Overview of the 2025 Hypertension Guidelines

The 2025 American College of Cardiology (ACC)/American Heart Association (AHA) hypertension guidelines update the previous version, last released in 2017, by integrating new evidence, and emphasizing prevention and optimized management of hypertension.¹ Recommendations that remain the same include the definitions and criteria for normal, elevated, and stage 1 and 2 hypertension as well as the recommendations for first-line agents. Major revisions in the 2025 Guidelines include using the PREVENT calculator to calculate risk; updates to lifestyle recommendations and terminology, recommendations for broader screening for secondary causes of hypertension; guidance for special populations including patients with diabetes, chronic kidney disease (CKD), pregnancy, and stroke; and considerations for renal denervation in patients with resistant hypertension. A summary of the major changes will be reviewed, including key recommendations and the evidence supporting them.

The following table defines class of recommendations and level of evidence used in the recommendations.

Risk Prediction Tools
The 2017 guideline relied on the Pooled Cohort Equations (PCEs) to estimate atherosclerotic cardiovascular disease (ASCVD) risk, which were based on older, less diverse data, limited to ages 40–79 years, and excluded statin users. The 2025 guideline adopts the new PREVENT calculator, which was released by the AHA in 2023 and uses modern, diverse data to estimate total cardiovascular disease (CVD), ASCVD, and heart failure risk over 10 and 30 years. PREVENT is thought to predict risk more accurately than the PCEs by including variables such as statin use, CKD, and social risk factors. It also can be applied to adults aged 30–79 years, and for guiding therapy initiation and blood pressure (BP) targets in adults without clinical CVD.

Lifestyle Recommendations: Potassium-Based Salt Substitutes
New Recommendation: For adults with or without hypertension, potassium-based salt substitutes can help prevent or manage elevated blood pressure, especially in individuals whose salt intake mainly comes from food prepared or seasoned at home. However, they should be used with caution in patients with CKD or those taking medications that reduce potassium excretion (Class of Recommendation [COR]: 2a, Level of Evidence [LOE]: A).

Data referenced in the guidelines to support this recommendation include a large cluster-randomized trial of nearly 21,000 adults in rural China with a history of stroke or age greater than 60 years with high blood pressure.² In this study, use of a potassium salt substitute (75% sodium chloride and 25% potassium chloride) significantly reduced rates of stroke, major cardiovascular events (MACE) and all-cause mortality over a mean follow-up duration of 4.74 years, without an increased risk of hyperkalemia. In the US, most sodium comes from processed or restaurant foods, therefore salt substitutes may be most beneficial for individuals who primarily add salt at home while cooking. Additional data comes from a variety of systematic reviews and meta-analyses, which have examined the evidence surrounding salt substitutes. Since most data did not include Western diets, generalizability may be limited. However, this data does suggest that salt substitution may reduce all-cause and cardiovascular mortality, and several trials have demonstrated reductions in both systolic and diastolic blood pressure.^3-6 The guidelines note that use of a salt substitute may be of greatest benefit for those who consume most of their sodium at home.

Primary Aldosteronism Screening
With regard to screening, new recommendations were added for secondary forms of hypertension and primary aldosteronism.

New Recommendation: In adults with resistant hypertension, screening for primary aldosteronism is recommended regardless of whether hypokalemia is present (COR: 1, LOE: B-NR).

This recommendation was added because data suggests that primary aldosteronism can exist in the absence of hypokalemia. Therefore, screening should not rely on the marker of hypokalemia alone.^7,8

New Recommendation: In adults with an indication for primary aldosteronism screening, continuation of antihypertensive therapy other than mineralocorticoid receptor antagonists is recommended prior to initial testing to reduce barriers and avoid delays in screening (COR: 1, LOE: C-EO).

Previous guidelines recommended stopping certain antihypertensive medications before screening for primary aldosteronism. However, this may have been a barrier to screening and is unlikely to interfere with result interpretation for most patients. The new guidelines do note that if screening results are negative or borderline despite a high level of suspicion for primary aldosteronism and the diagnosis will change the clinical management, then the screening can be repeated while temporarily discontinuing the suspected interfering medications.

Primary Prevention Thresholds
Revised Recommendation: In adults with hypertension without clinical CVD and diabetes, CKD, or an elevated 10-year CVD risk (≥7.5% based on PREVENT), initiation of antihypertensive therapy is recommended when average systolic blood pressure (SBP) is ≥130 mmHg or diastolic blood pressure (DBP) is ≥80 mmHg to reduce the risk of CVD events and total mortality. (COR: 1, LOE: A-SBP, C-LD-DBP).

The 2025 guideline replaces the Pooled Cohort Equations with the PREVENT tool, which estimates 10- and 30-year total CVD risk, including ASCVD and heart failure, and expands recommendations to patients with diabetes and CKD.

Revised Recommendation: In adults with hypertension without clinical CVD and a 10-year CVD risk <7.5% based on PREVENT, initiation of antihypertensive therapy is recommended if average SBP remains ≥130 mmHg or average DBP remains ≥80 mmHg after 3 to 6 months of lifestyle interventions to prevent target organ damage and limit further BP increases. (COR: 1, LOE: B-R).

A key change from the 2017 guidelines is that adults without clinical CVD who are at lower 10-year predicted CVD risk were previously recommended to start antihypertensive therapy only at a blood pressure of 140/90 mmHg or higher. Evidence supporting medication use in this lower-risk group is still limited, so lifestyle changes should be the first approach to lowering blood pressure. The PREVER-Prevention trial showed that adults aged 30 to 70 years with elevated BP (120–139/80–89 mmHg) who did not achieve optimal control after 3 months of lifestyle intervention had lower rates of progression to stage 2 hypertension (≥140/90 mm Hg) and end organ damage when treated with a diuretic compared with placebo.⁹ This highlights that medications should be considered as an additional tool when lifestyle measures alone are not enough.

Special Populations

• Diabetes

Revised Recommendation: In adults with diabetes and hypertension, an angiotensin converting enzyme inhibitor (ACEI) or angiotensin II receptor blocker (ARB) is recommended in the presence of CKD, defined by an estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m² or albuminuria ≥30 mg/g, and should be considered even with mild albuminuria (<30 mg/g) to delay progression of diabetic kidney disease. (COR: 1, LOE: A)

The word “considered” has been replaced with “recommended” in the new version of the guidelines regarding ACEI or ARB treatment. The guidelines reference a large randomized controlled trial (RCT) involving 12,821 patients with type 2 diabetes that demonstrated reduction of major cardiovascular events with intensive blood pressure lowering compared to standard treatment with a similar incidence of serious adverse events.¹⁰ In addition, the guidelines define CKD using specific cutoffs and recommend ACE inhibitors or ARBs, especially those with moderate to severe albuminuria, upgrading the class of recommendation from 2b to 1. Guidelines note that these agents are also appropriate for less severe CKD if albuminuria is present. In CKD without albuminuria, these agents may be considered primarily for cardiovascular risk reduction.

• Chronic Kidney Disease

Revised Recommendation: For adults with hypertension and CKD, defined by an eGFR <60 mL/min/1.73 m² or albuminuria ≥30 mg/g, a renin-angiotensin-aldosterone system (RAAS) inhibitor (either an ACE inhibitor or an ARB, but not both) is recommended to reduce cardiovascular risk and slow progression of kidney disease. (COR: 1, LOE: B-R)

A Bayesian network meta-analysis of 119 RCTs published since the last edition of the guidelines showed that both ACEI inhibitors and ARBs significantly reduce kidney failure, MACE, and all-cause mortality.¹¹ The updated guidelines change ACE inhibitors and ARBs to a class 1 recommendation. Previously, ACE inhibitors were a class 2a and ARBs 2b, used only if an ACE inhibitor was not tolerated. The guidelines now state that either may be used, but not both, to slow CKD progression and reduce cardiovascular risk.

• Acute Intracerebral Hemorrhage (ICH)

New Recommendation: In adult patients with acute spontaneous ICH and SBP between 150 and 220 mmHg, it may be beneficial to lower SBP immediately to 130 to <140 mm Hg for at least 7 days to improve functional outcomes. Antihypertensive therapy should be held if SBP drops below 130 mm Hg. (COR: 2a, LOE: A)

Revised Recommendation: In adults with acute spontaneous ICH who require blood pressure lowering, careful titration to achieve smooth, stable, and sustained SBP control, avoiding peaks and large variability in SBP, can improve functional outcomes. (COR: 2a, LOE: B-NR)

These recommendations were based on controlled clinical trials and meta-analyses demonstrating improvements in overall function and quality of life when SBP is lowered to less than 140 mmHg and maintained for 7 days in patients with ICH.^12-15 In addition, data show that higher SBP variability in the first 24 hours after ICH is linked to worse functional outcomes at 90 days. Agents with rapid onset and short duration that allow careful titration help maintain smooth, sustained BP control, and avoid large fluctuations in BP.

• Acute Ischemic Stroke

Revised Recommendation: In patients who undergo successful endovascular reperfusion for large vessel occlusion, lowering SBP below 140 mm Hg within the first 24 to 72 hours may worsen long-term functional outcomes. (COR: 3-Harm, LOE: A)

While the notion of more permissive blood pressure recommendations for patients with ICH is a COR3 in both the 2017 and 2025 version of the guidelines, the 2017 guidelines noted that immediate lowering of blood pressure was not a benefit and could potentially be harmful. The 2025 guidelines note that it can worsen long-term functional outcomes. The revised recommendation also clarifies the language to note that this recommendation applies to patients undergoing successful brain reperfusion with endovascular treatment for a large vessel occlusion; the 2017 version referred to adults with spontaneous ICH who presented within 6 hours of the acute event and had an SBP between 150 and 220 mg Hg.

Data to support this recommendation include randomized trials and meta-analyses that consistently show that lowering systolic blood pressure below 140 mm Hg after successful endovascular thrombectomy provides no benefit and may worsen outcomes. The ENCHANTED-2 MT and OPTIMAL BP trials were both stopped early because lower SBP targets were associated with worse 90-day disability. The BEST-II trial similarly suggested potential harm with SBP targets <140 mm Hg.^16-18

• Mild Cognitive Impairment and Dementia

Revised Recommendation: In adults with hypertension, a goal of <130 mmHg SBP is recommended to prevent mild cognitive impairment and dementia. (COR: 1, LOE: A)

The revised recommendation includes a specific goal for SBP of less than 130 mmHg, whereas the 2017 guidelines noted that BP lowering was reasonable, but did not provide a goal. In addition, the recommendation for lowering BP to prevent cognitive decline has been upgraded from a class 2a to class 1 recommendation, changing from reasonable to recommended. Recent meta-analyses of RCTs support that lowering SBP reduces dementia risk.^19-21 In addition, a recent analysis of the SPRINT trial noted that intensive BP lowering to a goal of < 120 mmHg reduced early cognitive decline and mild cognitive impairment, with benefits persisting for at least seven years.²²

Pregnancy
Several new recommendations were added for the management of hypertension in pregnancy. Previously outlined by ACOG, these recommendations are now incorporated into the AHA/ACC guidelines. The CHAP trial demonstrated that maintaining BP <140/90 mm Hg in chronic hypertension during pregnancy improves maternal and fetal outcomes, without compromising fetal growth.²³ Preferred first-line agents are labetalol and extended-release nifedipine; low-dose aspirin is recommended to reduce preeclampsia risk. The guidelines also expand the list of medications to avoid in pregnancy, now including ARBs, nitroprusside and mineralocorticoid receptor antagonists.

Severe Hypertension
Current guidance replaces the term hypertensive urgency with severe hypertension, defined as BP >180/120 mmHg, and recommends management with scheduled medications and close monitoring rather than rapid BP lowering. Hospitalized patients with asymptomatic severe hypertension often experience spontaneous BP reductions, so aggressive intravenous or as-needed antihypertensives can increase risks such as mortality, acute kidney injury (AKI), and longer hospital stays.^24-26

Conclusion
The 2025 ACC/AHA hypertension guidelines bring together the latest evidence to refine how we assess risk, identify secondary causes, and manage hypertension across different patient populations. Overall, the changes reflect a more patient-centered approach to preventing complications and improving long-term health outcomes.

References:

1. Jones DW, Ferdinand KC, Taler SJ, et al. 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: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Hypertension. 2025 Oct;82(10):e212-e316.
2. Neal B, Wu Y, Feng X, et al. Effect of salt substitution on cardiovascular events and death. N Engl J Med. 2021;385:1067–1077.
3. Greenwood H, Barnes K, Clark J, et al. Long-term effect of salt substitution for cardiovascular outcomes: a systematic review and meta-analysis. Ann Intern Med. 2024;177:643–655.
4. Aliasgharzadeh S, Tabrizi JS, Nikniaz L, et al. Effect of salt reduction interventions in lowering blood pressure: a comprehensive systematic review and meta-analysis of controlled clinical trials. PLoS One. 2022;17:e0277929.
5. Hernandez AV, Emonds EE, Chen BA, et al. Effect of low-sodium salt substitutes on blood pressure, detected hypertension, stroke and mortality. Heart. 2019;105:953–960.
6. Jafarnejad S, Mirzaei H, Clark CCT, et al. The hypotensive effect of salt substitutes in stage 2 hypertension: a systematic review and meta-analysis. BMC Cardiovasc Disord. 2020;20:98.
7. Rossi GP, Bernini G, Caliumi C, et al. A prospective study of the prevalence of primary aldosteronism in 1125 hypertensive patients. J Am Coll Cardiol. 2006;48:2293–2300.
8. Xu Z, Yang J, Hu J, et al. Primary aldosteronism in patients in China with recently detected hypertension. J Am Coll Cardiol. 2020;75:1913–1922.
9. Fuchs SC, Poli-de-Figueiredo CE, Figueiredo Neto JA, et al. Effectiveness of chlorthalidone plus amiloride for the prevention of hypertension: the PREVER-Prevention randomized clinical trial. J Am Heart Assoc. 2016;5:e004248.
10. Bi Y, et al. Intensive blood-pressure control in patients with type 2 diabetes. N Engl J Med. 2025 Mar 27;392(12):1155-1167.
11. Xie X, Liu Y, Perkovic V, et al. Renin-angiotensin system inhibitors and kidney and cardiovascular outcomes in patients with CKD: a Bayesian network meta-analysis of randomized clinical trials. Am J Kidney Dis. 2016;67:728–741.
12. Anderson CS, Heeley E, Huang Y, et al. Rapid blood-pressure lowering in patients with acute intracerebral hemorrhage. N Engl J Med. 2013;368:2355–2365.
13. Ma L, Hu X, Song L, et al. The third Intensive Care Bundle with Blood Pressure Reduction in Acute Cerebral Haemorrhage Trial (INTERACT3): an international, stepped wedge cluster randomised controlled trial. Lancet. 2023;402:27–40.
14. Moullaali TJ, Wang X, Martin RH, et al. Blood pressure control and clinical outcomes in acute intracerebral haemorrhage: a preplanned pooled analysis of individual participant data. Lancet Neurol. 2019;18:857–864.
15. Manning L, Hirakawa Y, Arima H, et al. Blood pressure variability and outcome after acute intracerebral haemorrhage: a post-hoc analysis of INTERACT2, a randomised controlled trial. Lancet Neurol. 2014;13:364–373.
16. Yang P, Song L, Zhang Y, et al. Intensive blood pressure control after endovascular thrombectomy for acute ischaemic stroke (ENCHANTED2/MT): a multicentre, open-label, blinded-endpoint, randomised controlled trial. Lancet. 2022;400:1585–1596.
17. Nam HS, Kim YD, Heo J, et al. Intensive vs conventional blood pressure lowering after endovascular thrombectomy in acute ischemic stroke: the OPTIMAL-BP randomized clinical trial. JAMA. 2023;330:832–842.
18. Mistry EA, Hart KW, Davis LT, et al. Blood pressure management after endovascular therapy for acute ischemic stroke: the BEST-II randomized clinical trial. JAMA. 2023;330:821–831.
19. Hughes D, Judge C, Murphy R, et al. Association of blood pressure lowering with incident dementia or cognitive impairment: a systematic review and meta-analysis. JAMA. 2020;323:1934–1944.
20. Lennon MJ, Lam BCP, Lipnicki DM, et al. Use of antihypertensives, blood pressure, and estimated risk of dementia in late life: an individual participant data meta-analysis. JAMA Netw Open. 2023;6:e2333353.
21. Peters R, Xu Y, Fitzgerald O, et al. Blood pressure lowering and prevention of dementia: an individual patient data meta-analysis. Eur Heart J. 2022;43:4980–4990.
22. Reboussin DM, Gaussoin SA, Pajewski NM, et al. Long-term effect of intensive vs standard blood pressure control on mild cognitive impairment and probable dementia in SPRINT. Neurology. 2025;104:e213334
23. Tita AT, Szychowski JM, Boggess K, et al. Treatment for mild chronic hypertension during pregnancy. N Engl J Med. 2022;386:1781–1792.
24. Anderson TS, Herzig SJ, Jing B, et al. Clinical outcomes of intensive inpatient blood pressure management in hospitalized older adults. JAMA Intern Med. 2023;183:715–723.
25. Garg K, Staunton MK, Peixoto AJ, et al. Correlates of spontaneous blood pressure reduction following severe inpatient hypertension development. Am J Hypertens. 2023;37:273–279.
26. Mohandas R, Chamarthi G, Bozorgmehri S, et al. Pro re nata antihypertensive medications and adverse outcomes in hospitalized patients: a propensity-matched cohort study. Hypertension. 2021;78:516–524.

Prepared by:
Jessica Opalka, PharmD Candidate
UIC Retkzy College of Pharmacy

Reviewed by:
Jen Phillips, PharmD, BCPS, FCCP, FASHP
Clinical Professor and Director, Drug Information Group
UIC Retzky College of Pharmacy
December 2025

The information presented is current as of November 24, 2025. This information is intended as an educational piece and should not be used as the sole source for clinical decision-making.