What are the 2025 American Heart Association (AHA) guidelines for blood pressure management in adults with hypertension?

2025 AHA Blood Pressure Guidelines Summary

The 2025 ACC/AHA guidelines recommend an office blood pressure target of <130/80 mm Hg for all adults with confirmed hypertension, with encouragement to further reduce systolic blood pressure to <120 mm Hg if tolerated. 1

Blood Pressure Classification

The classification system remains unchanged from 2017, eliminating the outdated term "prehypertension": 2, 3

• Normal BP: <120/<80 mm Hg 3
• Elevated BP: 120-129/<80 mm Hg 3
• Stage 1 Hypertension: 130-139/80-89 mm Hg 3
• Stage 2 Hypertension: ≥140/≥90 mm Hg 3

Critical measurement requirements: Patient must be seated quietly for ≥5 minutes with back supported, feet flat on floor, arm at heart level, using proper cuff size on bare arm, with no conversation and empty bladder. 3 Base diagnosis on an average of at least 2 readings obtained on at least 2 separate occasions. 2

Blood Pressure Targets

Primary Target for Most Adults

Target <130/80 mm Hg for all adults with confirmed hypertension, with systolic BP further reduced to <120 mm Hg if tolerated. 1 This represents the optimal target range of 120-129 mm Hg for systolic BP. 4

Risk-Stratified Approach

• High-risk patients (known CVD or 10-year ASCVD risk ≥10%): BP target <130/80 mm Hg is a Class I recommendation 2
• Lower-risk patients (without additional CVD risk markers): BP target <130/80 mm Hg is a Class IIb recommendation (may be reasonable) 2

Special Populations

For patients ≥85 years with symptomatic orthostatic hypotension: Consider a more lenient target of <140/90 mm Hg 5. For patients with moderate-to-severe frailty or limited life expectancy, a target of <140/90 mm Hg may also be considered. 2

For patients with CKD (stage 3 or higher, or stage 1-2 with albuminuria ≥300 mg/d): Target remains <130/80 mm Hg, with consideration of further reduction to <120 mm Hg systolic if tolerated in moderate-to-severe CKD (eGFR >30 mL/min/1.73 m²). 5

Treatment Initiation Strategy

Stage 1 Hypertension (130-139/80-89 mm Hg)

• Low-risk patients: Start with lifestyle modifications alone; add drug therapy only if BP remains ≥140/90 mm Hg after 3-6 months 3
• High-risk patients: Immediately initiate lifestyle modifications PLUS single antihypertensive agent 3

Stage 2 Hypertension (≥140/≥90 mm Hg)

Immediately initiate both nonpharmacologic therapy AND antihypertensive medications. 3 For patients with stage 2 hypertension and average BP more than 20/10 mm Hg above target, initiate therapy with 2 first-line agents of different classes (either as separate agents or fixed-dose combination) - Class I recommendation. 2

For stage 1 hypertension with BP goal <130/80 mm Hg, initiating therapy with a single antihypertensive drug is reasonable, with dosage titration and sequential addition of other agents - Class IIa recommendation. 2

First-Line Pharmacologic Therapy

Four major drug classes are recommended as first-line agents: 4, 6

1. ACE inhibitors (e.g., enalapril) 4, 6
2. Angiotensin receptor blockers (ARBs) (e.g., candesartan) - use if ACE inhibitor not tolerated 4, 6
3. Calcium channel blockers (preferably dihydropyridine, e.g., amlodipine) 4, 6
4. Thiazide or thiazide-like diuretics (especially chlorthalidone and indapamide; hydrochlorothiazide acceptable) 4, 6

Combination Therapy Approach

Combination therapy is recommended as initial treatment for most patients with confirmed hypertension (≥140/90 mm Hg). 4 Preferred initial combinations include a RAS blocker (ACE inhibitor or ARB) with either a calcium channel blocker or diuretic. 4

Special Indications

For patients with established coronary artery disease: Initiate beta-blockers and ACE inhibitors (or ARBs if ACE inhibitor not tolerated) as the foundation of treatment - high strength of evidence. 5

For patients with CKD (stage 3 or higher, or stage 1-2 with albuminuria ≥300 mg/d): Initiate an ACE inhibitor as first-line therapy (moderate strength of evidence); use ARB if ACE inhibitor not tolerated (low strength of evidence). 5

Resistant Hypertension

Spironolactone is favored as the first-line agent for resistant hypertension (if not contraindicated). 2

Lifestyle Modifications

Intensive lifestyle interventions are recommended alongside pharmacologic therapy: 5

• Sodium restriction: <1500 mg/day 5
• Dietary potassium: 3500-5000 mg/day 5
• Weight management: Target healthy BMI (20-25 kg/m²) and waist circumference (<94 cm in men, <80 cm in women) 4
• Physical activity: 150 minutes of moderate-intensity or 75 minutes of vigorous-intensity aerobic exercise per week, plus resistance training 2-3 times/week 4
• Dietary pattern: Mediterranean or DASH diet with increased vegetables, fruits, fish, nuts, and unsaturated fatty acids 4
• Alcohol moderation: ≤2 drinks per day in men, ≤1 per day in women 5

The BP-lowering effects of individual lifestyle components are partially additive and enhance the efficacy of pharmacologic therapy. 6

Monitoring and Follow-Up

Out-of-Office BP Monitoring

Home BP monitoring (HBPM) and ambulatory BP monitoring (ABPM) are strongly recommended to confirm diagnosis and detect white coat hypertension, masked hypertension, white coat effect, and masked uncontrolled hypertension. 2

• White coat hypertension: High office BP but normal out-of-office BP (CVD risk approximates normal BP) 2
• Masked hypertension: Normal office BP but high out-of-office BP (CVD risk similar to sustained hypertension) 2

Follow-Up Strategy

Follow-up should include systematic strategies to improve BP control - Class I, Level A recommendation: 2

• Use of HBPM 2
• Team-based care 2, 4
• Telehealth strategies 2

After initiation of drug therapy: Monthly evaluation of adherence and therapeutic response until control is achieved. 4

For ACE inhibitor/ARB therapy: Check serum creatinine and potassium within 1-2 weeks of initiating or titrating, then every 1-2 weeks as needed. 5

Maintain BP-lowering drug treatment lifelong, even beyond age 85 if well tolerated. 4

Clinical Impact

An SBP reduction of 10 mm Hg decreases risk of CVD events by approximately 20% to 30%. 6 The relationship between BP and cardiovascular disease is continuous and progressive, with risk doubling for every 20 mm Hg systolic or 10 mm Hg diastolic increase. 3

Common pitfall: Despite the benefits of BP control, only 44% of US adults with hypertension have their SBP/DBP controlled to less than 140/90 mm Hg. 6 The 2025 guidelines emphasize multidisciplinary approaches with appropriate task-shifting away from physicians to improve implementation. 2