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

New AHA 2025 Guidelines for Managing Hypertension

The 2025 American Heart Association (AHA) guidelines recommend a target blood pressure of <130/80 mmHg for most adults to reduce cardiovascular morbidity and mortality, with treatment decisions based on cardiovascular risk assessment. 1

Definition and Classification of Hypertension

• The AHA defines hypertension as persistent blood pressure ≥130/80 mmHg, which differs from the European Society of Cardiology (ESC) definition of ≥140/90 mmHg 1, 2
• Elevated blood pressure is defined as systolic blood pressure (SBP) 120-129 mmHg with diastolic blood pressure (DBP) <80 mmHg 2
• Stage 1 hypertension is characterized by SBP 130-139 mmHg or DBP 80-89 mmHg 2
• Stage 2 hypertension is defined as SBP ≥140 mmHg or DBP ≥90 mmHg 2

Risk Assessment and Treatment Thresholds

• The AHA guidelines emphasize cardiovascular disease (CVD) risk assessment using the ASCVD risk calculator to guide treatment decisions, particularly for those with BP 130-139/80-89 mmHg 1
• Pharmacological treatment is recommended for:
  • All patients with BP ≥140/90 mmHg regardless of CVD risk 1
  • Patients with BP 130-139/80-89 mmHg who have high CVD risk (≥10% 10-year risk), established CVD, diabetes, or chronic kidney disease 1
• For patients with elevated BP (120-129/<80 mmHg) or stage 1 hypertension without high CVD risk, lifestyle modifications are recommended as initial therapy 2, 3

Blood Pressure Targets

• The AHA recommends a BP target of <130/80 mmHg for most adults, including those with diabetes and chronic kidney disease 1
• More lenient targets may be considered for specific populations:
  • Patients aged ≥85 years (target <140/90 mmHg) 1
  • Those with moderate-to-severe frailty 1
  • Patients with symptomatic orthostatic hypotension 1

Lifestyle Modifications

• Lifestyle modifications are recommended for all patients with elevated BP or hypertension 2, 3:
  • Dietary approaches: DASH or Mediterranean diet with sodium restriction (<2300 mg/day) 2, 3
  • Regular physical activity: 150 minutes/week of moderate-intensity aerobic activity plus resistance training 2-3 times/week 2, 4
  • Weight management: maintain BMI 18.5-24.9 kg/m² and healthy waist circumference (<102 cm for men, <88 cm for women) 2, 5
  • Alcohol limitation: ≤2 drinks/day for men and ≤1 drink/day for women 2, 4
  • Adequate potassium intake through diet 2, 4

Pharmacological Treatment

• First-line antihypertensive medications include 1, 2:
  • Thiazide or thiazide-like diuretics
  • Angiotensin-converting enzyme (ACE) inhibitors
  • Angiotensin receptor blockers (ARBs)
  • Calcium channel blockers (CCBs)
• Beta-blockers are no longer recommended as first-line therapy unless there are compelling indications such as heart failure, coronary artery disease, or post-myocardial infarction 1, 2
• Initial combination therapy (two drugs) is recommended for patients with BP ≥20/10 mmHg above target 1
• Single-pill combinations are preferred to improve adherence 1, 2

Special Populations

• For resistant hypertension (BP uncontrolled on 3 medications including a diuretic):
  • Spironolactone is recommended as the fourth-line agent if not contraindicated 1
  • Adherence assessment and evaluation for secondary causes should be performed 2
• For older adults (≥65 years):
  • Target BP remains <130/80 mmHg if well tolerated 1
  • More gradual BP lowering and careful monitoring for orthostatic hypotension is advised 1
• For patients with diabetes or chronic kidney disease:
  • Target BP <130/80 mmHg is recommended 1
  • ACE inhibitors or ARBs are preferred first-line agents 2, 5

Implementation Strategies

• The AHA guidelines emphasize multidisciplinary approaches to hypertension management 1:
  • Team-based care involving physicians, nurses, pharmacists, and other healthcare providers
  • Home BP monitoring to guide treatment decisions
  • Use of electronic health records and clinical decision support systems
  • Performance measures and financial incentives for clinicians to improve hypertension control

Key Differences from Previous Guidelines

• Stronger emphasis on cardiovascular risk assessment to guide treatment decisions 1
• More aggressive BP targets (<130/80 mmHg) for most adults based on evidence from recent clinical trials including SPRINT, STEP, and ESPRIT 1, 6
• Greater emphasis on combination therapy, particularly single-pill combinations 1, 2
• Expanded recommendations for special populations including older adults and those with comorbidities 1

Common Pitfalls to Avoid

• Relying on a single office BP measurement for diagnosis or treatment decisions; multiple measurements on different occasions are recommended 2, 6
• Failing to assess for white coat hypertension or masked hypertension; out-of-office BP measurements are valuable 2, 6
• Overlooking medication adherence issues when BP is not controlled 2
• Neglecting lifestyle modifications when initiating pharmacological therapy 3, 4
• Using beta-blockers as first-line therapy without compelling indications 1, 2