New 2025 AHA/ACC Hypertension Guidelines

Written by Babatunde Carew

Spoon Feed
The 2025 AHA/ACC hypertension guidelines recommend a universal BP goal of <130/80 with antihypertensive therapy initiation, guided by hypertension severity, comorbidities, and PREVENT risk score.

Pressure Points: 2025 HTN Guideline Highlights 
Since 1980, the American College of Cardiology (ACC) and American Heart Association (AHA) have issued evidence-based guidelines to guide cardiovascular care. The 2025 hypertension guidelines reemphasize HTN as the leading and most modifiable contributor to cardiovascular morbidity and mortality, while introducing several important updates from the 2017 recommendations. I’ve highlighted below what I believe are the most clinically relevant take home points.

Categories of Blood Pressure in Adults

• Patients should be categorized based on an average of ≥2 careful readings obtained on ≥2 occasions (see Table below).
• Out-of-office blood pressure monitoring improves accuracy in identifying HTN. Options include ambulatory blood pressure monitoring (ABPM) and home blood pressure measurement (HBPM). ABPM typically involves wearing a fully automated device, usually over a period of 24 hours. HBPM involves measuring BP at home over days to weeks.

Secondary Hypertension

• Secondary hypertension is more likely in patients with stage 2 or resistant hypertension, abrupt onset, early-onset (<30 years), diastolic hypertension in older adults, or disproportionate target organ damage. The most common are primary aldosteronism (5–25%) and obstructive sleep apnea (25–50%).
• Screening for primary aldosteronism is recommended in patients with resistant hypertension (with or without hypokalemia), unexplained hypokalemia, obstructive sleep apnea, incidentally discovered adrenal mass, a family history of early onset hypertension, or stroke before age 40. When screening for primary aldosteronism, all antihypertensive medications except mineralocorticoid receptor antagonists (MRA) should be continued to avoid unnecessary delays or barriers to screening.

Management of Hypertension

• All patients with hypertension should be counseled on lifestyle modification, including weight loss if overweight (goal ≥ 5% weight loss), dietary modification (e.g. DASH diet), reduction of dietary sodium, alcohol reduction or abstinence, and increased physical activity.
• In patients with Stage 1 HTN and low CV risk (PREVENT <7.5%), initiation of medication is recommended if average BP remains ≥130/80 mm Hg after 3–6 month trial of lifestyle modification.
• In patients with Stage 2 HTN or Stage 1 HTN with co-existing cardiovascular disease history, diabetes, chronic kidney disease, or high CV risk (PREVENT ≥7.5%), initiation of medication is recommended.
• Thiazide-type diuretics, long-acting dihydropyridine CCB, and ACEi/ARB are first line therapy for HTN.
• In patients with stage 1 hypertension, initial therapy with a single first-line antihypertensive is reasonable, with dosage titration and sequential addition of other agents as needed to achieve BP goal.
• In patients with stage 2 hypertension, initiation of antihypertensive therapy with 2 first line agents of different classes, ideally in single pill combination (SPC), is recommended.

Blood Pressure Goals

• A SBP goal of <130 mm Hg, with encouragement to achieve SBP <120 mm Hg, is recommended. A DBP goal <80 mm Hg is also recommended.
• In patients with T2D and HTN, antihypertensive therapy should be initiated at an SBP of ≥130 mm Hg with goal of <130 mm Hg, with encouragement to achieve SBP <120 mm Hg; antihypertensive therapy should also be initiated at a DBP of ≥80 mm Hg with goal of <80 mm Hg. 
• In patients with HTN and CKD, SBP goal of <130 mm Hg is recommended. ACEi or ARB is recommended to delay progression of renal disease. 

Resistant Hypertension

• In resistant hypertension, a thorough evaluation for secondary causes—including careful medication review—is recommended to improve control and streamline management.
• In patients with uncontrolled resistant hypertension despite optimal therapy (ACEi or ARB plus CCB plus thiazide-like diuretic) and an eGFR ≥45, adding a MRA is recommended.
• In patients with uncontrolled resistant hypertension who cannot use MRAs, it is reasonable to add amiloride, a beta-blocker, an alpha-blocker, a central sympatholytic, a dual endothelin receptor antagonist, or a direct vasodilator.
• In select patients with resistant hypertension and eGFR ≥40 who remain uncontrolled on optimal therapy and/or cannot tolerate further medication, renal denervation (RDN) may be reasonable to consider with guidance of a multidisciplinary team with expertise in resistant hypertension and RDN. 

Severe Hypertension

• Severe hypertension (>180/120 mm Hg) in nonpregnant adults without acute end organ damage should be managed in the outpatient setting.
• In hypertensive emergency (severe hypertension with acute end organ damage), ICU admission for continuous BP monitoring, staged BP lowering, and consideration of parenteral antihypertensive therapy is recommended. 
• In hospitalized patients with severe hypertension without acute end organ damage, intermittent IV or oral antihypertensives should not be used for rapid BP reduction.

How does this change my practice?
The two guidelines that will change my practice most are likely the recommendation to continue antihypertensives (other than MRAs) when screening for primary hyperaldosteronism and the push to initiate single pill combination (SPC) therapy in stage 2 hypertension as initial therapy.

The call to avoid holding medications when screening for hyperaldosteronism will likely assist in identifying more cases, but aldosterone/renin ratios will need to be considered more closely when performed on patients taking ACEi or ARBs.

I often use SPCs (olmesartan-amlodipine or olmesartan-amlodipine-HCTZ are my go-to combos) to improve adherence, but not as initial therapy. Starting SPCs earlier may improve outcomes; interestingly, the guidelines referenced data suggesting that fewer CV events and deaths occur with SPCs compared to equivalent multi pill regimens and the growing evidence base for polypill therapy in general.

Editor’s note: Dr. Carew is an internist and primary care physician. His perspective on how he treats HTN and views these guidelines is invaluable for us in the ED. ~Clay Smith

Source
2025 AHA/ACC/AANP/AAPA/ABC/ACCP/ACPM/AGS/AMA/ASPC/NMA/PCNA/SGIM Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Hypertension. 2025 Aug 14. doi: 10.1161/HYP.0000000000000249. Epub ahead of print. PMID: 40811516.