The 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 marks a major milestone in cardiovascular medicine. This comprehensive update retires and replaces the 2017 ACC/AHA Hypertension Guideline, reflecting nearly a decade of new evidence and clinical practice experience.
The primary goal of the new guideline is to provide up-to-date, evidence-based recommendations for the prevention, diagnosis, and treatment of high blood pressure in adults. It serves as a living, working document intended for:
Primary care clinicians managing patients in everyday practice
Specialists such as cardiologists, nephrologists, endocrinologists, and geriatricians
Healthcare teams involved in prevention, detection, and long-term management of hypertension
The document emphasizes an integrated approach—spanning lifestyle, psychosocial interventions, pharmacological therapy, and comorbidity management—tailored to individual patient needs.
To ensure recommendations reflect the best available science, the writing committee conducted a comprehensive evidence review:
Timeframe: December 2023 – June 2024
Sources: MEDLINE (PubMed), EMBASE, the Cochrane Library, Agency for Healthcare Research and Quality (AHRQ), and other databases
Inclusion criteria: Clinical studies, systematic reviews, and meta-analyses on human subjects, published in English since February 2015
This rigorous process ensures that the guideline incorporates emerging therapies, diagnostic tools, and treatment strategies relevant to modern practice.
Below are the major updates and shifts introduced in the 2025 guideline:
A central new element is the recommendation to use the PREVENT (Predicting Risk of Cardiovascular Disease Events) risk calculator to estimate 10- and 30-year cardiovascular risk.
PREVENT includes not only traditional cardiovascular risk factors (age, sex, BP, lipids etc.) but also kidney and metabolic health and social determinants (including ZIP code as a proxy) to give more precise, individualized risk estimates.
The idea is that risk stratification will better guide decisions about when to initiate pharmacotherapy (drug treatment) vs. relying solely on lifestyle measures.
The 2025 guideline keeps the same four blood pressure categories introduced in 2017:
Normal: < 120/80 mm Hg
Elevated: 120-129 / < 80 mm Hg
Stage 1 hypertension: 130-139 / 80-89 mm Hg
Stage 2 hypertension: ≥ 140 / ≥ 90 mm Hg
However, the new guideline places more emphasis on earlier detection, earlier use of therapy, and more individualized decision-making, especially in patients with “stage 1” BP but additional risks.
In particular, for individuals with stage 1 hypertension and existing clinical cardiovascular disease (CVD), the guideline recommends consideration of antihypertensive therapy.
Urine albumin-to-creatinine ratio (UACR) is now recommended for all patients with high BP (previously optional in 2017). This helps assess kidney damage/function.
Primary aldosteronism screening (via plasma aldosterone-to-renin ratio) is expanded. Now, patients with resistant hypertension are recommended for screening regardless of whether hypokalemia is present.
It also suggests continuing most antihypertensive medications (except mineralocorticoid receptor antagonists) before screening, to avoid delays or barriers.
The 2025 version highlights blood pressure control as a means to protect cognitive function and to reduce the risk of dementia and small vessel brain injury.
Accordingly, earlier therapy is more strongly considered to prevent cognitive decline, not just cardiovascular or renal outcomes.
The guideline updates management of chronic hypertension in pregnancy: it recommends initiating treatment when BP reaches ≥ 140/90 mm Hg in pregnant women with chronic hypertension, a somewhat tighter threshold than past practice in some settings.
It also underscores monitoring postpartum, because hypertension can persist or manifest after delivery.
Incorporation of BP guidelines across pre-pregnancy, pregnancy and postpartum periods is more explicit.
For stage 2 hypertension (≥140/90 mm Hg), the guideline retains the recommendation to start with two medications, ideally as a single-pill combination, to improve adherence and control.
The guideline continues endorsing major classes: ACE inhibitors, ARBs, long-acting dihydropyridine calcium channel blockers, and thiazide-type diuretics.
It allows newer therapies, such as GLP-1 receptor agonists (in patients with hypertension plus overweight/obesity), as adjunct in appropriate patients.
It recommends tailored escalation, i.e., if BP is uncontrolled with one agent, either increase dose or add a second from a different class.
The guideline places greater emphasis on team-based care models (involvement of nurses, pharmacists, allied health, etc.) to support BP control in real-world settings.
Self-measured blood pressure monitoring (home BP monitoring, HBPM) and ambulatory BP monitoring (ABPM) remain integral, and their roles are further emphasized for diagnosis, confirming control, and titration.
The guideline discusses implementation strategies (barriers, health systems factors, health equity) to make guideline-based care feasible in practice.
The BP categories and cutoff thresholds (normal, elevated, stage 1, stage 2) remain unchanged from 2017.
The core pharmacologic classes (ACE/ARB, CCB, thiazide) remain foundational.
The concept that lifestyle modification is foundational, across prevention and treatment, is maintained — though the guideline strengthens and updates recommendations on those lifestyle domains.
Earlier initiation of treatment: More patients with “stage 1” hypertension plus risk factors may be considered for pharmacotherapy earlier, rather than waiting longer or relying exclusively on lifestyle changes.
Greater role for risk stratification: Rather than a one-size-fits-all approach based on BP alone, decisions will increasingly consider individualized cardiovascular, renal, and brain risk (via PREVENT).
Expanded diagnostic workup: Routine UACR testing and broader primary aldosteronism screening may detect secondary causes and early kidney disease.
Focus on cognitive outcomes: Managing BP with an aim of preserving brain health may influence target aggressiveness, especially in vulnerable populations.
Integration across life stages: For women planning pregnancy or currently pregnant, this guideline offers more explicit BP targets, monitoring guidance, and postpartum follow-up.
Team-based delivery and systems-level interventions: To meet more ambitious control goals, practices may need to rely more on collaborative care, nonphysician providers, use of home BP devices, digital tracking, and quality-improvement infrastructure.
Newer adjuncts in selected patients: Use of GLP-1 agonists or other emerging therapies may be considered in selected patients with comorbid obesity or metabolic disease.
Though it is a “living guideline,” the speed of evidence emergence (especially for newer therapies or technologies) may challenge real-time updating.
Implementation in resource-limited settings (e.g., with limited access to ABPM, lab tests, or multidisciplinary teams) may lag, potentially causing disparities.
Use of the PREVENT risk tool presumes availability of required metabolic, renal, and social data; in settings where inputs are missing, risk estimates may be less precise.
Balancing more aggressive treatment with the risk of side effects (e.g., falls, orthostatic hypotension) is especially relevant in older adults, so clinician judgment remains critical.
While the guideline is U.S.-centric, much of its evidence and recommendations are applicable globally — though local adaptation (cost, resources, epidemiology) will be needed.
| Category | 2017 Guideline | 2025 Guideline |
|---|---|---|
| Definition of Hypertension | Hypertension defined as ≥130/80 mm Hg | Retains 130/80 mm Hg threshold but adds refined subcategories (white-coat, masked, resistant hypertension) |
| BP Measurement | Emphasis on accurate in-office measurement | Stronger focus on standardized technique, use of validated devices, and confirmation with ABPM or HBPM |
| Out-of-Office Monitoring | ABPM/HBPM recommended for suspected white-coat or masked hypertension | Broader recommendation: ABPM/HBPM should be integrated into routine diagnosis and management |
| Prevention Strategies | Lifestyle changes emphasized: diet, exercise, sodium reduction, alcohol moderation | Expanded to include psychosocial factors, social determinants of health, obesity prevention, and public health interventions |
| Treatment Thresholds | Pharmacologic therapy recommended at ≥130/80 mm Hg for high-risk patients (CVD, diabetes, CKD) | Maintains thresholds but more precise integration of CVD risk scores to guide drug initiation |
| Pharmacological Treatment | First-line: thiazide diuretics, ACE inhibitors, ARBs, CCBs | Same classes, but greater emphasis on combination therapy for faster BP control and improved outcomes |
| Medication Adherence | Encouraged but limited strategies provided | Expanded adherence strategies, including digital reminders, pharmacist-led interventions, and simplified regimens |
| Special Populations | Covered diabetes, CKD, older adults, and pregnancy | Broader coverage: atrial fibrillation, coronary artery disease, obesity, metabolic syndrome, cerebrovascular disease, HF prevention, and pregnancy-related hypertension |
| Resistant Hypertension | Defined but limited management guidance | Expanded section with new evidence on renal denervation and device-based therapies |
| Complications of Management | Addressed hypertensive emergencies and orthostatic hypotension | Expanded to include sexual dysfunction, perioperative hypertension, and special risks in frail populations |
| Technology in Care | Limited mention | Strong support for digital health tools, telemedicine, mobile apps, and remote monitoring |
| Equity in Care | Not explicitly emphasized | Highlights health equity and disparities, urging clinicians to address social and economic barriers |
| Future Directions | Called for more research on treatment thresholds and outcomes | Identifies precision medicine, long-term outcomes of new devices, and population health strategies as key research areas |
The 2025 Hypertension Guideline provides a roadmap for clinicians to deliver evidence-based, comprehensive, and equitable care for adults with high blood pressure. By integrating updated definitions, prevention strategies, pharmacological thresholds, and special population management, it advances both clinical practice and public health outcomes.
As a living guideline, it is designed to evolve with future evidence, ensuring that clinicians remain aligned with the latest science in hypertension management.
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