In an interview with Pharmacy Times, Stacey M. Cutrell, PharmD, BCACP, CDCES, a clinical pharmacist practitioner in the family medicine department at UNC Health, discussed the 2025 American College of Cardiology (ACC)/American Heart Association (AHA) hypertension guideline and its practical implications for pharmacists. The discussion was based on her presentation at the 2026 Association of Diabetes Care and Education Specialists Annual Meeting in Columbus, Ohio.
Cutrell highlighted the PREVENT risk calculator, which replaces the pooled cohort equations and guides treatment in stage 1 hypertension, where a 10-year risk score of 7.5% or greater supports initiating therapy. Cutrell emphasized screening for secondary causes in resistant hypertension—defined as uncontrolled blood pressure on 3 agents or at goal on 4 or more—and referring positive screens to appropriate specialists. On targets, she noted strong evidence for less than 130/80, with stronger support for a systolic below 120 in high-risk patients, individualized to tolerability and kidney function. Finally, she urged pharmacists to rule out pseudo-resistance and non-adherence, optimize regimens, use single-pill combinations, and consider switching hydrochlorothiazide to chlorthalidone before escalating therapy.
Pharmacy Times: What are the most practice-changing updates in the 2025 ACC/AHA guideline that pharmacists should act on?
Stacey M. Cutrell, PharmD, BCACP, CDCES: That's a great question. There are several exciting changes with this guideline update. A major change, especially one that pharmacists can act on, is the adoption of the PREVENT risk calculator, which has now replaced the pooled cohort equations. One thing to highlight is that the PREVENT risk calculator uses larger, more contemporary data and provides a broader assessment of cardiovascular risk compared to the pooled cohort equation. It's now utilized in recommendations when assessing those with stage 1 hypertension—to determine what threshold we should use to add blood pressure medicine or not. After calculating that risk score with the PREVENT calculator, if patients have a score of 7.5% or greater, we should be initiating blood pressure medicines. The guidelines also focus on identifying secondary hypertension. While that was in the 2017 guideline as well, there is more emphasis, and there are newer recommendations, particularly with primary aldosteronism, and this is really aimed at the underdiagnosing of secondary causes. And then, lastly, another major update is providing more detailed recommendations for special populations. This includes individuals with CKD, diabetes, pregnancy, and neurologic conditions. So as a pharmacist, these are all practice-changing updates that we can take part in.
Pharmacy Times: How can a pharmacist practically distinguish resistant hypertension from secondary causes before escalating therapy?
Key Takeaways
- Apply the PREVENT calculator. It replaces the pooled cohort equations; initiate blood pressure medication in stage 1 hypertension at a 10-year risk score of 7.5% or greater.
- Screen before escalating. Once a patient meets the definition of resistant hypertension, screen for secondary causes and refer positive screens rather than reflexively adding another agent.
- Optimize, then intensify. Rule out non-adherence, target below 120 in high-risk patients, use single-pill combinations, and switch hydrochlorothiazide to chlorthalidone before adding a drug.
Cutrell: This is a good question, because it is really challenging to distinguish resistant hypertension from secondary causes. One thing I wanted to highlight is that the guidelines set up a framework, or stepwise approach, for managing those with resistant hypertension. There are 2 definitions of resistant hypertension: either blood pressure is elevated despite being on 3 blood pressure medications or blood pressure is at goal, but the patient requires 4 or more agents. After resistant hypertension is identified based on those definitions, we should be screening for secondary causes. This is because there is a high prevalence of secondary causes in individuals with resistant hypertension. This is a new emphasis on screening for secondary causes. It is challenging to distinguish, so we want to make sure we are screening early so we can identify it. And if those screens are positive, we want to make sure we are referring out to clinicians who have expertise in that specific secondary cause to help with confirming the diagnosis as well as management.
Pharmacy Times: Where do blood pressure targets for patients with diabetes now stand, and how firm is the evidence behind them?
Cutrell: Right now, the guidance says that for most adults with confirmed hypertension, we should be targeting a blood pressure goal of less than 130/80. However, in those with increased cardiovascular risk, we should be encouraging and really aiming for a systolic blood pressure less than 120 to reduce the risk of cardiovascular mortality and morbidity. Particularly in those with diabetes, the historic data was conflicting, showing that when we were treating them to an intensive goal, there wasn't a significant reduction in cardiovascular outcomes compared to those in the standard treatment arm. However, there is new and emerging data, as well as robust meta-analyses, really supporting and favoring those more intensive treatment goals—a systolic less than 120. What I would say is that the evidence for a blood pressure target of less than 130/80 is quite strong; however, we have much stronger support for considering below 120 in those high-risk patients. Those high-risk patients could include those with established cardiovascular disease, diabetes, CKD, or even heart failure. But we want to make sure that we're individualizing these blood pressure targets based on tolerability, kidney function, orthostasis, and other adverse events.
Pharmacy Times: What are the most common medication-related reasons that blood pressure won't budge, and how can pharmacists intervene?
Cutrell: One thing that immediately pops to my mind is thinking about medication behaviors and non-adherence, which could appear as more of a pseudo-resistance. When we're identifying those hard-to-treat, treatment-resistant patients, we also want to be thinking about excluding pseudo-resistance, and medication behaviors and non-adherence are a big part of that. As pharmacists, we can have those conversations with patients—those open-ended questions about how they are taking their medications and how often they miss a dose. Whether you're in the pharmacy setting or in a clinic setting, you can access those pharmacy dispense reports or even call the pharmacy to assess adherence and then think about what we can do to help improve those medication behaviors. So, always recommending pill boxes and setting alarms to help remember. But one thing the guidelines really emphasize is utilizing single-pill combination medications. If patients are on 2 or 3 blood pressure medications, can we switch them over to a single combination tablet to really help with those medication behaviors and non-adherence? And then another thing I think about, medication-related, is asking ourselves: are they on the optimized medication regimen? Are they on the first-line medications? Are they increased to the maximally tolerated dose? That's a really important role that we, as pharmacists, can play—making sure they're on the best medications. And then, thinking specifically with resistant hypertension, if they're on a thiazide like hydrochlorothiazide, can we optimize and switch them to a medication like chlorthalidone, which has a longer duration and a more potent blood pressure–lowering effect, before having to add on a medication? So those are just some of the things I think about to help with those medication-related issues when it's hard to reach blood pressure goals.
