A trans-Atlantic perspective on the 2025 AHA/ACC Guidelines for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults

Introduction

The 2025 joint AHA/ACC/AANP/AAPA/ABC/ACCP/ACPM/AGS/AMA/ASPC Guidelines for the Prevention, Detection, Evaluation, and Management of High Blood Pressure (BP) in Adults¹ represent the first major update since 2017, incorporating new evidence and offering updated recommendations for high BP management. These U.S. guidelines closely follow two distinct European updates: the 2023 European Society of Hypertension (ESH)² and the 2024 European Society of Cardiology (ESC)³ guidelines. While all three aim to reduce hypertension-related morbidity and mortality by recommending evidence-based care, there are important differences.

Diagnostic Thresholds and BP Categories

The AHA/ACC defines stage 1 hypertension as an office systolic BP (SBP) ≥130 and/or diastolic BP (DBP) ≥80 mmHg, maintaining its 2017 threshold. Stage 2 hypertension is based on a 140/90 mmHg cutoff. In contrast, both ESC and ESH guidelines use 140/90 mmHg as the diagnostic threshold. The ESH adds granularity by categorizing hypertension into grades and clinical phenotypes, while the ESC focuses on rapid diagnostic confirmation for higher BP readings. Each guideline also defines an “elevated BP” or “high-normal BP” category below the hypertension threshold, with differing SBP/DBP cutoffs. Consequently, many individuals labeled Stage 1 hypertensive in the U.S. are considered as having elevated BP by ESC criteria or high-normal BP by ESH criteria. Furthermore, definitions of normal BP (AHA/ESH) or non-elevated BP (ESC) also vary (Table). All three guidelines recommend accurate office BP measurement using validated oscillometric devices, and recommend confirmation via home BP monitoring (HBPM) or ambulatory BP monitoring (ABPM) to rule out white-coat or masked hypertension

Table.

Comparison of 2025 AHA/ACC Guidelines with contemporary European Guidelines

Domain	AHA/ACC 2025	ESC 2024	ESH 2023
Hypertension Definition (Office BP threshold)	SBP ≥130 and/or DBP ≥80	SBP ≥140 and/or DBP ≥ 90	SBP ≥140 and/or DBP ≥ 90
	Further stratified into stages: Stage 1 : 130–139 or 80–89 Stage 2 : ≥140 or ≥90	No formal BP stage/grade: 140–159 or 90–99: Confirm by HBPM/ABPM 160–179 or 100–109: Confirm by HBPM/ABPM within 1 month ≥180 or ≥110: Exclude hypertensive emergency	Further stratified into grades for severity: Grade 1 : 140–159 or 90–99 Grade 2 : 160–179 or 100–109 Grade 3 : ≥180 or ≥110 Additional staging: Stage 1 : uncomplicated without HMOD, diabetes, CVD and CKD ≥3 Stage 2 : HMOD, diabetes, or CKD 3 Stage 3 : CVD or CKD 4/5
	Uncontrolled hypertension: ≥130 or ≥80	Uncontrolled hypertension: ≥140 or ≥90	Uncontrolled hypertension: ≥140 or ≥90 (varies by age-specific goal)
BP Categories below threshold	Elevated BP: 120–129 and <80 Normal BP: <120 and < 80	Elevated BP: 120–139 or 70–89 Non-elevated BP: <120 and < 70 (no “normal” defined per se)	High-Normal BP: 130–139 or 85–89 Normal BP: 120–129 and 80–84 Optimal BP: <120 and <80
When to Initiate Lifestyle measures	Always (Elevated BP and above)	Always (Elevated BP and above)	Always (High normal BP and above)
When to Initiate Drug Therapy	Immediate treatment: BP ≥140 or ≥90, regardless of age and CV risk or Stage 1 : 130–139 or 80–89 with high risk (prior CVD event, diabetes, CKD, or 10- year CVD risk of ≥7.5%)	Immediate treatment: BP ≥140 or ≥90, regardless of age and CV risk	Immediate treatment: Grade 2 or 3 regardless of age and CV risk or Grade 1: BP level : 140–159 or 90–99 with high risk BP level : 150–159 or 95–99 with low risk or High-Normal BP: ≥130 or ≥80 with established CVD (CAD)
	Delayed treatment: Stage 1: 130–139 or 80–89 with low risk (without CVD and with estimated 10- year CVD risk <7.5%): after 3–6 months of lifestyle intervention if BP remains ≥130 or ≥80	Delayed treatment: Elevated BP: 130–139 or 80–89 with high risk (prior CVD event, diabetes, CKD, HMOD, or 10-year CVD risk of ≥10%, or 10-year CVD risk of 5–10% with risk modifier): after 3 months of lifestyle intervention if BP remains ≥ 130 or 80 Elevated SBP 130–139 with high low risk AND 10-year CVD risk < 10% and NO risk modifier)/ Lifestyle measures only. Monitor BP and CVD risk yearly Elevated BP: 120–129; Lifestyle measures only. Monitor BP and CVD risk yearly	Delayed treatment BP level 140–149 or 90–94 : after 3–6 months of lifestyle intervention if BP remains ≥140 or ≥90
	Age ≥80 yrs: BP ≥130 or ≥ 80 after individualized consideration	Age < 85 yrs: similar than in younger patients for hypertension and elevated BP Age ≥85 yrs, or orthostatic hypotension, frailty, and/or limited lifespan (<3 years) : BP ≥140 or ≥ 90 after individualized consideration	Age ≥80 yrs: SBP ≥160 or SBP of 140–159 after individualized consideration
Risk Assessment Tool	Predicting Risk of cardiovascular disease EVENTs (PREVENT™)	Systematic COronary Risk Evaluation 2 (SCORE2 for age of 40–69 years) SCORE2– Older Persons (SCORE2-OP, for age of 70–89 years)	Systematic COronary Risk Evaluation 2 (SCORE2 for age of 40–69 years) SCORE2– Older Persons (SCORE2-OP, for age of 70–89 years)
Initial Medication Choices	First-line : ACEi, ARB, CCB, thiazide or thiazide-like diuretic β-Blockers: Not first-line unless compelling indication (e.g. heart failure, post-MI, angina, heart rate control etc)	First-line : ACEi, ARB, CCB, thiazide or thiazide-like diuretic β-Blockers: Not first-line unless compelling indication (e.g. heart failure, post-MI, angina, heart rate control etc)	First-line : ACEi, ARB, CCB, thiazide or thiazide-like diuretic β-Blockers: Included as an first-line agent (especially if compelling indication)
	Dual fixed-dose single pill combination for Stage 2 hypertension or non-frail with BP ≥20/10 mmHg above goal Preferential combinations: ACEi or ARB + CCB or diuretic	Dual fixed-dose single pill combination for most patients with BP ≥140 or ≥90 Preferential combinations: ACEi or ARB + CCB or diuretic	Dual fixed-dose single pill combination for most patients with BP ≥140 or ≥90 Preferential combinations: ACEi or ARB + CCB or diuretic
Initial Treatment Strategy	Initial monotherapy for patients with Stage 1 hypertension	Initial monotherapy for patients with: Elevated BP Frailty, age ≥85 yrs, or symptomatic orthostatic hypotension	Initial monotherapy for patients with Grade 1 hypertension (<150/95) and low CV risk High-normal BP and high CV risk Frailty or advanced age
BP Treatment Targets	General target: <130 and <80 with encouragement to achieve SBP <120 No different target for elderly or frail patients but use clinical judgment (avoid side effects; individualize higher if needed)	General target: 120–129 and 70–79 Age ≥85 yrs with moderate to severe frailty, orthostatic hypotension or a life expectancy <3 years: SBP <140 or “as low as reasonably achievable”	General target: <140 and 80 mmHg in most patients 18 to 64 yrs: 120–129 and 70–79 65 to 79 yrs: <140 and <80, but a lower BP target of 120–129 and 70–79 may be considered if well-tolerated ≥80 yrs: SBP of 140–150; a lower SBP target of 130–139 may be considered if well-tolerated. Frailty: individualize treatment target

All values reflect an office BP measurement in mm Hg.

ABPM: ambulatory blood pressure monitoring; AHA/ACC: American College of Cardiology/American Heart Association; ACEi: angiotensin converting enzyme inhibitor; ARB: angiotensin receptor blocker; BP: blood pressure; CAD: coronary artery disease; CCB: calcium channel blockers; CKD: chronic kidney disease; CV: cardiovascular; CVD: cardiovascular disease; DBP: diastolic blood pressure; ESH: European Society of Hypertension; ESC: European Society of Cardiology; HBPM: home blood pressure monitoring; HMOD: hypertension-mediated organ damage; SBP: systolic blood pressure

Treatment Initiation and Risk Stratification

All three guidelines recommend lifestyle modifications — sodium reduction, increased potassium intake, less than moderate alcohol use, weight reduction, regular physical activity, and stress management — irrespective of BP level. However, office BP thresholds for initiation of drug therapy diverge. The AHA/ACC recommends initiating antihypertensive medication therapy in (i) all patients with BP ≥140/90 mmHg, regardless of age or cardiovascular (CV) risk, and (ii) at BP ≥130/80 mmHg in individuals with established CV disease (CVD), diabetes, chronic kidney disease (CKD), or ≥7.5% 10-year CVD risk from the Predicting Risk of cardiovascular disease EVENTs (PREVENT^™) metric.^{4, 5} The ESC recommends pharmacotherapy in all individuals aged <85 years at BP ≥140/90 mmHg but allows treatment at 130–139/80–89 mmHg in high-risk patients, defined by the presence of established CVD or high-risk comorbidities (diabetes, CKD, hypertension-mediated organ damage), or 10-year risk ≥10% from the Systematic COronary Risk Evaluation 2 (SCORE2 for age of 40–69 years) and SCORE2–Older Persons (SCORE2-OP, for age of 70–89 years) or a combination of 10- year risk (5–10%) with risk modifiers after 3 months of lifestyle intervention if BP remains ≥ 130 or 80 mmHg. The ESH recommends immediate treatment in grade 2 or 3 hypertension and in grade 1 cases with high risk (e.g., symptomatic, hypertension-mediated organ damage, CKD stage 3, CVD) or with BP ≥150/95 mmHg at low risk. For patients with BP <150/95 mmHg and low CV risk, antihypertensive therapy is deferred pending a 3 to 6 months lifestyle trial with pharmacotherapy initiated if BP remains uncontrolled (≥140/90 mmHg). The ESH adopts a more conservative approach in the high-normal BP range (130–139/80–89 mmHg), recommending immediate initiation of antihypertensive therapy only for patients with established CVD, primarily coronary artery disease. For low-to-moderate risk individuals in this BP range, the ESH advises initial lifestyle intervention alone without pharmacologic treatment, combined with regular BP monitoring. Finally, in patients aged ≥80 years, the ESH recommends antihypertensive treatment initiation when SBP is ≥160 mmHg, although treatment may also be considered for SBP in the 140–159 mmHg range based on clinical judgment.

Initial Medication Choices and Strategies

All guidelines endorse the same first-line classes: angiotensin-converting enzyme inhibitors (ACEi) or angiotensin receptor blockers (ARBs), calcium channel blockers (CCBs), and thiazide or thiazide-like diuretics). However, the AHA/ACC and ESC reserve beta-blockers for compelling indications (angina, post-myocardial infarction, heart failure with reduced ejection fraction, or for heart rate control etc.), whereas the ESH includes beta-blockers among first-line options. In most patients with BP ≥140/90 mmHg, all three guidelines recommend initiating therapy with a dual fixed-dose single-pill combination instead of separate pills to reduce pill burden and improve adherence (Table).

Treatment Targets

The AHA/ACC uses a uniform target of <130/<80 mmHg, regardless of age or comorbidity. The ESC recommends a range of 120–129/70–79 mmHg for patients <85 years, allowing more flexibility in the very old (> 85 years) or frail (<140 mmHg). The ESH recommends that the first objective of antihypertensive treatment should be to lower BP to <140/80 mmHg in most patients but adds granularity according to age. ESH recommends a target range of 120–129/70–79 mmHg for adults aged 18–64 years, but of 130–139 mmHg for those aged 65–79 years, and 140–150 mmHg for those aged ≥80 or frail—with optional tighter targets if well-tolerated. The AHA/ACC also recommends treating to a target of <130 mmHg to prevent cognitive decline and dementia.

Resistant Hypertension (RHTN)

All guidelines define RHTN as failure to reach target BP despite ≥3 agents (including a diuretic) at optimal doses — typically combination of an ACEi/ARB, a CCB, and a thiazide/thiazide-like diuretic. The AHA/ACC uses a lower BP threshold (130/80 mmHg) for defining uncontrolled hypertension, while both the ESC and ESH use ≥140/90 mmHg. AHA/ACC guidelines also include patients needing ≥4 medications to maintain BP control. Management aligns across all three guidelines: confirm true RHTN with ABPM/HBPM, exclude pseudo-resistance (e.g., poor adherence, therapeutic inertia), and secondary causes (especially primary aldosteronism), reinforce lifestyle changes, optimize diuretic use, and add spironolactone (or other mineralocorticoid receptor antagonist (MRA) if estimated glomerular filtration rate ≥45 ml/min/1.73 m² (AHA/ACC) or ≥30 ml/min/1.73 m² (ESH) and serum K⁺ ≤4.5 mmol/L). Referral to a hypertension specialist is advised for persistent uncontrolled BP.

Renal Denervation (RDN)

Catheter-based RDN by radiofrequency or ultrasound ablation is incorporated into all three guidelines for the first time. FDA-approved for uncontrolled hypertension in late 2023, RDN is now considered for carefully selected patients with RHTN and eGFR ≥40 ml/min/1.73 m² and suitable renal anatomy. The AHA/ACC restricts RDN to patients with SBP of 140 to 180 mmHg and DBP ≥90 mmHg despite four drugs (including an MRA), or in patients with uncontrolled hypertension intolerant to drug escalation. Both the ESC and ESH position RDN as a fourth-line option in RHTN (≥140/90 mmHg), with ESC also allowing its use in high-risk patients with uncontrolled BP on <3 antihypertensive medications without requiring MRA therapy. All three guidelines consider RDN as class IIB and emphasize that RDN be performed by trained specialists in the context of shared decision-making by the patient, healthcare team, and multidisciplinary assessment.

Conclusions and Commentary

In summary, all three guidelines globally converge to provide high quality of care to patients with hypertension. However, the AHA/ACC guidelines remain more aggressive than European guidelines. The European stratified approach maintains alignment with physiological heterogeneity but may delay intervention in early disease. The more aggressive thresholds and universal targets proposed by the AHA/ACC align well with payment incentives in U.S. primary care settings that reward practices for achieving population-wide benchmarks. Given the inherent variability in BP measurement, if a practice is aiming to have 75% of its population <140 mm Hg/<90 mm Hg (i.e., the Healthcare Effectiveness Data and Information Set −HEDIS− benchmark for hypertension; https://www.ncqa.org/hedis/), it will need to target a lower individual treatment goal to ensure that at any given visit, the majority of patients are below the benchmark goal. Thus, the AHA/ACC guidelines reflect underlying regional healthcare realities— physician practice patterns, reimbursement frameworks, and system-level priorities, while sharing a commitment to personalized care, multidimensional risk assessment, and increasingly patient-centered models.

For clinicians navigating guidelines, the opportunity lies not in choosing one guideline over the other, but in harmonizing strengths to deliver contextually appropriate, high-quality patient-centered care. Implementation of all these guidelines, however, poses considerable challenges. Success depends not only on clinician awareness and training, but also on the availability of a multi-disciplinary team (physicians, nurses, pharmacists etc.) and system-level support for long-term follow-up.

Beyond the clinical and logistical aspects of implementation, all three guidelines bring to light a major public health challenge: how to manage millions of individuals with hypertension, the number of whom is increasing, within overburdened care systems already constrained by limited healthcare provider availability. Team-based care led by pharmacists, advanced practice providers (such as physician associates or nurse practitioners), and community health workers may be essential, as this approach has been shown to effectively facilitate BP control. While this model is recommended in both AHA/ACC and European guidelines, it may not be universally accessible across European countries. Moreover, a coordinated public health policy is crucial to reduce the incidence and burden of hypertension. This includes nationwide initiatives to lower sodium content in processed foods, promote healthy diet and physical activity, reduce overweight and obesity, as well as curb tobacco use as promoted by the AHA in its Life’s Essential 8 program. Without structural changes and preventive strategies embedded in food, urban, and educational policies, medical interventions alone will be insufficient to meaningfully impact population-level CV risk. Public awareness campaigns, policy-level food reformulation, and support for community-based lifestyle interventions must complement medical care in achieving the ambitious targets set by these guidelines.

Abbreviations:

ABPM

ambulatory blood pressure monitoring

AHA/ACC

American Heart/ American College of Cardiology

ACEi

angiotensin converting enzyme inhibitor

ARB

angiotensin receptor blocker

BP

blood pressure

CAD

coronary artery disease

CCB

calcium channel blockers

CKD

chronic kidney disease

CV

cardiovascular

CVD

cardiovascular disease

DBP

diastolic blood pressure

ESH

European Society of Hypertension

ESH

European Society of Cardiology

HBPM

home blood pressure monitoring

HMOD

hypertension-mediated organ damage

MH

masked hypertension

PREVENT

Predicting Risk of cardiovascular disease EVENTs

RHTN

resistant hypertension

RDN

renal denervation

SBP

systolic blood pressure

SCORE2

Systematic COronary Risk Evaluation 2

SCORE2-OP

SCORE2–Older Persons

SPC

single-pill combination

WCH

white-coat hypertension