2025 AHA/ACC Multisociety Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults
Reaffirms the 130/80 mm Hg threshold, adopts the PREVENT risk calculator in place of the pooled cohort equations, and strengthens recommendations on resistant hypertension, primary aldosteronism screening, pregnancy, and renal denervation.
What changed in this edition
- Hypertension definition unchanged at ≥130/80; confirmation with out-of-office measurement (HBPM or ABPM) when feasible.
- PREVENT risk calculator replaces the pooled cohort equations, incorporating renal function, statin use, and social drivers of health.
- Target <130/80 for most adults; intensive control toward SBP <120 supported when tolerated (SPRINT-style technique).
- Renal denervation recognized as a treatment option for resistant hypertension after confirmed adherence and optimization.
- Primary aldosteronism screening recommended for all patients with resistant hypertension.
- Pregnancy: treat chronic hypertension at ≥140/90 per CHAP trial evidence.
- Updated guidance on hypertension in chronic kidney disease, diabetes, and mild cognitive impairment/dementia.
- Expanded lifestyle and psychosocial recommendations; emphasis on team-based care.
Clinical takeaways
Confirm before you treat
A single office reading ≥130/80 is a prompt to verify with ambulatory or home measurement. Roughly a third of apparent hypertension is white-coat; missing masked hypertension is equally consequential.
Start with combination therapy
Most adults requiring treatment should start on a single-pill combination (e.g., ACEi/ARB + CCB or + thiazide). Monotherapy is reserved for stage 1 with low ASCVD risk.
Resistant hypertension workflow
Confirm with ABPM, verify adherence (urine drug screen or witnessed dose), exclude secondary causes (aldosterone/renin ratio, renal artery imaging if indicated), optimize spironolactone 25–50 mg, then consider renal denervation.
Pregnancy
Initiate labetalol, nifedipine XL, or methyldopa at BP ≥140/90. Avoid ACEi, ARB, direct renin inhibitors, and MRAs in pregnancy and when pregnancy is possible.
Lifestyle still matters
DASH or Mediterranean pattern, sodium <1.5 g/day when tolerated, 150 minutes/week of aerobic exercise, alcohol ≤1 drink/day women and ≤2 men, and weight loss of 1 mm Hg per kg lost.
Quick reference
BP category thresholds (standardized office)
| Normal | <120 and <80 |
|---|---|
| Elevated | 120–129 and <80 |
| Stage 1 hypertension | 130–139 or 80–89 |
| Stage 2 hypertension | ≥140 or ≥90 |
| Hypertensive crisis | ≥180 and/or ≥120 |
Supporting trials
- SPRINTPubMed 26551272
Intensive SBP <120 reduced CV events and mortality vs. <140 in high-risk nondiabetic adults.
- STEPPubMed 34491661
Extended benefit of intensive BP lowering to older Chinese adults aged 60–80.
- CHAPPubMed 35363951
Treating mild chronic hypertension in pregnancy at ≥140/90 reduced severe preeclampsia and preterm birth.
- PATHWAY-2PubMed 26414968
Spironolactone outperformed bisoprolol and doxazosin for resistant hypertension.
- SPYRAL HTN-ON MEDPubMed 35390320
Renal denervation produced durable SBP reductions on top of medical therapy.
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