New 2025 Hypertension Management Guidelines Include Key Updates

Introduction

Hypertension affects more than 115 million adults in the US and represents the most prevalent and modifiable risk factor for the development of cardiovascular diseases (CVDs).¹ The American Heart Association (AHA) and American College of Cardiology (ACC) have recently furnished an updated 2025 guideline¹ for the prevention, diagnosis, and management of hypertension to replace the 2017 version.² This update is pertinent given the historic differences in clinical recommendations for hypertension care between US professional societies and their international counterparts. This article summarizes notable updates of the 2025 AHA/ACC guideline for hypertension care.

Blood Pressure Treatment Threshold

In determining the blood pressure (BP) treatment threshold and using CVD risk estimation to guide drug treatment of hypertension, the Predicting Risk of Cardiovascular Disease Events (PREVENT) scale is now recommended. The PREVENT scale was developed in 2023 to assess broad cardiovascular risk, such as the risk of developing atrial fibrillation or heart failure, and is reported at 10- and 30-year risk levels. This contrasts with the previous version of the guideline, which analyzed CVD risk using the 2013 atherosclerotic CVD (ASCVD) risk scale. In contrast to PREVENT, the ASCVD scale assesses only the risk of myocardial infarction and uses a 10-year risk estimate.

The use of the PREVENT scale led to the revision of 2 guideline recommendations that lowered the hypertension treatment threshold. It was previously recommended to begin primary prevention in adults with a 10-year ASCVD risk of 10% or higher at a BP threshold of 130/80 mm Hg. Although maintaining the same threshold, the revised guideline broadens primary prevention in adults by lowering the CVD risk to at least 7.5% or greater on the PREVENT scale. It also broadens the primary prevention recommendation to include patients with diabetes or chronic kidney disease (CKD), even in patients without established CVD.

For adults without CVD, antihypertensive therapy was previously recommended in the presence of a 10-year ASCVD risk of less than 10% and a systolic BP (SBP) of 140 mm Hg or higher or a diastolic BP (DBP) of 90 mm Hg or greater. According to the updated recommendations, antihypertensive therapy is now indicated in adults without clinical CVD who have a PREVENT risk of less than 7.5% and a BP of 130/80 mm Hg or higher after 3 to 6 months of lifestyle interventions. This is designed to prevent target organ damage and further increases in BP.

Notably, these recommendations still differ from those of international societies, which recommend higher BP thresholds for antihypertensive therapy. For example, the World Health Organization (WHO) recommends a BP target below 140/90 mm Hg in patients without comorbidities and an SBP below 130 mm Hg for patients with known CVD.³ One landmark trial that led to this divergence of recommendations was SPRINT (NCT01206062),⁴ whose findings showed a marked improvement in BP reduction and clinical outcomes in patients treated with a target SBP below 120 mm Hg, including in those without established CVD. Although this would encourage a lower treatment threshold, the WHO factors in the increased health care costs of $23,000 per patient per year associated with targeting this new threshold. Despite this, the 2025 AHA/ACC guideline did not align its recommendations with those of the WHO, and the discord between US and international bodies regarding the extent of medicalization warranted regarding hypertension remains unresolved.

Dietary Modifications

In terms of dietary modifications, the guidelines newly recommend potassium-based salt substitutes for adults with or without hypertension, as this intervention can help to prevent or treat the condition. However, patients with CKD or who use medications that reduce potassium excretion fall outside the scope of this recommendation.

Resistant Hypertension

For adults with resistant hypertension, it is newly recommended to conduct a thorough evaluation of secondary causes and a review of all medications. This includes discontinuing medications that interfere with BP, as this is beneficial for controlling BP and simplifying treatment. Patients with hypertension being considered for renal denervation (RDN) should not be assessed by a single provider. Instead, they should be evaluated by a multidisciplinary team that is experienced in both resistant hypertension and RDN. Finally, for hypertensive patients being considered for RDN, the potential BP-lowering benefits and procedural risks should be weighed against continued medical therapy. This should be a shared decision-making process to ensure that the chosen approach aligns with the patient’s expectations.

Additionally, one new recommendation in the context of resistant hypertension entails screening for primary aldosteronism in adults with the condition regardless of the presence of hypokalemia. It is also recommended not to discontinue antihypertensive medications, except for mineralocorticoid receptor antagonists, in the time frame leading up to the initial screening.

Comorbidities

A previous recommendation to treat hypertension with an angiotensin-converting enzyme inhibitor (ACEi) or angiotensin II receptor blocker (ARB) in the presence of diabetes and albuminuria has been elaborated upon. The new guidelines recommend treatment with an ACEi or ARB specifically in the presence of CKD with an estimated glomerular filtration rate of below 60 mL/min/1.73 m² or albuminuria greater than 30 mg/g, and to consider treatment in patients with milder albuminuria (< 30 mg/g). Additionally, in patients with CKD, treatment with an ACEi or ARB is indicated not only to delay progression to diabetic kidney disease but also to reduce the risk of CVD.

Complications

If an adult patient develops an acute intracerebral hemorrhage (ICH) with an SBP between 150 and 220 mm Hg, it is newly recommended to aim to lower the SBP to 130 to 139 mm Hg and maintain this level for at least 7 days. However, if the SBP drops below 130 mm Hg, then antihypertensives should be stopped. Careful titration in lowering the SBP is pertinent to avoid peaks and large variability in SBP with the goal of improving functional outcomes post ICH. Furthermore, in patients with acute ischemic stroke who undergo successful endovascular treatment for large vessel occlusion, lowering the SBP below 140 mm Hg within 24 to 72 hours after reperfusion can worsen long-term functional outcomes.

Furthermore, in adults with severe hypertension who are not pregnant and have not had a stroke and are hospitalized for noncardiac conditions, intermittent use of intravenous or oral antihypertensives for acute BP reduction is not recommended. Notably, the term severe hypertension has been introduced in this guideline to replace the term hypertensive urgency, with severe hypertension still defined as a BP level greater than 180/120 mm Hg without evidence of acute target organ damage.

Regarding dementia and hypertension, the guidelines newly specify a treatment goal below 130–mm Hg SBP to prevent mild cognitive impairment and dementia.

Pregnancy

Several recommendations have been updated for pregnant women with hypertension. Firstly, those with an SBP of 160 mm Hg or greater, or a DBP of 110 mm Hg or greater, confirmed on a repeat reading within 15 minutes, should be treated to lower BP to less than 160/110 mm Hg within 30 to 60 minutes. Secondly, pregnant patients with chronic hypertension should receive antihypertensive therapy to achieve a BP below 140/90 mm Hg. Thirdly, patients with hypertension who are planning to become pregnant or who become pregnant should be counseled on the benefits of low-dose aspirin, which include a reduced risk of preeclampsia, preterm birth, and perinatal mortality. Lastly, a previous recommendation to avoid ACEis and direct renin inhibitors in pregnant women has been expanded to warn against the use of ACEis, ARBs, direct renin inhibitors, nitroprusside, mineralocorticoid receptor antagonists, and atenolol in pregnant patients and those planning to become pregnant.

Conclusion

The 2025 AHA/ACC hypertension guidelines are an important resource for the prevention, diagnosis, and management of hypertension and the optimization of therapy selection and patient safety across a wide variety of hypertensive conditions. Health care providers should stay up to date on recommendations from US and international organizations to optimize hypertension care for individual patients.

REFERENCES

1. Writing Committee Members; 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. 2025;152(11):e114-e218. 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. Hypertens. 2017;71(6):e13-e115. doi:10.1161/HYP.0000000000000065

3. Guideline for the pharmacological treatment of hypertension in adults. World Health Organization. 2021. Accessed September 30, 2025. https://iris.who.int/server/api/core/bitstreams/f062769d-f075-4a00-87af-0a2106e0bd04/content

4. SPRINT Research Group; Wright JT Jr, Williamson JD, Whelton PK, et al. A randomized trial of intensive versus standard blood-pressure control. N Engl J Med. 2015;373(22):2103-2116. doi:10.1056/NEJMoa1511939