What are the ACC/AHA 2025 hypertension guidelines?

ACC/AHA 2025 Hypertension Guidelines Summary

Blood Pressure Classification and Diagnosis

The 2025 ACC/AHA guidelines define hypertension as blood pressure ≥130/80 mmHg, with treatment recommendations based on both BP levels and cardiovascular risk assessment. 1

• Normal BP: <130/85 mmHg (remeasure after 3 years)
• Elevated BP: 130-139/85-89 mmHg (remeasure in 2-3 office visits)
• Stage 1 Hypertension: 140-159/90-99 mmHg
• Stage 2 Hypertension: ≥160/100 mmHg

BP measurement should be performed using validated devices with appropriate cuff size. Diagnosis requires repeated office BP readings ≥140/90 mmHg, particularly when confirmed by home BP ≥135/85 mmHg or 24-hour ambulatory BP ≥130/80 mmHg.

Treatment Approach

Lifestyle Modifications (First-Line for All Patients)

The guidelines strongly emphasize lifestyle modifications for all patients 1, 2:

1. Dietary changes:

   • Sodium restriction to <1500 mg/day or minimum reduction of 1000 mg/day
   • Increased potassium intake (3500-5000 mg/day)
   • DASH-like diet rich in fruits, vegetables, whole grains, and low-fat dairy

2. Physical activity:

   • 90-150 minutes/week of aerobic or dynamic resistance exercise
   • 3 sessions/week of isometric resistance training

3. Weight management:

   • Target ideal body weight or minimum weight loss of 1 kg if overweight/obese

4. Alcohol moderation:

   • ≤2 drinks per day for men
   • ≤1 drink per day for women

5. Smoking cessation

Pharmacological Treatment Thresholds

Immediate drug therapy is recommended for:

• All patients with BP ≥140/90 mmHg
• Patients with BP 130-139/80-89 mmHg who have:
  • Established cardiovascular disease
  • Diabetes mellitus
  • Chronic kidney disease
  • 10-year ASCVD risk ≥10% 1

First-Line Medications

The guidelines recommend these first-line antihypertensive medications 1, 2:

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

Initial therapy approach:

• For most patients with BP ≥140/90 mmHg: Start with combination therapy, preferably as a single-pill combination
• For low-risk Stage 1 hypertension or patients >80 years: Consider monotherapy
• For Black patients: Initial therapy should include a diuretic or CCB

Blood Pressure Targets

The 2025 guidelines recommend a target SBP of 120-129 mmHg in most adults if tolerated, with SBP 120 mmHg being the optimal point within this range. 1

• Standard target: SBP 120-129 mmHg for all adults if tolerated
• DBP target: 70-79 mmHg for all patients
• Modified targets for special populations:
  • More lenient targets (e.g., <140/90 mmHg) for patients ≥85 years, those with symptomatic orthostatic hypotension, or moderate-to-severe frailty

Monitoring and Follow-up

• Patients initiating drug therapy: Follow-up approximately monthly for dose titration until BP control
• After achieving BP target: Follow-up every 3-6 months
• Annual monitoring of renal function, electrolytes, and other cardiovascular risk factors
• White coat hypertension: Annual rechecks with home or ambulatory BP monitoring

Treatment for Special Populations

Comorbidity-Specific Recommendations 1

Comorbidity	Preferred Agents	Agents to Avoid	Comments
Atrial fibrillation	ARBs	-	May reduce AF recurrence
Heart failure (reduced EF)	GDMT beta blockers	Non-DHP calcium antagonists	-
Heart failure (preserved EF)	Diuretics	-	Consider ACEI/ARB and beta blockers
Chronic kidney disease	ACEI or ARB	-	ARB if ACEI not tolerated
Diabetes	ACEI or ARB if albuminuria	-	Consider usual first-line drugs if no albuminuria
Stroke prevention	Thiazide, ACEI, ARB	-	Restart drugs a few days post-event
Stable ischemic heart disease	GDMT beta blockers, ACEI or ARB	-	-

Race/Ethnicity Considerations

• Black patients: Initial therapy should include a diuretic or CCB, either alone or in combination with a RAAS blocker 2
• Asian populations: Higher prevalence of salt-sensitivity, morning hypertension, and nighttime hypertension 1

Common Pitfalls to Avoid

• Failing to confirm hypertension diagnosis with out-of-office measurements before starting treatment
• Using β-blockers as first-line therapy in uncomplicated hypertension
• Combining ACE inhibitors and ARBs (increases risk of kidney disease and stroke)
• Inadequate monitoring of electrolytes and renal function when using RAAS blockers
• Not addressing medication adherence issues

Treatment of Resistant Hypertension

For patients not reaching target BP on three medications (including a diuretic):

• Reinforce lifestyle measures, especially sodium restriction
• Add low-dose spironolactone
• If spironolactone is not tolerated, consider amiloride, doxazosin, eplerenone, clonidine, or beta-blocker

The guidelines emphasize that achieving BP control within 3 months is crucial for reducing cardiovascular risk, and simplifying medication regimens with once-daily dosing and single-pill combinations improves adherence 2.