What are the 2025 American Heart Association (AHA) guidelines for managing hypertension?

2025 AHA Hypertension Guidelines: Key Updates and Recommendations

The 2025 American Heart Association (AHA) guidelines recommend a blood pressure target of <130/80 mmHg for most adults with hypertension, with a more aggressive target of 120-129 mmHg systolic blood pressure for high cardiovascular risk patients. 1, 2

Blood Pressure Classification and Targets

Updated BP Categories

• Nonelevated BP: <120/70 mmHg (drug treatment not recommended)
• Elevated BP: 120-139/70-89 mmHg (treatment based on CV risk and follow-up BP)
• Hypertension: ≥140/90 mmHg (prompt confirmation and treatment recommended) 1

Target Blood Pressure Goals

• Standard target: SBP 120-129 mmHg for most adults (Class I recommendation) 1, 2
• High-risk patients (established CVD, target organ damage, diabetes, CKD, or 10-year CVD risk ≥10%): SBP <130/80 mmHg (Class I recommendation) 1
• DBP target: 70-79 mmHg (Class IIb recommendation) 2
• Modified targets for special populations:
  • Age ≥85 years: Consider more lenient target (<140/90 mmHg) 1, 2
  • Symptomatic orthostatic hypotension: Consider <140/90 mmHg 1
  • Moderate-to-severe frailty: Consider <140/90 mmHg 1
  • Limited life expectancy: Consider <140/90 mmHg 1

Treatment Approach

Lifestyle Modifications

• Recommended for all patients with BP ≥120/70 mmHg 2
• Key components:
  • Sodium restriction (<2300 mg/day)
  • DASH diet (rich in fruits, vegetables, whole grains, low-fat dairy)
  • Regular physical activity (150 minutes/week of moderate-intensity exercise) 2, 3
  • Weight management (BMI <25 kg/m²)
  • Limited alcohol consumption (≤1 drink/day for women, ≤2 drinks/day for men)
  • Smoking cessation 2

Pharmacological Treatment

• Initiation thresholds:

  • BP ≥140/90 mmHg: Initiate drug therapy in all adults 1, 2
  • BP 130-139/80-89 mmHg: Initiate drug therapy after 3 months of lifestyle therapy in:
    • High-risk CVD conditions (established CVD, target organ damage, diabetes, CKD)
    • 10-year CVD risk ≥10%
    • Borderline 10-year CVD risk (5-10%) with risk modifiers 1

• First-line medications (Class I recommendation):

  • ACE inhibitors (e.g., lisinopril, enalapril)
  • ARBs (e.g., losartan, candesartan)
  • Dihydropyridine CCBs (e.g., amlodipine)
  • Thiazide or thiazide-like diuretics (e.g., chlorthalidone, hydrochlorothiazide) 1, 2, 4

• Combination therapy:

  • Single-pill fixed-dose combinations strongly recommended to improve adherence 1, 2
  • Initial 2-drug combination recommended for BP ≥140/90 mmHg 1, 5
  • Beta-blockers only recommended when there's a compelling indication (e.g., heart failure with reduced ejection fraction, coronary artery disease) 1, 2

Management of Resistant Hypertension

• Definition: BP ≥140/90 mmHg despite three antihypertensive agents, including a diuretic 2
• First-line agent: Spironolactone (if not contraindicated) (Class IIa recommendation) 1, 2
• Approach:
  1. Verify diagnosis (ensure accurate BP measurements, rule out white coat effect)
  2. Assess medication adherence
  3. Address contributing factors (discontinue interfering substances)
  4. Optimize diuretic therapy
  5. Add spironolactone if not contraindicated
  6. Consider additional agents with different mechanisms of action 2

Implementation Strategies

• Team-based care: Multidisciplinary approaches strongly recommended (Class I) 1
• Home BP monitoring: Recommended for diagnosis confirmation and treatment monitoring 2
• Electronic health records: Beneficial for recognizing uncontrolled hypertension 2
• Telehealth strategies: Useful adjuncts to interventions for BP lowering 2
• Performance measures: Financial incentives to clinicians may improve hypertension control (Class IIa) 1

Common Pitfalls and Caveats

• J-curve phenomenon: The 2023 European Society of Hypertension (ESH) guidelines warn against targeting BP below 120/70 mmHg based on observational data suggesting harm, but this contradicts evidence from recent intensive treatment trials 1
• White coat hypertension: Confirm office readings with home or ambulatory BP monitoring 2
• Medication adherence: Major barrier to BP control; address with single-pill combinations and simplified regimens 2
• Orthostatic hypotension: Monitor for symptoms, especially in older adults and those on multiple agents 1, 2
• Laboratory monitoring: Check renal function and electrolytes within 1-2 weeks of adding a new antihypertensive agent, particularly with ACE inhibitors, ARBs, or spironolactone 2

The 2025 AHA guidelines reflect a more aggressive approach to BP management than previous iterations, emphasizing lower targets based on recent clinical trial evidence while still allowing for individualization in specific populations like the very elderly and frail patients.