Addressing barriers to using fixed-dose combination antihypertensive medications: lessons from the Million Hearts initiative

In the United States, 119.9 M adults have hypertension, defined as blood pressure ≥130/80 mmHg [ 1 ]. Among this group, 67.9 M adults have uncontrolled high blood pressure and are recommended to be on antihypertensive medications according to clinical guidelines. Of those with uncontrolled high blood pressure, 51.2% are not taking any antihypertensive medication [ 1 , 2 ]. The remaining 48.8% are undertreated and would benefit from additional treatment with antihypertensive therapy to achieve blood pressure control [ 1 ]. Furthermore, previous analyses have suggested that approximately 40% adults with stage 2 hypertension (blood pressure ≥140/90 mmHg) tend to be on monotherapy. In contrast, for years, clinical guidelines on diagnosing and managing high blood pressure have stated that most people with hypertension will require two or more antihypertensive agents to achieve control [ 2 , 3 ]. The latest 2025 American College of Cardiology/American Heart Association clinical guideline recommends initiation with two first-line antihypertensive agents of different classes, ideally in a fixed-dose combination (FDC) , to improve BP control and medication adherence, for patients with stage 2 hypertension and some high-risk patients with stage 1 hypertension (blood pressure 130–139 mmHg systolic or 80–89 mmHg diastolic), including patients with type 2 diabetes or chronic kidney disease [ 3 ].