What are the new guidelines for managing hypertension (high blood pressure) in adult patients?

New Hypertension Guidelines

Blood Pressure Classification and Definition

The 2017 ACC/AHA guidelines redefined hypertension as BP ≥130/80 mm Hg, a significant departure from the previous threshold of ≥140/90 mm Hg. 1

The current classification system includes four categories: 2

• Normal BP: <120/<80 mm Hg 2
• Elevated BP: 120-129/<80 mm Hg (replaces the old "prehypertension" term) 3, 2
• Stage 1 Hypertension: 130-139/80-89 mm Hg 3, 2
• Stage 2 Hypertension: ≥140/≥90 mm Hg 3, 2

This reclassification means approximately 46% of U.S. adults now meet criteria for hypertension, though only an additional 1.9% will require immediate drug therapy. 1

Blood Pressure Targets

For adults with confirmed hypertension and known CVD or 10-year ASCVD risk ≥10%, target BP <130/80 mm Hg (Class I recommendation). 3, 4, 1

For adults with confirmed hypertension without additional CVD risk markers, a BP target of <130/80 mm Hg may be reasonable but carries lower strength of recommendation (Class IIa). 3, 4

The 2025 ACC/AHA guideline goes further, encouraging reduction of systolic BP to <120 mm Hg when possible. 5

Special Populations

• Older adults (≥65 years): Target systolic BP <130 mm Hg for noninstitutionalized, ambulatory, community-dwelling adults if tolerated, with careful monitoring for orthostatic hypotension. 4, 1
• Diabetes: Initiate treatment at BP ≥130/80 mm Hg with target <130/80 mm Hg, as most have ≥10% 10-year ASCVD risk. 4
• Chronic kidney disease: Initiate treatment at BP ≥130/80 mm Hg with target <130/80 mm Hg, as they are automatically high-risk. 4

When to Initiate Drug Therapy

For Stage 2 Hypertension (BP ≥140/≥90 mm Hg or >20/10 mm Hg above target): Immediately initiate two first-line antihypertensive agents from different classes (Class I recommendation). 3, 4, 2

For Stage 1 Hypertension (130-139/80-89 mm Hg): 2

• High-risk patients (known CVD or 10-year ASCVD risk ≥10%): Start lifestyle modifications PLUS single antihypertensive agent immediately 2
• Low-risk patients: Lifestyle modifications alone initially, with drug therapy only if BP remains ≥140/90 mm Hg after 3-6 months 2

Diagnostic Confirmation

Out-of-office BP measurements using ambulatory BP monitoring (ABPM) or home BP monitoring (HBPM) should be used to confirm the diagnosis before initiating treatment. 3, 1, 2

This approach helps detect: 3

• White coat hypertension (high office BP but normal out-of-office BP)
• Masked hypertension (normal office BP but elevated out-of-office BP)

Proper measurement technique requires: patient 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. 2

Follow-Up and Monitoring

Adults initiating new or adjusted antihypertensive therapy require monthly follow-up until BP control is achieved (Class I, Level B-R recommendation). 3, 4

Once at goal, follow-up every 3-6 months is appropriate. 4

Implementation Strategies

Team-based care is recommended for all adults with hypertension (Class I recommendation). 1, 2

Additional strategies to improve control include: 1, 2

• Once-daily dosing and combination pills to improve adherence
• Electronic health records and patient registries to identify uncontrolled hypertension
• Telehealth strategies as useful adjuncts
• Systematic use of home BP monitoring

Resistant Hypertension

Resistant hypertension is now defined as BP ≥130/80 mm Hg despite adherence to ≥3 antihypertensive agents at optimal doses (including a diuretic), or requiring ≥4 medications. 1

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

Critical Pitfalls

Women who become pregnant must be transitioned off ACE inhibitors, ARBs, and direct renin inhibitors immediately, and switched to methyldopa, nifedipine, or labetalol. 1

The European Society of Hypertension recommends against targeting BP <120/70 mm Hg due to potential J-curve harm, representing a point of divergence from American guidelines. 4

For patients ≥85 years with symptomatic orthostatic hypotension, a more lenient target of <140/90 mm Hg may be considered. 2

Evidence Base

These guidelines were heavily influenced by the SPRINT trial, which demonstrated that intensive BP control (SBP <120 mm Hg) reduced cardiovascular events and all-cause mortality compared to standard control (SBP <140 mm Hg). 1, 6