What are the guidelines for classifying and treating hypertension in 2025?

Hypertension Classification 2025: New Guidelines for Management

According to the 2024 European Society of Cardiology (ESC) guidelines, hypertension is now classified into three categories: nonelevated BP (<120/70 mmHg), elevated BP (120-139/70-89 mmHg), and hypertension (≥140/90 mmHg), with treatment recommendations based on these classifications and cardiovascular risk assessment. 1

New Blood Pressure Classification System

The 2024/2025 hypertension classification system has been simplified to better guide treatment decisions:

1. Nonelevated BP (<120/70 mmHg)

   • Drug treatment not recommended
   • Continue healthy lifestyle habits

2. Elevated BP (120-139/70-89 mmHg)

   • Lifestyle modifications recommended for all
   • Drug treatment recommended based on:
     • Cardiovascular disease (CVD) risk assessment
     • Follow-up BP measurements
     • After 3 months of lifestyle intervention if BP remains ≥130/80 mmHg in high-risk individuals

3. Hypertension (≥140/90 mmHg)

   • Prompt confirmation and drug treatment recommended for most individuals
   • Immediate treatment initiation alongside lifestyle modifications

Cardiovascular Risk Assessment

For patients with elevated BP (120-139/70-89 mmHg), cardiovascular risk assessment is crucial:

• SCORE2 is recommended for ages 40-69 years 1
• SCORE2-OP is recommended for ages ≥70 years 1
• Individuals with a SCORE2 or SCORE2-OP CVD risk ≥10% are considered at increased risk 1
• Patients with established CVD, moderate/severe CKD, HMOD, diabetes mellitus, or familial hypercholesterolemia are automatically considered high-risk

Treatment Targets

The default systolic BP treatment target has been lowered:

• Primary target: 120-129 mmHg systolic BP for most adults 1, 2
• Diastolic target: 70-79 mmHg 2
• Modified targets (BP as low as reasonably achievable) for:
  • Treatment intolerance
  • Adults ≥85 years
  • Symptomatic orthostasis
  • Moderate-to-severe frailty
  • Limited life expectancy

Diagnosis and Confirmation

• For elevated BP (120-139/70-89 mmHg): Out-of-office BP measurement using ABPM and/or HBPM is recommended, or repeated office measurements if not feasible 1
• For BP 140-159/90-99 mmHg: Diagnosis should be based on out-of-office BP measurement 1
• For BP 160-179/100-109 mmHg: Confirm as soon as possible (within 1 month) preferably by home or ambulatory BP measurements 1
• For BP ≥180/110 mmHg: Exclude hypertensive emergency 1, 3

Lifestyle Modifications

Lifestyle modifications are recommended for all patients with BP ≥120/70 mmHg:

• Sodium restriction to approximately 2g per day 1
• Regular physical activity: ≥150 min/week moderate aerobic exercise plus resistance training 2-3 times/week 1
• Weight management: target BMI 20-25 kg/m² and waist circumference <94 cm (men) and <80 cm (women) 1
• Mediterranean or DASH diet 1, 2
• Limited alcohol consumption (<100g/week of pure alcohol) or preferably none 1
• Smoking cessation 1
• Limiting free sugar consumption to <10% of energy intake 1

Pharmacological Treatment

• First-line agents: ACE inhibitors, ARBs, dihydropyridine CCBs, and thiazide/thiazide-like diuretics 2, 4
• Fixed-dose single-pill combinations are strongly recommended to improve adherence 2, 5
• Initiation timing:
  • Immediate for BP ≥140/90 mmHg alongside lifestyle modifications 1, 2
  • After 3 months of lifestyle therapy for BP 130-139/80-89 mmHg in high-risk individuals 2

Special Considerations

• Resistant hypertension (BP ≥140/90 mmHg despite three antihypertensive agents including a diuretic): Spironolactone is recommended as first-line agent 2
• Monitoring: Check renal function and electrolytes within 1-2 weeks of adding new antihypertensive agents, particularly ARBs or spironolactone 2
• Hypertensive emergency (BP ≥180/110 mmHg with acute end-organ damage): Requires immediate BP reduction with short-acting titratable IV antihypertensive medication in an intensive care setting 3

Implementation Strategies

• Team-based care approach
• Home BP monitoring
• Electronic health records and patient registries
• Telehealth strategies as adjuncts to interventions for BP lowering 2

This updated classification system represents a significant shift toward earlier intervention based on cardiovascular risk assessment, with a focus on reducing morbidity and mortality through appropriate BP control.