What are the initial management recommendations for hypertension according to the 2025 American Heart Association (AHA) guidelines?

Initial Management Recommendations for Hypertension According to the 2025 AHA Guidelines

The initial management of hypertension should begin with lifestyle modifications for all patients, followed by pharmacological therapy with ACE inhibitors, ARBs, calcium channel blockers, or thiazide diuretics when blood pressure is ≥140/90 mmHg or 130-139/80-89 mmHg in high-risk patients. 1, 2

Diagnosis and Assessment

• Blood pressure should be measured out-of-office using ambulatory blood pressure monitoring (ABPM) and/or home blood pressure monitoring (HBPM) when possible
• For screening office BP of 140-159/90-99 mmHg, diagnosis should be confirmed with out-of-office measurements
• For BP ≥160/100 mmHg, confirm as soon as possible (within 1 month)
• For BP ≥180/110 mmHg, exclude hypertensive emergency 1

Risk Assessment

• Conduct comprehensive cardiovascular risk assessment using validated risk calculators (SCORE2 for ages 40-69, SCORE2-OP for ages ≥70)
• Patients with 10-year CVD risk ≥10% are considered high-risk 1, 2
• Basic screening for hypertension-mediated organ damage (HMOD) should be performed in all hypertensive patients, including:
  • 12-lead ECG
  • Serum creatinine, eGFR, and urine albumin/creatinine ratio
  • Additional tests (echocardiogram, fundoscopy) for specific indications 1

Lifestyle Modifications

Lifestyle modifications are recommended as first-line therapy for all patients with hypertension and should be continued even when medications are prescribed 2, 3, 4:

1. Dietary Modifications:

   • DASH diet or Mediterranean diet 1, 2
   • Sodium restriction to approximately 2g per day (equivalent to 5g salt) 1, 2
   • Limit free sugar consumption, especially sugar-sweetened beverages 1

2. Physical Activity:

   • Moderate-intensity aerobic exercise ≥150 minutes/week (30 min, 5-7 days/week) or 75 minutes of vigorous exercise per week
   • Complement with resistance training 2-3 times/week 1, 2

3. Weight Management:

   • Target healthy BMI (20-25 kg/m²) and waist circumference (<94 cm in men, <80 cm in women) 1, 2

4. Alcohol Limitation:

   • Maximum 100g/week of pure alcohol (approximately 7-12 standard drinks)
   • Preferably avoid alcohol completely for best health outcomes 1, 2

5. Smoking Cessation:

   • Complete cessation of tobacco use 1, 2

Pharmacological Therapy

When lifestyle modifications alone are insufficient, initiate pharmacological therapy:

• First-line medications (any of the following classes):

  • ACE inhibitors (e.g., lisinopril)
  • ARBs (e.g., losartan)
  • Calcium channel blockers
  • Thiazide or thiazide-like diuretics 2, 3

• Initial dosing:

  • Lisinopril: Start with 10 mg once daily, adjust to 20-40 mg daily based on response 5
  • Losartan: Start with 50 mg once daily, increase to maximum 100 mg daily as needed 6
  • Consider lower starting doses in patients on diuretics (lisinopril 5 mg, losartan 25 mg) 5, 6

• Combination therapy:

  • Fixed-dose combinations are recommended when no cost disadvantages exist
  • More than 70% of patients will eventually require at least two antihypertensive agents 2

Treatment Thresholds and Targets

• Treatment threshold:

  • BP ≥140/90 mmHg for most patients
  • BP 130-139/80-89 mmHg for high-risk patients (established CVD, target organ damage, diabetes, CKD, or 10-year CVD risk ≥10%) 1, 2

• Treatment targets:

  • Target BP <130/80 mmHg for most adults under 65 years
  • For adults ≥65 years, target SBP 120-129 mmHg if tolerated
  • For adults ≥85 years or those with frailty, target <140/90 mmHg or "as low as reasonably achievable" 1, 2

Monitoring and Follow-up

• Follow-up within 2-4 weeks after starting or changing medications
• Monitor serum creatinine, eGFR, and potassium levels at baseline and at least annually
• Annual monitoring for stable patients 2

Special Considerations

• Elderly patients: More gradual dose titration with careful monitoring for orthostatic hypotension
• Black patients: Consider calcium channel blocker as first-line therapy
• Resistant hypertension: Consider referral to specialist centers and adherence testing 1, 2

Common Pitfalls to Avoid

• Neglecting to screen for secondary hypertension, especially in young adults (<40 years)
• Overly aggressive BP lowering in frail elderly, which can lead to falls and decreased quality of life
• Failing to monitor renal function when using ACE inhibitors or ARBs
• Using ACE inhibitors and ARBs simultaneously (increased risk of hyperkalemia and acute kidney injury) 1, 2