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

Abstract

Risk assessment plays a central role in the primary prevention of cardiovascular disease. The 2017 High Blood Pressure Clinical Practice Guideline incorporated quantitative risk assessment for the first time to guide the initiation of antihypertensive drug therapy and recommended calculation of 10-year risk of atherosclerotic cardiovascular disease with the Pooled Cohort Equations. Although the 2025 High Blood Pressure Guideline reaffirmed this overarching paradigm for risk-based initiation of antihypertensive drug therapy, it updated the recommended risk model to the Predicting Risk of Cardiovascular Disease Events equations, which estimate 10-year risk of total cardiovascular disease (including atherosclerotic cardiovascular disease and heart failure), and defined a new risk threshold for initiation of antihypertensive therapy in patients with stage 1 hypertension. This American Heart Association/American College of Cardiology scientific statement summarizes the rationale to recommend the use of the Predicting Risk of Cardiovascular Disease Events equations, the evidence base for the new threshold of 10-year risk of cardiovascular disease of ≥7.5%, and the population-level implications of these revised recommendations. This scientific statement also offers practical advice for implementing risk assessment as the first step in the comprehensive approach to hypertension management with shared decision-making between patients and clinicians. Remaining gaps in awareness and treatment of hypertension underscore the need for innovative strategies to improve implementation of and adherence to risk-based guideline recommendations, including automation of risk assessment in electronic health records, decision-support aids, and refinement of risk assessment, to equitably improve the initiation of antihypertensive drug therapy, blood pressure control, and outcomes.