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 for Uncontrolled Hypertension

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 emphasize comprehensive lifestyle interventions that should be implemented for 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 2
• Adopt DASH or Mediterranean dietary 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

Alcohol Limitation

• Moderate alcohol consumption is recommended, though specific limits are not detailed in the 2025 guidelines 1

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

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

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 more aggressive treatment 1.

Common Pitfalls to Avoid

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

• Avoid initiating treatment without out-of-office BP confirmation when feasible, as this reduces overdiagnosis and overtreatment 1, 2
• Do not delay combination therapy in favor of sequential monotherapy titration, as this prolongs time to BP control 2
• Monitor electrolytes and renal function closely when using RAS blockers and mineralocorticoid receptor antagonists, particularly in elderly patients 2
• Recognize that the 120-129 mmHg systolic target is aspirational and should only be pursued if well tolerated, avoiding excessive hypotension 1, 2