What are the current guidelines for managing hypertension in adults in 2025?

2025 Hypertension Management Guidelines

According to the 2025 European Society of Cardiology (ESC) guidelines, hypertension management now recommends a systolic blood pressure (SBP) target of 120-129 mmHg for most adults, with treatment initiation at BP ≥140/90 mmHg or at 130-139/80-89 mmHg in high-risk patients. 1

Blood Pressure Classification and Treatment Thresholds

Definition of Hypertension

• Hypertension: BP ≥140/90 mmHg
• Elevated blood pressure: 120-139/70-89 mmHg (new ESC 2024 category) 2

When to Initiate Pharmacological Treatment

• Immediate treatment (lifestyle + medication concurrently):

  • BP ≥140/90 mmHg regardless of age or risk 1

• Treatment after 3 months of lifestyle modifications:

  • SBP 130-139 mmHg or DBP 80-89 mmHg with:
    • High-risk conditions (established CVD, hypertension-mediated organ damage, diabetes, familial hypercholesterolemia, or moderate/severe CKD)
    • SCORE2/SCORE2-OP 10-year CVD risk ≥10%
    • SCORE2/SCORE2-OP 10-year CVD risk 5-<10% with abnormal risk modifiers 1

Special Populations

• Older adults (≥85 years): Consider more lenient target (BP <140/90 mmHg) 1
• Frail patients: Consider more lenient target (BP <140/90 mmHg) 1
• Symptomatic orthostatic hypotension: Consider more lenient target (BP <140/90 mmHg) 1

Blood Pressure Targets

General Population

• Primary target: SBP 120-129 mmHg (Class I recommendation) 1
• If standard target not tolerable: "as low as reasonably achievable" (ALARA) 1
• DBP target: 70-79 mmHg (Class IIb recommendation) 1

Older Adults

• Adults <85 years: Same as general population (SBP 120-129 mmHg) 1
• Adults ≥85 years: Consider SBP <140/90 mmHg 1

First-Line Pharmacological Treatment

Recommended First-Line Agents

• ACE inhibitors
• Angiotensin receptor blockers (ARBs)
• Dihydropyridine calcium channel blockers (CCBs)
• Thiazide or thiazide-like diuretics 1

Combination Therapy

• Fixed-dose single-pill combinations strongly recommended to improve adherence 3
• Beta-blockers recommended only when there's a compelling indication (e.g., heart failure with reduced ejection fraction) 1

Management of Resistant Hypertension

Definition

• BP ≥140/90 mmHg despite three antihypertensive agents, including a diuretic 3

Treatment Approach

1. Verify diagnosis:

   • Ensure accurate BP measurements
   • Rule out white coat effect with home or ambulatory BP monitoring
   • Assess medication adherence 1

2. Address contributing factors:

   • Discontinue interfering substances (NSAIDs, stimulants, oral contraceptives)
   • Address lifestyle factors
   • Exclude secondary causes 1

3. Optimize treatment:

   • Maximize diuretic therapy (consider chlorthalidone or indapamide instead of hydrochlorothiazide)
   • Add spironolactone (first-line agent for resistant hypertension, Class IIa recommendation) 1, 3
   • Consider additional agents with different mechanisms of action
   • Use loop diuretics in patients with CKD
   • Consider referral to hypertension specialist if BP remains uncontrolled 1

Lifestyle Modifications

• Recommended for all patients with elevated BP (≥120/70 mmHg) 2
• Key components:
  • Sodium restriction
  • DASH diet
  • Regular physical activity
  • Weight management
  • Limited alcohol consumption
  • Smoking cessation 3

Implementation Strategies

• Team-based care approach: Class I recommendation for multidisciplinary approaches, including task-shifting away from physicians 1
• Patient-centered care: Emphasize shared decision-making 1
• Home BP monitoring: Recommended for diagnosis confirmation and treatment monitoring 1
• Electronic health records and patient registries: Beneficial for recognizing uncontrolled hypertension 1
• Telehealth strategies: Useful adjuncts to interventions for BP lowering 1

Key Differences Between Guidelines

• ESC 2024: SBP target 120-129 mmHg for most adults; treatment at 130-139/80-89 mmHg for high-risk patients 1
• ESH 2023: Age-stratified targets (BP <130/80 mmHg if <65 years; <140/80 mmHg if 65-79 years; 140-150/<80 mmHg if ≥80 years) 1
• ACC/AHA 2017: BP target <130/80 mmHg for all adults; stronger recommendation for those with high CVD risk 1

Pitfalls and Caveats

• J-curve phenomenon: Be cautious about excessive BP lowering, especially in older adults 4
• Medication adherence: Only 1 in 5 patients has sufficient adherence to achieve benefits seen in clinical trials 1
• Orthostatic hypotension: Always measure BP in both sitting and standing positions, especially in older adults 3
• Monitoring: Check renal function and electrolytes within 1-2 weeks of adding a new antihypertensive agent, particularly with ARBs or spironolactone 3

The 2025 hypertension guidelines reflect a trend toward more intensive BP control based on evidence from trials showing cardiovascular benefit with lower targets, while still recognizing the need for individualized approaches in specific populations such as the very elderly and frail.