What are the initial management recommendations for hypertension according to the 2025 American Heart Association (AHA) guidelines?

2025 AHA Hypertension Guidelines: Initial Management Recommendations

Note: As of the evidence provided, there are no published 2025 AHA-specific hypertension guidelines available; the most recent comprehensive American guidelines are the 2017 ACC/AHA guidelines, which remain in effect. However, the 2024 European Society of Cardiology (ESC) guidelines and 2025 American Diabetes Association standards provide the most current evidence-based recommendations for hypertension management 1.

Blood Pressure Diagnosis and Confirmation

Hypertension is diagnosed when office blood pressure is ≥140/90 mmHg, confirmed by out-of-office measurements (home or ambulatory BP monitoring) when feasible 1.

• For screening BP 140-159/90-99 mmHg: confirm diagnosis with ambulatory BP monitoring (ABPM) or home BP monitoring (HBPM) 1
• For screening BP ≥160/100 mmHg: confirm within 1 month, preferably by home or ambulatory measurements 1
• For BP ≥180/110 mmHg: exclude hypertensive emergency immediately 1
• Elevated BP (120-139/70-89 mmHg) requires out-of-office confirmation in patients with increased cardiovascular disease (CVD) risk 1

Lifestyle Modifications (First-Line for All Patients)

All patients with BP >120/80 mmHg should implement comprehensive lifestyle modifications before or alongside pharmacological therapy 1.

Dietary Interventions

• Sodium restriction to <2,300 mg/day (approximately 5g salt/day or 1 teaspoon) 1
• More aggressive sodium reduction to <1,500 mg/day provides additional benefit 1
• Adopt DASH (Dietary Approaches to Stop Hypertension) or Mediterranean diet pattern 1
• Increase dietary potassium to 3,500-5,000 mg/day 1
• Consume 8-10 servings of fruits and vegetables daily 1
• Include 2-3 servings of low-fat dairy products daily 1

Weight Management

• Target BMI 20-25 kg/m² and waist circumference <94 cm (men) or <80 cm (women) 1
• Weight loss of at least 1 kg provides measurable BP reduction in overweight/obese patients 1

Physical Activity

• ≥150 minutes/week of moderate-intensity aerobic exercise (30 minutes, 5-7 days/week) 1
• Complement with low- or moderate-intensity dynamic or isometric resistance training 2-3 times/week 1
• Alternative: 75 minutes of vigorous exercise weekly over 3 days 1

Alcohol and Tobacco

• Limit alcohol to ≤2 drinks/day for men, ≤1 drink/day for women 1
• European guidelines recommend <100g/week of pure alcohol, with preference for complete avoidance 1
• Complete tobacco smoking cessation is mandatory 1

Sugar Restriction

• Restrict free sugar consumption to maximum 10% of energy intake 1
• Discourage sugar-sweetened beverages including soft drinks and fruit juices 1

Pharmacological Treatment Initiation

Treatment Thresholds

For confirmed hypertension ≥140/90 mmHg: initiate pharmacological treatment promptly alongside lifestyle modifications, irrespective of CVD risk 1.

For elevated BP (130-139/80-89 mmHg) with high CVD risk (≥10% 10-year risk): initiate pharmacological treatment after 3 months of lifestyle intervention if BP remains ≥130/80 mmHg 1.

Initial Drug Regimen

For most patients with confirmed hypertension (BP ≥140/90 mmHg), initiate combination therapy with two drugs as first-line treatment 1.

Preferred Initial Combinations:

• RAS blocker (ACE inhibitor OR ARB) + dihydropyridine calcium channel blocker (CCB) 1
• RAS blocker (ACE inhibitor OR ARB) + thiazide/thiazide-like diuretic 1
• Single-pill fixed-dose combinations are strongly preferred to improve adherence 1

Exceptions to Combination Therapy (Start with Monotherapy):

• BP 130-150/80-90 mmHg (diabetes patients) 1
• Age ≥85 years 1
• Symptomatic orthostatic hypotension 1
• Moderate-to-severe frailty 1
• Elevated BP (120-139/70-89 mmHg) with specific compelling indication 1

First-Line Drug Classes

The four evidence-based first-line drug classes that reduce cardiovascular events are 1:

1. ACE inhibitors (e.g., enalapril) 1, 2
2. Angiotensin receptor blockers (ARBs) (e.g., candesartan) 1, 2
3. Thiazide-like diuretics (chlorthalidone and indapamide preferred over hydrochlorothiazide) 1, 2
4. Dihydropyridine calcium channel blockers (e.g., amlodipine) 1, 2

Special Populations and Compelling Indications

Diabetes with albuminuria (UACR ≥30 mg/g): ACE inhibitor or ARB is mandatory first-line therapy 1.

Diabetes with coronary artery disease: ACE inhibitor or ARB is recommended first-line 1.

Heart failure with reduced ejection fraction: guideline-directed beta-blockers (carvedilol, metoprolol succinate, bisoprolol) plus ACE inhibitor/ARB; avoid non-dihydropyridine CCBs 1.

Post-myocardial infarction or stable ischemic heart disease: guideline-directed beta-blockers plus ACE inhibitor/ARB 1.

Chronic kidney disease: ACE inhibitor or ARB (ARB if ACE inhibitor not tolerated) 1.

Atrial fibrillation: favor ARBs to reduce recurrence 1.

Critical Contraindications

Never combine two RAS blockers (ACE inhibitor + ARB) 1.

ACE inhibitors, ARBs, mineralocorticoid receptor antagonists, direct renin inhibitors, and neprilysin inhibitors are contraindicated in pregnancy and must be avoided in sexually active individuals of childbearing potential not using reliable contraception 1.

Blood Pressure Targets

Target office BP <130/80 mmHg for most adults, with encouragement to achieve systolic BP 120-129 mmHg if well tolerated 1, 3.

For patients ≥85 years, with symptomatic orthostasis, moderate-to-severe frailty, or treatment intolerance: target BP "as low as reasonably achievable" (ALARA principle) rather than strict numerical goals 1.

Medication Titration Strategy

If BP not controlled on two-drug combination: escalate to three-drug combination (RAS blocker + dihydropyridine CCB + thiazide-like diuretic), preferably as single-pill combination 1.

For resistant hypertension (uncontrolled on 3 drugs including diuretic): add mineralocorticoid receptor antagonist 1.

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

Monitoring Requirements

Monitor serum creatinine, eGFR, and potassium levels at routine visits and 7-14 days after initiating or changing doses of ACE inhibitors, ARBs, or mineralocorticoid receptor antagonists 1.

Monitor for hypokalemia when using diuretics 1.

Obtain 12-lead ECG in all patients with hypertension 1.

Measure serum creatinine, eGFR, and urine albumin-to-creatinine ratio in all hypertensive patients; repeat annually if moderate-to-severe CKD diagnosed 1.

Medication Timing

Take medications at the most convenient time of day to establish habitual pattern and improve adherence; bedtime dosing is NOT preferentially recommended 1.

Common Pitfalls to Avoid

• Do not delay pharmacological treatment in confirmed hypertension ≥140/90 mmHg waiting for lifestyle modifications alone 1
• Do not start with monotherapy when BP ≥150/90 mmHg (diabetes) or ≥160/100 mmHg (general population) 1
• Do not use beta-blockers as first-line therapy unless compelling indication (post-MI, heart failure, angina) 1
• Do not continue ACE inhibitors/ARBs in pregnancy 1
• Do not accept suboptimal BP control; maintain treatment lifelong, even beyond age 85 if well tolerated 1