Under Pressure: A Brief Overview of the Updated Hypertension Guidelines

Hypertension is a prevalent condition characterized by an elevation in blood pressure. If uncontrolled, hypertension can lead to significant cardiovascular complications, including stroke, coronary artery disease, and heart failure.^1-3 In August 2025, the American Heart Association (AHA) and the American College of Cardiology (ACC) released updated guidelines for evaluating and managing hypertension. Updated recommendations include changing the thresholds for initiating antihypertensive therapy using the Predicting Risk of Cardiovascular Disease EVENTS (PREVENT) equation.¹

RISK ASSESSMENT AND THRESHOLDS FOR INITIATING THERAPY

The decision to initiate pharmacologic treatment for hypertension has been based on the degree/classification of blood pressure elevation in addition to the patient’s risk for cardiovascular disease. The classification of blood pressure as normal, elevated, stage 1 hypertension, or stage 2 hypertension remains unchanged from the 2017 AHA/ACC guidelines.^1,2 However, new recommendations endorse using the PREVENT equation to assess risk for cardiovascular disease and to determine when to initiate antihypertensives for primary prevention.¹

Unlike previously used pooled cohort equations that just estimated atherosclerotic cardiovascular disease (ASCVD) risk, the PREVENT equation estimates the 10-year and 30-year risks for total cardiovascular disease (CVD), comprising heart failure in addition to ASCVD.^1,4,5 The equation eliminates the race-based component used in prior assessment tools. It is based on sex, age, total cholesterol, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, systolic blood pressure (SBP), diastolic blood pressure (DBP), body mass index, estimated glomerular filtration rate (eGFR), smoking status, presence of diabetes, and use of antihypertensives or lipid-lowering medications.^4,5

PREVENT also has 3 optional predictors to further determine risk: urine albumin-to-creatinine ratio (uACR), hemoglobin A1c, and zip code. This equation was validated using data from over 6 million adults, although it is important to note that only adults aged 30 to 79 years were included, and patients with baseline ASCVD and heart failure at baseline were excluded.⁴ The initiation of antihypertensive therapy is recommended in patients with stage 1 hypertension (SBP, 130-139 mm Hg; or DBP, 80-89 mm Hg) and CVD risk of 7.5% or higher based on PREVENT.¹ This is a significant change from the 2017 guidelines, which recommended antihypertensive therapy when CVD risk is 10% or greater.²

CHRONIC KIDNEY DISEASE PARAMETERS

In addition, the chronic kidney disease (CKD) parameters that warrant antihypertensive therapy have also been adjusted. The 2017 guidelines recommended starting an angiotensin-converting enzyme (ACE) inhibitor or an angiotensin receptor blocker (ARB) in patients with hypertension and one of the following²:

1. Stage 3 CKD or greater (eGFR, ≤59 mL/min/1.73 m²)

2. Stage 1 or 2 CKD (eGFR, ≥60 mL/min/1.73 m²) with albuminuria (uACR, ≥300 mg/g)

ACC/AHA now recommends earlier initiation of antihypertensives in this cohort to decrease mortality, decrease cardiovascular disease, and delay the progression of kidney disease.¹ Antihypertensives should be initiated in patients with hypertension and CKD (now identified as eGFR <60 mL/min/1.73 m² or albuminuria [uACR] ≥30 mg/g). Based on expert opinion, antihypertensive therapy may also be considered in patients with hypertension and CKD with a uACR less than 30 mg/g. ACE inhibitors or ARBs remain the treatment of choice in patients with CKD, and the goal SBP is still less than 130 mm Hg.¹

ADDITIONAL CHANGES AND CONSIDERATIONS

In addition, the 2025 guidelines also mention the following changes/updates¹:

• Verbiage stating that calcium channel blockers (CCBs) or thiazide-type diuretics should be preferred in Black patients without heart failure or CKD has been removed. It is recommended that first-line therapy for thiazide-type diuretics, CCBs, ACE inhibitors, or ARBs.

• For patients with stage 2 hypertension (SBP ≥140 mm Hg or DBP ≥90 mm Hg), initiation with a combination medication containing fixed doses of 2 first-line antihypertensives with differing mechanisms of action to promote adherence is recommended.

• The threshold for treating chronic hypertension in pregnancy has been reduced from 160/110 or greater to 140/90 or greater.

• All patients with resistant hypertension should be screened for primary aldosteronism.

• The term hypertensive urgency has been replaced with severe hypertension without evidence of acute target organ damage.

• Potassium-based salt substitutes should be used in place of salt for patients who do not have a contraindication (eg, CKD).

CONCLUSION

Considering the change in the thresholds for initiating antihypertensives, the 2025 ACC/AHA guideline recommendations will increase the number of patients on these therapies. Pharmacists are expected to play a key role in identifying patients who would benefit from blood pressure-lowering agents, interpreting total CVD risk using PREVENT, and managing blood pressure within a multidisciplinary team.

REFERENCES

1. Jones DW, Ferdinand KC, Taler SJ, et al. 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. Circulation. Published online August 14, 2025. doi:10/1161/CIR.0000000000001356

2. Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA 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 Task Force on clinical practice guidelines. Hypertension. 2018;71(6):e13-e115. doi:10.1161/HYP.0000000000000065

3. Saseen JJ, MacLaughlin EJ. Chapter 13: Hypertension. In: DiPiro JT, Talbert RL, Yee CG, Matzke GR, Wells BG, Posey LM, eds. Pharmacotherapy: A Pathophysiologic Approach, 10e. 2017; McGraw-Hill Education.

4. Khan SS, Matsushita K, Sang Y, et al; Chronic Kidney Disease Prognosis Consortium and the American Heart Association Cardiovascular-Kidney-Metabolic Science Advisory Group. Development and validation of the American Heart Association’s PREVENT equations. Circulation. 2024;149(6):430-449. doi:10.1161/CIRCULATIONAHA.123.067626

5. The American Heart Association PREVENT Online Calculator. American Heart Association. Accessed September 3, 2025. https://professional.heart.org/en/guidelines-and-statements/prevent-risk-calculator/%20prevent-calculator