New Blood Pressure Guidelines: Key Takeaways
New Blood Pressure Guidelines: Key Takeaways
Source: Medscape J.Mandrola, MD
-August 21, 2025
Four Things to Like
1. Accurate BP Measurement
• Guidelines place strong emphasis on proper technique: patient seated, feet on the floor, arm supported.
• In practice, accurate measurement is almost never done correctly (the author notes in 30 years, he has never seen it done right).
• A simple improvement in this vital sign recording could instantly raise healthcare quality.
2. Home-Based BP Monitoring
• Class I, Level A: office BP readings should be supplemented with home monitoring.
• Multiple RCTs show home monitoring + lifestyle changes → sustained BP reduction for ≥12 months.
• Cuffless wearable devices remain unreliable for clinical use.
• Patients need education: don’t obsess over each reading; focus on averages over days to weeks.
• Goal is not just “good BP,” but also a “good life.”
3. Single-Pill Combination Drugs
• Class I recommendation: fixed-dose combination pills for stage 2 hypertension (≥140/90 mm Hg).
• More effective, since most patients require >1 drug.
• Improves efficiency: one pill, one prescription to fill/refill → better adherence.
4. Caution on Renal Denervation (RDN)
• Evidence is weak: trials show either no significant benefit or only small reductions (3–5 mm Hg).
• No sham-controlled efficacy data beyond a few months; no outcome data at all.
• Guidelines give RDN a Class IIb rating (lowest recommendation), but inclusion in colored boxes risks premature widespread use.
• Mandrola: RDN is not a long-term solution—patients need BP control for decades, not months.
• He believes RDN should not have been highlighted at all until stronger evidence exists.
Two Concerns
5. Summary Boxes & Simplified Statements
• Guidelines start with “take-home messages” and colored boxes.
• Concern: This oversimplifies complex medicine and discourages clinicians from reading details and references.
• Hypertension is one of the most important modifiable risk factors → requires deep knowledge, not shortcuts.
• Summary boxes risk giving false confidence, while many patients don’t fit neatly into algorithms.
6. Use of the New PREVENT Risk Score
• Treatment decisions are now based on both BP level + PREVENT 10-year cardiovascular risk.
• Advantages:
• Includes broader outcomes (HF, AF, stroke, CKD, atherosclerotic disease).
• Based on more diverse, contemporary data.
• Factors in kidney function and social determinants of health.
• Provides better calibration of expected vs. observed risk.
• Concerns:
• PREVENT labels fewer patients as “high-risk” → risk of undertreatment.
• Removal of race from calculation may improve equity but could lower accuracy for vulnerable groups.
• No trials directly comparing PREVENT with the older Pooled Cohort Equations (PCE) as risk modifiers.
• Even a small degree of undertreatment in BP could be a public health disaster.
Overall Message
• Positive steps: focus on accurate BP measurement, home monitoring, and rational drug use (combination pills).
• Major caution: avoid premature enthusiasm for RDN and beware of oversimplification (summary boxes, PREVENT risk).
• Mandrola urges clinicians to read the full details of the 105-page guideline and understand the evidence deeply to prevent cardiovascular disease effectively.
