Hypertension (HTN) remains the most prevalent chronic condition among adults in the United States (US) and a leading modifiable risk factor for cardiovascular morbidity and mortality worldwide (Mills et al., 2020; Dorans et al., 2018). It accounts for nearly half of all cardiovascular events, including myocardial infarction and stroke, and contributes to more than 10 million deaths annually (Mills et al., 2020; Wu et al., 2025). Despite decades of public health efforts and the availability of effective, affordable pharmacological therapies, HTN control remains suboptimal. Recent National Health and Nutrition Examination Survey data (2021–2023) indicated that nearly half of US adults meet diagnostic criteria for HTN (≥130/80 mm Hg), yet fewer than half achieve adequate blood pressure (BP) control (Fryar et al., 2023). Therapeutic inertia and suboptimal medication utilization continue to undermine effective HTN management, reinforcing the need to optimize antihypertensive treatment strategies to reduce adverse cardiovascular outcomes (Zhou et al., 2021).

HTN management in the US has evolved through successive guidelines updates informed by emerging clinical evidence and expert consensus (Chobanian et al., 2003; James et al., 2014; Whelton et al., 2017). The Seventh Report of the Joint National Committee (JNC 7), published in 2003, defined HTN using a threshold of ≥140/90 mm Hg and emphasized lifestyle modification alongside stepwise pharmacological therapy, recommending thiazide diuretic as first-line treatment for most patients and specific drug classes for compelling indications (Chobanian et al., 2003). In 2014, the Eighth Joint National Committee (JNC 8) retained the diagnostic threshold of ≥140/90 mm Hg but relaxed BP targets for adults aged ≥60 years to <150/90 mm Hg. JNC 8 also expanded first-line treatment options to include thiazide diuretic, angiotensin-converting enzyme inhibitors (ACEI), angiotensin receptor blocker (ARB), and calcium channel blocker (CCB) (James et al., 2014). Additionally, Beta-blocker (BB) were no longer recommended as initial therapy owing to inferior stroke and composite cardiovascular outcomes, compared with other classes (James et al., 2014). Although JNC 8 offered greater therapeutic flexibility, it was criticized for potentially reducing treatment intensity in high-risk older adults. Evidence of suboptimal BP control and of rising cardiovascular events under the JNC 8 targets prompted renewed emphasis on risk-stratified, earlier pharmacologic intervention (James et al., 2014; Shrout et al., 2017).

A major shift in HTN management was introduced by the 2017 American College of Cardiology (ACC)/American Heart Association (AHA) HTN guidelines, which redefined HTN as BP ≥ 130/80 mm Hg, expanding the treatment eligibility (Whelton et al., 2017; Muntner et al., 2018). By lowering the BP threshold for HTN diagnosis and recommending pharmacotherapy for stage 1 HTN with elevated atherosclerotic cardiovascular disease risk, the 2017 guideline increased the number of adults eligible for antihypertensive treatment (Whelton et al., 2017; Muntner et al., 2018). Additionally, the new guidelines recommended initiating two antihypertensive agents, preferably as a fixed-dose combination (FDC), when baseline BP exceeded the target by ≥ 20/10 mm Hg (James et al., 2014; Whelton et al., 2017). The 2017 update also standardized the target BP goal (<130/80 mm Hg) across adult populations, including those with diabetes and chronic kidney disease (CKD). The 2017 ACC/AHA guidelines recommended thiazide diuretic, ACEI, ARB, and CCB as first-line options, and discouraged the use of beta blockers outside specific compelling indications, such as heart failure or post-myocardial infarction (Whelton et al., 2017).

Despite these substantial changes, the real-world impact of the 2017 ACC/AHA guidelines on antihypertensive prescribing patterns remains poorly characterized (Muntner et al., 2018). Most post-guidelines studies have focused on HTN prevalence, control, or treatment eligibility, rather than on temporal changes in medication utilization (Dorans et al., 2018; Muntner et al., 2018; Khera et al., 2018; Hussain et al., 2022). The existing evidence on the impact of the 2017 ACC/AHA guidelines on antihypertensive utilization relied on data up to 2019, limiting the ability to capture long-term antihypertensive prescribing trends (Lin et al., 2024). Moreover, little is known about whether the guidelines implementation had a differential impact on high-risk populations, such as Non-Hispanic Black adults and those with compelling indications.

To address this gap, this study aimed to evaluate the impact of the 2017 ACC/AHA HTN guidelines on antihypertensive medication utilization, using nationally representative data from the Medical Expenditure Panel Survey (MEPS) from 2013 through 2022. Antihypertensive prescribing patterns were examined over the 5 years preceding (2013–2017) and 5 years following (2018–2022) guidelines publication. By leveraging a decade of population-level data, this study provided contemporary, real-world evidence on how major HTN guidelines influenced antihypertensive medication use, with implications for clinical practice, health policy, and strategies to improve HTN control in the US.

Despite major changes in HTN guidelines over the past decade, national trends in antihypertensive prescribing patterns, particularly following the 2017 ACC/AHA guidelines update, remain uncharacterized. Most post-guidelines studies have focused on HTN prevalence, control, or treatment eligibility, rather than longitudinal changes in medication utilization. Furthermore, the existing evidence on antihypertensive use after the 2017 ACC/AHA guidelines has relied on data only through 2019 from non–nationally representative cohorts, leaving a gap in understanding long-term, population-level prescribing patterns (Dorans et al., 2018; Muntner et al., 2018; Khera et al., 2018; Hussain et al., 2022; Lin et al., 2024). To address this, we conducted a nationally representative analysis using MEPS data from 2013 to 2022 to evaluate changes in antihypertensive utilization before and after the 2017 ACC/AHA guidelines release. The results showed significant changes in antihypertensive prescribing patterns following the guidelines update. The use of ARB and CCB increased, whereas the use of FDC therapies declined. Other drug classes showed minimal but not statistically significant change. These findings suggest a partial alignment between real-world prescribing and guidelines recommendations, while also highlighting a persistent gap in the optimal management of HTN.

Following the 2017 ACC/AHA guidelines update, ARB use increased significantly among US adults with treated HTN. This trend reflects the evolving clinical practice shaped by ARB efficacy, tolerability, and accessibility. Although both ACEI and ARB are recommended as first-line agents, ARB are associated with a lower incidence of cough and angioedema, adverse effects that frequently lead to ACEI discontinuation (Whelton et al., 2017; Chen et al., 2021; Li et al., 2014). This favorable safety profile may have contributed to ARB being increasingly prescribed, particularly for patients with prior ACEI intolerance or when clinicians anticipate adherence challenges. A recent observational study supports this trend. Lin et al. (2024), analyzing large EHR datasets, demonstrated a significant post-2017 ACC/AHA guidelines rise in ARB prescriptions, concurrent with a decline in ACEI use in hypertensive patients (Lin et al., 2024). Cost and accessibility factors may also explain this trend, as numerous ARB agents became available in generic forms after patent expirations, reducing financial barriers for both patients and payers (Cooper-DeHoff and Elliott, 2013). Beyond tolerability and affordability, ARB provides BP-lowering efficacy comparable to ACEI, with accumulating evidence supporting similar cardiovascular and renal protective effects (Chen et al., 2021).

In parallel, we observed an increase in CCB utilization following the 2017 ACC/AHA guidelines update. This finding is consistent with prior observational studies reporting increased CCB prescribing in the post-guidelines era (Lin et al., 2024). CCB has long been recommended as a first-line agent for the Non-Hispanic Black population in both the JNC 8 and 2017 ACC/AHA guidelines, given their robust evidence of BP-lowering efficacy and favorable cardiovascular outcomes (James et al., 2014; Whelton et al., 2017). The broad availability of long-acting, generic CCBs such as amlodipine has enhanced affordability and accessibility, likely contributing to the increased use (Jacobs et al., 2024). Furthermore, CCBs are generally well tolerated, offer convenient once-daily dosing, and have low discontinuation rates, making them attractive options for long-term HTN management (Koracevic et al., 2015). The observed increase in CCB prescribing may also reflect the clinician’s preference for agents with fewer metabolic adverse effects, particularly among patients with diabetes or dyslipidemia risk (Whelton et al., 2017).

Major HTN guidelines, including the 2017 ACC/AHA and European Society of Cardiology/European Society of HTN, advocate FDC use as initial or early add-on therapy, due to strong evidence that FDC improves medication adherence by 15%, simplifies regimens, and is associated with better BP control and improved cardiovascular outcomes (Whelton et al., 2017; McEvoy et al., 2024; Du et al., 2018). Despite this, our study showed a significant decline in FDC utilization following the 2017 ACC/AHA guideline, representing a concerning gap between the recommended guidelines and real-world practice (Whelton et al., 2017). Consistent with our findings, a recent study reported a reduction in FDC antihypertensive utilization from 11% to 9% in 2018–2019, compared with the 2015–2017 period (Lin et al., 2024). Similarly, a recent nationally representative analysis demonstrated a decline in FDC antihypertensives use between 2009 and 2020 from 35.8% to 25.8% (Mobley et al., 2023). Some barriers may explain this decline in FDC use. One of the barriers is the prescribers’ preference for flexible, individualized dose titration and treatment intensification; clinicians often favor separate agents so each drug can be adjusted independently, which is not always feasible with available FDC. Clinical inertia may further limit FDC adoption, especially among patients already stable on multi-pill regimens. Additionally, a lack of familiarity with the growing number of FDC options may limit prescribing FDC (Essa et al., 2024). Finally, some prescribers are concerned about distinguishing side effects when prescribing FDC (Essa et al., 2024).

Beyond clinician-level factors, several health system and policy barriers likely contribute to the decline in FDC prescribing. Formulary restrictions and incomplete inclusion of many antihypertensive FDCs on public and private formularies can limit access to guideline-preferred combinations or specific dose strengths, and in some cases, place them on higher cost-sharing tiers (O'Hagan et al., 2024). Insurance coverage policies and prior authorization requirements may further discourage routine FDC use when separate agents are more easily approved (An et al., 2020). Additionally, although several FDCs are now available as generics, many clinically preferred combinations and strengths are still not commercially available, which constrains prescribers’ ability to align real-world regimens with guideline-recommended single-pill combinations (An et al., 2020). These system-level barriers, together with clinician preferences and treatment inertia, likely contribute to the declining FDC use we observed despite strong evidence and guideline support for their role in improving adherence and BP control.

Subgroup analyses revealed prescribing patterns largely concordant with guidelines recommendations and established clinical evidence. Increased CCB use among non-Hispanic Black adults aligns with evidence demonstrating superior BP reduction and cardiovascular outcomes in this population (Whelton et al., 2017; Officers, 2002). Similarly, increased ARB utilization among individuals with diabetes and stroke reflects the translation of evidence-based, organ-protective strategies into routine practice, as recommended by the guidelines (Whelton et al., 2017). The decline in ACEI use among Black adults is both guideline-concordant and clinically appropriate, acknowledging the lower efficacy of ACEI and increased risk of cough and angioedema in this population (Whelton et al., 2017; Ogedegbe et al., 2015; Reichman et al., 2017). In addition, the increased use of ARA among CKD and heart failure patients demonstrates greater adoption of therapies proven to reduce morbidity and mortality in these patients (Pitt et al., 1999; Zannad et al., 2011; Bakris et al., 2020; Pitt et al., 2021). FDC use decreased across the majority of the subgroups. Collectively, these subgroup findings highlight encouraging improvements in adherence with guidelines recommendations, but also reveal a persistent gap, particularly the underuse of FDC.

These findings have important implications for clinical practice and health policy. The increased use of ARB and CCB suggests meaningful progress toward implementing evidence-based care that is likely to enhance BP control and cardiovascular risk reduction. However, the persistent decline in FDC antihypertensive utilization across the cohort signals a missed opportunity to improve medication adherence and BP control, especially in those with multiple comorbidities, who require multi-drug therapeutic strategies and are at greater risk of adverse cardiovascular outcomes. Given the strong evidence supporting FDC for simplifying therapy and improving clinical outcomes, this trend emphasizes the need for targeted provider education and health system interventions to promote appropriate FDC use. Further research and policy efforts are needed to identify and address barriers to FDC adoption.

This study has some limitations that warrant consideration. First, antihypertensive medication use was identified through self-report and prescription fill data; although MEPS includes validated pharmacy records, prescription fills do not guarantee medication adherence, potentially leading to misclassification of true drug exposure. Second, the dataset offers limited insight into the clinical rationale behind prescribing decisions, such as intolerance, medication cost, or formulary availability, making it challenging to interpret prescribing shifts. Third, we did not distinguish between incident and prevalent HTN or account for baseline BP severity or timing of treatment initiation, which may influence medication selection. Also, as MEPS lacks BP measurements to allow for stage 1 and stage 2 HTN classification, we could not determine whether the observed increase in ARB and CCB use occurred among patients with stage 1 HTN newly targeted for treatment under the 2017 guideline. Fourth, while major comorbidities such as diabetes, heart failure, and CKD were captured, MEPS lacks granular clinical detail (e.g., left ventricular ejection fraction, proteinuria, or stroke subtype), limiting the ability to assess appropriateness of therapy relative to guideline-based indications. Fifth, MEPS does not contain a complete list of FDC products. Sixth, the observed post-guidelines increase in antihypertensives utilization may reflect changes in prescriber behavior, a larger pool of patients qualifying for therapy, or both, after the 2017 ACC/AHA guidelines lowered diagnostic and treatment threshold. Lastly, despite robust multivariable adjustment, unmeasured confounding, such as provider preference, patient preferences, or institutional prescribing policies, may still bias the associations observed. Despite these limitations, this study offers several notable strengths. The study provided a nationally representative assessment of antihypertensive prescribing patterns among US adults with treated HTN. The decade-long study period allowed for a robust pre- and post-guidelines comparison that captures changes in prescribing behavior following the 2017 ACC/AHA HTN guidelines update. Inclusion of a broad range of antihypertensive classes and clinically relevant subgroups enabled a comprehensive assessment of real-world prescribing patterns.

Our study showed both encouraging progress and persistent gaps in antihypertensive prescribing following the release of 2017 ACC/AHA HTN guidelines. The observed increase in ARB and CCB use reflects progress toward more evidence-based HTN management. In contrast, the decline in FDC utilization in the cohort represents a missed opportunity for improving adherence, BP control, and ultimately cardiovascular outcomes, especially in patients with multiple comorbidities. These findings highlight the need for enhanced provider education, targeted health system interventions, and supportive policy efforts to bridge the gap between clinical guidelines and real-world practice.