external validation of PREVENT has demonstrated good to excellent discrimination (C-statistic) for CVD in an in­ dependent health system not included in development (0.72)15 and for CVD mortality in a population dataset (0.89).16 The 10-year risk threshold of ≥7.5% calculated with PREVENT is also equivalent to the Framingham Risk Score threshold of ≥15%, which was an inclusion criterion in SPRINT.7,17 While the specific risk thresholds or cut points for cardiovascular risk that would result in therapeutic action are based on clinical trial and observa­ tional epidemiological data, future research should study the impact of risk-based management of hypertension using these thresholds. Figure 6 summarizes the recom­ mendations to initiate antihypertensive therapy for all adults when average BP level is ≥140/90 mm Hg and the groups that receive key benefits when average BP is ≥130/80 mm Hg.

Recommendation-Specific Supportive Text

1.	 In adults with hypertension and an average SBP ≥140

mm Hg, observational data, clinical trials, and metaanalyses of individual-level participant data from clini­ cal trials support reduction in CVD event rates with initiation of antihypertensive therapy at an average SBP ≥140 mm Hg for primary and secondary preven­ tion.1,2,4,5,9 In a large analysis of 344 716 participants from 48 RCTs, similar relative benefit in CVD risk reduction was observed for each 5-mm Hg systolic lowering. The benefit was similar among those with CVD (relative risk: 0.89 [95% CI: 0.86-0.92]) or with­ out CVD (relative risk: 0.91 [95% CI: 0.89-0.94]).3 In another meta-analysis of 15 266 patients from 13 tri­ als with BPs of 140 to 159/90 to 99 mm Hg and without CVD, antihypertensive treatment resulted in a lower risk of CVD death (relative risk, 0.75 [95% CI: 0.57-0.98]).10

2 In adults with hypertension and an average DBP

of ≥90 mm Hg, observational data, clinical trials, and meta-analyses of individual-level participant data from clinical trials support reduction in CVD with initiation of antihypertensive therapy for pri­ mary and secondary prevention.1,2,4,5,9 A DBP of ≥90 mm Hg was an entry criterion in several older antihypertensive RCTs (ABCD [Appropriate Blood Pressure Control in Diabetes], ANBP2 [The Second Australian National Blood Pressure Study], UKPDS [UK Prospective Diabetes Study], and EWPHE [European Working Party on High Blood Pressure in the Elderly]) that demonstrated benefit of initiation of antihypertensive therapy in reduction of CVD events.3

3 In adults with hypertension and clinical CVD (coro­

nary heart disease, stroke, HF), data from 3 RCTs that evaluated different BP treatment goals pro­ vide the evidence base to support initiation of anti­ hypertensive treatment at a lower BP threshold of ≥130/80 mm Hg.3,7,8,10–12 The SPRINT trial, which

Recommendations for BP Treatment Threshold and the Use of CVD Risk Estimation to Guide Drug Treatment of Hypertension (Continued) COR LOE Recommendations

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