The American Heart Association (AHA) and American College of Cardiology (ACC) have released comprehensive updated guidelines for hypertension management, marking the first major revision since 2017. The new "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" introduces evidence-based recommendations aimed at reducing cardiovascular disease risk through earlier intervention and personalized treatment strategies.
"High blood pressure is the most common and most modifiable risk factor for heart disease," said Daniel Jones, MD, dean and professor emeritus of the University of Mississippi School of Medicine and Chair of the guideline writing committee. "By addressing individual risks earlier and offering more tailored strategies across the lifespan, the 2025 guideline aims to aid clinicians in helping more people manage their blood pressure and reduce the toll of heart disease, kidney disease, type 2 diabetes, and dementia."
Key Lifestyle and Dietary Recommendations
The updated guidelines emphasize comprehensive lifestyle modifications as foundational therapy. Key recommendations include limiting sodium intake to less than 2,300 mg per day, with an ideal target of 1,500 mg daily. For alcohol consumption, the guidelines recommend complete abstinence or, for those who choose to drink, no more than two drinks per day for men and one per day for women.
Physical activity recommendations specify 75-150 minutes of weekly exercise, including both aerobic and resistance training components. The guidelines also emphasize stress management through exercise and stress-reduction techniques such as meditation or yoga, alongside maintaining a healthy weight with at least 5% body weight reduction in adults with obesity or overweight.
Novel Screening and Monitoring Approaches
The 2025 guidelines introduce several new screening recommendations based on literature reviews conducted from December 2023 to June 2024. Adults with hypertension should now receive regular screening for primary aldosteronism, and the plasma aldosterone-to-renin ratio test has expanded indications as a screening tool.
The guidelines recommend utilizing potassium-based salt substitutes to prevent elevated blood pressure and maintaining systolic blood pressure below 130 mm Hg to avoid mild cognitive impairment. Additionally, clinicians are now recommended to use the ratio of urine albumin and creatinine for all patients with high blood pressure, rather than viewing it as optional.
Advanced Risk Assessment Tools
A significant update involves the recommendation to use the Predicting Risk of CVD EVENTs (PREVENT) risk calculator, which incorporates contemporary data from more diverse racial and ethnic populations compared to traditional pooled cohort equations. PREVENT expands the investigatory scope to total cardiovascular disease risk, including myocardial infarction, stroke, and heart failure, rather than measuring solely atherosclerotic cardiovascular disease.
Emerging Therapeutic Options
The guidelines acknowledge newer treatment methods, including aprocitentan (Tryvio) and GLP-1 receptor agonists. Aprocitentan, a dual endothelin A and B receptor antagonist, demonstrated reductions in 24-hour ambulatory systolic blood pressure by 4 to 6 mm Hg versus placebo in clinical trials and received FDA approval in March 2024 for uncontrolled hypertension.
"Aprocitentan had been studied in a resistant hypertensive population but curiously was approved by the FDA for a broader indication than that," noted Vivek Bhalla, MD, associate professor of medicine at Stanford Medicine. "The lower dose of aprocitentan was approved by the FDA for uncontrolled hypertension, which is a broader term than resistant hypertension."
Regarding GLP-1 receptor agonists, the guidelines recognize their blood pressure-lowering effects due to the correlation between obesity and hypertension. These medications also offer potential secondary benefits, such as slowing kidney decline and reducing urinary albumin. However, Bhalla emphasized that "it should not be prescribed as an end-line medication in blood pressure because it simply hasn't been tried and tested in that way."
Pregnancy-Related Hypertension Management
The guidelines specifically address hypertension risks during pregnancy, highlighting chronic pre- and postpartum hypertension, preeclampsia, and eclampsia as significant concerns. Clinicians are encouraged to recommend aspirin and other medications when systolic blood pressure reaches 140 mm Hg or higher and/or diastolic blood pressure reaches 90 mm Hg or higher.
Clinical Implementation
"This updated guideline is designed to support health care professionals—from primary care teams to specialists, and to all clinicians across health systems—with the diagnosis and care of people with high blood pressure," Jones explained. "It also empowers patients with practical tools that can support their individual health needs as they manage their blood pressure, whether through lifestyle changes, medications, or both."
The comprehensive guidelines represent a collaborative effort among multiple medical organizations to provide clinicians with evidence-based tools for managing hypertension across diverse patient populations, emphasizing both traditional approaches and emerging therapeutic options in the evolving treatment landscape.
