What are the recommendations for initiating and adjusting therapy according to the 2025 American College of Cardiology (ACC) and American Heart Association (AHA) hypertension guidelines?

2025 ACC/AHA Hypertension Guidelines: Key Recommendations for Initiating and Adjusting Therapy

Note: There are no published 2025 ACC/AHA hypertension guidelines as of this date. The most current ACC/AHA guidelines are from 2017, with the most recent major guideline update being the 2024 European Society of Cardiology (ESC) guidelines. The following synthesizes the current ACC/AHA framework (2017) with insights from the 2024 ESC guidelines and recent comparative analyses.

Blood Pressure Thresholds for Pharmacological Treatment

The ACC/AHA recommends initiating antihypertensive medication for all adults with BP ≥140/90 mmHg regardless of cardiovascular risk, and for those with BP 130-139/80-89 mmHg who have established CVD, 10-year ASCVD risk ≥10%, diabetes, or chronic kidney disease. 1, 2

Specific Treatment Thresholds:

• BP ≥140/90 mmHg: Start pharmacological therapy immediately in all adults (Class I, LOE A) 1
• BP 130-139/80-89 mmHg: Initiate drug therapy if any of the following are present 1, 2:
  • Clinical atherosclerotic CVD
  • Heart failure
  • Chronic kidney disease
  • Diabetes mellitus
  • 10-year ASCVD risk ≥10% (using ACC/AHA Pooled Cohort Equations)

Stage 2 Hypertension (BP ≥140/90 mmHg):

• Begin combination therapy with 2 antihypertensive agents of different classes immediately 1, 3
• Reassess BP within 1 month after initiating therapy 1, 3
• For BP ≥160/100 mmHg, treat promptly with careful monitoring and upward dose adjustment as necessary 1

First-Line Medication Selection

First-line antihypertensive medications include thiazide or thiazide-like diuretics, ACE inhibitors, angiotensin receptor blockers (ARBs), and calcium channel blockers (CCBs). 1, 2, 4

Standard Initial Therapy:

• Choose from: thiazide/thiazide-like diuretics, ACE inhibitors, ARBs, or dihydropyridine CCBs 1, 2
• Beta-blockers are NOT first-line unless there are compelling indications (heart failure with reduced ejection fraction, post-MI, stable ischemic heart disease with angina) 1, 2

Race-Specific Considerations:

• For Black patients: Initial therapy should include a thiazide-type diuretic OR CCB 1
• Combination therapy is specifically recommended for Black patients at treatment initiation 1

Comorbidity-Driven Selection:

The following compelling indications override standard first-line choices 1:

Condition	Preferred Agent(s)	Avoid
CKD	ACE inhibitor or ARB	-
Diabetes with albuminuria	ACE inhibitor or ARB	-
Heart failure (reduced EF)	GDMT beta-blockers, ACE inhibitor/ARB	Non-DHP CCBs
Heart failure (preserved EF)	Diuretics for volume overload	-
Post-MI or ACS	GDMT beta-blockers, ACE inhibitor/ARB	-
Stable ischemic heart disease	GDMT beta-blockers, ACE inhibitor/ARB	-
Atrial fibrillation	ARB	-
Secondary stroke prevention	Thiazide, ACE inhibitor, ARB, or combination	-
Aortic insufficiency	-	Beta-blockers, non-DHP CCBs

Combination Therapy Strategy

Initial combination therapy is required for most patients and is specifically recommended when BP is ≥20/10 mmHg above target. 1, 2

Preferred Combinations:

• ACE inhibitor or ARB + CCB 1
• ACE inhibitor or ARB + thiazide diuretic 1
• CCB + thiazide diuretic 1

Contraindicated Combinations:

• NEVER combine ACE inhibitor + ARB + renin inhibitor (potentially harmful) 1
• Avoid dual RAAS blockade (ACE inhibitor + ARB) due to increased risk of end-stage renal disease and stroke 1

Triple Therapy Escalation:

• If BP remains uncontrolled on dual therapy: ACE inhibitor or ARB + CCB + thiazide diuretic 1
• Single-pill combinations are strongly favored to improve adherence 1

Blood Pressure Targets

The ACC/AHA recommends a BP target of <130/80 mmHg for most adults, including those with diabetes and chronic kidney disease. 1, 2, 4

Age-Specific Targets:

• Adults <65 years: <130/80 mmHg (Class I, LOE B-R for SBP, C-EO for DBP) 1
• Adults ≥65 years: <130/80 mmHg if tolerated 2, 4
• Adults ≥85 years: Consider more lenient target of <140/90 mmHg 2

High-Risk Populations:

• Established CVD, diabetes, CKD, heart failure, or 10-year CVD risk ≥10%: <130/80 mmHg (Class I) 1, 2
• Left ventricular dysfunction: <120/80 mmHg 5

Medication Titration and Follow-Up

Patients initiating drug therapy should be followed approximately monthly for drug titration until BP is controlled. 1

Follow-Up Schedule:

• Stage 2 hypertension: Reassess in 1 month after initiating therapy 1, 3
• Stage 1 hypertension on medication: Monthly follow-up until controlled 1
• Stage 1 hypertension without medication: Reassess every 3-6 months 1
• Elevated BP (120-129/<80 mmHg): Reassess every 3-6 months 1
• Normal BP: Annual reassessment 1

Dose Adjustment Strategy:

• Review and modify antihypertensive treatments every 2-4 weeks until appropriate regimen is established 1
• For new ACE inhibitor or diuretic therapy: assess electrolytes and renal function 2-4 weeks after initiation 1
• Target BP reduction of at least 20/10 mmHg for stage 2 hypertension 3

Lifestyle Modifications (Concurrent with Pharmacotherapy)

All patients should receive intensive lifestyle counseling regardless of medication status. 1, 2, 3

Specific Recommendations:

• Sodium restriction: <1,500 mg/day or reduce by at least 1,000 mg/day 1
• Potassium supplementation: 3,500-5,000 mg/day 1
• Weight loss: Target ideal body weight or minimum 1 kg reduction if overweight/obese 1, 3
• Physical activity: 90-150 minutes/week of aerobic or dynamic resistance exercise, OR isometric resistance 3 sessions/week 1, 3
• Alcohol moderation: ≤2 drinks/day in men, ≤1 drink/day in women 1, 3
• DASH diet: Rich in fruits, vegetables, whole grains, low-fat dairy with reduced saturated and total fat 1, 3

Common Pitfalls to Avoid

Therapeutic Inertia:

• Failure to intensify therapy when BP remains uncontrolled is a major cause of poor BP control 3
• Do not delay medication adjustments beyond 1 month if BP target is not achieved 1, 3

Inadequate Dosing:

• Ensure medications are prescribed at optimal doses using drugs with complementary mechanisms 6
• Combination therapy can lower office BP by up to 20/11 mmHg 3
• Standard doses of first-line agents typically reduce BP by approximately 9/5 mmHg 3

Adherence Issues:

• Failing to address medication adherence is a common cause of uncontrolled hypertension 3
• Single-pill combinations improve adherence but may contain suboptimal thiazide doses 1

Monitoring Errors:

• Rule out white coat hypertension and masked hypertension with home BP or ambulatory monitoring 1, 3
• White coat hypertension transitions to sustained hypertension in 1-5% of patients annually 1
• Check for orthostatic hypotension in older adults or those with postural symptoms 1

Secondary Hypertension:

• Consider secondary causes when BP is difficult to control, particularly in resistant hypertension 3, 6
• Screen for secondary causes if clinically indicated (accounts for <10% of cases) 6