What are the American Heart Association (AHA) guidelines for 2025 regarding blood pressure targets and treatment approaches for adults with hypertension?

AHA Guidelines for 2025: Blood Pressure Targets and Treatment Approaches

The 2025 American Heart Association (AHA) guidelines recommend a systolic blood pressure (SBP) target of 120-129 mmHg for all adults with hypertension if tolerated, regardless of age. 1

Blood Pressure Classification and Targets

Definition of Hypertension

• Hypertension is defined as BP ≥130/80 mmHg (consistent with 2017 ACC/AHA guidelines) 1, 2
• Classification:
  • Normal: <120/80 mmHg
  • Elevated: 120-129/<80 mmHg
  • Stage 1 Hypertension: 130-139/80-89 mmHg
  • Stage 2 Hypertension: ≥140/90 mmHg

BP Treatment Targets

• Primary target: SBP 120-129 mmHg for all adults if tolerated 1
• Diastolic BP target: 70-79 mmHg 1
• For patients who cannot achieve this target due to tolerability issues, the goal should be "as low as reasonably achievable" 1
• More lenient targets (BP <140/90 mmHg) should be considered for:
  • Individuals with symptomatic orthostatic hypotension
  • Adults aged ≥85 years
  • Those with moderate-to-severe frailty or limited life expectancy 1

When to Initiate Pharmacological Therapy

Immediate Treatment (Class I recommendation)

• BP ≥140/90 mmHg regardless of age 1
• SBP 130-139 mmHg or DBP 80-89 mmHg despite 3 months of lifestyle treatment plus any of:
  • Established cardiovascular disease (CVD)
  • Hypertension-mediated organ damage (HMOD)
  • Diabetes mellitus
  • Familial hypercholesterolemia
  • Moderate or severe chronic kidney disease
  • 10-year CVD risk ≥10% 1

Pharmacological Treatment Approach

First-Line Medications (Class I recommendation)

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

Treatment Strategy

1. Initial therapy:

   • For most patients, start with combination therapy using two first-line agents (preferably as single-pill combination) 1
   • Recommended combinations: ACE inhibitor or ARB plus CCB or diuretic 1
   • For Black patients, initial therapy should include a thiazide-type diuretic or CCB 1

2. If BP remains above target:

   • Advance to triple therapy: ACE inhibitor/ARB + CCB + diuretic (preferably as single-pill combination) 1

3. If BP still above target:

   • Add spironolactone or other diuretic, alpha-blocker, or beta-blocker 1
   • Consider referral to a specialist center 1

4. Avoid: Simultaneous use of ACE inhibitors and ARBs (not recommended) 1

Special Populations

Older Adults

• The 2025 guidelines have moved away from age-stratified targets, as meta-analyses have not shown age to be an effect modifier for treatment efficacy up to 85 years 1
• For adults ≥85 years or with moderate-to-severe frailty, a more lenient target (<140/90 mmHg) may be appropriate 1

Comorbid Conditions

• Beta-blockers are recommended as first-line therapy only when there are specific indications (e.g., heart failure with reduced ejection fraction) 1
• For patients with chronic kidney disease, the SBP target remains 120-129 mmHg 1

Monitoring and Follow-up

• Follow-up within first 2 months after initiation of drug therapy 1
• After achieving BP target, monitor every few months 1
• Reassess risk factors and evidence of asymptomatic target organ damage every 2 years 1

Implementation Strategies

• Multidisciplinary team-based care approach (Class I recommendation) 1
• Home blood pressure monitoring to confirm diagnosis and monitor treatment response 2
• Patient-centered care with shared decision-making 1

The 2025 AHA guidelines represent a significant shift toward more intensive BP control based on recent clinical trials that have demonstrated improved outcomes with lower BP targets, including SPRINT, STEP, and ESPRIT trials 1. This approach prioritizes cardiovascular risk reduction through more aggressive BP management while still allowing for individualization based on tolerability and specific patient characteristics.