What are the current recommendations for managing hypertension according to the 2025 guidelines?

What's New in 2025 Hypertension Guidelines

The 2025 guidelines introduce a more aggressive systolic blood pressure target of 120-129 mmHg for most adults with hypertension, representing a significant shift toward lower treatment goals compared to previous recommendations. 1

Key Changes in Blood Pressure Targets

The European Society of Cardiology now recommends:

• Target office BP <130/80 mmHg for most adults, with encouragement to achieve systolic BP 120-129 mmHg if well tolerated 1, 2
• This represents a departure from the traditional <140/90 mmHg threshold that dominated previous guidelines 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 2

Diagnosis and Confirmation Requirements

Hypertension is diagnosed when office BP is ≥140/90 mmHg, but must be confirmed by out-of-office measurements using ambulatory BP monitoring (ABPM) or home BP monitoring (HBPM) 1, 2

The confirmation strategy varies by BP level:

• For screening BP 140-159/90-99 mmHg: Confirm with ABPM or HBPM 2
• For screening BP ≥160/100 mmHg: Confirm within 1 month, preferably by home or ambulatory measurements 2
• For BP ≥180/110 mmHg: Immediately exclude hypertensive emergency 2
• For elevated BP (120-139/70-89 mmHg) in high-risk patients: Out-of-office confirmation is required 1, 2

Treatment Initiation Thresholds

Pharmacological treatment should be initiated at BP ≥140/90 mmHg regardless of cardiovascular risk, or at BP ≥130/80 mmHg in high-risk patients (≥10% 10-year CVD risk) after 3 months of lifestyle modifications 1, 2

This represents a more aggressive approach than prior guidelines, eliminating the previous practice of delaying treatment based solely on cardiovascular risk stratification at the ≥140/90 mmHg threshold 1.

First-Line Pharmacological Strategy

Combination therapy with two drugs is now recommended as first-line treatment for most patients with confirmed hypertension (BP ≥140/90 mmHg), rather than monotherapy 1, 2

Preferred initial combinations include:

• RAS blocker (ACE inhibitor OR ARB) + dihydropyridine calcium channel blocker (CCB) 1, 2
• RAS blocker (ACE inhibitor OR ARB) + thiazide/thiazide-like diuretic 1, 2

This shift toward initial combination therapy aims to achieve BP control more rapidly and improve adherence through single-pill combinations 2.

Escalation Strategy

If BP remains uncontrolled on two-drug combination:

• Escalate to three-drug combination: RAS blocker + dihydropyridine CCB + thiazide-like diuretic, preferably as single-pill combination 2
• For resistant hypertension (uncontrolled on 3 drugs including diuretic): Add mineralocorticoid receptor antagonist 2

Lifestyle Modifications

The 2025 guidelines continue to emphasize comprehensive lifestyle interventions, which should be implemented in all patients with BP >120/80 mmHg 2:

Dietary Recommendations

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

Physical Activity

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

Weight Management

• Target BMI 20-25 kg/m² and waist circumference <94 cm (men) or <80 cm (women) 2
• Weight loss of at least 1 kg provides measurable BP reduction in overweight/obese patients 2

Special Populations

Diabetes

• Initial treatment should include ACE inhibitors or ARBs, particularly in those with albuminuria 1
• For resistant hypertension in diabetes, consider mineralocorticoid receptor antagonist therapy 1

Elderly 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

Cardiovascular Risk Assessment

SCORE2 is recommended for assessing 10-year CVD risk in individuals aged 40-69 years with elevated BP 1

• Individuals with elevated BP and SCORE2 or SCORE2-OP risk ≥10% are considered at increased risk for CVD and warrant earlier pharmacological intervention 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 2

Additional monitoring includes:

• Monitor for hypokalemia when using diuretics 2
• Obtain 12-lead ECG in all patients with hypertension 2
• Measure serum creatinine, eGFR, and urine albumin-to-creatinine ratio in all hypertensive patients, repeating annually if moderate-to-severe CKD diagnosed 2

Common Pitfalls to Avoid

The shift to lower BP targets and initial combination therapy requires careful attention to:

• Avoid overtreatment in elderly frail patients—use the ALARA principle rather than strict numerical targets 2
• Do not delay out-of-office BP confirmation, as office measurements alone may lead to misdiagnosis 1, 2
• Monitor electrolytes closely when initiating combination therapy, particularly with RAS blockers and diuretics 2
• Do not discontinue treatment in patients >85 years if well tolerated—lifelong treatment is recommended 1