2025 AHA/ACC Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults

Authors, Journal, Affiliations, Type, DOI

• Writing Committee Chair: Daniel W. Jones, MD, FAHA; Vice Chairs: Keith C. Ferdinand MD, Sandra J. Taler MD
• Journal: Hypertension (AHA Journals), 2025;82:e212–e316
• Organizations: AHA, ACC, AANP, AAPA, ABC, ACCP, ACPM, AGS, AMA, ASPC, NMA, PCNA, SGIM
• Type: Clinical Practice Guideline — replaces and retires the 2017 AHA/ACC Hypertension Guideline
• DOI: 10.1161/HYP.0000000000000249
• Literature search: December 2023 – June 2024; additional studies through January 2025

Overview

The 2025 AHA/ACC hypertension guideline is a comprehensive multi-society update to the 2017 guideline, retaining the same four-tier BP classification and the overarching treatment goal of <130/80 mmHg for all adults. The most consequential change is the replacement of the Pooled Cohort Equations (PCEs) with the PREVENT™ (Predicting Risk of CVD EVENTs) score for CVD risk estimation, lowering the high-risk CVD threshold from ≥10% to ≥7.5%, and switching the outcome from ASCVD-only to total CVD (including heart failure). Key new recommendations include: mandatory primary aldosteronism screening in resistant hypertension regardless of hypokalemia; single-pill combination (SPC) therapy preferred for Stage 2 hypertension; cuffless/smartwatch devices explicitly not recommended; SBP <130 mmHg upgraded to COR 1 for cognitive protection; expanded pregnancy hypertension guidance; and new renal denervation recommendations for resistant hypertension.

Keywords

Antihypertensive agents; blood pressure; blood pressure control; blood pressure monitoring; cardiovascular disease; hypertension; lifestyle; MACE; PREVENT; risk factors

Key Takeaways

2. Definition and Classification of Blood Pressure

• BP Categories (Table 4):

  Category	SBP	DBP
  Normal	<120 mmHg	and <80 mmHg
  Elevated	120–129 mmHg	and <80 mmHg
  Stage 1 Hypertension	130–139 mmHg	or 80–89 mmHg
  Stage 2 Hypertension	≥140 mmHg	or ≥90 mmHg

• Diagnosis requires average of ≥2 readings on ≥2 occasions
• Prevalence: 46.7% of US adults (2017–2020 NHANES); highest in Black adults (56.7–56.8%), age 75–80 (83–85%)

3. Evaluation and Diagnosis

3.1 Accurate BP Measurement

• Standardized oscillometric method preferred over auscultatory (COR 2a); device must be validated (validatebp.org)
• Automated office BP (AOBP) with unattended measurement recommended
• Cuffless devices (smartwatches): COR 3: No Benefit — not recommended for diagnosis or management due to insufficient validation

3.1.3–3.1.4 Out-of-Office BP Monitoring

• ABPM or HBPM recommended to confirm diagnosis of hypertension (COR 1, LOE A)
• HBPM + cointerventions (telehealth, education, medication titration algorithms) recommended for monitoring antihypertensive medication titration (COR 1, LOE A)
• Correspondence thresholds (Table 7):

  Office	HBPM	24h ABPM
  130/80	130/80	125/75
  140/90	135/85	130/80

3.2 Patient Diagnosis

• White-coat hypertension: screen with out-of-office monitoring if office SBP 130–159 mmHg (COR 2a, LOE B-NR)
• Masked hypertension: more common in Black populations; associated with CVD risk similar to sustained hypertension

3.2.3 Secondary Hypertension

• Present in 5–25% of adults with hypertension; more common with resistant HT, Stage 2 HT, sudden onset, or early onset (<30 years)
• Most common secondary causes: Obstructive sleep apnea (25–50%), CKD (14%), Primary aldosteronism (5–25%), Drug/alcohol-induced (2–20%), Renovascular hypertension (0.1–5%)
• New (COR 1): Screen ALL adults with resistant hypertension for primary aldosteronism regardless of whether hypokalemia is present — hypokalemia is present in only 20–50% of cases
• New (COR 1): Continue most antihypertensives (except MRA) prior to initial primary aldosteronism screening to minimize delays

4. Prevention Strategies

• SDOH including social deprivation are incorporated into PREVENT™ and should inform management
• Community-level screening and team-based prevention approaches recommended (COR 1)

5. BP Management

5.1 Lifestyle Interventions (Table 12)

• DASH eating plan ranked most effective lifestyle intervention (COR 1, LOE A); Mediterranean, low-sodium, Mediterranean diets less effective
• Sodium: Reduce to <2300 mg/d; ideal <1500 mg/d (COR 1, LOE A)
• Potassium-based salt substitutes: New COR 2a — useful for home food preparers; caution if CKD or drugs reducing potassium excretion (ACEi, ARB, MRA, K-sparing diuretics)
• Potassium supplementation: COR 1 — aim 3500–5000 mg/d via dietary sources; avoid >80 mmol/d supplement
• Alcohol: Optimal goal is abstinence; maximum ≤1 drink/d women, ≤2 drinks/d men (COR 1, LOE A)
• Physical activity: Aerobic + dynamic resistance + isometric resistance exercise all effective (COR 1, LOE A)
• Stress reduction: Transcendental meditation (COR 2b, LOE B-R); breathing control, yoga (COR 2b, LOE B-R)

5.2 Medical Management

5.2.1–5.2.2 Treatment Thresholds (UPDATED)

• All adults with SBP ≥140 or DBP ≥90: initiate antihypertensives (COR 1, LOE A) — unchanged
• Adults with CVD, diabetes, CKD, or PREVENT ≥7.5% 10-year CVD risk: initiate if SBP ≥130 or DBP ≥80 (COR 1) — threshold lowered from PCE ≥10% to PREVENT ≥7.5%
• Adults without CVD and PREVENT <7.5%: initiate if SBP ≥130 remains after 3–6 month lifestyle trial (COR 1)
• PREVENT™ replaces PCEs: derived from 3.2M individuals (1992–2022); includes statin use, eGFR, social deprivation index; estimates total CVD (not just ASCVD); PCEs overpredicted risk 2-fold; applicable ages 30–79

5.2.3–5.2.4 Medication Selection

• First-line agents: Thiazide-type diuretics, long-acting CCB, ACEi, ARB
• Stage 2 HT or high CVD risk: Initiate 2 first-line agents preferably as SPC (COR 1, LOE A) — new recommendation; SPC over separate pills
• Avoid ACEi + ARB combination (increased risk AKI and hyperkalemia); avoid dual RAS blockade
• Non-dihydropyridine CCB + beta blocker: avoid (bradycardia/AV block risk)
• Beta blockers: not first-line for HT unless CCD, HFrEF, or specific arrhythmia indication

5.2.5 Medication Adherence

• Once-daily dosing preferred (COR 1, LOE B-R); SPC reduces pill burden (COR 1, LOE B-R)
• Medication synchronization, reminders, patient education all supported (COR 2a, LOE B-R)
• ~50% of patients non-adherent at 1 year; screen for SDOH, health literacy, depression/anxiety as barriers

5.2.7 BP Goals

• High CVD risk (PREVENT ≥7.5%): SBP goal ≤130 mmHg (with encouragement to achieve <120 mmHg); DBP goal <80 mmHg (COR 1, LOE A)
• Lower CVD risk (PREVENT <7.5%): SBP goal <130 mmHg reasonable (COR 2b, LOE B-NR)
• SPRINT demonstrated SBP <120 mmHg vs <140 mmHg reduces MACE, HF, and mortality; similar benefit in CKD and T2D (BPROAD trial)
• J-curve concern for DBP: monitor symptoms and eGFR; no fixed lower DBP threshold established

5.3 Comorbidities

5.3.1 Diabetes

• ACEi or ARB recommended (COR 1, LOE A, upgraded from COR 2b) if CKD (eGFR <60 mL/min/1.73m² or albuminuria ≥30 mg/g); should be considered for mild albuminuria <30 mg/g
• SBP goal <130 mmHg (encourage <120 mmHg); DBP goal <80 mmHg (COR 1, LOE A)
• All first-line antihypertensive classes effective in T2D; SGLT2i and GLP-1 agonists have additional BP-lowering effects

5.3.2 Obesity and Metabolic Syndrome

• GLP-1 receptor agonists (COR 2b): adjunct BP lowering in overweight/obesity; semaglutide −5.7 mmHg SBP
• Bariatric surgery (COR 2b): BMI ≥35 kg/m²; sustained weight reduction required to prevent BP rebound

5.3.3 Chronic Coronary Disease

• SBP <130 mmHg recommended; optimal DBP 70–80 mmHg range when SBP <130 mmHg; ACEi/ARB/BB preferred; conflicting evidence for BB >1 year post-MI in preserved EF

5.3.4 Heart Failure Prevention

• Antecedent HT present in 71% of HF; treating SBP to <130 mmHg and DBP to <80 mmHg recommended to prevent HF (COR 1, LOE B-R/B-NR)
• HFrEF: Uptitrate GDMT (ARNi > ACEi/ARB, BB, MRA, SGLT2i); add dihydropyridine CCB only if BP remains elevated despite GDMT; avoid non-DHP CCB (negative inotropic effects)
• HFpEF: RAASi (ARNi/ARB/MRA) for SBP <130 mmHg; diuretics for volume; SGLT2i; BB NOT recommended for BP control in HFpEF (avoid negative chronotropy); adjust antihypertensives if hypotension after SGLT2i

5.3.5 Atrial Fibrillation

• Hypertension has highest attributable risk for AF development; present in >80% of AF patients
• BP control reduces incident AF (especially in HF) and MACE/stroke in established AF
• Goal BP <130/80 mmHg in AF (general hypertension guidelines apply)
• ACEi/ARB: meta-analyses suggest reduction in recurrent AF (more definitive evidence needed); MRAs reduce AF burden in small studies

5.3.6 Valvular Heart Disease

• ACEi/ARB post-TAVI associated with reduced mortality; ACEi/ARB in chronic aortic regurgitation reduces CV events
• Rate-reducing agents may paradoxically increase SBP in chronic aortic regurgitation (wide pulse pressure); caution with non-DHP CCB

5.3.7 Aortic Disease

• Optimal BP <130/80 mmHg; BB recommended; abdominal aortic aneurysm rupture risk increases 30% per 10 mmHg elevation

5.3.8 Chronic Kidney Disease

• SBP goal <130 mmHg (COR 1, LOE A) for eGFR <60 or albuminuria ≥30 mg/g
• RAASi (ACEi or ARB, not both) recommended if albuminuria ≥30 mg/g (COR 1, LOE B-R, upgraded); acceptable with eGFR <30 mL/min (discontinuation not beneficial per RCT)
• Expected eGFR dip ≤30% with RAASi is acceptable and not an indication to stop
• Post-kidney transplant: no specific BP target or drug class has robust RCT evidence

5.3.9 Cerebrovascular Disease

• Acute ICH (SBP 150–220 mmHg): COR 2a — immediately lower SBP to 130–<140 mmHg for ≥7 days; stop if SBP <130 mmHg; avoid BP lability/variability
• Acute ICH (SBP >220 mmHg): Do NOT lower below 130 mmHg (COR 3:Harm)
• Acute ischemic stroke post-EVT (large vessel occlusion): Lowering SBP <140 mmHg within 24–72h post-reperfusion is HARMFUL (COR 3:Harm, LOE A) — ENCHANTED-2 MT, OPTIMAL BP, BEST-II trials
• Acute ischemic stroke (no thrombolysis or EVT, SBP <220/120): Starting antihypertensives within 48–72h NOT effective for death/disability (COR 3:No Benefit, LOE A)
• Secondary stroke prevention: SBP/DBP goal <130/80 mmHg (COR 1, LOE B-R); thiazide-type diuretics, ACEi, ARB preferred; initiate if SBP ≥130/80 mmHg even without prior hypertension diagnosis

5.3.9.4 Cognitive Impairment and Dementia

• New COR 1 (upgraded from COR 2a): SBP goal <130 mmHg recommended to prevent mild cognitive impairment and dementia (LOE A)
• SPRINT-MIND: 12% SBP reduction with intensive treatment reduced cognitive impairment; benefit persisted 7 years post-trial
• No RCT of BP lowering has demonstrated adverse cognitive effects

5.3.10 Peripheral Artery Disease

• BP goal <130/80 mmHg; no evidence that lower BP worsens claudication
• ACEi/ARB preferred first-line (cardiovascular benefit shown)

5.4 Plan of Care

• Team-based care recommended for uncontrolled HT (COR 1, LOE A): physicians, pharmacists, nurses, NPs, PAs, dieticians, community health workers, social workers
• Monthly follow-up until control achieved after new/intensified therapy (COR 1, LOE B-R)
• Telehealth (synchronous and asynchronous): COR 1 for improving BP control, medication adherence, and access to care

5.5 Hypertension and Pregnancy

• New COR 1: Treat acute severe-range HT (SBP ≥160 or DBP ≥110 mmHg confirmed within 15 min) with antihypertensives to <160/110 mmHg within 30–60 minutes
• New COR 1: Chronic HT in pregnancy (prepregnancy or SBP 140–159/DBP 90–109 before 20 weeks) — treat to BP <140/90 mmHg
• New COR 1: Low-dose aspirin recommended for all hypertensive individuals planning or in pregnancy (preeclampsia prevention, from 12 weeks)
• Contraindicated in pregnancy (COR 3:Harm, updated): Atenolol, ACEi, ARB, direct renin inhibitors, nitroprusside, MRA
• Safe oral agents in pregnancy: labetalol, nifedipine (extended release), methyldopa, HCTZ (second/third line)
• Post-delivery: annual BP check for those with resolved HDP; treat as sex-specific CVD risk enhancer for statin decisions; discuss contraception if on teratogenic agents

5.6 Resistant Hypertension and Renal Denervation

• Definition: BP above goal on ≥3 antihypertensives with complementary mechanisms including a diuretic at maximally tolerated doses, or BP at goal on ≥4 agents
• Prevalence: ~8.5–20% of hypertensive US adults; more common in older, obese, CKD, Black populations
• Evaluation: Exclude pseudoresistance (white-coat effect, medication non-adherence, interfering drugs, inaccurate measurement); screen for secondary hypertension
• New COR 1: Detailed review and removal of interfering medications before adding agents
• 4th agent (COR 1, LOE B-R): MRA (spironolactone 25–50 mg/d) if eGFR ≥45 mL/min; reduces home/24h SBP by 6.6–8.7 mmHg vs placebo; superior to alpha-blocker or bisoprolol
• 4th agent alternatives (COR 2a): Amiloride (equally effective as spironolactone), beta-blockers, alpha-blockers, central sympatholytics, dual endothelin receptor antagonists (aprocitentan), direct vasodilators
• Aprocitentan (new): Dual ERA; reduces 24h ambulatory SBP by 4–6 mmHg vs placebo in resistant HT; fluid retention in 9% at approved dose
• Renal Denervation (RDN):
  • COR 2b: May be reasonable for carefully selected patients (office SBP 140–180 mmHg, DBP ≥90 mmHg, eGFR ≥40 mL/min) with resistant HT despite optimal therapy or intolerable side effects
  • Reduces 24h ambulatory SBP by 3–5 mmHg vs sham in some trials; inferior/similar to spironolactone as 4th agent
  • COR 1: Multidisciplinary team evaluation mandatory before RDN
  • COR 1: Shared decision-making required; only 60–70% have ≥5 mmHg ambulatory SBP reduction
  • Not curative; does not replace antihypertensives; renal artery stenosis risk 0.2%/yr post-procedure

6. Complications of Management

6.1 Orthostatic Hypotension (OH)

• Common with antihypertensive intensification, especially in older adults
• Monitor with orthostatic vitals when initiating or adjusting therapy

6.2 Hypertensive Emergencies and Severe Hypertension

• Terminology change: "Hypertensive urgency" replaced by "Severe hypertension" (SBP >180/120 mmHg)
• Severe HT without target organ damage: Evaluate and treat in outpatient setting with oral antihypertensives (COR 1)
• New COR 3:Harm: IV/additional oral antihypertensives for hospitalized patients with severe HT but no acute target organ damage and non-cardiac admission — not recommended

Limitations of the Document

• Literature search closed June 2024; some post-2024 trials not included
• Most RCT data on BP targets from high-risk populations; limited data on optimal targets for lower-risk adults
• ABPM thresholds derived primarily from European/Australian/Asian populations; limited US-specific threshold data
• Resistant hypertension RDN trials have short follow-up (2–3 months) with no CVD outcome data
• Pregnancy hypertension recommendations limited by small, poor-quality RCTs
• Lack of robust evidence for specific BP targets in post-kidney transplant patients
• PCE-to-PREVENT transition may re-classify large numbers of patients; implementation will require clinical adaptation

Key Concepts Mentioned

• concepts/ASCVD-Risk-Assessment — PREVENT™ replaces PCEs for CVD risk estimation in HT; threshold lowered to 7.5%
• concepts/HFpEF — specific antihypertensive guidance (BB avoided, ARNi/MRA/SGLT2i preferred)
• concepts/LV-Diastolic-Function — hypertension as leading cause of diastolic dysfunction and HFpEF
• concepts/OSA-Arrhythmogenic-Substrate — OSA as most common secondary HT cause (25–50%)
• concepts/Drug-Induced-Arrhythmia — multiple drugs elevate BP; drug-induced secondary HT recognized

Key Entities Mentioned

• entities/Atrial-Fibrillation — HT highest attributable AF risk; BP control reduces AF burden; ACEi/ARB/MRA studied for AF prevention
• entities/Heart-Failure — HT antecedent in 71% HF; specific guidance for HFrEF (GDMT uptitration) and HFpEF
• entities/Obstructive-Sleep-Apnea — most common secondary HT cause; STOP-Bang screening
• entities/Amiodarone — not directly discussed; note interaction with antihypertensives (CYP2D6 inhibition → increased beta-blocker levels)

Wiki Pages Updated

• Created: wiki/sources/HT-AHA-2025.md
• Created: wiki/entities/Hypertension.md
• Updated: wiki/sourceindex.md
• Updated: wiki/wikiindex.md
• Updated: wiki/concepts/ASCVD-Risk-Assessment.md (PREVENT use in HT)
• Updated: wiki/entities/Atrial-Fibrillation.md (HT-AF relationship)
• Updated: wiki/entities/Heart-Failure.md (HT management in HFrEF/HFpEF)