2025 ACC/AHA Hypertension Guideline — GP Practical Summary
2025 ACC/AHA Hypertension Guideline — GP Practical Summary
Source & Date: American Heart Association / American College of Cardiology Hypertension Guideline (May–Aug 2025).
Published in: JACC, Circulation, Hypertension (DOI: 10.1016/j.jacc.2025.05.007).
1. BP Classification (Office)
1. Normal: <120/<80 mmHg
2. Elevated: 120–129/<80 mmHg
3. Stage 1 HTN: 130–139/80–89 mmHg
4. Stage 2 HTN: ≥140/≥90 mmHg
• Always classify into the higher category if SBP/DBP differ.
• Confirm with ≥2 readings per visit on ≥2 occasions.
2. Accurate BP Measurement
5. Use validated devices (validatebp.org); correct cuff size.
6. Avoid caffeine, exercise, smoking 30 min before.
7. Average ≥2 readings per visit; repeat at ≥2 visits.
8. Re-train staff every 6–12 months.
3. Out-of-Office Monitoring
9. ABPM/HBPM recommended for diagnosis, titration, white-coat & masked HTN.
10. Thresholds:
• HBPM ≥130/80
• Daytime ABPM ≥130/80
• Night ABPM ≥110/65
• 24h ABPM ≥125/75
4. When to Start Medications
11. High risk (CVD, CKD, diabetes, 10y risk ≥7.5%): ≥130/80.
12. Lower risk (<7.5%): ≥140/90; or ≥130/80 after 3–6 months lifestyle.
13. Stage 2 HTN: start 2 first-line drugs, ideally in single-pill combo.
5. Treatment Targets
14. General goal: <130/80 mmHg for most adults.
15. Exceptions: frail elderly, institutionalized, pregnancy (specific targets).
6. Lifestyle Interventions
16. Weight loss: Aim BMI 18.5–24.9; ≥5% loss if overweight.
17. Diet: DASH; Na <2.3 g/day (ideal <1.5 g); ↑ K⁺ if safe.
18. Exercise: ≥150 min/week moderate aerobic + resistance ≥2/week.
19. Alcohol: ≤1 drink/day (women), ≤2 (men).
20. Stress: yoga, meditation, breathing techniques.
7. Special Populations
Stroke / ICH
21. ICH: SBP 150–220 → lower to 130–140 for 7 days; avoid <130 early.
22. Ischemic stroke with thrombolysis: <185/110 before, then <180/105 for 24h.
23. No reperfusion & BP ≥220/120: reduce by ~15% in 24h.
24. Secondary prevention: target <130/80; use thiazide, ACEi, or ARB.
CKD
25. Target <130/80; ACEi/ARB first-line if albuminuria ≥30 mg/g.
26. Avoid ACEi + ARB combo.
Diabetes
27. Target <130/80; ACEi/ARB preferred with albuminuria.
Pregnancy
28. Acute severe HTN (≥160/110): treat within 30–60 min, with gradual reduction over ~30 min. First-line: IV labetalol, oral nifedipine, or methyldopa.
29. Chronic HTN: target <140/90.
30. Safe drugs: labetalol, nifedipine, methyldopa.
• Avoid ACEi, ARB, direct renin inhibitors, mineralocorticoid antagonists, and atenolol (linked to fetal growth restriction & neonatal complications).
OSA
31. Screen in resistant HTN or suggestive symptoms.
32. CPAP + weight loss modestly improve BP.
HIV
33. Standard treatment; monitor drug–drug interactions (esp. with CCBs).
Transplant
34. First-line: amlodipine; avoid verapamil/diltiazem with calcineurin inhibitors.
8. Resistant Hypertension
35. Defined as uncontrolled BP on ≥3 drugs (incl. diuretic) or controlled on ≥4.
36. Add spironolactone if eGFR ≥45; alternatives: amiloride, β-blocker, α-blocker, clonidine.
37. Exclude secondary causes; remove interfering drugs.
38. Renal Denervation (RDN) – Class IIb option if uncontrolled.
9. What’s New in 2025
39. “Hypertensive urgency” renamed “Severe Hypertension” (no organ damage).
40. Primary aldosteronism screening expanded (all resistant HTN).
41. Potassium-based salt substitutes broadly recommended.
42. Avoid lowering SBP <140 in first 24–72h post-reperfusion stroke.
43. Emphasis on community-based screening & team-based care.
10. Hypertensive Emergencies (BP >180/120 + organ damage)
• ICU admission; titratable IV drugs (nicardipine, clevidipine, labetalol, esmolol, hydralazine, enalaprilat).
• Nitrates only for ACS or pulmonary edema.
• If IV unavailable: oral captopril (preferred; rapid under tongue or swallowed).
• Oral nifedipine only in preeclampsia/eclampsia.
• Evidence note: Sublingual captopril reduces SBP & MAP more rapidly than oral in first 30 min, but effect is similar at 60 min.
• Target: reduce ≤25% in 1h, then <160/100 in 2–6h, then 130–140/80–90 in 24–48h.
11. Other Clinical Notes
• Orthostatic Hypotension: Check baseline & after intensification; not a reason to avoid intensive BP control.
• Sexual dysfunction: Diuretics & β-blockers worsen it; ARBs safest. PDE-5 inhibitors safe (not with nitrates).
• Perioperative BP: Continue most drugs; stop ACEi/ARB 24h before major surgery; defer elective surgery if ≥180/110.
12. GP Quick Checklist
☐ Confirm diagnosis with ABPM/HBPM.
☐ Classify & stage BP.
☐ Assess 10y risk (PREVENT tool).
☐ Initiate lifestyle ± drugs per stage/risk.
☐ Use single-pill combos where possible.
☐ Monitor monthly until goal achieved.
☐ Screen for secondary causes if resistant/atypical.
Key Takeaway:
For most adults, target <130/80 mmHg using validated BP methods, lifestyle change, risk-based thresholds for treatment, and single-pill drug combinations.
Special attention: treat pregnancy-related severe hypertension within 30–60 minutes, avoid atenolol, use safe drugs, and apply new terminology (Severe Hypertension).
Resistant hypertension requires structured evaluation and, in select cases, renal denervation.