What are the current guidelines for managing hypertension in 2025?

2025 Hypertension Guidelines

The 2024 European Society of Cardiology (ESC) guidelines recommend a target systolic blood pressure of 120-129 mmHg for most adults with hypertension, with pharmacological treatment initiated at BP ≥140/90 mmHg regardless of cardiovascular risk, or at BP ≥130/80 mmHg in high-risk patients after lifestyle modifications. 1

Diagnosis of Hypertension

• Hypertension is diagnosed when office BP is ≥140/90 mmHg, preferably confirmed by out-of-office measurements using ambulatory BP monitoring (ABPM) or home BP monitoring (HBPM) 1
• For screening BP of 120-139/70-89 mmHg in individuals with increased cardiovascular risk, out-of-office BP measurements are recommended 1
• When screening BP is ≥160/100 mmHg, confirmation should be obtained as soon as possible, preferably with home or ambulatory BP measurements 1
• For BP ≥180/110 mmHg, hypertensive emergency should be excluded 1

Cardiovascular Risk Assessment

• SCORE2 is recommended for assessing 10-year CVD risk in individuals aged 40-69 years with elevated BP 1
• SCORE2-OP is recommended for individuals aged ≥70 years 1
• Individuals with elevated BP and SCORE2 or SCORE2-OP risk ≥10% are considered at increased risk for CVD 1
• Comprehensive screening for secondary hypertension is recommended in adults diagnosed with hypertension before age 40, except in obese young adults where obstructive sleep apnea evaluation should be prioritized 1

When to Initiate Pharmacological Treatment

• BP ≥140/90 mmHg: Immediate pharmacological treatment is recommended regardless of age or cardiovascular risk 1
• BP 130-139/80-89 mmHg: After 3 months of lifestyle intervention, pharmacological treatment is recommended for those with:
  • High-risk conditions (established CVD, hypertension-mediated organ damage, diabetes, familial hypercholesterolemia, or moderate-to-severe CKD) 1
  • SCORE2/SCORE2-OP 10-year CVD risk ≥10% 1
  • SCORE2/SCORE2-OP 10-year CVD risk 5-<10% with abnormal risk modifiers 1

Blood Pressure Targets

• Target systolic BP: 120-129 mmHg for most adults if tolerated 1
• When the target is not tolerable due to side effects, aim for systolic BP that is "as low as reasonably achievable" (ALARA principle) 1
• Special considerations for treatment initiation at ≥140/90 mmHg only:
  • Patients aged ≥85 years 1
  • Moderate-to-severe frailty 1
  • Pre-treatment symptomatic orthostatic hypotension 1
  • Limited predicted lifespan (<3 years) 1

First-Line Medications

• Four major drug classes are recommended as first-line treatments 1:
  • ACE inhibitors
  • Angiotensin receptor blockers (ARBs)
  • Dihydropyridine calcium channel blockers (CCBs)
  • Thiazide or thiazide-like diuretics
• Beta-blockers are recommended when there are specific indications such as angina, post-myocardial infarction, or heart failure with reduced ejection fraction 1

Treatment Strategy

• Combination therapy is recommended for most patients with confirmed hypertension (≥140/90 mmHg) as initial therapy 1
• Preferred combinations are a RAS blocker (ACE inhibitor or ARB) with either a dihydropyridine CCB or diuretic 1
• Fixed-dose single-pill combinations are recommended to improve adherence 1
• If BP is not controlled with a two-drug combination, a three-drug combination is recommended (RAS blocker + dihydropyridine CCB + thiazide/thiazide-like diuretic) 1
• Combining two RAS blockers (ACE inhibitor and ARB) is not recommended 1
• Medications should be taken at the most convenient time of day for the patient to establish a habitual pattern and improve adherence 1

Lifestyle Modifications

• Sodium restriction to approximately 2g per day (equivalent to about 5g of salt) is recommended 1
• Moderate-intensity aerobic exercise of ≥150 minutes/week plus resistance training 2-3 times/week 1
• Aim for a healthy BMI (20-25 kg/m²) and waist circumference (<94 cm in men, <80 cm in women) 1
• Adopt Mediterranean or DASH dietary patterns 1
• Limit alcohol consumption to less than 100g/week of pure alcohol, with complete avoidance preferred 1
• Restrict free sugar consumption, particularly sugar-sweetened beverages, to a maximum of 10% of energy intake 1
• Smoking cessation is strongly recommended 1
• For patients without moderate-to-advanced CKD and with high sodium intake, increasing potassium intake by 0.5-1.0g/day should be considered through potassium-enriched salt or diets rich in fruits and vegetables 1

Monitoring and Follow-up

• Once BP is controlled and stable, yearly follow-up for BP and other CVD risk factors is recommended 1
• For patients with resistant hypertension (BP ≥140/90 mmHg despite appropriate lifestyle management plus a diuretic and two other antihypertensive drugs at adequate doses), referral to specialist centers should be considered 1
• Adherence testing with either direct observed therapy or drug level measurement should be considered in resistant hypertension 1
• In patients increasing dietary potassium while taking potassium-sparing medications, monitoring serum potassium levels is recommended 1

Special Populations

Diabetes

• In patients with diabetes, initial treatment for hypertension should include ACE inhibitors or ARBs, particularly in those with albuminuria 1
• For resistant hypertension in diabetes, mineralocorticoid receptor antagonist therapy should be considered 1

Older and Frail Patients

• Treatment of hypertension in patients <85 years who are not moderately to severely frail follows standard recommendations 1
• BP-lowering treatment should be maintained lifelong, even beyond age 85 years, if well tolerated 1

Pregnancy

• Low to moderate-intensity exercise is recommended in pregnant women without contraindications to reduce risk of gestational hypertension and pre-eclampsia 1
• HBPM and ABPM should be considered to exclude white-coat and masked hypertension, which are more common in pregnancy 1

Renal Denervation

• Renal denervation is not recommended as a first-line BP-lowering intervention due to lack of adequately powered outcomes trials demonstrating safety and CVD benefits 1
• It is also not recommended for treating hypertension in patients with moderate-to-severely impaired renal function (eGFR <40 mL/min/1.73 m²) 1