What are the 2025 American Heart Association (AHA) guidelines for managing hypertension in adults with a history of cardiovascular disease or kidney disease?

2025 American Heart Association Hypertension Guidelines for Adults with CVD or CKD

Blood Pressure Targets

For adults with cardiovascular disease or chronic kidney disease, target blood pressure <130/80 mm Hg, with encouragement to further reduce systolic blood pressure to <120 mm Hg if tolerated. 1

• The 2025 ACC/AHA guideline represents a shift toward more aggressive blood pressure control, recommending an office blood pressure goal of <130/80 mm Hg for all adults with confirmed hypertension 1
• The optimal systolic blood pressure target is 120-129 mm Hg in most adults if tolerated 2, 1
• For patients with CKD (stage 3 or higher, or stage 1-2 with albuminuria ≥300 mg/d), the target remains <130/80 mm Hg 2, 3
• For moderate-to-severe CKD (eGFR >30 mL/min/1.73 m²), aim for systolic BP 120-129 mm Hg if tolerated, as this provides additional cardiovascular and renal protection 3

Age-Specific Considerations

• For patients ≥85 years with symptomatic orthostatic hypotension, consider a more lenient target of <140/90 mm Hg 2
• For patients with moderate-to-severe frailty or limited life expectancy, a target <140/90 mm Hg may be considered 2
• If the optimal target cannot be achieved due to tolerability, target blood pressure "as low as reasonably achievable" 2

First-Line Pharmacologic Therapy

For Patients with CVD

Initiate beta-blockers and ACE inhibitors (or ARBs if ACE inhibitor not tolerated) as the foundation of treatment for patients with established coronary artery disease. 2

• For stable ischemic heart disease or post-MI/ACS: Use guideline-directed medical therapy beta-blockers (carvedilol, metoprolol succinate, or bisoprolol) plus ACE inhibitor or ARB 2
• For angina: Add dihydropyridine calcium channel blockers for additional blood pressure control 2
• For heart failure with reduced ejection fraction: Use guideline-directed beta-blockers, ACE inhibitor or ARB, and thiazide or loop diuretic; avoid non-dihydropyridine calcium antagonists 2
• For heart failure with preserved ejection fraction: Use diuretics for volume overload, add ACE inhibitor or ARB and beta-blocker for incremental BP control; consider angiotensin receptor-neprilysin inhibitor and mineralocorticoid receptor antagonists 2

For Patients with CKD

Initiate an ACE inhibitor as first-line therapy for all patients with CKD stage 3 or higher, or stage 1-2 with albuminuria ≥300 mg/d. 2, 3, 4

• ACE inhibitors are reasonable to slow kidney disease progression in adults with CKD 2
• If ACE inhibitor is not tolerated, use an ARB 2, 4
• Continue ACE inhibitor even when eGFR falls below 30 mL/min/1.73 m² 4
• Never combine ACE inhibitor, ARB, and direct renin inhibitor in patients with CKD 4

Add-On Therapy

• When blood pressure goal is not achieved with ACE inhibitor/ARB alone, add a long-acting dihydropyridine calcium channel blocker (amlodipine 5-10 mg daily) or thiazide-type diuretic (chlorthalidone 12.5-25 mg daily) 3
• First-line agents include ACE inhibitors, ARBs, dihydropyridine calcium channel blockers, and thiazide or thiazide-like diuretics 2

Monitoring Strategy

Initial Monitoring

• Check serum creatinine and potassium within 1-2 weeks of initiating or titrating ACE inhibitor/ARB 3, 4
• Measure blood pressure at least twice daily during admission (morning and evening) to assess response to therapy 3
• Continue ACE inhibitor therapy unless serum creatinine rises by more than 30% within 4 weeks of starting treatment, symptomatic hypotension develops, or uncontrolled hyperkalemia occurs despite medical treatment 4

Long-Term Monitoring

• Schedule clinic follow-up every 6-8 weeks until blood pressure goal is safely achieved 3
• Once target blood pressure is achieved, laboratory monitoring and clinic follow-up should occur every 3-6 months 3
• For patients with moderate-to-severe CKD, measure serum creatinine, eGFR, and urine albumin-to-creatinine ratio at least annually 2
• Patients initiating drug therapy should be followed approximately monthly for drug titration until blood pressure is controlled 2

Risk Assessment and Evaluation

Cardiovascular Risk Stratification

• Assess for clinical atherosclerotic CVD, heart failure, CKD, and diabetes mellitus 2
• Patients with moderate/severe CKD, established CVD, hypertension-mediated organ damage, diabetes, or familial hypercholesterolemia are considered high risk 2
• Calculate 10-year CVD risk using ACC/AHA pooled cohort equations for patients without established high-risk conditions 2

Screening for Hypertension-Mediated Organ Damage

• Obtain 12-lead ECG in all patients with hypertension 2
• Measure serum creatinine, eGFR, and urine albumin-to-creatinine ratio in all patients with hypertension and CKD 2, 3
• Consider echocardiogram for patients with ECG abnormalities or signs/symptoms of cardiac disease 2
• Consider renal ultrasound for hypertensive patients with CKD 2

Screening for Secondary Hypertension

• Screen patients presenting with suggestive signs, symptoms, or medical history of secondary hypertension 2
• Consider screening for primary aldosteronism by renin and aldosterone measurements in all adults with confirmed hypertension, as prevalence ranges from 5-20% among hypertensive individuals 2

Lifestyle Modifications

All patients should receive intensive lifestyle interventions alongside pharmacologic therapy. 2

• Sodium restriction to <1500 mg/day or minimally an absolute reduction of at least 1000 mg/day 2
• Increased dietary potassium intake (3500-5000 mg/day) 2
• Weight loss if overweight/obese (target ideal body weight or at least 1 kg reduction) 2
• Aerobic or dynamic resistance exercise 90-150 minutes/week or isometric resistance 3 sessions/week 2
• Moderate alcohol intake (≤2 drinks per day in men, ≤1 per day in women) 2
• DASH-like diet rich in fruits, vegetables, whole grains, and low-fat dairy products with reduced saturated and total fat 2

Referral Indications

• Refer to nephrology if eGFR <30 mL/min/1.73 m², rapidly progressive kidney disease (>30% decline in eGFR within 4 weeks), or uncertainty about CKD etiology 3

Common Pitfalls

• Avoid treating to higher blood pressure targets in older adults without specific contraindications - the 2025 guidelines support lower targets across age groups up to 85 years 2, 1
• Do not discontinue ACE inhibitors prematurely when creatinine rises - continue unless rise exceeds 30% within 4 weeks 4
• Recognize masked hypertension in CKD patients - occurs in up to 30% and portends higher risk of CKD progression; use home or ambulatory blood pressure monitoring 2
• Do not use beta-blockers as first-line monotherapy - reserve for compelling indications such as heart failure with reduced ejection fraction or post-MI 2