Impact of the 2017 ACC/AHA hypertension guidelines on antihypertensive prescribing in the United States: real-world evidence from a nationally representative population

Background: Hypertension (HTN) remains a major contributor to cardiovascular morbidity and mortality in the United States (US). The 2017 ACC/AHA HTN guidelines introduced major changes to diagnostic thresholds and treatment recommendations, including earlier pharmacological initiation and greater emphasis on combination therapy. However, the long-term, population-level impact of these guidelines on antihypertensive medication utilization in the US remains uncharacterized. Methods: We conducted a pooled cross-sectional study using data from the Medical Expenditure Panel Survey (2013-2022). Adults ≥18 years with diagnosed HTN were included. Antihypertensive classes utilization was defined as any use of the medication class with ≥2 prescription refills within the same year among eligible participants. Utilization of antihypertensive classes was then pooled and examined across two periods: pre-guidelines (2013-2017) and post-guidelines (2018-2022). Survey-weighted multivariable logistic regression models were used to assess the impact of the 2017 ACC/AHA guidelines on the overall utilization of antihypertensive drug classes and within subgroups with compelling indications. Results: A total of 29,901 adults were included. Following guidelines implementation, angiotensin receptor blockers (ARBs) utilization increased from 18% to 26% (adjusted OR [aOR] = 1.35; 95% confidence interval [CI]: 1.21-1.50, p < 0.0001), and calcium channel blocker (CCB) use increased from 28% to 32% (aOR = 1.24; 95% CI: 1.13-1.36, p < 0.0001). In contrast, fixed-dose combination (FDC) utilization declined from 22% to 16% (aOR = 0.67; 95% CI: 0.59-0.75, p < 0.0001). Utilization of other antihypertensive classes did not change significantly. Conclusion: After the 2017 ACC/AHA guidelines update, antihypertensive prescribing in the US showed increased use of ARBs and CCBs. However, declining FDC use highlights a persistent gap between evidence-based guidance and real-world practice.