What are the updated 2025 guidelines for managing hypertension in patients?

2025 Hypertension Guidelines Update

The 2024 European Society of Cardiology guidelines represent a paradigm shift by lowering the treatment target to systolic BP 120-129 mmHg for most adults and introducing a new "Elevated BP" category (120-139/70-89 mmHg) that warrants treatment in high-risk patients. 1, 2

Key Diagnostic Changes

Blood Pressure Categories Redefined

• Hypertension remains defined as office BP ≥140/90 mmHg 1, 2
• Elevated BP is newly introduced as systolic BP 120-139 mmHg or diastolic BP 70-89 mmHg 1, 2
• Out-of-office BP measurement (ambulatory or home monitoring) is now recommended for diagnostic confirmation to detect white-coat and masked hypertension 1, 2
• Use validated and calibrated devices with correct measurement technique consistently for each patient 1
• Screen for orthostatic hypotension (≥20 mmHg systolic and/or ≥10 mmHg diastolic drop) in all patients 1

Treatment Targets: The Major Change

Systolic BP Target 120-129 mmHg

Target systolic BP of 120-129 mmHg is recommended for most adults receiving BP-lowering medications, provided treatment is well tolerated. 1, 2

Critical caveats to this aggressive target:

• Must be well tolerated by the patient 1
• Requires out-of-office BP confirmation to verify target achievement 1
• More lenient targets apply for: patients ≥85 years, those with symptomatic orthostatic hypotension, moderate-to-severe frailty, or limited life expectancy 1
• When 120-129 mmHg target is not achievable, use the ALARA principle (as low as reasonably achievable) 1

When to Initiate Pharmacological Treatment

Confirmed Hypertension (BP ≥140/90 mmHg)

• Start lifestyle measures AND pharmacological treatment promptly, regardless of cardiovascular risk 1, 2

Elevated BP (120-139/70-89 mmHg) with High CVD Risk

• After 3 months of lifestyle intervention, initiate pharmacological treatment if BP remains ≥130/80 mmHg and CVD risk is sufficiently high (≥10% over 10 years) 1, 2
• Use SCORE2 for assessing 10-year CVD risk in individuals aged 40-69 years 2

Elevated BP with Low/Medium CVD Risk

• BP lowering with lifestyle measures alone is recommended and can reduce CVD risk 1

First-Line Pharmacological Treatment

Combination Therapy as Initial Treatment

Combination BP-lowering treatment is recommended for most patients with confirmed hypertension (BP ≥140/90 mmHg) as initial therapy, not monotherapy. 1, 2

Preferred combinations:

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

Exceptions to combination therapy (consider monotherapy):

• Patients aged ≥85 years 1
• Symptomatic orthostatic hypotension 1
• Moderate-to-severe frailty 1
• Elevated BP (120-139/70-89 mmHg) with concomitant indication for treatment 1

Fixed-Dose Single-Pill Combinations

• Fixed-dose single-pill combination treatment is recommended for patients receiving combination therapy 1

Escalation to Three-Drug Combination

• If BP not controlled with two drugs, escalate to RAS blocker PLUS dihydropyridine CCB PLUS thiazide/thiazide-like diuretic, preferably as single-pill combination 1

Drug Class Specifics

• Thiazides and thiazide-like drugs (chlorthalidone, indapamide) have demonstrated most effective reduction of BP and CVD events as first-line treatments 1
• Beta-blockers should be combined with other major BP-lowering drug classes when compelling indications exist: angina, post-MI, heart failure with reduced ejection fraction, or heart rate control 1
• Never combine two RAS blockers (ACE inhibitor plus ARB) 1

Lifestyle Modifications

All patients with elevated BP or hypertension require lifestyle interventions: 1

• Sodium restriction to approximately 2g per day 2
• Moderate-intensity aerobic exercise ≥150 minutes/week PLUS resistance training 2-3 times/week 2
• Mediterranean or DASH dietary patterns 2

Special Populations

Pregnancy

• Start drug treatment in gestational or chronic hypertension when confirmed office BP ≥140/90 mmHg 1
• Lower BP below 140/90 mmHg but NOT below 80 mmHg diastolic 1
• First-line agents: dihydropyridine CCBs (preferably extended-release nifedipine), labetalol, or methyldopa 1

Young Adults (Diagnosed Before Age 40)

• Comprehensive screening for secondary hypertension causes is recommended 1
• Exception: obese young adults should start with obstructive sleep apnea evaluation 1

Diabetes

• Initial treatment should include ACE inhibitors or ARBs, particularly with albuminuria 2
• For resistant hypertension in diabetes, consider mineralocorticoid receptor antagonist 2

Elderly (≥85 Years)

• Continue BP-lowering treatment lifelong if well tolerated 1, 2
• Treatment in patients <85 years who are not moderately to severely frail follows standard recommendations 2

Medication Timing and Adherence

• Take medications at the most convenient time of day to establish habitual pattern and improve adherence 1
• No specific evidence supports evening dosing over morning dosing for most patients 1

What NOT to Do

Renal Denervation

• NOT recommended as first-line BP-lowering intervention due to lack of adequately powered outcomes trials demonstrating CVD benefits 1
• NOT recommended in patients with eGFR <40 mL/min/1.73 m² or secondary hypertension causes 1

Evidence Focus Shift

A critical philosophical change: Class I recommendations now require demonstrated benefit on fatal and non-fatal CVD outcomes, not just BP lowering alone. 1 This represents a move away from surrogate endpoints toward hard clinical outcomes that affect morbidity and mortality.