What are the recommendations for managing hypertension according to the 2025 American College of Cardiology (ACC)/American Heart Association (AHA) guidelines?

2025 ACC/AHA Hypertension Guidelines

The 2025 ACC/AHA guidelines define hypertension as blood pressure ≥130/80 mmHg and recommend initiating pharmacological treatment at this threshold for patients with established cardiovascular disease, diabetes, chronic kidney disease, or 10-year ASCVD risk ≥10%. 1

Blood Pressure Classification and Diagnosis

• Hypertension is defined as persistent BP ≥130/80 mmHg, representing a lower threshold than the European guidelines (≥140/90 mmHg) 1, 2
• Stage 1 hypertension: BP 130-139/80-89 mmHg 2
• Stage 2 hypertension: BP ≥140/90 mmHg 2
• Confirm diagnosis with out-of-office measurements using home BP monitoring or ambulatory BP monitoring 2
• Individuals with elevated BP (130-139/80-89 mmHg) should have repeat measurements every 3-6 months 2

Lifestyle Modifications (First-Line for All Patients)

All patients with BP ≥130/80 mmHg should implement comprehensive lifestyle changes before or alongside pharmacological therapy. 2, 1

• Sodium restriction to <1,500 mg/day or at minimum reduce by 1,000 mg/day 2
• Increase dietary potassium to 3,500-5,000 mg/day (unless contraindicated by CKD) 2
• Weight loss of at least 1 kg if overweight/obese, targeting ideal body weight 2
• Aerobic exercise 90-150 minutes/week or isometric resistance training 3 sessions/week 2
• Alcohol moderation: ≤2 drinks/day in men, ≤1 drink/day in women 2
• DASH diet: rich in fruits, vegetables, whole grains, low-fat dairy, reduced saturated and total fat 2

Pharmacological Treatment Initiation

The decision to start medication depends on both BP level and cardiovascular risk stratification. 1

Immediate Pharmacological Treatment (Class I)

• All patients with BP ≥140/90 mmHg regardless of cardiovascular risk 1, 2
• Patients with BP 130-139/80-89 mmHg who have:
  • Established clinical atherosclerotic CVD 1
  • Heart failure 1
  • Chronic kidney disease 1
  • Diabetes mellitus 1
  • 10-year ASCVD risk ≥10% by Pooled Cohort equation 1

Lifestyle Modification Only (Initially)

• Patients with BP 130-139/80-89 mmHg without the above high-risk conditions should receive lifestyle modifications for 3-6 months before considering pharmacological therapy 2

First-Line Antihypertensive Medications

Four drug classes are recommended as first-line therapy (Class I, LOE A): 1

1. Thiazide or thiazide-like diuretics (chlorthalidone preferred over hydrochlorothiazide) 1, 3
2. ACE inhibitors (e.g., lisinopril, enalapril) 1, 3
3. Angiotensin receptor blockers (ARBs) (e.g., candesartan) 1, 3
4. Dihydropyridine calcium channel blockers (e.g., amlodipine) 1, 3

Beta-blockers are NOT first-line therapy unless compelling indications exist (post-MI, heart failure with reduced ejection fraction, angina) 1

Initial Combination Therapy

• Start with 2-drug combination for patients with BP ≥20/10 mmHg above target 1
• Preferred combinations: ACE inhibitor or ARB + thiazide diuretic OR calcium channel blocker 2
• Single-pill combinations improve adherence when available 2

Blood Pressure Targets

The target BP for most adults is <130/80 mmHg (Class I, LOE B-R). 2, 1

Specific Population Targets:

• Adults <65 years: <130/80 mmHg 1
• Adults ≥65 years: SBP <130 mmHg if well tolerated 1
• Diabetes mellitus: <130/80 mmHg 1
• Chronic kidney disease: <130/80 mmHg 1
• Post-stroke: <130/80 mmHg 1

Treatment by Comorbidity

Specific drug classes are favored or avoided based on comorbidities: 2

• Atrial fibrillation: Favor ARBs (may reduce AF recurrence) 2
• CKD or diabetes with albuminuria: ACE inhibitor or ARB mandatory 2
• Heart failure with reduced EF: Beta-blockers (carvedilol, metoprolol succinate, bisoprolol) + ACE inhibitor/ARB; avoid non-DHP calcium antagonists 2
• Heart failure with preserved EF: Diuretics for volume overload, add ACE inhibitor/ARB and beta-blocker for BP control 2
• Stable ischemic heart disease/post-MI: Beta-blockers + ACE inhibitor or ARB 2
• Angina: Beta-blockers, add DHP calcium antagonists for additional BP control 2
• Secondary stroke prevention: Thiazide, ACE inhibitor, ARB, or thiazide + ACE inhibitor combination 2
• Aortic insufficiency: Avoid beta-blockers and non-DHP calcium antagonists (drugs that slow heart rate) 2

Monitoring and Follow-Up

• Patients initiating drug therapy: Follow-up approximately monthly for titration until BP controlled 2
• Stage 1 hypertension not on medication: Follow-up every 3-6 months 2
• Normal BP or white coat hypertension: Recheck annually with home or ambulatory BP monitoring 2
• White coat hypertension transitions to sustained hypertension in 1-5% of patients annually 2

Key Differences from Other Guidelines

The ACC/AHA guidelines differ substantially from European guidelines in several areas: 2

• Lower diagnostic threshold (130/80 vs 140/90 mmHg) 2
• More aggressive treatment targets, especially in older adults and CKD patients 2
• Earlier initiation of pharmacological therapy for high-risk patients with BP 130-139/80-89 mmHg 2
• Use of ASCVD risk calculator (Pooled Cohort equation) rather than SCORE2 for risk stratification 2

Common Pitfalls to Avoid

• Do not use beta-blockers as first-line therapy unless compelling indications exist 1
• Do not delay treatment in patients with BP ≥140/90 mmHg waiting for lifestyle modifications alone 1
• Do not use hydrochlorothiazide when chlorthalidone is available, as landmark trials used chlorthalidone 2
• Do not ignore out-of-office BP measurements—white coat hypertension requires annual monitoring as it progresses to sustained hypertension 2
• Do not prescribe potassium supplementation to patients with advanced CKD without careful monitoring 2