What are the 2025 guidelines for managing hypertension in a typical adult patient?

2025 Hypertension Guidelines

The 2024 European Society of Cardiology (ESC) guidelines represent the most current evidence-based approach to hypertension management, with a major shift toward lower blood pressure targets (systolic 120-129 mmHg) for most adults and combination therapy as initial treatment. 1

Key Diagnostic Updates

New Blood Pressure Categories

• Elevated BP is now a distinct category: systolic 120-139 mmHg or diastolic 70-89 mmHg 1
• Hypertension remains defined as office BP ≥140/90 mmHg 1
• Out-of-office BP measurement (home or ambulatory monitoring) is recommended to confirm diagnosis and detect white-coat or masked hypertension 1

Screening Requirements

• Screen for primary aldosteronism (renin and aldosterone measurements) in all adults with confirmed BP ≥140/90 mmHg 1
• Comprehensive screening for secondary hypertension is mandatory in adults diagnosed before age 40 years, except obese young adults where obstructive sleep apnea evaluation should be prioritized first 1

Treatment Targets: The Major Change

Standard Target for Most Adults

• Target systolic BP: 120-129 mmHg for most adults receiving BP-lowering medications, provided treatment is well tolerated 1, 2
• This represents a significant shift from previous guidelines and is based on cardiovascular outcomes data, not just BP reduction 1

More Lenient Targets Apply For:

• Patients aged ≥85 years 1, 2
• Those with symptomatic orthostatic hypotension 1
• Moderate-to-severe frailty 1
• Limited life expectancy 1

When Target Cannot Be Achieved

• Apply the ALARA principle ("as low as reasonably achievable") when the 120-129 mmHg target is poorly tolerated 1

Pharmacological Treatment Strategy

Initial Therapy: Combination Over Monotherapy

Combination BP-lowering treatment is recommended as initial therapy for most patients with confirmed hypertension (BP ≥140/90 mmHg). 1, 2

Preferred First-Line Combinations

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

Exceptions to Combination Therapy

Consider monotherapy for: 1

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

Medication Formulation

• Fixed-dose single-pill combinations are strongly recommended to improve adherence 1, 2

Escalation Strategy

• If BP not controlled with two-drug combination, escalate to three-drug combination: RAS blocker + dihydropyridine calcium channel blocker + thiazide/thiazide-like diuretic, preferably as single-pill combination 1

What NOT to Combine

• Do not combine two RAS blockers (ACE inhibitor + ARB) 1

Beta-Blockers

• Recommended when combined with other major BP-lowering drug classes for compelling indications: angina, post-myocardial infarction, heart failure with reduced ejection fraction, or heart rate control 1

Treatment Initiation Thresholds

Confirmed Hypertension (BP ≥140/90 mmHg)

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

Elevated BP (120-139/70-89 mmHg)

• Low/medium CVD risk (<10% over 10 years): BP lowering with lifestyle measures 1
• High CVD risk (≥10% over 10 years): After 3 months of lifestyle intervention, initiate pharmacological treatment if confirmed BP ≥130/80 mmHg 1, 2

Lifestyle Modifications

Sodium Restriction

• Reduce dietary sodium to approximately 2 g/day (equivalent to ~5 g salt/day) 1
• This shows dose-response relationship with BP reduction down to <1.5 g/day 1

Potassium Supplementation

• Increase potassium intake by 0.5-1.0 g/day through potassium-enriched salt (75% sodium chloride/25% potassium chloride) or fruits and vegetables 2

Physical Activity

• Moderate-intensity aerobic exercise ≥150 minutes/week PLUS resistance training 2-3 times/week 2

Dietary Pattern

• Adopt Mediterranean or DASH dietary patterns 2

Sugar Restriction

• Limit free sugar to maximum 10% of energy intake, discourage sugar-sweetened beverages 2

Weight Management

• Achieve and maintain BMI 20-25 kg/m² 2

Tobacco and Alcohol

• Refer to smoking cessation programs as tobacco use strongly and independently causes CVD 1
• Limit alcohol to 2 or fewer standard drinks per day (maximum 14/week for men, 9/week for women) 3

Medication Timing and Adherence

• Take medications at the most convenient time of day to establish habitual pattern and improve adherence 1, 2
• No specific evidence supports evening over morning dosing for most patients 2

Special Populations

Pregnancy

• Start drug treatment when confirmed office BP ≥140/90 mmHg in both gestational and chronic hypertension 1, 2
• Lower BP below 140/90 mmHg but NOT below 80 mmHg diastolic 2

Elderly Patients (≥85 years)

• Continue BP-lowering treatment lifelong if well tolerated 1, 2
• More lenient BP targets may be appropriate 1

Young Adults (<40 years)

• Comprehensive screening for secondary hypertension is mandatory, except in obese patients where sleep apnea evaluation comes first 1, 2

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, 2
• Not recommended for patients with eGFR <40 mL/min/1.73 m² or secondary hypertension until further evidence available 1

Drug Combinations to Avoid

• Do not combine ACE inhibitor with ARB 1

Critical Implementation Points

Out-of-Office BP Monitoring

• Essential for confirming the 120-129 mmHg systolic target is achieved without causing excessive BP lowering 1
• Helps detect white-coat effect and masked hypertension 1

Cardiovascular Risk Assessment

• Use SCORE2 for assessing 10-year CVD risk in individuals aged 40-69 years with elevated BP 2
• Individuals with SCORE2 risk ≥10% are considered at increased risk 2

Duration of Treatment

• Maintain BP-lowering drug treatment lifelong, even beyond age 85 years, if well tolerated 1, 2