What are the current guidelines for managing hypertension in 2025?

2025 Hypertension Management Guidelines

The 2025 hypertension management guidelines recommend a target systolic blood pressure of 120-129 mmHg for most adults if tolerated, with prompt initiation of pharmacological treatment when confirmed blood pressure is ≥140/90 mmHg, regardless of cardiovascular risk. 1

Diagnosis and Classification

• Hypertension is defined as persistent blood pressure ≥140/90 mmHg
• For screening blood pressure 120-139/70-89 mmHg, out-of-office measurements (ABPM or HBPM) are recommended 2
• For screening blood pressure 140-159/90-99 mmHg, diagnosis should be confirmed with out-of-office measurements 2
• For screening blood pressure ≥160/100 mmHg, confirm as soon as possible (within 1 month) 2

Treatment Thresholds and Targets

• Blood pressure ≥140/90 mmHg: Start pharmacological treatment immediately along with lifestyle measures 2, 1
• Blood pressure 130-139/80-89 mmHg: Start pharmacological treatment after 3 months of lifestyle intervention if:
  • Established cardiovascular disease
  • Hypertension-mediated organ damage
  • Diabetes mellitus
  • Moderate or severe chronic kidney disease
  • Familial hypercholesterolemia
  • 10-year cardiovascular risk ≥10% 2, 1
• Target blood pressure: 120-129 mmHg systolic for most adults if tolerated 2, 1
• If target cannot be achieved, follow the "as low as reasonably achievable" (ALARA) principle 2

Pharmacological Treatment Algorithm

Initial Treatment

• First-line medications: ACE inhibitors, ARBs, dihydropyridine calcium channel blockers (CCBs), and thiazide/thiazide-like diuretics 2
• Preferred initial approach: Combination therapy for most patients with confirmed hypertension (BP ≥140/90 mmHg) 2
• Preferred combinations: RAS blocker (ACE inhibitor or ARB) with either a dihydropyridine CCB or diuretic 2
• Single-pill combinations are recommended to improve adherence 2

Exceptions for Initial Monotherapy

• Patients aged ≥85 years
• Symptomatic orthostatic hypotension
• Moderate-to-severe frailty
• Elevated BP (120-139/70-89 mmHg) with concomitant indication for treatment 2

Treatment Intensification

• If BP not controlled with a two-drug combination, increase to a three-drug combination: RAS blocker + dihydropyridine CCB + thiazide/thiazide-like diuretic 2
• For resistant hypertension (BP ≥140/90 mmHg despite three drugs including a diuretic), add a mineralocorticoid receptor antagonist (spironolactone) 2, 3

Special Populations

• Black patients: Dihydropyridine CCBs and thiazide/thiazide-like diuretics may be more effective; ARBs preferred over ACE inhibitors due to lower risk of angioedema 2
• Young adults (<40 years): Screen for secondary causes of hypertension 2
• Patients with coronary artery disease: ACE inhibitors or ARBs recommended as first-line therapy 2
• Patients with albuminuria: Initial treatment should include an ACE inhibitor or ARB 2

Lifestyle Modifications

• Physical activity: ≥150 minutes/week of moderate-intensity aerobic exercise (30 minutes, 5-7 days/week) or 75 minutes/week of vigorous exercise, plus resistance training 2-3 times/week 2, 1
• Dietary sodium: Restrict to approximately 2g per day (equivalent to 5g of salt) 2, 1
• Diet pattern: Mediterranean or DASH diet 2, 1
• Weight management: Target BMI 20-25 kg/m² and waist circumference <94 cm in men, <80 cm in women 2, 1
• Alcohol: Limit to <100g/week (approximately 7-12 standard drinks); preferably avoid completely 2, 1
• Sugar: Restrict free sugar consumption, especially sugar-sweetened beverages 2
• Tobacco: Complete cessation recommended 2, 1

Monitoring and Follow-up

• Monthly follow-up after initiating or changing medications until target is reached 1
• Follow-up every 3-5 months for patients with controlled blood pressure 1
• Annual monitoring of renal function, electrolytes, and other cardiovascular risk factors 1
• Medication timing: Take medications at the most convenient time of day to establish a habitual pattern and improve adherence 2

Important Considerations and Pitfalls

• Avoid combining two RAS blockers (ACE inhibitor and ARB) 2
• Beta-blockers should be used only when there are other compelling indications (angina, post-MI, heart failure with reduced ejection fraction, or heart rate control) 2
• Renal denervation is not recommended as a first-line treatment for hypertension due to lack of outcomes data 2
• White coat hypertension and masked hypertension should be excluded using ambulatory or home blood pressure monitoring 1
• Medication adherence: Address barriers such as cost and side effects; consider single-pill combinations to improve adherence 2

The 2025 guidelines represent a shift toward more intensive blood pressure control with lower targets (120-129 mmHg systolic) and earlier initiation of combination therapy, reflecting growing evidence that more aggressive treatment improves cardiovascular outcomes 1.