2025 Guidelines for Managing Hypertension
The 2025 hypertension guidelines recommend a target systolic blood pressure of 120-129 mmHg for most adults receiving BP-lowering medications, with 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, 2
Blood Pressure Classification
- Hypertension is defined as office systolic BP ≥140 mmHg or diastolic BP ≥90 mmHg, preferably confirmed by out-of-office measurements 3
- A new BP category called "Elevated BP" is defined as office systolic BP of 120-139 mmHg or diastolic BP of 70-89 mmHg 3
- Non-elevated BP is defined as systolic BP <120 mmHg and diastolic BP <70 mmHg 3, 2
Diagnostic Approach
- BP should be measured using validated and calibrated devices with correct measurement technique 3
- Out-of-office BP measurement (home or ambulatory monitoring) is recommended for diagnostic purposes to detect white-coat and masked hypertension 3, 1
- For patients with elevated BP (120-139/70-89 mmHg), out-of-office measurements are particularly important 1
- When out-of-office measurements aren't feasible, diagnosis should be confirmed with repeat office BP measurements using standardized technique 3
Risk Assessment
- SCORE2 is recommended for assessing 10-year CVD risk in individuals aged 40-69 years with elevated BP 1, 2
- Individuals with elevated BP and SCORE2 or SCORE2-OP risk ≥10% are considered at increased risk for CVD 1
- Risk assessment should guide treatment decisions, particularly for those with elevated BP but not yet meeting hypertension thresholds 3, 2
Treatment Recommendations
Lifestyle Modifications
Pharmacological Treatment
- Initial combination therapy is recommended for most patients with confirmed hypertension (≥140/90 mmHg) 1, 2
- Preferred combinations are a RAS blocker (ACE inhibitor or ARB) with either a dihydropyridine CCB or diuretic 1, 2
- For patients with elevated BP (130-139/80-89 mmHg) and high cardiovascular risk (≥10%), pharmacological treatment should be considered after 3 months of lifestyle intervention 2
- The target systolic BP is 120-129 mmHg if tolerated 3, 1
- More lenient BP targets can be considered in persons with symptomatic orthostatic hypotension, those aged ≥85 years, or those with moderate-to-severe frailty 3
Special Populations
- For patients with diabetes, initial treatment 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
- BP-lowering treatment should be maintained lifelong, even beyond age 85 years, if well tolerated 1
- In children and adolescents, elevated BP is defined as 90th to <95th percentile for age, sex, and height or, in adolescents ≥13 years, 120-129/<80 mmHg 3
- Treatment for elevated BP in youth focuses on lifestyle modification including nutrition, physical activity, sleep, and weight management 3
Important Changes from Previous Guidelines
- The 2025 guidelines emphasize a more aggressive BP target (120-129 mmHg systolic) compared to previous recommendations 3, 6
- There is increased focus on evidence related to fatal and non-fatal CVD outcomes rather than surrogate outcomes like BP lowering alone 3
- The guidelines introduce the new "Elevated BP" category (120-139/70-89 mmHg) to recognize the continuous nature of BP-related cardiovascular risk 3
- There is greater emphasis on out-of-office BP measurement for diagnosis and treatment monitoring 3, 1
- The guidelines recommend a risk-based approach to treatment decisions, particularly for those with elevated BP 3, 2