What are the latest guidelines for hypertension management?

Latest Guidelines for Hypertension Management (2025)

According to the most recent guidelines, hypertension management should target a systolic blood pressure of 120-129 mmHg and diastolic blood pressure of 70-79 mmHg for most adults, with treatment decisions based on cardiovascular risk assessment and comorbidities. 1

Diagnosis and Classification

• Definition: Hypertension is defined as BP ≥140/90 mmHg
• Measurement:
  • Use validated automated upper arm cuff device with appropriate cuff size
  • At first visit, measure BP in both arms; use arm with higher BP if consistent difference
  • Confirm elevated office readings (≥130/85 mmHg) with home or ambulatory BP monitoring
  • Office BP <130/85 mmHg: remeasure after 3 years
  • Home BP threshold: ≥135/85 mmHg
  • 24h ambulatory BP threshold: ≥130/80 mmHg 2, 1

Treatment Thresholds

• Grade 1 Hypertension (140-159/90-99 mmHg):

  • Start immediate drug treatment in high-risk patients (CVD, CKD, diabetes, organ damage, or aged 50-80 years)
  • For low-moderate risk: Try lifestyle modifications for 3-6 months before initiating medications 2

• Grade 2 Hypertension (≥160/100 mmHg):

  • Start drug treatment immediately alongside lifestyle interventions 2

• Elevated BP (120-139/70-89 mmHg):

  • Cardiovascular risk assessment is crucial using SCORE2 (ages 40-69) or SCORE2-OP (≥70 years)
  • Start medications after 3 months of lifestyle therapy for BP 130-139/80-89 mmHg in high-risk individuals 1

Treatment Targets

• Default target: 120-129/70-79 mmHg for most adults
• Modified targets for:
  • Treatment intolerance
  • Adults ≥85 years
  • Symptomatic orthostasis
  • Moderate-to-severe frailty
  • Limited life expectancy 1

Lifestyle Modifications

All patients with BP ≥120/70 mmHg should implement:

• Sodium restriction to ~2g per day
• Regular physical activity (30-60 minutes, 4-7 days/week)
• Weight management (BMI 18.5-24.9 kg/m²)
• Mediterranean or DASH diet
• Limited alcohol consumption
• Smoking cessation
• Limited free sugar consumption (<10% of energy intake) 2, 1

Pharmacological Treatment Algorithm

Non-Black Patients:

1. Start with low-dose ACEI/ARB
2. Increase to full dose
3. Add thiazide/thiazide-like diuretic
4. Add spironolactone (or if not tolerated: amiloride, doxazosin, eplerenone, clonidine, or beta-blocker) 2

Black Patients:

1. Start with low-dose ARB + DHP-CCB or DHP-CCB + thiazide-like diuretic
2. Increase to full dose
3. Add diuretic or ACEI/ARB
4. Add spironolactone (or if not tolerated: amiloride, doxazosin, eplerenone, clonidine, or beta-blocker) 2

Simplification Strategies:

• Consider monotherapy only in low-risk grade 1 hypertension and patients >80 years or frail
• Prioritize once-daily dosing and single-pill combinations to improve adherence 2, 1

Special Populations

Diabetes or Chronic Kidney Disease:

• Target BP <130/80 mmHg
• First-line: ACEI/ARB (particularly with albuminuria)
• Without albuminuria: thiazides or dihydropyridine CCBs are also appropriate 2, 1

Cardiovascular Disease:

• For patients with angina, recent MI, or heart failure: beta-blockers and ACE inhibitors are recommended as first-line therapy 1

Monitoring and Follow-up

• Monitor BP control (achieve target within 3 months)
• Check renal function and electrolytes within 1-2 weeks after adding new agents, particularly ARBs or spironolactone
• Watch for orthostatic hypotension, especially in older adults
• If BP remains uncontrolled despite optimal therapy, refer to a provider with hypertension expertise 2, 1

Resistant Hypertension Management

• Definition: BP ≥140/90 mmHg despite three antihypertensive agents including a diuretic
• First-line agent for resistant hypertension: spironolactone
• Verify diagnosis by ensuring accurate BP measurements and medication adherence
• Rule out white coat effect with home or ambulatory monitoring
• Consider secondary causes of hypertension 1

Implementation Strategies

• Team-based care improves hypertension control
• Home BP monitoring enhances management
• Electronic health records and patient registries help identify uncontrolled hypertension
• Telehealth strategies can be useful adjuncts to BP-lowering interventions 1